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INTRODUCTION
INTRODUCTION:
Patients with diagnosis of adhesive capsulitis are commonly seen in physiotherapy department4.
The condition was first recognized as being distinct from glenohumeral arthritis at least as early as 1872 by Duplay 2.
Codman introduced the term “adhesive capsulitis” in 1934 to describe patient who had a painful loss of shoulder motion with normal radiographic studies, describing the presentation as a slow onset of shoulder pain, an inability to sleep on the affected side, restricted glenohumeral elevation and external rotation.3,15
The term”adhesive capsulitis”, theorizing that this pathology results from thickening and eventual contracture of the glenohumeral capsule.3, 15
Over the years the adhesive capsulitis has had many different names, including shoulder periarthritis, adherent subacromial bursitis and adhesive capsulitis. Currently adhesive capsulitis and adhesive capsulitis are the preferred term and may be used interchangeably 2.
Approximately 2-3 % of adult aged between 40 and 65 years developed adhesive capsulitis with greater occurrence in women3. The exact cause is not known. The autoimmune theory has been proposed, but conclusive evidence has not been found yet1.
There is higher than normal association between adhesive capsulitis and diabetes mellitus1.
Anatomy and Biomechnics:
Glenohumeral joint is a multiaxial ball and socket synovial joint that depends on muscles rather than bones and ligaments for its support, stability and integrity 8. Since the glenoid fossa of the scapula is the proximal segment of the glenohumeral joint, any motion of the scapula may affect glenohumeral joint function 11.
These are spherical surfaces, typical of ball and socket joint which has three axes and three degrees of freedom 5.
Articulation occurs between the rounded head of, the humerus and the shallow, pear shaped glenoid cavity of the scapula. The articular surfaces are
covered by hyaline articular cartilage and the glenoid cavity is deepened by the presence of a fibro cartilaginous rim called the glenoid labrum. 6
The radius of the curvature of the glenoid cavity in the coronal plane is greater than that of the humeral head 7. In most positions these curvatures are not fully congruent, the joint being loosely packed.Full congruence (close packing) is reached with the humerus abducted and laterally rotated 7.
A fibrous capsule envelops the joint attaching medially to the glenoid margin, outside the glenoid labrum and encroaching on the coracoid process to include the attachment of the long head of biceps. Laterally, it is attached to the humeral anatomical neck that is near the articular margin, except, inferomedially where it descends more than 1cm on the humeral shaft 7.
The capsule is thin and lax, allowing a wide range of movement. It is strengthened by fibrous slips from the tendons of the subscapularis (in front), supraspinatus (above) infraspinatus and teres minor (behind) and by the long head of triceps (below) 6,7.Triceps blend with the capsule as the rotator cuff which reinforces the capsule and actively supports it unless the muscles are fully relaxed 7.The capsule is also strengthened in front by extensions from the tendons of pectoralis major and teres major7.
There are four groups of motion possible at the shoulder joint –
- Flexion and extension.
- Abduction and adduction.
- Medial and lateral rotation.
- Horizontal abduction and adduction.
Given the forward movement of the humerus in flexion, the greater tubercle automatically slides behind the acromion process.The range of motion for flexion and abduction of the glenohumeral joint are reported to be anywhere from 90o to 120o or as much as 135o.The plane of the scapula lies approximately midway between the frontal and sagittal planes. When the humerus moves in the plane of the scapula there is less restriction to motion.
The glenoid fossa and humeral head are incongruent surfaces. The convex humeral head is not parallel to concave fossa11. If the humeral head simply rotates in the glenoid fossa it would run out of the articular surface before much abduction has occurred and the vertical pull of the deltoid muscle would pull the head up against the acromion process. It is the arthrokinematic motions of glide, spin and roll that keep the head of the humerus articulating with the glenoid fossa10.
As the abduction occurs, the humeral head rolls across the glenoid fossa. At the same time the head glides inferiorly, keeping the head of the humerus articulating with the glenoid fossa.. The suprspinatus muscle, in addition to abducting the shoulder joint pulls the humeral head into the glenoid fossa. The other rotator cuff muscles (subscapularis, infraspinatus and teres minor) pull the head in and downward against the glenoid fossa. The glenoid labrum serves to slightly deepen the glenoid fossa making the joint surfaces more congruent.10
With motions of the humerus (physiologic motions) the convex head slides in the opposite direction of the humerus12.
If the humerus is stabilized and the scapula moves, the concave glenoid fossa slides in the same direction that the scapula moves12.
Given the incongruence of the glenohumeral articular surfaces, the bony surface alone can not maintain joint contact in the dependent position (arm hanging at the side). As the humeral head rests on the fossa gravity acts
on the humerus parallel to the shaft in downward direction (negative translatory force).This would appear to require a vertical upward pull to restore equilibrium. Such a vertical force would only be supplied by muscle such as anterior deltoid or the long heads of the biceps brachii and tricep brachii.
Basmajian ,Bazant and MacConnail have shown that all muscles of the shoulder complex are electrically silent in the relaxed, unloaded limb and even when the limb is tugged vigorously downward. The mechanism of joint stability, therefore must be passive. Given the axis and the line of pull, gravity creates an adduction movement on the humerus. As can be, the gravity must be offset by a force that can apply a torque of equal magnitude in the direction of abduction. Such a force can be applied by the superior joint capsule and the coracohumeral ligaments, which are taut when the arm is at the side.
The passive tension in the capsule and coracohumeral ligament is sufficient in most cases to counteract the effect of gravity. When the limb is loaded, the adduction movement (gravity plus the load) may require more force than can be safely provided by these structures.
The shoulder complex acts in a coordinated fashion to provide the smoothest and greatest range of motion possible to the upper limb. Motion available to the glenohumeral joint alone would not account for the full range of the elevation (abduction or flexion) available to the humerus. The remainder of the range is contributed by the scapulothoracic joint through its sternoclavicular and acromioclavicular linkages. Under normal and unconstrained conditions, each joint makes its contribution not only in a fairly consistent manner, but following a pattern of concomitant and coordinated movement known as scapulohumeral rhythm11.
The scapulothoracic joint contributes to both flexion and abduction (elevation) of the humerus by upwardly rotating the glenoid fossa 60o from its resting position. If the humerus were fixed to the fossa; this alone would result in 60o of elevation of the humerus. The humerus is not fixed, of course but can move independently on the glenoid fossa. The glenohumeral joint contributes 120o of flexion and anywhere from 90o to 120o of abduction (depending on individual structural variations and on ones philosophy of available glenohumeral abduction). The combination of scapular and humeral movement results in what is commonly held to be a maximum range of elevation to 180o11.
There is roughly a 2:1 ratio of movement of humerus to the scapula with 120o of movement occurring at the glenohumeral joint and 60o at the scapulothoracic joint.
During this total simultaneous movement at the four joints, there are three phases8.
1) In the first phase of 30o of elevation through abduction, the scapula is said to be “setting”. This setting phase means that the scapula may rotate slightly in, rotate slightly out or not move at all. There is no 2:1 ratio of movements during this phase. The angle between the scapular spine and the clavicle may also increase up to 5o by elevating at the sternoclavicular or acromioclavicular joints, but this will depend on whether the scapula moves during this phase. There is no rotation of clavicle in this phase.
2) During the next 60o of elevation (second phase) the scapula rotates about 20o and the humerus elevates 40o with minimal protraction or elevation of the scapula. Thus there is 2:1 ratio of scapulohumeral movement. During phase two, the clavicle elevates because of the scapular rotation, but there is still no rotation of clavicle. During the second and third phase, the rotation of the scapula (total 60o) is possible because there is 20o of motion at the acromioclavicular joint and 40o at the sternoclavicular joint.
3) During the final 90o of motion (third phase) there continues to be 2:1 ratio of scapulohumeral movement, and the angle between scapular spine and clavicle increases an addition 10o. Thus scapula continues to rotate and now begins to elevate. The amount of protraction continues to be minimal when the abduction movement is performed. It is in this stage that the clavicle rotates posteriorly 30o to 50o on the long axis and elevates up to a further 15o. Also during this final stage, the humerus laterally rotates 90o, so that the greater tuberosity of the humerus avoids the acromion process.
If the clavicle does not rotate and elevate, elevation through abduction at the glenohumeral joint is limited to 120o.
If the glenohumeral joint does not move, elevation through abduction is limited to 60o which occurs only in the scapulothoracic joint.
If there is no lateral rotation of the humerus, during the abduction, total movement available is 120o, 60o of which occurs at the glenohumeral joint and 60o of which occurs at the scapulothoracic joint 8.
Reverse scapulohumeral rhythm means that the scapula moves more than humerus. This is seen in the conditions such as adhesive capsulitis 8.
The following have been blamed 13.
Tendinitis of rotator cuff muscles and other shoulder injuries, Bicipital tenosynovitis, Muscle imbalance developed from inactivity, Reflex sympathetic dystrophy etc.
Adhesive capsulitis is ubiquitous term applied to any condition that limit’s passive glenohumeral motion. It is often the result of the contracture of the soft tissue which causes mechanical block.27
There are some factors, like pain, disuse and periarthritic personality are considered to contribute to the development of adhesive capsulitis.
Pain in shoulder can result from various intrinsic and extrinsic sources. Whatever the source, pain usually forces the patients to protect the arm from use. Immobilization of a synovial joint has been shown to have detrimental effects on the periarticular connective tissue.
The clinically observed loss of shoulder movement resulting from disuse may be the result of underlying connective tissue changes. Some investigators states that the psychological factors especially depression, apathy and emotional stress contribute to adhesive capsulitis. Patients with periarthritic personality have a low pain threshold, therefore any shoulder pain will be probably lead to early voluntary immobilization of the extremity therefore more likely to develop adhesive capsulitis 13.
A adhesive capsulitis may a late consequence of rotator cuff lesion and some time follows myocardial infarction, hemiplegia, herpes zoster infection or breast or thoracic surgery14.
Bilateral disease occurs in approximately 10% of patients but can be as high as 40% in patients with a history of insulin dependent diabetes15. It is believed that in patients with diabetes, associated micro vascular disease causes abnormal collagen repair, which predisposes them to adhesive capsulitis 16.
The shoulder is a closely fitted joint. The humeral head barely clears beneath the coracoacromial arch. The rotator cuff and the bicep tendon are exposed to the trauma of being forced against the arch. This causes reactive engorgement, edema, round cell infiltration and degeneration. The consequent thickening of these tissues acts as an additional mechanical barrier to passage of the head beneath the arch. Attempt to do so accentuate the traumatic inflammation and cause further swelling and greater interference with movement. A vicious circle is instituted 13.
If early rest is started, swelling subsides, gliding surfaces are preserved and a full range of motion is obtained. If constant trauma continues, the tissue degenerates further and attempts at healing by granulation tissues results in production of fibrous adhesion and adherence of all tissue, including the bicep tendon, the cuff, the bursa, the capsule, the humeral head and the acromion. The chronic inflammatory process tends to spread to the rest of the capsule and distally along the tendon sheet in the bicipital groove. Finally almost all movements are lost13.
In 1938, Mc Laughlin reported that in surgical exploration of number of adhesive capsulitiss, he found no histological evidence of inflammation. He too observed a loss of the inferior redundant fold. Mc Laughlin consistently found that the rotator cuff tendon was contracted and shrunken, holding the humeral head tight in the glenoid and allowing little motion at this articulation4.
Some arthroscopic studies described a proliferative synovitis that is especially evident in the early stage of adhesive capsulitis. Early arthroscopic studies described intra-articular adhesions particularly in the axillary fold, but later studies found anterior capsular thickening particularly at the coracohumeral ligament and superior glenohumeral ligament. Microscopic evaluation of these surgical specimens shows fibrosis and a decrease number of synovial cells. Though the initiating events in adhesive capsulitis remain unknown, but the end result appears to be fibrotic thickening of the anterior capsule at the rotator interval 2.
Neuropathic mechanism including suprascapular nerve compression, have been considered, but none account for most cases of adhesive capsulitis.Although strong evidence suggest an association among these neuropathic and vascular conditions and adhesive capsulitis, no pathophysiologic mechanisms are convincing. Theories regarding autoimmune reactions to tendon degeneration have led to immunologic investigations. Although random and inconsistent, the inflammatory indexes measured (e.g. erythrocyte sedimentation rate) were partially supported because they were slightly evaluated and improved as the disease improved. Synovial fluid offers no clue to etiology of adhesive capsulitis. Biopsies of the synovial lining have revealed increased fibroblasts and vascular dilatation but few or no perivascular inflammatory cells16.
Clinical Picture:
The clinical profile of the patients with adhesive capsulitis is fairly well established2.
Adhesive capsulitis is classically characterized by three stages. The length of each stage is variable, but typically the first stage lasts for 3 to 6 months, the second stage from
The first stage is the “freezing phase”, characterized by the onset of an aching pain in the shoulder. The pain is usually more severe at night and with activities and may be associated with a sense of discomfort that radiates down the arm. As symptoms progress, there are fewer arm positions that are comfortable. Most patients will position the arm in adduction and internal rotation. This position represent the “neutral isometric” position of relaxed tension for the, inflamed glenohumeral capsule, biceps and rotator cuff15.
The second stage is the progressive stiffness or “frozen phase”. Pain at the rest, usually diminishes during this stage, leaving the patient with shoulder that has restricted motion in all planes. Activities of daily living become severely restricted. Patients complain about their inability to reach into the back pocket, fasten the bra, comb the hair or wash the opposite shoulder. When performing these activities, a sharp, acute discomfort can occur as the patient reaches the restraint of the tight capsule15.
The final stage is resolution or “thawing phase”. This stage is characterized by a slow recovery of motion. Aggressive treatment with physical therapy, closed manipulation or surgical release may accelerate recovery, moving the patient from frozen phase into thawing phase.15
The clinical picture is one of the insidious onsets of generalized aching discomfort about the shoulder1. Many patients will have residual signs and symptoms years after the onset of their disease. The diagnosis of adhesive capsulitis may be suggested by careful history and physical examination2.
The finding of physical examination varies depending on the stage at which the patient present for the treatment. In general a global loss of active and passive motion is present. The loss of external rotation with the arm at the patient’s side is a hallmark of this condition15. The loss of passive external rotation is the single most important finding on physical examination and helps to differentiate the diagnosis from rotator cuff problem because problem of the rotator cuff generally do not result in loss of passive external rotation15. Passive mobility is also limited in capsular pattern with external rotation being limited most followed by abduction and then internal rotation4.The movement of flexion and internal rotation are involved to a lesser extent. No apparent muscular weakness will be present in available range of motion but the over pressure at the end of range will elicit pain17.The humeral head is held high against the acromion as compared with the opposite side and the pectoralis major is contracted. Signs of reflex sympathetic dystrophy often develop in the hand13.
The total time for greatest recovery is between one and four years after onset of the symptoms. More than half of the patients get permanent loss of shoulder motion as compared to the normal shoulder range of motion without any limitation in functional activities4.
In assessing a patient’s shoulder pain the examiner must distinguish between true glenohumeral joint problems and extra articular derangements. Active range of motion most likely be limited and painful in both cases but decreased passive range of motion which is often painful as well most likely indicate true joint pathology16.
The diagnosis of adhesive capsulitis is confirmed when radiographic studies are normal15. X-ray usually reveals normal joints or shows minimal degenerative changes. Clinical signs and symptoms of systemic inflammatory disorder are absent and other joints remain unaffected2.
“APLEY’S SCRATCH TEST” TO TEST
THE FUNCTIONAL CAPABILITY OF
THE PATIENT”
Arthrographic findings appear to be one of the most prevalent characteristics of adhesive capsulitis. In adhesive capsulitis, arthrogram finding include retraction of joint capsule away form the greater tuberosity, a ragged and irregular outline of the capsule and absence of the axillary redundant folds4.
Special Tests:
Various physical examination tests performed are as follows:
i) Tests for common muscle and tendon pathology: 8
- Speed’s test (Biceps).
- Empty can test (supraspinatus).
- Lift off test (subscapularis).
4. Drop arm test (Codman’s test).
ii) Test for impingement:8, 18
Hawkins’s Kennedy impingement test.
iii) Test for functional capacity of the patient: 8
Apley’s scratch test.
Treatment Approaches:
There is no unanimous opinion regarding the proper method of treatment. A greater number of the therapeutic regimes have been advocated, none have proved consistently successful 19. The first line of treatment is usually a course of oral analgesic drug such as NSAIDs with physical therapy. It is believed that physical therapy is of little or no use during the freezing or frozen phases, but may help to speed up recovery during the thawing phase. Patient may have a more than dozen physical therapy session during this time including ultrasound, TENS mobilization and exercise regimens. One of the several more invasive treatment option includes manipulation under anesthesia followed by several months of intensive physical therapy, or if severe, more intensive surgery19.
Though many treatments have been advised to improve outcome in-patients with adhesive capsulitis following treatment approches are commonly being used more or less effectively2,16.
i. Rest, analgesia and range of motion exercises:
This regimen is the simplest of all treatments and is used when the patient presents earlier in the course of disease. Rest is prescribed and perhaps even a sling is used. Pain medication is given as needed. Range of motion pendulum exercises and table crawls are began as soon as pain allows.
ii. Active home exercises:
These excercises are used when the painful phase has resolved and patient needs to regain the motion.
iii. Physical therapy:
Formal physical therapy programs may help those who require a more structured rehabilitation program. Programs incorporate various modalities to decrease pain and employ passive mobilization to improve range of motion.
iv. Oral prednisone:
Oral prednisone has been prescribed by some clinicians on the presumption that adhesive capsulitis is an inflammatory disorder. The results demonstrates some relief of pain but no change in range of motion.
v. Corticosteroid injections:
The rationale for corticosteroid is the same as for prednisone. Injection is generally intra articular but some studies showed equivalent results using subacromal injections. The dosing schedule varies from a single injection to one injection weekly for six weeks to one injection every 6 weeks for upto 3 injections. All corticosteroid injections generally bring moderate relief of pain but minimal changing range of motion
vi. Capsular distention:
The procedure seeks to rupture the contracted capsule with an intrarticular injection of fluid or air. Capsular distention can provide substantial pain relief in some patients. But pain can be aggravated in less than 10 degrees.
vii. Manipulation under anesthesia:
In this procedure capsular fibrosis is manually ruptured while patients are under general anesthesia or have had an interscalene brachial plexus block. Manipulation may require a intensive pain control and physical therapy afterward. The technique has also been reported to cause humerus fracture and vascular and neurologic injury.
viii. Surgical capsular release:
This procedure is done arthroscopically or via incision.Contracted tissues are directly visualized and released. Reports indicate that patients are 90% pain free and have normal to near normal motion within three months after surgery.
It is difficult to draw reliable conclusions about the efficacy of one treatment versus another based on the current studies.
AIMS OF THE STUDY
AIM OF THE STUDY:
To do a comparative study between the efficacy of Maitland’s mobilization
and Muscle Energy Technique in the treatment of adhesive capsulitis.
HYPOTHESIS
HYPOTHESIS:
Null Hypothesis:
There will be no significant difference in improvement in the range of motion and shoulder pain and disability index between two groups before and after treatment.
Alternative Hypothesis:
There will be a significant difference in improvement in the range of motion and shoulder pain and disability index between two groups before and after treatment.
REVIEW OF LITERATURE
REVIEW OF LITERATURE:
Ekelund and Rydall (1992) compared the outcomes of patients treated with distension arthrography, local anesthetic and manipulation followed by physical therapy. At four to six weak follow up, 91% of the subject who had undergone this combination of treatment reported complete or partial relief of pain and 82% exhibited normal active range of motion or near normal active range of motion. 28
Waldberg et al (1992) reported that physical therapy combined with subcutaneous calcitonin injections, performed daily for 21 days, resulted in significantly greater pain reduction compared to physical therapy alone. Both group received identical physical therapy including active mobilization with electro-analgesia and cryotherapy. However there was no significant difference in the time to functional recovery between the two groups. 29
Mao et al (1997) reported statistically significant improvement in glenohumeral active range of motion and reappearance of the axillary recess (via.arthrography) in subjects managed with 12 to 18 sessions of physical therapy including moist heat, ultrasound, passive joint mobilization flexibility and strengthening exercises.30
Placzek J D et al (1998) studied the long term effect of glenohumeral joint translation (gliding) manipulation on range of motion, pain and functions in patients with adhesive capsulitis. Thirty-one patients underwent brachial plexus block followed by translation manipulation of glenohumeral joint. Changes in the range of motion and pain were assessed before manipulation with the patient under anesthesia, immediately after manipulation with the patient still under anesthesia, at early follow up (5.3±3.2 weeks) and to long term follow up (14.4±7.3 months). Passive range of motion increased significantly for flexion, abduction, external rotation and internal rotation. Significant decrease in visual analog pain score between initial evaluation and the follow up assessment also occurred. 22
Vermeulen et al (2000) reported that patient subjected to end range mobilization techniques demonstrated significant increases in active range of motion. At a nine month follow up appointment, four patients (57%) rated there improvement in shoulder function as excellent, while two (29%) rated it a good and one (14%) rated it as moderate21.
Arslan s et al compared the efficacy of local steroid injection and physical therapy measures for the treatment of adhesive capsulitis. Ten male and Ten female patients were enrolled in the study. The patients were divided randomly in to two groups and treated with either 40-mg methylprednisolone acetate injection with local anesthetic (Group A) or physical therapy measures plus NSAIDs (Group B). In conclusion, local steroid injection therapy was found to be as effective as physical therapy for the treatment of adhesive capsulitis. 22
Most of the articles reviewed suggest that physical therapy alone or as part of a combination of modalities is beneficial for patients with adhesive capsulitis but the extend of this benefit is not clear 3.
The International Federation of Manual Medicine defines manipulation as “the use of the hands in the patient management process, using instructions and maneuvers to maintain maximal, and painless movement of the musculoskeletal system in postural balance”. The goal of manipulation or manual medicine is to help, maintain optimal body mechanics and to improve motion in restricted areas, in order to enhance maximal pain free movement in postural balance and optimize function .20
It includes passive mobilization and manipulation of spinal and peripheral joints, muscle energy techniques, and passive stretching of contractile tissue, manual muscle relaxation techniques, and hands on muscle rehabilitation techniques, myofascial release, and mobilization of nervous system and massage .32
The clinical utilization of soft tissue manipulation has increased dramatically in recent years in all areas of manual health care provision. It is becoming increasingly clear that manual techniques are essential in the proper management of patients. 24, 25
To regain the normal extensibility of shoulder capsule, passive stretching of shoulder capsule in all planes of motion by means of mobilization techniques has been recommended by G.D Maitland .
Passive mobilization techniques are used predominantly in the treatment of mechanical disorders. These techniques include both physiological and accessory movements.
Manual therapy assessment also enables the early detection of restriction of accessory movements. These movements have been found in number of studies to be restricted and symptomatic prior to any detectable involvement of physiological movements (Trott 1980, Milde 1982,Jhonstone 1985) and can there fore be considered the most sensitive indicators of joint dysfunctions 32.
Passive movements of the joint surfaces requires a knowledge of arthrokinematics, first described by Basmajian and Macconail such as intimate movements of roll, spin, glide, compression and distraction. These movements occur between the joint surfaces (arthrokinematics) and are necessary for normal physiological (osteokinematics) movements of bones33.
According to G.D.Maitland, passive oscillatory movements two or three per second of small or large amplitude can be applied any where in a range of motion for treating joint dysfunction .21, 26
Maitland’s description of grades of joint movements has been a major contribution to manual therapy. He uses oscillatory movements of different amplitudes applied at different parts of the range of motion, accessory or physiologic.
Grade I & II oscillations are used for pain relief.
Grade III & IV oscillations are used for joint stiffness.
Osteopathy mainly view adhesive capsulitis syndrome (FSS) as having a multi-factorial etiology and its treatment approach is based on following four elements.
1) Stretching soft tissue structures.
2) Neuromuscular techniques.
3) Increasing range of motion.
4) Exercises for rehabilitation for wasted muscles.
It mainly addresses any associated osteopathic lesions using muscle energy, active resisted and functional techniques 19.
The Muscle Energy Technique (MET) was introduced by F.L.Mitchell.and involves voluntary contraction of muscles, by the patient against the resistance supplied by the practitioner. This is an active manual medicine that can be applied to increase the mobility of hypomobile segment, increase functional range of motion, allow the return of symmetrical motion to affected segments, strengthen weakened muscles and lengthen contracted muscles. 20
The health of any joint is depend upon balance in the strength of its opposing muscles. If for any reason a flexor group loses part or all of its function its opposing tensor group will draw the joint in to a hyperextended position with abnormal stress on the joint margins. Muscle energy techniques have wide application and it can be applied to muscle hypertonicity and muscle tightness but can be equally effective when applied to joint dysfunction and joint capsule adhesions 24, 25.
According to Norris (1994) it equals the resting tone of agonist and antagonist muscles and allow the joint to take up balanced position, where joint surfaces are evenly loaded and the insert tissue at the joint are not excessively stressed. However if the muscles of one side of the joint are tight, the opposite muscle relax, the joint will pull out of alignment towards tight muscles 24, 25.
According to
“Sandra Yale” (osteopathic physician, 1991) states that muscle energy technique can be used effectively in older patients who may have severely restricted motion from arthritis or who have brittle osteoporosis bones 24.
“Phillip Greenman” (Professor of biomechanics, 1996) states that function of any articulation of body, which can be moved by voluntary muscle action either directly or indirectly, can be influenced by muscle energy technique.
Among the key muscle energy technique clinicians is Edward Stiles (1984) states that “somatic dysfunction may increase energy demands and it can affect wide variety of bodily process”. According to him, the most useful manipulative tool available is muscle energy technique .24, 25
MET is commonly used to treat patients with pain and dysfunctions. No randomized controlled trials examining the outcomes of this treatment in symptomatic population have been reported in the literature 23.
Although these treatment techniques can be effectively used, data to support the use of these treatment techniques in adhesive capsulitis of shoulder is lacking.
METHODOLOGY
METHODOLOGY:
SAMPLE DESIGN:
A quasi-experimental approach was followed with two experimental groups or comparison, using before and after treatment scores.
Place of Study:
Then patient were taken from hospital and clinical settings in and around
SAMPLE SELECTION:
The selection of sample is based on purposive sampling. The subjects diagnosed as adhesive capsulitis by Orthopaedician and who showed a capsular pattern of restriction were requested to participate in the study.
The purpose of the study was explained to all the subjects and all volunteered to take part in the study. An informed consent was taken from each subject.
All subjects were assessed using specific proforma. All subjects were assigned randomly, following random number table to either Maitland’s mobilization group (Group-A) or Muscle Energy Technique group (Group- B).
The total no of subjects in the study were, N=30 in the age group of 40-65 years with variable duration of pain (3 to 8 months).
The total number of subjects in group A, n = 15 with mean age of 55.60 years and SD 6.80 with mean duration of pain 5.6 months and SD 1.11 were taken.
The total number of subjects in group B, n = 15 with mean age of 53.93 years and SD 7.32 with mean duration of pain 5.4 months and SD 1.76 were taken.
There were six male and nine female patient’s in-group A and nine male and six female patients in group B.
CRITERIA FOR SELECTION:
Inclusion criteria for both the groups:
1) The age group of patient within 40-65 years.
2) Subjects having stiff painful shoulder for at least 3 months duration.
3) Subjects who show minimum 50% restriction of movements (compared to opposite side) in a typical capsular pattern, in which external rotation is most restricted, followed by abduction and internal rotation.
Exclusion criteria for both groups:
1) Patients below 40 years or above 65 years of the age
2) Uncontrolled diabetes.
3) Post traumatic shoulder stiffness.
4) History of fracture of shoulder joint.
5) Thoracic outlet syndrome.
6) Concurrent cervical sign and symptoms.
7) Peripheral nerve injury / pathology.
8) Hemiplegics shoulder joint.
9) Post surgical cases.
MATERIAL USED:
1) Treatment couch
2) Short wave Diathermy
3) Goniometer
4) Shoulder pain & disability index etc.
MEASUREMENT TOOLS:
1) Goniometer: 34
The range of motion measurements are taken with universal goniometer of the extremity joints which generally have good to excellent reliability.
The accurate application of knowledge and skill, combined with interpreting the results as measurement of ROM only, provide sufficient evidence to ensure content validity.
Active flexion, abduction and lateral and medial rotation were measured with the patient in supine position using procedures described by Norkin and White.The measurements were rounded to nearest 50.
2) Shoulder pain and disability index35:
It has good group level reliability with acceptable validity. The test and retest reliability of measurements obtained with the SPADI found that the SPADI measurements are reliable with interclass correlation coefficients (ICC) =0.66 - 0.91, thus supporting its use for group level comparisons.
Patient is asked to place a mark on the line that best represent his/her experience during the last week attributable to the shoulder problem.
Pain Scale: (How severe is your pain?).
Patient is asked to circle the number that best describe his/her pain, where
0 = no pain and 10= the worst pain imaginable.
(Total pain score = …/50×100= … %)
Disability scale: (How much functional difficulty do you have?)
Patient is asked to circle the number that best describes his experience, where 0 = no difficulty and 10 = so difficult, it require help.
(Total disability score =…/80×100 = … %)
Total SPADI = …/130 ×100 =…%
PROCEDURE:
Both group patients were given SWD before starting the treatment.
Group A patients were given Maitland’s mobilization technique of suitable grades for 24 sitting in 4 weeks.
Group B patients were given muscle energy techniques for 24 sitting in 4 weeks. 3-5 muscle contractions with 5-7 seconds each contraction (not more than 20% of total muscle strength) for three repetitions.
The patients attended physical therapy session daily i.e 6 days in a week.
MAITLAND’S MOBILIZATION:
1) Caudal glide of the humeral head:
AIM: To increase the abduction range of motion.
Starting postion: (Grade-I)
Therapist stands / kneels alongside of the patient’s right elbow. Therapist flexes the patients elbow and holds his wrist in right hand gently, and then places the fingers of his left hand over the patients upper arm anteriorly with the lateral border of the proximal phalanx of the index finger against the anterior surface of the proximal end of the patients forearm and thumb against the lateral surface of the elbow. Patient’s right upper arm is lifted
fractionally off the couch.
POSITION OF THE PATIENT AND HAND PLACEMENT
FOR CAUDAL GLIDE OF THE HUMERAL HEAD
AN ALTERNATIVE POSITION BY APPLYING
DIRECT PRESSURE ON THE HUMERAL
HEAD FOR CAUDAL GLIDE
Method (Grade-I):
Grade-I movement tiny oscillations (superio-inferiorly) are performed by alternating pressure against the patients arm through the therapists index finger.
Starting position (Grade II -IV):
Grade II, III and IV can be performed very similar starting position with the variations in the amplitude and depth of range being controlled by the therapist.
When direct pressure is used against the head of the humerus, the therapist stands beyond the patients head (at the right side) and places the pads of his thumbs against the head of the humerus, immediately adjacent to the anterior and lateral border of the acromion process (so that caudal movement of the head of the humerus can be felt in relation to them).
The fingers of his left hand are spread over scapular area while the fingers of his right hand spread laterally over the deltoid. (Whenever it is necessary to avoid pain as for grade- I treatment of pain, the patients arm is fully supported in pain free neutral position).
Method (Grade-II-IV):
To make the technique more comfortable for the patient and to enable the therapist to feel the movement of the head of the humerus in relation to the acromion process. The oscillatory movements given by therapists arm, not by the intrinsic muscles of the thumb. It is also necessary to use the middle of the pad of the thumb rather than its tip.
2) Anteroposterior movement:
AIM: To increase flexion and internal rotation.
Starting position:
Therapist stands by the patient’s right upper arm facing across his body. With the fingers of his right hand therapist supports the lower end of the patient’s humerus posteriorly from the medial side and then rests patients forearm on his forearm. Therapist raises patient’s upper arm approximately 20o anteriorly to the coronal plane of the trunk so that the head of the humerus will not impinge against the inferior surface of the acromion process posteriorly.
This position also allows better anteroposterior movement of the head of the humerus in the glenoid. Therapist then places the cupped heel of his left hand anteriorly over the head of the humerus, while his fingers extending superiorly and posteriorly over the acromion process.
Method:
The anteroposterior oscillations are produced by pressure of the cupped heel of therapist’s left hand against the head of the humerus.
POSITION OF THE PATIENT AND HAND
PLACEMENT FOR ANTERIO-POSTERIOR
MOVEMENT (GRADE-I) OF THE HEAD OF
HUMERUS
POSITION OF THE PATIENT AND HAND
PLACEMENT FOR ANTERIO-POSTERIOR
MOVEMENT (GRADE II – IV) OF HEAD OF
HUMERUS
Different degrees of pressure are required for different grades of movement and greater recoil is permitted for the larger amplitude.
In abduction:
This movement is only applicable when treatment requires grade II and IV movements.
Starting position:
Therapist stands by the patient’s right shoulder facing his feet. Therapist supports the distal end of patient’s humerus posteriorly from the medial side with his right hand, abducts his arm, and then rests his forearm on patients forearm. Therapist then places the cupped heel of his left hand anteriorly against the head of the humerus, with his finger extending medially across the adjacent clavicular area.
Method:
The oscillatory movement is produced by the pressure against the head of humerus with therapist’s left hand.
3) Posteroanterior movement:
AIM: To increase external rotation.
Starting position:
The patient is in supine with his/her elbow flexed and forearms resting against the pillow on his trunk and a pillow or blanket should be placed
POSITION OF THE PATIENT & HAND PLACEMENT
FOR POSTERIOR-ANTERIOR MOVMENT OF THE
HEAD OF HUMERUS
AN ALTERNATIVE POSITION AND HAND
PLACEMENT FOR POSTERIO-ANTERIOR
MOVEMENT
under his elbow. This is to support his forearm so that medial rotation, abduction and extension are avoided.
The position must be adjusted until it is a symptom free position. The therapist kneels laterally and superiorly to the patient’s shoulder and positions his two thumbs, back to back, with there tips in contact with the posterior surface of the head of the humerus adjacent to the acromion process and pointing towards the ceiling.
The finger of his left hand, are spread over clavicular area and those of right hand spread over the deltoid.
Method:
It is of prime importance that the oscillatory movement should be produced by the physiotherapists arm. If the movement is produced by the thumb flexors, the movement becomes uncomfortable for patient and physiotherapist loses all feel of movement.
Alternative starting position:
When pain is minimal and both accessory and physiological movements are used to mobilize the joint. It may be more suitable to use the patients arm as a lever. This change uses a completely different technique.
The therapist stands by the patient’s right forearm facing his head. Therapist holds the patients forearm against his right side and supports under the posterior surface of the head of the humerus.
The posterior surface of the right hand is placed in the palmer surface of the left hand, so that the index finger overlap and the lateral borders of the index finger contact the back of the head of the humerus.
Therapists thumb hold around the humerus to form an encompassing grasp. Patient is most commonly positioned in a small degree of abduction (and can be progressed to further degree of abduction).
Method:
The slack of scapular movement is taken up by lifting the head of the humerus so that any further oscillatory movements will be associated with the posterioanterior glenohumeral movement.
MUSCLE ENERGY TECHNIQUES (MET):
1) Muscle energy technique for shoulder flexion restriction:
The therapist’s cephalad hand cups the shoulder of the side lying patient firmly compressing the scapula and clavicle to the thorax, while the patient’s flexed elbow is held by the therapist’s caudal hand. The therapist’s slowly introduces shoulder flexion in the horizontal plane as range of motion to 180o is assessed. At the position of very first indication of restriction in movement, the patient is instructed to pull the elbow towards the feet or posteriori or to push further towards the direction of flexion, utilizing more than 20% of their strength, and building up force slowly. This effort is firmly
POSITION OF THE PATIENT AND HAND
PLACEMENT FOR INCREASING FLEXION
BY MET
POSITION OF THE PATIENT AND HAND
PLACEMENT FOR INCREASING ABDUCTION
BY MET
resisted and after 7 to 10 seconds, the patient is instructed to slowly cease the efforts simultaneously with the therapist. After complete relaxation and on an exhalation, the therapist moves the arm to take the shoulder in to further flexion to the next restriction barrier, where the MET procedure was repeated.
Three to four repetitions in each direction were given.
2) Muscle energy technique for abduction restriction:
Patient in side lying. Therapist cups the patients shoulder and compress the scapula and clavicle to the thorax with the cephalad hand while cupping flexed elbow with the caudal hand. The patient hand is supported on the therapists cephalad forearm /wrist to stabilize the arm. The elbow is abducted towards the patient’s head, as the range of motion is assessed. At the position of very first indication of resistance to movement, the patient is instructed to pull the elbow towards the waist or to push further towards the direction of abduction, utilizing not more than 20% of there strength, building up force slowly.
Three to four repetitions in each direction were given.
POSITION OF THE PATIENT AND HAND
PLACEMENT FOR INCREASING EXTERNAL
ROTATION BY MET
POSITION OF THE PATIENT AND HAND
PLACEMENT FOR INCREASING INTERNAL
ROTATION BY MET
3) Muscle energy technique for external rotation:
Patient lying in supine position and ensures that his/her shoulder remains in contact with the table throughout the procedure. The head turned to the left; the patient flexes, adducts and externally rotates the arm fully maintaining the elbow in extension (palm facing ceiling). The therapist stands at the head of table and supports the patients arm at proximal forearm and elbow. The patient is asked to begin process of returning the arm to his/her side, in stages against resistance. The first instruction is to pronate and internally rotate the arm followed by abduction and then extension. The amount of force used by the patient should not exceed 25% of their strength potential.
On complete relaxation, the therapist with patients assistance takes the arm further in to flexion, abduction and external rotation, stretching these muscles in to new barrier.
Three to four repetitions in each direction were given.
4) Muscle energy technique for internal rotation restriction:
The patient is in side lying. The patients flexed arm is placed behind his back to evaluate whether the dorsum of the hand can be painlessly placed against the dorsal surface of the ipsilateral lumber area. This arm position is maintained through out the procedure.The practitioner stands facing the side lying and cups the patient’s shoulder and compresses the scapula and clavicle to the thorax with cephalad hand while cupping the flexed elbow with the caudal hand. The practitioner slowly brings the patients elbow (ventrally) towards his body, notes any sign of restriction as this movement, which increases internal rotation, is performed.
At the position of first indication of resistance to this movement, the patient is instructed to pull his elbow away from the practitioner, either posteriorly or medially or both simultaneously using not more than 20% of his strength, building up force slowly. This effort is firmly resisted, after 7 to 10 seconds the patient is instructed to slowly cease the effort simultaneously with the practitioner. After complete relaxation the elbow is moved to take the shoulder further in to abduction and internal rotation, to the next restriction barrier, where the MET procedure was repeated.
Both group patients were given home exercise program (including mainly Codman’s exercises and finger ladder exercises) on the 1st day of treatment session Patients were advised to do each exercise 2-3 times a day for 10-15 repetitions.
Patients in both groups were assessed for same parameters (ROM and SPADI) at the end of 20th sitting of the treatment session.
Degrees of improvements in the range of motion and improvement in the shoulder pain and disability index (SPADI) were compared.
DATA ANALYSIS:
The scores were obtained by using goniometry for range of motion (of external rotation, abduction and flexion) and shoulder pain
and disability index scale.
The measures of central tendency of variables were obtained for the two groups on each of the pre and post treatment assessments.
The data was analyzed using Students “t” test.
Paired “t” test was used to compare the significance of difference in pre and post treatment scores within the groups.
Unpaired “t” test was used to compare the significance of difference in pre-pre and post-post treatment scores between the groups.
Results are tabulated in terms of mean, standard deviation and “t” values.
The “p” value less than 0.05 was considered significant.
RESULTS
RESULTS:
Using statistical methods for data analysis, the results obtained are as follows.
To study the effect of Maitland’s mobilization in patients with adhesive capsulitis, the ROM and SPADI score were compared before and after treatment. The results are given in the table IA.
TABLE IA :
Mean, SD, and t values for comparison of Pre and Post treatment under Maitland’s
|
Sl no. |
Variables |
Pre treatment |
Post treatment |
t (ttab14 = 2.15) | ||
|
Mean |
SD |
Mean |
SD | |||
|
01 |
External Rotation |
19.00 |
12.13 |
44.00 |
09.67 |
10.46 |
|
02 |
Abduction |
77.00 |
16.34 |
110.00 |
13.50 |
11.15 |
|
03 |
Flexion |
92.33 |
14.74 |
127.33 |
14.38 |
13.57 |
|
04 |
Total Pain Score |
71.53 |
09.61 |
25.83 |
08.07 |
35.98 |
|
05 |
Total Disability Score |
67.71 |
15.38 |
22.11 |
06.74 |
16.64 |
|
06 |
Total SPADI Score |
69.26 |
12.09 |
23.53 |
06.96 |
25.41 |
Using paired t test, it was found that results were significant at P<0.05. This suggests that there is a significant increase in the range of motion and decrease in the pain and disability after treatment.
To study the effect of Muscle Energy Techniques in patients with adhesive capsulitis, the ROM and SPADI score were compared before and after 20 days of treatment. The results are given in the table IB.
TABLE IB
.Mean, SD, and t values for comparison of Pre and Post treatment under Muscle Energy Technique.
|
Sl no. |
Variables |
Pre treatment |
Post treatment |
t (ttab14 = 2.15) | ||
|
Mean |
SD |
Mean |
SD | |||
|
01 |
External Rotation |
16.00 |
07.84 |
31.33 |
08.96 |
07.13 |
|
02 |
Abduction |
81.00 |
10.39 |
99.33 |
11.93 |
08.45 |
|
03 |
Flexion |
91.66 |
15.08 |
118.33 |
12.20 |
13.00 |
|
04 |
Total Pain Score |
74.13 |
09.96 |
26.67 |
05.94 |
37.67 |
|
05 |
Total Disability Score |
65.72 |
13.35 |
34.13 |
08.60 |
14.61 |
|
06 |
Total SPADI Score |
69.04 |
11.80 |
31.14 |
07.08 |
23.10 |
Using paired t test, it was found that results were significant at P<0.05.This suggests that there is a significant increase in the range of motion and decrease in the pain and disability after treatment.
TABLE IIA:
The comparison of Maitlands Mobilization and Muscle Energy Techniques is made on the measures of ROM and SPADI scores. A pretreatment comparison is given in the table IIA.
Mean, SD, and t values for comparison of Maitlands mobilization and MET groups on Pre treatment scores.
|
Sl no. |
Variables |
Maitlands Mobilization |
Muscle Energy Technique |
t (ttab28 = 2.05) | ||
|
Mean |
SD |
Mean |
SD | |||
|
01 |
External Rotation |
19.00 |
12.33 |
16.00 |
07.84 |
00.80 |
|
02 |
Abduction |
77.00 |
16.34 |
81.00 |
10.39 |
-00.79 |
|
03 |
Flexion |
92.33 |
14.74 |
91.66 |
15.08 |
00.12 |
|
04 |
Total Pain Score |
71.53 |
09.61 |
74.13 |
09.96 |
-00.72 |
|
05 |
Total Disability Score |
67.71 |
15.38 |
65.72 |
13.35 |
00.37 |
|
06 |
Total SPADI Score |
69.26 |
12.09 |
69.04 |
11.80 |
00.05 |
Using unpaired t test, it was found that these results do not indicate significant difference. It suggests that there is no significant difference in pre treatment scores of two groups (samples are Homogeneous).
A comparison of post treatment measures as indicated in table IIB suggest significant difference between the measures of the two groups.
The range of motion is much higher in Maitlands Mobilization for all types of movement assessed except for flexion.
Similarly the disability measures in Maitlands mobilization group is much less as compared to and Muscle Energy Technique group.
TABLE II B
Mean, SD, and t values for comparison of Maitlands mobilization and MET groups on Post treatment scores.
|
Sl no. |
Variables |
Maitlands Mobilization |
Muscle Energy Technique |
T (ttab28 = 2.05) | ||
|
Mean |
SD |
Mean |
SD | |||
|
01 |
External Rotation |
44.00 |
09.67 |
31.33 |
08.96 |
03.67 |
|
02 |
Abduction |
110.00 |
13.50 |
99.33 |
11.93 |
02.27 |
|
03 |
Flexion |
127.33 |
14.38 |
118.33 |
12.20 |
01.75 |
|
04 |
Total Pain Score |
25.83 |
08.07 |
26.67 |
05.94 |
-00.32 |
|
05 |
Total Disability Score |
22.11 |
06.74 |
34.13 |
08.60 |
-12.02 |
|
06 |
Total SPADI Score |
23.53 |
06.96 |
31.14 |
07.08 |
-02.93 |
Using unpaired t test, it was found that results were significant at P<0.05.This suggests that there is a significant difference in the post treatment scores of both groups
To examine the relative efficacy of the two treatment techniques the mean gain of various measures were compared as given in the table III.
The improvement in the ROM and decrease in disability noticed with Maitlands Mobilization group is significantly higher than the improvement noticed with Muscle Energy Technique group.
TABLE III:
Mean of gain scores and SD of gain scores for two treatments and t value for significance of difference.
|
Sl no. |
Variables |
Maitlands Mobilization |
Muscle Energy Technique |
tcal (ttab28 = 2.05) | ||
|
Mean |
SD |
Mean |
SD | |||
|
01 |
External Rotation |
25.00 |
09.26 |
15.33 |
08.34 |
02.87 |
|
02 |
Abduction |
33.00 |
11.46 |
18.33 |
08.38 |
03.95 |
|
04 |
Flexion |
35.00 |
10.00 |
26.67 |
07.94 |
02.49 |
|
05 |
Total Pain Score |
45.70 |
04.94 |
47.46 |
04.87 |
-00.97 |
|
06 |
Total Disability Score |
45.60 |
10.61 |
31.59 |
08.34 |
03.97 |
|
07 |
Total SPADI Score |
45.73 |
06.99 |
37.90 |
06.35 |
04.01 |
Using unpaired t test, it was found that results were significant at P<0.05.This suggests that there is a significant difference in the gain scores of both groups (Except total pain score for which‘t’ value is found to be nonsignificant)
Graph shows better improvement in ROM by Maitlands Mobilization
as compared to Muscle Energy technique.
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hiii....... nice work done.... but can i ask for complete thesis actually the reffrence pat