Comparison of Effectiveness of Maitland’s Mobilizations at End-Range Versus Within Pain-Free Joint Range of Movement in Treatment of Patients with Frozen Shoulder RCT

) Comparison of Effectiveness of Maitland’s Mobilizations at End-Range Versus Within Pain-Free Joint Range of Movement in Treatment of Patients with Frozen Shoulder RCT, British Journal of Multidisciplinary and Advanced Studies : Health and Medical Sciences 4 (5)


INTRODUCTION
Shoulder joint with Adhesive capsulitis AC is frequently described as a condition accompanied by escalating discomfort and a partial or complete loss of both active and passive shoulder girdle motion.Frozen shoulder or AC is described as severe pain in shoulder joint due to stiffness of soft tissue wrapping the shoulder joint and progressive loss of function due to limited ROMs of all muscles and soft tissue.. [1] Painful shoulder joint substantially compromise upper limb mobility and functional abilities, and may disturb sleep due to discomfort.It may also affect social wellbeing and psychological health.Subacromial joint pathology is the root of 70% of shoulder problems.[2] The majority of people affected are between the ages of 40 and 60, with incidence rates between 3% to 5% annually and reaching 40% among those who have diabetes.[4,5] AC is common is both types of Diabetes but it depend on age of patient and duration of Diabetes However, gender is also an important factor because AC affect women more than men.[6] Statistics shows that 2% or more of general population is affected with Frozen shoulder, majority of which are women.[7] Those having Type 1 Diabetes with poor control of glucose are known to have worsen pain in shoulder region [8] There are two types of AC known to us.These include Primary or idiopathic AC, the reason of which is still unknown and there is no other pathology.Secondary or Acquired AC is linked with other pathologies and co-morbidities.[3] Secondary AC has various causes that are directly or indirectly dependent on other pathologies.Major causes may include any recent surgical intervention, long term immobilization in bedridden such as in hemiplagia, RTAs, casting in POP as a result of fracture of elbow as well as chronic or systemic, illnesses, however the exact reason of primary AC is still questionable.A long standing history of Diabetes is also linked with AC. [9] Recently the prevalence of AC has been increased tremendously in all across the world due to different factors that has diverted the attention of patients towards Physical .[10] Understanding the anatomy of the shoulder bone, as well as precise and accurate ways to measure pain and functional limitations with subsequent disability, are crucial for determining the efficacy of particular treatments and creating successful management plans.Different physical therapy techniques are available to treat AC patients, however high-quality researches supported the role of joint movement in easing pain and enhancing shoulder joint mobility in these patients.[10] Kaltenborn suggested different grades of mobilisations, such as mid-range and end-range mobilisations, to increase joint mobility and decrease pain.According to Yang et al. [11], in AC patients, Mulligan mobilisation with movement (MWM) and Kaltenborn mobilisation (KM) are more helpful than Maitland mobilisation (MM).[12] According to Vermeulen HM et al. [13], KM (end-range) was more successful at enhancing glenohumeral mobility in AC patients.The management of AC may benefit from the use of steroid medication, thermotherapy, and manual mobilisation techniques, according to a number of researchers.According to Bal et al. [14], thermotherapy used before and after shoulder workouts increased glenohumeral mobility in AC patients more successfully.The shoulder is made up of the humerus, glenoid, scapula, acromion, clavicle, and nearby soft tissues.The sternoclavicular joint, acromioclavicular joint, and glenohumeral joint are the three major articulations.The most frequently displaced major joint in the body is the glenohumeral joint.The stability of the shoulder joint is because of surrounding musculature, especially the rotator cuff muscles, and ligaments.The supraspinatus, infraspinatus, teres minor, and subscapularis muscles work together as a single unit to form the rotator cuff.Importantly, these muscles depress the humeral head on the glenoid as the arm is raised in addition to aiding in internal and external rotation of the shoulder.The tendons come together to form the rotator cuff tendon, which is one tendon.
In the subacromial space, this passes.The area between the acromion and the rotator cuff tendons is filled by the subacromial bursa, which has many pain sensors.. Adhesive Capsulitis (AC) was categorised by Wong et al. as idiopathic (primary) or following shoulder surgery or trauma (secondary).Tradition dictates that the damaged shoulder will ultimately get better or "thaw out" independent of therapeutic intervention.This long-held belief that frozen shoulder will completely resolve on its own without therapy is false.[15] However, due to the paucity of knowledge regarding the initial 3-6 months of this condition, these clinical criteria were not determined to be reliable diagnostic indicators of AC Hence the diagnosis of AC is still debatable.The dearth of knowledge about early AC raises the possibility that prompt therapy may be required to prevent long-term functional impairments and disability.Furthermore, while addressing potential pathological reasons for frozen shoulder, reliance on low-level evidence may have contributed to more confusion.Duplay coined the term "scapulohumeral peri-arthritis" to characterise the painful and stiff shoulders caused by trauma that later became inflamed and formed fibrous adhesion bands.[16]The outcomes we get from supervised neglect method are better than any other technique such as stretching or passive mobilization.Additionally, diabetic individuals were not included in Diercks et al.'s [17] investigation due to worries that the condition behaved differently in this group subset.Therefore, diabetic individuals might not be candidates for the supervised-neglect strategy.Patients either with or without diabetes who had AC were monitored for 10 years by Vastama ki et al. [18].Although shoulder range of motion (ROM) increased over time in diabetes patients, it remained below normal ROM and was lower to that of those without diabetes.Additionally, several research have demonstrated that people with diabetes experience reduced range of motion (ROM), functional impairment, and chronic shoulder stiffness.These studies suggested that early shoulder evaluation and therapy were necessary to lessen disability and enhance quality of life for diabetic individuals.Wong et al research [16] .'s shown that appropriate evidence supports early treatment to minimise pain and enhance ROM.Several systematic reviews have investigated the efficacy of various AC therapy modalities in general populations, i.e., not just diabetics While some physical therapy techniques, like exercises and joint mobilisation, have been demonstrated to both temporarily and permanently relieve pain and regain shoulder range of motion and function.[19] Surgical release of capsule and Manipulation under anaesthesia (MUA) are proved beneficial for increasing ROM and decreasing pain index but reliability in these outcomes is disputed due to subpar methodological standards.. [20] Few evidence suggested that steroid injections had negligible short-term pain-relieving effects.,For acupuncture's efficacy on discomfort and range of motion, there is just scant to moderate data.
A recent randomised controlled trial (RCT) also revealed that acupuncture helped individuals with adhesive capsulitis by reducing discomfort and restoring shoulder function.In 1934 a series of pathologies of structures lying within shoulder joint and inflammation of bursa, Codman used the term Frozen Shoulder According to him, all these changes may re absorb eventually with time.[16,22] After surgically eliminating capsular contractures to reestablish flexibility in 10 % of patients of limited joint movement caused by minute capsular degradation, Neviaser used the term "adhesive capsulitis" in 1945.[23] Results from different researches shows that hyperplasia caused due to over use or other pathology cause capsular fibrosis of shoulder capsule that will restrict movement of joint and cause stiffness.This stiffness of joint is clinically proven and named as AC.[24] Thickening of capsule of shoulder joint is main cause of restriction in ROM of shoulder that may not be related joint adhesions.[26] Reeves claimed in the 1970s that AC is characterized by three phases.First it causes painful shoulder joint, in second phase stiffness progresses and all functional abilities are restricted.Third phase is recovery phase which reverses all the negative changesr Neviaser's 1953 [25] partial rotator cuff tear and 1945 adhesive capsulitis articles.Grey developed the notion, proposing that frozen shoulder was a self-limiting syndrome that entirely cured over time [27] The self-limiting natural history theory may be applicable to partial cuff tears, but it has lesser chance of being accurate when it comes to the fibrous adhesions and thickening of the joint capsule observed in frozen shoulders.Given the persistent and unresolved deficiencies previously recorded, even within Reeves' study, the natural history idea that frozen shoulders go from stiff to healing stages, leading to complete recovery without therapy was already debatable.The belief that frozen shoulder is a selflimiting illness that gets better with time has been around for a while, but evidence of long-term residual deficiencies years later [29], review articles [30], orthopaedic texts, and online health websites all continue to support it.The widespread belief that a self-limiting resolution will occur can have an impact on clinicians' and patients' clinical decisions.Patients and practitioners may decide against seeking treatment rather than bear the expense, discomfort, and inconvenience of doing so, only to later develop chronic residual deficits that can limit their ability to function.[31] Current evidence-based recommendations and clinical practise guidelines for the treatment of patients with AC were published by Kelley et al. [32].The therapies included joint mobilisations, translational mobilisations, manipulations, short-term corticosteroid injections, knowledge of patient about disease, physical therapy modalities including ultrasound and electrical stimulation, and stretching exercises.They came to the conclusion that some physiotherapeutic procedures provide evidence of both short-and long-term pain reduction or mobility improvement.. Shin et al. [33] utilised the Chuna manual therapy for frozen shoulder together with acupuncture and cupping

MATERIALS AND METHODS
Study design used is Randomized control trial.The duration of study was 4 weeks.Total of 36 patients were selected who fulfilled inclusion criteria.Three Groups were made and 12 patients were included in each group.Sampling technique was non-purposive probability sampling technique.

Sample technique:
Inclusion criteria: Patients who had following features were included in the study: This research was conducted in Department of Physical Therapy, Mayo Hospital Lahore after approval of synopsis.On the basis of inclusion and exclusion criteria for frozen shoulder pain, 36 patients were taken and divided in 3 groups randomly.Before treatment, informed consent was taken and complete procedure was discussed in native language.The examination included data that had undergone both subjective and objective examination.The demographic information related to patient having knowledge of age, sex, past medical history, social and economic interests, related to marriage, related to education, time span of pain, quality and location of symptoms was taken.I performed physical checkup and examination was also done on SPADI that has two aspects, one aspect is of pain and second aspect is for functions.Pain aspect has 5 questions related to pain of patient and Functional aspect has 8 questions related to functional abilities of patient.It helps in assessment after that patient was randomly assigned to receive either high grade mobilization or Low-grade mobilization technique.Numeric Pain Rating Scale (NPRS) was also used for numerical assessment of pain.Allocation of patients in three equal groups was random.On 0th day ROMs of shoulder joint of all patients were assessed by using goniometer and recorded for measuring outcomes.

High grade mobilization
Group A received expert mobilization methods.Intensities were used in accordance with Maitland grades III and IV.Depending on the patient's tolerance ("treating the stiffness"), the time duration of continuous stress on the shoulder capsule in the end-range position was adjusted.The patient was told to let the therapist know how much and what kind of pain they were experiencing both during and after therapy.The therapist adjusts the direction or intensity of mobilization if pain negatively affects how the procedures are carried out (by increasing reflex muscle activity).The mobilization procedures were applied to patients who felt a dull discomfort but no enhanced reflex muscle activity.Patients were advised that this ache would linger for a few hours following the treatment session, and that the strength of the mobilization techniques would be lowered in the following session if the pain became greater or persisted for longer than four hours ("treatment soreness").However, no patient reported this complaint.
3 sets for 10 repetitions with 1-minute rest between each set was given thrice a week for 4 weeks to each patient.Each patient received three sets of 10 repetitions with a 1-minute break in between each set, three times each week for four weeks.

Reflex muscle activity, amplitude of movements
Because reflex muscle activity can be a preliminary sign of joint pain, it was closely monitored.If joint mobility increases, mobilization methods should be modified, and the amplitude of motions will grow without going beyond the range of motion constraints (grade II).
Passive PNF patterns were used in the supine position during the final three minutes of each treatment session while operating in the pain-free zone.

Codman pendular exercises
Additionally, two minutes of prone Codman pendular movements were done to move the shoulder joint in multiple directions at once and to fully relax the shoulder muscles.Each patient received 3 sets of 10 repetitions of each exercise, with a minute of rest in between sets, three times each week for four weeks.

Group C receive:
Conventional therapy Subjects received exercise regimens and heat packs.The exercise therapy regimen includes wand, pulley, finger ladder, and Codman's pendulum activities, as well as active and active aided range of motion exercises, isometric exercises, and pectoral stretching.Everyone will be instructed to perform the Home Exercise Program (HEP) at least twice each day.RESULT: Pre mid and post treatment comparison of ranges in group A had showed that infraspinatus muscle before treatment 2.95±0.144which was improved to 4.58± 0.417 with the significant value of 0.000 which was less than 0.05 showing that improve ranges.

DISCUSSIONS
A total of 36 patients were involved in this investigation.This study was comparative.There were 3 patient groups, each with 12 patients.Group A received expert mobilization methods.Intensities were used in accordance with Maitland's grades III and IV.Depending along each patient's tolerance, that is the capacity to bear glides, the amount of time that the shoulder capsule was subjected to extended stress in the endrange position changed.The patient also provided information regarding the type and severity of their discomfort both during and after treatment.The therapist changed the direction or degree of mobilization as previously mentioned when pain adversely affected the application of the mobilization procedures (by increasing the reflex muscle activation).However, all of the patients felt content and relaxed.For four weeks, we performed three sets of 10 repetitions each with a one-minute break.The therapist has expressly told the patients in Group B that all procedures will be employed without generating shoulder pain or any discomfort; unlike the protocol used for the A group.With the joint close to its neutral position, displacement and distracting techniques were used to begin mobilization techniques in the fundamental initial positions.
Techniques for joint mobilization are thought to have a variety of positive outcomes.The stimulation of nerve endings and suppression of peripheral proprioception underlie the neurocognitive impact.When particular movements target the particular regions of the capsular tissue, the mechanical changes may include tearing up contractures, reshaping elastic, or enhancing fiber glide.By causing prolonged duration stress, alteration in synovial fluid, enhancing the interchange of synovium with chondrocytes, and increasing synovial fluid renewal, mobilization procedures are also designed to improve or preserve joint range of motion and flexibility.
://bjmas.org/index.php/bjmas/indexPublished by European Centre for Research Training and Development UK 102 therapy (PT) interventions that are more useful and long lasting treatment options instead of pain killers and operative procedures.
Understanding the aetiology of frozen shoulder would, in most circumstances, enhance treatment results and lessen pain and suffering brought on by the condition.The global loss of shoulder range of motion and Print ISSN: 2517-276X Online ISSN: 2517-2778 Website: https://bjmas.org/index.php/bjmas/indexPublished by European Centre for Research Training and Development UK 103 nocturnal pain have frequently been suggested as diagnostic criteria for AC by various doctors in the past.
://bjmas.org/index.php/bjmas/indexPublished by European Centre for Research Training and Development UK 104 for first time to all the degenerative changes of rotator cuff muscles and the adhesions within shoulder.
Print ISSN: 2517-276X Online ISSN: 2517-2778 Website: https://bjmas.org/index.php/bjmas/indexPublished by European Centre for Research Training and Development UK 105 (adhesive capsulitis).This clinical investigation revealed no significant safety risk associated with the intervention treatment.In individuals with FS, the intervention treatment appears to significantly improve quality of life, ROM, and pain levels..

 30 -
50 years age group range, Both genders (male and females)  Diabetic patient. Symptoms present up to 3 months. Restricted movements in ADLs.Exclusion criteria: Following subjects were excluded:  Those having Cancer or any other chronic illness. Pregnancy  Systemic disease  Vertebral fracture  Nerve root irritation  Rotator cuff rupture Data collection procedure: Print ISSN: 2517-276X Online ISSN: 2517-2778 Website: https://bjmas.org/index.php/bjmas/indexPublished by European Centre for Research Training and Development UK 106 ://bjmas.org/index.php/bjmas/indexPublished by European Centre for Research Training and Development UK 107 Group B receive: Low grade mobilization I expressly told the patients that all techniques would be applied without generating shoulder pain, in contrast to the regimen employed for the A group.Mobilization procedures were started at the fundamental starting positions, and Grade I and II joints were used for translation and distraction techniques since they are close to the joint's neutral position.
://bjmas.org/index.php/bjmas/indexPublished by European Centre for Research Training and Development UK 108 RESULTS

Table 4 : General Linear Models
General linear models showed that pretreatment SPADI test gave 80.57±3.29 value and mid 37.62±2.30and post treatment 5.00±1.95

Table 5 : Normality test: Result:
Table shows that; Shapiro-Wilk test for normality of data was normally distributed for all ROM, SPADI and NPRS with p-value greater than 0.05.

Table 6 : Paired Samples test 1. Factor 1 NPRSG 1 Pairwise Comparisons
*.The mean difference is significant at the .05level.b.Adjustment for multiple comparisons: Least Significant Difference (equivalent to no adjustments).Website: https://bjmas.org/index.php/bjmas/indexPublished by European Centre for Research Training and Development UK 111 RESULT: In paired wise comparison of group, A NPRSG 1 the mean values are 8.83, .66 and 1.08.Website: https://bjmas.org/index.php/bjmas/indexPublished by European Centre for Research Training and Development UK 113 RESULT: In paired wise comparison of group A supraspinatus the mean values are 3.167±0.0943.792±0.156and4.625±0.109whichclearly presented the improvement in post analysis of muscle activity after treatment.3:

Scapularis Manual muscle pre, mid and post testing results of Group A Descriptive Statistics
Results: Pre mid and post treatment comparison of mean vales of scapularis manual muscles testing in group A gave 3.12±0.376,3.79±0.498and 4.70±0.334values we see the vales improved in post treatment.

Table 6 :
ANOVA Petreatment ANOVA .The mean difference is significant at the 0.05 level.Website: https://bjmas.org/index.php/bjmas/indexPublished by European Centre for Research Training and Development UK Post treatment comparison of RANGES in all groups had showed that, mean values of in group A was 1.0833±1.311, in group B was 1.0833 ± 0.668 and in group C 1.50 ± 1.00 with p-value 0.000.Showing that high grade mobilization exercises were more effective than other techniques.Before treatment and after treatment the mean vales presented the improvement. *