Você está na página 1de 27

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA
ANNEXURE-II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1.

Name of the candidate & address

P.KHYATHI
K.T.G Girls Hostel,
Hegganahalli Cross, Vishwaneedam Post,
Sunkadakatte Via Magadi Road,

2.

Bangalore 560091.
K.T.G COLLEGE OF PHYSIOTHERAPY

Name of the Institution

Hegganahalli Cross, Vishwaneedam Post,


Sunkadakatte Via Magadi Road,
Bangalore 560091
3.

Course of study and subject

MASTER OF PHYSIOTHERAPY
( Musculoskeletal
Disorders & Sports Physiotherapy)

4.

Date of Admission To Course

5.

Title of The Topic:


COMPARITIVE EFFECT OF SPENCER TECHNIQUE VERSUS MULLIGANS
TECHNIQUE

FOR

SUBJECTS

WITH

BLINDED STUDY.

FROZEN

SHOULDER :

A SINGLE

6.

Brief resume of the intended work:


6.1 Need for the study:
Adhesive capsulitis or frozen shoulder is a syndrome defined in its purest sense as
idiopathic painful restriction of the shoulder movement that results in global restriction of the
glenohumeral joint. It is not associated with a specific underlying condition. It has also been
described as a condition of unknown etiology characterized by gradually progressive, painful
restriction of all joint motions with spontaneous restoration of partial or complete motion over
months to years1, affecting 2-5% of the general adult population and up to 20% of the patients
with diabetes2, mainly affects individuals of 40-60 years of age with female predominance. The
restriction of the shoulder movement is thought to be the result of inflammation and swelling in
the lining of the shoulder joint (capsule) and its associated ligaments with resultant contracture of
the shoulder joint capsule. The lining loses its normal characteristic of the flexibility and becomes
stiff and painful.3
The hallmarks of frozen shoulder are stiffness, difficulty sleeping on the affected side,
progressive limitation of the active and passive glenohumeral movements especially abduction
and external rotation4.
Frozen shoulder progressive through three clinical phases (1) painful phase- severe pain
usually worst at night and when lying on the affected side (2-9 months) (2) are stiffening or frozen
phase- difficulty with simple activities of daily living. Stiffness progresses and leads to disused
atrophy (4-12 months) (3) Thawing phase gradual increase in range of motion and improvement
in pain, although it may reappear as stiffness ceases (5-12 months)4.

Mobilization is a passive joint movement of varying amplitudes of low or high velocity when
applied to musculoskeletal tissue mobilizes them depending on the desired effect. Joint
2

Mobilization is important part of the treatment stimulating tissue heating, modulates pain,
decreases muscle tone, increase nutrition to the tissues, increases joint mobility and normalizes
physiological movement allowing better function of the musculoskeletal system5.
Spencer technique is an articulatory technique with seven different procedures
used to treat shoulder restriction caused by adhesive capsulitis. It is the high velocity low
amplitude technique which treats the restrictions in glenohumeral joint. In Spencer technique
passive, smooth, rhythmic motion is designed to stretch contracted muscles, ligaments and
capsules. Most of the force is applied at the end range of motion. This technique increases pain
free range of motion through stretching the tissues enhancing lymphatic flow and stimulating
increased joint circulation6. Studies have shown the effect of Spencer technique on improving
mobility and functional ability in subjects with frozen shoulder.
Mulligan incorporated kaltenborns principles of passive mobilization. It is a
combination of an active movement with simultaneous passive accessory mobilizations, to
achieve painless movement by restoring the reduced accessory glide. Therefore termed as
Mobilizations with movement (MWM). In essence, the limited painful physiological movement
is performed actively while the therapist applies a sustained accessory glide at right angles or
parallel to the joint to restore a restricted, painful movement to a pain free and full range state.
The combination of joint Mobilization with active movement may be responsible for the rapid
return of pain free movement7. The studies have shown the effect of MWM on improving mobility
and functional abilities in subject with frozen shoulder.

Even though various treatments exist in the management of frozen shoulder optimal
treatment intervention is not been agreed. There are studies that prove that both the techniques are

used effectively in the treatment of frozen shoulder. However there are no studies found in the
literature which compare the effects of Spencer technique versus mulligans technique.
Therefore there is a need to find the comparative effect of two treatment techniques
for subjects with frozen shoulder. Hence, the purpose of the study is to compare the effectiveness
of the Spencer technique versus mulligans technique on improvement of pain, mobility and
functional ability for subjects with frozen shoulder.
Research Question
Whether there is any difference between Spencer technique versus mulligans technique on
improving pain, mobility and functional ability in subjects with frozen shoulder.
Hypothesis:
Null hypothesis
There will be no significant difference in effect of Spencer technique versus mulligans technique
on pain, mobility and functional ability in subjects with frozen shoulder.
Experimental hypothesis
There will be a significant difference in effect of Spencer technique versus mulligans technique
on pain, mobility and functional ability in subjects with frozen shoulder.
6.2 Review of Literature:
Review on Frozen Shoulder
Shahbaz Nawaz Ansari, et.,al. (2012) studied on effectiveness between the treatment modalities
of ultra sound therapy and end range Mobilization over cryotherapy and stretching in alleviating
pain of patients with frozen shoulder and found the ultrasound therapy with end range
Mobilization produced a better result than cryotherapy with stretching in reducing pain in frozen
shoulder8.

Jing-Ian yang, et., al. (2012) Examined the effectiveness of the end range Mobilization/ scapular
mobilization treatment approach (EMSMTA) in a subgroup of subjects with frozen shoulder
syndrome (FSS). Subjects were assigned to the control group and to the criteria control group
with a standardized physical therapy program or to the EMSMTA group. ROM, disability score
and shoulder complex kinematics were obtained. EMSMTA was more effective than a
standardized physical therapy program in a subgroup of subjects who fit the criteria9.
Review on Spencer technique:
Matthew Pomykala, et.,al.(2008) conducted a study to determine patient perception of receiving
manipulative therapy while hospitalized. The same physician treated each patient and used
various manipulative techniques as needed. Main outcome measures include pain, need for pain
medication, anxiety about hospitalization and overall comfort level. They concluded that
manipulative treatment may be of tremendous benefit to hospitalized patients10.
J Licciardione, et.,al.(2002) conducted a patient survey to measure and explain patient
satisfaction and clinical outcomes associated with manipulative treatment. 459 people received
manipulative treatment. Subjects perceived manipulative treatment to be highly efficacious and
reported significant relief from pain or discomfort and improvement in mobility. These findings
suggest the need for greater access to manipulative therapy services11.
Knebl JA, et.,al.(2002) studied the efficacy of osteopathic manipulative treatment in an elderly
population to increase functional independence, increase range of motion of the shoulder, and
decrease pain associated with common shoulder problems. After treatment, these subjects who
had received osteopathic manipulative treatment demonstrated continued improvement in their
ROM, while ROM in the placebo group decreased12.
Eileen L Digiovanna, et.,al. stated that Spencer techniques are helpful in preventing a loss of

motion in painful shoulder and in restoring motion to a shoulder involved in adhesive capsulitis13.
Robert C. Ward stated that Spencer technique is a classic clinical application of step wise
articulating technique to increase one or more ranges of shoulder joint motion. It can be enhanced
by the addiction of muscle energy technique after barrier has been engaged14.
Leon Chaitow stated that the Spencer shoulder treatment, a traditional osteopathic procedure that
has been modified by the addition of to its Mobilization procedures of muscle energy techniques
is effective in improving range of motion in restricted shoulder15.
Review on Mulligans technique
Pamela Teys, et.,al. (2013) conducted a study to investigate the time course of the effects of a
single Mobilization with movement technique and to ascertain the effects of adding tape
following mobilization with movement in people with shoulder pain. They found that both
mobilization with movement and mobilization with movement along with tape provide a short
lasting improvement in pain and range of motion and mobilization with tape provide a sustained
improvement in ROM, to one week follow-up, which is superior to mobilization with movement
alone16.
Sakulrat Asawakosichai (2009) studied to compare clinical outcome of the Mulligans
mobilization with movement technique and conventional therapy on range of motion, pain scales
and shoulder functions in pain limited shoulder patients. He found that Mulligans mobilization
with movement technique was better than conventional therapy for decreasing pain and improving
function in pain limited shoulder17.

Srivastava Anoint, et., al. (2011) in their study they compared the effectiveness of the both
Maillands and Mulligans mobilization techniques in frozen shoulder rehabilitation. Both the

groups were compared with respect to pain visual Analogue scale (VAS), shoulder range of
motion and shoulder pain and disability index (SPADI) score. Both the treatment techniques
improved the pain VSA score, but the response to Mulligans was better18.
Pamela Teys, et.,al. (2008) studied to investigate the initial effects of Mulligans mobilization
with movements (MWM) technique on shoulder range of motion in the plane of scapula and pain
pressure threshold in participants with anterior shoulder pain. Range of motion and pain pressure
threshold were measured before and after the application of mobilization with movement, sham
and control conditions. They found that this specific manual therapy treatment has an immediate
positive effect on both Range of Motion and pain in subjects with painful limitation of shoulder
movement19.
Jing Ian Yang, et.,al. (2007) compared the use of 3 mobilization techniques end range
mobilization (ERM) Mid Range Mobilization (MRW) and Mobilization with movements (MWM)
in frozen shoulder syndrome and concluded End Range Mobilization (ERM) and mobilization
with movements (MWM) are more effective than Mid-range Mobilization (MRW) in increasing
mobility and functional ability20.

Review on outcome measures:


Leighann Litcher Kelly, et.,al.(2007) studied a systematic review on measures used to access
chronic musculoskeletal pain in randomized controlled clinical trials by using many types of pain
assessments available to researchers conducting clinical trails, ranging from simple, single item
visual analogue scale (VAS) questions through extensive, multi dimensional inventories. In their
study they showed that visual analogue scale (VAS) was responsive than the other complex
multidimensional measures as VAS is a single item measure, it is easy to assess pain where pain is
a primary outcome21.
7

Richard L Gajdosik, et.,al. (1987) carried out a study on review of goniometry emphasizing
reliability and validity of goniometric measurements of extremities special emphasis is placed on
how the reliability of goniometry is influenced by instrumentation and procedures, different
among joint actions and body regions passive versus active measurements, intratester versus
interester measurements, and different patient types. In their review they stated that clinicians
should adopt standardized methods of testing and should interpret and report goniometric results
as range of motion measurements only, not as measurements of factors they may affect range of
motion22.
Riddle DL, et.,al.(1987) conducted this study to examine the intratester and inter tester
reliabilities for clinical goniometric measurements for shoulder passive range of motion (PROM)
using two different sizes of universal goniometers. Repeated passive range of movement
measurements of shoulder flexion, extension, abduction shoulder horizontal abduction, horizontal
adduction, lateral rotation and medial rotation were taken of 2 groups of 50 subjects each
goniometric passive range of movement measurements for the shoulder appear to be highly
reliable when taken by the same physical therapist, regardless of the size of the goniometers
used23.
Breckenridge ID, et., al (2011) the shoulder pain and disability index (SPADI) was developed to
measure current shoulder pain and disability in an outpatient setting. There are 2 versions of the
SPADI, the original version has each item scored on a Visual Analogy Scale (VAS) and a second
version has items scored on a Numerical Rating Scale (NRS). The questionnaire was developed
and initially tested in a Mixed diagnosis group of male patients presenting to ambulatory care
reporting shoulder pain. The SPADI demonstrates good construct validity, correlating well with

other region-specific shoulder questionnaires. It is responsive to change over time, in a variety of


patient populations and is able to discriminate adequately between patients with improving and
deteriorating conditions. Some caution is advised with regard to repeated use of instrument on the
same patient24.
A Paul, et.,al.(2004) conducted a study to compare the validity, responsiveness to change, and
user friendliness of four self completed, shoulder specific questionnaires in primary care. A cross
sectional assessment of validity and a longitudinal assessment of validity and a longitudinal
assessment of responsiveness to change of four shoulder questionnaires was carried out.SPADI
and SRQ were most responsive to change25.
6.3 Objectives of the study:
Primary objective:
1. To determine the comparative effect between Spencer technique and Mulligans technique on
improving pain, mobility and functional ability in the subjects with frozen shoulder.
Secondary objectives:
2. To evaluate the effect of Spencer technique by analyzing pre and post intervention pain,
mobility and functional disability in subjects with frozen shoulder.
3. To evaluate the effect of mulligans technique by analyzing pre and post intervention pain,
mobility and functional disability in subjects with frozen shoulder.

Materials and Method

7.1 Study Design


Pre to post test experimental study design with two groups- Spencer group and Mulligans group.
7.2 Methodology
Study Subjects:
Patients with frozen shoulder with limited abduction and external rotation.
Sample size
The study will be carried on 40 subjects. 20 subjects will be taken in Spencer group and 20
subjects in Mulligans group.
Source of data
Study will be carried out at KTG Hospital Bangalore.
Sampling Method
Simple Random Sampling method
Study Duration
One week intervention, 5 sessions in a week.
Sample Selection
Inclusion Criteria

Subjects with age of 40 to 60 years.

Both male and female subjects.

Unilateral Primary Adhesive capsulitis.

Subjects having a painful stiff shoulder for at least 3 months.

Subjects with more than 50% loss of passive movement of shoulder joint compared to the
unaffected side.

Exclusion Criteria

10

Subjects with recent history of surgery on particular shoulder.

Rheumatoid arthritis.

Subjects with history of fracture around shoulder complex.

Diabetes Mellitus.

Osteoporosis or malignancies in the shoulder function.

Neurological deficits affecting shoulder function.

Post traumatic subjects.

Subjects with rotator cuff rupture and, tendon calcification.

Pain or disorders of cervical spine, elbow, wrist or hand.

Materials used:

Paper

Pen
Pillow
Treatment couch
Chair
Universal goniometer
Shoulder pain and disability index(SPADI)
Mulligans mobilization belt
Outcome measures

Pain will be measured using Visual Analogue Scale (VAS). Reliability of VAS for acute
pain measurement as assessed by the Intraclass Correlation Coefficients (ICC) appears to
be high27.
11

Mobility such as active and passive range of motion (ROM) of shoulder abduction and
external rotation will be measured using goniometer in degrees. Goniometric range of
motion measurements for the shoulder appears to be highly reliable when taken by the
same physical therapist23.

Functional disability of shoulder will be measured using shoulder pain disability index
(SPADI). SPADI demonstrates good construct validity and is responsive to change
overtime24.

Variables
Independent Variable
Spencer technique, Mulligans technique.
Dependent Variable
Pain, shoulder abduction and external rotation ROM and functional ability.

7.3. Method of data collection


Ethical clearance and consent
As the study includes human subjects ethical clearance is obtained from ethical committee of
K.T.G. College of Physiotherapy. All the subjects fulfilling the inclusion criteria will be informed
about the study and written consent (ANNEXURE-1) will be taken.
Procedure of Randomization
The subjects were randomly allocated into two groups of 20 each. Forty pieces of paper were
used, in twenty papers written with the letter A to identify the subjects to take into Spencer
group and the other twenty with the letter B to identify the subjects to take into mulligans
group. All the forty pieces of paper were tightly folded and placed in a box. After shaking the box,

12

each subject was asked to withdraw a paper. 20 subjects with the letter A were enlisted under
Spencer group and the other 20 subjects with the letter B under mulligans group. Complete
explanations were given to both the groups separately but the subjects were unaware to which
group they belonged. Once the subject agrees to participate in the study, an informed written
consent (Annexure-1) was taken from the subjects.
Procedure of Blinding:
Subjects were blinded on either type of intervention and to which group they were belonged.
Throughout the treatment sessions, subjects from both the groups were not allowed to have any
interaction to each other and the subjects were not aware of what kind of treatment they received
and its effects.
Pre-test outcome measurement

Pain will be measured using VAS (Visual analogue scale).

Functional disability will be measured using SPADI (Shoulder pain disability index).

Range of motion for shoulder abduction and external rotation will be measured using
goniometer.

Procedure for measuring ROM :


Patient position: supine lying or sitting.
Therapist position: side of the patient stabilizing the scapula.
Procedure for measuring the shoulder abduction:
Fulcrum of goniometer will be placed over anterior aspect of acromion process. The stationary
arm will be parallel to the clavicle and movable arm along the middle of the shaft of the humerus.
Then the patient will be asked to abduct the arm. The movement of the humerus will be followed

13

with the movable arm of the goniometer until the subject ends the movement. For passive ROM
measurement the therapist will hold the patients arm along with the movable arm and perform the
movement passively. Both active and passive ROM is measured.
Procedure for measuring the shoulder external rotation:
If the subject will be in supine lying, affected shoulder will be out of couch then the subject will
be asked to flex the elbow and abduct the shoulder such that they are in 90 o-90o position. Fulcrum
of goniometer will be placed over the olecranon process of the elbow. Movable arm will be placed
parallel to the fore arm and stable arm will be placed in the straight line to the movable arm. Then
the subject will be asked to do external rotation of the arm. The movement of the forearm will be
followed with the movable arm of goniometer till the subject ends the movement. For passive
ROM measurement the therapist will hold the forearm of the patient along with movable arm of
the goniometer and perform external rotation passively. Both active and passive ROM is noted.
Procedure of intervention for Spencer group
Spencer technique The Spencer technique will be performed when the patient is lying on his
unaffected side with the affected shoulder facing up. Therapist will stand at his table alongside
patient, facing the patient. Therapist will use the cephalic hand to stabilize clavicle and scapula
against thorax and caudal hand to introduce the movements28.
To increase the external rotation:
Circumduction with compression technique: the patients elbow will be flexed and shoulder
will be abducted to 90o . Patients elbow will be used as a pivot to rotate humerus clockwise and
anti clockwise. Slight compression will be applied on the glenohumeral joint. The concentricity of
the circles will be performed to the maximum tolerance of the patient. The procedure will be
repeated 8-10 times28.

14

Circumduction with traction technique: the patients elbow will be flexed and shoulder will be
maintained in abducted position. Traction force will be applied on glenohumeral joint while
rotating the humerus in clock wise and counter clock wise circles. The concentricity of the circles
will be performed to the maximum tolerance of the patient. This technique can also be done with
elbow in extension. the therapist will hold the patients shoulder with his caudal hand and move
the patients arm in the same progressive concentric circles. The procedure will be repeated 8-10
times28.
To increase the shoulder abduction technique: The patients elbow will be flexed and the
shoulder will be abducted to 90o. Therapist will hold the elbow of the patient with one hand and
shoulder with the other hand and exert upward or cephalad pressure on elbow to increase
abduction till the end range is felt and then he will bring the arm back to the neutral position.
The procedure will be repeated for 8 to 10 times28.
Procedure of intervention for mulligans technique
.Mulligans Technique--The MWM technique will be performed on the involved shoulder as
described by Mulligan. The subject will be in a relaxed sitting position. Mulligan belt will be
placed around the head of the humerus to glide the humerus head appropriately (posterolateral and
slightly inferior). With one hand the therapist will hold the belt in place sustaining the glide. With
other hand he will stabilize the scapula inside the belt. The patient will be asked to perform slow
active shoulder movements (abduction and external rotation) to the end of pain free range. The
glide will be sustained during the movement and released after returning to the starting position.
The procedure will be performed three sets of 10 repetitions, with 1 minute rest between sets. The
same procedure will be performed 5 sessions in a week for 1 week29,30.
Post test outcome measures

15

Pain will be measured using Visual Analogue Scale (VAS).

Functional disability will be measured by shoulder pain and disability will measured by
shoulder pain and disability index (SPADI).

Range of motion will be measured using universal goniometer.

Statistical Texts.
Statistical analysis will be performed by using SPSS software for window (version16) and p value
will be set as 0.05 (1-tailed hypothesis).
Descriptive statistics and Chi square test will be used to analyze baseline data for demographic
data.
Unpaired t test and Wilcox on signed ranked test will be used to find the significance of
parameters pre to post test.
Independent t test and Mann Whitney U test will be used to find the significance of parameters
between the groups.
7.4 Ethical Clearance
As this study involve human subjects, the ethical clearance has been obtained from research and
ethical committee of K.T.G college of physiotherapy, Bangalore as per the ethical guidelines for
Bio-Medical, research on human subjects, 2000 ICMR, New Delhi.

List of References
1. Lori B. Siegel, Norman J. Cohen, and Eric P. Gall. Adhesive capsulitis: A sticky issue.
16

American Family Physician 1999 April 1; 59(7):1843-50.


2. Nicholas Shah, Mark Lewis. Shoulder adhesive capsulitis: systematic review of randomized
trials using multiple corticosteroid injections. Br J Gen Pract 2007 August 1; 57(541):662-667.
3. Management of Frozen Shoulder: a systematic review and decision analytical model (HTA
No09/13).
4. Wong PLK, Tan HCA. A review on Frozen shoulder. Singapore Medical Journal. 2010; 51(9):
694.
5. Veli Pekka Sipila. The rationale for joint mobilization as a manual technique. Orthosport
Physical Therapy 2010.
6. Robert C. Ward. Foundations for Osteopathic Medicine. 2 nd ed. Lippincott Williams & Wilkins;
2003.
7. Linda Exelby. Peripheral mobilizations with movement. Manual Therapy (1996)1,118-126.
8. Shahbaz Nawaz Ansari, I.Lourdhuraj, Shiksha Shah, Nikitha Patel. Effect of ultrasound therapy
with end range mobilization over cryotherapy with capsular stretching on pain in frozen shouldera comparative study. International Journal of Current Research and Review 2012; 4(24):68-73.
9. Jing-Ian Yang Mei-Hwa Jan, Chein-wei Chang, Jiu-jeng Lin. Effectiveness of the end range
mobilization & scapular mobilization approach in a subgroup of subjects with frozen shoulder
syndrome: A randomized control trial. Manual Therapy 2012; 17(1):47-52.
10. Matthew Pomykala, OMS IV;Brain McElhinney,PhD,OMS IV; Bryan L.Beck,DO; Jane E
Carreiro DO. Patient perception of osteopathic manipulative treatment in a hospitalized setting. A
survey based study. Journal of American Osteopathic Association 2008;108(11):665-668.
11. J Licciardone; R Gamber; K Cardarelli. Patient satisfaction & clinical outcomes associated
with osteopathic manipulative treatment. Journal of American Osteopathic Association 2002;

17

102(1):13-20.
12. Knebl JA, Shores JH, Gamber RG, Gray WT, Herron KM. Improving functional ability in the
elderly via the spencer technique, an osteopathic manipulative treatment: A randomized controlled
trial. Journal of American Osteopathic Association 2002; 102(7):387-96.
13.. Eileen L.DiGiovanna, Stanley Schiowitz, Dennis J.Dowling. An Osteopathic Approach to
Diagnosis and Treatment. 3rd ed. Lippincott Williams & Wilkins; 2005.
14. Robert C. Ward. Foundations for Osteopathic Medicine. 2 nd ed. Lippincott Williams &
Wilkins; 2003.
15. Leon Chaitow. Muscle Energy Techniques. 3rd ed. Churchill Livingstone Elsevier; 2006.
16. Pamela Teys, Leanne Bisset, Natalie Collins, Brooke Coombes, Bill Vicenzio. One week time
course of the effects of Mulligans mobilization with movement & taping in painful shoulders.
Manual Therapy 2013; 18(5):372-377.
17. Sakulrat Asawakosinchai. Comparisons between the Mulligans mobilizations with movement
technique. The Journal of Prapokklao Hospital Clinical Medical Education Centre 2012; 29(4).
18. Shrivastava Ankit, Shyam Ashok K, Sabnis Shaila, Sancheti Parag. Randomized controlled
study of Mulligans Vs. Maitlands mobilization technique in adhesive capsulitis of shoulder joint.
Indian Journal 2011; 5(4):12-15.
19. Pamela Teys, Leanne Bisset, Bill Vicenzino. The initial effects of a Mulligans mobilization
with movement technique on range of movement and pressure pain threshold in pain limited
shoulders. Manual Therapy 2008 ;( 13):37-42.
20. Jing-Ian Yang, Chein-wei Chang, Shiau-yeechen, Shwu-Fen Wang and Jiu-Jeng Lin.
Mobilisation techniques in subjects with frozen shoulder: Randomized multiple treatment trial.
Physical Therapy 2007; 87(10):1307-1315.

18

21. Leighann Litchr Kelly, Sharon A. Martino, Joan E. Broderick and Arthur A. Stone. A systemic
review of measures used to assess chronic musculoskeletal pain in clinical and randomized
controlled clinical trials. Journal of pain 2007;8(12):906-913.
22 Richard L Gajdosik and Richard W Bohannon. Review of goniometry emphasizing reliability
and validity. Journal of the American Physical Therapy Association 1987; 67(12):1867-72.
23. Riddle DL, Rothstein JM, Lamb RL, Goniometric reliability in a clinical setting. Shoulder
measurements. Physical Therapy 1987; 67(5):668-73.
24. Breckenridge JD, Mc Auley JH. Shoulder pain and disability index (SPADI). Journal of
Physiotherapy 2011; 57(3):197.
25. A Paul, M Lewis, MF Shadforth, PR Croft, DAWM Vander Windt, EM Hay. A Comparison
of four shoulder specific questionnaires in primary care. Annals of the Rheumatic diseases 2004;
63(10):1293-99.
26.W.B Van den Hour, H.M Vermulen, P.M.Rozing, T.P.M Vliet Vlieland. Impact of

Adhesive

capsulitis and economic evaluation of high grade and low grade mobilization Techniques.
Australian Journal of Physiotherapy2005; 51:141-49.
27.Polly E. Bijur, Wendy Silver MA, E.John Gallagher MD. Reliability of the visual analogue
scale for measurement of acute pain. Official Journal of the Society for Academic Emergency
Medicine 2001;8(12):1153-57.
28. Nicholas S. Nicholas. Atlas of Osteopathic Techniques. 2 nd ed. Classic Osteopathic Medical
Works; 1974.
29. Jing-Ian Yang, Chein-wei Chang, Shiau-Yee Chen, Shwn-Fen Wang and Jiu-jeng Lin.
Mobilization Techniques in subjects with frozen shoulder syndrome: Randomized multiple
treatment trial. Journal of the American Physical Therapy Association 2007; 87(10):1307-15.

19

30.Aimie F.Kachingwe, Beth Phillips, Scott W. Plunkett. Comparison of manual therapy


techniques with therapeutic exercise in the treatment of shoulder impingement: Randomized
controlled pilot clinical trial. The Journal of Manual and Manipulative therapy 2008; 16(4):238247.

Signature of Candidate

20

10

Remarks of the Guide

11

Name and Designation of

11.1 Guide

ASHA. D
ASSOCIATE PROFESSOR

11.2 Signature

11.3 Co-Guide

VINOD BABU.K
ASSISTANT PROFESSOR

11.4 Signature

11.5 Head of Department

11.6 Signature
12

12.1 Remarks of the Chairman & Principal

.
12.2 Signature

ANNEXURE -1
CONSENT FORM
I P.KHYATHI has explained to........... (Subject name) ...........the purpose of the research, the

21

procedures required, and the possible risks and benefits to the best of my ability.
.........................................

...............................................

Investigator Signature

Date

College:
Place:
CONSENT TO PARTICIPATE IN THE STUDY
Purpose of Research
I have been informed that this study is for shoulder joint pain like
mine. All test measures are acceptable physiotherapy interventions for this problem. This study
will help physiotherapy better to understand the use of Effectiveness of spencer technique and
mulligans technique on pain, mobility and functional ability in subjects with frozen shoulder.
Procedure
I understand that I will be examined for pain , Shoulder mobility and functional ability in
subjects with Frozen Shoulder.
I am aware that in addition to ordinary care received. The Physiotherapy examination consists
of Visual Analogue Scale, shoulder pain and disability index and ROM. I have been asked to
undergo these tests at the beginning of the study and after 1 week study.
Risk and Discomforts
I understand that I may experience some pain or discomfort during the examination or during
my treatment. This is mainly the result of my condition, and the procedures of this study are
not expected to exaggerate these feelings which are associated with the usual course of

22

treatment.
Benefits
I understand that my participation in the study will have no direct benefit to me other than
potential benefit of the treatment which is planned to reduce my pain and increase mobility in
subject with Frozen Shoulder. The major potential benefit is to find out which treatment
program is more effective.
Confidentiality
I understand that the information produced by this study will became part of my research
record and will be subject to the confidentiality and privacy regulation, but will be stored in
the investigators research file.
If the data are used for publication in the literature or for the teaching purpose, no names will
be used, and other identifiers, such as photographs and audio or videotapes, will be used with
my special written permission.
Refusal or Withdrawal of Participation
I understand that my participation is voluntary and that I may refuse to participate or may
withdraw consent and discontinue participation in the study at any time without prejudice to
my present or future care at the Hospital. I also understand that P.Khyathi may terminate my
participation in this study at any time after she explained the reasons for doing so.
I confirmed that .P.Khyathi has explained to me the purpose of the research, the study
procedures that I will undergo, and the possible risks and discomforts as well as benefits that I
may experience. Alternatives to my participation in the study have also been discussed. I have
23

read and I understand this consent form. Therefore, I agree to give my consent to participate as
a subject in this research project.

...............................................

..........................................

Participant Signature

Date

..............................................

..........................................

Witness to Signature

Date

ANNEXURE - 2

Visual Analog Scale (VAS):


VAS is presented as 10cm line.

24

No pain at one end and worst imaginable pain at other end.


Patient is asked to mark a 100mm line to indicate pain intensity.

I------------------------------------------------------------------------------------------------------I
No Pain

Pain as bad as it could possibly be

If used as a graphic rating scale, a 10 cm baseline is recommended


A 10 cm baseline is recommended for VAS scale.

ANNEXTURE-3

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?
25

Circle the number that best describes your pain where: 0 = no pain and 10 = the worst pain
imaginable.
At its worst?

10

When lying on the involved side?

10

Reaching for something on a high shelf? 0

10

Touching the back of your neck?

10

Pushing with the involved arm?

10

Disability scale
How much difficulty do you have?
Circle the number that best describes your experience where: 0 = no difficulty and 10 = so
difficult it requires help.
Washing your hair?

10

Washing your back?

10

Putting on an undershirt or jumper?

10

Putting on a shirt that buttons down the 0


front?

10

Putting on your pants?

10

Placing an object on a high shelf?

10

Carrying a heavy object of 10 pounds 0


(4.5 kilograms)

10

Removing something from your back 0


pocket?

10

Interpretation of scores
Total pain score: / 50 x 100 = %

26

(Note: If a person does not answer all questions divide by the total possible score, eg. if 1
question missed divide by 40)
Total disability score: / 80 x 100 = %
(Note: If a person does not answer all questions divide by the total possible score, eg. if 1
question missed divide by 70)
Total Spadi score: / 130 x 100 = %
(Note: If a person does not answer all questions divide by the total possible score, eg. if 1
question missed divide by 120)
The means of the two subscales are averaged to produce a total score ranging from 0 (best) to
100 (worst).
Minimum Detectable Change (90% confidence) = 13 points
(Change less than this may be attributable to measurement error)

27