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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 6  |  Issue : 4  |  Page : 142-146

Incidence and clinical profile of patients with frozen shoulder after cardiac surgery


1 Department of Cardiology, Chettinad Hospital and Research Institute, Chennai, Tamil Nadu, India
2 Department of Pharmacology, Chettinad Hospital and Research Institute, Chennai, Tamil Nadu, India

Date of Web Publication27-Oct-2017

Correspondence Address:
S Saradha
Department of Pharmacology, Chettinad Hospital and Research Institute, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JCPC.JCPC_17_17

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  Abstract 

Background: Frozen shoulder is a condition characterized by pain and global restriction of movement with loss of external rotation. Cardiac surgery may predispose frozen shoulder as patients tend to immobilize their upper limbs after surgery. Objectives: The aim of this study is to analyze the clinical profile of patients presenting with symptoms of periarthritis shoulder and to determine the incidence of frozen shoulder among patients undergoing cardiac surgery as well as to find the factors associated with its development. Methods: It is a clinical observational study done in the Cardiology Department of Chettinad Hospital and Research Institute, Chennai, between August 2015 and May 2016, on 100 patients who underwent cardiac surgery and attended the follow-up session as an outpatient. Data were collected by face-to-face interview using a standardized questionnaire. Respondents presenting with pain and restricted movement of shoulder joint with positive limitation in lateral rotation, abduction, and medial rotation (LAM) test were considered to have frozen shoulder. Each participant was followed up for 3 months postcardiac surgery. Results: The mean age of the study participants was 53.63 ± 13.03 years, and 65% were males. Of the 100 participants, 20 (20%) developed frozen shoulder. Age (P < 0.01), diabetes mellitus (<0.01), hypertension (P < 0.001), type of surgery (P < 0.02), and regularity of physiotherapy follow-up (P < 0.01) had significant association with positive LAM test on univariate analysis. However, on multivariate logistic regression analysis, only hypertension and physiotherapy regularity were found to have a trend toward a significant independent association with the occurrence of frozen shoulder (P = 0.090 and 0.097, respectively). Conclusion: The present study shows that cardiac surgery increases the risk of developing frozen shoulder during the early postoperative period. Statistically significant correlation existed between positive LAM test and age of the patients, presence of diabetes mellitus and hypertension, type of cardiac surgery, and the regularity of physiotherapy follow-up.

Keywords: Adhesive capsulitis, cardiac surgery, frozen shoulder, limitation in lateral rotation, abduction, and medial rotation test


How to cite this article:
Chokkalingam M, Saradha S, Navitha A, Nayar PG. Incidence and clinical profile of patients with frozen shoulder after cardiac surgery. J Clin Prev Cardiol 2017;6:142-6

How to cite this URL:
Chokkalingam M, Saradha S, Navitha A, Nayar PG. Incidence and clinical profile of patients with frozen shoulder after cardiac surgery. J Clin Prev Cardiol [serial online] 2017 [cited 2019 Sep 17];6:142-6. Available from: http://www.jcpconline.org/text.asp?2017/6/4/142/217392


  Introduction Top


The frozen shoulder otherwise known as adhesive capsulitis was identified as a separate clinical entity by Duplay in 1872.[1] It is one of the most common causes of shoulder pain and disability. The prevalence of frozen shoulder is 2%–3% worldwide.[2] It occurs usually between 40 and 70 years of age.[3] It is a common problem in our country in the 5th and 6th decades of life. There is a female preponderance, but there is no predilection for race.

Frozen shoulder is a condition characterized by pain and global restriction of movement with loss of external rotation. It clinically categorized into three stages.

Stage I: Patients could not actively move their shoulder due to acute pain, but full range of passive movements was possible.

Stage II: Both active and passive movements of shoulder were restricted.

Stage III: Shoulder pain was negligible, and patients could move their shoulder to certain extent.

Frozen shoulder can be divided into primary and secondary forms. In the primary form, there is no associated disease or a history of trauma or surgery of the shoulder. Secondary form may be due to traumatic injury, surgery (including but not limited to the shoulder), or other causes for which shoulder was immobilized.

In our experience, there was a correlation between postcardiac surgery patients and frozen shoulder. This study was designed to check the hypothesis if cardiac surgery can predispose frozen shoulder.


  Objectives Top


  1. To assess the incidence of frozen shoulder in patients undergoing cardiac surgery
  2. To determine the clinical profile of patients who develop frozen shoulder after cardiac surgery.



  Methods Top


It is a cross-sectional, clinical observational study. This study was done in the Cardiology Department of Chettinad Hospital and Research Institute, Chennai, between August 2015 and May 2016. Institutional Human Ethics Committee approval was obtained before the study was started.

All patients above 18 years of age with no history of previous shoulder problems and who presented for follow-up till 3 months after cardiac surgery were included. Informed consent was taken from all the participants. One hundred patients fulfilling the above criteria were included in the study. The data were collected on key variables of interest from the respondents by face-to-face interview using a standardized questionnaire by a trained physician assistant. The questionnaire included the demographic data of the patient, symptoms of frozen shoulder, details of comorbid diseases such as diabetes, hypertension and dyslipidemia, type of cardiac surgery, number of postoperative visits, and regularity of physiotherapy follow-up.

Respondents presenting with pain and restricted movement of shoulder joint with positive limitation in lateral rotation, abduction, and medial rotation (LAM) test were considered as having frozen shoulder.

Follow-up to physiotherapy was categorized into regular, irregular, and no follow-up. The study participants were followed up for 3 months post operatively.


  Statistical Analysis Top


Data collected was expressed as actual numbers and percentages. The statistical significance was calculated using Mann–Whitney U-test and Pearson's Chi-square test to check the significance between the incidence of frozen shoulder after cardiac surgery in comparison with the regularity of physiotherapy follow-up and associated comorbidities. Multivariate logistic regression analysis was performed to study the independent predictors of the development of frozen shoulder after a cardiac surgery.


  Results Top


The mean age of the study participants was 53.63 ± 13.03 years and 65% were males; 40% had diabetes and 37% had hypertension. Of the 100 participants, 20 (20%) developed frozen shoulder [Table 1].
Table 1: Association between various parameters and LAM test

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Correlation between age and LAM test

Among 20 patients with positive LAM test, 5% were in ≤30 years of age category, 5% were in 31–45 years category, 30% were in 46–60 years category, and 60% were in >60 years category [Table 1]. The mean age of LAM test positive participants was 61.35 years whereas that of LAM-negative participants was 51.70 years [Table 2]. Thus, advancing age was a statistically significant risk factor for the incidence of frozen shoulder.
Table 2: Correlation between age and LAM test

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Correlation between cardiovascular risk factors and LAM test

The occurrence of frozen shoulder was significantly associated with the presence of hypertension and diabetes. Of the 37 hypertensive participants, 14 (37.8%) developed frozen shoulder whereas only 6 (9.5%) of those without hypertension developed this complication (P < 0.001) [Table 1]. Similarly, diabetics also had significantly higher incidence of frozen shoulder as compared to nondiabetics (32.5% vs. 11.7%, P < 0.001).

Type of surgery and LAM test

Out of 62 patients who underwent coronary bypass surgery (CABG) with or without valve surgery, 18 (29.0%) developed frozen shoulder. This was significantly higher than in patients who underwent isolated valve surgery (2 of 35, 5.7%, P = 0.006) [Table 1].

Correlation between physiotherapy follow-up and LAM test

In patients who had undergone regular physiotherapy, only 14% developed frozen shoulder and 86% did not develop the frozen shoulder. In contrast, 33% of those who did not have regular physiotherapy follow-up developed frozen shoulder (P = 0.013) [Table 1].

Independent predictors for postoperative frozen shoulder

A multivariate analysis was performed to identify the independent predictors for the risk of developing postoperative frozen shoulder [Table 3]. Age, diabetes, hypertension, type of surgery (i.e., CABG or not), and regularity of the physiotherapy follow-up were included as independent variables. Of these risk factors, only hypertension and physiotherapy regularity were found to have a trend toward a significant independent association with the occurrence of frozen shoulder (P = 0.090 and 0.097, respectively).
Table 3: Independent predictors of frozen shoulder incidence in this study

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  Discussion Top


Idiopathic frozen shoulder is a self-limiting regional skeletal problem of unknown etiology. Clinically, patients first experience a phase of pain, progressing to a freezing stage when glenohumeral motion is lost, followed by a thawing phase when pain gradually subsides and most of the lost motion returns.

The common risk factors include diabetes, old age, postoperative period, especially after cardiac surgery and postpacemaker implantation.

Frozen shoulder begins with an early phase of pain which eventually leads to stiffness. This suggests that there is an inflammatory response which later evolves into a fibrotic reaction.[4] Currently accepted theory is that there is an initial active fibroblastic proliferation with subsequent transformation of fibroblasts to myofibroblasts.[4],[5] This causes an inflammatory contracture of the shoulder, decrease in the capsular volume, and restriction of the glenohumeral movements.[3] The role of matrix metalloproteinases in the construction of the extracellular matrix and in the various cytokines that control collagen deposition has also been described.

Codman in 1934, described a diagnostic criterion comprising of idiopathic onset, painful restriction of all glenohumeral movements with limitation of flexion, and external rotation with a normal radiograph.[6]

In our study, 20% of the study population developed frozen shoulder. In a previous study from the United States, Tuten et al. demonstrated a higher incidence (33%) of adhesive capsulitis of the shoulder in male postcardiac surgery patients.[7]

Age appeared to be an important risk factor for frozen shoulder in our study as the incidence of frozen shoulder increased with increasing age. However, there was no gender predilection.

Adhesive capsulitis or frozen shoulder is considered to be one of the long-term complications of diabetes. While the prevalence of frozen shoulder is only 2% in the general population, it is reported to occur in 10%–29% of those with diabetes. Studies have shown that adhesive capsulitis is caused by glycosylation of the collagen within the shoulder joint triggered by the presence of high blood sugars.[8] Adipose tissue may also have a role to play in these patients. Adipocytes secrete proteins and cytokines such as tumor necrosis factor alpha and interleukin-6 resulting in overproduction of other proinflammatory cytokines, which in turn exacerbate inflammation. Chronic inflammation, production of free fatty acids from adipocytes, increased expression of synovial vascular endothelial growth factor result in persistence of inflammation and limited disease resolution.[9],[10],[11],[12] Consistent with these results, we also found a significantly higher incidence of frozen shoulder among diabetics.

Among the different types of cardiac surgeries, CABG was associated with significantly greater risk of causing frozen shoulder as compared to other forms of cardiac surgeries. The underlying mechanism for this association is difficult to explain but may be related to the differences in age and the prevalence of other risk factors such as diabetes.

Patients in the postoperative period tend to restrict the movement of upper limbs due to fear of pain, which tends to precipitate the development of frozen shoulder. Therefore, physiotherapy plays a vital role during this period. In our study, the regularity with which the patient attends the follow-up sessions for physiotherapy was categorized as regular, irregular, and no follow-up. Regular physiotherapy was associated with significantly lower risk of developing frozen shoulder with 76% of LAM score negative participants being in the regular follow-up group.

Thus, it may be suggested that regular postoperative physiotherapy to the upper limbs should be insisted to the patients by the medical and paramedical personnel as it can prevent the development of frozen shoulder in the immediate postoperative period.

Early diagnosis with prompt referral and treatment may prevent progression to chronic, treatment-resistant adhesive capsulitis. When diagnosed early, it can be treated by application of heat to the affected area, giving nonsteroidal anti-inflammatory drugs and intra-articular corticosteroid injections. Physiotherapy and stretching exercises can widen the range of the shoulder movement.

Limitations

  • Small sample size limits our study; due to time constraint, we had to stop enrollment.
  • Long-term outcomes were not evaluated as the patients were followed up only for 3 months postcardiac surgery.



  Conclusion Top


It can be concluded that cardiac surgery increases the chances of development of frozen shoulder during the early postoperative period. Older age, presence of diabetes and hypertension, type of cardiac surgery, and the regularity of physiotherapy follow-up are important risk factors for the development of frozen shoulder postcardiac surgery. Regular follow-up with continuous physiotherapy after cardiac surgery may be helpful in reducing the incidence of frozen shoulder in the early postoperative period.

Acknowledgment

All the authors are thankful to Chettinad Hospital and Research Institute and Professor S Govindaraju for his statistical assistance.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Duplay E. De la periarthritescapulo-humérale et des raideurs de l'épaule qui ensont la conséquence. Arch Gen Med 1872;20:513-42.  Back to cited text no. 1
    
2.
Manske RC, Prohaska D. Diagnosis and management of adhesive capsulitis. Curr Rev Musculoskelet Med 2008;1:180-9.  Back to cited text no. 2
[PUBMED]    
3.
Robinson CM, Seah KT, Chee YH, Hindle P, Murray IR. Frozen shoulder. J Bone Joint Surg Br 2012;94:1-9.  Back to cited text no. 3
    
4.
Hand GC, Athanasou NA, Matthews T, Carr AJ. The pathology of frozen shoulder. J Bone Joint Surg Br 2007;89:928-32.  Back to cited text no. 4
    
5.
Bunker TD, Anthony PP. The pathology of frozen shoulder. A dupuytren-like disease. J Bone Joint Surg Br 1995;77:677-83.  Back to cited text no. 5
    
6.
Codman EA. The Shoulder: Rupture of the Supraspinatus Tendon and Other Lesions in or about the Subacromial Bursa. Thomas Todd; 1934..  Back to cited text no. 6
    
7.
Tuten HR, Young DC, Douoguih WA, Lenhardt KM, Wilkerson JP, Adelaar RS. Adhesive capsulitis of the shoulder in male cardiac surgery patients. Orthopedics 2000;23:693-6.  Back to cited text no. 7
    
8.
Tighe CB, Oakley WS Jr. The prevalence of a diabetic condition and adhesive capsulitis of the shoulder. South Med J 2008;101:591-5.  Back to cited text no. 8
    
9.
Sugimoto R, Enjoji M, Nakamuta M, Ohta S, Kohjima M, Fukushima M, et al. Effect of IL-4 and IL-13 on collagen production in cultured LI90 human hepatic stellate cells. Liver Int 2005;25:420-8.  Back to cited text no. 9
    
10.
Kaviratne M, Hesse M, Leusink M, Cheever AW, Davies SJ, McKerrow JH, et al. IL-13 activates a mechanism of tissue fibrosis that is completely TGF-beta independent. J Immunol 2004;173:4020-9.  Back to cited text no. 10
    
11.
Glass CK, Olefsky JM. Inflammation and lipid signaling in the etiology of insulin resistance. Cell Metab 2012;15:635-45.  Back to cited text no. 11
    
12.
Kanter JE, Kramer F, Barnhart S, Averill MM, Vivekanandan-Giri A, Vickery T, et al. Diabetes promotes an inflammatory macrophage phenotype and atherosclerosis through acyl-CoA synthetase 1. Proc Natl Acad Sci U S A 2012;109:E715-24.  Back to cited text no. 12
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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  In this article
Abstract
Introduction
Objectives
Methods
Statistical Analysis
Results
Discussion
Conclusion
References
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