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 later adhesive 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 1

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.

Frozen shoulder causes a typical set of signs and symptoms. They are 1. 2. 3. 4. 5. 6. 7. Shoulder pain; usually dull aching pain. Limited movement of the shoulder. Difficulty with activities such as combing hair, putting on shirts. Pain when trying to sleep on affected side. Pain is felt near the insertion of deltoid. Painful and incomplete elevation and external rotation. Atrophy of the spinatii.

Like frozen shoulder, there are many other disorders of the shoulder such as impingement, which are far more common, and also come on slowly. Codman had noticed that they usually give a story of slight trauma or overuse. Surgery may be another initiating factor, for instance breast surgery and it had been thought it was the immobilization, which led to the development of the frozen shoulder. But, it is more likely the molecular response to the injury or surgery that is responsible to the development of frozen shoulder. The first distinguishing feature of frozen shoulder is painful external rotation. There are only four conditions that restrict external rotation. They are arthritis, locked posterior dislocation, the late stage of a massive cuff tear and frozen shoulder. All of these have specific radiographic changes. Arthritis shows diminution of joint space, inferior osteophytes, sclerosis and occasional cysts; locked posterior dislocation shows a light bulb sign on the anteroposterior film and posterior dislocation on the axillary view; massive 3

cuff tear shows upward subluxation of the head with a break in Shentons line of the shoulder and irregularity of the greater tuberosity; while frozen shoulder shows an entirely normal radiographic appearance of the shoulder. There is limitation of both active and passive movement. Limitation of passive movement in the shoulder can only be caused by two things: firstly, irregularity of the joint surface, as is found in arthritis and locked dislocation; and secondly contracture of the ligaments that bind the humerus to the glenoid. Cyriax proposed that pathologies involving the glenohumeral joint capsule result in a predictable pattern of joint restriction (capsular pattern) with lateral rotation most restricted, abduction next most restricted, and medial rotation third most restricted. Frozen shoulder can be divided into three stages. Stage 1 (Painful/freezing stage): This is the most painful stage of a frozen shoulder. Here, the symptoms last for duration of 3 months and there will be pain with active and passive range of motion. There will be limitation of forward flexion, abduction, internal rotation and external rotation. Stage 2 (Frozen stage): This stage lasts for 4 to 6 months. During the stage the pain usually eases up, but the stiffness worsens. There will be significant limitation of forward flexion, abduction, internal rotation and external rotation. The pain is very difficult for the patient to localize. The movement restriction may have begun and the restriction is usually in both active and passive range of motion. The patient often reports an impairment of a normal daily activity 4

such as combing hair, fastening a bra strap, putting on a coat, etc. The pain most often interrupts sleep and sleeping on the affected side is impossible. Stage 3 (Thawing stage): It lasts for more than year. This stage is gradual with minimal pain and motion steadily improves over a lengthy period of time. The total course of the disorder has been reported to self-resolve in 18 to 24 months. The diagnosis of idiopathic frozen shoulder is made when other causes of pain and motion loss are eliminated. Night pain and pain at rest are common in the early presentation. The primary mode of treatment for frozen shoulder is prevention. The overall goal of treatment is to relieve pain, restore motion, and function. Although frozen shoulder is generally considered to be a self-limiting condition that can be treated with physical therapy, the best treatment has been the subject of extensive investigation. A variety of different treatments have been recommended, they are chiropractic manipulation, oral corticosteroids, physical therapy exercises and modalities, manipulation under anesthesia and arthroscopic and open releases of the contracture. Recent studies have emphasized the surgical management of recalcitrant shoulder stiffness. Identifying the stage of frozen shoulder in which a patient is presenting is important to determine the appropriate treatment regimen. Stretching and exercise are the key to successful frozen shoulder treatment. In this study the treatment for frozen shoulder mainly consists of Capsular stretching and Muscle energy technique. 5

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

more pronounced, but it is impairment of lateral rotation that is most marked. In a case of medium severity, medial rotation would be limited by some 10-15 degrees, shoulder abduction by about 45 degrees and lateral rotation by 60-70 degrees. In a very mild attack, medial rotation is full but painful and the other limitations amount to between 10 and 30 and some 45 degrees respectively. The treatment of frozen shoulder should initially be conservative, with the emphasis on passive stretching of the capsular structures. Stretching for the anterior, inferior and posterior shoulder should be performed by the patient as a part of the motion programme. Stretching a frozen shoulder can be painful but stretching slightly past the point of pain is necessary to make forward progression in range of motion. Stretching exercises for frozen shoulders serve two functions. 1. 2. To increase the motion in the joint To minimize the loss of muscle on the affected arm (muscle atrophy)

MUSCLE ENERGY TECHNIQUE: Muscle Energy Technique is a form of massage therapy that utilizes the patient's muscle contractions and body positioning to normalize joint motion. It was originally developed by Dr. Fred Mitchell, a senior osteopathic physician, and his son Dr. Fred Mitchell, Jr. The main principle behind Muscle Energy Technique is that if a joint isnt used to its full range of motion, its function will lessen and it will be at risk of suffering strains and injuries. Thus, it is a comprehensive manual therapy system for evaluating and treating joint restrictions of the spine, rib cage, pelvis, and extremities.

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 Technique can be used to treat most joints in the body, including the intervertebral 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

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 9

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 10

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 12

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 14

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. 16

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 17

based on the number circled by the patient. Therefore, the patient can achieve 10 points for this section. Self assessment of function is based on a 20 item questionnaire with a 4 category Liker scale for responses. Scoring for this section is calculated in the following ways; 3 points are awarded if the patient can perform the activity without difficulty, 2 points for some difficulty 1 point for much difficulty and 0 for cannot do at all .Therefore, the patient can achieve 60 points if he or she can perform every item without difficulty. Because some items may not be applicable to all patients, the response option did not do before injury is included. When the patient chooses this response option or leaves an item blank, an average of the items that were responded to is multiplied by 3 (maximum score for each item), to yield the maximum possible score achievable by that patient. The score for each relevant item is then added, and this total raw score is divided by the total achievable maximum score for all relevant items, to yield a percentage of the points assigned to this category. This percentage is multiplied by 60 points, to yield the final functional score.

Group A: Subjects received treatment with moist pack for 10 minutes followed by capsular stretching for the anterior, inferior and posterior capsules of the shoulder. To stretch the anterior capsule the subject was positioned either in side lying with the affected arm upwards or in high sitting and the shoulder and arms were brought backwards into extension and this stretch was maintained for a minimum of 30 seconds and maximum duration up to the point of pain experienced by the patient. Posterior capsule stretching was performed with the subject in supine position and therapist performing cross body adduction. Antero- inferior capsule was stretched with the subject in supine position. To 18

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 19

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 Group A Group B 24.06 7.03 Standard Deviation 7.98 1.92 Paired t Test 11.66 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<0.001) t cal > t table Hence the proposed hypothesis is accepted indicating that there is a significant difference between the pre and post test values for Group A.

The data is subjected to statistical analysis for Group B t cal = 14.17 ttable = 4.14

The calculated t value 14.17 for Group B is greater than table value 4.14 (P<0.001) t cal > t table Hence the proposed hypothesis is accepted indicating that there is a significant difference between the pre and post test values for Group B

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Table 2 Mean of pre and post test value for Group A & Group B Pre Test 33.97 Mean Group A Post Test 58.02 Pre Test 31.95 Group B Post Test 38.98

GRAPH 1

Mean of pre and post test values for Group A & Group B

Table 3: 24

Mean, Standard Deviation and unpaired t Value for comparing Group A & B

Mean Group A Group B 24.06 7.03

Standard Deviation 7.98

Unpaired t Test

8.18 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<0.001) t cal > t table Hence the proposed hypothesis is accepted indicating that there is a significant difference between the groups.

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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<0.001). 2) In Group B the calculated t value (14.17) is greater than the table value (4.14) i.e., (P<0.001). 3) When comparing group A with Group B the calculated t value (8.18) is greater than the table value (3.67) i.e., (P<0.001) From this statistical interpretation the study shows that muscle energy technique is better than capsular stretching on reducing pain and improving function in frozen shoulder patients.

LIMITATION OF THE STUDY 1) Sample size was limited to 30. 2) There was no long term follow up of the patients after the study. SUGGESTIONS FOR FUTURE STUDY 1) The same techniques can be applied for a longer duration for 4 weeks also. 2) The same techniques can be applied in combination with other exercise program also. 3) The same study can be done with a longer follow up also.

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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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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. Reach the small of your back to tuck in your 1. shirt with your hand. 2. 3. 4. 5 6 held straight out to the side Dress self (including put on coat and pull 7 shirt off overhead 8 Sleep on the affected side 3 2 1 34 3 2 1 0 X Wash middle of your back /hook bra Perform necessary toileting activities Wash the back of opposite shoulder Comb hair Place hand behind head with your elbow 3 2 1 0 X 0 X 3 3 3 3 2 1 2 1 2 1 2 1 0 X 0 X 0 X 3 2 1 0 X 0 X

9 10 11

Open a door with affected side Carry a bag of groceries with affected arm Carry a briefcase / small suitcase with

3 3 3

2 1 2 1 2 1 2 1

0 0 0 0

X X X X

affected arm Place a soup can ( 1 -2 lbs) on shelf at 12 shoulder level without bending elbow Place a one gallon container ( 8-10 lbs) 13 on a shelf at shoulder level without bending elbow Reach a shelf above your head without 14 bending elbow Place a soup can (1-2lbs) on a shelf above 15 your head without bending your elbow Place a one gallon container (8 10 lbs) on a 16 shelf overhead without bending elbow 17 18 laundry, cooking) Throw overhand/swim /overhead racquet 19 sports (circle all that apply to you) 20 Work fulltime at your regular job 3 2 3 2 Perform usual sport/hobby Perform household chores (cleaning, 3 2 3 2 3 2 3 2 3 2 3 2 3

0 1 0 1 0 1 0 1 0 1 0 1 0 1 0 1

X X

X X

Scoring Total of columns = _________(a) 35

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

PENNSYLVANIA SHOULDER SCORE FOR GROUP A S. No. 1 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Pre Test Values 35.22 27.88 35.25 29.35 15.44 27.88 37.55 38.00 37.88 24.18 65.33 24.66 55.97 24.55 30.38 Post Test Values 60.00 56.55 67.71 57.87 42.22 45.11 65.33 56.82 59.55 56.08 71.33 49.33 66.15 57.33 58.97

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MASTER CHART 2 University of Pennsylvania Shoulder Score (1st Subset) for Group B PENNSYLVANIA SHOULDER SCORE FOR GROUP B S. No. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Pre Test Values 20.56 33.70 25.66 21.81 32.11 27.28 24.22 50.00 26.55 50.83 27.00 22.15 38.44 44.43 34.56 Post Test Values 24.24 43.77 30.44 25.29 40.11 32.53 31.33 57.11 33.88 58.21 35.11 30.58 45.77 53.56 42.84

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