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CHAPTER – 1 (INTRODUCTION)

INTRODUCTION
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In world population frozen shoulder is occuring more commonly and is considered as major
health problem . It is a common shoulder ailment that is marked by pain and progressive
loss of range of motion, particularly in external rotation. Frozen shoulder appears when the
strong connective tissue surrounding the shoulder joint (called the shoulder joint capsule)
become thick, stiff, and inflamed. (The joint capsule contains the ligaments that attach the
top of the upper arm bone [humeral head] to the shoulder socket [glenoid], firmly holding
the joint in place. This is more commonly known as the "ball and socket" joint.)( McMahon
PJ, et al.2021)

The condition is called "frozen" shoulder because the more pain that is felt, the less likely
the shoulder will be used. Lack of use causes the shoulder capsule to thicken and becomes
tight, making the shoulder even more difficult to move -- it is "frozen" in its position .( Codsi
MJ.,2007)

Anatomy of Shoulder Joint

The shoulder girdle is composed of the clavicle and

the scapula, which articulates with the proximal
humerus of the upper limb. Four joints are present
in the shoulder: the sternoclavicular (SC),
acromioclavicular (AC), and scapulothoracic joints,
and glenohumeral joint. lenohumeral joint is a highly
moveable ball-and-socket synovial joint that is
stabilized by the rotator cuff muscles that attach to
the joint capsule, as well as the tendons of the
biceps and triceps brachii. The humeral head
articulates with the glenoid fossa of the scapula. It is
a shallow articulation, as the fossa accommodates
less than one-third of the humeral head. The labrum,
a fibrocartilaginous ring, attaches to the outer rim of
the glenoid fossa and provides additional depth and Figure 1.1 SHOULDER JOINT
stability securing the humeral head.[FIG1] A small number
of fluid-filled sacs known as bursae surround the capsule and aid in mobility. These are the
(Kadi R, Milants A, Shahabpour
subacromial, subdeltoid, subscapular, and subcoracoid bursae .
M ,December 2017).

The major movements at the glenohumeral joint are: ( Nicola Mclaren,2023 )

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 Abduction: upward lateral movement of humerus out to the side, away from the body, in
the plane of the scapula
 Adduction: downward movement of humerus medially toward the body from abduction,
in the plane of the scapula
 Flexion: the movement of humerus straight anteriorly
 Extension: the movement of humerus straight posteriorly
 External rotation: the movement of humerus laterally around its long axis away from the
midline
 Internal rotation: the movement of humerus medially around its long axis toward the
midline
 Horizontal adduction (transverse flexion): the movement of the humerus in a horizontal
or transverse plane toward and across the chest
 Horizontal abduction (transverse extension): the movement of the humerus in a
horizontal or transverse plane away from the chest .

BLOOD SUPPLY AND LYMPHATICS

The axillary artery is the major blood vessel in the shoulder, with many of its branches
supplying the area. These branches include the superior thoracic artery, thoracoacromial
artery, lateral thoracic artery, subscapular artery, anterior humeral circumflex artery, and
posterior humeral circumflex artery. Before becoming the axillary artery, after passing
beyond the lateral edge of the first rib, the subclavian artery also includes branches that
supply the area of the shoulder. The thyrocervical trunk off of the subclavian artery adds the
suprascapular artery and the transverse cervical artery. The dorsal scapular artery most
often branches off of the subclavian, but may sometimes branch off the transverse cervical
artery. (Cael, C. (2010), Moore, K. L., Dalley (2014)

MUSCLES

MUSCLES OF THE SHOULDER JOINT ARE :

( Mohammed A. Miniato; Prashanth Anand; Matthew Varacallo., 2022)

Deltoid
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Figure 1.2 deltoid muscle.

 Function:
o Anterior aspect is responsible for flexion and medial rotation of the arm
o Middle aspect is responsible for the abduction of the arm (up to 90 degrees)
o The posterior aspect is responsible for extension and lateral rotation of the arm

 Origin: Lateral clavicle, acromion and scapular spine[Fig.2]

 Insertion: Deltoid tuberosity

Teres major ( Jones J, Rasuli B, Vadera S, et al. 2023)

Figure 1.3 TERES MAJOR MUSCLE

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 Function: Adduction and medial rotation of the arm

 Origin: Posterior surface of the scapula at its inferior angle [Fig.3]
 Insertion: Intertubercular groove of the proximal humerus on its medial aspect [Fig.3]

Supraspinatus (Rotator Cuff) (Teruhisa, M. 2019)

 Function: Initiation of arm abduction (first 15 degrees), stabilize glenohumeral joint

 Origin: Posterior scapula, superior to the scapular spine/supraspinous fossa
 Insertion: Top of the greater tubercle of the humerus[ Fig.4]

Infraspinatus (Rotator Cuff)

 Function: Lateral rotation of the arm, stabilize glenohumeral joint

 Origin: Posterior scapula, inferior to the scapular spine/Infraspinous fossa
 Insertion: Greater tubercle of the humerus, between the supraspinatus and teres minor
insertion[Fig.4]

Teres minor (Rotator Cuff)

 Function: Lateral rotation of the arm,stabilize glenohumeral joint. [Fig.4]

 Origin: Inferior angle of the scapula
 Insertion: Inferior aspect of the greater tubercle
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 Innervation: Axillary nerve (C5, C6)

Figure 1. 4 Showing TERES MINOR, SUPRASPINATUS,INFRASPINATUS MUSCLE

Subscapularis (Rotator Cuff)

Function:
Adduction and medial rotation of the arm, stabilize glenohumeral joint.[Fig.5]
 Origin: Anterior aspect of the scapula

Figure1. 5 Subscapularis muscle.

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 Insertion : Lesser tubercle of the humerus.[Fig No.5]

 Innervation: Subscapular nerves (C5, C6, C7)
Trapezius

Figure1. 6 Trapezius muscle

 Function:

o Upper fibers elevate the scapula and rotate it during abduction of the arm (90 to 180
degrees) [Fig 6]
o Middle fibers retract the scapula[Fig 6]
o Lower fibers pull the scapula inferiorly.[Fig 6]

 Origin: Skull, nuchal ligament and the spinous processes of C7 to T12

 Insertion: clavicle, acromion and the scapular spine
 Innervation: Accessory nerve ( C5, C6)
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Figure 1.7 Lattismus Dorsi Muscle

Latissmus dorsi
 Function: Extends, adducts and medially rotates the upper limb
 Origin: Spinous processes of T6 to T12, iliac crest, thoracolumbar fascia, and the inferior
three ribs[ Fig 7]

 Insertion: Intertubercular sulcus of the humerus[Fig. 7]

Pectoralis major

Figure 1.8 SHOWING PECTORALIS MAJOR AND MINOR MUSCLE

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 Function:
 Clavicular head flexes and adducts arm
 Sternal head adducts and medially rotates the arm
 Accessory for inspiration
 Origin:
 Clavicular head: medial half clavicle[Fig.8]
 Sternocostal head: Lateral manubrium and sternum, six upper costal cartilages and external
oblique aponeurosis

 Insertion: Intertubercular groove of the proximal humerus on its lateral aspect

 Innervation: Medial and lateral pectoral nerves (C6, C7, C8)
Pectoralis minor
 Function: Depression of the shoulder, protraction of the scapula
 Origin: Third, fourth, fifth ribs close to their respective costal cartilages
 Insertion: Coracoid process [Fig.8]
 Innervation: Medial pectoral nerve (C8, T1)

NORMAL RANGE OF MOTION AT VARIOUS MOVEMENTS AT SHOULDER JOINT :

The glenohumeral joint possesses the capability of allowing an extreme range of motion in
multiple planes (Bakhsh W, Nicandri G.,2018)

 Flexion – Defined as bringing the upper limb anterior in the sagittal plane. The usual range of
motion is 180 degrees. The main flexors of the shoulder are the anterior deltoid,
coracobrachialis, and pectoralis major. Biceps brachii also weakly assists in this action .

 Extension—Defined as bringing the upper limb posterior in a sagittal plane. The normal range
of motion is 45 to 60 degrees. The main extensors of the shoulder are the posterior deltoid,
latissimus dorsi, and teres major.
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 Internal rotation—Defined as rotation toward the midline along a vertical axis. The
normal range of motion is 70 to 90 degrees. The internal rotation muscles are the
subscapularis, pectoralis major, latissimus dorsi, teres major, and the anterior aspect of the
deltoid.
 External rotation - Defined as rotation away from the midline along a vertical axis. The
normal range of motion is 90 degrees. Primarily infraspinatus and teres minor are
responsible for the motion.
 Adduction – Defined as bringing the upper limb towards the midline in the coronal plane.
Pectoralis major, latissimus dorsi, and teres major are the muscles primarily responsible for
shoulder adduction.
 Abduction - Defined as bringing the upper limb away from the midline in the coronal
plane. The normal range of motion is 150 degrees. Due to the ability to differentiate several
pathologies by the range of motion of the glenohumeral joint in this plane of motion, it is
essential to understand how different muscles contribute to this action .

I. The supraspinatus is responsible for the first 0 to 15 degrees of abduction.

II. The middle fibers of the deltoid are responsible for approximately 15 to 90 degrees of
abduction .

Codman defined frozen shoulder as a clinical condition that can hardly be defined, it is
complicated to enclose it in a single pathological mechanism, and therefore, even less easy
to define its treatment. Instead, the term “adhesive capsulitis” was introduced by Neviaser
describe it as a tissue inflammation condition . (Neviaser, JS,1945) Shoulder stiffness is very
common often related with to a history of shoulder trauma or underlying disease, when left
untreated results in frozen shoulder . As conditions like diabetes are increasing , chances of
developing frozen shoulder are at high risk. (Dias R, Cutts S, Massoud S,2005)

 Frozen shoulder is mainly by an insidious and progressive loss of active and passive mobility
in the glenohumeral joint presumably due to capsular contracture. ( McMahon PJ, et al.,2021)

 Frozen Shoulder may be:

1. Primary - Onset is generally idiopathic (it comes on for no attributable reason)

2. Secondary - Results from a known cause, predisposing factor or surgical event.A
secondary frozen shoulder can be the result of several predisposing factors. For
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example, post surgery, post-stroke and post-injury. Where post-injury, there may be an
altered movement pattern to protect the painful structures, which will in turn change
the motor control of the shoulder, reducing the range of motion, and
gradually stiffens up the joint .(Griggs SM, Ahn A, Green A 2000)

EPIDEMIOLOGY OF FROZEN SHOULDER

Adhesive capsulitis occurs in up to 5%. Females are 4 times more often affected than men,
while the non-dominant shoulder is more prone to be affected

ETIOLOGY OF FROZEN SHOULDER(Codman E.A 1934)

The etiology of frozen shoulder is not yet fully understood. However, some plausible risk
factors have been identified:
 Diabetes mellitus (with a prevalence up to 20%)
 Stroke
 Thyroid disorder
 Shoulder injury
 Dupuytren disease
 Parkinson disease
 Cancer
 Complex regional pain syndrome

PATHOPHYSIOLOGY OF FROZEN SHOULDER

Frozen Shoulder (FS) is a common cause of shoulder pain associated with restricted active
and passive range of motion. Although this condition has been recognized as a clinical
disease entity for about 150 years, we still have not unraveled the pathophysiology yet. FS
has often been described as a self-limiting condition, with recovery within two to three
years for the majority of patients [14]. However, symptoms of mild to moderate pain and
stiffness are reported in 27–50% of patients at long term [14]. Even in patients with a
favorable natural course of the condition, there is still an extensive period to deal with pain,
and functional limitations. Frozen shoulder is usually described as fibrotic, inflammatory

contracture of the rotator interval, capsule, and ligaments. However, the development of AC
remains not fully understood. Although disagreements exist, the most recognized pathology
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is cytokine-mediated synovial inflammation with fibroblastic proliferation based on

arthroscopic observations. Additional findings include adhesions around the rotator
interval caused by increased collagen and nodular band formation(Tamai K, Akutsu M, Yano Y 2014)
The structure usually affected first is the coracohumeral ligament the roof of the rotator cuff
interval. Contraction of the coracohumeral ligament limits external rotation of the arm,
which is usually first affected in early AC. In advanced stages, thickening and contraction of
the glenohumeral joint capsule develop, further limiting the range of motion in all
directions.

STAGES OF FROZEN SHOULDER

 Acute/freezing/painful phase: Gradual onset of shoulder pain at rest with sharp
pain at extremes of motion, and pain at night with sleep interruption which may last
anywhere from 2-9 months.
 Adhesive/frozen/stiffening phase: Pain starts to subside, progressive loss of GH
motion in capsular pattern. Pain is apparent only at extremes of movement. This phase
may occur at around 4 months and last till about 12 months.
 Resolution/thawing phase: Spontaneous, progressive improvement in functional
range of motion which can last anywhere from 5 to 24 months. Despite this, some
studies suggest that it's a self limiting condition, and may last up to three years. Though
other studies have shown that up to 40% of patients may have persistent symptoms
and restriction of movement beyond three years .
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TABLE 1.1 [STAGES OF FROZEN SHOULDER]

Diagnosis

Clinical diagnosis
Primary frozen shoulder is essentially clinical diagnosis. Frozen shoulder is characterized by
an insidious and progressive loss of active as well as passive mobility in the glenohumeral
joint mainly due to capsular contracture. Patients typically demonstrate a characteristic
history, clinical presentation, and recovery. Clinical syndromes include pain, a limited range
of motion (ROM), and muscle weakness from disuse . There are four movements that are
useful in the examination—flexion, abduction, internal rotation, and external rotation.

Flexion , abduction and internal rotation are evaluated with active and passive
mobilization, while external rotation is evaluated only with passive mobilization. (Bunker T,
Anthony P) (1995)

MANAGEMENT OF FROZEN SHOULDER

The main approaches to treat frozen shoulder are to increase ROM with active , passive
movements along with mobilisation and muscle energy technique.The goal is to maintain
and gain ROM and achieve painfree shoulder movement after treatment.
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Modalities such as TENS help to decrease shoulder pain and HOT PACK when given prior to
movement , help relax the shoulder muscles which ultimately aids in providing relaxation to
patient and perform smooth ,less painful active and passive movements . ( Bal A, Eskioglu E, Gulec B,
Aydog E, et . al( 2008)

Transcutaneous Electrical Nerve Stimulation (T.E.N.S) is the use of electrical

current produced from a device to stimulate nerves for therapeutic purposes to reduce pain
of any origin by using the application of pulsed rectangular monophasic/biphasic current
with the pulse duration of 50-200 us and frequency of 1-120Hz and a maximum peak
current of 50mA-100mA applied through surface electrodes.(Jagmohan singh ) (2012)

HOT PACK /HYDROCOLLATOR PACK:

Hot pack (hp) are noninvasive modalities that are commonly used in the management of both
acute as well as chronic pain arising from several conditions.Commercially, available hot packs
are usually a canvas cover filled with a hydrophillic substance such as bentonite . HOT packs are
kept in a commercial water filled container that maintains a temprature of 71 degree Celsius.

MAITLAND MOBILIZATION
The international Maitland Teachers Association(IMTA) defines the maitland concept as a
process of examination, assessment and treatment of neuromusculoskeletal disorder by
manipulative physiotherapy.( Maitland G 1983)
Grades I and II of maitland mobilization techniques are primarily used for treating joints
limited by pain. The oscillations may have an inhibitory effect on the perception of painful
stimuli by repetitively stimulating mechanoreceptors that block nociceptive pathways at the
spinal cord or brain stem levels.These nonstretch motions help move synovial fluid to
improve nutrition to cartilage whereas Grades III and IV are primarily used as stretching
manoeuvres. Appropriate selection of mobilization technique for treatment can take place
after a thorough assessment and examination.(Magee DJ.)(2008) Different Glides used in shoulder
joint are –

 A-P (Anteroposterior)
 P-A (Posteroanterior)
 Longitudinal Caudad
 Longitudinal Cephalad
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 Joint Distraction
 Medial Glide
 Lateral Glide

This glides are applied on the basis of convex – concave rule which states that(

 When a convex surface (i.e Humeral Head) moves on a stable concave surface (i.e
Glenoid Fossa) the sliding of the convex articulating surface occurs in the opposite
direction to the motion of the bony lever (i.e the Humerus)

The opposite can be said for

 When a concave surface (i.e Tibia; talocrural joint) is moving on a stable convex surface
(i.e Talus) sliding occurs in the same direction of the bony level .

 Examples:To improve shoulder flexion one have to perform an A-P

mobilisation due to the way the convex humerus articulates with the
concave glenoid fossa .( Schomacher J.)(2009 )

Fig 1.9 MAITLAND CONCEPT

GRADES OF MAITLAND MOBILIZATION(Wise CH.et al )

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Fig.1.10 GRADES OF MAITLAND MOBILIZATION

M.E.T [ MUSCLE ENERGY TECHNIQUE]

Muscle energy technique(MET) help relieve restriction and pain at the shoulder. It is unique
in its application as the client provides the initial effort while the practitioner facilitates the
process. It is a standardized series of shoulder treatments with broad application in
diagnosis, treatment, and prognosis. It is developed by Spencer , D.O. in 1916. Spencer
technique is an articulatory technique with seven different procedures used to treat
shoulder restriction caused by adhesive capsulitis. In this technique passive,smooth,rythmic
motion is designed to stretch contracted muscles,ligaments,and capsules.Most of the force
is applied to end range of motion. This technique increases pain free range of motion
through stretching the tissues,enhancing lymphatic flow, and stimulating increased joint
circulation. Muscle energy is a direct and active technique; meaning it engages a restrictive
barrier and requires the patient’s participation for maximal effect .. (Stephanie D Moore, Kevin G Launder
et al), (2011)

TYPES OF M.E.T

There are mainly 2 types of MET :

1. Autogenic Inhibition MET

 Post Isometric Relaxation (PIR)
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 Post Facilitation Stretching (PFS)

2. Reciprocal Inhibition MET

1) AUTOGENIC INHIBITION:

-Autogenic inhibition reflex is a sudden relaxation of muscle upon the development of high
tension. It is a self-induced, inhibitory, negative feedback prolong lengthen reaction against
tear muscles. Golgi tendon organs are receptors responsible for that.

Autogenic inhibition (historically known as the inverse myotatic reflex or autogenetic

inhibition) shows a decrease in the excitability of a contracting or stretched muscle that in
the past has been merely ascribed to the increased inhibitory input arising from Golgi
tendon organs (GTOs) within the same muscle. (Waxenbaum JA et al.)(2020)

The reduced efferent (motor) send to the muscle through autogenic inhibition is a factor
that will help muscle elongation.

Figure 1. 11 NEUROMUSCULAR INHIBTION

Golgi tendon organs are receptors responsible for that Autogenic inhibition (historically
known as the inverse myotatic reflex or autogenetic inhibition) shows a decrease in the
excitability of a contracting or stretched muscle that in the past has been merely ascribed to
the increased inhibitory input arising from Golgi tendon organs (GTOs) within the same
muscle.

The reduced efferent (motor) send to the muscle through autogenic inhibition is a factor
that will help muscle elongation.(Lewit K, Simons DG.)(1984 )
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Ex. GTOs sense muscular tension within muscles when they contract or are stretched. When
the GTO is activated during contraction, it causes inhibition of the contraction (autogenic
inhibition), which is an automatic reflex. Static stretching is one example of how muscle
tension signals a GTO response.

 –POST ISOMETRIC RELAXATION (PIR):- Post Isometric Relaxation is a technique developed

by Karel Lewitt. Post Isometric Relaxation(PIR) is the effect of the decrease in muscle tone in
a single or group of muscles, after a brief period of submaximal isometric contraction of the
same muscle. PIR works on the concept of autogenic inhibition.

Autogenic and reciprocal inhibition both occur when certain muscles are inhibited from
contracting due to the activation of the Golgi tendon organ (GTO) and the muscle
spindles. These two musculotendinous proprioceptors located in and around the joints
and muscles respond to changes in muscle tension and length, which helps manage
muscular control and coordination.

The GTO, located between the muscle belly and its tendon, senses increased tension
when the muscle contracts or stretches. When the muscle contracts, the GTO is
activated and responds by inhibiting this contraction (reflex inhibition) and contracting
the opposing (antagonist) muscle group. This process is known as autogenic inhibition.

The GTO response plays an important role in flexibility. When the GTO inhibits
the (agonist) muscle’s contraction and allows the antagonist muscle to contract more
readily, the muscle can be stretched further and easier. Autogenic inhibition is often
seen during static stretching, such as during a low-force, long-duration stretch. After 7
to 10 seconds, muscle tension increases and activates the GTO response, causing the
muscle spindle in the stretched muscle to be inhibited temporarily, which makes it
possible to stretch the muscle further. (Fig.11)

The muscle spindle is located within the muscle belly and stretches along with the
muscle itself. When this occurs, the muscle spindle is activated and causes a reflexive
contraction in the agonist muscle (known as the stretch reflex) and relaxation in the
antagonist muscle. This process is known as reciprocal inhibition .(Goodridge JP) (1981)

MECHANISM OF ACTION:
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Muscle energy is a direct and active technique; meaning it engages a restrictive barrier and
requires the patient’s participation for maximal effect.

Figure 1. 12 MECHANISM OF MET

As the patient performs an isometric contraction, the following physiologic changes occur:-

 Golgi tendon organ activation results in direct inhibition of the agonist’s muscles.
 A reflexive reciprocal inhibition occurs at the antagonistic muscles .(FIG 12)
 As the patient relaxes, agonist and antagonist muscles remain inhibited allowing the joint to
be moved further into the restricted range of motion.

Benefits of MET:

1. Restoring normal tone in hypertonic muscles

2. Strengthening weak muscles
3. Preparing muscle for subsequent stretching restricted mobility. A restrictive barrier
describes the limit in the range of motion that prevents
4. Improved joint mobility

USES:
 Lengthen a shortened, contractured, or spastic muscle.
 Strengthen physiologically weakened muscles.
 Reduce pain.
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 Stretch the tight fascia.

 Reduce localized edema.
 Mobilize an articulation with

Muscle Energy Techniques can be used for frozen shoulder in which the goal is to cause
relaxation and lengthening of the muscles and improve range of motion (ROM) in joints.
(Leon chaitow)(4th edition)

CHAPTER – 2

AIMS AND OBJECTIVES

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AIM OF THE STUDY

To compare the effect of maitland mobilization versus Muscle energy technique in Grade II
adhesive capsulitis.

OBJECTIVE OF THE STUDY

To compare the effect of maitland mobilization versus Muscle energy technique in Grade II
adhesive capsulitis.

HYPOTHESIS
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NULL HYPOTHESIS
There will be statistically non-significant difference between Maitland mobilization versus
muscle energy technique on factors pain,range of motion(ROM) in grade II frozen shoulder.

EXPERIMENTAL HYPOTHESIS
There will be statistically significant difference between Maitland mobilization technique
versus Muscle energy technique on factors pain, range of motion (ROM)in grade II frozen
shoulder.

NEED OF THE STUDY

The physiotherapy interventions for the management of Adhesive Capsulitis which is

commonly known as Frozen Shoulder is wide and variable, and Some interventions used are
Maitland Mobilization and Muscle Energy Technique. There is an increased awareness of
this condition , but still have difficulty to manage it, thus, the patients with this condition
have maintained some functional stability by the support of this treatment and helpful for
the daily activities in life. Thus, there is need to find out to compare the effectiveness of
Maitland Mobilization versus Muscle Energy Technique on factors R.O.M and Pain in Grade
2 Frozen shoulder .
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SIGNIFICANCE OF THE STUDY

This comparative protocoal will be helpful in dealing with the problems , disciples in the
medical sector which is recommended for the management of Stage II Adhesive Capsulitis
among geratric, diabetic and other individuals suffering from Frozen Shoulder, who
underwent Shoulder Trauma or any other cause that led to stiffening of shoulder joint along
with pain and restriction in movements , making the daily life activities of lifting , combing ,
holding difficult and painful.
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OPERATIONAL DEFINATIONS :

MOBILIZATION:
They are passive skilled manual therapy techniques applied to joints and related soft tissues
at varrying speeds and amplitudes using physiological or accessory motions for therapeutic
purposes. The technique of mobilization used in the study is Maitland mobilization .

MAITLAND MOBILIZATION :

Maitland concept is named after its pioneer Geoffery Maitland. It has 5 grades.
GRADE I-[small amplitude movement at the beginning of the available range of movement]
GRADE II- [large amplitude movement at within the available range of movement]
GRADE III- [large amplitude movement that moves into stiffness or muscle spasm]
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GRADE IV - [small amplitude movement stretching into stiffness or muscle spasm]

GRADE V-[small amplitude, quick thrust,manipulation at end range.

. lower grades I and II are used to reduce pain and irritability.

. Higher grades III AND IV are used to stretch the joint capsule and passive tissues which
support and stabilize the joint to increase range of movement.

MUSCLE ENERGY TECHNIQUE (M.E.T):

The muscle energy technique (MET) which is used to stretch or lengthen the muscle and
fascia that lack flexibility, is a manual therapy intervention. .It is a form of manual therapy
technique that uses muscle’s own energy in the form of gentle isometric contractions to
relax the muscles via autogenic or reciprocal inhibition and to lengthen the muscle .

In MET, the patient must exert force by contracting the targeted muscle against the
therapist's counterforce before relaxing and receiving a passive stretch from the therapist.
Three to five contractions can be included in one MET application, each contraction is hold
for 5 seconds and each contraction is followed by a stretch that ranges from 3 - 5 seconds to
30-60 seconds13. This technique can be used for any joint with restricted ROM. One of the
indications for using this technique is to normalize the joint range of motion .(John Gibbons) ( 2011)

TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (T.E.N.S):

It is a non-invasive method of electrical stimulation to reduce pain of any origin by using the
application of pulsed rectangular monophasic /biphasic current with the pulse duration of
50-200us and frequency of 1-120 HZ and a maximum peak current of 50mA-100mA applied
through surface electrodes. It works on blocking the pain and alters the level of pain. The 3
forms of TENS are High TENS, Low TENS and Burst TENS which varies in intensity and
frequency. The frequency of TENS most commonly used is 100-150 Hz, in continuous mode
with 12-30mA intensity for time duration of 10 -15 minutes. (Edward bellis Clayton) (1981)
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HOT PACK/HYDROCOLLATOR PACK:

Hot pack (HP) is the most traditional method of providing superficial heating. It has been
suggested that a deep heating agent could produce a greater increase in tissue extensibility
than superficial heating

Commercially available hot packs are usually a canvas cover filled with a hydrophillic
substance such as bentonite . Hot packs are kept in a commercial water filled container that
maintains a temperature of approximately 71 degree Celsius.(Edward bellis Clayton)(1981)

CHAPTER - 3

REVIEW OF LITERATURE
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REVIEW OF LITERATURE

Abhay kumar et al.(2012) did clinical study on effictiveness of maitland techniques in

idiopathic shoulder adhesive capsulities in two groups .The study confirmed that addition of
the maitland mobilization technique with the combination of exercise have proved their
efficacy in pain and improving R.O.M and shoulder function .

Mehboob ali et al.(2022) studied effectiveness of Muscle energy Technique and Maitland
Mobilization technique on pain,(R.O.M),disability index in the patients with adhesive
capsulitis.They concluded that Maitland Mobilization is more effective in reducing pain and
increasing function and Disability among the patients having adhesive capsulitis as
compared to MET for pain ,ROM and shoulder function.

Noman Ghaffar Awan et al(2022) compared the effectiveness of movement with

mobilization and muscle energy technique in reducing pain and improving functional status
in patients with frozen shoulder. The outcome assessment instruments, goniometer for
ROM’’ And shoulder pain, and disability index,’’ revealed that Motion by Mobility is more
effective than Muscle Energy Technique in increasing ROM and operational condition ‘’ of
patient havinf frozen shoulder. Movement with mobilization is more effective in allevating
pain , and enhancing functional capacity in patients with shoulder pain .
 SANT BABA BHAG SINGH UNIVERSITY

Suzie Notan,Mira Meeus et al(2016)did study to systematically review the literature for
efficacy of isolated articular mobilization technique in patients with adhesive capsulitis.
Overall, they concluded mobilization techniques have beneficial effects in patients with
primary AC of the shoulder .

Narayan Anupama,Jagga,Vinay(2014) did a experimental study using convenient random

sampling of 30 patients ,divided into groups of two . Each group divided into 15
each,GroupA(Experimental),Group B (Control). Control group was treated with conventional
physiotherapy treatment alone. The Experimental group was treated with MET for shoulder
Flexion,Abduction,and External rotation along with Conventional physiotherapy treatment.
The results showed that Group A of Experimental Study shows better result than Group B .
Thus , concluded that muscle energy technique is effective on functional ability of shoulder
in adhesive capsulitis.

Ujwal L YEOLE et al (2017) conducted a randomized controlled trial on effictiveness of

movement with mobilization in adhesive capsulitis of shoulder . Two groups of 15 each
participants were formed namely Group A ,Group B.(n=30). Group A unerwent maitland
mobilization with movement whereas Group B performed supervised exercise only.They
concluded that movement with mobilization proved to be a better technique for improving
range of motion and pain in adhesive capsulitis of frozen shoulder

Sami S Almureef et al (2020) gave a systematic review of effectiveness of mobilization with

conventional Physiotherapy in Frozen shoulder.The review includes randomized controlled
trials . The result concluded that mobilization program with conventional therapy designed
for frozen shoulder can be more effective in increasing shoulder ROM .

Shah Atika Suri ,Misra Anand(2013) did a study to establish best and efficient protocol for
treatment of idiopathic adhesive capsulitis.30 subjects including both sexes between 40-60
years,, diagnosed adhesive capsulitis were selected and with lottery random sampling
method were assigned in two groups (A and B ) with 15 subjects each. Group A received
moist pack for 15 min, Active ROM exercises and Maitland mobilization. Group B received
moist pack for 15 min,active ROM exercises and MET (muscle energy technique).All the
subjects were measured for pain by VAS, for all shoulder movements by goniometer on first
day before starting treatment and on 15 th day after treatment. Research concluded that
MET can potently be of value and as soon as the pain subsides. Maitland mobilization can be
incorporated to increase ROM.
 SANT BABA BHAG SINGH UNIVERSITY

NITHYA JAISWAL et al (2019) studied efficacy of muscle energy techniques as an adjunct

with mulligans mobilization in adhesive capsulitis.The results showed a significant
improvement in pre and post levels of both groups . Mulligans’s mobilization along with
Muscle Energy Technique is found to be more effective in improving quality of life in
subjects with adhesive capsulitis of shoulder than mulligans mobilization alone

Muhammad Hashim et al.(2022) did a comparative study of maitland mobilization and

Muscle Energy Technique on pain ,Range of motion and functions in adhesive capsulitis. The
study concluded that Maitland mobilization is more effective in reducing pain and increasing
function and disability among the patients having Adhesive Capsulitis as compared to MET
for pain,ROM and shoulder functions.

Dr Abdullah Al Shehri et al. (2018) published a research paper on efficacy of maitland

mobilization in frozen shoulder. The study comprised of a total of 40 patients in randomized
control trial .They concluded that Maitland Mobilization improves the symptoms of frozen
shoulder . Better improvement was shown by Maitland’s mobilization group.

N Maricar (2009) published a single case design on effect of maitland mobilization and
exercise for the treatment of shoulder adhesive capsulitis. The purpose of this single-case
design was to investigate the response of shoulder motions, pain, and function to two
commonly used physiotherapy management approaches. The Shoulder Pain and Disability
Index (SPADI) was used to monitor pain and functional disability, and four shoulder
movements (flexion, abduction, internal, and external rotations) were measured. The results
were evaluated by using single-case design analysis method of Split Middle Technique and
visual observation. The results showed that the exercise plus mobilization intervention
shows promise as a cost-effective management.

Kiran Satpute , Suie Reid et al. (2021) did a study to assess the effects of mobilization with
movement (MWM) on pain, range of motion (ROM), and disability in the management of
shoulder musculoskeletal disorders. Six databases and Scopus, were searched for
randomized control trials. The ROB 2.0 tool was used to determine risk-of-bias and GRADE
used for quality of evidence. Meta-analyses were performed for the sub-category of frozen
shoulder and shoulder pain with movement dysfunction to evaluate the effect of MWM in
isolation or in addition to exercise therapy and/or electrotherapy when compared with
other conservative interventions. Out of 25 studies, 21 were included in eight separate
 SANT BABA BHAG SINGH UNIVERSITY

meta-analyses for pain, ROM, and disability in the two sub-categories.The results
interpreted that for shoulder pain with movement dysfunction, the addition of movement
with mobilization significantly improved pain.

Aime F.Kachingwe, Beth Phillips et al.(2013) did a randomized controlled trial to compare
the effectiveness of four physical therapy interventions in the treatment of primary shoulder
impingement syndrome: (1) supervised exercise only, (2) supervised exercise with
glenohumeral mobilizations, (3) supervised exercise with a mobilization-with-movement
(MWM) technique, or (4) a control group receiving only physician advice. Thirty-three
subjects diagnosed with primary shoulder impingement were randomly assigned to one of
these four groups. Main outcome measures included 24-hour pain (VAS), pain with the Neer
and Hawkins-Kennedy tests, shoulder active range of motion (AROM), and shoulder function
(SPADI). The MWM group had the highest percentage of change in AROM, and the
mobilization group had the lowest. This pilot study suggests that performing glenohumeral
mobilizations and MWM in combination with a supervised exercise program may result in a
greater decrease in pain and improved function.

Manmitkaur A Gill , Bhavika P Gohel et al .(2018) did an interventional study to study the
effect of Muscle Energy Technique on pain in adhesive capsulitis and to study the effect of
Muscle Energy Technique on function in adhesive capsulitis.The patients were divided
randomly in control group and interventional group. In control group patients received only
conventional physiotherapy in the form of hot packs for 10 minutes, Codman‟s exercise,
finger ladder exercises, wand exercises, active exercises and capsular stretching. In
interventional group patients were treated with MET for shoulder flexion, abduction and
external rotation along with conventional treatment. The protocol for MET includes 5
repetitions/set, 3 sets/session, 1 session/day for 15 days. Treatment was given once a day
for 15 days except Sunday to both groups. VAS score, shoulder ROM and shoulder pain and
disability index was taken before and after the treatment in both groups. The results
concluded that: conventional physiotherapy and MET along with conventional
physiotherapy, both are individually effective in relieving pain, improving range of motion
and functional ability in patients with adhesive capsulitis, but among these two, the group
which received MET along with conventional physiotherapy is found to be more effective in
relieving pain, improving range of motion and functional ability in patients with adhesive
capsulitis

Ayesha Razaaq et. al (2022) did a comparative study to compare the effect of muscle
energy technique versus Mulligan mobilization with movement on pain, range of motion
 SANT BABA BHAG SINGH UNIVERSITY

and disability in patients of adhesive capsulitis. The study comprised patients of either
gender aged 30-70 years with adhesive capsulitis stage 2. The subjects were randomised
using the lottery method into Mulligan mobilisation with movement group A, and the
muscle energy technique grouo B. Conventional treatment, including hot packs and
exercises like pulley rope exercise, wall climbing, and shoulder wheel, were part of both the
groups. Each technique was applied five times per set, 2 sets per session 3 days a week for
three weeks. The results showed of the 70 individuals assessed, 64(91.4%) were included;
32(50%) in each of the two groups. The mean age in group A was 49.93±6.69 years, while in
group B it was 49.17±8.92 years. Group A showed significantly better results compared to
group B (p<0.05). Muscle energy technique and Mulligan mobilisation with movement were
both found to be effective, but the latter was significantly better compared to the former

Raksha R. Jivani , Dharti N Hingarajia (2021) published a research paper on comparative

study on effect of Spencer Muscle Energy Technique Versus Maitland’s Mobilization
Technique on Pain, ROM and Disability in Patients with Frozen Shoulder. Total 58 patients
with frozen shoulder were included. Inclusion criteria were male and female with age of 40
to 60 year with unilateral frozen shoulder (at least 3-month duration). Patients were
randomly allocated in two groups with 29 patients in each group: SPENCER MET and
Conventional physiotherapy and MM and conventional physiotherapy for 5days a week with
total duration of 4 weeks. Pre and post intervention assessment was carried out by using
VAS, SPADI and ROM. Data was analysed by using SPSS 15 version. The study concludes
that both the techniques used in the present study i.e., Spencer Muscle Energy Technique
and Maitland Mobilization are effective for improving pain, reducing disability, and
increasing ROM. However, SPENCER MET is the more effective for improving pain, reducing
disability, and increasing ROM compared to Maitland Mobilization in patients with frozen
shoulder.

Arvind kumar(2015) did a comparative study on the efficacy of Maitland mobilization versus
Muscle energy technique on frozen shoulder. A quasi-experimental approach was followed
with two experimental groups or comparison, using before and after treatment scores.A
total number of 30 patients are selected, male and female patient between age group 40 –
65 years were selected.A total duration of the study is one month. The duration of
programmed for each subject is four week’s once a day, for six days a week. Group A
patients were given Maitland’s mobilization technique of suitable grades for 24 sitting in 4
weeks. Group B patients were given muscle energy techniques for 24 sitting in 4 weeks. 3-5
 SANT BABA BHAG SINGH UNIVERSITY

muscle contractions with 5-7 seconds each contraction (not more than 20% of total muscle
strength) for three repetitions.The patients attended physical therapy session daily i.e 6
days in a week.Maitland’s mobilization. The results concluded that patients with frozen
shoulder largely benefit from manual therapy treatment techniques. Maitland’s
Mobilization is more effective in improving range of motion and decreasing functional
disability in patients with frozen shoulder as compared to Muscle Energy Technique.

Ekelund and Rydall (1992) compared the outcomes of patients treated with distension
arthrography, local anesthetic and manipulation followed by physical therapy. At four to six
weak follow up, 91% of the subject who had undergone this combination of treatment
reported complete or partial relief of pain and 82% exhibited normal active range of motion
or near normal active range of motion.

Placzek J D et al (1998) studied the long term effect of glenohumeral joint translation
(gliding) manipulation on range of motion, pain and functions in patients with frozen
shoulder. Thirty-one patients underwent brachial plexus block followed by translation
manipulation of glenohumeral joint. Changes in the range of motion and pain were assessed
before manipulation with the patient under anesthesia, immediately after manipulation
with the patient still under anesthesia, at early follow up (5.3±3.2 weeks) and to long term
follow up (14.4±7.3 months). Passive range of motion increased significantly for flexion,
abduction, external rotation and internal rotation. Significant decrease in visual analog pain
score between initial evaluation and the follow up assessment also occurred .

MUBASHSHIRAH FIRDAUS, ANSARI AND RITA SHARMA (2022) did a case study is to check
the effect of Virtual Reality versus Conventional Physiotherapy in the patients having stage II
Frozen Shoulder. Outcome measure taken were Pain and functional disability measured by
Shoulder pain and disability index scale (SPADI), Range of Motion (ROM) measured by
Universal Goniometer. Physiotherapy was incorporated to see the outcomes in large
number of patients who were seeking the treatment with the help of this technique. The
benefits of above mentioned Physiotherapy lead to pain reduction, simultaneously
increasing functional independence and reduction in fear of avoidance and improvement in
sleep pattern and quality.
SANT BABA BHAG SINGH UNIVERSITY
 SANT BABA BHAG SINGH UNIVERSITY

CHAPTER – 4 ( METHODOLOGY)

METHODOLOGY
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STUDY DESIGN - Experimental study.

SETTING - Study was done in outpatient department of civil hospital Jalandhar.

DURATION OF STUDY - Total duration of study was half a year.

SAMPLE SIZE - A minimum of 30 subjects were selected for the study, minimum of 15
subjects in each group.

SAMPLING - Convenient sampling.

SELECTION CRITERIA :

All the subjects were selected on the basis of following criteria.

INCLUSION CRITERIA :

1. Age group between 40 – 60 years.

2. Gender both males and females.
3. Patients diagnosed with grade II adhesive capsulitis. (Frozen Stage), Restriction in all the
movements of shoulder flexion , Abduction and External Rotation.
4. Unilateral frozen shoulder .
5. Patients willing to participate in study and co-operative.
 SANT BABA BHAG SINGH UNIVERSITY

EXCLUSION CRITERIA :

1. Any surgery related to affected shoulder.

2. Fracture of shoulder joint.( Malunion ,Nonunion)
3. Infection (any infection involving shoulder).
4. Skin lesions involving shoulder.
5. Patients above the age of 60 and below 40 years.
6. Rheumatoid arthritis.
7. Neurological deficits affecting shoulder function.
8. Subjects with rotator cuff lesion and tendon calcification.
9. Pain or disorders of cervical spine, elbow, wrist or hand of affected side.
10. Uncooperative patients.

INSTRUMENTATION :

 T.E.N.S
 Hot packs
 VAS Questionnaire
 Shoulder Pain and Disability Index(SPADI).
 Goniometry.

PROTOCOL
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Subjects with Stage II ( frozen stage) shoulder pain who visited civil hospital Jalandhar were
selected by convenience sampling method. Patients who meet the inclusion criteria were
selected in the study. A written consent was obtained from all the subjects. A minimum of
30 subjects were selected for the study and were conveniently divided into two groups with
15 subjects in each group.

GROUP A GROUP B
T.E.N.S, Hot pack , Maitland T.E.N.S , Hot pack, muscle energy
Mobilization . technique. (MET)

TOOLS :
 Visual analogue Scale.
 Mobility i.e , all shoulder range of motions (ROM) were measured using universal
goniometer in degrees.
 Functional disability of shoulder was measured using shoulder pain and Disability index .
(SPADI).

PROCEDURE :

INTERVENTION FOR GROUP A :

The temperature was set at 63°C. The subjects were informed that the only purpose of the
heating was to relax muscles and produce a feeling of comfortable warmth. If they felt that
the heat was excessive, the temperature of the electrical Hot pack was adjusted
immediately to ensure that the heat remained at a comfortably warm level only throughout
the treatment.(fig.13)
 SANT BABA BHAG SINGH UNIVERSITY

Fig.4.1 HOT PACK

To perform Maitland mobilization, patient was in supine lying with arm abducted to 30
degrees and therapist was in walk standing position holding proximal end of the humerus
and maintaining a lateral humeral distraction in its midrange position. Glenohumeral caudal,
anterior and posterior glide mobilization were given at the rate of 2-3 glides per second for
30 seconds for each glide,given for 5 sets (Fig.14) , fig (15), fig. (16).The technique was
applied thrice a week for four weeks (12 sessions).

Glenohumeral caudal glide

Indications
To increase abduction .
 SANT BABA BHAG SINGH UNIVERSITY

Patient Position
Supine lying and the arm in the loose pack position. The therapist supports
the arm between the trunk and the elbow.

Hand placement

One hand of the therapist is placed in the axilla to give distraction (grade 1)
The therapist's other hand(webspace) is kept just below the acromion process.

Mobilizing force
The force is applied on the head of the humerus in the inferior direction, through the
hand which is placed superiorly. Fig. (14)

Figure 4.2 CAUDAL GLIDE

GH posterior glide
Indications
To improve flexion and internal rotation of the shoulder
 SANT BABA BHAG SINGH UNIVERSITY

Position of patient
Supine lying while keeping the arm in resting position.Position of the therapist and
hand placement (Fig. 15)
The therapist stands with the back towards the patient, in between the arm and the
trunk.
The distal aspect of the arm is grasped against the trunk of the therapist to give grade
one distraction to the shoulder joint.
Another hand is placed over the joint (distal to anterior margin) to provide the
mobilizing force.
Mobilizing force
The head of the humerus is glided posteriorly.

Figure 4.3 POSTERIOR GLIDE

GH anterior glide
Indications
To increase the extension of the shoulder with external rotation.
Position of the patient
Prone lying at the edge of the plinth, the limb is in resting position.
Position of the therapist with hand placement

The patient's arm is supported on the therapist's thigh and the therapist stands on the
top of the table and places one hand over the arm to give distraction at GH joint.
 SANT BABA BHAG SINGH UNIVERSITY

Mobilizing hand's ulnar border is placed just next to the posterior angle of the
acromion.

MOBILIZING FORCE It is applied to the humeral head in the anterior direction . Fig. (16)

Figure 4.4 ANTEROR GLIDE

TENS (Trans cutaneous electrical nerve stimulation) in Asymmetric biphasic mode

with 150 Hz frequency and the intensity was set according to level of capacity for 10
minutes. Patient is in sitting position , Two channels of tens
iare used which are applied over deltoid muscle as well as concerning painful area of
shoulder.(Fig. 17)
 SANT BABA BHAG SINGH UNIVERSITY

Figure 4.5 TENS

INTERVENTION FOR GROUP B :

In all the subjects of Group B, an electrical hot pack sized 35.5 × 68.5 cm was used to
deliver superficial heating at shoulder joint for 10 minutes in supine lying position. The
temperature was set at 63°C. The subjects were informed that the only purpose of the
heating was to relax muscles of shoulders and pproduce a feeling of comfortable warmth. If
they felt that the heat was excessive, the temperature of the electrical Hot pack was
adjusted immediately to ensure that the heat remained at a comfortably warm level only
throughout the treatment.
 SANT BABA BHAG SINGH UNIVERSITY

Figure 4.6 Hot pack

Patients were initially offered 7 to 10 minutes of heating pack control treatment (fig.18), after
which the glenohumeral joints were moved via muscle energy technique. The afflicted
shoulder was elevated as the patient was laying on their side. With the proximal hand, the
therapist stabilized the shoulder girdle, and in 7 separate motions, the distal hand applied
force into the shoulder’s constricted barrier. In 7 distinct movements, the therapist used
force on the shoulder’s constrictive barrier with the distal hand while supporting the
shoulder girdle with the proximal hand. These included glenohumeral pump, distraction,
abduction with internal rotation, shoulder extension, circumduction with compression, and
shoulder flexion. [55] Following the complete action, patients were encouraged to use their
muscles to 5 seconds against little resistance provided by the therapist.The exercise was
done 3- 5 times with rest periods .(fig 19, 20, 21, 22, 23, 24, 25)

FIG .4.7 shoulder extension (MET) FIG. 4.8 Circumduction with Compression(MET)

FIG.4.9 Shoulder flexion (MET) FIG . 4.10 Shoulder internal rotation(MET)

 SANT BABA BHAG SINGH UNIVERSITY

FIG.4.11 CIRCUMDUCTION WITH TRACTION (MET) Fig. 4.12 ABDUCTION AND ADDUCTION (MET)

Fig.4.13 Distraction with circumduction(MET)

 SANT BABA BHAG SINGH UNIVERSITY

After application of M.E.T , TENS (Trans cutaneous electrical nerve stimulation) in

Asymmetric biphasic mode with 150 Hz frequency and the intensity was set according to
level of capacity for 10 minutes. Patient is in sitting position , Two channels of tens are used
which are applied over deltoid muscle as well as concerning painful area of shoulder.
Fig. 26
common shoulder exercises are taught and performed with both groups

Fig 4.14 ( Home exercise) for both A and B groups

SANT BABA BHAG SINGH UNIVERSITY

CHAPTER – 5 (Results and Data Analysis)

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Table No: 5.2 shows comparison between group A and group B on the basis
of gender.

Gender
Frequency (%)
Group A Group B
Male% 46.7 40.0
Female% 53.3 60.0
Male 7.00 6.00
Female 8.00 9.00

Graph 5.1.1 Discuss graphical presentation on the basis of gender between

the Group A and group B
 SANT BABA BHAG SINGH UNIVERSITY

Ge n d e r D is t r ib u t io n
Male% Female%
100%

90%

80%
53.3
70% 60.0

60%

50%

40%

30%
46.7
20% 40.0

10%

0%
Group A Group B
Gender

Table No: 5.3 shows comparison between group A abd group B on the basis
of age.

Comparison
Unpaired T Test AGE
Group A Group B
Mean 51.13 54.13
S.D. 4.882 3.852
Number 15 15
Maximum 60 59
Minimum 45 47
Range 15 12
Mean Difference -3.00
Unpaired T Test 1.868
P value 0.0722
Table Value at 0.05 2.05
Result Not-Significant
 SANT BABA BHAG SINGH UNIVERSITY

Graph 5.2.1 Discuss graphical presentation of age between Group A and

Group B

Comparison Between the Groups

60.00 54.13
51.13
50.00
40.00
30.00
20.00
4.882 3.852
10.00
0.00
Group A Group B
AGE
Comparison

Mean S.D.

Within Group Analysis (Repeated ANOVA)

Table No: 5.4 Shows VAS scale comparison within the group A
. Group A
VAS
Repeated ANOVA
BASELINE DAY 7TH DAY 14TH
Mean 7.00 4.07 1.60
S.D. 0.845 0.884 1.056
Median 7 4 2
Number 15 15 15
DF1 2
DF2 28
F Test 379.46
Table Value 3.340
P value <0.001
Result Significant
Tukey’s method for
Pairwise comparison BASELINE
Mean Difference &
DAY 7TH 2.93Sig DAY 7TH
Result>
DAY 14TH 5.4Sig 2.47Sig
 SANT BABA BHAG SINGH UNIVERSITY

Graph 5.3.1 Discuss graphical presentation pf VAS scale within the group

Comparison within the Group

7.00
7.00

6.00

5.00
4.07
4.00

3.00
1.60
2.00
0.845 0.884 1.056
1.00

0.00
BASELINE DAY 7TH DAY 14TH
VAS
Group A

Mean S.D.

Table No: 5.5 Shows VAS scale comparison within the group B :
 SANT BABA BHAG SINGH UNIVERSITY

. Group B
VAS
Repeated ANOVA DAY
BASELINE DAY 7TH
14TH
Mean 7.13 4.80 2.33
S.D. 1.060 1.082 0.724
Median 7 5 2
Number 15 15 15
DF1 2
DF2 28
F Test 264.30
Table Value 3.340
P value <0.001
Result Significant

Tukey’s method for

Pairwise comparison BASELINE
Mean Difference &
DAY 7TH 2.33Sig DAY 7TH
Result>
DAY 14TH 4.8Sig 2.47Sig

Graph 5.4.1 Discuss graphical presentation of VAS within the group B.

Comparison within the Group

8.00 7.13
7.00
6.00
4.80
5.00
4.00
3.00 2.33
2.00 1.060 1.082
0.724
1.00
0.00
BASELINE DAY 7TH DAY 14TH
VAS
Group B

Mean S.D.

Table No: 5.6 Shows SPADI Comparison within the GROUP A

 SANT BABA BHAG SINGH UNIVERSITY

. Group A
SPADI
Repeated ANOVA
BASELINE DAY 7TH DAY 14TH
Mean 67.26 52.45 21.37
S.D. 7.491 6.283 5.762
Median 66.3 53.8 19.2
Number 15 15 15
DF1 2
DF2 28
F Test 258.68
Table Value 3.340
P value <0.001
Result Significant
Tukey’s method for
Pairwise comparison BASELINE
Mean Difference & DAY 7TH
14.81Sig DAY 7TH
Result>
DAY 14TH 45.9Sig 31.08Sig

Graph 5.5.1Discuss graphical presentation SPADI within the Group A

Comparison within the Group

70.00 67.26

60.00 52.45
50.00

40.00

30.00 21.37
20.00
7.491 6.283 5.762
10.00

0.00
BASELINE DAY 7TH DAY 14TH
SPADI
Group A

Mean S.D.

Table No: 5.7 Shows SPADI comparison within the group B

 SANT BABA BHAG SINGH UNIVERSITY

. Group B
SPADI
Repeated ANOVA DAY
BASELINE DAY 7TH
14TH
Mean 67.62 59.01 30.94
S.D. 4.921 4.377 6.505
Median 68.8 59.2 28.5
Number 15 15 15
DF1 2
DF2 28
F TEST
442.99
Table Value 3.340
P value <0.001
Result Significant

Tukey’s method for

Pairwise BASELINE
comparison

Mean Difference &

DAY 7TH 8.61Sig DAY 7TH
Result>
DAY
36.68Sig 28.07Sig
14TH
 SANT BABA BHAG SINGH UNIVERSITY

Comparison within the Group

67.62
70.00
59.01
60.00

50.00

40.00
30.94
30.00

20.00
4.921 4.377 6.505
10.00

0.00
BASELINE DAY 7TH DAY 14TH
SPADI
Group B

Mean S.D.

Graph 5.6.1 Discuss graphical presentation of SPADI within the group B

Between the Group Analysis (Unpaired T test)

VAS

Unpaired T Test BASELINE DAY 7TH DAY 14TH

Group Group Group Group Group Grou
A B A B A B
Mean 7.00 7.13 4.07 4.80 1.60 2.33
S.D. 0.845 1.060 0.884 1.082 1.056 0.724
Number 15 15 15 15 15 15
Maximum 8 9 6 7 3 4
Minimum 6 6 3 3 0 1
Range 2 3 3 4 3 3
Mean Difference 0.13 0.73 0.73
Unpaired T Test 0.381 2.033 2.219
P value 0.7062 0.0517 0.0348
Table Value at 0.05 2.05 2.05 2.05
Result Not-Significant Not-Significant Significant
Table No. 5.8 shows VAS scale comparison between Group A and Group B
 SANT BABA BHAG SINGH UNIVERSITY

Graph 5..1 Discuss graphical representation of VAS scale between group A

and Group B

Comparison Between the Groups

8.00
7.00 7.13
7.00

6.00
4.80
5.00
4.07
4.00

3.00 2.33

2.00 1.60
1.060 0.884 1.082 1.056
0.845 0.724
1.00

0.00
Group A Group B Group A Group B Group A Group B
BASELINE DAY 7TH DAY 14TH
VAS

Mean S.D.

Table No: 5.9 Shows SPADI Comparison between the group A and group :

SPADI

Unpaired T Test BASELINE DAY 7TH DAY 14TH

Group Group Group Group Group Group
A B A B A B
Mean 67.26 67.62 52.45 59.01 21.37 30.94
S.D. 7.491 4.921 6.283 4.377 5.762 6.505
Number 15 15 15 15 15 15
Maximum 77.7 74.6 60 65 37.5 44.6
Minimum 51.2 60 33.8 51.5 13.8 22.5
Range 26.5 14.6 26.2 13.5 23.7 22.1
Mean Difference 0.36 6.56 9.57
Unpaired T Test 0.156 3.318 4.267
P value 0.8775 0.0025 <0.0012
Table Value at 0.05 2.05 2.05 2.05
Result Not-Significant Significant Significant
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Graph 5.8.1 Discuss graphical representation of SPADI between Group A and

Group B

Comparison Between the Groups

70.00 67.26 67.62

59.01
60.00
52.45

50.00

40.00

30.94
30.00
21.37
20.00

7.491 6.283 6.505

10.00 4.921 5.762
4.377

0.00
Group A Group B Group A Group B Group A Group B
BASELINE DAY 7TH DAY 14TH
SPADI

Mean S.D.
SANT BABA BHAG SINGH UNIVERSITY

CHAPTER - 6 ( DISCUSSION)
 SANT BABA BHAG SINGH UNIVERSITY

In this study 30 patients were included and divided into 2 groups. All of them suffering from
Stage II Frozen shoulder. The 2 groups were made so as to compare the effectiveness of
Maitland mobilization versus muscle energy technique in both two groups. Analysis of the
results of this study showed that both Maitland Mobilization technique and MET are an
effective treatment for adhesive capsulitis but Maitland Mobilization is more effective in
increasing both active and passive joint ROM, while MET is more effective in reducing pain
in patients with adhesive capsulitis. The response from Maitland mobilizations are explained
to be different from MET as Maitland mobilization is a passive technique and MET is active
technique.

In this study where 46.7% of male and 53.3% of females were included in group A and 40%
males and 60% females in group B, Group A was given Maitland mobilization and it showed
better result by the end of sessions on VAS scale as well as on SPADI scale . The performance
of participants increased in both the groups effectively but as compared to MET much
improvement was seen in Maitland mobilization group i.e Group A . By the end of sessions ,
there was increase in ROM and reduction of pain in both the groups

In a study done by Muhammad Hashim et al.(2022) between maitland mobilization and

Muscle Energy Technique on pain ,Range of motion and functions in adhesive capsulitis. It
was concluded that Maitland mobilization is more effective in reducing pain and increasing
function and disability among the patients having Adhesive Capsulitis as compared to MET
for pain,ROM and shoulder functions.
As discovered by Maitland the technique is passive direct articulatory procedure, it would
have relieved the joint restriction more effectively the MET.18 MET does not involve direct
thrust through a physiologic and restrictive barrier it introduces minimal force relieving the
joint hypo mobility through the isometric contraction of shoulder muscle.9 Repetitive
passive joint oscillations carried out at the limit of
the joint’s available range may have a mechanical effect on joint mobility and improve a
joint restriction, stretch joint capsules, lubricate tissues, induce metabolic changes in soft
tissues, cartilage bone, increases range of motion, alters joint mechanics, and counters the
effects of joint immobilization.(K) Maitland GD: Peripheral manipulation. Ed. 3. Butterworth-
Heinemann. Boston, 1991.
Arvind kumar(2015) did a comparative study on the efficacy of Maitland mobilization versus
Muscle energy technique on frozen shoulder. A quasi-experimental approach was followed
 SANT BABA BHAG SINGH UNIVERSITY

with two experimental groups or comparison, using before and after treatment scores.A
total number of 30 patients are selected, male and female patient between age group 40 –
65 years were selected.A total duration of the study is one month. The duration of
programmed for each subject is four week’s once a day, for six days a week. Group A
patients were given Maitland’s mobilization technique of suitable grades for 24 sitting in 4
weeks. Group B patients were given muscle energy techniques for 24 sitting in 4 weeks. 3-5
muscle contractions with 5-7 seconds each contraction (not more than 20% of total muscle
strength) for three repetitions.The patients attended physical therapy session daily i.e 6
days in a week.Maitland’s mobilization. The results concluded that patients with frozen
shoulder largely benefit from manual therapy treatment techniques. Maitland’s
Mobilization is more effective in improving range of motion and decreasing functional
disability in patients with frozen shoulder as compared to Muscle Energy Technique .
SANT BABA BHAG SINGH UNIVERSITY

CHAPTER - 7 ( CONCLUSION )
 SANT BABA BHAG SINGH UNIVERSITY

Maitland Mobilization and muscle energy technique both are effective techniques to
manage pain and increase range of motion in stage II frozen shoulder but Maitland
mobilization showed better results on VAS and SPADI scale as compared to muscle energy
technique.
The study revealed that both the techniques are effective but Maitland mobilization shows
superior results as compared to Muscle Energy Technique group.
SANT BABA BHAG SINGH UNIVERSITY

CHAPTER - 8 ( Summary )
 SANT BABA BHAG SINGH UNIVERSITY

AIM OF THE STUDY

To compare the effect of maitland mobilization versus Muscle energy technique in Grade II
adhesive capsulitis.

OBJECTIVE OF THE STUDY

To compare the effect of maitland mobilization versus Muscle energy technique in Grade II
adhesive capsulitis.

HYPOTHESIS

NULL HYPOTHESIS
There will be statistically non-significant difference between Maitland mobilization versus
muscle energy technique on factors pain,range of motion(ROM) in grade II frozen shoulder.

EXPERIMENTAL HYPOTHESIS
There will be statistically significant difference between Maitland mobilization technique
versus Muscle energy technique on factors pain, range of motion (ROM)in grade II frozen
shoulder.
 SANT BABA BHAG SINGH UNIVERSITY

METHODOLOGY

STUDY DESIGN - Experimental study.

SETTING - Study was done in outpatient department of civil hospital Jalandhar.

DURATION OF STUDY - Total duration of study was half a year.

SAMPLE SIZE - A minimum of 30 subjects were selected for the study, minimum of 15
subjects in each group.

SAMPLING - Convenient sampling.

SELECTION CRITERIA :
All the subjects were selected on the basis of following criteria.

INCLUSION CRITERIA :
1. Age group between 40 – 60 years.
2. Gender both males and females.
3. Patients diagnosed with grade II adhesive capsulitis. (Frozen Stage), Restriction in all the
movements of shoulder flexion , Abduction and External Rotation.
4. Unilateral frozen shoulder .
 SANT BABA BHAG SINGH UNIVERSITY

5. Patients willing to participate in study and co-operative.

EXCLUSION CRITERIA :
1. Any surgery related to affected shoulder.
2. Fracture of shoulder joint.( Malunion ,Nonunion)
3. Infection (any infection involving shoulder).
4. Skin lesions involving shoulder.
5. Patients above the age of 60 and below 40 years.
6. Rheumatoid arthritis.
7. Neurological deficits affecting shoulder function.
8. Subjects with rotator cuff lesion and tendon calcification.
9. Pain or disorders of cervical spine, elbow, wrist or hand of affected side.
10. Uncooperative patients.

INSTRUMENTATION :
 T.E.N.S
 Hot packs
 VAS Questionnaire
 Shoulder Pain and Disability Index(SPADI).
 Goniometry.
 SANT BABA BHAG SINGH UNIVERSITY

PROTOCOL
Subjects with Stage II ( frozen stage) shoulder pain who visited civil hospital Jalandhar were
selected by convenience sampling method. Patients who meet the inclusion criteria were
selected in the study. A written consent was obtained from all the subjects. A minimum of
30 subjects were selected for the study and were conveniently divided into two groups with
15 subjects in each group.

GROUP A GROUP B
T.E.N.S, Hot pack , Maitland T.E.N.S , Hot pack, muscle energy
Mobilization . technique. (MET)

TOOLS :
 Visual analogue Scale.
 Mobility i.e , all shoulder range of motions (ROM) were measured using universal
goniometer in degrees.
 Functional disability of shoulder was measured using shoulder pain and Disability index .
(SPADI).

PROCEDURE :
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INTERVENTION FOR GROUP A :

In all the subjects of group A, Maitland mobilization technique is used .

● Treatment given

● TENS + MOIST pack for 15 minutes.

● MAITLAND mobilization - patients were given Maitland mobilization Grade 3 and Grade 4
dose – 2 set of 10 repetitions, 6 sessions per week for 2 weeks.

⮚ ACTIVE Glenohumeral Exercises

▪ Codman’s Exercises

▪ Wand Exercises in Supine.

▪ Home Exercises

▪ Active shoulder movements

▪ Towel Exercises.

Experimental Group B : In group B MET technique is used.

Treatment given :
⮚ T.E.N.S + Moist pack for 15 MINUTES

⮚ MET : Patients were given post isometric relaxation, 3 – 5 Contractions with 5 -7 seconds
hold of each contraction for 3 repetition .

Dose : 2 sets of 3 repetitions, 6 sessions per week for 2 weeks.

⮚ Active Glenohumeral exercises.

 SANT BABA BHAG SINGH UNIVERSITY

● Codman’s Exercises.

● Wand Exercises in supne.

❖ Home Exercises

● Active shoulder movements.

● Towel Exercises.

RESULT:

This chapter deals with the data analyasis and results of the study. The study was done to
compare Maitland Mobilization versus Muscle Energy Technique in grade II frozen
shoulder.Two readings were taken on SPADI questionnaire and VAS scale on Day 1 pre-
treatment session, day 7 post treatment session and day 15 post treatment session.

Total of 30 subjects were selected for this study . 30 subjects were divided into 2 groups
and each group contains 15 patients. Group A was Maitland Mobilization and Group B was
Muscle Energy Technique.

DATA ANALYSIS:

Data was tabulated on master chart. Data analysis was performed using SPSS software
version 2.1,Intergroup and Intragroup was done. Following test are used –

 For within the group analysis, post hock tukey’s method and repeated measures were used.
 For between group analysis, one way unpaired T- TEST was used.

Variables: Shoulder Pain and Disability index,(SPADI Questionnaire),and VAS scale.

 SANT BABA BHAG SINGH UNIVERSITY

DAYS OF DATA COLLECTED :

Day 1 – pre treatment

Day 7 – post treatment
Day 15 – post treatment

DISCUSSION : The study was aimed to compare the effects of maitland mobilization
versus muscle energy technique on factors pain , range of motion in grade II frozen
shoulder.
The subjects of Group A were given Maitland mobilization , Hot pack and TENS .
The subjects of Group B were given Muscle Energy Technique , Hot pack ,TENS.

CONCLUSION :
Maitland Mobilization and muscle energy technique both are effective techniques to mange
pain and increase range of motion in stage II frozen shoulder but Maitland mobilization
showed better results on VAS and SPADI scale as compared to muscle energy technique.
The study revealed that both the techniques were effective in increasing ROM and
reducing pain in grade II frozen shoulder but Maitland Mobilization was more effective than
Muscle Energy Technique.
 SANT BABA BHAG SINGH UNIVERSITY

CHAPTER - 9 ( BIBLIODRAPHY )

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 Kumar, A (2015) Indian Journal of Physiotherapy and Occupational Therapy .

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 SANT BABA BHAG SINGH UNIVERSITY

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Pharmaceutical Sciences , Volume 5 , Issue 12.
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 SANT BABA BHAG SINGH UNIVERSITY

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SANT BABA BHAG SINGH UNIVERSITY
 SANT BABA BHAG SINGH UNIVERSITY

CHAPTER - 10 ( APPENDICES )

APPENDIX 1

CONSENT FORM
 SANT BABA BHAG SINGH UNIVERSITY

I have been informerd by Ms. Bulbul Rani, a student in SANT BABA BHAG SINGH University,
Jalandhar that study entitled “ To Compare the effects of Maitland Mobilization VS Muscle
Energy Technique on Factors – Pain , ROM in Frozen shoulder” is being conducted. The
purpose of this study is to compare the effect of Maitland mobilization Versus Muscle
Energy Technique in patients of Grade II Frozen shoulder. As a part of this study , the subject
will have to fill a questionnaire
I understand that there is no risk involved in this study. All the information regarding me will
be kept confidential, only Ms Bulbul Rani and her guide Dr. Mandeep kaur , MPT (NEURO),
will have access to the name of the subjects participating in this study and will not be shared
with any other person. I understand that my consent is voluntary and I have my right to
withdraw or discontinue the participation at any stage of the study without assigning any
reason to it.
I , BULBUL RANI, have explained to Mr./ Ms./Mrs._______________ the purpose of the
research , the procedure, required in the language he / she could understand to the best of
my ability.
I,_____________ voluntarily agree to participate in her study . My entire questions have
been answered satisfactorily . I reserve my right to withdraw at any instant and I have the
contact address of Ms Bulbul Rani if required any further information.

Signature of the Participant Signature of Researcher

APPENDIX – 2
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PAIN ASSESSMENT (VAS SCALE)

VISUAL ANALOGUE SCALE

APPENDIX 3

Patient’sName __________ Number _____________ Date ____________

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Shoulder Pain and Disability Index (SPADI)

The Patient is instructed to choose the number the number that best describes their level of
pain and extent of difficulty using the involved shoulder. The pain scale is summed up to a
total of 50 while the disability scale sums up to 80. The

total SPADI score is expressed as a percentage. A score of 0 indicates best 100 indicates
worst. A higher score shows more disability.

In scoring SPADI, any question missed should be taken out of the total score of each
subscale. i.e if 1 question is omitted in the pain section, the total score is divided by 40.

Scoring instructions

To answer the questions, patients place a mark on a 10cm visual analogue scale for each
question. Verbal anchors for the pain dimension are “ no pain at all” and “worst pain
imaginable” and those for the functional activities are “No Difficulty” complete and is the
only reliable and valid region – specific measure for the shoulder.

INTERPRETATION OF SCORES

Total pain score _________/ 50 x 100 =%

(Note: if a person does not answer all the questions divide by the total of possible score,eg.
if 1 question missed divide by 40)

Total disability score___________/ 80x100=%

( Note : if a person does not answer all the questions divide by the total possible score, eg.
if 1 question is missed divided by

Total SPADI score ____________/ 130x 100 =%

(Note : if a person does not answer all questions divide by the total possible score,eg.if one
question is missed divide by 120)

The means of these two subscales are averaged to produce a total score ranging from
0(best) to 100(worst).
 SANT BABA BHAG SINGH UNIVERSITY

Minimum detectable change (90% confidence) = 13 points.

(change less than this may be subject to measurement error

(change less than this may be subject to measurement error)

Shoulder Pain and Disability Index (SPADI)

Please place a mark on the line that best represents your experience during the last week
attributable to your shoulder problem .

Pain scale

How severe is your pain?

Circle the number that best describes your pain where 0 = no pain and 10 = the worst pain
imaginable.
At its worst ? 0 1 2 3 4 5 6 7 8 9 10

When lying on the involved side ? 0 1 2 3 4 5 6 7 8 9 10

Reaching for something on a high shelf ? 0 1 2 3 4 5 6 7 8 9 10

Touching the back of your neck ? 0 1 2 3 4 5 6 7 8 9 10

Pushing with the involved arm ? 0 1 2 3 4 5 6 7 8 9 10

DISABILITY SCALE

HOW MUCH DISABILITY DO YOU HAVE ?

 SANT BABA BHAG SINGH UNIVERSITY

Circle the number that best describes your experience where 0 = no difficulty and 10 = so
difficult it requires help.

Washing your hair ? 0 1 2 3 4 5 6 7 8 9 10

Washing your back ? 0 1 2 3 4 5 6 7 8 9 10

Putting on a undershirt or jumper? 0 1 2 3 4 5 6 7 8 9 10

Putting on a shirt that buttons downs the front 0 1 2 3 4 5 6 7 8 9 10

?
Putting on your Pants? 0 1 2 3 4 5 6 7 8 9 10

Placing an object on high shelf? 0 1 2 3 4 5 6 7 8 9 10

Carrying a heavy object of 10 pounds ( 4.5 0 1 2 3 4 5 6 7 8 9 10

Kilograms)

Removing something from your back pocket ? 0 1 2 3 4 5 6 7 8 9 10

 SANT BABA BHAG SINGH UNIVERSITY

APPENDIX - 4

SUBJECTIVE EXAMINATION

Name :

Age :

Gender :

Occupation :

Address :

Chief Complaint :

History of –

 Present illness
 Past illness
 Medical
 Surgical

Pain evaluation –

 Site
 Onset
 Type
 Pattern
 Relieving factors
 Aggravating factors

VAS
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OBJECTIVE EXAMINATION

Observation :
Built –
 Ectomorphic
 Mesomporphic
 Endomorphic
Gait
Posture
Attitude
Deformity

ON PALPATION
 Tenderness
 Temperature
 Swelling
SENSORY EVALUATION
 Superficial
 Deep
MOTOR EXAMINATION
 R.O.M
 ACTIVE
 PASSIVE
 Reflexes
 Manual Muscle Testing

SPECIAL TEST:

 RADIOLOGICAL INVESTIGATION
 X- RAY OF AFFECTED SHOULDER
 M.R.I OF AFFECTED
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APPENDIX 5

DATA COLLECTION FORM

NAME
AGE
GENDER
DATE
OCCUPATION
CHIEF COMPLAINT
GROUP

VARIABLES BASELINE AFTER 7TH AFTER 14TH

SESSION SESSION
VAS
SPADI

GROU
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 SANT BABA BHAG SINGH UNIVERSITY

GROUP B VAS SPADI

SE BASELIN DAY DAY BASELIN DAY DAY

Sub AGE
X E 7TH 14TH E 7TH 14TH
A 1 47 7 4 2 62.5 53.1 25.4
B 1 55 7 4 1 62.3 55.4 27.7
C 2 48 6 4 2 64.6 56.2 25.4
D 1 54 9 6 3 70 59.2 32.3
E 2 57 7 4 2 68.8 59.2 22.5
F 2 48 6 6 3 71.3 61.5 33.1
G 1 57 6 3 2 61.5 52.5 32.5
H 2 59 6 5 2 74.6 65 42.3
J 1 54 8 5 3 68.8 61.5 44.6
K 2 55 6 4 2 71.5 62.3 39.2
L 1 53 7 5 2 72.3 61.5 29.8
M 2 58 9 7 4 73.8 64.6 28.5
N 2 54 8 6 3 70 63.1 27.7
O 2 59 8 5 2 60 51.5 26.9
P 2 54 7 4 2 62.3 58.5 26.2