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INTRODUCTION
The shoulder is the most movable but unstable joint in the body because of the range of
motion it allows. It is easily to subject to injury because the ball of the upper arm is larger
than the socket that holds it. To remain stable, its muscles, tendons and ligaments must
anchor the shoulder.
Frozen shoulder or Adhesive capsulitis is a condition that causes restriction of motion in
the shoulder joint. The cause of frozen shoulder is not well understood, but it often occurs
for no known reason. Frozen shoulder cause the capsules surrounding shoulder joint to
contract and forms scar tissue.
Frozen shoulder is pathology of often unknown aetiology characterized by painful and
gradually progressive restriction of active and passive glenohumeral joint motion.
Approximately 2-3% of adults aged between 40 and 70 years develop frozen shoulder with
a greater occurrence in women. Full or partial restoration of motion may occur over months
or years with or without medical intervention.
Over the years, the stiff shoulder was labeled initially periarthritis by Duplay in 1872,
then frozen shoulder by Codman in 1934 and lateradhesive capsulitis by Neviaser in
1945. Codman described the disorder known as frozen shoulder as a condition difficult to
define, difficult to treat and difficult to explain from the point of view of pathology.
Neviaser was the first to recognize a chronic inflammatory process that resulted in
capsular fibrosis, or thickening and contracture of the capsule.
Peariarthritis covers a large group of disorders including tendonitis and tears of the rotator
cuff, calcifying tendinitis, bursitis. Therefore, this is not an acceptable term so frozen
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shoulder and adhesive capsulitis are the preferred terms.
Normally the shoulder joint allows more motion then any other joint in the body. When a
patient develops frozen shoulder the capsule that surrounds the joint becomes contracted
and forms band of scar time called adhesions. The contraction of the capsule and the
formation of adhesions cause the frozen shoulder to because till and cause movement to
become painful.
Based on the etiology frozen shoulders can be classified as primary or secondary. Primary
frozen shoulder is an idiopathic condition, where the exact underlying cause is not known.
Frozen shoulder associated with a known underlying disorder is considered to be
secondary. Zuckerman and Cuomo have separated secondary frozen shoulder into
intrinsic, extrinsic and systemic categories. Intrinsic shoulder abnormalities include
rotator cuff tendinitis, rotator cuff tears, tendinitis of the long head of the biceps tendon,
calcific tendinitis and acromioclavicular joint arthritis. Extrinsic disorders which represent
pathologic conditions remote from the shoulder region, include ischemic heart disease and
myocardial infarction, pulmonary disorders including tuberculosis, chronic bronchitis,
emphysema, and tumor, cervical disc disease and radiculopathy, cerebral vascular
hemorrhage, previous coronary artery bypass graft surgery, previous breast surgery, lesions
of the middle humerus, and central nervous system disorders, such as Parkinsons disease.
Extrinsic causes refer to the posttraumatic category, which can be iatrogenic (post surgical)
or may result from high-impact forces or low-level activity. Systemic disorders represent
generalized medical conditions that are known to occur in association with frozen shoulder
which include diabetes mellitus, hypothyroidism, hyperthyroidism, and hypoadrenalism.
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CAPSULAR STRETCHING:
The glenohumeral joint capsule has a significant degree of inherent laxity with a surface
area that is twice that of the humeral head. This redundancy allows for a wide range of
motion. Medially, the capsule attaches both directly onto (anteroinferiorly) and beyond the
glenoid labrum and laterally it reaches to the anatomical neck of the humerus. Superiorly, it
is attached at the base of the coracoid, enveloping the long head of the biceps tendon and
making it an intra articular structure.
The capsule also has a stabilizing role tightening with various arm positions. In adduction,
the capsule is taut superiorly and lax inferiorly; with abduction of the upper extremity this
relationship is reversed and inferior capsule tightens. As the arm is externally rotated, the
anterior capsule tightens while internal rotation induces tightening posteriorly. The
posterior capsule in particular has been shown to be crucial in maintaining glenohumeral
stability, acting as a secondary restraint to anterior dislocation (particularly in positions of
abduction) as well as acting as a primary posterior stabilizing structure.
On Pathologic examination of the shoulder joint capsule, in frozen shoulder the joint tends
to be contracted, thickened and closely adherent to the humeral head, contributing to the
limitation of movement. In frozen shoulder, limitation of external rotation with the arm in
abduction typically is associated with an anteroinferior capsular restriction, whereas limited
internal rotation and cross-body adduction are associated with a posterior capsular
restriction. The capsular pattern is designated by a hard end-feel and limitation of all three
passive movements in fixed proportions. Limitation of medial rotation is slight; the patient
cannot fully put her arm behind her back. The restriction of glenohumeral abduction is
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During a typical Muscle Energy Technique session, the patient is asked to contract a
muscle in the affected area for approximately five seconds while overcoming a resistance
to this contraction which is applied by the therapist. This set of contractions may be
performed two to three times in a row. These series of contractions helps to stretch and
lengthen the shortened, contracted or spastic muscle. This in turn strengthens the muscle
group in that area and brings about increased mobility and pain relief.
Muscle Energy Technique is also used as a diagnostic tool to identify restrictions in the
particular range of motion and correct these restrictions. When a joint has restricted
movement, no amount of massage will correct this problem until these restrictions are first
addressed and removed. Muscle Energy Technique helps to restore the full range of
movement to frozen joints and aids in the strengthening of the associated muscles.
Muscle Energy Techniquecan be used to treat most joints in the body, including the inter-
vertebral joints, in a safe and effective manner.
There are two types of Muscle Energy Therapy
Post-Isometric Relaxation uses the patients muscle to stretch the same muscle by
stretching it to the point of bind, and then getting the patient to use this muscle by pushing
against a resistance put the therapist. The therapist then asks the patient top relax the
muscle and then moves it to re-align the muscle fibers.
Reciprocal Inhibition is different from post-isometric relaxation in that it uses the
patients muscle to stretch the opposing muscle. The therapist then takes the muscle being
stretched to its point of bind. The patient then uses the opposing muscle by moving away
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from the therapist. The therapist then stretches the muscle fibers to re-align it when the
muscle is relaxed.
In treating joint restriction with muscle energy technique Sandra Yates in 1991 has
suggested the following simple criteria to be maintained:
1. The joint should be positioned at its physiological barrier-specific in
three planes.
2. The patient should be asked to statically contract muscles towards
their freedom of motion away from the barrier of restriction as the operator
resists totally any movement of the part, the contraction held for 10 seconds.
3. The patient is asked to relax for 2 seconds or so between the
contraction efforts, at which time,
4. The operator re-engages the joint at its new motion barrier.
Muscle Energy Techniques are used to mobilize joint dysfunctions of both the spine and
peripheral joints. When a joint becomes locked up or moves out of neutral position, this
technique can work well to restore proper joint space.
1. 1. NEED FOR THE STUDY:
The usual method of treatment for frozen shoulder consists of heat therapy (superficial and
deep) and joint mobilization. A new method of approach, MET targets mainly the
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relaxation of the soft tissues. Studies have been conducted to find out the effects of
capsular stretching and MET but there is no study to compare the efficacy of these two
techniques on frozen shoulder. So this study is done to compare the effectiveness of these
two techniques on frozen shoulder. In this study 15 subjects are treated with MET and 15
subjects treated with capsular stretching in order to compare their efficacy on frozen
shoulder.
1.2. AIM OF THE STUDY:
To study the effects of capsular stretching and Muscle Energy Technique in Frozen
shoulder patients.
1. 3. OBJECTIVES OF THE STUDY:
1. To find out the effectiveness of capsular stretching in frozen
shoulder patients.
2. To find out the effectiveness of muscle energy technique in frozen
shoulder patients.
3. To compare the effectiveness of capsular stretching over muscle
energy technique in frozen shoulder patients.
1. 4. HYPOTHESIS:
Experimental Hypothesis:
1. There is a significant effect on reducing pain and improving function by
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Capsular stretching in frozen shoulder patients.
2. There is a significant effect on reducing pain and improving function by
Muscle Energy Technique in frozen shoulder patients..
3. There is a significant difference between Capsular stretching and Muscle
Energy Technique in reducing the pain and improving function on frozen
shoulder. in frozen shoulder patients.
Null Hypotheses:
1. There is no significant effect on reducing pain and improving function by
Capsular stretching in frozen shoulder patients.
2. There is no significant effect on reducing pain and improving function by
Muscle Energy Technique in frozen shoulder patients.
3. There is no significant difference between Capsular stretching and Muscle
Energy Technique in reducing the pain and improving the function in frozen
shoulder patients.
REVIEW OF LITERATURE
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Recent placebo controlled study found that stretching exercise program on 30 patients
who had stage 2 Idiopathic adhesive capsulitis successfully reduced pain at rest (84% of
subjects) and with activity (73% of subjects)
- Griggs et al
A study randomized 90 frozen shoulder subjects to two treatment groups. One received
corticosteroid injection combined with stretching exercise and the other group with
corticosteroid injection alone. The combine corticosteroid injection and stretching
treatment proved to be more effective in improving shoulder range of motion compared to
treatment with corticosteroid injection alone.
- Carett et al
77 patients with idiopathic frozen shoulder syndrome were included in a prospective study
to compare the effect of intense physical rehabilitation treatment including passive
stretching and manual mobilization (Stretching group) versus supportive therapy and
exercises with the pain limits (supervise neglect group). The study concluded that
supervised neglect yields better outcome than intense physical therapy and passive
stretching in patients with frozen shoulder.
- Diercks et al
A study was conducted to compare the efficacy of Maitlands mobilization over MET on
30 frozen shoulder patients using range of motion (ROM) and shoulder pain and disability
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index (SPADI) score scale in a hospital and clinical setting in and around Meerut. Shoulder
ROM and function improvement was much better by Maitland mobilization when
compared to treatment with MET.
- Dr. Ravi Mahalawat
A Study was conducted to examine the effect of a 3sec, 6sec and 10sec maximum
contraction phase in a CRAC (Combination of Contract Relax Antagonist Contract)
stretching procedure on the range of internal rotation of the shoulder joint in 60 subjects. It
was found that all MET treatments produce greater range of motion (ROM) and there was
no significant difference in the effect of varying the contraction duration in MET.
- Nelson and Cornellius (1991)
A study performed MET on 244 patients who complained of shoulder pain and were found
to have pain points within the muscle as well as increase tension on stretching. The
problematic muscle was passively stretched to a point just short of pain and the patient
instructed to perform gentle isometric contraction for 10 secs followed by the relaxation
and further stretching. The treatment resulted in immediate pain relief in 94 % of the
patients and lasting relief in 63%.
- Lewit and simons (1984)
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A study was conducted on 30 frozen shoulders subjects to compare the effectiveness of
MET combined with PNF and resistance exercises over PNF and resistance exercises. The
combined MET, PNF and resistance exercises was more effective than PNF and resistance.
- Captain Eric Wilson et al
Study was conducted to examine the psychometric properties of reliability and validity of
pennysylvannia shoulder scale (PSS) on 40 patients with shoulder disorder undergoing a
course of out patient physical therapy completed the PSS at initial visit and again within 72
hours to assess test - retest reliability and demonstrated that the PSS is a reliable and valid
measure for reporting outcome of patients with various shoulder disorders.
Brian G. Leggin et al
A Study was conducted to evaluate four scales of shoulder functions
Four scales are
a. ASES (American shoulder and Elbow surgeons)
b. SPADI (Shoulder pain and disability index)
c. Simple shoulder Test
d. Function sub scale of university of Pennysylvania shoulder scale.
With respect to
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Their precision at different levels of shoulder functions.
The measurement level of their raw scores (Interval vs Ordinal)
On 192 shoulder patients and concluded that the scales raw scores were found to be not of
equal interval, calling into question, the scoring systems recommended by the developers
of these scale and the use of scores in some statistical procedures.
Cook K.F. et al
METHODOLOGY
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3.1 STUDY DESIGN
True experimental study was conducted in the form of pre test, post test with two
experimental groups.
3.2 STUDY SETTING
The study was conducted at out patient department of Cherraans College of
Physiotherapy.
3.3 STUDY SAMPLING
A total number of 30 subjects was selected by simple random Sampling after due
consideration of inclusion and exclusion criteria.
STUDY DURATION
2 Months
3.4 INCLUSION CRITERIA
1. Both Sex
2. Patients with stage 2 or stage 3 frozen shoulder of any age group.
3.5 EXCLUSION CRITERIA
patients who underwent a surgical procedure of the shoulder less than 4
weeks prior to study enrolment.
patients who have undergone total shoulder arthroplasty.
Patients with reflex sympathetic dystrophy.
patients with rheumatoid arthritis.
Patients with glenohumeral arthritis.
patients with neoplasm in and around the shoulder joint.
Patients with cervical pathology.
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3.6 ASSESSMENT TOOL USED FOR STUDY
University of Pennsylvania, Shoulder scale 1st subset.
3.7 PROCEDURE
The study was conducted on 30 patients with 2 goups of 15 each . Group A was
treated with moist heat, capsular stretching and icing whereas group B was treated with
moist heat, muscle energy technique and icing.
Pain & function scores using university of Pennsylvania shoulder scale
(1st subset) was measured prior to treatment and at the end of treatment. (after 2 Weeks)
Testing protocol for University of Pennsylvania shoulder score (1st Subset)
The university of Pennsylvania shoulder score includes two 100 points scoring systems.
The self assessment 100-point scoring system is based on scoring of the patients report of
pain, satisfaction and function. The 100 point impairment score consists of objective
measures of ROM and strength. In this study the 1st subset of self assessment is only taken
to measure the patents report of pain, satisfaction and function. It contains three pain items
that address pain with the arm at rest by the side, pain with normal activities, and pain with
strenuous activities. All are based on a 10 point numeric rating scale with end points of no
pain and worst possible pain. Ten points can be awarded for each item by subtracting
the number circled from 10. Therefore, a patient can be awarded 30 points for absence of
pain.
The patients satisfaction with the function of the shoulder is also assessed with a numeric
rating scale. The end points chosen were not satisfied and very satisfied. Scoring is
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stretch the antero inferior capsule the affected arm is taken towards the extreme of
attainable elevation and counter pressure is maintained at the patients sternum to prevent
spinal extension. Each stress is gentle but firm and not released until pain rather than
discomfort is experienced. Group A received capsular stretching of 5 repetitions per set, 5
sets per session, 1 session per day and 5 days a week for 2 weeks. Capsular stretching was
followed by 10 minutes of icing to prevent post exercise muscle soreness.
Group B: Subjects received treatment with moist pack for 10 minutes followed by MET
for abduction, flexion, extension, and rotation restriction which were again followed by
icing for 10 minutes. Subjects were positioned in the lateral recumbent position with the
involved upper extremity upper most.
MET for G.H. Joint restricted flexion: Therapist stands in front of the patient and places
one hand over the top of the patients shoulder at the superior part of the scapula and cup
the G.H. joint to palpate for motion .The other hand and forearm support the patients
flexed elbow and flex the humerus at the G.H. Joint in the sagittal plane up to the initial
point of resistance. Direct the patient to extend the elbow against your equal counterforce.
Maintain the forces for 3-5 seconds allow the patient to relax for 2 seconds, take up the
slack and then repeat.
MET for G.H. Joint restricted extension: Therapist stands in front of the patient and
places one hand over the top of the patients shoulder at the superior part of the scapula and
cups the G.H. joint to palpate for motion. Uses the other hand to support patients flexed
elbow and direct the patient to push the elbow anteriorly.
MET for G.H.joint restricted abduction: Therapist stands in front of the patient, places
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her one hand over the top of patients shoulder, cups the G.H. joint to palpate for motion.
direct the patient to press the elbow towards the body.
MET for G.H.joint restricted internal rotation: Therapist stands facing the patient.
Carefully place the dorsum of the patients hand against the patients back. Therapist places
her hand over the top of shoulder and superior part of the scapula and other palm protecting
anterior side of the shoulder capsule. Places her other hand posterior to the patients flexed
elbow. Direct the patient Press your elbow against my fingers
MET for G.H.joint restricted external rotation: Therapist stands behind the patient.
Places her hand superior to the patients GH joint. Places her forearm of the other hand
medial to the patients flexed forearm with her hand supporting the patients hand and the
wrist. Direct the patient to internally rotate the arm by pressing the hand.
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3.8 STATISTICAL MEASURES
Data collected for pre test and post test values using Pennsylvania shoulder scale (1st
subset) from Group A & Group B and was analyzed by using paired t test to find the
difference within the group and unpaired t test to find significant difference between the
groups.
s1, s2 = Standard deviation of two groups.
X1, X2 = Mean difference of two groups.
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DATA ANALYSIS AND INTERPRETATION
Data analysis is method of evaluation in research study. In this study evaluating the data is
through descriptive statistical method (i.e) paired t test and unpaired t test.
DATA INTEPRETATION
Paired t test is used to analyze the significant difference between the pre and post
test values within the group.
Unpaired t test is used to analyze the significant difference between the groups.
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Table 1:
Mean, Standard Deviation and paired t Values for Groups A & B
Mean Standard Deviation Paired t Test
Group A 24.06 7.98 11.66
Group B 7.03 1.92 14.17
Mean and standard deviation are calculated from pre and post test values of
Group A and Group B (Refer Annexure III)
Results
The data is subjected to statistical analysis for Group A
t cal = 11.66 ttable = 4.14
The calculated t value 11.66 for Group A is greater than table value 4.14 (P t table
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Table 2
Mean of pre and post test value for Group A & Group B
Group A Group B
Mean
Pre Test Post Test Pre Test Post Test33.97 58.02 31.95 38.98
GRAPH 1
Mean of pre and post test values for Group A & Group B
Table 3:
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Mean, Standard Deviation and unpaired t Value for comparing Group A & B
Mean Standard Deviation Unpaired t Test
Group A 24.06 7.98
8.18
Group B 7.03 1.92
Results
The data is subjected to statistical analysis for Group A & Group B
t cal =8.18 ttable = 3.67
The calculated t value 8.18 for Group A and Group B is greater than table
value 3.67 (P t table
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GRAPH 2
Graph I shows Mean difference between Group A & B after the treatment.
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RESULTS
The data collected and subjected to statistical analysis supports the hypothesis that
both capsular stretching and muscle energy technique are effective on reducing pain and
improving the function in patients with frozen shoulder.
Further analysis also supports the hypothesis that there is a significant difference in
the effectiveness of both capsular stretching and muscle energy technique in frozen
shoulder patients.
The study proves that both can be preferred for treatment of frozen shoulder
patients but muscle energy technique is more effective than capsular stretching in reducing
pain and improving function.
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DISCUSSION
In frozen shoulder patients capsular stretching and muscle energy technique are
effective treatment for reducing pain & improving function. In this study we compared the
pre and post test values for Group A & Group B using the university of Pennsylvania
shoulder scale (1st subset)
1) In Group A the calculated t value (11.66) is greater than the table value (4.14) i.e.,
(P
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CONCLUSION
From the results of the present study it can be concluded that muscle energy
technique is more effective than capsular stretching in reducing pain and improving
function in frozen shoulder patients.
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20. Andersen NH, Sajlurg Jo, Johansen HV, Sheffen G. Frozen shoulder. Arthroscopy &
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ANNEXURE 1
UNIVERSITY OF PENNSYLVANIA SHOULDER SCALE (Ist Subset):
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PART 2: FUNCTION: Please circle the number that best describes the level of
Difficulty you might have performing each activity.
3= no difficulty
2= some difficulty
1 = much difficulty
0 = cannot do at all
X= did not do before injury
Sl. No.
1.
Reach the small of your back to tuck in your
shirt with your hand.
3 2
1
0 X
2. Wash middle of your back /hook bra 3 2
1
0 X
3. Perform necessary toileting activities 3 21
0 X
4. Wash the back of opposite shoulder 3 2
1
0 X
5 Comb hair 3 2
1
0 X
6Place hand behind head with your elbow
held straight out to the side
3 2
1
0 X
7
Dress self (including put on coat and pull
shirt off overhead
3 2
1
0 X
8 Sleep on the affected side 3 2
1
0 X
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9 Open a door with affected side 3 21
0 X
10 Carry a bag of groceries with affected arm 3 2
1
0 X
11
Carry a briefcase / small suitcase with
affected arm
3 2
1
0 X
12
Place a soup can ( 1 -2 lbs) on shelf at
shoulder level without bending elbow
3 2
1
0 X
13
Place a one gallon container ( 8-10 lbs)
on a shelf at
shoulder level without bending elbow
3 21
0 X
14Reach a shelf above your head without
bending elbow
3 2
1
0 X
15Place a soup can (1-2lbs) on a shelf above
your head without bending your elbow
3 2
1
0 X
16
Place a one gallon container (8 10 lbs) on a
shelf overhead without bending elbow
3 2
1
0 X
17 Perform usual sport/hobby 3 21
0 X
18Perform household chores (cleaning,
laundry, cooking)
3 2
1
0 X
19
Throw overhand/swim /overhead racquet
sports (circle all that apply to you)
3 2
1
0 X
20 Work fulltime at your regular job 3 21
0 X
Scoring
Total of columns = _________(a)
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Number of Xs x 3 = ________(b), 60 - ______ (b) = _________(c) (if no Xs are circled
functions source = total of columns)
Function score = _____(a) / ____(c) = _____ x 60 ______ / 60
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ANNEXURE II
CONSENT LETTER FROM THE PATIENT
Sl. No.
Name :
Age:
Sex:
I ________________________ authorize Mrs. Vishnu Priya .A student of Cherran College
of Physiotherapy of perform physiotherapy intervention on me to relieve pain & improve
function.
The purpose of the study and the need for the procedure has been explained to me
in the language I understand.
(Signature of the patient)
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ANNEXURE III
MASTER CHART - 1
University of Pennsylvania Shoulder Score (1st subset) for Group A
S. No.
PENNSYLVANIA SHOULDER SCORE FOR GROUP A
Pre Test Values Post Test Values
1 35.22 60.00
2. 27.88 56.55
3. 35.25 67.71
4. 29.35 57.87
5. 15.44 42.22
6. 27.88 45.11
7. 37.55 65.33
8. 38.00 56.82
9. 37.88 59.55
10. 24.18 56.08
11. 65.33 71.33
12. 24.66 49.33
13. 55.97 66.15
14. 24.55 57.33
15. 30.38 58.97
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MASTER CHART 2
University of Pennsylvania Shoulder Score (1st Subset) for Group B
S. No.
PENNSYLVANIA SHOULDER SCORE FOR GROUP B
Pre Test Values Post Test Values
1. 20.56 24.24
2. 33.70 43.77
3. 25.66 30.44
4. 21.81 25.29
5. 32.11 40.11
6. 27.28 32.53
7. 24.22 31.33
8. 50.00 57.11
9. 26.55 33.88
10. 50.83 58.21
11. 27.00 35.11
12. 22.15 30.58
13. 38.44 45.77
14. 44.43 53.56
15. 34.56 42.84