COMPARISON OF MAITLAND JOINT MOBILIZATION WITH SOFT TISSUE MOBILIZATION FOR SUBSCAPULARIS MUSCLE TO IMPROVE GLENOHUMERAL EXTERNAL ROTATION

IN PERIARTHRITIS SHOULDER PATIENT

Adhesive capsulitis is an insidious painful condition with gradual restriction of all planes of movement in the shoulder. It is the main cause of shoulder pain and dysfunction in middle aged and elderly populations [1, 2]. Approximately 70% of frozen shoulder patients are women; however, males with frozen shoulder are at greater risk for longer recovery and greater disability3-4. Although the exact pathophysiologic cause of this pathology remains elusive, there are two types identified in the literature: idiopathic and secondary adhesive capsulitis.5 Idiopathic (primary) adhesive capsulitis occurs spontaneously without a specific precipitating event. Primary adhesive capsulitis results from a chronic inflammatory response with fibroblastic proliferation, which may actually be an abnormal response from the immune system.6 Secondary adhesive capsulitis occurs after a shoulder injury or surgery, or may be associated with another condition such as diabetes, rotator cuff injury, cerebrovascular accident (CVA) or cardiovascular disease, which may prolong recovery and limit outcomes.7 Reeves [8] has described three stages of the disease: In Stage I(freezing stage) is mainly characterised by pain usually lasting 29 months. In Stage II (frozen stage); pain gradually subsides but stiffness is marked lasting 412 months. In Stage III (thawing phase) pain resolves and improvement in range of motion (ROM) appears. The shoulder is a vastly complex structure. Seven joints are involved in functional movement of the shoulder girdle. Each of these joints is interdependent on the integrity and function of the others. The glenohumeral joint is considered by many to be the most important joint of the shoulder girdle.. Even when other joints of the girdle are restricted, if movements of the glenohumeral joint are healthy, the arm may be functional (at least to some degree) and allow some use of the limb. However, when the glenohumeral joint is restricted, there will be little or no use of the arm. Stabilization of the humeral head is provided through muscular support by supraspinatus, infraspinatus, teres minor and subscapularis, which are commonly called the rotator cuff or SITS

muscles. The fibers of the SITS tendons blend with the joint capsule, which makes them especially vulnerable to injury since they are so closely approximated to the joint. Subscapularis, a particularly important muscle when considering shoulder dysfunctions, is almost hidden from palpation. It has a broad attachment to the subscapular fossa and spans the glenohumeral joint to attach to the lesser tubercle of the humerus and the articular capsule. It passes over the anterior joint capsule and lies horizontally between the two almost vertical tendons of biceps brachii. Although it is a large, thick muscle, only a small portion of its belly can be palpated. A primary indication for treatment of subscapularis is loss of lateral rotation and/or abduction of the humerus, common symptoms of frozen shoulder syndrome. It may be injured or torn when the person throws the hands back to bear the bodys weight when falling backward. This impact will force the head of the humerus anteriorly against the joint capsule, the tendon of subscapularis and the subscapular bursa, which lies between the tendon and the joint capsule. The bursa communicates with the shoulder joint cavity and, if it becomes inflamed, may play a role in true frozen shoulder (Cailliet 1991, McNab & McCulloch 1994, Simons et al 1999), a condition associated with adhesions within the joint capsule. When the initial action of abduction forces the humerus cephaladly, toward the overhanging acromion process, subscapularis provides downward tension on the head ,thereby preventing bony impaction and entrapment of soft tissues. However, trigger points or hypertonicity in subscapularis can cause the muscle to hold the humeral head fast to the glenoid fossa, creating a pseudo frozen shoulder (Simons et al 1999). Chaitow & DeLany (2000) note the humeral head appears immobile, as in true frozen shoulder syndrome, but without associated intrajoint adhesions. Ultimately, however, long-term reduced mobility and capsular irritation from subscapularis dysfunction may result in adhesive capsulitis (Cailliet 1991). Additionally, the subscapularis lies in direct relationship with serratus anterior within the scapulothoracic joint space. Myofascial adhesions of these tissues to each other may contribute to full or partial loss of scapular mobility.(9) According to Travell and simon The pain and restricted range of motion of a frozen shoulder and of the shoulder of a patient with hemiplegia are frequently caused by subscapularis TrPs that have been overlooked

Reason the shoulder became so painful and frozen when a patient develops subscapularis TrPs is that so many other girdle muscles also became involved adding their pain pattern and restriction of movement. The other TrPs are easier to identify than subscapularis TrPs ,and other often inactivated with at least temporary improvement but until primary cause(the subscapularis TrPs involvement ) is identified and corrected symptoms will persist. Specific identification of subscapularis TrPs as a focus of therapeutic attention is rarely mentioned in literature and no controlled research studies could be found that specially address the TrPs components of frozen shoulder. Many clinician aggress the subscapularis TrPs can be responsible for the symptoms of frozen shoulder and can be simply and effectively treated .howover in the current climate of managed health care ,clinical success is not sufficient; competent research substantiation is essential.(10) Cadaver studies and outcomes of subscapular surgical releases suggest that subscapularis muscle flexibility deficits are responsible for glenohumeral external rotation limitations in the lower ranges of abduction. A contrasting clinical and cadaver finding is where glenohumeral external rotation becomes more limited as the humerus moves toward 90 of abduction, suggestive of glenohumeral capsular restrictions.(11) Thus, a patient who has greater limitation of glenohumeral external rotation at 45 of abduction, when compared to the available external rotation at 90 of abduction, may have a subscapularis muscle flexibility deficit rather than a glenohumeral capsular restriction. The results of subscapular nerve block in various painful situations of the shoulder region suggest the importance of subscapularis muscle in the etiology of the frozen shoulder(12). Joint mobilization techniques are assumed to induce various beneficial effects. The neurophysiologic effect is based on the stimulation of peripheral mechanoreceptors and the inhibition of nociceptors. The biomechanical effect manifests itself when forces are directed toward resistance but within the limits of a subjects tolerance. The mechanical changes may include breaking up of adhesions, realigning collagen, or increasing fiber glide when specific movements stress the specific parts of the capsular tissue. Furthermore, mobilization techniques are supposed to increase or maintain joint mobility by inducing rheologic changes in synovial fluid, enhanced exchange between synovial fluid and cartilage matrix, and increased synovial fluid turnover(13)

So the purpose of this study is To compare the effectiveness of maitland joint mobilisation with soft tissue mobilization of subscapularis muscle in increasing the range of motion of external rotation of shoulder in patients with periarthritis.

REVIEW OF LITERATURE

Joseph J. Godges et al, Soft tissue mobilization of the subscapularis for 7minutes and 5 repetitions of contract-relax to the shoulder internal rotators, followed by 5 repetitions of PNF facilitating the flexion, abduction, and external rotation diagonal, was found to be effective in gaining glenohumeral external rotation during a single intervention session in patients with shoulder dysfunction.(14)

Van den Dolder, in his randomised, controlled trial has shown that soft tissue massage around the shoulder in subjects with shoulder pain. Of local mechanical origin produces significantly greater improvements in pain, function and range of motion than does no treatment over a twoweek period. These results highlight the importance of assessing and treating muscle dysfunction in patients with painful shoulders. (15)

A systematic review in 2003 Manual therapy in myofascial trigger point treatment such (ischemic compression, spray and stretch, strain and counterstrain (Jones, 1981; DAmbrogio and Roth, 1997), muscle energy techniques (Chaitow, 2001), trigger point pressure release (Lewit, 1991), transverse friction massage (Cyriax and Cyriax, 1992). Some of the studies

reviewed conrmed that MTrP treatment is effective in reducing the pressure pain threshold, and scores on visual analogue scales. Pressure pain threshold and visual analogue scale were the outcome measures most used in the analyzed studies. MPS is characterized by restricted range of motion (ROM), which suggests the need to include ROM measurements in future studies. Bodywork and Journal of Movement Therapies(16) Vermeulen et a patients with adhesive capsulitis In each direction of mobilization, 10 to 15 repetitions were performed, and the mobilization grade (3 or 4) and the duration of prolonged stress varied according to the patients tolerance., which increases in joint capacity and glenohumeral mobility were observed after 3 months of treatment with end-range mobilization (EMTs). After finishing the treatments, all patients maintained their regained mobility at the 9month follow. There seems to be a role for intensive mobilization techniques in the treatment of

adhesive capsulitis. Controlled studies regarding the effectiveness of end-range mobilization techniques in the treatment of adhesive capsulitis are warranted. (17)

(Nicholson GG et al) comparing the effects of passive mobilization techniques (2 or 3 times per week for 4 weeks, up to grade IV accessory motions according to the Maitland classification system) in addition to active exercises with active exercises alone, a positive effect regarding passive abduction was seen after 4 weeks in the mobilization group.(18)

( Maricar NN) In the other study, no additional effect of passive mobilization techniques (once per week for 58 weeks, grades III and IV according to the Maitland classification system, without further specification of techniques) could be demonstrated(19).

Vermeulen et al In his study comparing the effectiveness of 2 treatment strategies including mobilization techniques with different levels of intensity in subjects with unilateral adhesive capsulitis of the shoulder, it appeared that HGMTs were more effective than LGMTs in increasing mobility and functional ability. However, the differences were small overall, and with both treatment strategies, subjects showed clinically significant improvement(13).

A systematic review of randomised controlled trials (RCTs) was conducted to determine the effectiveness of manual therapy (MT) techniques for the management of musculoskeletal disorders of the shoulder. Seven electronic databases were searched up to January 2007, and reference lists of retrieved articles and relevant MT journals were screened. . MT was not shown to be more effective than other conservative interventions for adhesive capsulitis. Manual Therapy (2009) (20)

AIMS AND OBJECTIVES

To determine the effectiveness of maitland joint mobilisation with soft tissue mobilization of subscapularis muscle in increasing the range of motion of external rotation of shoulder in patients with periarthritis. RESEARCH HYPOTHESIS MAITLAND MOBILISATION with SOFT TISSUE MOBILIZATION to the subscapularis muscle will improve glenohumeral external rotation effectively in patients with periarthritis. MAITLAND MOBILISATION will improve glenohumeral external rotation effectively in patients with periarthritis.

NULL HYPOTHESIS MAITLAND MOBILISATION with SOFT TISSUE MOBILIZATION to the subscapularis muscle will not improve glenohumeral external rotation effectively in patients with periarthritis. MAITLAND MOBILISATION will not improve glenohumeral external rotation effectively in patients with periarthritis.

METHODOLOGY

SUBJECTS: A total of 30 subjects with idiopathic periarthritis shoulder were obtaining from the SVNIRTAR physiotherapy department and a written consent is obtained from each subject. INCLUSION CRITERIA

1. Patients diagnosed with idiopathic periarthritis shoulder. 2. Pain in the shoulder joint with restriction of glenohumeral external rotation is more in the lower ranges of abduction i.e. = 45 of abduction. 3. Age group between 40-60 yrs 4. Duration of symptoms more than 4 months.

EXCLUSION CRITERIA

1. Secondary adhesive capsulitis occurs after a shoulder injury or surgery, or may be associated with another condition such as diabetes, rotator cuff injury, cerebrovascular accident (CVA) or cardiovascular disease, which may prolong recovery and limit outcomes 2 .Total shoulder arthroplasty 3 .Reflex sympathetic dystrophy 4 .Rheumatoid arthritis 5. Any trauma to the shoulder and post immobilization 6 .Acute painful stage of periarthritis shoulder joint

OUTCOME MEASURE TOOLS: RANGE OF MOTION Shoulder pain and disability index (SPADI) PROCEDURE: Study group is divided into 2 groups Group A: 15 patient maitland joint mobilisation with subscapularis soft tissue mobilisation Group B: 15 patient maitland joint mobilisation alone
The examiner first abducts the arm of the supine patient away from the chest wall to 90 deg, if possible. In the patient with marked shortening of subscapularis muscle due to hyperactive TPs, it may not be possible to abduct the arm beyond 30 deg. The arm is abducted to 90 deg position for examination. Abduction (lateral displacement) of the scapula is necessary to adequately expose the ventral surface of the scapula and its subscapularis for palpation. Next the examiner grasps the latissmus dorsi and teres major muscle in a pincer grip and locates the hard edge of scapula with the tips of the digits. The pressure is directed cephalad and towards the spine of scapula to locate firm band of muscle fibre in the TPs area. (10) Soft tissue mobilization (ischemic compression) of subscapularis muscle: On palpation of subscapularis muscle, trigger points or taut bands were located. The trigger points were treated with soft tissue mobilization using ischemic compression technique. The pressure was applied over the trigger points by using index and middle finger perpendicular to the plane of muscle. Having confirmed the trigger points by Jump signor characteristic pattern of referred pain distant from the point of contact, the applied pressure was increased till pain occurs (pain threshold) and this was maintained for 90 seconds.(21) . Followed by which both group recieves maitland grade 3 & 4 joint mobilisation technique with active range of motion exercise

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