A comparative study on the effectiveness of Mulligan mobilization versus Positional release therapy technique in patients with Adhesive capsulitis

Chandrasekaran K*1, SundaramM S1, Senthil Selvam P1, Viswanath Reddy A2, Senthilkumar S3, Rathnapandi V4 1Department of physiotherapy, Vels Institute of Science Technology & Advanced Studies (VISTAS), Thalambur, Chennai 600 130, Tamilnadu, India 2Department of physiotherapy, SVIMS University, Tirupathi – 517 501, Andhrapradesh, India 3Department of physiotherapy, Saveetha Institute of Medical & Technical Sciences, Thandalam, Kancheepuram,600 128, Tamilnadu, India 4Department of physiotherapy, Sri hospitals, Tondiarpet, Chennai – 600 081, Tamilnadu, India


INTRODUCTION
Adhesive capsulitis is termed as a glenohumeral joint stiffness resulting from a non-contractile element unless it coexists with a non-contractile lesion both active motion and passive motion are painful and restricted in the capsular pattern with external rotation is the most limited followed by abduction and internal rotation (Donatelli, 2011).
The painful phase typically lasts 10 to 36 weeks. The patient presented with spontaneous onset of shoulder pain with stiffness and the glenohumeral capsule volume is greatly reduced. Stiffening Phase which may last up to 4 to 12 months and patient has restricted range of motion in this phase with a characteristic pattern in the loss of external rotation, internal rotation, and abduction. Thawing phase is characterized by the gradual recovery in the range of motion. The thawing phase lasts an average of 5 to 26 months (Reeves, 1975).

Figure 2: SPADI score for group A intervention
The causes of adhesive capsulitis include immunologic, in lammatory, biochemical, and endocrine alterations Secondary causes can be after surgery, soft tissue trauma, and fracture in the shoulder. The movement produced by manual therapy techniques can also reduce pain by the activation of mechanoreceptors which can inhibit nociceptive stimulus through the pain gate-control mechanism (Threlkeld, 1992).
Mulligan mobilization with movement technique improve the quality of joint intra-articular gliding, neurodynamics and the facilitation of correct muscle recruitment. Mulligan mobilization with move-ment was a combination of an active movement with simultaneous passive accessory mobilization to achieve painless range of motion by restoring the reduced accessory glide (Excelby, 1996). Positional release therapy was originally termed as strain-counter strain technique. It was a therapeutic technique that uses the tender points (Tps) and a position of comfort (POC) in a muscle to resolve the somatic dysfunction of the muscle. Positional release technique was opposite to the stretching mechanism (Speicher and Draper, 2006). Positional release technique was used to normalize the muscle tone, decreases the fascial tension, improve joint mobility and increase localized circulation (D'ambrogio and Roth, 1997).

Study procedure
In the study, 30 subjects were selected by random sampling method based on inclusion criteria. The procedure and purpose of the study were explained and informed consent was obtained from each patients. The subjects were divided into two groups. Group A (N = 15) received Mulligan mobi-lization technique, group B (N = 15) received positional release therapy for two weeks. The shoulder range of motion (Abduction, External rotation, Internal rotation) was measured by using the goniometer the functional activity by SPADI questionnaire at irst day of visit before treatment and after two weeks.

Outcome Measures
Range of motion: The range of motion of shoulder abduction, internal rotation, and external rotation is measured by goniometer.

Shoulder functional disability :
The SPADI (Shoulder Pain And Disability Index) questionnaire was used to measure the shoulder functional disability.

Data Analysis and Result
Descriptive statistical analysis was carried out in the present study. Outcome measures are analyzed & presented as mean. The mean values were used to compare the outcomes within the groups. Signi icance assessed at 5% level of signi icance with p value was set at alpha=0.05(p value <0.05) less than this is considered as statistically signi icant difference. The statistical software namely SPSS 25.0 were used for analysis of data.
This study was completed with a total of 30 subjects. In Mulligan group 15 subjects with mean age 56.40, in positional release therapy group 15 subjects with mean age 54.33 are included in this study.

Range of motion:
Abduction the post test mean difference values of two groups were analyzed. The mean difference in the Mulligan group were 49.67 and the positional release therapy group were 27.67 and the p value is 0.000 (p<0.05) are presented in Table 1 and Table 2 & shown in Figure 1 and Figure 3.
Internal rotation the mean difference in the Mulligan group was 27.67 and the positional release therapy group was 16. External rotation the post test mean difference values between the two groups are analyzed, the mean difference of Mulligan group was 30 and the positional release therapy group was 13.67 are presented in Table 1 and Table 2

Shoulder Pain And Disability Index (SPADI):
The post test values between the two groups are compared the mean difference of Mulligan group was 26 and the positional release therapy group was 18.6 are presented in Table 1and Table 2 & shown in Figure 2 and Figure 4 it indicates Mulligan mobilization improved the shoulder function when compared to the positional release therapy.
The post-test values of both groups were analyzed it shows a statistically signi icant difference in the p values of p<0.05. The mean difference between the two groups are compared the Mulligan group shows statistically signi icant difference than the positional release therapy group are presented in Table 3.
The concept of adhesive capsulitis leads to tight and thickened capsule which sticks to the humerus and restricts the movements of shoulder joint. The normal shoulder range of motion and shoulder function can be improved by renovation of shoulder joint capsule extensibility and the mobilization techniques has been recommended to improve the shoulder range of motion and shoulder function (Diercks and Stevens, 2004).
Mobilization techniques is given to improve the normal tissue extensibility of the shoulder joint capsule and it also stretches the tightened capsule to encourage bene icial effects in the shoulder joint (Yang Wang S-F and J, 2007).
The mechanism in the Mulligan mobilization with movement (MWM) treatment effects may include changes in the shoulder joint, and the muscles around it. The changes in motor control systems and pain gate mechanism will produce an instantaneous pain relief and it also improves shoulder range of motion (Wright, 1995).
The Mulligans mobilization with movement (MWM) technique has further bene it which may activate the additional proprioception in the muscles by tendon stretch, which will help to renovate the affected shoulder range of motion (Kachingwe et al., 2008).

CONCLUSIONS
This study concludes that Mulligan mobilization technique is more signi icant improvement in shoulder Range of motion and functional ability than positional release technique in patients with adhesive capsulitis. Mulligan mobilization with movement (MWM) is a manual therapy technique was used to correct the positional fault in the joint and helps to restore the joint play movements. The movement produced by manual therapy techniques can also reduce pain by the activation of mechanoreceptors which can inhibit nociceptive stimulus through the pain gate mechanism this will decrease the pain and reduce disability.

ACKNOWLEDGEMENT
The Authors are grateful to the Ishari Velan Mission Hospital, Chennai, to conduct the study at physiotherapy department and also thankful to the patients who are involved, supported and cooperated for the study.