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Adhesive capsulitis can be defined as a common condition characterized by insidious and gradual inflammation of the glenohumeral joint capsule leading to its contracture and thus resulting in stiffness and loss of shoulder mobility 1. The prevalence rate has been reported to be 2—5. Secondary adhesive capsulitis is a result of a pre-existing shoulder condition such as dislocation, humeral fracture, and osteoarthritis or a neurological condition leading to muscular imbalances.
The prevalence of secondary adhesive capsulitis related to type 2 diabetes and thyroid disease is between 4. According to the literature, inflammatory changes in the capsule and synovium of the glenohumeral joint are responsible for contracture of the capsule 8 , 9 , This contracture brings the humeral head close to the glenoid fossa The overall active and passive range of motion ROM of the shoulder joint in the capsular pattern is reduced, with the largest changes in ROM observed, in descending order, in external rotation, abduction, and internal rotation This results in a greater emotional and economic distress, with the patient suffering from long-term pain and limited shoulder movement The purpose of the mobilizing exercise therapy for a frozen shoulder is primarily to increase shoulder movement by stretching the glenohumeral joint capsule These techniques mobilize the glenohumeral joint while keeping the scapula fixed relative to the thorax and glenohumeral joint Harryman et al.
Some researchers have found that the external and internal rotation ROM increases with posterior gliding manipulation of the shoulder 20 , Thus, according to Roubal et al. Johnson et al. Sarkari et al. Stenvers 17 stated that the glenohumeral joint capsule can be stretched by fixing the scapula and moving the humerus or by fixing the humerus and moving the scapula. In terms of biomechanics, it was suggested that during the movement of the humerus with respect to the scapula, the scapula is eventually fixed, but in an unnatural position.
Furthermore, movement of the humerus causes pain. Because of this pain, it is not possible to exert force on the glenohumeral joint capsule. For this reason, movement of the humerus with respect to the fixed scapula, as implemented in traditional gliding techniques, is not an effective mobilization method.
Movement of the scapula with respect to the humerus is a better mobilization method because it stretches the capsule directly and is painless. Vermeulen et al. Their results showed an increase in mean capacity of the glenohumeral joint capsule, improved active mobility for flexion and external rotation, and improvement in shoulder function after 3 months of treatment. Although both manual shoulder mobilization techniques are widely used in the treatment of adhesive capsulitis, they are different in terms of therapeutic implementation.
The studies mentioned above used the reverse distraction technique involving movement of the scapula relative to the thorax, with the glenohumeral joint distracted in combination with other mobilization techniques; at present, there is no evidence proving that reverse distraction alone can be effective in the management of adhesive capsulitis.
Thus, the aim of the present study was to compare the efficiency of the reverse distraction technique with that of traditionally used gliding techniques posterior and caudal glides in improving joint mobility and alleviating pain and disability in patients with adhesive capsulitis. Initially, 43 patients were evaluated at a physiotherapy outpatient department, Jamia Millia Islamia, New Delhi, India.
The exclusion criteria were presence of neurological disorders e. Ethical approval was granted by the institutional human ethical committee, and the subjects who agreed to participate signed written informed consent in accordance with the declaration of Helsinki.
Instructions were given to use their effected arm in activities of daily living within pain-free limits and to avoid activities demanding resisted movements e. Patients were asked about their occupation, dominant arm, affected arm, time when they started to experience the discomfort when moving the arm, and any minor or trivial injury preceding the onset of the symptoms. Two subjects, one from each group, left the study within two weeks of the intervention. Assessments were made at baseline before the first treatment session and after 18 treatment sessions 6 weeks.
All the measurements were performed by the same therapist SA. For assessing pain during shoulder joint movement, subjects used a visual analogue scale VAS 12 consisting of a cm vertical line, with one end corresponding to no pain during shoulder movement and the other end to maximal pain. The reliability of this test was reported to be 0. Criterion validity has not been evaluated because of the absence of a gold standard for pain measurement In the present study, active and passive abduction in the frontal plane and external rotation with the arm at 0 degrees of abduction ROM was measured with a conventional goniometer as per the guidelines given by the American Academy of Orthopaedic Surgeons Goniometric measurements are highly reliable provided measurements are conducted by same therapist 29 test-retest reliability: 0.
Hand behind back HBB reach was measured in centimeters using inch tape with subjects in the standing position. They were instructed to achieve the maximum HBB reach position by moving their affected extremity upwards and towards the midline with the thumb extended. In this position, the distance between the L5 spinous process and the radial styloid process was measured.
The radial styloid process was used to decrease the measurement error related to movements at the wrist and thumb joints If the hand could not reach the midline, measurements were taken by drawing a horizontal line from the reached position to the central level The distance between the L5 and C7 spinous processes was also measured to normalize the distance between the L5 spinous process and the radial styloid process, thereby eliminating differences due to variations in height Functional disability was measured with a self-administered, shoulder-specific, fixed-item index, Flexilevel score of shoulder dysfunction FLEX-SF.
FLEX-SF measures three levels of function, with each item scoring the level of function as low, medium, or high. Subjects responded only to the items that reflected their functional level. Scores ranged from 0, indicating the most limited function, to 60, signifying no functional limits. In the reverse distraction group, patients were asked to lie on their unaffected side at the edge of a plinth.
The upper hand maintained the required angle of abduction or flexion, whereas the lower hand was placed on the lateral border of the scapula for mobilizing it in medial and downward rotation 17 , There were 10—15 repetitions per each of 3 treatment sessions administered each week; a total of 18 sessions were performed during 6 weeks. After each session of mobilization, movements within the active, pain-free ROM were encouraged.
For posterior glide, lateral humeral distraction was maintained with abduction in the end range, with the patient in the supine lying position and the scapula stabilized. The progression arm was put at the flexion end range, and posterior stretch mobilization was performed along with lateral humeral distraction. For caudal glide, the patient was placed in the supine position with the scapula stabilized.
Lateral humeral distraction was maintained, and caudal stretch mobilization was done in the resting position of the shoulder joint. For progression of the caudal glide, lateral humeral distraction was followed by caudal stretch mobilization.
Subjects were treated in 3 sessions per week for 6 weeks. Both mobilization techniques were administered by the same therapist SA to minimize the inter-therapist variability. The conventional physical therapy treatment for adhesive capsulitis was administered in both groups. A hot pack was applied as a superficial heating modality at the shoulder joint for 15—20 minutes.
Four-direction shoulder stretching in forward elevation, external rotation, horizontal adduction, and internal rotation was performed Stretches were performed 2—3 times a day and maintained for 1—5 seconds in a comfortable range The Shapiro-Wilk test was applied to assess the normal distribution of scores.
Accordingly, we log-transformed the VAS scores. Since HBB reach data could not be normalized because of the presence of negative values, a non-parametric test was applied for analysis. VAS, abduction and external rotation active and passive ROM, and FLEX SF score were measured at baseline and at the end of the 6-week therapy 18 treatment sessions using the dependent t-test and compared between the groups using the independent t-test. Changes in HBB reach were assessed using the Wilcoxon signed rank test, and between-group changes were analyzed using the Mann-Whitney U test.
At baseline, the VAS scores of the two groups were similar Table 1. The patients were treated for 3 sessions per week for 6 weeks, and changes in pain, ROM, and functional disability were recorded before and after the intervention. No published study has compared these two techniques directly. Although some studies have evaluated the effectiveness of the reverse distraction technique along with other mobilization techniques 24 , 25 , the effectiveness of reverse distraction alone in increasing mobility and reducing pain has not been investigated.
Most variables were comparable at baseline; however, the right arm was dominant in 13 and 12 cases in the reverse distraction group and Kaltenborn group, respectively. This small difference was found to be statistically significant. However, a one-unit change between the groups will hardly influence the result clinically. Similarly, although differences in affected arm, occupation, and minor injury history were statistically significant between the groups at baseline, they are unlikely to be important clinically as the groups were assembled randomly.
Scapular mobilization has been proven to be an effective treatment technique for improving shoulder mobility in patients with adhesive capsulitis 30 , The corresponding studies used scapular mobilization procedures, such as superior and caudal gliding, upward and downward rotations, and distraction of the scapula from the thorax with the patient lying on the unaffected side.
Surenkok et al. This increased scapular movement may constitute the mechanism of improving shoulder movement. The reverse distraction technique, which was proposed by Stenvers 17 and later used by Vermeulen 24 , is different from the scapular mobilization technique in that glide is applied to the scapula in the medial and downward rotation direction, along with lateral distraction at desired elevation angles to the humerus at the glenohumeral joint, with the patient lying on the unaffected side.
In this study, there was a significant improvement in pain in both groups, which is in accordance with previous studies 17 , 22 , 24 , A decrease in pain after joint mobilization has been attributed to various mechanisms, such as neurophysiological effects achieved by the stimulation of type II mechanoreceptors and by inhibition of type IV nociceptors 38 , stimulation of Golgi tendon organ activity, and reflex inhibition of the muscle at the end of the passive joint mobilization Joint mobilization decreases muscle activity, reducing muscle concentric activation, pain, and muscle tension in periarticular tissue The comparison of the two techniques revealed that the reverse distraction technique was significantly better than the Kaltenborn technique.
There is presently no published study that can support and explain this finding, and further research is required in this regard. Stenvers 17 stated in a retrospective study that the glenohumeral joint capsule can be stretched both by fixing the scapula and mobilizing the humerus and by fixing the humerus and mobilizing the scapula.
In biomechanical terms, it was suggested that during the movement of the humerus relative to the scapula, the scapula is not stabilized effectively. As a result, a laterally directed force is applied to the acromion and further to the clavicle to help stabilize the scapula indirectly via the sternoclavicular and acromioclavicuar joints.
Furthermore, the movement of the humerus causes pain. Because of this pain, it is not possible to exert force on the glenohumeral joint capsule effectively. Thus, the movement of the humerus relative to the fixed scapula, as used in traditional gliding techniques, is not an effective mobilization method. In contrast to the first method, in reverse distraction no force is applied to the acromion in order to counteract the rotation of the scapula since the scapula is held in place by the joint capsule.
The mobilizing force on the scapula is applied only to load the joint capsule, with no pain being caused.
During the movement of the scapula with respect to the humerus, only the glenohumeral joint is involved, and the glenohumeral joint capsule is stretched without causing pain.
The Kaltenborn Convex-Concave Rule is a familiar concept in manual therapy joint techniques and arthrokinematics. The rule is based on the relationship between normal bone rotations and the gliding component of the corresponding joint movements. When a convex joint surface is moving, the roll and glide occur in the opposite direction. The therapist moves a convex joint surface opposite to the direction of restricted movement to provoke the capsule in the same direction as the glide. When a concave joint surface is moving the roll and the glide occur in the same direction. The therapist moves a concave joint surface in the same direction as the direction of the restricted movement. The opposite capsule is provoked.