PERIARTHRITIS SHOULDER/ FROZEN SHOULDER

1. PRESENT BY
DEBANJAN MONDAL
MPT(ORTHO)
A COMPARATIVE STUDY BETWEEN
EFFICACY OF END RANGE MOBILIZATION
AND MOBILIZATION WITH MOVEMENT TO
IMPROVE THE ABDUCTION RANGE IN
PERIARTHRITIS SHOULDER.

2. INTRODUCTION
The common condition in the shoulder joint is Periarthritis
of the glenohumeral joint which affects the function of the
shoulder causing pain and limitation of range of motion.
Mobilization is a form of passive exercise designed to
restore joint play motions of roll, glide and joint
separation. They are passive skilled manual therapy
techniques applied to joints at varying speeds and
amplitudes using physiological or accessory motions. The
quantity of movement can be measured by using an
Universal Goniometer, quality of movement is tested by
the therapist observing the active movement.

3. End range mobilization of extremity joints consists of two passive
rectilinear movements traction/separation and translatoric gliding,
called joint play, and depends on concave convex rule.
There are 3 grades of Mobilization-
Grade I(Loosen) Small amplitude distraction is applied where no
stress is placed on the capsule. It equalizes the cohesive forces, muscle
tension, and atmospheric pressure acting on the joint and is used with
all gliding movement and may be used for relief of pain.
Grade II(Tighten) Enough distraction or glide is applied to tighten
the tissues around the joint “taking up the slack” and is used for initial
treatment to determine how sensitive the joint is. Once joint reaction is
known, the dosage of treatment is either increased or decreased
accordingly.
Grade III (stretch) A distraction or glide is applied with an amplitude
large enough to place a stretch on the joint capsule and on surrounding
periarticular tissues.

4. Brian Mulligan’s concept of Mobilization With Movement
is the progression in the development of manual therapy from
active stretching exercise to therapist applied passive
physiological movement to passive accessory mobilization
techniques. MWM is the application of a sustained accessory
mobilization applied by the therapist and an active
physiological movement to end range applied by the patient.
Both the End range mobilization and Mobilization with
movement concepts place particular emphasis on restoration
of glide component of joint movement to facilitate full pain
free range of movement.1

5. AIMS AND OBJECTIVES
1. To study the efficacy of End range mobilization
on improving the abduction Range of Motion
and function in subjects with Periarthritis
shoulder.
2. To study the efficacy of mobilization with
movement on improving the abduction ROM
and function in subjects with Periarthritis
shoulder.
3. To compare the efficacy of End range
mobilization and Mobilization With Movement on
improving the abduction ROM and Function in
subjects with Periarthritis shoulder.

6. HYPOTHESIS
Experimental Hypothesis
Mobilization With Movement will be more effective than End
range mobilization technique in improving abduction range and
function in subjects with Periarthritis shoulder.
Alternative Hypothesis
End range Mobilization will be more effective than Mobilization
With Movement technique in improving abduction range and
function in subjects with Periarthritis shoulder.
Null Hypothesis
Mobilization With Movement will be as effective as End range
mobilization technique.

7. METHODOLOGY
SAMPLING METHOD
The study included a sample of 40 subjects
who were diagnosed as having Periarthritis
of the glenohumeral joint and having a typical
restriction of external rotation, abduction and
internal rotation the most. The subjects
between the age group of 40 and 70 years
were randomly selected.

8. METHOD OF COLLECTION OF DATA
These subjects were then divided randomly into 2
groups, Group A and Group B.
Group A of 20 subjects were given End range
mobilization technique.
Group B of 20 subjects were given Mobilization
With Movement.
The treatment for both the groups were given for 10
to 15 repetitions in 6 sitting. Although subjects will
be treated for improving all the restricted movements
of shoulder joint, recording and study were
conducted on abduction range.

9. SOURCE OF DATA COLLECTION
Data will be taken from physiotherapy
department of Doon paramedical college,
Dehradun.

10. VARIABLES
Independent variable
 Universal goniometer (3600).
 Mulligan belt.
Dependent variable
 Range of motion.
 Shoulder pain and disability index.

11. INCLUSION CRITERIA
 Subjects with restriction of external rotation,
abduction and internal rotation of the
glenohumeral joint when compared to the
opposite side.
 Subjects with the history of painful, restricted
shoulder for at least 3 months and not more
than 9 months.

12. EXCLUSION CRITERIA
 Subjects with Uncontrolled diabetes.
 Unstable joint
 Post traumatic shoulder stiffness
 Hemiplegic Shoulder joint
 Concurrent cervical signs and symptoms
 History of fracture and dislocation of the shoulder
 Post surgical cases around shoulder
 Bicipital tendonitis
 Supraspinatus tendonitis
 Painful arc syndrome
 Thoracic outlet syndrome
 Cases of diagnosed bone infections

13. PROTOCOL
Subjects meeting the inclusion criteria
Subjects included in the study (n=60)
Subjects randomly assigned into two group
Number of subjects
randomly assigned for
hip muscle
strengthening (n=30)
Number of subjects
randomly assigned for
hip muscle
strengthening (n=30)
Received allocated
treatment (n=30)
Received allocated
treatment (n=30)
Data collected Data collected
Interpreted Interpreted

14. PROCEDURE
 They were then randomly divided into Group
A and Group B of 20 subjects each. The
base line data of ROM of all the movements
of shoulder is obtained using universal
goniometer, but the recording and study were
done only on abduction range pre and post
treatment on alternate days for 6 sitting. The
pain and disability data were obtained using
SPADI to check for the functional outcome on
the 1st sitting before the treatment and on
the 6th sitting after the treatment.

15. ROM MEASUREMENT
ROM is measured by using Universal Goniometer
(3600)
1. The patient is in sitting position.
2. Center of the fulcrum of the goniometer close to the
posterior aspect of the acromial process.
3. Align the proximal arm parallel to the spinous process
of the Vertebral column.
4. At the end of ROM align the distal arm with the lateral
midline of the humerus using the lateral epicondyle
reference.

16. SPADI SCORE MEASUREMENT
 Pain and disability is evaluated by using SPADI.
It consist of 2 self report sub scales of pain and
disability. The two sub scale are VAS and ADL.
The VAS consist of 5 question in order to
evaluate patient’s pain during ADL and each
question is anchored by the descriptions “no
pain” (left anchor) and “worst pain imaginable”
(right anchor). The second scale (ADL) consist
of 8 disability question asked to the patient
about their difficulty in performing ADL. These
questions are anchored with the descriptions
“no difficulty” (left anchor) and “so difficult it
required help”(right anchor).

17. Each item is scored by measuring the distance from
the left anchor to the mark made by the person. First,
questions scored within the sub scale are summed.
Second, this sum is divided by the summed distance
possible across all questions of the subscales to which
the patient responded. Third, this ratio is multiplied by
100 to obtain a percentage. Higher scores on the sub
scale indicate greater pain and greater disability. To
obtain the total score of SPADI both the pain and
disability subscales are averaged.

18. Group A of 20 subjects received End range
mobilization for 6 sitting on alternate days. Prior to the
treatment the subjects were evaluated for the
abduction range. Moist heat is applied prior to the
treatment for 10 minutes. End range mobilization is
then performed for all the restricted movements of the
glenohumeral joint but the recording is done on
abduction ROM.

19. There are 3 grades of Mobilization-
Grade I (Loosen) Small amplitude distraction is applied
where no stress is placed on the capsule.
Grade II (Tighten) Enough distraction or glide is applied to
tighten the tissues around the joint “taking up the slack” and is
used for initial treatment to determine how sensitive the joint.
Grade III (Stretch) A distraction or glide is applied with an
amplitude large enough to place a stretch on the joint capsule.
The traction mobilization using grade 3 is held for 5 to 10
seconds using as much force as the patient can comfortably
tolerate and it is not necessary to release the joint completely
between traction mobilization, a return to the place between
grade 1 and grade 2 is adequate before repeating the process.

20. END RANGE MOBILIZATION TECHNIQUE
Starting position: Patient lies supine on the table with
the arm abducted approximately to 550. The therapist
stands facing the lateral side of the upper arm.
Fixation: Will be done using a towel for scapular
fixation.
Procedure: Therapists right hand hold around patients
elbow and forearm from the ventral side. Left hand holds
around the humeral head with the thumb ventrally just
distal to the acromium and the direction of movement is
towards caudal assisted by therapists body.

21. Group B of 20 subjects were received Mobilization
With Movement for 6 sitting on alternate days 10 to 15
repetition. Prior to the treatment subjects were
evaluated for abduction range. Moist heat is applied
for 10 minutes. Mobilization With Movement
technique is then performed for all the restricted
movements of the glenohumeral joint but the
recording is done for abduction ROM.

22. MOBILIZATION WITH MOVEMENT TECHNIQUE
Starting position: The subjects made to sit, the therapist stands
behind the patient and places the belt around his both hips and the
patients shoulder.
Fixation: The therapist places his hand on the scapula for fixation.
Procedure: The patient is asked to raise his arm up from his side
while the glide is applied posteriorly by the therapist over the head of
the humerus by leaning back in such a way as to glide the humeral
head in the treatment plane. Before and after the treatment in both
groups, abduction ROM is measured using universal goniometer on
alternate days for ten sittings and functional outcome is measured
using SPADI on the first sitting day before and the tenth sitting day
after the treatment.

23. THANK YOU