Kripa. M: Master of Physiotherapy (M.P.T.)

A COMPARATIVE STUDY TO FIND OUT THE EFFECTS OF
CAPSULAR STRETCHING OVER MUSCLE ENERGY

TECHNIQUE IN THE MANAGEMENT
OF FROZEN SHOULDER
BY
KRIPA. M
Dissertation submitted to the

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
Karnataka, Bangalore.
In Partial fulfillment of the award of
MASTER OF PHYSIOTHERAPY (M.P.T.)

In
Musculoskeletal Disorders & Sports Physiotherapy
Under the guidance of

PROF. UMASANKAR MOHANTY
SRINIVAS COLLEGE OF PHYSIOTHERAPY

PANDESHWAR, MANGALORE
2004-2006
i
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
KARNATAKA
DECLARATION BY THE CANDIDATE
I here by declare that this dissertation entitled “A COMPARATIVE

STUDY TO FIND OUT THE EFFECTS OF CAPSULAR STRETCHING
OVER MUSCLE ENERGY TECHNIQUE IN THE MANAGEMENT OF
FROZEN SHOULDER”, is a bonafide and genuine research work carried out by
me under the guidance of Prof. Umasankar Mohanty, Professor, Srinivas
College of Physiotherapy.
Date: Signature:
Place: Mangalore. Name: KRIPA. M
ii
Srinivas College of Physiotherapy
(Affiliated to Rajiv Gandhi University of Health Science, Bangalore)
Admn. Office: Ganapathi High School Road, Mangalore – 575 001, Phone No.: (0824)- 2425966, 2440061 (10 lines)
CERTIFICATE BY THE GUIDE
This is to certify that the dissertation entitled “A COMPARATIVE STUDY

TO FIND OUT THE EFFECTS OF CAPSULAR STRETCHING OVER
MUSCLE ENERGY TECHN IQUE IN THE MANAGEMENT OF FROZEN
SHOULDER” is a bonafide research work done by Kripa M. in partial
fulfillment of the requirement for the degree of Masters of Physiotherapy in
Musculoskeletal Disorders and Sports Physiotherapy.
Date: Signature of the Guide

Place: Mangalore. Prof. Umasankar Mohanty
Professor,
Srinivas Campus, Pandeshwar, Mangalore – 575 001, Phone No.: (0824)-2429139, 2411381 Fax No.: (0824)- 243302
Cable: “MYHOME”, E-mail: principalscpt@hotmail.com
iii
(Affiliated to Rajiv Gandhi University of Health Science, Bangalore
Admn, Office: Ganapathi High School Road, Mangalore – 575 001, Phone No.: (0824)- 2425966, 2440061 (10 lines)
ENDORSEMENT BY THE HOD /PRINCIPAL
This is to certify that the dissertation entitled “A COMPARATIVE

STUDY TO FIND OUT THE EFFECTS OF CAPSULAR STRETCHING
OVER MUSCLE ENERGY TECHNIQUE IN THE MANAGEMENT OF
FROZEN SHOULDER” is a bonafide research work done by KRIPA .M
under the guidance of Prof. Umasankar Mohanty, Professor, Srinivas College
of Physiotherapy, Mangalore.
Asst. Prof. K. Selvamani Associate Prof. Ramprasad M.

P.G. Co-ordinator Principal
Date : Date :
Place :Mangalore. Place : Mangalore.
Srinivas Campus, Pandeshwar, Mangalore – 575 001, Phone No.: (0824)-2429139, 2411381 Fax No.: (0824)- 243302
Cable: “MYHOME”, E-mail: principalscpt@hotmail.com
iv
COPY RIGHT
DECLARATION BY THE CANDIDATE
I here by declare that the RAJIV GANDHI UNIVERSITY OF HEALTH

SCIENCES, KARNATAKA, shall have the rights to preserve, use and
disseminate this dissertation in print or electronic format for academic/ research
purpose.
Date: Signature:
Place: Mangalore Name: KRIPA . M
© Rajiv Gandhi University of Health Sciences, Karnataka.
v
ACKNOWLEDGEMENT
First and foremost, I offer this study to the Almighty without whose blessings this
dissertation work would have been impossible, my parents Mr.Murari Chiplunkar and
Mrs.Anupama Chiplunkar,my beloved brother Mr.Kiran Chiplunkar and my dear sister
Miss.Keerthi Chiplunkar whose valuable support gave me courage and confidence
throughout the study.
I wish to express gratitude to my guide Prof. Umasankar Mohanty, Professor,
Srinivas College of Physiotherapy, Pandeshwar, Mangalore for his guidance and interest
shown in my dissertation without whom this work would not have been possible.
I wish to express my sincere thanks to our Principal, Associate
Prof. Ramprasad. M for his guidance and support to my study.
I wish to express my thanks to my Co-Guide Asst. Prof. Anup Johney for the help
and guidance in my study.
I would like to thank our P.G.Co-Ordinator Asst. Prof. Selvamani. K for his help
throughout my study.
I wish to express my sincere thanks to all the respectable staff members of
Srinivas College of Physiotherapy without whose co-operation this study would not have
been successful.
I extend my sincere thanks to Mrs. Reshma and Mr. Kotian for helping me in
statistical analysis and I also convey my special thanks to library staff Mrs. Shubha,
Miss. Manorama and Mr. Lokaraj for their timely help in lending books and journals for
my references all the while.
I am deeply thankful to my friends Ajay, Siva, Nibe and Ino for their valuable
support and my seniors Prasant, Purushottam, Sriram and Vamsi for their valuable
guidance and co-operation throughout the study.
My sincere thanks to all the contributors whose name I have not mentioned but
though they all deserve my gratitude.
Last but not the least I would like to thank all the subjects of my study without
whom this task would not have been possible. I thank all who have helped me all the
while.
Date: Signature:
Place: Mangalore Name: KRIPA.M
vi
LIST OF ABBREVIATIONS USED
1. ANOVA (Analysis of Variance)
2. ESI (Employees State Insurance)
3. GH (Gleno Humeral)
4. MET (Muscle Energy Technique)
5. ROM(Range Of Motion)
vii
ABSTRACT
Background: -Frozen shoulder is an insidious condition that begins with pain and
gradual restriction of movement in the shoulder region. There are various methods of
treating frozen shoulder (both surgical and non-surgical).Among the non-surgical
methods there is no specific method accepted universally. Capsular stretching has been
used in the management of frozen shoulder but Muscle Energy Technique is a recent
technique and there are no studies done to study its effects on frozen shoulder. The main
objective of this study was to find out the effects of capsular stretching over Muscle
Energy Technique in the management of frozen shoulder.
Method: - This study includes 60 individuals with frozen shoulder who were randomly
divided into two groups and one group received Capsular stretching and the other group
received Muscle energy technique. The ROM and University of Pennsylvania Shoulder
Score (Ist subset) were considered for assessment and analysis.
Conclusion: - This study concluded that both Capsular stretching and Muscle energy
technique are effective in the management of frozen shoulder but Capsular stretching is
more effective in the management of frozen shoulder. Hence Capsular stretching can be
used as an effective method in the management of frozen shoulder.
Key words:-MET, Capsular stretching, Frozen shoulder.
viii
TABLE OF CONTENTS
S.L.NO TOPIC PAGE NO.
1. INTRODUCTION 1 – 13
2. AIMS AND OBJECTIVES 13 - 15
3. REVIEW OF LITERATURE 16 – 22
4. METHODOLOGY 23 -34
5. RESULTS 35 – 48
6. DISCUSSION 49 – 52
7. CONCLUSION 53
8. SUMMARY 54 – 55
9. BIBLIOGRAPHY 56 – 61
10. ANNEXURE 62 – 77
ix
LIST OF TABLES
S.L.NO TABLES PAGE

NO.
5.1 Mean and Standard deviation of ROM of Group A 35
5.2 Mean and Standard deviation of ROM of Group B 36

5.3 Inter group comparison of ROM by independent t-test 37
5.4 One way ANOVA for overall changes in ROM of Group 38
A
5.5 One way ANOVA for overall changes in ROM of Group 39
B
5.6 Multiple Scheffe for week wise comparison of ROM of 40
Group A
5.7 Multiple Scheffe for week wise comparison of ROM of 41
Group B
5.8 University of Pennsylvania Shoulder Score (1st subset) 42
values of Group A and Group B obtained by Friedman
test.
5.9 ANOVA analysis for Group B Week wise comparison of 42
University of Pennsylvania Shoulder Score (Ist subset)
values of Group A and B obtained by Wilcoxon test.
5.10 Intergroup comparison of University of Pennsylvania 43
Shoulder Score(1st subset) values of Group A and B
obtained by Mann-Whitney U test.
x
TABLE OF FIGURES
S.L.NO FIGURES PAGE NO.
1 Tools used for the study 25

2 Intial position of goniometric measurement of 28
internal and external rotation
3 End position of internal rotation 28
4 End position of external rotation 28
5 Capsular stretching for antero-inferior capsule 31
6 Capsular stretching for posterior capsule 31
7 Capsular stretching of anterior capsule 31
8 MET for GH joint restricted external rotation 34
9 MET for GH joint restricted abduction 34
10 MET for GH joint restricted internal rotation 34
TABLE OF GRAPHS
S.L.NO GRAPHS PAGE NO.
5.1 Comparison of the Mean of ROM of Group A & 44

Group B
5.2 Mean Difference of week wise comparison of ROM 45
of Group A
5.3 Mean Difference of week wise comparison of ROM 46
of Group B
5.4 Mean Difference of Inter - Group Comparison of 47
ROM of Group A and Group B.
5.5 Mean Rank of intergroup comparison of University 48
of Pennsylvania shoulder score (Ist subset)
xi
Dedicated
To The
Almighty Lord
And
To My
Beloved
Parents, Brother & Sister
xii
INTRODUCTION
The expression “If you don’t use it you loose it” applies perfectly to diseases of
the shoulder because any voluntary or involuntary guarding of the shoulder may result in
loss of mobility.1The 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.1
Shoulder pain and stiffness are common presenting symptoms in patients who
seek evaluation from musculoskeletal physicians. A common quandary with this set of
complaints exists in determining the cause and effect cycle of the symptoms. It is often
difficult to establish which came first and whether pain results from stiffness or produces
it. To answer these important questions thorough understanding of the differential
diagnosis and pathophysiology of shoulder stiffness is necessary.2
Shoulder stiffness is a poorly understood disorder of the glenohumeral joint and
this poor understanding is partly due to the use of confusing terminology. 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 1945.3Codman
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.2
1
Some of the more common terms that are synonyms for frozen shoulder are
adhesive capsulitis, periarthritis, stiff and painful shoulder, periarticular adhesions,
Duplay’s disease, scapulohumeral periarthritis, tendinitis of the short rotators, adherent
subacromial bursitis, painful stiff shoulder, bicipital tenosynovitis, subdeltoid bursitis,
humeroscapular fibrositis, shoulder portion of the shoulder of the shoulder hand
syndrome, bursitis calcarea, supraspinatus tendinitis, periarthrosis humeroscapularis,and
a host of foreign language terms.3
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 and
frozen shoulder and adhesive capsulitis are the preferred terms.4
The debate continues as to whether inflammation or fibrosis is the primary
pathologic process underlying frozen shoulder. It is generally well accepted that this
process whatever it is, is localized to the joint capsule to include synovial lining and
subsynovial tissue. Neviaser and Lundberg observed the role of inflammtion in the
development of frozen shoulder. The reason for this histologically observed
inflammatory reaction is unclear.3 It has been hypothesized that it could represent a
response to injury, an infectious agent, a chemical mediation.or an autoimmune reaction.
Cytokines seem to have a primary role in the inflammatory reaction and subsequent
capsular fibrosis. The role of cytokines in the initiation of inflammation is well known
and it has been shown that the sustained production of these substances can result in
fibrosis by stimulating fibroblasts. Radeo et al observed the role of specific cytokines
(platelet derived growth factor, transforming growth factor-β and hepatocye growth
factor in the inflammatory and fibrosing cascades specifically in frozen shoulder, in the
2
primary and secondary forms. The initial trigger resulting in the proposed inflammatory
cascade and subsequent fibrosis is still unknown.2
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.2 Frozen shoulder associated with a known underlying disorder is cosidered to
be secondary.5 Zuckerman and Cuomo have separated secondary frozen shoulder into
intrinsic, extrinsic and systemic categories.6 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
Parkinson’s disease.5 Extrinsic causes refer to the posttraumatic category, which can be
iatrogenic (post surgical) or may result from high-impact forces or low-level activity.2
Systemic disorders represent generalized medical conditions that are known to occur in
association with frozen shoulder which include diabetes mellitus, hypothyroidism,
hyperthyroidism, and hypoadrenalism.5
Frozen shoulder is a pathology of often unknown aetiology characterized by
painful and gradually progressive restriction of active and passive glenohumeral joint
motion (Baslund et al,1990;Pearsall and Speer,1998).Approximately 2-3% of adults aged
between 40 and 70 years develop frozen shoulder with a greater occurrence in women
3
(Anton,1993;Connolly,1998;Stam,1994). Full or partial restoration of motion may occur
over months or years with or without medical intervention (Ogilvie-Harris et al, 1995).7
Codman stated that the patients with frozen shoulder have twelve features in
common. ‘The condition comes on slowly; pain is felt near the insertion of deltoid;
inability to sleep on the affected side; painful and incomplete elevation and external
rotation; restriction of both spasmodic and adherent type; atrophy of the spinatii; little
local tenderness; X-rays negative except for bony atrophy, the pain very tiring to every
one of them; but they were all able to continue their daily habits and routines.8
Condition comes on slowly 8Like 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.
Painful and incomplete external rotation 8Is the first distinguishing feature of
frozen shoulder. 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 cuff tear shows upward subluxation of the head with a
4
break in Shenton’s line of the shoulder and irregularity of the greater tuberosity; while
frozen shoulder shows an entirely normal radiographic appearance of the shoulder.
Limitation of the spasmodic and mildly adherent type 8 In other words this is
better stated as ‘limitation of 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.
There are some rare muscular conditions such as deltoid contracture, which also
cause restricted passive movement, but in pragmatic terms, if the radiograph is normal
and the joint shows passive restriction, this can only be caused by contracture of the
ligaments of the shoulder capsule. The symptoms and signs of frozen shoulder suggest
that there is a contracture of the shoulder joint capsule.
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.7
Stages of Frozen Shoulder9: -Neviaser and Neviaser described the arthroscopic
stages of frozen shoulder and stressed the importance of an individualized treatment plan
based on an understanding of the clinical stages of the disease. Frozen shoulder can be
broken down into four stages.
Stage 1: 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,
5
abduction, internal rotation and external rotation. Examination with the patient under
anesthesia reveals normal or minimal loss of range of motion. Arthroscopy reveals
diffuse glenohumeral synovitis, which is often more, pronounced in the anterosuperior
capsule.
Stage 2: is also known as the freezing stage and it lasts for 3 to 9 months. The
pain will be of chronic nature with both active and passive movements. There will be
significant limitation of forward flexion, abduction, inernal 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 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: This stage is also known as the “frozen stage”. The symptoms last for
duration of 9-15 months. The pain will be minimal except at the end range of motion.
There will be significant limitation of range of motion with rigid “end feel”. In this stage
the primary restriction pattern is external rotation, abdction, followed by internal rotation.
Stage 4: This stage is known as “thawing phase” in which there will be minimal
pain and it lasts for duration of 15-24 months.
The total course of the disorder has been reported to self-resolve in 18 to 24
months.
6
The diagnosis of idiopathic frozen shoulder is made when other causes of pain
and motion loss are eliminated. Determining from the history which stage a patient is
vital to determine the appropriate treatment. Night pain and pain at rest are common in
the early presentation. Identifying associated factors in a patient’s medical history and
other medical conditions that may contribute to shoulder stiffness is important in
determining a diagnosis of idiopathic frozen shoulder.2
It is suggested that the diagnosis of frozen shoulder be one of exclusion (i.e, other
conditions should be ruled out before identifying the condition as frozen shoulder).
The conditions regarded as subgroups under the term periarthritis should be
eliminated before the term frozen shoulder is applied.4
Therefore, the term frozen shoulder should be reserved for limitation of specific
active and passive range of motion that is due to no known underlying disorder. If an
underlying disorder is found and frozen shoulder is present a qualification as secondary
frozen shoulder be given.4 The physical examination helps to identify secondary causes
of frozen shoulder and other diagnoses that may mimic symptoms suggesting frozen
shoulder and to document shoulder range of motion. Adequate documentation of the
range of motion is important in assessing the resolution or progression of shoulder
stiffness.2
The examination should not be limited to the symptomatic shoulder but should
include the opposite shoulder, cervical spine, and trunk. A thorough neurologic and
vascular examination of the upper extremities is imperative to evaluate for radiculopathy
or vascular causes of shoulder pain. The examination should include measurements of
7
forward elevation, external rotation at the side, external an internal rotation in abduction
(preferably at 90° of abduction or maximal abduction if the patient cannot reach 900),
internal rotation up the back, and cross-body adduction. A limitation of external rotation
with the arm in abduction typically is associated with an anteroinferior capsular
restriction, whereas limited internal rotation and limited cross-body adduction are
associated with a posterior capsular restriction.2
Plain radiographs usually are normal in frozen shoulder, although they may show
osteopenia usually secondary to disuse and are helpful in identifying other causes of
shoulder stiffness and pain, such as osteoarthritis and tumor. More advanced imaging
techniques are not routinely necessary in the evaluation of the stiff shoulder but are
helpful in determining alternative treatment if the patient is not improving with the
typical rehabilitation program.2
The primary mode of treatment for frozen shoulder is prevention. Avoiding
prolonged immobilization of the shoulder after trauma or when shoulder pain develops is
key. Other than the importance of prevention, there is poor agreement on an optimal
treatment protocol. Because the pathophysiology of frozen shoulder is poorly understood,
many different forms of treatment are used empirically.
The overall goal of treatment is to relieve pain, restore motion, and to restore
function.2
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
8
extensive investigation. A variety of different treatments have been recommended, and
numerous studies have demonstrated successful results.
The types of treatment have included benign neglect, chiropractic manipulation,
oral corticosteroids, physical therapy exercises and modalities, brisement, manipulation
under anesthesia and arthroscopic and open releases of the contracture. Recent studies
have emphasized the surgical management of recalcitrant shoulder stiffness. Many of
these studies have been flawed because they have lacked objective and subjective
outcome criteria.10 Non-steroidal anti-inflammatory drugs, local anaesthetic and
corticosteroid injections into the glenohumeral joint, calcitonin and antidepressants,
distension arthrography, closed manipulation, physical therapy modalities and stretching
exercises can be listed among the most common non-surgical approaches to treatment in
frozen shoulder.11
Identifying the stage of frozen shoulder in which a patient is presenting is
important to determine the appropriate treatment regimen. Exercise is the key to any
treatment protocol for frozen shoulder.2 In this study the treatment for frozen shoulder
mainly consists of Capsular stretching and Muscle energy technique.
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. 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.
9
Superiorly, it is attached at the base of the coracoid, enveloping the long head of the
biceps tendon and making it an intraarticular structure.12
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.12
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.13In 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.2The 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, glenohumeral 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.14
10
The treatment of frozen shoulder should initially be conservative, with the
emphasis on passive stretching of the capsular structures.15Stretching for the anterior,
inferior and posterior shoulder should be performed by the patient as a part of the motion
programme.16Stretching a frozen shoulder can be painful but stretching slightly past the
point of pain is necessary to make forward progression in range of motion.2
Muscle energy technique17,18 is a direct hands-on therapy originally developed
by Dr.Fred Mitchell, Sr. Osteopathic physician, and continued by Dr.Fred Mitchell,Jr.
It utilizes the patient’s own gentle muscle contractions and body positioning to
normalize joint motion. It is a non-invasive technique that can be used to lengthen a
shortened contracted or spastic muscle; to strengthen a physiologically weakened muscle
or group of muscles; to reduce localized oedema to relieve passive congestion and to
mobilize an articulation with restricted mobility. Muscle energy technique targets the soft
tissues primarily, but it also makes a major contribution towards joint mobilization.
According to Bourdillon much of the joint restriction is a result of muscular tightness and
shortening. When damage to the soft or hard tissues of a joint is a factor, the periarticular
and osteophytic changes are the major limiting factor in joint restrictions. However, in
both situations muscle energy technique may be useful. 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.
11
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.
NEED FOR THE STUDY
The treatment of patients with frozen shoulder remains controversial. Many
studies have been reported in the orthopaedic and rheumatology literature during the last
30 years. Treatment options documented in the literature include: benign neglect19,
supervised physical rehabilitation20,21, nonsteroidal antinflammatory medications, oral
corticosteroid, intraarticular injections, distension arthrography, closed manipulation22 ,
open surgical release, and more recently, arthroscopic capsular release.23 It is difficult to
compare the results reported in these studies because of the lack of documentation of the
stage of frozen shoulder being treated Shoulder pain and stiffness are common presenting
symptoms in patients with frozen shoulder. 2With its diverse origins pain about the
shoulder joint is most commonly related to the periarticular soft tissues. Keeping in view
the pattern of restriction is external rotation followed by abduction and internal rotation
12
the treatment procedure should include methods to stretch the capsule so as to avoid the
frozen shoulder.10
Conventionally, treatment of frozen shoulder consists of heat therapy (superficial
and deep) along with joint mobilization.3As a new method of approach, the Muscle
Energy Technique targets mainly the relaxation of the soft-tissues. Studies have been
conducted to find the effects of capsular stretching and muscle energy technique but no
study has attempted to compare the effectiveness of these two techniques on frozen
shoulder. So this study attempts to compare the effectiveness of these two techniques on
frozen shoulder. In this study comparison of two treatment techniques i.e. muscle energy
technique and capsular stretching is done on 60 subjects with frozen shoulder.30 subjects
are treated with capsular stretching and the other 30 subjects are treated with muscle
energy technique
13
AIMS AND OBJECTIVES OF THE STUDY
AIM: To Study the effects of Capsular stretching and Muscle energy technique in the
management of frozen shoulder.
Objectives :
1. To find out the effectiveness of capsular stretching on frozen shoulder.
2. To find out the effectiveness of muscle energy technique on frozen shoulder.
3. To compare the effectiveness of capsular stretching exercises over muscle energy
technique in the management of frozen shoulder.
14
HYPOTHESIS
Experimental Hypothesis:
1. Capsular stretching may have an effect on reducing pain and improving ROM and
function in frozen shoulder.
2. Muscle Energy Technique may have an effect on reducing pain and improving
ROM and function in frozen shoulder.
3. There may be a significant difference between Capsular stretching and Muscle
Energy Technique in improving ROM and function in frozen shoulder.
Null Hypotheses:
1. Capsular stretching may not have an effect in reducing pain and improving ROM
and function in frozen shoulder.
2. Muscle Energy Technique may not have an effect in reducing pain and
improving ROM and function in Muscle Energy Technique.
3. There may not be a significant difference between Capsular stretching and
Muscle Energy Technique in improving ROM and function in frozen shoulder.
15
REVIEW OF LITERATURE
M.A.Harrast, Anita G.Rao (2004)2, have mentioned the use of a typical exercise
program of active and passive stretching with the goal of maintaining and regaining range
of motion in frozen shoulder. The basis of this program is four-quadrant stretching of
shoulder joint capsule which includes forward flexion, internal rotation, external rotation
and cross-body adduction. These exercises should be prescribed 4-5 times daily in the
supine position in order to stabilize the scapula and stretch the glenohumeral joint
capsule. Stretching slightly past the point of pain is necessary to make forward
progression in range of motion. At the initiation of the exercise, application of heat can
be helpful to reduce pain and facilitate stretching. After stretching, ice application can
help reduce inflammation and irritation.
Fusun Guler et al (2004)11 mentioned that nonsteroidal anti-inflammatory drugs,
local anaesthetic and corticosteroid injections into the glenohumeral joint,calcitonin and
antidepressants, distension arthrography,closed manipulation, physical therapy modalities
and stretching exercises are the most common non-surgical approaches to treatment in
frozen shoulder.
P.W.McClure et.al (2004)23 used the University of Pennsylvania Shoulder Scale,
which has subscales for pain, satisfaction, and functional activities. The combined total of
the the subscale scores may be used to determine a composite score based on 100 points,
with higher score being better. This scale has documented psychometric characteristics,
16
including test-retest reliability (ICC=0.94), responsiveness (standardized response
mean=8.6, 90%confidence interval (CI), and a minimal detectable change score of
12.1(90%CI).
Captain Eric Wilson et al (2003)24 reported that MET combined with
supervised neuromuscular re-education and resistance exercises may be superior to
supervised neuromuscular re-education and resistance exercises alone for decreasing
disability and improving function in patients with low back pain.
Sarah Jackins (2000)16 has used capsular stretching in the non-operative
treatment of rotator cuff injuries, where she recommended her patients to perform the
capsular stretching of the shoulder 5 times a day. Each stretch is performed to the point
where the patient feels a pull against the shoulder tightness, but not to the point of pain.
Each stretch is performed for one minute and is found useful in improving the range of
motion.
Mantone et al (2000)16 have documented the importance of stretching exercises
for the anterior, posterior and inferior shoulder capsule as a part of the motion
programme to improve the joint range of motion in stiff shoulder.
Griggs et al (2000)10 reported that following a physical therapy programme
consisting of passive stretching exercises (forward elevation, external rotation, horizontal
adduction and internal rotation) at a mean follow-up of 22 months, patients demonstrated
a reduction in pain score from 1-57 to1-16 in a range from one to five points,
improvements in active range of motion, and 64 patients (90%) reported a ‘satisfactory
outcome.’
17
Hannafin and Chiaia (2000)9 have mentioned that low load; prolonged stretch
produces plastic elongation of tissues as opposed to high tensile resistance seen in high
load, brief stretch. Heat may be used to promote muscle relaxation before stretching and
cryotherapy may be used to reduce discomfort after stretching.
BenzaminA.Goldberg et.al (1999)26 the majority of patients with frozen
shoulder can be successfully treated with a strictly home based physiotherapy program
consisting of 5 repetitions of each exercise 5 times every day with gentle stretching as
tolerated against directions of stiffness. For each exercise, gentle pressure as tolerated
against directions of stiffness. For each exercise, gentle pressure against the firm end
point of the range is maintained for a minimum count of ten.
Levit K (1999)25 states ‘The usual mobilization and manipulation techniques are
useless in dealing with the shoulder joint itself’. This highlights the critical importance of
soft tissue evaluation and treatment in shoulder joint in particular.
Frances Cuomo (1999)6 mentioned that nonoperative treatment is indicated for
those primary or secondary frozen shoulders with stiffness of less than 6 months and or
no previous treatment. Each patient should begin an active-assisted range of motion
exercise program complying with gentle, passive, stretching exercises. These exercises
should be performed four to five times daily, including forward elevation, internal and
external rotation, and cross body adduction. They can be performed standing or sitting,
but are most readily performed in the supine position. It is important to perform these
exercises gently, but it needs to be stressed that at each session the arm should be pushed
18
slightly past the point of pain, otherwise no progress in the range of motion would be
expected.
BenzaminA.Goldberg et.al (1999)26 anterior capsule tightens during external
rotation and the posterior capsule tightens with internal rotation and cross body
adduction.
Harryman DT (1998)27 reported that in 226 frozen shoulders treated with
stretching exercises alone, Watson-Jones found that only 5% of patients did not regain
satisfactory motion with 6 months. However, Rizk et al (1998) noted that 60% of patients
treated with physical therapy achieved the ability to sleep pain free after 5 months
duration.
Helen Owens (1997)3 has mentioned the use of cryotherapy in frozen
shoulder.Cryotherapy, like heat application, produces increased circulation and
vasodilatation to the area. There is however, an initial vasoconstriction with cold
application. Ice can prove beneficial in reducing any post exercise soreness.
Mao et al (1997) 7reported statistically significant improvements 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 mobilizations, and flexibility and strengthening exercises.
Craig Liebenson DC (1997)28 mentioned that in post-isometric relaxation or in
muscle energy technique for joint we first take up the slack and engage the barrier and
ask the patient to gently contract against your resistance away from the barrier. After a
19
brief isometric effort, the patient is asked to relax and we wait for a release of the barrier,
when we feel it, we follow by taking up the slack to the new barrier.
Schenk et al (1997)25,29 performed a randomized controlled trial to determine the
effectiveness of MET for increasing lumbar extension in asymptomatic individuals with
each session lasting less than 5 minutes with each subject receiving 4 repetitions of the
MET maneuver two times a week for four weeks and reported a statistically significant
difference (p<0.5) in the increase of lumbar extension in the increase of lumbar extension
in the experimental group.
Melzer et al (1995) and Waldberg et al (1992)7 prospectively compared
outcomes of patients treated with a physical therapy regimen of moist heat, gentle
stretching, range of motion exercises, mobilisation, electro-analgesia (TENS) and
cryotherapy to outcomes of patients treated with either manipulation under anaesthesia
(Melzer et al, 1995) or subcutaneous calcitonin injections (Waldberg et al, 1992). Patients
treated with physical therapy in the Melzer et al (1995) investigation gained an average
active motion that exceeded that of the manipulation group, but the results were not
reported as statistically significant.
Pollock et al(1994)3, inspected 30 frozen shoulders arthroscopically and noted
subacromial bursal adhesions in al patients. He stated that a contracted glenohumeral
joint capsule is the primary structure responsible for frozen shoulder.
Petriquin 1992, Spencer 191625 mentioned that Spencer sequence offers precise
evaluation of even minor restriction in shoulder range and quality of motion, with the
added advantage of allowing treatment from the test position. Over the years the
20
sequence of assessment has been modified to include treatment elements other than the
original mobilization intent which includes MET.
DiGiovanna 1991,Greenman 1989,Janda 1989,Lewit 1986,Liebenson
1989/1990,Mitchell 1967,Travell and Simons 199225 defined MET (Muscle energy
techniques )are sift tissue manipulative methods in which the patient on request, actively
uses her muscles from a controlled position, in a specific direction, with mild effort
against a precise counterforce. The counterforce can match the patient’s effort
(isometrically) or fail to match it (isotonically) or overcome it (isolytically), depending
upon the therapeutic effect required. Depending upon the relative acuteness of the
situation, the contraction will be commenced from or short of a previously ascertained
barrier of resistance. When MET is applied to joints, the acute model is always used i.e,
no stretching, simply movement to the new barrier and repetition of isometric contraction
of agonist or antagonist.
P.E.Greenman in 198917 told that MET can be used to lengthen a shortened,
contracted or spastic muscle; to strengthen a physiologically weakened muscle or group
of muscles; to reduce localized edema, to relieve congestion, and to mobilize an
articulation with restricted mobility.
Vladimir Janda (1988)16, acknowledges that it is not known whether dysfunction
of muscles causes joint dysfunction or vice versa, he points out to the undoubted fact that
they massively influence each other and that it is possible that a major element in the
benefits noted following joint manipulation derives from the effects such methods (high
velocity thrust, mobilization etc.)have on associated soft tissues. Normalization of the
21
muscle tone by muscle energy technique provides an equally useful basis for joint
manipulation.
Robert J. Neviaser & Thomas J. Neviaser (1987)14 have mentioned the use of
gentle stretching exercise into elevation, external rotation and internal rotation under the
supervision of a physician and a knowledgeable therapist in the treatment of frozen
shoulder.
Lewit and Simons (1984) 30wrote that, “the use of post-isometric relaxation was
pioneered by Fred Mitchell Sr.and clearly described by F.L.Mitchell Jr.as a mobilization
technique that applies gentle force to improve ‘articulation’ and thereby restore
previously restricted movement”.
John Connolly et al (1972)31 have proved that self-induced passive stretching
exercise program was eventually successful in restoring satisfactory functional range of
shoulder motion in a large percentage (44%) of the hospitalized patients in their study.
McLaughlin (1961)31,32 has applied the analogy of the shrinkage which occurs in
immobilized uncured leather to the collagenous capsular shrinkage associated with the
“frozen shoulder”. In an attempt to combat this capsular shrinkage, the exercise program
should be designed to exert forces on the shoulder, stretching it beyond its limited range.
This can best be done by multiple, self-induced,repetitive passive stretching .
22
METHODOLOGY
Sample selection:
Sampling:-Simple random sampling.
Source of data: -. Patients with frozen shoulder were selected from the Out Patient
Department of Srinivas College of Physiotherapy and Rehabilitation Center, Government
District Wenlock Hospital and ESI Hospital. Prior permission was taken from the above-
mentioned hospitals to conduct the study and for ethical clearance.
Sampling Procedure: - A total number of 110 subjects were screened out of which 60
subjects were selected for the study. Each patient was screened initially by using a simple
selection proforma relevant to the inclusion and exclusion criteria. Those who fulfilled
this symptomatic criterion underwent a detailed physical examination of the shoulder for
baseline assessment (Refer Annexure 10.1).
Then the selected patients who were willing to participate were randomly divided
into two groups of 30 each in Group A and Group B. The details and the purpose of the
study were explained to all the patients and informed consent was obtained (Refer
Annexure 10.3) and demographic data (Refer Annexure 10.2) were collected from each
patient.
Group A subjects of frozen shoulder (18 females and 12 males) were treated with heat
therapy, capsular stretching and icing. Group B subjects with frozen shoulder (16 males
and 14 females) were treated with heat therapy, muscle energy technique and icing.
23
Study design: - Experimental study
Criteria for selection: Subjects for the study were selected based on the following
criteria.
Inclusion Criteria
1. Patients with stage 2 or stage 3 frozen shoulder of any age group.
Exclusion Criteria
1. Patients who have undergone a surgical procedure of the shoulder less than 4
weeks prior to study enrollment.
2. Patients who have undergone total shoulder arthroplasty.
3. Patients with reflex sympathetic dystrophy.
4. Patients with rheumatoid arthritis.
5. Patients with glenohumeral arthritis.
6. Patients with neoplasms in and around the shoulder joint.
7. Patients with cervical pathology.
24
Materials used
1. Treatment couch
2. Towels
3. Moist pack
4. Universal double arm (360º) goniometer
5. Cold pack
6. University of Pennsylvania Shoulder Score (1st sub set).
Figure.1: Tools used

Tools used for for
thethestudy
study
25
Procedure
The range of motion of the affected shoulders was assessed actively with a
universal double-armed transparent goniometer by placing the subjects in supine lying
position. The measurements were taken for shoulder flexion, extension, abduction,
internal rotation and external rotation.
Testing protocol for ROM2,33
Shoulder flexion
Subjects were positioned in supine with the knees flexed to flatten the lumbar
spine. The shoulder was positioned in 0 degree of abduction, adduction and rotation. The
forearm was positioned in 0 degree of supination and pronation so that the palm of the
hand faces the body. The scapula was stabilized to prevent elevation posterior tilting
(inferior angle presses against the rib cage) and upward rotation and thorax was stabilized
to prevent extension of the spine. Initially end feel was tested to measure flexion. The
fulcrum of the goniometer was flexed close to the acromial process. The midaxillary line
of the thorax and lateral epicondyle of the humerus were used as reference.
Shoulder extension
Subjects were positioned in prone with the head facing away from the shoulder
being tested and no pillow was used under the head. The shoulder was positioned in
slight flexion so that tension in the long head of biceps brachii muscle will not restrict the
motion. The forearm was positioned in 0 degrees of supination and pronation so that the
palm of the hand faces the body. Scapula was stabilized to prevent elevation and anterior
26
tilting (inferior angle protrudes posteriorly) of the scapula and thorax was stabilized to
prevent forward flexion of the spine. Initially end feel was tested and to measure
extension, centre of the fulcrum of the goniometer was placed to the acromial process and
mid axillary line of the thorax and lateral epicondyle of humerus were used as reference
point.
Shoulder abduction
Subjects were positioned in supine and the shoulder was positioned in 0 degrees
of flexion and extension and available range of lateral rotation so that the palm of the
hand faces anteriorly. The elbow was extended so that tension in long head of triceps
would not restrict the motion. Scapula was stabilized to prevent upward rotation and
elevation and thorax was stabilized to prevent lateral flexion. Initially the end feel was
tested. To measure abduction, the fulcrum of the goniometer was placed close to the
anterior aspect of the acromial process and midline of the anterior aspect of the sternum
and medial midline of the humerus were taken as reference.
Internal rotation
Subjects were positioned in supine with arm being tested in available range of
shoulder abduction .The forearm in 0 degree of supination and pronation so that the hand
was facing the feet. The full length of the humerus was resting on the supporting surface.
The elbow was not supported and pad was placed under the humerus so that it was in
level with the acromial process. Initially the end feel was tested .To measure initial
rotation the goniometer was placed over the olecranon process and ulnar styloid was used
as reference.
27
External rotation
The testing position is same as that for internal rotation of the shoulder. In the
beginning of the ROM, distal end of the humerus is stabilized to keep the shoulder in
available range of abduction. Initially the end feel is tested, to measure external rotation,
the goniometer is the same as for testing internal rotation of the shoulder.
Figure.2 : Initial position to measure internal and external rotation
Figure.3: End position of internal Figure .4: End position of external

rotation rotation
28
Pain and function scores were taken using University of Pennsylvania Shoulder
score(1st sub set ) before the treatment ,after first week of treatment and after two weeks
of treatment.
Testing protocol for University of Pennsylvania shoulder score (I st Subset)5
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
patient’s report of pain, satisfaction and function. The 100 point impairment score
consists of objective measures of ROM and strength. In this study the Ist subset of self
assessment is only taken to measure the patent’s 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 patient’s 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 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
Likert 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,
29
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.
ROM and University of Pennsylvania shoulder score (1st sub set) was assessed for
both group A and group B subjects prior to the study, at the end of 1 week and at the end
of 2nd week i.e., on the day of completion of the study.
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.15 Posterior
capsule stretching was performed with the subject in supine position and therapist
performing cross body adduction.15 Antero- inferior capsule was stretched with the
subject in supine position. To stretch the antero inferior capsule the affected arm is taken
towards the extreme of attainable elevation and counter pressure is maintained at the
patient’s sternum to prevent spinal extension. Each stress is gentle but firm and not
30
released until pain rather than discomfort is experienced.13 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.
Figure.5: Capsular stretching for antero-inferior capsule
Figure.6: Capsular stretching for Figure. 7: Capsular stretching for

posterior capsule anterior capsule
31
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 flexion34: Therapist stands in front of the patient
and places one hand over the top of the patient’s 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 patient’s 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 extension34: Therapist stands in front of the
patient and places one hand over the top of the patient’s shoulder at the superior part of
the scapula and cups the G.H. joint to palpate for motion. Uses the other hand to support
patient’s flexed elbow and direct the patient to push the elbow anteriorly.
MET for G.H.joint restricted abduction34: Therapist stands in front of the
patient, places her one hand over the top of patient’s 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 rotation34: Therapist stands facing the
patient. Carefully place the dorsum of the patient’s 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
32
posterior to the patient’s flexed elbow. Direct the patient “Press your elbow against my
fingers”
MET for G.H.joint restricted external rotation34: Therapist stands behind the
patient. Places her hand superior to the patient’s GH joint. Places her forearm of the other
hand medial to the patient’s flexed forearm with her hand supporting the patient’s hand
and the wrist. Direct the patient to internally rotate the arm by pressing the hand.
Group B received muscle energy techniques for the shoulder joint of 5 repetitions
per set, 5 sets per session, 1 session per day, 5 days a week for 2 weeks with each
repetition maintained for duration of 7 – 10 seconds.
33
Figure .8: MET for GH joint
restricted external rotation
Figure .10 MET for GH joint

restricted abduction
Figure .8: MET for GH joint

restricted internal rotation
34
RESULTS
TABLE 5.1 Mean and Standard deviation of ROM of Group A.
Range Duration Mean Standard deviation

Flexion Pre-Rx 91.30 22.79
After 1 week 112.43 20.12
After 2 weeks 128.26 18.94
Extension Pre-Rx 32.03 8.01
After 1 week 42.26 9.66
After 2 weeks 50.93 9.24
Abduction Pre-Rx 54.66 14.78
After 1 week 71.76 14.91
Internal rotation Pre-Rx 43.10 11.25

After 1 week 57.20 11.47
External rotation Pre-Rx 31.13 7.17
After 1 week 48.00 9.18
Table 5.1 The mean and standard deviation of ROM of affected shoulder of
Group A measured before the treatment(Pre-Rx),after1 week of treatment and at the end
of the treatment (after2 weeks). The mean of base line of flexion is 91.30 and after 2
weeks the mean is 128.26. For extension base line mean is 32.03 and after 2 weeks
50.93, for abduction base line mean is 54.66 and after 2 weeks it is 91. 73. For internal
rotation base line mean is 43.10 and after 2 weeks it is 64.03, for external rotation the
base line means is 31.13 and after 2 weeks it is 64.03 it shows that there is improvement
in range of motion head the end of 2 weeks of treatment when compared to the first day
in all the ranges.
35
TABLE 5.2 Mean and Standard deviation of ROM of Group B.
Range Duration Mean Standard deviation

Flexion Pre-Rx 94.80 26.38
After 1 week 100.36 25.42
After 2 weeks 113.13 26.21
Extension Pre-Rx 29.56 10.87
After 1 week 35.30 10.57
Abduction Pre-Rx 52.00 12.70
After 1 week 59.20 16.35
Internal rotation Pre-Rx 40.46 14.71

After 1 week 45.13 14.63
External rotation Pre-Rx] 27.13 6.61
After 1 week 26.70 11.15
Table 5.2 The mean and standard deviation of ROM of affected shoulder of
Group B measured before the treatment(Pre-Rx),after1 week of treatment and at the end
of the treatment (after2 weeks). The mean of base line of flexion is 94.80 and after 2
weeks of treatment it is 113.13, the base line mean of extension is 29.56 and after 2
weeks it is 42.16. The base line mean of abduction is 52.00, and after 2 weeks it is 72.43.
The base line mean for internal rotation is 40.46 and after 2 weeks it is 51.70, the base
line mean for external rotation is 27.13 and after 2 weeks is 35.66. It shows that there is
improvement in range of motion at the end of 2 weeks treatment in all the ranges when
compare to the first day (that is before treatment).
36
TABLE 5.3 Inter-group comparison of ROM of Group A and B obtained by
Independent t-Test
Range Duration Mean Diff. t p

Flexion Pre-Rx 3.5 0.550 0.585 *
After 1 wk 12.06 2.038 0.046 **
After 2 wks 15.13 2.562 0.013 **
Extension Pre-Rx 2.466 1.000 0.321 *
After 1 wk 6.966 2.664 0.010 **
After 2 wks 8.766 3.465 0.001 ***
Abduction Pre-Rx 2.666 0.749 0.457 *
After 1 wk 12.566 3.111 0.003 ***
After 2 wks 19.30 4.643 0.000 ****
Internal rotation Pre-Rx 2.633 0.779 0.439 *
After 1 wk 12.066 3.554 0.001 ***
After 2 wks 18.566 6.319 0.000 ****
External Pre-Rx 4.000 2.245 0.029 **
rotation After 1 wk 21.30 8.074 0.000 ****
After 2 wks 28.36 11.544 0.000 ****
**** = very highly significant, ***= highly significant, **= significant, *= not
significant.
Table 5.3 shows the ‘p’value is .000 at the end of 2 weeks for abduction, internal rotation
and external rotation which means that there is very high significant changes in these
ranges at the end of 2 weeks of treatment. p=.001 for extension and p=.013 for flexion at
the end of 2 weeks of treatment which is also significant.
37
TABLE 5.4 One way ANOVA for overall changes in range of motion of GroupA.
Range Source Sum of Mean F p

Squares Square
Flexion Between wks 20638.467 10319.233 24.112 0.000 ****
Within week 37233.533 427.972
Total 57872.000
Extension Between wks 2387.822 1193.911 10.643 0.000 ****
Within week 9759.833 112.182
Total 12147.656
Abduction Between wks 20650.156 10325.078 46.539 0.000 ****
Within week 19301.900 221.861
Total 39952.056
Internal Between wks 11075.756 5537.878 50.804 0.000 ****
rotation Within week 9483.367 109.004
Total 20559.122
External Between wks 16239.622 8119.811 120.418 0.000 ****
Total 22106.056
****= very highly significant.

Table 5.4 shows the overall changes in range of motion of Group A following treatment
with Capsular stretching in frozen shoulder between the weeks and within the weeks of
treatment. p= .000 which means that very high significant difference in ROM between
the weeks and within the weeks following treatment with capsular stretching.
38
TABLE 5.5 One way ANOVA for overall changes in range of motion in Group B.
Range Source Sum of Mean Square F p

Squares
Flexion Between wks 5300.867 2650.433 3.917 0.024 **
Within week 58871.233 676.681
Total 64172.100
Extension Between wks 5370.422 2685.211 33.133 0.000 ****
Within week 7050.700 81.043
Total 12421.122
Abduction Between wks 6444.822 3222.411 13.386 0.000 ****
Within week 20944.167 240.738
Total 27388.989
Internal Between wks 1910.867 955.433 4.617 0.012 **
Total 19914.100
External Between wks 1534.067 767.033 8.136 0.001 ***
Total 9736.500
**= significant, ***= highly significant, ****=very highly significant.
Table 5.5 shows the overall changes in range of motion of Group B following treatment
with Muscle energy technique in frozen shoulder between the weeks and within the
weeks of treatment. p=0.000 for extension and abduction, 0.001for external rotation,
0.024 and 0.012 for flexion and internal rotation which means that there is a significant
difference in ROM of all the ranges but extension and abduction showed more
improvement when compare to the other ranges.
39
TABLE 5.6: Multiple Scheffe for week wise comparison of Range Of Motion of
Group A.
ROM Week Mean Standard p

Difference error
Flexion Pre-Rx-1wk -21.1333 5.34148 0.001***
1wk-2wks
Pre-Rx-2wks -15.8333 5.34148 0.015 **
-36.9667 5.34148 0.000 ****
Extension Pre-Rx-1wk -6.4667 2.54109 0.044 **

1wk-2wks
Pre-Rx-2wks -8.6667 2.54109 0.004 ***
-15.1333 2.54109 0.000 ****
Abduction Pre-Rx-1wk -17.1000 3.84587 0.000 ****

1wk-2wks
Pre-Rx-2wks -19.9667 3.84587 0.000 ****
-37.0667 3.84587 0.000 ****
Internal rotation Pre-Rx-1wk -14.1000 2.69573 0.000 ****

1wk-2wks
Pre-Rx-2wks -13.0667 2.69573 0.000 ****
-27.1667 2.69573 0.000 ****
External Pre-Rx-1wk -16.8667 2.12022 0.000 ****

1wk-2wks
rotation Pre-Rx-2wks -16.0333 2.12022 0.000 ****
-32.9000 2.12022 0.000 ****
**=significant, ***=highly significant, ****=very highly significant.
Table 5.6 there are significant changes in ROM after 2 weeks of treatment in Group A
per all the ranges but abduction, internal and external rotation showed significant
difference in ROM through out the treatment.
40
TABLE 5.7 Multiple Scheffe for week wise comparison of ROM of Group B
Range Duration Mean Diff. p

Flexion Pre-Rx-1wk -5.5667 0.710 *
1wk-2wks -12.7667 0.170 *
Pre-Rx-2wks -18.3333 0.028 **
Extension Pre-Rx-1wk -10.2333 0.000 ****
1wk-2wks -8.667 0.002 ***
Pre-Rx-2wks -18.900 0.000 ****
Abduction Pre-Rx-1wk -7.2000 0.205 *
1wk-2wks -13.23 0.006 ***
Pre-Rx-2wks -20.43 0.000 ****
Internal rotation Pre-Rx-1wk -4.666 0.457 *
1wk-2wks -6.566 0.215 *
Pre-Rx-2wks -11.233 0.013 **
External rotation Pre-Rx-1wk -0.4333 0.985 *
1wk-2wks -8.9667 0.003 ***
Pre-Rx-2wks -8.533 0.004 ***
*=not significant, **=significant, ***=highly significant, ****=very highly significant.
Table 5.7 there are significant changes in ROM after 2 weeks of treatment in Group B
for all the ranges but very highly significant difference in ROM for extension and
abduction.
41
TABLE 5.8 University of Pennsylvania Shoulder Score (1st subset) values of
Group A and Group B obtained by Friedman test.
Group Z p
A 60.00 0.000 ****
B 60.00 0.000 ****
****=very highly significant
Table 5.8 shows that both the groups A and B showed significant improvement in pain
and function over a period of 2 weeks.
TABLE 5.9 Week wise comparison of University of Pennsylvania Shoulder Score
(Ist subset) values of Group A and B obtained by Wilcoxon test.
Group Duration Z p
A Pre Rx – 1st week -4.782 0.000 ****
1st week – 2nd week -4.782 0.000 ****
Pre Rx – 2nd week -4.782 0.000 ****
B Pre Rx – 1st week -4.783 0.003 ***
1st week – 2nd week -4.782 0.000 ****
Pre Rx – 2nd week -4.783 0.000 ****
***=highly significant, ****=very highly significant
Table 5.9 shows there is significant improvement in pain and function in Group A and B
throughout 2 weeks of treatment except for the first week in Group B where ‘p’ is less
significant.
42
TABLE5.10 Intergroup comparison of University of Pennsylvania Shoulder
Score(1st subset) values of Group A and B obtained by Mann-Whitney U test.
Duration U P
Pre Rx 417.50 0.631 *
After 1 week 263.00 0.006 ***
After 2 weeks 159.00 0..000 ****
*=not significant, ***=highly significant, ****=very highly significant.
Group Duration Mean Rank

A Pre Rx 31.58
After 1 week 36.73
After 2 weeks 40.20
B Pre Rx 29.42
After 1 week 24.27
After 2 weeks 20.80
Table 5.10 when comparing both groups A and B ‘p’ is significant after 1st and 2nd week
of treatment but is highly significant after 2 weeks of treatment.When we compare the
mean ranks, Group A is better than Group B.
43
GRAPH 5.1
Comparison of the Mean of ROM of Group A &

Group B
140
120
100
ROM (degree)
80
60
40
20
0
After 1
After 2
After 1
After 2
After 1
After 2
After 1
After 2
After 1
After 2
Pre-Rx
Pre-Rx
Pre-Rx
Pre-Rx
Pre-Rx
weeks
weeks
weeks
weeks
weeks
week
week
week
week
week
Flexion Extension Abduction Internal External

rotation rotation
Duration (in weeks)
Mean Group A Mean Group B
44
GRAPH 5.2
Mean Difference of week Wise comparison of

ROM of Group A
50
45
40
ROM (degree)
35
30
25
20
15
10
5
0
Pre-Rx-1wk
1wk-2wks
Pre-Rx-2wks
Pre-Rx-1wk
1wk-2wks
Pre-Rx-2wks
Pre-Rx-1wk
1wk-2wks
Pre-Rx-2wks
Pre-Rx-1wk
1wk-2wks
Pre-Rx-2wks
Pre-Rx-1wk
1wk-2wks
Pre-Rx-2wks

rotation rotation
Duration (in weeks)
Mean Difference
45
GRAPH 5.3
Mean Difference of week Wise comparison of

ROM of Group B
25
20
Mean (degree)
15
10
5
0
Pre-Rx-1wk
1wk-2wks
Pre-Rx-2wks
Pre-Rx-1wk
1wk-2wks
Pre-Rx-2wks
Pre-Rx-1wk
1wk-2wks
Pre-Rx-2wks
Pre-Rx-1wk
1wk-2wks
Pre-Rx-2wks
Pre-Rx-1wk
1wk-2wks
Pre-Rx-2wks

rotation rotation
Duration (in Weeks)
Mean Diff.
46
GRAPH -5.4
Mean Difference of Inter group comaprison of ROM

of Group A & D
30
25
ROM (degrees)
20
15
10
5
0
Pre-Rx
Pre-Rx
Pre-Rx
Pre-Rx
Pre-Rx
After 1 wk
After 2 wks
After 1 wk
After 2 wks
After 1 wk
After 2 wks
After 1 wk
After 2 wks
After 1 wk
After 2 wks

rotation rotation
Duration (in weeks)
Mean Difference
47
GRAPH 5.5
Mean Rank of Intergroup comparison of Univesity

of Pennsylvania shoulder score (1st subset)
60
50
40.2
36.73
40 31.58
29.42
Mean
30 24.27
20.8
20
10
0
Pre Rx After 1 week After 2 weeks
Group
Mean Rank Group A Mean Rank Group B
48
DISCUSSION
Frozen Shoulder is characterized by painful stiffness of the shoulder that may
persist for several years. It is a common disorder, with an estimated annual incidence of
3% to 5% in the general population (Bridgman 1972, Pal et al 1986).Advocated
treatments include rest and analgesics, corticosteroid injections, acupuncture, physical
therapy, manipulation under anaesthesia, and arthroscopic or open surgery. There is no
general acceptance of one standard treatment (Green et al 2000).35
Frozen shoulder is a contracture of the capsule and depending on how severe the
contracture is (for it varies in intensity from patient to patient) the treatment is decided.8
The first objective in the treatment of patients with frozen shoulder syndrome is pain
relief. This is essential, for it permits patients to more readily participate in an exercise
program aimed at restoring motion and recovering function. 5The various physical
therapy approaches for treating patients with frozen shoulder include passive joint
mobilization, moist heat, electrotherapy, extensibility-enhancing exercises, strengthening
exercises and so on.7
The study was conducted on 60 patients with two groups of 30 each. Group A was
intervened with moist heat, Capsular stretching and icing whereas Group B was
intervened with moist heat, Muscle energy technique and icing. The output parameters
i.e,the range of motion(taken with 360 degrees universal goniometer)and pain and
function scores using University of Pennsylvania Shoulder Score(Ist Sub set) was
49
measured prior to treatment (Pre-Rx), after 1 week of treatment and at the end of two
weeks of treatment.
1st objective of this study was to find the effectiveness of capsular stretching
(Group A) on frozen shoulder. In Group A subjects who received Capsular stretching its
overall effectiveness on range of motion was found using one way ANOVA which
showed p=0.000 which is very highly significant for all shoulder ranges between weeks
and within weeks of treatment. This means that capsular stretching is effective in
increasing overall shoulder range of motion. The week wise comparison of ranges of
motion obtained by Multiple Scheffe showed very highly significant ‘p’values for Group
A through out 2 weeks of treatment.
The 2nd objective of this study was to find the effectiveness of Muscle energy
technique (Group B) on frozen shoulder. In Group B subjects who received Muscle
energy technique its overall effectiveness on range of motion was found using one way
ANOVA which showed ‘p’ significant for all the ranges but highly significant for
extension and abduction. The week wise comparison of ranges of motion obtained by
Multiple Scheffe also showed highly significant ‘p’values for Group B through out 2
weeks of treatment.
The 3rd objective of the study was to compare the effectiveness of Capsular
stretching over Muscle energy technique in the management of frozen shoulder.
Comparison of range of motion of both Group A and Group B was done using
independent t-test which showed ‘p’ value significant for all the ranges and highly
significant for abduction, internal and external rotation during the last week of treatment
50
which means that there is significant increase in these ranges of motion at the end of two
weeks of treatment and the positive mean difference proved that Group A is better than
Group B in improving the ROM.
The overall changes in pain, satisfaction and shoulder function of Group A and B
was obtained using Friedman test which showed p=0.000 for both groups which means
that there is significant overall reduction in pain and improvement in shoulder function in
both the Groups A and B.The week wise comparison of pain and current shoulder
function of Group A and B was done using Wilcoxson test which showed p=0.000 for
both Group A and B throughout the treatment but less significant for group B during the
first week of treatment. The intergroup comparison of pain and shoulder function was
done using Mann Whitney test which showed ‘p’significant after first week and highly
significant after two weeks of treatment. When we compare the mean ranks we can
conclude that Group A is better than Group B in improvement of shoulder function.
The results of this study supported the experimental hypothesis that both Capsular
stretching and Muscle energy technique are effective in improving the shoulder range of
motion in patients with frozen shoulder. On further analysis it also supported the
hypothesis that there is significant difference in effectiveness of both Capsular stretching
and Muscle energy technique. Our results support the study of Griggs et al (2000)35 who
reported that following a physical therapy programme consisting of passive stretching
exercises patients demonstrated a reduction in pain score from n1.57 to 1.16 in a range
from one to five points, improvements in active range of motion, and 64 patients reported
a satisfactory outcome. The mechanism by which Capsular stretching caused
improvement in shoulder range of motion and function could be elongation of tissues
51
which could be the probable reason helping to improve range of motion and function
after Capsular stretching.7
The reason for MET being not so effective in improving shoulder ROM and
function in frozen shoulder could be attributed to the conclusion of the study conducted
by Johannes Buchmann et al. 200438 on upper cervical apophyseal joints with
mobilization and manipulation before, during and after endotracheal anaesthesia. They
concluded that post-isometric relaxation (MET) seems to reach mainly the muscular parts
of the treated motion segment and less to the other parts such as affiliated joint capsule,
ligaments and fascia.
From this study it can be said that Capsular stretching is better than Muscle
energy technique and can be used as method of choice for the treatment of patient with
frozen shoulder.
Limitations of the study
1. There was no control group due to ethical reasons.
2. Sample size was limited to 60.
3. There was no long-term follow-up of the patients after the study.
Recommendations for future study are
1. The same techniques applied for a longer duration say 4 weeks
2. On effectiveness of other exercise programmes.
3. The same study can be done with a longer follow-up.
52
CONCLUSION
Both Capsular stretching and Muscle Energy Technique are effective treatment
techniques in the treatment of frozen shoulder. Further Capsular stretching is more
effective in increasing the range of motion and function in frozen shoulder.
53
SUMMARY
This study was conducted on 60 subjects at Srinivas College of Physiotherapy,
with an aim to find out the effectiveness of Capsular stretching over Muscle energy
technique on frozen shoulder. The subjects were divided into two groups of 30 each.
Group A received Capsular stretching with 5 sets per day, 5 repetitions per set and
5 days in a week each stretch held for a minimum duration of 30 seconds and maximum
duration up to the point of pain experienced by the patient with 10 minutes of moist pack
application prior to and 10 minutes of ice pack application after the stretching.
Group B received Muscle energy technique with 5 repetitions per set, 5 sets per
day and 5 days in a week with each contraction held for a period of 7-8 seconds followed
by a brief period of relaxation.
The shoulder range of motion (ROM) and University of Pennsylvania Shoulder
Score (part I) was considered as tool to measure the effectiveness of the interventions.
The range of motion and University of Pennsylvania Shoulder Score were taken prior to
treatment, at the end of 1 week of treatment and at the end of two weeks of treatment.The
analysis led to the finding that:
1. Both the groups showed improvement in shoulder range of motion and function
after 2 weeks of treatment.
54
2. Group A of Capsular stretching showed better results when compared to Group B
of Muscle energy technique in the improvement of range of motion and function.
3. Capsular stretching showed a significant difference when compared to Muscle
energy technique in its effectiveness on frozen shoulder.
4. Both the groups showed improvement in shoulder range of motion and function
on frozen shoulder.
This proves that both can be preferred for treatment of frozen shoulder whereas
the first preference can be given to Capsular stretching as it is more effective in
improving shoulder range of motion and function in frozen shoulder.
55
BIBLIOGRAPHY
1. Lori B. Siegel, Norman J. Cohen and Eric P. Gall. Adhesive capsulitis: A sticky issue,
American Family Physician 1999:59:7.
2. Mark A. Harrast & Anita G. Rao. The stiff shoulder. Physical Medicine &
Rehabilitation clinics of North America 2004; 15:557-573.
3. Robert A. Donatelli, Physical therapy of the shoulder 3rd edition, Churchill
Livingstone, New York 1997.
4. Thomas A. Souza, Sports injuries of the shoulder: Conservative management,
Churchill Livingstone, New York 1994.
5. Joseph P. Iannotti and Gerald R. Williams, Jr. Disorders of the shoulder, Diagnosis &
Management. Lippincott Williams & Wilkin, Philadelphia 1999.
6. A.F.W. Chamber, A.J. Carr. Aspects of current management: The role of surgery in
frozen shoulder. The Journal of Bone & Joint Surgery 2003; 85-B: 789-795.
7. Cleland J & Durall J. Physical therapy for adhesive capsulitis. Systematic rescue.
Physiotherapy 2002; 88:450-457.
8. T.D. Bunker Frozen shoulder. Current Orthopaedics 1998; 12:193-201.
9. J.A. Hannafin and Theresa A. Chiaia Adhesive Capsulitis: A treatment approach.
Clinical Orthopaedics & Related Research 2000; 372:95-109.
56
10. Sean M. Griggs, Anthony Ahn and Andrew Green. Idiopathic Adhesive capsulitis. A
perspective functional outcome study of non-operative treatment. The journal of Bone
& Joint Surgery 2000: 82-A: 1398-1407.
11. Fusun Guler-Uysal, Erkan Kozanoglu. Comparison of the early response to two
methods of rehabilitation in adhesive capsulitis. Swiss Medical weekly 2004;
134:353-358.
12. Margareta Nordin & Victor H. Frankel. Basic Biomechanics of the Musculoskeletal
system, 3rd edition, Lippincott Williams & Wilkins 2001.
13. J. H. Cyriax & P.J. Cyriax, Cyriax’s illustrated manual of orthopaedic medicine 2nd
edition, Butterworth & Heinneman 1983.
14. Robert J. Neviaser and Thomas J. Neviaser. Frozen shoulder Diagnosis &
Management. Current Orthopaedics & Related Research 1987;223:53-64.
15. James K. Mantone, Wayne Z. Burkhead Jr. & Joseph Noonan Jr.. Non operative
treatment of rotator cuff tears. Orthopaedic Clinics of North America 2000; 31:295-
311.
16. Leon Chaitow, Muscle Energy Techniques, Churchill Livingstone New York 1996.
17. Greenman P. Manual Medicine. Williams & Wilkins, Baltimore 1989
18. Miller MD, Rockwood Jr. CA. Thawing the frozen shoulder: The “patient” patient
Orthopaedics 1997; 19: 849-85.
19. Mao CY, Jaw WC Frozen shoulder: Correlation between the response to physical
therapy & follow up shoulder arthrography. Arhives of Physical Medicine &
Rehabilitation 1997; 78: 857-85.
57
20. Nicholson Gly. The effects of passive joint manipulation on pain & hypomobility
associated with adhesive capsulitis of the shoulder. Journal of Orthopaedics & Sports
Physical therapy 1985;6:238-248.
21. Andersen NH, Sajlurg Jo, Johansen HV, Sheffen G. Frozen shoulder. Arthroscopy &
manipulation under general anaesthesia & early possible motion. Journal of Shoulder
Elbow Surgery 1998;7:28-222.
22. 0.Pollock RG, Duralde YA, Flatow EL, Bigliani LU. The use of arthroscopy in
treatment of resistant frozen shoulder. Clinical Orthopaedics 1994;304:3-36.
23. Philip W. Mc Clure, Jason Bialker, Nancy Neff, Gerald & Williams & Andrew
Karduna. Shoulder Function & 3- Dimensonal Kinematics in people with shoulder
impingement syndrome before and after a 6-week exercise program. Physical therapy
2004; 84:832-848
24. Captain Eric Wilson, Otto Payton, Lisa Donegan Shoaf & Katherine Dec. Muscle
Energy Technique in patients with acute low back pain: a pilot clinical trail. Journal
of Orthopaedic & sports Physical therapy 2003;33:502-812.
25. Leon Chaitow & Judith Walker Delany. Clinical application of Neuromuscular
techniques Volume 1. The upper body, Churchill Livingstone 2000.
26. Benzamin A. Goldberg, Marius M. Scarlat & Douglas T. Harryman II. Management
of the stiff shoulder. Journal of Orthopaedic Science 1999;4: 462-471.
27. Rockwod C, Matsen F III The shoulder Vol. 2. Philadelphia, Saunders, 1998.
28. Craig Liebenson DC. The role of manipulation in rehabilitation.Dynamic
Chiropractice 1997:15;16.
58
29. Schenk R, Adelman K, Rouselle J. The effects of muscle energy technique on
cervical range of motion. J Man Manip Ther 1994;2:149-155.
30. Karel Lewit & David G. Simons Myofascial pain. Relief by post-isometric
Relaxation. Archives of Physical Medicine & Rehabilitation 1984;65: 452-456.
31. John Connolly, Eugene Regen and O.B. Evans. The management of the painful, stiff
shoulder. Clinical Orthopaedics & Related Research 1972; 84:97-103.
32. Mc. Laughlen, H.L. The frozen shoulder. Clinical Orthopaedics 1961;20:126-131.
33. Cynthia C. Norkin D. Joyce White Measurement of Joint motion. A guide to
goniometry 3rd edition, A. Davis Philadelphia, Jaypee publishers, New Delhi 2004.
34. Robert C. Ward. Foundations for Osteopathic medicine. Williams & Wilkins 1997.
35. Wilbert B van den Hout, Henricus M Vermeulen, Piet M. Rozing & Thea PM Vliet
Vlietland. Impact of adhesive capsulitis & economic evaluation of high grade & low-
grade mobilization techniques. Australian Journal of Physiotherapy 2005;51 :141-
149.
36. B.G.Leggin, M.A.Shaffer R.M.Neuman ,G.R.Williams J.P.Iannoti. Relationship of
the Penn shoulder score with measures of Range of Motion and Strength in patients
with shoulder disorders: A Preliminary report, The University of Pennsylvania
Orthopaedic Journal 2003;16:39-44
37. K.Nobuhara, D.Sugiyama, H.Ikeda , M.Makiura, Contracture of the shoulder, Clinical
Orthopaedics and Related research,1990,May,No.254, 105-110
38. J.Buchmann, K.Wende, G.Kundt, F.Haessler. Manual treatment effects to the upper
cervical apophysial joints before, during, and after endotracheal anaesthesia: A
59
Placebo controlled comparison, American Journal of Physical Medical
Rehabilitation,2005,Vol.84,No.4,251-257.
39. T.E. Rizk, R.P. Christopher, R.S.Pinals, A.C. Higgins, Adhesive capsulitis (Frozen
shoulder) :Anew approach to its management, Archives of Physical Medical
Rehabilitation 1983,Vol 64,29-33
40. Neville. R.M. Kay. The clinical diagnosis and management of frozen shoulders, The
Practitioner,1981,Vol 225, 164-172.
41. Robert. E. Booth, Jr, James. P. Marvel . Differential diagnosis of shoulder pain,
Orthopaedics Clinics of North America 1975,Vol. 6,No.2,353-379
42. Jeffrey. S. Scheib. Diagnosis and Rehabilitation of the Shoulder Impingement
Syndrome in the overhand and throwing athlete, Rheumatic disease Clinics of North
America,1990,Vol. 16,No.4,971-988.
43. E.W. Emig, M. E. Schweitzer, D. Karasick, J. Lubowitz . Adhesive capsulitis of the
shoulder ; MR Diagnosis, American Journal of Roentology,1995, 164,1457-1459.
44. J.J. Godges, M.M.Bell, D. Thorpe, D. Shah. The immediate effects of soft tissue
mobilization with proprioceptive neuromuscular facilitation on glenohumeral external
rotation and overhead reach, Journal of Orthopaedic & Sports Physical
therapy,2003,Vol 33, No.12,713-718.
45. J.D.Placzek ,P.J.Roubal ,D.C.Freeman, K.Kulig, S.Nasser ,& B.T.Pagett. Long term
effectiveness of translational manipulation for Adhesive capsulitis, Clinical
Orthopaedics and Related research1998, No.356, 181-191.
60
46. Robert.G.Grey. The natural history of Idiopathic Frozen Shoulder,The Journal of
Bone and Joint Surgery,1978,564.
47. Jules.S.Neviaser. Adhesive capsulitis and the stiff and painful shoulder, Orthopaedic
Clinics of North America – 1980,Vo. 11, NO.2,327-331.
48. D.J.Ogilvie-Harris,D.J.Biggs,D.P.Fitsialos,& M.Mackay.Clinical Orthopaedics and
Related Research,1995,No. 319,238-248.
49. Paul AVan Den Dolder & D.L.Roberts.A trial into the effectiveness of soft tissue
massage in the treatment of shoulder pain,Australian Journal of Physiotherpy
2003,Vol.49,183-188.
50. D.Robinson ,N.Halperin ,G.Agar, Doron Alk ,& K.Rami.Shoulder girdle neoplasms
mimicking frozen shoulder syndrome. gJournal of Shoulder Elbow Surgery
2003;12;451-455.
51. Piotte F, et al. Effects of repeated distension arthographies combined with a home
exercise program among adults with idiopathic adhesive capsulitis of the shoulder.
American Journal of Physical Medicine and Rehabilitation 2004; 6: 537-546.
52. Paula M Ludewig, Thomas M Cook. Alterations in shoulder kinematics and
associated muscle activity in people with symptoms of shoulder impingement.
Physical Therapy 2000;80:276-289.
61
ANNEXURE -10.1
EVALUATION TOOL
1. DEMOGRAPHIC DATA :
NAME:
AGE:
GENDER:
ADDRESS:
2. CHIEF COMPLAINTS:
3. HISTORY :
PRESENT HISTORY :
PAST HISTORY
FAMILY HISTORY
MEDICAL HISTORY : DM/HT/CARDIAC PROBLEMS / PREVIOUS

SURGERIES
PERSONAL HISTORY : SMOKING/ALCOHOL/DRUGS/FOOD

HABITS/PERSONALITY TYPE.
PSYCHOLOGICAL STATUS: DEPRESSED/CONFIDENT
SOCIO – ECONOMIC STATUS :
62
4. GENERAL EXAMINATION :
VITAL SIGNS :
1] TEMP: 2] PULSE : 3] B.P 4] R.R.
5. ON OBSERVATION:
BUILT POOR/MODERATE/WELL
POSTURAL ATTITUDE:
OBVIOUR MUSCLE WASTING
TROPICAL CHANGES
REDNESS :
CYANOSIS :
PIGMENTATION :
LOSS OF HAIR
SCARS :
SWELLING :
DEFORMITIES :
EXTERNAL APPLIANCES :
6. ON PALPATION :
TENDERNESS :
WARMTH :
SPASM :
SCAR :
CREPITUS AND BONY SPUR :
63
7. ON EXAMINATION :
SENSORY EXAMINATION :
TOUCH :
TEMPERATURE :
PAIN :
MOTOR EXAMINATION :
MUSCLE TONE:
MMT/BREAK TEST :
RESISTED FLEXION
RESISTED EXTENSION
RESISTED ABDUCTION
RESISTED INTERNAL ROTATION
RESISTED EXTERNAL ROTATION
RANGE OF MOTION :
ACTIVE : RIGHT LEFT
FLEXION :
EXTENSION :
ABDUCTION :
INTERNAL ROTATION :
EXTERNAL ROTATION:
64
PASSIVE :
RIGHT LEFT
FLEXION :
EXTENSION :
ABDUCTION :
INTERNAL ROTATION :
EXTERNAL ROTATION :
END – FEEL :
CAPSULAR
SPASM (MUSCLE GUARDING) :
EMPTY :
ACCESSORY MOTIONS :
ANTERIOR GLIDE
POSTERIOR GLIDE
INFERIOR GUIDE
SPECIAL TESTS :
APLEY’S SCRATCH TEST
LOAD AND SHIFT TEST (STABILITY TESTING)
IMPINGEMENT TESTS
SUPRASPINATUS TEST
SPEED’S TEST
DROP ARM TEST
65
PROVISIONAL DIAGNOSIS:
ACCEPTED FOR THE STUDY
REJECTED FOR THE STUDY
DATE:
SIGNATURE OF RESEARCHER:
SIGNATURE OF CO-GUIDE: SIGNATURE OF GUIDE:
66
ANNEXURE – 10.2
DATA COLLECTION TOOL FOR FROZEN SHOULDER
SUBJECT NAME :
SUBJECT NO:
AGE :
SEX :
OCCUPATION :
ADDRESS :
CONTACT NUMBER:
GROUP A ( ) Capsular Stretching GROUP B ( ) Muscle Energy Technique
TREATMENT MODE :
INSTRUMENTATION :
1. TREATMENT COUCH
2. TOWEL
3. 360° UNIVERSAL GONIOMETER
4. MOIST PACK
5. COLD PACK
6. PILLOW
7. UNIVERSITY OF PENNSYLVANIA SHOULDER SCORE (1ST SUB SET)
67
MEASUREMENTS
ROM of affected side measured using 360° Universal double arm goniometer.
RANGE PRE- AFTER 1 WK OF AFTER 2 WEEKS
TREATMENT TREATMENT OF TREATMENT
FLEXION
EXTENSION
ABDUCTION
INTERNAL
ROTATION
EXTERNAL
ROTATION
Evaluator Guide Co-guide
68
UNIVERSITY OF PENNSYLVANIA SHOULDER SCORE (Ist Subset):
PART 1 : PAIN AND SATISFACTION :
Please circle the number closest to your level of pain and satisfaction.
0 day (before After 1st week of After 2nd week of

treatment) treatment treatment
Pain at rest with your arm
by your side: 10 10 10
0 1 2 3 4 5 6 7 8 9 10
0 = no pain
10 = worst pain possible
Pain with normal activities
(eating, dressing, bathing) :
0 1 2 3 4 5 6 7 8 9 10 10 10 10
0 = no pain
10 = worst pain possible
Do you have pain at night Yes
on a regular basis ?
Yes No
Pain Score = 30 30 30
How satisfied are you with
the current level of function
of your shoulder?
0 1 2 3 4 5 6 7 8 9 10
0= Not satisfied
10 = Very satisfied
TOTAL(30+10=40)
69
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 = cant do at all
X= did not do before injury
Sl. No. 0 day (before After 1 week After 2

treatment) of treatment weeks of
treat
1. Reach the small of your 3210x 3210x 3210x
back to tuck in your shirt
with your hand.
2. Wash middle of your back 3210x 3210x 3210x
/hook bra
3. Perform necessary toileting 3210x 3210x 3210x
activities
4. Wash the back of opposite 3210x 3210x 3210x
shoulder
5 Comb hair 3210x 3210x 3210x
6 Place hand behind head 3210x 3210x 3210x
with your elbow held
straight out to the side
7 Dress self (including put on 3210x 3210x 3210x
coat and put shirt off
overhead
8 Sleep on the affected side 3210x 3210x 3210x
9 Open a door with affected 3210x 3210x 3210x
side
10 Carry a bag of groceries 3 2 10 x 3210x 3210x
with affected arm
11 Carry a briefcase / small 3210x 3210x 3210x
suitcase with affected arm
12 Place a soup can ( 1 -2 lbs) 3210x 3210x 3210x
on shelf at shoulder level
without bending elbow
13 Place a one gallon container 3210x 3210x 3210x
( 3-10 lbs) on a shelf at
70
shoulder level without
bending elbow
14 Reach a shelf above your 3210x 3210x 3210x
head without bending elbow
15 Place a soup can (1-2lbs) on 3210x 3210x 3210x
a shelf above your head
without bending your elbow
16 Place a one gallon container 3210x 3210x 3210x
(8 – 10 lbs) on a shelf
overhead without bending
elbow
17 Perform usual sport/hobby 3210x 3210x 3210x
18 Perform household ehores 3210x 3210x 3210x
(cleaning, laundry, cooking)
19 Throw 3210x 3210x 3210x
overhands/swim/overhead
racquet sports (circle all
that apply to you)
20 Work full – time at your 3210x 3210x 3210x
regular job
TOTAL=60
Overall Total of Pain &
Function=100
Evaluator Guide Co-guide
71
ANNEXURE 10.3
CONSENT FORM
TITLE OF THE PROJECT :
“Effects of Capsular Stretching and Muscle Energy
Technique in the management of Frozen Shoulder”
NAME OF THE PRINCIPLE INVESTIGATOR : KRIPA M
PURPOSE OF THE STUDY : My aim of the study is to
1. Find out the effectiveness of Capsular stretching and Muscle Energy Technique in
the management of Frozen Shoulder & to
2. Compare the effectiveness of Capsular Stretching and Muscle Energy Technique
in the management of Frozen Shoulder.
PROCEDURE AND METHOD
You will be participating in the study of 2 weeks duration. ( 5 days/week).
Your will be categorized in either of the groups i.e Group A or Group B.
Group B.
Group A will be receiving Capsular Stretching.
Group B will receive Muscle Energy Technique.
Initial measurements will be taken before beginning the treatment regime.
Post treatment measurements will be taken at the end of each week.
RISK INHERENT
At this study is concerned, known and expected risks have been taken care of
72
BENEFITS
It will help us to decide a better treatment protocol for Frozen Shoulder.
CONFIDENTIALITY
Your name and identity will be kept confidential. You will be assigned a number
of identification, which will be used for the research procedure.
CONSENT FROM THE PARTICIPANT
I Mr/Mrs.________________________________ was explained in detail about
the study and the problems to be faced by me in my own language and was given
freedom to withdraw at any moment during the course of the study. I have understood
the information stated by the investigator and with a clear understanding I am willing to
participate in the study on my own risk and my sign at the bottom of this form indicates
that I am participating in the study on my own interest but not on any body’s
compulsions
PARTICIPANT NAME : SIGNATURE

DATE :
NAME OF WITNESS : SIGN OF WITNESS

DATE:
INVESTIGATOR : KRIPA . M
GUIDE : Prof. UMASANKAR MOHANTY SIGNATURE :

DATE:
CO-GUIDE : Asst Prof. ANUP JOHNEY SIGNATURE

DATE : DATE
73
MASTER CHA RT OF ACTIVE SHOULDER ROM MEASUREMENT OF
GROUP A (CAPSULAR STRETCHING)
Sl.No. Fl0 Fl1 Fl2 Ex0 Ex1 Ex2 Ab0 Ab1 Ab2 IR0 IR1 IR2 ER0 ER1 ER2
1 95 113 125 25 26 28 70 84 95 50 63 70 30 44 56
2 103 122 135 50 52 58 67 83 95 55 66 73 25 39 52
3 80 110 118 12 15 20 45 70 97 48 63 75 32 48 62
4 100 125 150 30 36 40 50 68 93 24 38 62 28 45 60
5 90 110 130 40 44 48 70 85 102 26 40 65 33 48 63
6 72 100 109 17 18 22 25 38 51 45 61 72 19 33 56
7 100 128 140 40 46 52 55 74 100 56 67 74 28 44 62
8 85 100 118 20 25 32 48 60 72 38 52 65 40 59 71
9 110 135 145 33 38 40 80 95 107 52 68 75 38 56 72
10 135 150 172 30 40 55 49 65 90 42 55 71 44 63 72
11 135 150 165 35 42 50 58 74 98 53 69 76 38 54 68
12 90 120 135 20 30 45 40 58 70 60 72 80 36 48 70
13 80 100 110 15 20 30 51 64 78 60 72 80 39 63 73
14 60 80 110 10 25 35 65 90 109 30 44 60 30 52 70
15 50 75 108 20 28 39 44 62 85 47 58 65 38 53 68
16 120 145 155 30 36 40 38 52 78 38 44 62 15 28 42
17 60 95 110 15 20 32 63 80 100 52 68 77 39 58 72
18 50 90 118 30 38 45 42 56 75 20 38 51 25 41 59
19 90 110 115 30 33 36 33 65 93 36 47 62 28 41 65
20 90 115 130 35 38 42 75 93 110 23 35 52 30 49 68
21 85 100 112 45 48 54 68 88 102 40 56 73 34 55 70
22 92 115 135 26 32 40 50 65 84 38 53 73 26 41 60
23 95 110 120 28 35 40 38 50 65 44 63 76 35 54 72
24 72 95 110 35 44 52 45 67 90 48 69 79 23 38 57
25 105 120 135 48 53 59 78 93 110 28 39 56 33 55 74
26 75 90 108 20 28 35 55 69 93 41 60 74 23 37 51
27 70 85 100 25 28 40 44 61 88 58 66 78 20 35 52
28 120 135 150 38 44 50 70 89 112 46 64 78 28 43 65
29 100 110 125 45 52 56 79 93 112 50 66 79 41 62 74
30 130 140 155 40 45 50 45 62 98 45 60 75 36 52 65
74
MASTER CHA RT OF ACTIVE SHOULDER ROM MEASUREMENT OF
GROUP B (MET)
Sl.No. Fl0 Fl1 Fl2 Ex0 Ex1 Ex2 Ab0 Ab1 Ab2 IR0 IR1 IR2 ER0 ER1 ER2
1 83 89 98 25 46 55 42 48 60 40 45 50 12 14 23
2 160 165 175 30 39 46 70 75 90 45 50 55 22 25 30
3 100 104 110 35 45 55 41 48 52 28 32 35 18 20 25
4 90 90 95 30 50 60 45 53 70 38 42 49 22 26 40
5 100 100 105 25 30 40 45 50 69 43 48 53 43 46 50
6 83 89 98 37 44 50 47 50 71 40 45 54 10 14 23
7 90 95 110 30 35 44 44 50 73 41 46 50 30 33 40
8 82 88 100 15 19 24 45 52 74 45 50 60 38 40 55
9 70 73 78 48 55 60 35 38 45 38 42 48 10 16 32
10 135 140 164 40 60 60 99 108 116 75 80 80 30 35 50
11 95 95 100 35 55 60 52 60 76 30 37 42 23 28 40
12 100 105 125 25 40 60 57 65 72 34 40 50 8 12 26
13 60 66 90 25 40 45 60 70 90 40 45 50 45 50 52
14 170 175 180 27 40 45 57 62 70 7 12 28 5 10 25
15 130 135 160 26 40 60 58 63 74 22 28 35 20 25 30
16 90 90 95 30 44 58 47 65 82 23 30 35 28 33 42
17 60 76 100 25 30 55 61 70 90 40 45 50 45 50 56
18 90 95 100 30 35 40 65 68 75 75 80 80 23 25 30
19 95 95 100 25 30 40 50 58 64 20 23 25 13 18 28
20 100 105 112 25 30 40 68 78 92 25 29 30 15 18 26
21 75 85 110 40 45 55 29 34 40 54 58 64 13 15 20
22 63 72 90 34 40 50 50 55 72 45 48 55 20 25 34
23 80 92 108 35 55 60 25 33 42 63 66 72 25 28 40
24 78 90 105 40 52 60 67 80 90 48 53 60 24 30 35
25 92 98 110 40 44 50 49 56 70 35 38 44 25 30 40
26 68 75 88 32 48 56 25 30 45 48 52 63 38 40 45
27 87 95 108 25 34 40 76 82 95 47 50 58 37 38 50
28 105 110 125 48 53 58 60 65 74 35 40 58 15 18 26
29 125 130 150 30 35 42 44 48 60 56 60 66 10 15 22
30 88 94 105 45 55 50 55 62 80 38 40 52 20 24 35
75
MASTER CHART OF
UNIVERSITY OF PENNSYLVANIA SHOULDER SCORE ( 1st Subset) for
Group A
Pre – Treatment After 1 week After 2 weeks

35.22 48.44 60
27.88 41.55 56.55
35.25 53.58 67.71
29.35 45.66 57.87
15.44 24.33 42.22
27.88 33.88 45.11
37.55 56.66 65.33
38 46.33 56.82
37.88 49.66 59.55
24.18 48.51 56.08
65.33 68.44 71.33
24.66 36.55 49.33
55.97 61.07 66.15
24.55 39.22 57.33
30.38 45.76 58.97
47.21 61.86 68.43
41.74 58.2 64.2
30 45.77 59.71
26.17 36.51 52
26.77 35.44 46
42 51 63
37.61 45.71 60.84
31.88 42.22 49.88
33.77 44.44 53.11
24.33 33.99 46.33
41 47 55
37.94 48.18 56.59
29 30 33
26.4 37.22 45.55
46.2 54.77 62.88
76
MASTER CHART OF
UNIVERSITY OF PENNSYLVANIA SHOULDER SCORE ( 1st Subset) for
Group B
Pre – Treatment After 1 week After 2 weeks

20.56 22.97 24.24
33.7 35.54 43.77
25.66 28.44 30.44
21.81 24.81 25.29
32.11 34.88 40.11
27.28 29.41 32.53
24.22 28.22 31.33
50 53.66 57.11
26.55 30.22 33.88
50.83 55.75 58.21
27 31.99 35.11
22.15 24.25 30.58
38.44 40.22 45.77
44.43 48.43 53.56
34.56 37.28 42.84
14.02 17.12 20
32.11 37.55 42.55
29.44 33.22 37.44
27.44 30.72 34.33
26.72 30.54 36.92
45.55 50.77 60.11
42.18 45.59 50.48
27.3 29.46 33.66
33.51 37.71 40.87
27 29 32
43.77 48.77 50.22
56.66 59.77 62.33
31 35 39
62.13 65.4 69.97
47.82 50.92 53.13
77

Kripa. M: Master of Physiotherapy (M.P.T.)

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Kripa. M: Master of Physiotherapy (M.P.T.)

Uploaded by

Copyright:

Available Formats

A COMPARATIVE STUDY TO FIND OUT THE EFFECTS OF

CAPSULAR STRETCHING OVER MUSCLE ENERGY

Dissertation submitted to the

In Partial fulfillment of the award of

MASTER OF PHYSIOTHERAPY (M.P.T.)

Under the guidance of

SRINIVAS COLLEGE OF PHYSIOTHERAPY

DECLARATION BY THE CANDIDATE

I here by declare that this dissertation entitled “A COMPARATIVE

CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled “A COMPARATIVE STUDY

Date: Signature of the Guide

ENDORSEMENT BY THE HOD /PRINCIPAL

This is to certify that the dissertation entitled “A COMPARATIVE

Asst. Prof. K. Selvamani Associate Prof. Ramprasad M.

DECLARATION BY THE CANDIDATE

I here by declare that the RAJIV GANDHI UNIVERSITY OF HEALTH

© Rajiv Gandhi University of Health Sciences, Karnataka.

1. ANOVA (Analysis of Variance)

2. ESI (Employees State Insurance)

4. MET (Muscle Energy Technique)

Key words:-MET, Capsular stretching, Frozen shoulder.

S.L.NO TOPIC PAGE NO.

2. AIMS AND OBJECTIVES 13 - 15

S.L.NO TABLES PAGE

5.2 Mean and Standard deviation of ROM of Group B 36

S.L.NO FIGURES PAGE NO.

1 Tools used for the study 25

S.L.NO GRAPHS PAGE NO.

5.1 Comparison of the Mean of ROM of Group A & 44

Parents, Brother & Sister

and ligaments must anchor the shoulder.1

it. To answer these important questions thorough understanding of the differential

diagnosis and pathophysiology of shoulder stiffness is necessary.2

Shoulder stiffness is a poorly understood disorder of the glenohumeral joint and

shoulder by Codman in 1934 and later adhesive capsulitis by Neviaser in 1945.3Codman

described the disorder known as frozen shoulder as a “condition difficult to define,

fibrosis, or thickening and contracture of the capsule.2

adhesive capsulitis, periarthritis, stiff and painful shoulder, periarticular adhesions,

Duplay’s disease, scapulohumeral periarthritis, tendinitis of the short rotators, adherent

subacromial bursitis, painful stiff shoulder, bicipital tenosynovitis, subdeltoid bursitis,

humeroscapular fibrositis, shoulder portion of the shoulder of the shoulder hand

syndrome, bursitis calcarea, supraspinatus tendinitis, periarthrosis humeroscapularis,and

a host of foreign language terms.3

Peariarthritis covers a large group of disorders including tendonitis and tears of

frozen shoulder and adhesive capsulitis are the preferred terms.4

The debate continues as to whether inflammation or fibrosis is the primary

development of frozen shoulder. The reason for this histologically observed

inflammatory reaction is unclear.3 It has been hypothesized that it could represent a

response to injury, an infectious agent, a chemical mediation.or an autoimmune reaction.

fibrosis by stimulating fibroblasts. Radeo et al observed the role of specific cytokines

cascade and subsequent fibrosis is still unknown.2

Based on the etiology frozen shoulders can be classified as primary or secondary.

intrinsic, extrinsic and systemic categories.6 Intrinsic shoulder abnormalities include

calcific tendinitis and acromioclavicular joint arthritis. Extrinsic disorders which

disease and myocardial infarction, pulmonary disorders including tuberculosis, chronic

association with frozen shoulder which include diabetes mellitus, hypothyroidism,

hyperthyroidism, and hypoadrenalism.5

Frozen shoulder is a pathology of often unknown aetiology characterized by

motion (Baslund et al,1990;Pearsall and Speer,1998).Approximately 2-3% of adults aged

responsible to the development of frozen shoulder.

frozen shoulder shows an entirely normal radiographic appearance of the shoulder.