Effect of manual therapy techniques on pain and range of motion in patients with Adhesive Capsulitis

Abstract

Background: Idiopathic adhesive capsulitis is a self-limiting condition with an unknown cause. It is characterized by restriction to the shoulder range of motion in a capsular manner. The main aim of treatment is to reduce pain, increases ROM and therefore restores upper limb functional activities.

The Objective of the study is to find out the effect of manual therapy techniques on pain and range of motion in patients with Adhesive Capsulitis

Methodology: Patients from Physiotherapy department of Fortis O.P. Jindal hospital, Raigarh diagnosed with shoulder adhesive capsulitis were included in this study. 20 Subjects were selected from both the gender between 40-60 years of age with capsular pattern. In respective with the criteria of the study were randomized 2 groups or 2 types of techniques. Group 1st technique was given soft tissue mobilization followed by Antero-inferior glide and Group 2nd technique was given Muscle energy techniques followed by Antero- inferior glide. The outcome measure was taken by using VAS and Goniometer.

Results: Data was analyses using T-Test (Paired two Sample for means) of 20 subjects using excel calculations and that there was graph reveals that there was significant improvement in the outcome measures of group 1st was given soft tissue mobilization followed by Antero-inferior glide and group 2nd technique was given Muscle energy techniques followed by Antero- inferior glide.

Conclusion: Both the Manual therapy techniques is effective in reducing pain and increase ROM and restores shoulder functions but is more applicable manual therapy technique Group 2nd technique was given Muscle energy techniques followed by Antero- inferior glide is more effective than Group 1st technique was given soft tissue mobilization followed by Antero-inferior glide.

Key words: Adhesive Capsulitis, Pain, Range of motion, Maitland Mobilization

Introduction

ADHESIVE CAPSULITIS

Adhesive Capsulitis (AC) is a shoulder problem and represented by a abrupt and painful loss of both active and passive range of motion in all planes of glenohumeral joint, mainly external rotation due to gradual fibrosis and contracture of the glenohumeral joint capsule.1

This condition was first described as ‘periarthritis’ by Duplay in 1872 and the word Frozen

Shoulder was first coined by Codman in 1934 and described this condition as a steadily developing condition, featured by pain close to the deltoid insertion, lack of ability to a functional activities of the affected side or lack of ability to sleep on the affected side, painful and limitation of abduction and external rotation and a standard radiological appearance.2

Neviaser said that, frozen shoulder and adhesive capsulitis are commonly used interchangeably, identifications that many pathology can cause a stiff and painful shoulder while adhesive capsulitis is a definite pathological entity.3 {Figure 1]

It has been categorized into two parts

Primary adhesive capsulitis Secondary adhesive capsulitis

Primary adhesive capsulitis Secondary adhesive capsulitisIt is also called as idiopathic frozen shoulder.It is not correlated with any other systemic conditions.It is not associated with any other injury of history.4

It is commonly defined as a correlate between a disease and any pathology.Such as any cardiovascular disease, neurological and any further disease.4

Aim and Objective:

Examine the effect of manual therapy techniques regarding pain and range of motion in patients with Adhesive Capsulitis.

Group 1st Technique: Soft tissue mobilization followed by Antero-inferior glide.

Group 2nd technique: Muscle energy techniques followed by Antero- inferior glide.

Two objective of this study:1. Pain2. Range of motion

Need of study: The need of a study is to find out a best possible protocol for treating Adhesive Capsulitis in least possible time duration comparing the two techniques.

Null Hypothesis {H0}

There will be significant difference in improvement in the pain and Range of motion between Group 1st technique was given soft tissue mobilization followed by Antero-inferior glide and Group 2nd technique was given Muscle energy techniques followed by Antero- inferior glide.

Experimental Hypothesis {H1}

There will be significant difference in improvement in the pain and Range of motion and VAS between Group 1st technique was given soft tissue mobilization followed by Antero-inferior glide and Group 2nd technique was given Muscle energy techniques followed by Antero- inferior glide.

Methodology:

• Subject- 20 patients • Site- Fortis op Jindal hospital, Raigarh• Study design- experimental study• Method: Convenient Sampling

INCLUSION CRITRERIA

• Idiopathic cases

• Age 40-60 years{5)

• Painful and restricted active and passive range of motion of the shoulders.• Both Males and Females • Diabetes present for at least 6 months• Symptom present for at least for 2 month

EXCLUSION CRITERIA

• Pregnancy• Carcinogenic • Metallic IMPLANTS or foreign bodies• Tumors• Spread of infection• Tuberculosis• Secondary Adhesive capsulitis• Atherosclerosis

Assessment Parameters

Range of motion by universal Goniometer{5}

Visual analogue Scale to measure Pain{5}

Procedure

Pre-test measurements were taken with the help of Visual analogue scale and goniometer prior to the intervention. The subjects 20 were selected and divided in to 2 groups. Group 1st technique was given soft tissue mobilization followed by Antero-inferior glide and Group 2nd technique was given Muscle energy techniques followed by Antero- inferior glide.

Group 1st

1st techniques:- There will be used on 10 patients• MOIST HEAT {DOSAGE- 10 TO 15 MINUTES} will be applied around the glenohumeral

joint. (Figure 2)

• Soft tissue mobilization (DTFM) for 3 to 5 minutes (Pectoralis minor, teres minor ad deltoid)

• Maitland Mobilization: 1st seven session grade 3 and next 8 session grade 4 Antero-Inferior glide for glenohumeral joint: (Figure 3)

Subject’s Placement: Subject was made to sit on the couch. Physical Therapist Placement: The Physical therapist stands a side of

the subject couch at the same side of the involvement. Procedure:

1. The Physical therapist interlocks the fingers of both hands. Hands Placement at the supero-lateral angle of the humeral head.

2. The therapist applies the force directed antero-inferior. Clinical Significance: As the anterior-inferior part of the capsule is

affected while applying the mobilization the antero-inferior capsule gets stretched, this facilitates more abduction and external rotation.

• CRYOTHERAPY (dosage 10 to 15 minutes) will be applied around the glenohumeral joint. (Figure 4)

• 15 session in 3 weeks (per session 30 to 45 minutes)

Group 2nd

2nd technique:- There will be used on another 10 patients• Moist heat(dosage 10 to 15 minutes) (see Figure 2)• Muscle energy techniques

Muscle energy technique for glenohumeral joint: (Figure 5)

Subject’s Placement: Patients was made to sit on the couch Physical Therapist Placement: The Physical therapist stands a side of

the subject couch at the same side of the involvement. Procedure:

1. The subject glenohumeral joint is taken to the restricted to the barrier.

2. The subject is asked to move away from the barrier. The muscular effort is 20-30% and the muscle is concentrically contracted for 6-10 seconds with repetitions 6-10 times.

Clinical Significance: In case of movement restriction the muscle may become tight with the MET may get lengthened and permit more movement.

Muscle energy technique for Pectoralis Minor: (Figure 6)

Subject’s Placement: Patients was asked to lie on the back in the couch.

Physical Therapist placement: The Physical therapist stands a side of the subject couch at the same side of the involvement.

Procedure: 1. The subject anterior aspect of the acromion is taken posterior

and superior.2. The Physical therapist reaches for the barrier and asks the

subject to bring the anterior shoulder antero-inferior (action of pectoralis minor). The muscular effort is 20-30% and muscle concentrically contractions for 6-10 seconds with repetitions 6-10 times.

Clinical Significance: In case of movement restriction the muscle may become tight with the MET may get lengthened and permit more movement.{6}

• Maitland Mobilization: 1st seven session grade 3 and next 8 session grade 4

Subject’s Placement: Subject was made to sit on the couch. Physical Therapist Placement: The Physical therapist stands a side of

the subject couch at the same side of the involvement. Procedure:

3. The Physical therapist interlocks the fingers of both hands. Hands Placement at the supero-lateral angle of the humeral head.

4. The therapist applies the force directed antero-inferior. Clinical Significance: As the anterior-inferior part of the capsule is

affected while applying the mobilization the antero-inferior capsule gets stretched, this facilitates more abduction and external rotation.

• Cryotherapy for 10 to 15 minutes will be applied around the Glenohumeral joint.• 15 sessions in 3 weeks (per session 30 to 45 minutes)

Both groups patients were given home exercise programme (including Codman’s exercise and finger ladder exercise, advanced anterior capsular stretch, hand behind back in standing, capsular stretches).{6}

HOME EXERCISE PROGRAMME CHART:

Codman’s pendulum 3-5 mins*5times/day

Finger ladder 15-30sec*10-15 rep*5/day

Capsular stretches 3 times/week*3weeks

Advanced anterior shoulder stretches 3/day- 15 sec hold-5 rep 3-5/day

Hand behind back in standing 5/day- 15 sec hold rep. 5-7/day

Patients in both the groups were assessed at the end of 15 sittings of the treatment session.

Data analyses:

Data was analyses using T-Test (Paired two Sample for means)

Result:

Visual analogue scale (Graph: 1) Represents that the pre- treatment and post treatment readings of Vas analogue scale.

Table 1 showing pain distribution scores measured with the help of visual analogue scale in patients treated in GROUP 1 and GROUP2

GROUP 1: Soft tissue mobilization followed by antero-inferior glide.

GROUP 2: Muscle energy technique followed by antero-inferior glide.

Table1

Showing pain distribution scores measured with the help of visual analogue scale in patients treated in GROUP 1 and GROUP2

Pre-treatment value

Post treatment value

T value p value

Mean MeanGroup 1 7.6 1.6 40.2 p 0.0001Group 2 7.6 0.8 51 p 0.0001

Graph1: Represents that pre- treatment and post treatment readings of Vas analogue Scale.

Group A Group B0

1

2

3

4

5

6

7

8

Pre-treatment ReadingsPost- treatment readings

Group 1 patients, prior treatment VAS score was 7.6 and which was reduced to 1.6 after the treatment, showing significant differences (p 0.0001) between the before and after score (t=40.2).

Group 2 patients, prior treatment VAS score was 7.6 and which was reduced to 0.8 after the treatment, showing significant differences (p 0.0001) between the before and after score (t=51).

RANGE OF MOTION (Abduction) Graph 2 Represents that the pre-treatment and post treatment readings of mean range of motion.

Table 2

Represent scores distribution in shoulder abduction range of motion (ROM) in group 1 and group 2 Patients.

Pre- treatment value

Post treatment value

t-value P-value

Mean MeanGroup 1 87.5 176 172.5 P 0.0001Group 2 90.5 178.5 136.5 P 0.0001

Graph 2 Represent that the pre-treatment and post treatment readings of mean range of motion in abduction.

Group A Group B0

20

40

60

80

100

120

140

160

180

200

Pre-treatmet reading mean range of motion in abductionPost- Treatment Reading mean range of motion in abduction

Table 2 Represent scores distribution in shoulder abduction range of motion (ROM) in group 1 and group 2 Patients. Group 1 patients, prior treatment ROM score was 87.5 and which was increased 176 after the treatment showing highly significant differences (p 0.0001) between the before and after treatment score (t=172.5). Group 2 patients, prior treatment ROM score was 90.5 and which was increased 178.5 after the treatment showing highly significant differences (p 0.0001) between the before and after treatment score (t=136.5).

Range of motion (External Rotation) Graph 3 Represents that the pre-treatment and post treatment readings of mean range of motion in external rotation.

Table 3

Represent scores distribution in shoulder external rotation range of motion (ROM) in group 1 and group 2 Patients.

Pre- treatment value

Post treatment value

t-value P-value

Mean MeanGroup 1 42 86.7 172.5 P 0.0001Group 2 42 87.5 136.5 P 0.0001

Graph 3 Reprsent that the pre-treatment and post treatment readings of mean range of motion in external rotation.

Group A Group B0

10

20

30

40

50

60

70

80

90

100

Pre- treatment reading mean range of motion in external ro-tationPost- treatment reading mean range of motion in external ro-tation

Table 3 Represent scores distribution in shoulder External rotation range of motion (ROM) in group 1 and group 2 Patients. Group 1 patients, prior treatment ROM score was 42 and which was increased 86.7 after the treatment showing highly significant differences (p 0.0001) between the before and after treatment score (t=172.5). Group 2 patients, prior treatment ROM score was 42 and which was increased 87.5 after the treatment showing highly significant differences (p 0.0001) between the before and after treatment score (t=136.5).

Discussion:

The present study was done to evaluate effectiveness of two procedures that is STM and MET followed by Antero-inferior glide in both the procedures on adhesive capsulitis of the shoulder joint, and also to compare which of the procedure in better in terms of decreasing pain, improving functional range of motion of and the joint mobility. All the participants have received intervention for a period of 15 days following which the mobilization were discontinue and the patients were put on the home exercise programme. The pain relief was positive in both the groups. Statistically significant difference was shown in between both the groups when the response were compared between the groups, the results showed significant difference at 15 days of intervention which means that MET followed by antero-inferior glide is better than STM followed by antero- inferior glide in relieving pain.

According to the previous study Sengya Phukon et. al. (Comparative study between the Maitland mobilization and Muscle energy techniques in 2nd stage of shoulder Adhesive capsulitis) concluded that the both the treatment protocols are equally effect but is more effective Group A means Maitalnd Mobilisation is more effective than Group B means Muscle energy techniques in 2nd stage of Shoulder adhesive Capsulitis.{5}

The present study shows there was significant differences in Range of motion at followed up both the groups. Both the procedure is effective in increasing ROM in patients with the adhesive capsulitis. Both the groups on follow up shows functional improvement and achievement and ROM. Abduction and external rotation ROM has shown maximal improvements in between the groups received MET and STM followed by antero- inferior glide.

Limitations:

Sample size is small. Study duration is short

Conclusion:

The results represent that both the manual therapy techniques are effective in decreasing pain intensity and increasing shoulder Range of motion and resulting in restoring upper limb functional activities in patients with Adhesive Capsulitis, group 1st was given soft tissue mobilization followed by Antero-inferior glide and group 2nd was given Muscle energy techniques followed by Antero- inferior glide. But comparing the highest level of positive outcomes within the techniques. The improvement after 15 sessions of either group 1 or group 2 was significant. Group 2 (MET followed by antero- inferior glide) is more effective in the treatment of patients suffering from adhesive capsulitis than group 1 (STM followed by Antero-inferior glide).

Acknowledgements:

The authors thank Dr Anupma Sharma (PT) and Dr Sumit Sharma (PT) for support in making manuscript special gratefulness are extended Dr Dinesh kumar (PT) and Dr Ashok Panda (PT) and Dr Abhishek Tripathi (MS, Ortho) for their support and guidance throughout their study. The author’s acknowledgment the special support received from the scholars whose articles are included in this manuscript. The author is equally thankful to authors/editors/publishers of all those articles, journals and books from where the literature for this article has been referred and discussed.

Abbreviations: Range of motion (ROM), AC (Adhesive capsulitis), Soft tissue mobilizations (STM), Muscle energy techniques (MET), Physiotherapists (PT), Master of Science (MS)