Adhesive capsulitis(AC) is an enigmatic condition characterized by painful, progressive and
disabling loss of active and passive shoulder joint range of motion in multiple planes.
Approximately 2% to 5% of adults between age 40 and 70 develop adhesive capsulitis with a
greater occurrence in women and in individuals with thyroid disease or diabetes. AC is an
arthrofibrosis involving the formation of excessive adhesions along the glenohumeral joint. It
is a disease of unknown aetiology and is classified as primary and secondary. Primary
adhesive capsulitis includes cases of idiopathic origin resulting from chronic inflammation
with fibroblast proliferation. Secondary adhesive capsulitis includes central nervous system
problem, prolonged immobilisation of the arm, trauma or fracture, infectious diseases, etc.
The progression of adhesive capsulitis is characterised by four stages, each stage showing a
distinctive clinical presentation:
Painful phase: lasts less than three months and is characterised by shoulder pain at
night with preserved glenohumeral motion.
Freezing phase: lasts three to nine months and is characterised by severe pain and
stiffness in the glenohumeral joint.
Frozen shoulder process: lasts nine to fourteen months and is characterised by loss of
movement and pain in all directions at the end.
Thawing phase: lasts fifteen to twenty-four months and is characterised by persistent
stiffness, minimal pain, delayed recovery of shoulder movement.
Interventions for this pathology usually include physical therapy, nonsteroidal
anti-inflammatory drug therapy, intra-articular steroid injections, distension arthrography
and surgery. Physical therapy is the mainstay of treatment for patients with adhesive
capsulitis. Conventional physical therapy consists of electrotherapy modalities such as TENS,
Interferential current, Ultrasound, low intensity laser and exercises such as stretching
exercises, Codman Exercise, Wand exercises and joint mobilisation and is used to control
pain, increase flexibility and improve range of motion.
It is known that it takes a long time to achieve pain relief and a good improvement in ROM in
adhesive capsulitis. This situation affects the quality of life of patients and creates a
need for easily accessible treatment options that provide faster recovery.
One of the main challenges facing the therapist in the treatment of adhesive capsulitis is to
motivate the patient throughout conventional therapy. As noted in a recent review,
individuals are more interested in leisure activities rather than performing repetitive tasks
during therapy. Virtual reality (VR) is a three-dimensional computer-aided programme built
with a system that creates virtual reality movements and generates a high amount of visual
and sensory feedback during exercise. As a result, virtual reality (VR) has been used in many
medical indications and has been shown to promote adherence to treatment by increasing
patient motivation.
Different VR systems have been shown to be effective in individuals with kinesiophobia as
well as stroke patients. Virtual reality guided exercise is a proven method already used in
stroke, Parkinson's, cerebral palsy rehabilitation, vestibular rehabilitation and orthopaedic
rehabilitation. However, there is limited data on its effectiveness in patients with adhesive
capsulitis. This randomized controlled study will contribute to the literature by
investigating the effects of VR based exercises in individuals with AC.
The estimated number of volunteers expected to participate in the study was determined
according to power analysis. The sample size of the study was determined by the GPower
3.1.9.7 program, and by using the finding in a similar study in the literature, it was used
with 80% power and 5% margin of error to catch the medium effect size between dependent
measurements. It was decided to work with a total of minimum 60 people, 20 in each group.
Considering the patients who may be excluded from follow-up in the study, it is planned to
start the study with 75 patients. The diagnosis of the disease will be made by history and
clinical physical examination and no additional imaging technique will be required.
Patients will be randomly divided into 3 groups. They will be selected by simple random
sampling using the closed envelope method, and then Group A (virtual reality + home exercise
), Group B (conventional therapy+ home exercise ) and Group C ( only home exercise ).
Individuals in the first group to be included in the study group will be included in a
VR-based exercise program for half an hour a day, 5 days a week for a total of 3 weeks, in
addition to home exercise programs for half an hour a day, 5 days a week for a total of 3
weeks. These individuals will use the Microsoft Kinect for Azure VR system in the virtual
environment. They will play the registered games. These games will include purpose-oriented
activities such as lying on the shelf and using bilaterally, which are intended to use the
upper extremities of individuals with AC in daily life. Participants will be treated under
the constant supervision of a physiotherapist, will be rested at the end of the exercise, and
will leave the clinic after making sure that there is no problem.
Individuals in the second group, who will be included in the traditional exercise group, will
be included in the stretching and strengthening exercise program for half an hour a day, 5
days a week for a total of 3 weeks, in addition to home exercise programs for half an hour a
day, 5 days a week for a total of 3 weeks. The exercises will be performed by a
physiotherapist working in the clinic and blind to the study.
Individuals in the third group, who will be included in the home exercise group, exercises
will be taught to the patient and will be applied for half an hour a day, 5 days a week for a
total of 3 weeks.
The home exercise programme will be demonstrated by the physiotherapist at the beginning of
the treatment and all groups will be asked to perform these exercises at home. Patients will
be given a chart and they will be asked to mark this chart on the day they exercise. The
exercise compliance of the patients will be monitored with this chart.
Home exercises will be organised as pendulum (Codman), finger ladder, Wand exercises, towel
stretch and will be given to the patient as a visually printed exercise sheet.