Clinical identifiers for early stage primary/idiopathic adhesive capsulitis

Research Doctorate - Doctor of Philosophy (PhD)Adhesive capsulitis is a shoulder disorder commonly encountered in musculoskeletal practice. It is recognised as consisting of three stages, and is characterized initially by pain followed by a gradual loss of active and passive ranges of movement. In its early stage, confusion with other shoulder disorders with the potential to cause pain and limited range of movement is common and may result in inappropriate or untimely treatment. Musculoskeletal medicine relies on clinical findings together with medical imaging to inform the diagnosis of many disorders. These findings may be useful in contributing to a diagnosis as well excluding other potential diagnoses. The overall aim of this thesis was to identify and investigate the clinical identifiers or diagnostic criteria that may facilitate recognition of the early stage of adhesive capsulitis. Four research studies and one literature review were undertaken to meet this aim. A correspondence-based Delphi study was initially undertaken to investigate whether consensus could be achieved among a group of experts on the diagnostic criteria/clinical identifiers that are associated with the early stage of adhesive capsulitis. This study established eight identifiers that clustered into two discrete domains of pain and movement. Secondly, a review of the diagnostic imaging literature was undertaken to determine the current and future contribution that this modality may make to the clinical diagnosis of adhesive capsulitis. As Doppler ultrasonography was identified as having potential to contribute to the early diagnosis of adhesive capsulitis, it was explored in a second study. This study demonstrated that it may be possible to visualise an area of increased vascularity in the rotator interval area of the shoulder in patients clinically diagnosed with early stage adhesive capsulitis. A third study aimed to evaluate patients diagnosed with early stage adhesive capsulitis to determine the existence of any pattern of movement loss and associated pain that may facilitate early recognition. The limiting factor to movement was also analysed. Although pain is reportedly a characteristic in the early stage, the results of this study suggested it may be less useful than percentage loss of active range of movement in identifying patients with primary/idiopathic adhesive capsulitis. Interestingly overall, external rotation in abduction emerged as the most painful active and passive movement and the movement most frequently limited by pain rather than resistance, which may provide valuable information to both the clinician and researcher. The aim of final study was to validate the clinical identifiers established in the earlier Delphi study. This study, unexpectedly suggested the identifiers from the earlier study may not be true predictors of early stage adhesive capsulitis. The study findings presented in this thesis provide a number of features that may facilitate identification of early stage adhesive capsulitis, as well as enable future researchers to determine more homogeneous samples. Importantly, the overall results of the studies challenge the commonly recognised clinical identifiers or diagnostic criteria for adhesive capsulitis and suggest they may not be able to adequately diagnose this disorder in its early stage. The findings also highlight the difficulty of rigorously investigating this stage of the disorder. Future directions for research and implications for clinical practice are discussed in relation to the findings of the studies in this thesis