Capsulitis
Description:
The capsulitis represents the diffusion defeat of the capsule and a synovial membrane of a shoulder joint which is quite often leading to a long invalidism of the patient.
For the first time the peculiar "humeral" syndrome which is followed by pain and considerable restriction of volume of movements, but is not connected with damage of actually shoulder joint in 1882 described Duplay. It entered the term "humeroscapular periarthritis" which began to be applied to all group of periartikulyarny diseases of area of a shoulder joint unreasonably later into practice. In 1932 Codman offered the term "the frozen shoulder" for designation of this state; which is popular in English-speaking orthopedic literature so far. This name reflects one of the most characteristic symptoms of a disease – natural approach during a disease of the period of "constraint" – bezbolevy restriction of movements in a shoulder joint. In domestic medicine similar terms – "the blocked shoulder", a humeroscapular periarthritis with restriction of movements in a shoulder joint were used. In 1945 Naviesar offered the modern name – "an adhesive capsulitis";. In spite of the fact that under such name the disease appears in the International classification of diseases of the 10th review (the code of M75.0), the term is fairly criticized because at this disease of adhesion neither the capsule, nor synovia is observed more likely joint capsule retraction takes place. In the majority of modern scientific articles the state is designated just as "capsulitis".
Who is ill a capsulitis?
In the limited number of works on epidemiology of a capsulitis its considerable prevalence is shown. In particular, in the Scandinavian countries incidence among adult population makes about 2% a year. In absolute majority of cases the capsulitis occurs at persons aged from 50 up to 70 years. The disease seldom meets up to 40 years, practically it is always a secondary form. Women are ill more often than men (a ratio 3:1–5:1). The dominating and not dominating extremity are surprised with an equal frequency. Damage of the second joint with an interval from 6 months of year to 5 years develops in 7–10% of cases against the background of permission of process in one joint. Development of process in the second joint is autonomous and does not influence the course of a disease in originally struck. After recovery repeated episodes of a capsulitis in the same joint are extremely rare.
Capsulitis symptoms:
Staging of a current is characteristic of a capsulitis. Clinical manifestations are various during the different periods of a disease. The beginning is usually spontaneous, without any previous events, has subacute character when within 1–3 weeks one shoulder joint pains accrue. At the same time pain is a little connected with some certain movement, often amplifies at night and in a prone position on a sore shoulder. The first, painful phase without treatment lasts from 3 months to one year, then pains gradually decrease and there comes the phase of "constraint" – actually bezbolevy restriction of volume of movements in a joint. The characteristic type of the patient during this period of a disease also gave the name to a disease – "ankylosed" or "the frozen shoulder". This phase lasts from 4 to 12 months, being replaced by the period of permission during which the volume of movements in a joint is gradually recovered. In most cases the disease comes to the end with recovery, however at a half of patients of full return to the initial volume of movements does not occur that, however, does not disturb them in everyday life. Permission phase duration – 12–24 months. There is a certain pattern – the longer the painful phase lasts, the also the recovery phase proceeds longer. Disease duration without treatment averages from 1,5 to 2 years, however in some cases can reach 4 years. In isolated cases considerable residual restriction of volume of movements in a shoulder joint is observed. Despite the general good forecast, during the entire period of a disease disability of the patient is limited, in the first two phases he experiences considerable difficulties in self-service that assumes the active intervention aiming to reduce the invalidism period. Classical phase disease can be broken. So, during subsiding of an acute pain the careless movement (breakthrough by a hand, falling), rough manipulations with a joint can strengthen a pain syndrome again.
Capsulitis reasons:
The capsulitis etiology is unknown so far. It is supposed that the neurotrophic disturbances in the capsule and a synovial membrane of a joint leading to specific morphological changes – to fibrosis and considerable reduction of volume of a cavity of a joint are the reason. Arthroscopic data in a painful phase confirm existence of moderate inflammatory process (hyperemia) in synovia. At a biopsy in the capsule deviations in the content of cytokines, growth factors and matriksny metalproteinases which, perhaps, participate in pathological processes are found. However as far as the inflammation is related to the main pathological process – capsule fibrosis, it is unknown. At least, at other reasons of an aseptic synovitis, such as pseudorheumatism or secondary synovitis at an osteoarthrosis, so expressed capsule fibrosis is never observed. A number of signs pulls together a capsulitis with diseases of group of reflex sympathetic dystrophy or a complex regional pain syndrome of the I type which bright representative is Zudek's syndrome. These signs include: staging of a current, development of fibrosis in a late stage, clear medical effect of glucocorticosteroids. Simultaneous ipsilateralny damage of a shoulder joint and a brush in the form of classical options of a capsulitis and Zudek's syndrome is well known ("a syndrome a shoulder brush" or Shtaynbrokera) that assumes the general pathogeny of these diseases.
The capsulitis meets independently or can develop against the background of any other state. In the latter case speak about a secondary capsulitis. Among the reasons of a secondary capsulitis the diabetes mellitus 2 types at which the capsulitis meets in 10–30% of cases is known. Frequent cases of a capsulitis at patients with a hyper thyroidism, oncological diseases, after a myocardial infarction, a stroke, operative measures on heart and catheterization of a brachial artery are described. In addition to association of a capsulitis with Zudek's syndrome, communication of this disease with one more mysterious representative of neurotrophic frustration – Dyupiitren's contracture is proved. This disease is also associated with diabetes and has the sign, general with a capsulitis, – at it fibrosis, but without pain syndrome, a palmar aponeurosis also develops.
Now there are no data, testimonial that the simple tendinitis of a rotatorny cuff of a shoulder (the most frequent reason of pains in a shoulder joint) can evolve in a capsulitis. These are various both on a pathogeny, and on clinical displays of a disease.
Treatment of the Capsulitis:
Treatment of a capsulitis depends on a disease phase. It is necessary to encourage the patient, having reported to him about the general good forecast of a disease. It is important as patients are quite often concerned by the accruing restriction of movements and lack of effect of the undertaken treatment methods. Treatment and outcomes of an idiopathic capsulitis and its secondary forms do not differ, however at development of a capsulitis against the background of a diabetes mellitus there are certain restrictions in use of GKS.
Treatment in a painful phase of a disease.
During this period of a disease treatment is directed to reduction of a pain syndrome. It is necessary to limit load of a joint to a portability limit. Criterion is pain. All movements which do not cause strengthening of pain are allowed (and are recommended). Rest (carrying a hand in a "kosynochny" bandage) is recommended only at very severe pain, and that only at several o'clock a day. It is known that the long immobilization increases further functional insufficiency of a joint.
Medicinal therapy in this phase of a disease is directed to the fastest stopping of pain and transfer of a disease in a phase of permission of process. Treatment of a pain syndrome at a capsulitis is traditional begin with non-steroidal anti-inflammatory drugs (NPVP). Despite an originality of inflammatory process at a capsulitis, it is present, and use of NPVP at this disease has pathogenetic justification. However, in view of the age contingent of the diseased (these are people of mature and senior age), it is necessary to consider risk of development of undesirable reactions (a medicinal gastropathy, damage of kidneys, intestines, cardiovascular system). In this regard has advantages over other NPVP ацеклофенак (Aertal). Without conceding on antiinflammatory activity to such standard NPVP as diclofenac and indometacin, ацеклофенак at the same time has authentically the best portability that is proved in numerous researches. The favorable profile of portability of an atseklofenak is caused by preferential inhibition in TsOG-2 organism. Atseklofenak treats drugs with short half-life (4–6 hours) that excludes the cumulative effect (observed, for example, at piroxicam and a lornoksikam) undesirable at senior citizens.
The daily dose of an atseklofenak makes 50–200 mg and is determined by the patient by criterion of sufficiency. Reception duration is also defined by efficiency concerning a pain syndrome. Drug is accepted until pain disappears.
At a capsulitis effectively intra joint introduction of glyukokokortikosteroid (GKS). It is necessary to carry out introduction of GKS to the affected joint, but not "obkalyvaniye" of periartikulyarny fabrics which if has effect, then only at the expense of systemic action of drug. Early carrying out an intra joint injection of GKS allows to stop a pain syndrome, reducing the natural duration of a painful phase. The scheme and a puncture of a shoulder joint are shown in the figure 2.
The effect of GKS is caused not only antiinflammatory action, but, perhaps, some other mechanism of impact on pathological process. The effect of GKS at a syndrome of Zudek at which there is practically no inflammation is known. The mode of intra joint introductions is defined by a specific situation. At a number of patients the effect of an injection of GKS lasts a limited span (2–3 weeks) after which pains amplify again. To such patients intra joint injections of GKS repeat with the interval determined by duration of effect of the previous injection (in 2–4 weeks), but no more than 3 injections. In the absence of contraindications to injections of GKS use full single doses of dlitelnodeystvuyushchy drugs as the dozozavisimost of the occurring effect is shown. Difficulties arise at the accompanying diabetes mellitus. In this case use of dlitelnodeystvuyushchy drugs with clear system effect (a triamsinolon and betamethasone) is fraught with increase in level of glucose in blood though special researches in this direction were not conducted. However it is shown that intra joint introduction of 35 mg of Methylprednisolonum of acetate at patients with diabetes does not influence glucose level in blood.
GKS at a painful phase of a capsulitis can be applied and orally. So, in placebo – the controlled research Buchbinder et al.pokazali efficiency at a capsulitis of reception of 30 mg of Prednisolonum a day within 4 weeks. However considering risk of undesirable reactions of system reception of GKS in such high dose, the method is not recommended for broad practice. This way is shown in cases of especially expressed pain syndrome, torpid to other methods of treatment (a syndrome "shoulder brush").
