Thesis Reviews

Adhesive capsulitis, or frozen shoulder, is a clinical condition often encountered by physical therapists. However, the condition remains a clinical enigma and much controversy exists with regard to the most efficient and cost-effective management strategies. While it is reported that adhesive capsulitis is a self-limiting condition, the process of recovery can take up to 2-3 years resulting in prolonged periods of pain, restricted range of motion, and functional limitations. Considering this and the current shift towards evidence-based practice, it is essential to identify accurate diagnostic procedures as well as effective management strategies for adhesive capsulitis that can decrease the pain and disability associated with this condition. In his dissertation work Dr. Eric Vermeulen has set forth to further elucidate various characteristics of adhesive capsulitis (and other shoulder disorders) with an emphasis on the clinical evaluation and on identifying the effectiveness of a commonly used physical therapy treatment approach, end-range joint mobilization. This thesis consists of 10 chapters, each of which investigates a distinct and separate aspect of adhesive capsulitis, evaluation of shoulder pathologies, and the psychometric properties of outcome measures. The first chapter is an introduction to the project and provides an historical overview of the diagnosis of adhesive capsulitis including the prevalence, proposed theories on the etiology, the clinical presentation, differential diagnosis, and proposed management strategies. The introduction makes a strong case for the need for further research in the area of the clinical evaluation and physical therapy treatment of frozen shoulder. The thesis is divided into 2 parts, the first of which consist of 3 chapters investigating the use of end-range mobilizations as a treatment option for adhesive capsulitis, while the second part consists of 6 chapters describing the clinical evaluation of patients with adhesive capsulitis as well as outcome measures used to capture data on functional limitations and disability. Chapter 2 describes the first study of this thesis project; it consisted of a multiple-subject case series. Seven patients with adhesive capsulitis were treated twice weekly for 3 months with end-range mobilization techniques. At the cessation of treatment all patients demonstrated an increase in range of motion, reduction in pain, and improvements in function. The patient ratings for improved shoulder function were excellent in 4 patients, good in 2, and moderate in 1. These improvements were also maintained at the time of a 9-month follow-up. While the results were encouraging, Dr. Vermeulen acknowledged the fact that a cause-and-effect relationship could not be inferred from such a study and discussed the need for further controlled studies. Further details on this multiple-subject case report can be found in Physical Therapy1. In Chapter 3, the author examined the use of both high-grade (HGMT) and low-grade manual mobilization techniques (LGMT) in a randomized clinical trial (RCT). One hundred patients with unilateral adhesive capsulitis of greater than 3 months’ duration were randomly assigned to receive either HGMT or LGMT for a total of 24 sessions. Patients were not eligible for participation if they had previously had manipulation under anesthesia, or had been diagnosed with rheumatoid or osteoarthritis, glenohumeral cartilage damage, a Hill-Sachs lesion, osteoporosis, neurological deficits, or pain disorders of the cervical spine, elbow, or wrists. Both groups demonstrated significant improvements for all outcome measures at 3 and 12 months, including range of motion, patient perceived improvement, pain, and improvement on the shoulder disability questionnaire (SDQ), the shoulder rating questionnaire (SRQ), and the short form-36 (SF-36). The HGMT group had significantly greater improvement for passive abduction, active external rotation, passive external rotation, SRQ scores (38% change in the HGMT vs. 31.7% change in LGMT), and SDQ scores (HGMT score –50 vs. LGMT score –38.8) at 12 months. Further details regarding this study can also be found in Physical Therapy2. In Chapter 4 Dr. Vermeulen performed an economic analysis of the previous study through the use of the Quality Adjusted Life Years Scale (QALY). The results of the economic analysis were reported in the Australian Journal of Physiotherapy3 and suggested that both mobilization treatments had similar costs and