Sarah Walmsley

Adhesive Capsulitis: Establishing Consensus on Clinical Identifiers for Stage 1 Using the Delphi Technique

Background: Adhesive capsulitis often is difficult to diagnose in its early stage and to differentiate from other commonly seen shoulder disorders with the potential to cause pain and limited range of movement. Objectives: The purpose of this study was to establish consensus among a group of experts regarding the clinical identifiers for the first or early stage of primary (idiopathic) adhesive capsulitis. Design: A correspondence-based Delphi technique was used in this study. Methods: Three sequential questionnaires, each building on the results of the previous round, were used to establish consensus. Results: A total of 70 experts from Australia and New Zealand involved in the diagnosis and treatment of adhesive capsulitis completed the 3 rounds of questionnaires. Following round 3, descriptive statistics were used to screen the data into a meaningful subset. Cronbach alpha and factor analysis then were used to determine agreement among the experts. Consensus was achieved on 8 clinical identifiers. These identifiers clustered into 2 discrete domains of pain and movement. For pain, the clinical identifiers were a strong component of night pain, pain with rapid or unguarded movement, discomfort lying on the affected shoulder, and pain easily aggravated by movement. For movement, the clinical identifiers included a global loss of active and passive range of movement, with pain at the end-range in all directions. Onset of the disorder was at greater than 35 years of age. Conclusions: This is the first study to use the Delphi technique to establish clinical identifiers indicative of the early stage of primary (idiopathic) adhesive capsulitis. Although limited in differential diagnostic ability, these identifiers may assist the clinician in recognizing early-stage adhesive capsulitis and may inform management, as well as facilitate future research.

Power Doppler Ultrasonography in the Early Diagnosis of Primary/Idiopathic Adhesive Capsulitis: An Exploratory Study

OBJECTIVE The purpose of this exploratory study was to determine if increased vascularity in the rotator interval area of the glenohumeral joint capsule could be visualized with power Doppler ultrasonography (PDUS) in patients with a clinical diagnosis of early-stage adhesive capsulitis. METHODS Demographic and clinical characteristics from a consecutive series of 41 patients diagnosed with early-stage adhesive capsulitis were recorded and examination with PDUS was undertaken. Images were reviewed by 3 musculoskeletal radiologists, and consensus was determined on the presence of increased signal in the rotator interval area. RESULTS Consensus was achieved on the presence of increased signal in 12 (29%) of the 41 cases. Participants with an increased PDUS signal did not demonstrate a characteristic set of identifying features, suggesting that those with increased vascularity may not constitute a distinct subgroup. CONCLUSION This study found that some patients diagnosed with early-stage adhesive capsulitis demonstrated increased vascularity in the rotator interval area when examined with PDUS. These findings suggest that PDUS may have the potential to assist in the identification of increased vascularization in early stages of this disorder. Further research in the use of PDUS in diagnosing early-stage adhesive capsulitis is warranted.

Movement and pain patterns in early stage primary/idiopathic adhesive capsulitis: a factor analysis

OBJECTIVES To evaluate patients clinically diagnosed with early stage primary/idiopathic adhesive capsulitis to determine the existence of any pattern of movement loss and associated pain that may facilitate early recognition. DESIGN Cross-sectional study. SETTING Private upper limb specialty clinic, Newcastle, Australia. PARTICIPANTS Fifty-two patients clinically diagnosed with early stage adhesive capsulitis by a medical practitioner or physiotherapist. MAIN OUTCOME MEASURES Percentage loss of active and passive ranges of eight shoulder movements and the pain level at the end of each movement. The reason for limitation of movement was also recorded. RESULTS Factor analysis clearly identified two groups for percentage loss of active range of movement. Notably external rotation movements grouped separately from other movements. A single group emerged for percentage loss of passive range of movement suggesting a non-specific global loss. For both pain at the end of active range of movement and passive range of movement two groups emerged, however the delineation between the groups was less clear than for percentage loss of active range of movement suggesting a pattern of end range pain may be less useful in identifying patients in this stage. CONCLUSIONS External rotation movements in neutral and abduction generally group together and behave differently to other shoulder movements in patients clinically diagnosed with early stage primary/idiopathic adhesive capsulitis. In particular external rotation in abduction has emerged as the most painfully limited movement in this sample. This study provides preliminary evidence of patterns of range of movement and end range pain that require testing in a population of mixed shoulder diagnoses to determine their diagnostic utility for early stage adhesive capsulitis.

Clinical Identifiers for Early-Stage Primary/Idiopathic Adhesive Capsulitis: Are We Seeing the Real Picture?

Background Adhesive capsulitis is often difficult to diagnose in its early stage and to differentiate from other common shoulder disorders. Objective The aim of this study was to validate any or all of the 8 clinical identifiers of early-stage primary/idiopathic adhesive capsulitis established in an earlier Delphi study. Design This was a cross-sectional study. Methods Sixty-four patients diagnosed with early-stage adhesive capsulitis by a physical therapist or medical practitioner were included in the study. Eight active and 8 passive shoulder movements and visual analog scale pain scores for each movement were recorded prior to and immediately following an intra-articular injection of corticosteroid and local anesthetic. Using the local anesthetic as the reference standard, pain relief of ≥70% for passive external rotation was deemed a positive anesthetic response (PAR). Results Sixteen participants (25%) demonstrated a PAR. Univariate logistic regression identified that of the proposed identifiers, global loss of passive range of movement (odds ratio [OR]=0.26, P=.03), pain at the end of range of all measured active movements (OR=0.06, P=.02), and global loss of passive glenohumeral movements (OR=0.23, P=.02) were associated with a PAR. Following stepwise removal of the variables, pain at the end of range of all measured active movements remained the only identifier but was associated with reduced odds of a PAR. Limitations The lack of a recognized reference standard for diagnosing early-stage adhesive capsulitis remains problematic in all related research. Conclusions None of the clinical identifiers for early-stage adhesive capsulitis previously proposed by expert consensus have been validated in this study. Clinicians should be aware that commonly used clinical identifiers may not be applicable to this stage.

Early diagnosis of primary/idiopathic adhesive capsulitis: Can imaging contribute?

Abstract Adhesive capsulitis is a frequently presenting shoulder disorder in musculoskeletal medicine. It is recognized as consisting of three stages, and is often difficult to diagnose in its early stage and differentiate from other shoulder disorders. Treatment of this disorder has been proposed to be dependant on the stage, with early treatment suggested to decrease the overall morbidity. Arguably therefore, recognition in this early stage is desirable. The purpose of this paper is to review the current evidence that may support the role of imaging facilitating a diagnosis of adhesive capsulitis and to discuss this in relation to the contemporary understanding of the pathology of this disorder. The emerging role of Doppler ultrasound in the diagnosis and management of inflammatory arthropathies is discussed, and in particular its potential to contribute to the early diagnosis of adhesive capsulitis. While the diagnosis of adhesive capsulitis is presently largely based on clinical examination, this review outlines the current and future role that radiology may be able to contribute to the clinical presentation.