RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA

BANGALORE

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. NAME OF THE CANDIDATEAND ADDRESS

SWATHI K.RNO 173 K.HB COLONY5THBLOCK 4THCROSSKORAMANGALA BANGALORE- 560095.

2. NAME OF THE INSTITUTION

KEMPEGOWDA INSTITUTEOF PHYSIOTHERAPYKR ROAD,V.V PURAM BANGALORE-560004.

3. COURSE OF THE STUDY MASTER OF PHYSIOTHERAPY. (MUSCULOSKELETAL DISORDERS AND SPORTS)

4. DATE OF ADMISSION 13TH AUGUST 2012.

5. TITLE OF THE TOPIC

A COMPARATIVE STUDY BETWEEN THE EFFICACY OF HIGH GRADE MOBILIIZATION WITH ACTIVE EXERCISES VERSUS CAPSULAR STRETCHING WITH ACTIVE EXERCISES ON PATIENTS WITH ADHESIVE CAPSULITIS.

6 BRIEF RESUME OF THE INTENDED WORK

6.1) NEED FOR THE STUDY

Adhesive capsulitis, also known as frozen shoulder, is an insidious and progressive pain with decreased active and passive mobility of the glenohumeral joint involving scapulohumeral pain. [1,2] In general, a global loss of active and passive motion is present; the loss of external rotation with the arm at the patient’s side is a hallmark of this condition.[3]

The annual incidences of adhesive capsulitis are 3-5% in the general population and up to 20% in people with diabetes.[2] It is more common between the ages of 40 to 60.[1,3]

The glenohumeral joint is one of the most complex and frequently injured jointsIn the human body. It has the largest range of motion of any joint, which also makes it one of the most unstable and easily dislocated joints in the body. Glenohumeral stability is maintained through a complex combination of bony contact and soft tissue restraints that include the joint capsule, ligaments, labrum and muscles. This joint is made up of the humerus, scapula, cartilage, rotator cuff, muscles and the ligamentous tissue of the capsule. The capsule is composed of a variably thick layer of tissue with discrete thickenings that constitute the glenohumeral ligaments, and includes the superior glenohumeral ligament (SGHL), middle glenohumeral ligament (MGHL) and the inferior glenohumeral joint.[3]

Adhesive capsulitis is a disease of unknown etiology.[4] In 1946, Nevasier named the condition Adhesive Capsulitis based on the radiographic appearance with arthrography, which suggested adhesions of the capsule of glenohumeral joint limiting overall joint space volume.[3,5] Cyriax, initially proposed that tightness in a joint capsule would result in a pattern of proportional motion restriction. He used the concept of a capsular pattern to differentiate in diagnosis between loss of motion secondary to bony and/or muscle or joint changes and that caused by the capsule. He believed that an irritated capsule would restrict motion in a predictable pattern. For the shoulder, he proposed that external rotation would be more limited than abduction, which would be more limited than internal rotation.[4,5] Capsular adhesions, soft tissue contractures, and adhesions in axillary space contribute to the pathogenesis of adhesive capsulitis.[4]

Adhesive capsulitis is usually classified as primary or secondary. Patients are classified as having primary or idiopathic adhesive capsulitis if no findings on history or examination explain the onset of disease.[1,2] Secondary adhesive capsulitis develops from known causes of stiffness and immobility such as immobilization, rotator cuff disease, biceps tendinitis, trauma, myocardial infarction, or psychological disturbances.[2]

This condition has 3 stages of clinical presentation

Stage one: The "freezing" or painful stage, which may last from 3 to 6 months, characterized by the onset of an aching pain in the shoulder. The pain is usually more severe at night and with activities and may be associated with a sense of discomfort that radiates down the arm.

Stage two: The "frozen" or adhesive stage this generally lasts for 3 to 18months .pain at rest usually diminishes during this stage, leaving the patient with a shoulder that has restricted motion in all planes. Activities of daily living become severely restricted. Pain at night is a common complaint.

Stage three: The "thawing" or recovery stage this generally lasts for 3 to 6 months. This stage is characterized by slow recovery of motion.[3]

The Clinical findings, course and prognosis of this condition are well known. As the patient progresses from the freezing to frozen stage, the pain Becomes more severe, and the restriction in elevation and rotation increases.[1]

Onset of the condition is usually gradual rather than acute. Patients will often describe an insidious onset of vague, dull pain at the deltoid insertion, over the anterior capsule and posterior capsule with deep palpation, a pain pattern that may be due to innervations of the joint capsule by the axillary nerve. Night pain is a very common feature, and sleeping on the affected shoulder is usually symptomatic. . In those with longstanding disease, increased compensatory scapulothoracic motion can create additional pain around the medial scapula.[1]

Proper scapula motion and stability are critical for normal shoulder function. The scapula forms a stable base from which all shoulder motion occurs, and correct positioning is necessary for efficient and powerful glenohumeral joint movement. Strengthening of the scapula stabilizers is an important component of the rehabilitation protocol after all shoulder injuries and is essential for a complete functional recovery of the shoulder complex.[3]

In physical therapy programs, mobilization techniques are an important part of the intervention. Mobilization techniques can be performed as physiologic Movements or accessory movements. [2] The intensity of the mobilization Techniques with rhythmic oscillatory movements usually are categorized according to the 5-grade classification system of Maitland. High grade mobilization group, mobilization techniques were applied with intensities according to Maitland grades III and IV. Grade III: Large amplitude reaching the limited Range of motion Grade IV: Small amplitude at the end of the limited Range of motion.[6,7]

Mobilization techniques improve the normal extensibility of the shoulder capsule and stretch the tightened soft tissues to induce beneficial effects. It may be attributed to the fact that the intent of end-range mobilizations is not only to restore joint play but also to stretch contracted periarticular structures .[6,8]

Stretching is a general term used to describe any therapeutic maneuver designed to increase mobility of soft tissues and subsequently improve range of motion by elongating structures that have shortened and have become hypo mobile over time. [6,

9] The lower the intensity, the longer the time the patient will tolerate stretching and soft tissues can be held in a lengthened position. The higher the intensity ,the less frequently the stretching intervention can be applied to allow time for tissue healing In hypo mobile patients manual stretching and self stretching is found to be effective Stretching takes soft tissues structures beyond their available length to increase range of motion. Self stretching enables a patient or increase range of motion gained as the result of direct intervention by the therapist.[9]

Active exercises within the pain free range of motion stimulate mechanoreceptors and decreases pain. Exercises within pain free range also move the synovial fluid, thus decrease Inflammation and decrease pain.[6,9]

Ultrasound is a deep heating agent commonly used in rehabilitation. Deep heating agents are capable of causing increased temperatures in tissues up to 3 to 5cm deep. It provides increased extensibility of collagen fibers, decreased joint stiffness, decreased muscle spasm, modulation of pain and increased blood flow.[3,14]

In order to measure the pain Visual Analogue Scale (VAS) is a good and reliable tool in clinical research. The pain can be measured using this scale. The VAS is a well studied method for measuring both acute and chronic pain, and its usefulness has been validated by several investigators. [23]

Goniometry is a reliable assessment scale for measuring shoulder range of motion in subjects with adhesive capsulitis.[24]

Shoulder Pain and Disability Index (SPADI) is valid and reliable assessment scale for measuring the functional improvement in subjects with shoulder disability.[25]

Due to above factors further studies are necessary to evaluate the effects of high grade mobilization with active exercise along with capsular stretching with active exercise. Hence a prospective randomized study is necessary to test the hypothesis in patients with adhesive capsulitis.

PURPOSE OF THE STUDY This study is to compare the effectiveness of high grade mobilization with active exercise versus capsular stretching with active exercise in adhesive capsulitis.

HYPOTHESIS:

Null hypothesis

There is no significant difference between the effects of high grade mobilization with active exercise and capsular stretching with active exercise on adhesive capsulitis patients.

Alternative hypothesis

There is significant difference between the effects of high grade mobilization with active exercise and capsular stretching with active exercise on adhesive capsulitis patients.

6.2) REVIEW OF LITERATURE

Vermeulen H.M (2006) conducted a study to compare the effectiveness of high-grade mobilization techniques (HGMT) with that of low-grade mobilization techniques (LGMT) in subjects with adhesive capsulitis of the shoulder and they concluded that In subjects with adhesive capsulitis of the shoulder, HGMTs appear to be more effective in improving glenohumeral joint mobility and reducing disability than LGMTs. [2]

Derya Çelik (2010) conducted a study to compare the effects of two different exercise programs on pain, range of motion (ROM), and functional results in frozen shoulder and concluded that In both groups, the Constant score and ROM were increased, and VAS was decreased at the end of 6 and 12 weeks.. In addition to glenohumeral ROM exercises, scapulothoracic exercises contribute to decreasing pain and increasing ROM in patients with frozen shoulder.[4]

Gea J Kok (2000) conducted a study on End-range mobilization techniques in adhesive capsulitis of the shoulder joint. The study concluded that After 3 month of treatment there were increases in active range of motion. All patients maintained their gain in joint mobility at the 9-month follow-up.[8]

Roberta Y.W. Law (2009) conducted a study Stretch Exercises Increase Tolerance to Stretch in Patients With Chronic Musculoskeletal Pain and concluded Stretch did not increase muscle extensibility, but it did improve stretch tolerance. Three weeks of stretch increases tolerance to the discomfort associated with stretch but does not change muscle extensibility in patients with chronic musculoskeletal pain.[10]

AnnM.Cools(2011)conducted a Study on Stretching the posterior shoulder structures in subjects with internal rotation deficit and concluded that stretching, angular as well as non-angular techniques, increases internal rotation ROM in overhead athletes, and may decrease sport specific shoulder pain in overhead athletes with impingement symptoms. [11]

Jing-lanYang(2007) conducted a study to compare the use of 3 mobilization techniques end-range mobilization (ERM), mid-range mobilization (MRM), and mobilization with Movement (MWM) in the management of subjects with frozen shoulder syndrome and concluded that in subjects with frozen shoulder syndrome , ERM and MWM were more effective than MRM in increasing mobility and functional ability. Movement strategies in terms of scapulohumeral rhythm

improved after 3 weeks of MWM.[12]

Rita A Wong (2007) conducted survey on Therapeutic Ultrasound and concluded that Ultrasound was likely to use to decrease soft tissue inflammation increase tissue extensibility, enhance scar tissue remodelling, increase soft tissue healing , decrease pain , and decrease soft tissue swelling .[14]

Robert C. Manske (2010) conducted a study on Stretching Versus Stretching and Joint Mobilization for Posterior Shoulder Tightness Measured by Internal Rotation motion Loss. In Both methods cross-body stretch and cross-body stretch plus joint mobilization may be beneficial for those with limited internal rotation range of motion. [15]

Irem Duzgun (2012) conducted a study Manual therapy is an effective treatment for frozen shoulder in diabetics concluded and that the range of motion, functional activity status and muscular strength were improved and the pain level was reduced after rehabilitation in all of the patients. Manual therapy approaches may be safely applied in diabetic patients with frozen shoulder.[16]

Griggs S.M (2000) conducted a study to evaluate the outcome of patients with idiopathic Adhesive capsulitis who were treated with a stretching-exercise program. The study concluded that vast majority of patients who have phase-II idiopathic adhesive capsulitis can be successfully treated with a specific four-direction shoulder stretching exercise program.[17]

Andrea J. Johnson (2007) conducted a study on the Effect of Anterior Versus Posterior Glide Joint Mobilization on External Rotation Range of Motion in Patients With Shoulder Adhesive Capsulitis. The study concluded that A posteriorly directed joint mobilization technique was more effective than an anteriorly directed mobilization technique for improving external rotation ROM in subjects with adhesive capsulitis. [18]

Abhay Kumar (2012) conducted a study on Effectiveness of Maitland Techniques in Idiopathic Shoulder Adhesive Capsulitis. The study concluded that addition of the Maitland mobilization technique with the combination of exercises have proved their efficacy in relieving pain and improving R.O.M. and shoulder function and hence should form a part of the treatment plan.[19]

Ngoc Quan Phan (2012) conducted a study on Prospective Study on Validity and Reliability of the Visual Analogue Scale The study concluded that high reliability and concurrent validity was found for VAS.[22]

Hayes K (2001) conducted a study on goniometry which demonstrated good reliability for the movements of shoulder in subjects with adhesive capsulitis. [23]

Joy C MacDermid (2006) conducted a study on The Shoulder Pain and Disability

7.

Index demonstrates factor, Construct and longitudinal validity. The study concluded SP ADI is a valid measure to assess pain and disability in community-based patients reporting shoulder pain due to musculoskeletal pathology.[24]

6.3 OBJECTIVES OF THE STUDY

To assess the effectiveness of high grade mobilization and active exercises with ultrasound on adhesive capsulitis

To assess the effectiveness of capsular stretching and active exercise with ultrasound on adhesive capsulitis

To compare the effectiveness of high grade mobilization and active exercises with ultrasound and capsular stretching and active exercise with ultrasound on relieving the pain

To compare the effectiveness of high grade mobilization and active exercise and capsular stretching and active exercise with ultrasound on improving the range of motion (ROM).

To compare the effectiveness of high grade mobilization and active exercises with ultrasound and capsular stretching and active exercise with ultrasound in the improvement of shoulder disability

MATERIALS AND METHODS:

7.1 SOURCE OF DATA:

1. Out Patient Department of Orthopedics, Kempegowda Institute of Medical Science Hospital and Research Center, Bangalore

2. Out Patient Department of Physiotherapy, Kempegowda Institute of Physiotherapy, Bangalore

7.2 METHODS OF COLLECTION OF DATA:

a) Study Design: Randomized study design

Sample size: 60 Sample method: Random Sampling Method

Materials used :

Assessment proforma

Pen

Universal goniometer

Treatment couch

Cotton

Towels

Cushions

Ultrasound equipment1MHz.

Conducting Gel.

Wand.

Shoulder wheel.

Measuring scales

a) VAS scale – To measure the pre and post treatment Pain.

b) Shoulder pain and disability index -To assess the functional out come.

c) Universal goniometer - To measure shoulder range of motions.

b)Inclusion Criteria

Patients aged between 40 to 60 years.

Patients diagnosed with adhesive capsulitis of shoulder by a certified medical practitioner.

Having a painful stiff shoulder for at least 3 months or more.

c)Exclusion Criteria

Intrinsic problems of the shoulder such as:

Tear of rotator cuff

biceps tendonitis

calcific tendonitis

history of any trauma, fracture or dislocation

rheumatoid arthritis

osteoarthritis

osteoporosis

malignancies

sympathetic dystrophy

Extrinsic problems such as neuro-muscular disorders or referred pain from an

associated condition such as cervical disc prolapse with radiculopathy

Musculoskeletal disorder with hypermobility.

Patients who have taken cortico steroid injections.

7.3) Does the study require any Investigations or Interventions to be conducted on Patients or other Humans or Animals? If so , Please describe briefly: Yes, an intervention on human subject is required in a consent form.

METHODOLOGY

Sixty subjects fulfilling the inclusion and exclusion criteria diagnosed with adhesive capsulitis are considered for the study. The study population consisted of individuals between 40 and 60 years of age.

After explaining the subjects about the treatment, written consent is taken. Pre –assessment will be taken prior to the commencement of treatment with self report outcome measures of VAS, shoulder pain and disability index, and range of motion with goniometry. The VAS is a reliable and valid outcome measure and has been used extensively. A visual analogue scale (VAS) will be used to grade the level of shoulder pain. The VAS is a 10 cm long horizontal line with polar descriptors of no pain and worst pain

possible. Subjects will indicate their pain by placing a vertical line representing the current level of symptoms. The participant’s functional status is assessed by means of the shoulder pain and disability index (SPADI). Measurement of Range of Motion (ROM): shoulder flexion, extension, abduction adduction, internal rotation and external rotation will be measured using universal goniometer.

After evaluation sixty subjects are divided into two groups i.e. Group-A and group-B. Each group consists of 30 subjects each.

Group-A will receive treatment using high grade mobilization, therapeutic ultrasound and active exercises. Group-B will receive treatment using capsular stretching, therapeutic ultrasound and active exercises.

GROUP-A: 30 subjects will be treated with high grade mobilization

a) Caudal glide (increases abduction):

Position of patient: Supine, with the arm abducted to the end of its available range. External rotation of the humerus should be added to the end-range position as the arm approaches and goes beyond 90°. Position of therapist and hand placement: Therapist stands facing the patient’s feet and stabilizes the patient’s arm against the trunk with the hand farther from the patient. Place the web space of the other hand just distal to the acromion process on the proximal humerus.Mobilizing force: With the hand on the proximal humerus, glide the humerus in an inferior direction.

b) Posterior glide (increases flexion and internal rotation): Position of patient: Supine, with the arm flexed to the end of its available range. Internal rotation of the humerus with elbow flexion should be added to the end-range position as the arm approaches and goes beyond 90°. The arm may also be placed in horizontal adduction.

Position of therapist and hand placement: Stride standing facing the patient. Place padding under the scapula for stabilization. Place one hand across the proximal surface of the humerus. And the other hand over the patient’s elbow. Mobilizing force: Glide the humerus posteriorly by pushing down at the elbow through the long axis of the humerus.

c) Anterior glide (increases external rotation):

Position of patient: prone, with the arm abducted to the end of its available range. Position of therapist and hand placement: Therapist stands facing the patient’s

feet and stabilizes the patient’s arm against the trunk with the hand farther from the patient.

Mobilizing force: With the hand pushing on the posterior part of the humeral head, glide the humerus.

d) Distraction of the humeral head with respect to the glenoid is performed by pulling the humeral head in the superior, lateral, and anterior directions.

e) Reversed distraction technique is applied with the subject lying on the unaffected side. The therapist will support the affected arm and to be moved to the end range of flexion. The heel of the other hand pushed against the lateral border of scapula in medial rotation to produce distraction within the glenohumeral joint.

Duration of the treatment High grade Mobilisation was given as 5 sets of 10 – 15 glides with a rest period of 1 minute in between the sets for 5 days a week for a duration of 3 weeks.

GROUP-B: 30 subjects will be treated with capsular stretching

a)Anterior capsular stretchPatient is made to stand on the door way and made to hold the door frame with the elbow straight and the shoulder abducted to90 degrees and externally rotated and is made to walk through the doorway until the stretch is felt at the front of the shoulder and made to hold for 10sec.

b)Posterior capsular stretch The therapists grasp the elbow of the involved arm across the chest to stretch the back of the involved shoulder and made to hold for 10sec.

c)Inferior capsular stretch The therapist holds the involved arm overhead with the elbow bent and the arm straight ahead and the arm is farther stretched overhead. And the stretch is made to hold for 10sec.

d)Pectoralis minor stretch Patient is made to lie on the back, pushing the shoulder towards ceiling With a therapist giving resistance down the shoulder and the stretch is made to hold for 10sec.

e) Pectoralis major stretch. Patient is made facing a corner. The arm is positioned one arm at each side with the arms approximately 90 degrees away from the side and the forearms resting on the wall and made to lean forward into the corner until a stretch is felt on shoulders and made hold for 10sec.

Duration of the stretch: The patient was instructed to hold the stretch for 10 seconds and repeat 5 times.

All the subject of both the group A and B will be given therapeutic ultrasound.

Using pulsed ultrasound therapy(1MHz) for 8 minutes with an intensity of 1W/cm², and the mark space ratio is 1:1 along with 1.5g of a standard coupling medium for the treatment . Treatment parameters :

Frequency-1MHz Intensity-1W/cm²Mode- Pulsed modeMark Space Ratio-1:1

Position of patient for ultrasound therapy : Subject will be in sitting position positioned in back rest chair with arm adducted and internal rotated and ultrasound, along with the coupling medium over the transducer, is given on the area of pain in the affected shoulder.

Duration of the treatment: 5 days per week for three weeks.

All the subject of both the group A and B will be given active exercises which are mentioned below:

a) Pendulum( Codman’s) exercises:

Patient position and procedure: standing with the trunk flexed at the hips about 90 degrees. The arm is held loosely in downward position. A swinging motion of the arm is initiated with Motions of flexion, extension, horizontal abduction, adduction and circumduction.If the patient experiences back pain from bending over prone position can be used.

b) Wand exercises:Shoulder flexion and return:

The wand is held with the hands with shoulders in wide position. The wand is lifted forward and upward through the available range, with the elbows kept in extension.

Shoulder horizontal abduction and adductionThe wand is lifted to 90 degrees flexion. Keeping the elbows in extension, the patient pushes and pulls the wand back and forth across the chest through the available range.

Shoulder internal and external rotationThe patient is on supine position. The patients arm is at the sides and the elbows are flexed to 90 degrees. Rotation of the arm is accomplished by moving the wand from side to side across the trunk while maintaining the elbows at the side.

c) Gear shift exercises:Patient is in sitting position with holding the wand in involved arm. With the tip resting on the floor to support weight of the arm. Patient is instructed to move the wand in forward, backward and diagonal directions similar to gear shifting movements in driving a car.

d) Towel exercises:Patient is in sitting position. Patient is instructed to hold the ends of the towel with one arm overhead and the arm to be stretched behind the lower back and then pull up the towel with the overhead hand.

e) Finger ladder / wall climbing exercises:The patient stands, facing the finger ladder or wall an arm’s length away and places the index or middle finger on a step of the ladder. The arm is moved into flexion by climbing with the fingers.The same exercise mentioned above is performed with patient standing side ways.

Each exercise is performed twice a day with ten repetitions. The patient is advised to perform the above mentioned active exercises at home also.

Outcome measures: Post treatment assessment will be taken for pain with VAS range of motion with goniometry and functional outcomes with shoulder pain and disability index on the last day of second and third week.

Frequency: - Intervention given is for 5days per week for three weeks for both the groups

Duration of the Study: one yearStatistical Analysis: Data collection will be analyzed by Repeated ANOVA test.

8.

7.4Has Ethical Clearance been obtained from your Institution in case of 7.3?

Yes.

LIST OF REFERENCES

1. JasonE.Hsu,Okechukwu A. Anakwenze,William J. Warrenderb,Joseph Abboud, Current review of adhesive capsulitis. Journal of Shoulder Elbow Surg.2011; 20:502-14.

2. Vermeulen HM, Rozing PM, Obermann WR, Saskia le cessie,Vlieland. Comparison of high-grade and low-grade mobilization techniques in the management of adhesive capsulitis. PHYS THER.2006; 86:355-68.

3. S.Brent Brotzmann,Kevin E.Wilk.Clinical Orthopaedic Rehab. 2nd edition 2003; 125-28,227-28.

4. Derya ÇELiK. Comparison of the outcomes of two different exercise Programs on frozen shoulder.Acta orthop traumatol. 2010;44(4):285-92

5. Peter J. Rundquist, Donald D. Anderson, Carlos A. Guanche,Paula M. Ludewig,

Shoulder Kinematics in Subjects With Frozen Shoulder. Arch phys med rehabil 2003; 84:1473-9.

6. Carolyn kisner,Lynn Allen Colby.Therapeutic exercise foundations and techniques. 4th edition.New Delhi. Jaypee Brothers. 2003; 221-24,229-32, 49-53,364-69,174-86.

7. Maitland GD.Treatment of the glenohumeral joint by passive movement. Physiotherapy 1983;69:3-7

8. Gea J Kok, Piet M Rozing , Cornelia HM Van den , Henricus M Vermeulen, Wim R Obermann, Bart J Burger Ende. End-range mobilization techniques in adhesive Capsulitis of the Shoulder Joint. PHYS THER. 2000;80:1204-13

9. Phil Page, Baton Rouge, Louisiana. Current Concepts in muscle stretching for exercise and rehabiltation. The International Journal of Sports Physical Therapy 2012; 7: 109-14.

10. Roberta Y.W. Law, Lisa A. Harvey, Michael K. Nicholas, Lois Tonkin, Maria

De Sousa , Damien G. Finniss . Stretch Exercises Increase Tolerance to Stretch in Patients with chronic musculoskeletal pain. PHYS THER 2009; 89:1016-26.

11. Ann M. Cools, Fredrik R. Johansson, Barbara Cagnie, Dirk C, Cambier , Erik E. Witvrouw. Stretching the posterior shoulder structures in subjects with internal rotation deficit: comparison of two stretching techniques. Shoulder and Elbow. 2011; 4: 56–63.

12. Jing-lan Yang, Chein-wei Chang, Shiau-yee Chen, Shwu-Fen Wang, Jiu-jenq Lin Mobilization Techniques in Subjects with Frozen Shoulder Syndrome: Randomized Multiple-Treatment trial. PHYS THER. 2007; 87:1307-15.

13. Kevin G. Laudner, Robert C. Sipes, James T. Wilson. The Acute Effects of Sleeper Stretches on Shoulder Range of Motion. Journal of athletic training. 2008; 43(4):359–63.

14. Rita A Wong, Britta Schumann, Rose Townsend, Crystal A Phelps. A Survey of Therapeutic Ultrasound Use by Physical Therapists Who Are Orthopaedic Certified Specialists. PHYS THER.2007; 87:986–94.

15. Robert C. Manske, Matt Meschke, Andrew Porter, Barbara Smith, Michael. Reimen. A Randomized Controlled Single-Blinded Comparison of Stretching Versus Stretching and Joint Mobilization for Posterior Shoulder Tightness Measured by Internal Rotation Motion Loss. Sports Physical Therapy. 2010; 2:94-98.

16. Irem Duzgun, Gul Baltacı, Ozgur Ahmet Atay, Manual therapy is an effective treatment for frozen shoulder in diabetics. Joint Diseases and Related surgery. 2012; 23(2):94-99.

17. Griggs SM, Ahn A, Green A. Idiopathic adhesive capsulitis: A prospective functional outcome study of nonoperative treatment. J Bone Joint Surg Am. 2000; 82:1398–407.

18. Andrea J. Johnson, Joseph J. Godges, Grenith J. Zimmerman, Leroy L. Ounanian, The Effect of Anterior Versus Posterior Glide Joint Mobilization on External Rotation Range of Motion in Patients With Shoulder Adhesive Capsulitis. J Orthop Sports Phys Ther.2007; 37(3):88-99.

19. Abhay Kumar, Suraj Kumar, Anoop Aggarwal, Ratnesh Kumar,Pooja Ghosh Das. Effectiveness of Maitland Techniques in Idiopathic Shoulder Adhesive Capsulitis. International Scholarly Research Network ISRN Rehabilitation 2012; Article ID 710235: 1-8.

20. Jose Orlando Ruiz. Positional Stretching of the Coracohumeral Ligament on a Patient with Adhesive Capsulitis A Case Report. Journal of manual and manipulative therapy. 2000; 17: 58-63.

21. Angst, J. Goldhahn, G. Pap, A. F. Mannion, K. E. Roach, D. Siebertz, S. Drerupet et al Cross-cultural adaptation, reliability and validity of the German Shoulder Pain and Disability Index (SPADI) Rheumatology. 2007; 46:87–92.

22. Ngoc Quan Phan, Christine Blome, Fleur Fritz, Joachim Gerss, Adam Reich, Toshi Ebata et al, Prospective Study on Validity and Reliability of the Visual Analogue Scale, Numerical Rating Scale and Verbal Rating Scale. Acta Derm Venereol 2012; 92: 502–07.

23. Hayes K, Walton JR, Sozmor LZ, AC Murrell. Reliability of five methods for assessing shoulder range of motion. Australian Journal of Physiotherapy. 2001; 47:289-94.

24. Joy C MacDermid, Pzatty Solomon,Kenneth Prkachin The Shoulder Pain and Disability Index demonstrates factor construct and longitudinal validity. BMC Musculoskeletal Disorders.2006; 7:1-11.

25. Nancy Berryman Reese,William D. Bandy. Joint Range Of Motion And Muscle Length Testing.W.B Saunders publications.2002; 66-76.

26. .Sheila Kitchen, Sarah Bazin. Electrotherapy Evidence-Based Practice.12th Edition. Churchill Livingstone publication.2008; 190-97.

27. John low, AnnReed. Therapeutic Ultrasound. Electrotherapy Explained Principles and Practice.2nd Edition.1994; 148-57.

28. James Camarinos,Lee Marinko.Effectiveness of manual physical therapy for painful shoulder conditions.The Journal of manual and manipulative therapy.2003;17:206-14.

9. Signature of the Candidate:

10. Remarks of the Guide:

11. Names and Designation of:11.1 Guide: Prof.R.BALASARAVANAN. M.P.T.

Principal. Kempegowda Institute of Physiotherapy

11.2 Signature:

11.3 Co-guide: Dr.H.B.SHIVAKUMAR M.S(ORTHO)Professor.Kempegowda Institute of Medical Sciences

11.4 Signature:

11.5 Head of the Department: Prof. R.BALASARVANANPrincipal, K.I.P.T

11.6 Signature :

12. 12.1 Remarks of the Chairman & Principal:

12.2 Signature: