Spencer's Muscle Energy Technique Along With Strain Counter Strain in Adhesive Capsulitis.

Numerous Physiotherapy techniques have been found to be beneficial but there is no consensus on the best treatment approach for speeding up rehabilitation process and rejuvenating functional capacity in patients suffering from Adhesive capsulitis. Spencer Muscle energy technique is found to be effective in treatment of shoulder pathologies. It increases pain free range of motion through stretching the tissues, enhancing lymphatic flow and increasing the joint circulation where as Strain Counter Strain is a technique derived from positional release therapy which uses a pain monitor (trigger points) to find the position of the pain when it is no longer felt at the monitoring point. The purpose of this study is to determine the effects of Spencer Muscle energy technique with and without the employment of Strain Counter Strain on pain, Range of motion and disability in Adhesive capsulitis.

Adhesive shoulder capsulitis or arthrofibrosis commonly known as frozen shoulder, depicts a pathological process in which the body forms excessive scar tissue or adhesions in the capsule around the glenohumeral joint, leading to stiffness, pain and dysfunction. The incidence of adhesive capsulitis in general population is approximately three to five percent and up to twenty percent in patients with diabetes. It is more common in women aged between forty and sixty years and in about twenty-thirty percent of cases it occurs bilaterally. In Pakistan, its precise prevalence is unknown, but in general it ranges from two-five percent. Adhesive capsulitis is classified into two categories: primary which is idiopathic in origin and occur spontaneously without any specific trauma or inciting event and is characterized by painful restriction of all shoulder movements, both active and passive, or Secondary which occurs as a result of some identifiable disorder, such as diabetes mellitus, or due to any inciting event such as cardiac surgery or trauma. There are four stages of frozen shoulder. Stage-one is painful shoulder. Stage - two is "Freezing Stage" with chronic pain and limitation in range of motion. Stage-three is "Frozen Stage" with considerable decreased Range Of Motion and rigid "end feel". Stage-four is "Thawing Phase" with progressive improvement in Range Of Motion. Physiotherapy methods such as active and active assisted exercises, pendular ex's, wand ex's, wall and ladder ex's, capsular stretching ex's and shoulder joint mobilization are often standard exercises in treating frozen shoulder. Electrotherapy modalities such as application of ultrasound, Interferential therapy, short-wave diathermy and LASER are used to relieve pain and promote hyperthermal effect to the tissues.

The Spencer technique is a standardized series of shoulder treatments with broad application in diagnosis, treatment and prognosis. It was developed by Spencer in 1961. This approach is a well-known osteopathic manipulative technique that focuses on mobilization of the glenohumeral and scapulothoracic joints. It is an articulatory technique with seven different procedures, in this technique passive, smooth, rhythmic motion of the shoulder joint is done by the therapist to stretch contracted muscles, ligaments and capsule. 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 circulation.

Positional release technique ( PRT), originally termed strain-counterstain, is a therapeutic technique that uses tender points (TPs) and a position of comfort (POC) to resolve the associated dysfunction. Essentially, Positional release technique is the opposite of stretching. For example, if a patient had a tight, tender area on the calf, if the clinician dorsiflex the foot to stretch the calf in an effort to reduce the tightness and pain. This might lead to muscle guarding and increased pain. Using the same example, a clinician who employs Positional release technique would place the tender point in the position of greatest comfort (plantar flexion), shortening the muscle in an effort to relax the tissues and decrease the tender points. Dr. Lawrence H. Jones, an osteopathic physician, was the first to publish a map of tender point locations and their associated treatment positions. Jones1964 proposed that when a muscle is strained by a sudden unexpected force, its antagonist attempts to stabilize the joint, resulting in a counterstain of the muscle in a resting or shortened position. Before the antagonist is counter strained, gamma neural activity is heightened as a result of its shortened position, making the spindle more sensitive propagating development of restriction, sustained contraction, and tender point development. The application of Positional release technique relaxes the muscle-spindle mechanism, decreasing aberrant gamma and alpha neuronal activity, thereby breaking the sustained contraction. The prevailing theory underlying Positional release technique involve spacing tissues in a relaxed shortened state, or position of comfort , for a period of time (ninety sec) to decrease gamma gain in order to facilitate restoration of normal tissue length and tension.

Eligibility Criteria:
Inclusion Criteria:

* Patients clinically diagnosed with unilateral adhesive capsulitis.
* Patients who had restricted ROM (loss of 25% or greater relative to non-
* involved shoulder in one or multidirectional).
* Stage 2 and 3 of frozen shoulder.
* Diabetic patients diagnosed with frozen shoulder.

Exclusion Criteria:

* A history of major shoulder injury or surgery.
* Other disorders possibly influencing existing shoulder symptoms e.g. cervical neuropathy.
* Paralysis or neurological changes of the affected upper limb.
* Fractures or open wounds;
* Degenerative, inflammatory, or infectious arthritis;
* History of intra-articular injection pain treatment.
* History of osteoporosis or malignancies in shoulder region