What are the goals and rehabilitation approach for patients with Adhesive Capsulitis?

Adhesive Capsulitis: Pathophysiology and Rehabilitation Goals

Pathophysiology

Adhesive capsulitis results from fibrosis and contracture of the glenohumeral joint capsule, leading to painful, progressive loss of both active and passive shoulder motion. 1

The condition progresses through three distinct phases 2:

• Freezing phase: Characterized by increasing pain and progressive loss of motion
• Frozen phase: Marked stiffness with complete reduction of range of motion
• Thawing phase: Gradual recovery of motion

The primary pathologic mechanism involves a pain-muscle guarding-pain cycle, particularly affecting the subscapularis muscle, which perpetuates the loss of motion and functional disability. 3

Primary Rehabilitation Goals

The primary goal of therapeutic intervention is to restore pain-free, functional range of motion of the shoulder while maximizing quality of life through control of symptoms, prevention of progressive functional limitation, and preservation of social participation. 3, 4

Specific measurable goals include 3, 2, 5:

• Pain reduction: Decrease pain intensity to allow functional activities
• Range of motion restoration: Prioritize external rotation and abduction, as these are most functionally limiting
• Functional capacity: Improve hand-behind-back reach and overhead activities
• Quality of life: Address depression and sleep disturbances that commonly accompany this condition 6

Rehabilitation Approach Algorithm

Phase 1: Early Intervention (Freezing Phase)

Early diagnosis and treatment before complete motion loss (Phase 2) yields significantly better outcomes. 2

Initial treatment components 7, 3, 1:

1. Gentle stretching and mobilization: Focus specifically on increasing external rotation and abduction 7
2. Active range of motion exercises: Increase gradually while restoring shoulder girdle alignment 7
3. Heat application before exercise: Use local heat (higher recommendation strength than ultrasound) 7
4. Analgesic modalities: Ice, heat, and soft tissue massage to reduce pain/swelling and improve tissue elasticity 7

Phase 2: Intensive Mobilization

Reverse distraction mobilization technique is superior to conventional Kaltenborn caudal/posterior glides for decreasing pain and improving abduction range of motion. 5

Treatment protocol 5, 8:

• Apply mobilization techniques 10-15 times per session
• Combine with conventional physical therapy
• Deliver 18 treatment sessions over 6 weeks
• Two repeated arthrographic distensions with steroid injection combined with intensive physiotherapy provides optimal benefit; a third distension does not provide further improvement 8

Phase 3: Strengthening and Functional Restoration

Post-mobilization exercises should focus on 4:

• Neck strengthening
• Rotator cuff strengthening
• Posterior shoulder girdle strengthening
• Anterior shoulder girdle flexibility

Critical Exercise Precautions

AVOID overhead pulley exercises—they encourage uncontrolled abduction and have the highest incidence of developing hemiplegic shoulder pain. 7

Aggressive passive range-of-motion exercises performed improperly cause more harm than good; exercises must be performed within the patient's visual field in safe, appropriate positions. 7

Treatment Duration and Surgical Threshold

Most patients improve with nonsurgical treatment consisting of gentle, progressive stretching exercises. 1

Surgical intervention should be considered only after ≥6 months of physical therapy with failure to obtain symptomatic improvement and continued functional disability. 1

Special Population Considerations

Breast cancer patients require monitoring for early signs of adhesive capsulitis, as early identification and treatment prevents unnecessary pauses during exercise programming. 4

Stroke patients with adhesive capsulitis experience delayed rehabilitation and functional recovery, making prevention and early treatment particularly critical. 6

Adjunctive Interventions

Consider the following as supplements to core rehabilitation 7:

• Functional electrical stimulation (FES): May improve shoulder lateral rotation and reduce pain
• Neuromuscular electrical stimulation (NMES): Can be used as adjunct, though efficacy data remain limited
• Proper positioning: Shoulder strapping during ambulation protects from traction injury
• Wheelchair adaptations: Lap trays and arm troughs reduce shoulder pain and subluxation

Common Pitfalls to Avoid

• Delaying treatment until Phase 2: Patients treated in Phase 1 recover internal rotation more effectively than those treated in Phase 2 2
• Excessive distension sessions: More than two distensions provide no additional benefit 8
• Overhead pulley exercises: These worsen pain and should be strictly avoided 7
• Aggressive passive stretching: Without proper technique and patient visual control, this causes harm 7