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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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BIBLIOGRAPHY

1. Lori B. Siegel, Norman J. Cohen and Eric P. Gall. Adhesive capsulitis: A sticky issue,

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2. Mark A. Harrast & Anita G. Rao. The stiff shoulder. Physical Medicine & Rehabilitation

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4. Thomas A. Souza, Sports injuries of the shoulder: Conservative management, Churchill

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5. Joseph P. Iannotti and Gerald R. Williams, Jr. Disorders of the shoulder, Diagnosis &

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11. Fusun Guler-Uysal, Erkan Kozanoglu. Comparison of the early response to two methods of

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20. Andersen NH, Sajlurg Jo, Johansen HV, Sheffen G. Frozen shoulder. Arthroscopy &

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Technique in patients with acute low back pain: a pilot clinical trail. Journal of Orthopaedic

& sports Physical therapy 2003;33:502-812.

24. Leon Chaitow & Judith Walker Delany. Clinical application of Neuromuscular techniques

Volume 1. The upper body, Churchill Livingstone 2000.

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27. Craig Liebenson DC. The role of manipulation in rehabilitation.Dynamic Chiropractice

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range of motion. J Man Manip Ther 1994;2:149-155.

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30. John Connolly, Eugene Regen and O.B. Evans. The management of the painful, stiff

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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

38


39/39

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

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