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 Table of Contents  
Year : 2022  |  Volume : 1  |  Issue : 2  |  Page : 79-87

Evidence-based physiotherapy for adhesive capsulitis—Current evidences, challenges, and future directions: Systematic review

Department of Musculoskeletal Sciences, Krishna College of Physiotherapy, KIMSDU, Karad, Maharashtra, India

Date of Submission28-Sep-2022
Date of Acceptance20-Jun-2023
Date of Web Publication26-Sep-2023

Correspondence Address:
Dr. Sandeep B Shinde
Department of Musculoskeletal Sciences, Krishna College of Physiotherapy, KIMSDU, Malkapur, Karad, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jahas.jahas_21_22

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Slow-onset shoulder pain, localized discomfort close to the deltoid insertion, an inability to sleep on the affected side, limited or restricted glenohumeral elevation and external rotation, and a normal radiological appearance are the primary symptoms of frozen shoulder. Although there is no known cause, variety of interventions have been used primarily due to the prolonged state of pain and disability. This systematic review evaluates and addresses the evidence-based physiotherapy management and challenges respectively for early and complete recovery of adhesive capsulitis patients. Six databases were searched for this systematic review and all were randomized control trials. Each study’s risk of bias was assessed using the Cochrane Collaboration Risk of Bias Tool. This systematic review was based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and Patient, Intervention, Comparison, and Outcomes design. Studies from 2000 to 2022 were considered for this systematic review. A total of 568 participants from 14 studies were included in the systematic review. Utilizing outcome measures such as visual analog scale, shoulder pain and disability index, SF-36, shoulder kinematics, and shoulder function questionnaire, the effectiveness of physiotherapy management was evaluated in these 14 research studies. The most frequent results included improvements in shoulder function, pain relief, and range of motion. According to the research cited in the current systematic review, patients with adhesive capsulitis respond very favorably to a combination of mobilization, proprioceptive neuromuscular technique, task-specific training, and modalities.

Keywords: Comorbidities, Frozen shoulder, Mobilization, PNF, Range of motion (ROM)

How to cite this article:
Shinde SB, Dhane SB, Jain PP, Mishra SD, Kumbhar VK, Thorat KA, Saptale AA. Evidence-based physiotherapy for adhesive capsulitis—Current evidences, challenges, and future directions: Systematic review. J Ayurveda Homeopath Allied Health Sci 2022;1:79-87

How to cite this URL:
Shinde SB, Dhane SB, Jain PP, Mishra SD, Kumbhar VK, Thorat KA, Saptale AA. Evidence-based physiotherapy for adhesive capsulitis—Current evidences, challenges, and future directions: Systematic review. J Ayurveda Homeopath Allied Health Sci [serial online] 2022 [cited 2023 Dec 10];1:79-87. Available from: http://www.dpujahas.org/text.asp?2022/1/2/79/386300

  Introduction Top

Frozen shoulder or adhesive capsulitis is described as a painful or stiff shoulder. The American Academy of orthopedic surgeons defines this condition as a condition of varying severity characterized by a gradual development of global limitation of active and passive shoulder motion where radiographic findings other than osteopenia are absent. Frozen shoulder involves the process of inflammation and fibrosis. A synovial hyperplasia with increased vascularity is present during an early period, which leads to fibrosis in the subsynovium and synovium capsule of tissues. Initiation of immune response proceeds inflammatory synovitis and capsular fibrosis.[1]

Jain and Sharma described four stages of frozen shoulder: stage 1, the preadhesive stage where the patient presents with mild or no end range limitation and pain, which may last between 0 and 3 months; stage 2, the acute adhesive or freezing stage where the patients have a high level of discomfort, limited passive and active range of motion (ROM), and increased pain near end ROM, which may last between 3 and 9 months; and stage 4 is the thawing stage, which is present with no pain compared with stage 3, which is the fibrotic or frozen stage and lasts between 9 and 15 months.[2] Slow-onset shoulder pain, localized discomfort close to the deltoid insertion, an inability to sleep on the affected side, limited or restricted glenohumeral elevation and external rotation, and a normal radiological appearance are the primary symptoms of frozen shoulder.[3] The scapulohumeral rhythm is disturbed, which impairs the function of the upper limbs and causes the rhythm to reverse.[4]

Patients who met the criteria for frozen shoulder based on pain and motion were split into two groups, primary and secondary frozen shoulder, according to a study by Lundberg.[5] Patients with primary frozen shoulder have no significant findings on history, clinical examination, or radiography, whereas patients with secondary frozen shoulder described events that occurred after the onset of frozen shoulder symptoms, such as trauma, immobilization, and metabolic or endocrine disorders.[5] Literature shows that the presence of comorbidities had a significant impact on clinical presentation and outcome intervention in patients.[6]

Idiopathic frozen shoulder is considered benign, but the prolonged period of pain and disability has been the main reason for the variety of interventions.[7] Conventionally, heat modalities, cryotherapy, and analgesic modalities such as interferential therapy, transcutaneous electrical nerve stimulation, and exercises were used.[8],[9] Later on treatments such as mobilization and manipulation techniques were advocated. Recent studies have shown that when exercises are modified to include games that are interactive and entertaining patients pay attention toward the games and ignore the tedious painful training.[10] Clinicians must achieve a balance between treating and not overtreating.


Despite being a relatively common condition, frozen shoulder is still a medical mystery that is challenging to understand and treat. However, from the perspective of a physiotherapist, some patients’ recovery is still not fully complete. The risk of unsuccessful treatment of a frozen shoulder increases with the number of comorbidities. The presence of these comorbid conditions significantly affects the clinical presentation and outcome of interventions, according to a large body of literature. These conditions include diabetes mellitus, thyroid disease, hypercholesteremia, cardiovascular diseases, and cancer.[11] Stroke, spinal cord injuries, and Parkinson’s disease predispose to frozen shoulder.[12] The patient’s psychological condition during the rehabilitation process is a crucial factor; depressed and anxious patients may feel more disabled and may be less able to adapt to and manage the condition.[13] Impaired adherence to prescribed therapy and response might also be responsible for an incomplete recovery. Thus, patient education is a milestone for physiotherapists that manage musculoskeletal conditions. Comorbid conditions should be successfully managed by drugs along with physiotherapy. Management decisions should be discussed with the patients and be based on comorbidities, severity, and natural history of the condition. This systematic review highlights the recent evidence-based practice and challenges.

  Materials and Methods Top

The current systematic review was carried out under the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The patient-centered, evidence-based physiotherapy approaches for adhesive capsulitis—current evidences, challenges, and future directions—were thoroughly reviewed by six reviewers.

Search methods

PUBMED, Google Scholar, MEDLINE, SCOPUS, the Physiotherapy Evidence Database, and Cochrane Library were used in the literature search. The search strategy and keywords were developed using the Patient, Intervention, Comparison, and Outcomes design. Adhesive capsulitis, physical therapy interventions, PNF, and frozen shoulder were a few of the keywords mentioned in the search strategy. In addition, we manually searched the library for literature and collected studies from the reference lists of articles as part of our literature search. For this systematic review, studies from 2000 to 2022 were taken into consideration.

Eligibility criteria

In this current systematic review, we included evidence-based treatment in patients diagnosed with adhesive capsulitis with complaints ranging from pain to decreased ROM. The articles included in this review article fulfilled all the mentioned inclusion criteria [Table 1].
Table 1: Eligibility criteria

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Study selection

Many databases were searched, and duplicates were removed. Studies were screened based on title and abstract and were excluded if they were not filling the eligibility criteria, interventions, outcome measures, and intrinsic factors. [Table 2] depicts the characteristics of our studies.
Table 2: Characteristics of included studies

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Data extraction

The reviewers were able to gather information about the study’s characteristics, including the author, study design, interventions for experimental and control groups, the type of physiotherapy intervention used, its characteristics, and treatment parameters. The reviewers also acquired information on the total number of participants, participants in each group, and participant characteristics (age, sex, and stage of adhesive capsulitis).

Quality assessment and data extraction

The Cochrane Collaboration Risk of Bias Tool (CCRBT) was used to assess the risk of bias in each study.[14] This tool evaluates the likelihood of bias in six different areas, including sequence generation, allocation concealment, blinding, insufficient outcome data, selective outcome reporting, and other possible validity threats. The CCRBT assessment involves choosing “yes,” “no,” or “unclear” for each domain, depending on whether there is a low, high, or uncertain risk of bias. Studies classified as low risk of bias have yes responses to the first three questions, moderate risk of bias for two domains with unclear or no responses, and high risk of bias for three domains with unclear or no responses.

  Results Top

Results for the literature search

A search was conducted in six databases from inception to September 2022 and identified 1029 articles. A total of 400 duplicate articles were removed and 629 studies remained for title and abstract screening. Ten additional studies were then identified through hand reference searching list and eventually 639 were further screened, from this 40 eligible studies for full-text assessment were identified and only 14 studies which fulfilled the criteria were included for this systematic review.

Study selection and study population

In this study, 14 studies were included in the systematic review. Included patients were termed as patients with frozen shoulder, frozen shoulder syndrome, adhesive capsulitis, and all stages of frozen shoulder patients.

Qualitative synthesis

All of the included studies were RCTs. A total of 568 participants were included in these studies. In the present systematic review, three studies evaluated the mobilization in combination with modalities and exercises.[20],[21],[24] Two studies evaluated movement with mobilization (MWM) with mid-range mobilization (MRM) and end range mobilization (ERM). Two studies evaluated the effect of proprioceptive neuromuscular technique (PNF) training on frozen shoulder.[17],[18] One study evaluated PNF with a combination of mobilization and exercises.[9],[16],[19] One study evaluated the combination of modalities (heating modalities) and exercises, one study evaluated the effect of only modality (ultrasound) on adhesive capsulitis and two studies evaluated mobilization with exercises.[1],[2],[10]

Risk of bias assessment

The results of the risk of bias are mentioned in [Table 3] of the 14 studies evaluated, 10 studies were rated as an overall risk of bias of “low risk,” and four studies were rated as having “moderate risk.”
Table 3: Risk of bias assessment of included studies

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The results of these risk-of-bias assessments are seen in [Figure 1].
Figure 1: Preferred reporting items for systematic review

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Physiotherapy management

Stretching, thermotherapy, physical modalities (interferential current, ultrasound), exercise (for instance, ROM and strengthening), proprioceptive neuromuscular facilitation (PNF), and passive mobilization are frequently used in the physical studies used in the reviewed studies. A home exercise program or various frequency and stretching exercises were used as part of the treatment, which was carried out daily, three times per week, or at various frequencies. The length of the treatment ranged from 2 to 3 months.

Scapular kinematics

In patients with frozen shoulder, the anterior-posterior technique along with the scapular superior/inferior and upward/downward mobilization techniques, scapular posterior tipping (>8.4) improved scapular motion, decreased shoulder dyskinesis, and affected improvement.[15],[16]

Shoulder kinematics

The fifth study examined the impact of internal and external rotations in studies on the variables influencing the function of shoulder kinematics.[12]

Interactive rehabilitation

Increased ROM (flexion, abduction, and internal and external rotations), decreased shoulder disability, and decreased pain were the outcomes of an interactive rehabilitation program (e.g., task-specific training). In addition, the treatment experimental group’s repeated shoulder interactions had more noticeable effects than the control group. These results might result from the added advantage of task-specific training.

Pain relief

Shoulder pain and disability index (SPADI) was used to assess shoulder pain, disability, and higher initial pain associated with worse activity before the treatment. The pain assessment conducted by visual analogue scale and CMS showed significant improvements in the pain and disability subscales and total SPADI scores in both groups.[8],[9],[17],[18],[19],[20],[21],[22],[23]


The PNF results demonstrated that mobilization combined with ultrasound was less effective than PNF stretching with movement pattern. Both groups demonstrated increased external and abduction ranges of motion.[18],[26] Compared with the muscle energy technique (MET), the PNF for the glenohumeral joint in frozen shoulder results showed a reduction in pain, restoration of ROM, and function.[17],[19],[25]


The study compared the high-grade and low-grade mobilization techniques for treating frozen shoulders, and it found that the high-grade mobilization produced greater active ROM of external rotation and passive ROM of abduction than the low-grade mobilization.[9] The mulligan technique increased ROM, pain, constant score and improved the scores of shoulders disabilitiy questionnaire.[20] The Cyriax technique significantly improves ROM (flexion, abduction, and internal and external rotations), and reduces pain[24] when combined with mobilization, stretching, and a home program. In comparison with anterior mobilization, which did not show a significant improvement, posterior mobilization significantly increased shoulder external rotation ROM.[24] Compared with PNF stretch techniques, the MET technique had a less significant impact.[15],[16],[25]

  Discussion Top

This systematic review’s goal was to pinpoint the evidence-based physiotherapy strategies, emerging data, obstacles, and potential future directions for patients with adhesive capsulitis.


Our findings show that using evidence-based physiotherapy treatments is beneficial to each of the categories. For patients with adhesive capsulitis, an effort was made to assess the evidence-based physiotherapy approaches, its current evidence, challenges, and various future directions with regard to pain, ROM, and disability. The majority of the studies we included in our review evaluated different shoulder mobilization methods intended to broaden the range of shoulder flexion, abduction, internal rotation, and external rotation. As a result, the studies that assessed each of these movements were included in the systematic review. In comparison with MRM, patients with frozen shoulder showed statistically significant and clinically relevant benefits from ERM and MWM.[15] Likewise, when compared with the standard of care, which included passive manual therapy, modalities such as ultrasound, short-wave therapy, flexion and abduction stretching techniques, and active exercises, specific ERM, scapular mobilization, and MRM, and high-grade mobilization technique (HGMT) showed statistically significant and clinical benefits.[9],[16] PNF exercises combined with joint mobilization, deep heating combined with stretching exercises, scapular PNF exercises combined with traditional exercises, stretching and strengthening exercises, and physiotherapy modalities such as hot moist pack, ultrasound, and transcutaneous electrical nerve stimulation (TENS) showed statistically significant improvement in pain intensity and increase in ROM in patients with frozen shoulder in addition to pain relief and ROM.[18],[22],[26]

Even it is seen that in these frozen shoulder patients, pain reduction was statistically significant with MWM even when passive joint mobilization techniques were given to the control group. As it is known that this MWM is applied always pain-free and with minimal force. This suggests that this MWM in relation to the stretching structures may be more associated with neurophysiological effects rather than the influence of mechanical effects on the extensibility of capsules and ligaments.[27] When compared with the MET, PNF demonstrated statistically significant and clinically relevant benefits in improving ROM of abduction, external rotation, and internal rotation.[25]

Following MWM, PNF exercises, and task-specific training in addition to the standard physiotherapy regimen of hot moist packs, ultrasound, Maitland mobilization, and conventional exercises, the degree of disability decreased more significantly.[19] This clinically relevant improvement in the intensity of pain and ROM may allow these frozen shoulder patients to exercise more enthusiastically and effectively during their period of rehabilitation and could result in drastic improvement in relation to disability. However, disagreement was seen in relation to disability. Our study also included a study comparing MWM with other interventions consisting of manual therapy and found statistically no effect in consideration of disability. Now, the results of the included studies can be explained by appropriate choices of outcomes. It is seen that this ROM, which is an outcome measure, is more valid for frozen shoulder patients with functional stiffness and is less valid where pain intensity with a disability is more important especially in subacromial pain syndrome patients.

Hence, considering all these studies, which were included in this review, it is also important to get sure that patient gets the treatment satisfaction. Each patient, according to the condition, may require different treatment options that are patient-centered, clinically relevant and reasoned, and satisfactory to gain the best results for these patients. This indicates that using the evidence-based treatment approaches for these adhesive capsulitis patients with personalized care can give clinically relevant treatment outcomes and patient satisfaction.

Future directions

When working with patients who have adhesive capsulitis, physiotherapists face some serious clinical difficulties. It is impossible to predict how an individual patient’s adhesive capsulitis will progress naturally based only on their medical history and physical examination. There is very little research on the prognostic factors for patients with adhesive capsulitis.[28] Immunological research seems to be crucial for getting better understanding of an individual variety in natural history of adhesive capsulitis.[29] However, despite the ubiquity of this condition and the advances in shoulder surgery over the last 14 decades, there are still many unknown results in deciding what the best treatment options are for this condition.[30]

Pain relief and effects on collagen-rich scar tissue are the main reasons for using modalities in people with adhesive capsulitis.[31] In contrast to heat combined with manipulation and exercises, TENS has shown remarkable results in increasing ROM. Even low-power laser therapy is better for treating patients with adhesive capsulitis than a placebo. Stretching and deep heating through diathermy have recently demonstrated superior outcomes to superficial heating for the treatment of adhesive capsulitis.[32] More studies are needed for the establishment of specific methods for detailed clinical disorders, such as adhesive capsulitis, and to get better-built results for valid and reliable outcome measures.

  Conclusion Top

The evidence-based physiotherapy management of patients with adhesive capsulitis is the main focus of this systematic review. According to the most recent research, physiotherapy works well for these patients to increase ROM and reduce pain. Comorbidities such as diabetes mellitus, thyroid disease, hypercholesteremia, cardiovascular diseases, and psychological status of the patients delays the recovery in a subset of patients present therapists with many challenges. To get over these challenges, a systematic treatment approach needs to be established, according to the literature included in the present systematic review combination of mobilization, PNF, task-specific training, and modalities proves to be very effective in the complete recovery of the patients with adhesive capsulitis.

Strength and limitations

This systematic review has several strengths. The search strategy was performed with a broad area of interest with many keywords and synonyms, which were combined to make sure no evidence was missed.

Limitations in this study are as follows:

  1. Only RCTs were included, which potentially increased the high risk of bias.

  2. Only English-language published studies were included, which may introduce English language bias.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1]

  [Table 1], [Table 2], [Table 3]


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