|
||||||
|
|
|
|
|||||||||||
|
|||||||||||||
| ||||||||||||||||||||||||||||||||||||
It started as a little achiness in her shoulder. But after several months of "just dealing with it," Eileen Foley found even ordinary tasks, such as washing her hair or fastening her brassiere, were painful and nearly impossible. And she couldn't get a good night's sleep. That's when Foley finally mentioned the problem to her primary care physician.
"I figured it was arthritis or just some other sign of age," says the 60-year-old northeastern Pennsylvania resident. But after an examination and some tests, her doctor suggested a more likely culprit behind her "frozen shoulder"—her type 2 diabetes.
"I had no idea there could be a connection," says Foley.
That's no surprise to Mary Jane Myslinski, PT, EdD, a New Jersey-based physical therapist who works with many patients with diabetes who have developed "frozen shoulder," or adhesive capsulitis.
"The patients I see usually have no clue their problem could be related to their diabetes," says Myslinski, an associate professor in the physical therapy doctoral program at University of Medicine and Dentistry of New Jersey in Newark. "But this condition is not uncommon in these patients."
In fact, while adhesive capsulitis affects about 5% of the general population, it affects nearly 20% of people with diabetes. What actually causes the disorder is unclear. But patients with type 1 and type 2 diabetes are at higher than average risk for developing it. Age and duration of the disease can push that risk even higher.1
"Educating patients with diabetes about the possibility of adhesive capsulitis is a good idea so they can be on the lookout for it and bring shoulder problems to their doctor's attention immediately," advises Myslinski. "Catching and treating it early always offer the best outcomes."
WHAT IS ADHESIVE CAPSULITIS?
Adhesive capsulitis is a condition characterized by pain, stiffness, and limited mobility in the shoulder joint. Typically, only one shoulder is affected. The condition tends to slowly develop and resolve over three stages, with each lasting up to several months.
First, patients experience pain with shoulder movement, generally as a result of aggressive synovitis. What insult kicks off that inflammatory response is almost always a mystery, although sometimes an injury or previous surgery can be a precursor. And it's been associated with diabetes as well as other chronic health conditions.1
After time—during which patients tend to favor the sore shoulder by limiting movement—a "freezing" stage begins. While pain may diminish somewhat, the shoulder stiffens and the ability to move it becomes a noticeable problem as adhesions build up inside the shoulder capsule and synovial fluid decreases.
"The stiffness is probably some sort of fibroblastic response to the inflammation that occurs," explains Steven Petersen, MD, co-director of the division of shoulder surgery in the department of orthopedic surgery at Johns Hopkins Hospital in Baltimore. "In other words, the healing process goes awry, and scar-forming cells become extraordinarily active, producing an unusual amount of scar tissue that involves the entire shoulder joint."
Patients with diabetes tend to have a particularly severe reaction, says Petersen. And they generally do not respond well to conventional treatments, according to the medical literature.
During the third and final "thawing stage," the condition improves. And although this can occur instantaneously, patients with diabetes rarely experience significant improvement without aggressive treatment, says Petersen.
RULING OUT OTHER CAUSES
"A lot of times, the term `frozen shoulder' is misused by physicians," says Richard Friedman, MD, clinical professor of orthopedic surgery at Medical University of South Carolina in Charleston. "You have to rule out an underlying injury or other reason that could be causing this type of shoulder pain to make a proper adhesive capsulitis diagnosis."
These conditions include rotator cuff injuries or other shoulder abnormalities, arthritis, and lung or neck problems that refer pain to the shoulder. The universal hallmark of adhesive capsulitis is limited active and passive motion.
"I often have patients referred to me with an adhesive capsulitis diagnosis who have only limited active motion. That's more likely to be a rotator cuff problem," says Petersen. He recommends examining patients in a supine position while distracting them to adequately assess passive shoulder motion.
To confirm the diagnosis, experts suggest ordering multiplanar X-rays—including a Grashe AP view of the shoulder joint, an axillary view, and a lateral scapular view. "These can help rule out calcific tendonitis, avascular nechrosis of the humeral head, and, more typically, glenohumeral joint arthritis," notes Petersen.
WORKING TOWARD RELIEF
Experts agree that prompt physical therapy is a must for regaining mobility in all patients with adhesive capsulitis. But the road can be a long one, particularly for patients with diabetes.
"Some patients do well in a month with physical therapy and home stretching exercises, and others are still struggling to get better 3 to 5 months later," says Myslinski. Easing pain and inflammation is clearly a priority before patients can undergo the intense physical therapy typically needed to restore shoulder mobility. Painful sessions can lead to discouragement and noncompliance, she notes.
"Trying to return lost motion right from the beginning can be a no-win proposition," adds Petersen. "You have to treat the inflammatory stage first and try to maintain the current range of motion before you move ahead."
Although cortisone injections are often used to reduce inflammation, these can temporarily increase glucose levels. "It doesn't make steroid injection a contraindication in patients with diabetes, but it may require a temporary adjustment to their medication and close followup," says Scott Zashin, MD, assistant clinical professor of rheumatology at University of Texas Southwestern School of Medicine in Dallas.
Many patients regain significant shoulder mobility after several months of a conventional course of anti-inflammation treatment and physical therapy, but the results can be disappointing for patients with diabetes.
"If physical therapy doesn't offer improvement over 4 to 8 weeks—and that's often the case with patients who have diabetes—it's time to refer to an orthopedic shoulder specialist," says Petersen.
A RACE AGAINST TIME
Shoulder arthroscopy is the surgical treatment preferred to treat adhesive capsulitis in patients with diabetes. This outpatient procedure involves making a few small incisions around the shoulder, excising scar tissue, releasing ligaments, and performing a manipulation of the shoulder to "release" the area. This can often be done with a regional anesthetic and sedation, contributing to a quick recovery from the procedure.
Following surgery, an aggressive physical therapy and pain relief program is typically started, often on the same day, to prevent fibroblasts from reaccumulating scar tissue in the opened space.
"It's a race against time," says Petersen. "This treatment is not universally successful, but in my experience if patients can comply with the physical therapy and therapy is started on the same day, the success rate is satisfying."
In fact, some clinicians now advocate discussing surgery with patients as a first-line approach.
"It's more aggressive but, especially for patients with diabetes who
generally don't respond well to conventional treatment, this approach can
relieve pain and get that motion back much more quickly," notes
Friedman. "In today's fast-paced world, that's an attractive alternative
for a lot of patients."
|
Teach Patients to Treat With RICE
If a patient discloses a shoulder injury, offer the following advice:
HOW TO TREAT ADHESIVE CAPSULITIS
Treatment focuses on restoring joint movement and reducing shoulder pain. Usually, treatment begins with nonsteroidal anti-inflammatory drugs and the application of heat, followed by gentle stretching exercises. Stretching exercises can be performed in the home with the help of a physical therapist and are the treatment of choice.
In some cases, transcutaneous electrical nerve stimulation (TENS) with a small battery-operated unit may be used to reduce pain by blocking nerve impulses. If these measures are unsuccessful, an intra-articular steroid injection into the glenoid humeral joint can result in marked improvement of adhesive capsulitis in a large percentage of cases. In rare cases where patients do not improve from nonoperative measures, manipulation of the shoulder under general anesthesia and arthroscopic procedure to cut remaining adhesions is usually highly effective.
Source: National Institute of Arthritis and Musculoskeletal and Skin Diseases: Questions & Answers About Shoulder Problems, NIH pub no. 06-4865. Available online at www.niams.nih.gov/hi/topics/shoulderprobs/shoulderqa.htm#infor_2. Accessed April 5, 2007.
Footnotes
For a patient education brochure published by the American Academy of Orthopaedic Surgeons, visit www.orthoinfo.aaos.org/fact/thr_report.cfm?Thread_ID=162&topcategory.
Questions & Answers About Shoulder Problems is available from the Department of Health and Human Services' National Institute of Arthritis and Musculoskeletal and Skin Diseases. Download the booklet as a PDF file at www.niams.nih.gov/hi/topics/shoulderprobs/shoulderqa.pdf.
References
CiteULike 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
| ||||||||||||||||||||||||||||||||||||
|
||||||
|
| DOC News | Diabetes | Diabetes Care | Clinical Diabetes | Diabetes Spectrum |
