COLLATION OF SCAPULAR PROPRIOCEPTIVE NEURO-MUSCULAR FACILITATION AND SCAPULAR MOBILIZATION WITH MOVEMENT IN ADHESIVE CAPSULITIS PATIENTS.

Dr. Dravya M. Mistry 1 , Dr. Nipa Shah 2 and Dr. Devathi Kothari 1 . 1. BPT, SBB College of Physiotherapy, VS Hospital Campus, Ahmedabad. 2. MPT (ORTHO), PG Guide of Sports Science, Lecturer at SBB College of of Physiotherapy, VS Hospital Campus, Ahmedabad. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 10 April 2019 Final Accepted: 12 May 2019 Published: June 2019


ISSN: 2320-5407
Int. J. Adv. Res. 7 (6), 573-581 574 Introduction:-Adhesive Capsulitis or Peri-arthritis or Frozen Shoulder is self-limiting condition of unknown cause, which affects usually middle-aged women of 40-70 yrs old 1 and rarely it occurs secondary to Rheumatoid Arthritis, Osteo-Arthritis, trauma or immobilization of shoulder joint. It is characterized by development of dense adhesions, capsular thickening, capsular restrictions which limitsactive and passive shoulder Range of Motion (ROM) with scapular dyskinesis. Though it is often self-limited, can persist for years and may never fully resolve. The disease process affects the anteriosuperior joint capsule, axillary recess, and the coracohumeral ligament. It has been shown through arthroscopy that patients tend to have a small joint with loss of the axillary fold, tight anterior capsule and mild or moderate synovitis but no actual adhesions. 2,3 Contracture of the rotator cuff interval has also been seen in adhesive capsulitis patients, and greatly contributes to the decreased range of motion, mostly seen in population. 4 Condition is frequently defined as loss of more than 25% of normal shoulder range of motion in at least two directions, particularly abduction and external ro tation 2,4,5,6,7,8 . Faulty posture and muscle strength imbalance also are pre-disposing factors.
Clinical Entity of Adhesive Capsulitis progresses in 4 stages. STAGE-I-(PRE-FREEZING STAGE) characterized by gradual onset of pain which increases with movement and is present at night, along with restricted external rotation. This stage lasts for 3 months. STAGE-II (FREEZING STAGE) characterized by persistent and intense pain at rest with limited motion in every direction. This stage lasts for 3 -9 months. STAGE-III (FROZEN STAGE) characterized by pain only with movement, significant adhesions, atrophy of scapular and shoulder muscles. This stage lasts for 9-15 months. STAGE-IV (THAWING STAGE) characterized by minimal pain and no synovitis but capsular restrictio n. This stage lasts for 15-24 months.The treatment of adhesive capsulitis aims at reducing pain, improving ROM and shoulder functional activities of patients by giving hotpack, capsular stretching, Shoulder ROM exercises, pendular exercise, scapula thoracic strengthening exercises 9 .
Scapulo-humeral rhythm which is playing an important role in increasing shoulder ROM. The disturbance in the scapulohumeral rhythm creates the alterations in alignment of scapula and interferes with the function of upper limb 10,11,12 . It is evident that the most effective techniques for adhesive capsulitis with scapular dyskinesis are Scapular Proprioceptive Neuromuscular Facilitation (PNF) and Scapular Mobilization with Movement (MWM). For proper functioning of the upper limb, the position of the scapula upon thorax and movement synchronization is mandatory 18,19 . The scapular patterns of PNF will facilitate and synchronize with Upper limb function of shoulder movements 20 .Manual therapy of scapula in adhesive capsulitis is used to realign the scapula in its normal position, by which correct recruitment of muscles will help in achieving pain free and increase shoulder ROM and shoulder function. The intent of MWM is to restore pain free motionat joints that have painful limitation of range of movement 21 .
The purpose of this clinical trial was to compare two techniques:-Scapular PNF and Scapular MWM, in patients having Adhesive Capsulitis with scapular dyskinesis.

Methodology:-
The Study design was Comparative Experimental Study, Sampling method was convenient sampling with the sample size of 20 subjects and study duration of 1 week, Study setting was on Ortho OPD, Municipal Corporation Hospital, Ahmedabad.
Our Inclusion Criterias were-Patient with Adhesive Capsulitis of Stage-II or Stage-III, with Scapular Dyskinesis with Lateral Scapular Slide Test Positive. And our Exclusion Criterias were-recent H/O trauma, dislocation or fractures of shoulder, altered cognition, neurological conditions and tumors.
Materials used for the study-Visual Analogue Scale, Simple Shoulder Function Test, pen and paper, goniometer. Figure 1 depicts the questionnaire of Simple Shoulder Function Test used during the study.

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Outcome measures were Visual Analogue Score for Pain, Goniometric Range of Motion and Simple Shoulder Functional Activities.

Group-A:-
In Group-A, patients were asked to go in side-lying position, where the affected shoulder is facing the roof, and the therapist stood behind the patient, therapist pulled the scapula in elongated position, and gave resistance for the desired pattern. D1 Pattern consists of Anterior Elevation of Scapula and Posterior Depression of Scapula 1 , as shown in Figure 2. D2 Pattern consists of Posterior Elevation and Anterior Depression of the Scapula 1 , as shown in Figure  3. Rhythmic Initiation of the scapular muscles helps muscles to activate and the pattern helps to gain the scapulahumeral rhythm of the joint 1 . The rhythmic initiation technique teaches the motion, helps the patient to relax, improves coordination, and normalizes the motion. The repeated contractions technique increases active range of motion and strength and guides the patient's motion towards the desired movement 22 . Usual dosage for this treatment was 20 repetitions with 20 second rest in between for each diagonal pattern, for 3 times 1 .  The right hand is on the superior part of the clavicle. The right hand thumb is on the spine of the scapula and the fingers anterior to the clavicle. The therapists moves/assists the scapula in upward rotation (left hand) and posterior tilting the scapula(right hand) as the patients goes into the end range of motion actively elevating the shoulder in scaption plane, as shown in Figure 4. It is done for the 10 repetitions for 3 times 28 . This technique combines a sustained application of a manual technique 'gliding' force to a joint with concurrent physiologic (osteo-kinematic) motion of joint, either actively performed by the subject or passively performed by the therapist 27 . Wilcoxon results for Group A are shown in Table 1 and in graphs 1a and 1b. Wilcoxon results for Group B are shown in Table 2 and in graphs 2a and 2b. Man-Whitney results for comparing post data of both the groups are shown in Table 3 and in graphs 3a and 3b.

Group-A Pre And Post Results
In Group-A, results signifies that; there is significant decrease in pain perception, that is decrease in VAS scores; increase in Shoulder Flexion, Abduction and External Rotation ROM and also there was significant improvement in daily Shoulder Functional Activities. Hence, there is SIGNIFICANT VARIATIIONin patient's pain perception, ROM, Shoulder Pain and function, after giving SCAPULAR PROPRIOCEPTIVE NEUROMUSCULAR FACILLIATATION for one week.

Group-B Pre And Post Results
In Group-B, results signifies that; there is significant decrease in pain perception, that is decrease in VAS scores; increase in Shoulder Flexion, Abduction and External Rotation ROM and also there was significant improvement in daily Shoulder Functional Activities. Hence, there is SIGNIFICANT VARIATIIONin patient's pain perception, ROM, Shoulder Pain and function, after giving SCAPULAR MOBILIZATION WITH MOVEMENT for one week.

Group-A And Group-B Pre And Post Results
By comparing both the groups, results clinically signifies that Group-A gave better results than Group-B, but statistically there is no significance between both the groups for VAS scores, Shoulder Flexion, Abduction and External Rotation and for Shoulder Functional Outcome Measure. Thus, the result shows there is NO SIGNIFICANT VARIATION in patient's ROM, Shoulder Pain and function BETWEEN THE GROUPS.

Discussion:-
According to result (WILCOXON), it suggests that there was significant difference (P<0.005) in Pain, ROM and Functional Outcome Measure in both the groups. And the comparison between Group A and B (MAN-WHITNEY) is not significant(P<0.01).
Scapular PNF is the therapeutic approach that works under the means such as stress relaxation, pain gate theory, autogenic inhibition that improves muscle activation and range of motion. 13,14. The greatest amount of muscle activation is by the reciprocal activation of both agonist and antagonists which are involved in PNF 15,16,17 .Scapular PNF has shown significant difference in VAS scores in single sessionalong with classic exercise and physiotherapy modalities in adhesive capsulitis.(Nilay Comuk Balc et al,2016) 22 . PNF techniques helps in improving ROM as it elongates the golgi tendon organ that facilitates relaxation of the antagonist muscles and early return to ADL. (Prasanna KJ et al, 2017) 1 .Weon-Sik et al. investigated the effects of scapular pattern and hold-relax technique of PNF on ROM and pain in 30 patients with Adhesive Capsulitis. They treated the patients for 4 weeks and found that PNF was effective for improving ROM and Pain. Similarly, we found scapular PNF exercises combined with physiotherapy modalities were effective for improving pain, shoulder function, and ROM. However, these improvements were not directly caused by scapular PNF exercises 24 . We believe that PNF may be effective when performed with a regular rehabilitation program over a long term.
Due to protracted and rounded shoulders, there is anterior tipping of scapula, which will limit the terminal ranges of shoulder; by tilting the scapula posteriorly and upward rotating the scapula (MWM), one can increase the terminal ranges of shoulder; especially shoulder external rotation. It has been described that during elevation of the arm in healthy subjects, the scapula should upwardly rotate and posteriorly tilt 25,26 , by applying the posterior tilting and upward rotation of scapula with MWM, one can correct the scapular kinesis. Correctional mobilization is sustained, pain free function is restored and several repetitions will begin to bring lasting improvements which are coordinated

Conclusion:-
The results of the study shows that both the treatments; Scapular PNF and Scapular MWM are equally effective in decreasing Pain, increasing Shoulder ROM and Shoulder Function. Both the techniques are useful in treating patients of Adhesive Capsulitis of Stage-II or III with Scapular Dyskinesis, and helps in improving function of shoulder joint.

Study Limitations And Future Study Prospectives:-
The limitations of the study were relatively small sample size; less duration of study and therefore cannot determine long-term effects of treatment. To increase the sample size and the duration of the study and to examine long-term effects of treatment are the future prospective of the study.