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  Clinical Practice Guidelines MARTIN J. KELLEY, DPT  ã MICHAEL A. SHAFFER, MSPT  ã JOHN E. KUHN, MD  ã LORI A. MICHENER, PT, PhD AMEE L. SEITZ, PT, PhD  ã TIMOTHY L. UHL, PT, PhD  ã JOSEPH J. GODGES, DPT, MA  ã PHILIP W. MCCLURE, PT, PhD Shoulder Pain and Mobility Deficits: Adhesive Capsulitis Clinical Practice Guidelines Linked to the  International Classification of Functioning,  Disability, and Health From the Orthopaedic Section of the American Physical Therapy Association J Orthop Sports Phys Ther 2013;43(5):A1-A31. doi:10.2519/jospt.2013.0302 REVIEWERS: Roy D. Altman, MD ã John DeWitt, DPT ã George J. Davies, DPT, MEd, MATodd Davenport, DPT ã Helene Fearon, DPT ã Amanda Ferland, DPT ã Paula M. Ludewig, PT, PhD ã Joy MacDermid, PT, PhDJames W. Matheson, DPT ã Paul J. Roubal, DPT, PhD ã Leslie Torburn, DPT ã Kevin Wilk, DPT For author, coordinator, contributor, and reviewer affiliations, see end of text. Copyright ©2013 Orthopaedic Section, American Physical Therapy Association (APTA), Inc, and the Journal of Orthopaedic & Sports Physical Therapy . The Orthopaedic Section, APTA, Inc, and the Journal of Orthopaedic & Sports Physical Therapy  consent to the reproduction and distribution of these guidelines for educational purposes. Address correspondence to: Joseph Godges, DPT, ICF Practice Guidelines Coordinator, Orthopaedic Section, APTA, Inc, 2920 East Avenue South, Suite 200, La Crosse, WI 54601. E-mail: RECOMMENDATIONS  ................................................... A2 INTRODUCTION ............................................................ A3 METHODS  ................................................................... A4 CLINICAL GUIDELINES:   Impairment/Function-Based Diagnosis  .................. A6 CLINICAL GUIDELINES:  Examination  ........................................................... A14 CLINICAL GUIDELINES:  Interventions  ........................................................... A16 SUMMARY OF RECOMMENDATIONS  ............................. A26 AUTHOR/REVIEWER AFFILIATIONS AND CONTACTS  ...... A27 REFERENCES  ............................................................. A28    J  o  u  r  n  a   l  o   f   O  r   t   h  o  p  a  e   d   i  c   &   S  p  o  r   t  s   P   h  y  s   i  c  a   l   T   h  e  r  a  p  y   ®    D  o  w  n   l  o  a   d  e   d   f  r  o  m  w  w  w .   j  o  s  p   t .  o  r  g  a   t  o  n   M  a  y   7 ,   2   0   1   4 .   F  o  r  p  e  r  s  o  n  a   l  u  s  e  o  n   l  y .   N  o  o   t   h  e  r  u  s  e  s  w   i   t   h  o  u   t  p  e  r  m   i  s  s   i  o  n .    C  o  p  y  r   i  g   h   t   ©   2   0   1   3   J  o  u  r  n  a   l  o   f   O  r   t   h  o  p  a  e   d   i  c   &   S  p  o  r   t  s   P   h  y  s   i  c  a   l   T   h  e  r  a  p  y   ® .   A   l   l  r   i  g   h   t  s  r  e  s  e  r  v  e   d .   Adhesive Capsulitis: Clinical Practice Guidelines  a2   |  may 2013 | volume 43 | number 5 | journal of orthopaedic &  sports physical therapy  PATHOANATOMICAL FEATURES:  Clinicians should assess for im-pairments in the capsuloligamentous complex and musculo-tendinous structures surrounding the shoulder complex when a patient presents with shoulder pain and mobility deficits (adhesive capsulitis). The loss of passive motion in multiple planes, particularly external rotation with the arm at the side and in varying degrees of shoulder abduction, is a significant finding that can be used to guide treatment planning. (Rec-ommendation based on theoretical/foundational evidence.) RISK FACTORS:  Clinicians should recognize that (1) patients  with diabetes mellitus and thyroid disease are at risk for developing adhesive capsulitis, and (2) adhesive capsulitis is more prevalent in individuals who are 40 to 65 years of age, female, and have had a previous episode of adhesive capsulitis in the contralateral arm. (Recommendation based on moderate evidence.) CLINICAL COURSE:  Clinicians should recognize that adhesive capsulitis occurs as a continuum of pathology characterized  by a staged progression of pain and mobility deficits and that, at 12 to 18 months, mild to moderate mobility deficits and pain may persist, though many patients report minimal to no disability. (Recommendation based on weak evidence.) DIAGNOSIS/CLASSIFICATION:  Clinicians should recognize that patients with adhesive capsulitis present with a gradual and progressive onset of pain and loss of active and passive shoulder motion in both elevation and rotation. Utilizing the evaluation and intervention components described in these guidelines will assist clinicians in medical screening, differential evaluation of common shoulder musculoskeletal disorders, diagnosing tissue irritability levels, and planning intervention strategies for patients with shoulder pain and mobility deficits. (Recommendation based on expert opinion.) DIFFERENTIAL DIAGNOSIS:  Clinicians should consider diag-nostic classifications other than adhesive capsulitis when the patient’s reported activity limitations or impairments of body function and structure are not consistent with the diagnosis/classification section of these guidelines, or when the patient’s symptoms are not resolving with interventions aimed at normalization of the patient’s impairments of body function. (Recommendation based on expert opinion.) EXAMINATION – OUTCOME MEASURES:  Clinicians should use  validated functional outcome measures, such as the Disabili-ties of the Arm, Shoulder and Hand (DASH), the American Shoulder and Elbow Surgeons shoulder scale (ASES), or the Shoulder Pain and Disability Index (SPADI). These should be utilized before and after interventions intended to alleviate the impairments of body function and structure, activity limitations, and participation restrictions associated  with adhesive capsulitis. (Recommendation based on strong evidence.) EXAMINATION – ACTIVITY LIMITATION MEASURES:  Clinicians should utilize easily reproducible activity limitation and participation restriction measures associated with their patient’s shoulder pain to assess the changes in the patient’s level of shoulder function over the episode of care. (Recom-mendation based on expert opinion.) EXAMINATION – PHYSICAL IMPAIRMENT MEASURES:  Clini-cians should measure pain, active shoulder range of motion (ROM), and passive shoulder ROM to assess the key impair-ments of body function and body structures in patients with adhesive capsulitis. Glenohumeral joint accessory motion may be assessed to determine translational glide loss. (Rec-ommendation based on theoretical/foundational evidence.) INTERVENTION – CORTICOSTEROID INJECTIONS:  Intra-articular corticosteroid injections combined with shoulder mobil-ity and stretching exercises are more effective in providing short-term (4-6 weeks) pain relief and improved function compared to shoulder mobility and stretching exercises alone. (Recommendation based on strong evidence.) INTERVENTION – PATIENT EDUCATION:  Clinicians should utilize patient education that (1) describes the natural course of the disease, (2) promotes activity modification to encourage functional, pain-free ROM, and (3) matches the intensity of stretching to the patient’s current level of irritability. (Rec-ommendation based on moderate evidence.) INTERVENTION – MODALITIES:  Clinicians may utilize short- wave diathermy, ultrasound, or electrical stimulation combined with mobility and stretching exercises to reduce pain and improve shoulder ROM in patients with adhesive capsulitis. (Recommendation based on weak evidence.) INTERVENTION – JOINT MOBILIZATION:  Clinicians may utilize  joint mobilization procedures primarily directed to the glenohumeral joint to reduce pain and increase motion and function in patients with adhesive capsulitis. (Recommenda-tion based on weak evidence.) Recommendations    J  o  u  r  n  a   l  o   f   O  r   t   h  o  p  a  e   d   i  c   &   S  p  o  r   t  s   P   h  y  s   i  c  a   l   T   h  e  r  a  p  y   ®    D  o  w  n   l  o  a   d  e   d   f  r  o  m  w  w  w .   j  o  s  p   t .  o  r  g  a   t  o  n   M  a  y   7 ,   2   0   1   4 .   F  o  r  p  e  r  s  o  n  a   l  u  s  e  o  n   l  y .   N  o  o   t   h  e  r  u  s  e  s  w   i   t   h  o  u   t  p  e  r  m   i  s  s   i  o  n .    C  o  p  y  r   i  g   h   t   ©   2   0   1   3   J  o  u  r  n  a   l  o   f   O  r   t   h  o  p  a  e   d   i  c   &   S  p  o  r   t  s   P   h  y  s   i  c  a   l   T   h  e  r  a  p  y   ® .   A   l   l  r   i  g   h   t  s  r  e  s  e  r  v  e   d .   Adhesive Capsulitis: Clinical Practice Guidelines journal of orthopaedic &  sports physical therapy | volume 43 | number 5 | may 2013 |  a3 INTERVENTION – TRANSLATIONAL MANIPULATION:  Clinicians may utilize translational manipulation under anesthesia directed to the glenohumeral joint in patients with adhesive capsulitis who are not responding to conservative interven-tions. (Recommendation based on weak evidence.) INTERVENTION – STRETCHING EXERCISES:  Clinicians should instruct patients with adhesive capsulitis in stretching exer-cises. The intensity of the exercises should be determined by the patient’s tissue irritability level. (Recommendation based on moderate evidence.) Recommendations (continued) AIM OF THE GUIDELINES The Orthopaedic Section of the American Physical Ther-apy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physi-cal therapy management of patients with musculoskeletal impairments described in the World Health Organization’s International Classification of Functioning, Disability and Health (ICF). 137  The purposes of these clinical guidelines are to:ã Describe evidence-based physical therapy practice, includ-ing diagnosis, prognosis, intervention, and assessment of outcome, for musculoskeletal disorders commonly man-aged by orthopaedic physical therapistsã Classify and define common musculoskeletal conditions us-ing the World Health Organization’s terminology related to impairments of body function and body structure, activity limitations, and participation restrictionsã Identify interventions supported by current best evidence to address impairments of body function and structure, ac-tivity limitations, and participation restrictions associated  with common musculoskeletal conditionsã Identify appropriate outcome measures to assess changes resulting from physical therapy interventions in body func-tion and structure as well as in activity and participation of the individualã Provide a description to policy makers, using internation-ally accepted terminology, of the practice of orthopaedic physical therapistsã Provide information for payers and claims reviewers re-garding the practice of orthopaedic physical therapy for common musculoskeletal conditionsã Create a reference publication for orthopaedic physical therapy clinicians, academic instructors, clinical instruc-tors, students, interns, residents, and fellows regarding the  best current practice of orthopaedic physical therapy  STATEMENT OF INTENT These guidelines are not intended to be construed or to serve as a standard of medical care. Standards of care are deter-mined on the basis of all clinical data available for an individ-ual patient and are subject to change as scientific knowledge and technology advance and patterns of care evolve. These parameters of practice should be considered guidelines only.  Adherence to them will not ensure a successful outcome in every patient, nor should they be construed as including all proper methods of care or excluding other acceptable meth-ods of care aimed at the same results. The ultimate judgment regarding a particular clinical procedure or treatment plan must be made in light of the clinical data presented by the patient and the diagnostic and treatment options available. However, we suggest that significant departures from accept-ed guidelines should be documented in the patient’s medical records at the time the relevant clinical decision is made. Introduction    J  o  u  r  n  a   l  o   f   O  r   t   h  o  p  a  e   d   i  c   &   S  p  o  r   t  s   P   h  y  s   i  c  a   l   T   h  e  r  a  p  y   ®    D  o  w  n   l  o  a   d  e   d   f  r  o  m  w  w  w .   j  o  s  p   t .  o  r  g  a   t  o  n   M  a  y   7 ,   2   0   1   4 .   F  o  r  p  e  r  s  o  n  a   l  u  s  e  o  n   l  y .   N  o  o   t   h  e  r  u  s  e  s  w   i   t   h  o  u   t  p  e  r  m   i  s  s   i  o  n .    C  o  p  y  r   i  g   h   t   ©   2   0   1   3   J  o  u  r  n  a   l  o   f   O  r   t   h  o  p  a  e   d   i  c   &   S  p  o  r   t  s   P   h  y  s   i  c  a   l   T   h  e  r  a  p  y   ® .   A   l   l  r   i  g   h   t  s  r  e  s  e  r  v  e   d .   Adhesive Capsulitis: Clinical Practice Guidelines  a4   |  may 2013 | volume 43 | number 5 | journal of orthopaedic &  sports physical therapy  Content experts were appointed by the Orthopaedic Section,  APTA as developers and authors of clinical practice guidelines for musculoskeletal conditions of the shoulder that are com-monly treated by physical therapists. These content experts  were given the task of identifying impairments of body function and structure, activity limitations, and participation restric-tions, described using ICF terminology, that could (1) catego-rize patients into mutually exclusive impairment patterns upon  which to base intervention strategies, and (2) serve as measures of changes in function over the course of an episode of care. The second task given to the content experts was to describe inter- ventions and supporting evidence for specific subsets of pa-tients based on the previously chosen patient categories. It was also acknowledged by the Orthopaedic Section, APTA content experts that only performing a systematic search and review of the evidence related to diagnostic categories based on Interna-tional Statistical Classification of Diseases and Related Health Problems (ICD) 136  terminology would not be sufficient for these ICF-based clinical practice guidelines, as most of the evidence associated with changes in levels of impairment or function in homogeneous populations is not readily searchable using the ICD terminology. Thus, the authors of these guidelines independently performed a systematic search of MEDLINE, CINAHL, and the Cochrane Database of Systematic Reviews (1966 through September 2011) for any relevant articles related to classification, examination, and intervention for musculo-skeletal conditions related to classification, outcome measures, and intervention strategies for shoulder adhesive capsulitis and frozen shoulder. Additionally, when relevant articles were identified, their reference lists were hand searched in an at-tempt to identify other relevant articles. These guidelines were issued in 2013, based on publications in the scientific literature prior to September 2011. These guidelines will be considered for review in 2017, or sooner if new evidence becomes avail-able. Any updates to these guidelines in the interim period will  be noted on the Orthopaedic Section of the APTA website: LEVELS OF EVIDENCE Individual clinical research articles were graded according to criteria described by the Centre for Evidence-Based Medicine, Oxford, UK ( for diagnostic, prospec-tive, and therapeutic studies. 100  An abbreviated version of the grading system is provided as follows. I Evidence obtained from high-quality diagnostic studies, prospective studies, or randomized controlled trials II Evidence obtained from lesser-quality diagnostic studies, prospective studies, or randomized controlled trials (eg, weaker diagnostic criteria and reference standards, im-proper randomization, no blinding, less than 80% follow-up) III Case-controlled studies or retrospective studies IV  Case series  V  Expert opinion GRADES OF EVIDENCE The overall strength of the evidence supporting recommenda-tions made in these guidelines was graded according to guide-lines described by Guyatt et al, 48  as modified by MacDermid et al 73  and adopted by the coordinator and reviewers of this project. In this modified system, the typical A, B, C, and D grades of evidence have been modified to include the role of consensus expert opinion and basic science research to dem-onstrate biological or biomechanical plausibility. GRADES OF RECOMMENDATION BASED ONSTRENGTH OF EVIDENCE  A  Strong evidenceA preponderance of level I and/or level II studies support the recommen-dation. This must include at least 1 level I study B Moderate evidenceA single high-quality randomized con-trolled trial or a preponderance of level II studies support the recommendation C Weak evidenceA single level II study or a preponder-ance of level III and IV studies, including statements of consensus by content experts, support the recommendation D Conflicting evidenceHigher-quality studies conducted on this topic disagree with respect to their conclusions. The recommendation is based on these conflicting studies E Theoretical/ foundational evidenceA preponderance of evidence from animal or cadaver studies, from conceptual models/principles, or from basic science/bench research supports this conclusion F Expert opinionBest practice based on the clinical experience of the guidelines development team Methods    J  o  u  r  n  a   l  o   f   O  r   t   h  o  p  a  e   d   i  c   &   S  p  o  r   t  s   P   h  y  s   i  c  a   l   T   h  e  r  a  p  y   ®    D  o  w  n   l  o  a   d  e   d   f  r  o  m  w  w  w .   j  o  s  p   t .  o  r  g  a   t  o  n   M  a  y   7 ,   2   0   1   4 .   F  o  r  p  e  r  s  o  n  a   l  u  s  e  o  n   l  y .   N  o  o   t   h  e  r  u  s  e  s  w   i   t   h  o  u   t  p  e  r  m   i  s  s   i  o  n .    C  o  p  y  r   i  g   h   t   ©   2   0   1   3   J  o  u  r  n  a   l  o   f   O  r   t   h  o  p  a  e   d   i  c   &   S  p  o  r   t  s   P   h  y  s   i  c  a   l   T   h  e  r  a  p  y   ® .   A   l   l  r   i  g   h   t  s  r  e  s  e  r  v  e   d .
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