Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018




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Prof. Somashekhar Nimbalkar
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Chairman, Research Group, Charutar Arogya Mandal, Karamsad
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On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




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Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2023 | Month : April | Volume : 17 | Issue : 4 | Page : YC01 - YC05 Full Version

Comparative Effect of Niel-Asher Technique and Positional Release Technique on Pain, Active ROM and Functional Disability in Adhesive Capsulitis: An Experimental Study


Published: April 1, 2023 | DOI: https://doi.org/10.7860/JCDR/2023/63082.17700
Prabhu Ram Kishnapandian , Deepak Raghav , Amit Dwivedi

1. Principal, Department of Physiotherapy, Santosh College of Physiotherapy, Delhi, India. 2. PhD Scholar, Department of Orthopaedics (Physiotherapy), Santosh Deemed to be University, Delhi, India. 3. Professor and Head, Department of Orthopaedics, Santosh Hospital, Delhi, India.

Correspondence Address :
Prabhu Ram Krishnapandian,
New No.1, Plot No. 1142, Pushkar Aishwaryam, 55th Street, Korattur, Chennai-600080, Tamil Nadu, India.
E-mail: prabhuramstin@gmail.com

Abstract

Introduction: Adhesive Capsulitis of Shoulder (ACS) is a common self-limiting disorder characterised by painful, progressive loss of active and passive shoulder motion due to fibrosis and rigidity of the joint capsule. ACS occurs in 2-5% of the population overall and up to 20% of those with diabetes. Women between the ages of 40 and 60 are at increased risk, and one in four patients may have bilateral illness. Several studies have been done to prove the effectiveness of electro-therapeutic modalities and manual mobilisation techniques on Adhesive Capsulitis, but very few studies have been done to find out and compare the effectiveness of Niel-Asher technique and Positional Release Technique (PRT) on adhesive capsulitis.

Aim: To compare effect of Niel-Asher technique and positional release technique on pain, active Range of Motion (ROM) and functional disability in patients with adhesive capsulitis.

Materials and Methods: This was a pre and post-experimental design conducted at Santosh Medical College and Hospital, Ghaziabad, India, for a duration of two years conducted on 110 patients with a diagnosis of stage II primary adhesive capsulitis. The patients were divided into group A and group B using a systematic random sampling procedure. Conventional physiotherapy and the Niel-Asher technique were used on patients in group A. Patients in group B received conventional physiotherapy and PRT. The therapy was given to patients, three times weekly for a total of six weeks. The Shoulder Pain and Disability Index (SPADI), Range of Motion (ROM) and Visual Analogue Scale (VAS) were measured in both groups in pre, mid and post-therapy. The analysis of the collected data was done by Statistical Package for Social Sciences (SPSS) software version 17.0.

Results: A total of 110 patients with adhesive capsulitis patients, 55 in each group A (mean age: 51.78±7.810 years) and group B (mean age: 52.33±7.794 years) were included in the study and the mean age of total study subjects was 52.05±7.80 years. On analysis of the collected data, statistically significant outcomes across all three measures (VAS, SPADI, and ROM) were observed with a p-value of less than 0.001. In pain, functional impairment and restricted ROM, group A, outperformed group B in this comparison.

Conclusion: Both conventional physiotherapy along with Niel-Asher technique group and conventional physiotherapy along with PRT group were individually effective in relieving pain and improving Range of Motion and Functional ability in patients with Adhesive capsulitis, but among these two groups, the group that received Niel-Asher technique in addition to conventional physiotherapy reported more significant improvements when compared to PRT group, in pain, range of motion and functional ability.

Keywords

Range of motion, Shoulder pain and disability index, Visual analog scale

Painful, progressive loss of active and passive shoulder motion due to fibrosis and rigidity of the joint capsule characterises ACS, a frequent self-limiting disorder (1). Though Duplay in 1896 reported a clinical illness with the similar features to ACS and labelled it periarthrite scapulohumerale, the term Frozen Shoulder (FS) is credited to Codman in 1934 (2),(3). Some other names for this issue are frozen shoulder syndrome and contracture of shoulder (4),(5). Through histological and surgical procedure of frozen shoulder patients, Nevasier was the first to explain the pathology and concluded that thickening and constriction of the capsule which becomes adherent to the humeral head is the main cause of frozen shoulder (6). Neviaser, writing in 1945, argued that the “misnomer frozen shoulder should be eliminated from the medical literature” since the word “adhesive capsulitis” more accurately characterised the disease (6).

In the general community, ACS occurs 2-5% of patients, but up to 15-20% of those with diabetes (7). The causes of ACS have been broken down into primary (idiopathic) and secondary (intrinsic, extrinsic and systemic) categories (8),(9). Although some have described adhesive capsulitis as a self-limiting disorder that resolves in 1-3 years (10). Other studies states that between 20% and 50% of patients with adhesive caspulitis suffer long-term ROM deficits that may last up to 10 years (11). Thus treating adhesive capsulitis is a real challenge to any physiotherapist or healthcare professional and an innovative novel manual therapy techniques are required to help such patients to get faster improvement with long term benefits.

The clinical examination and histological aspects of this syndrome have been associated with the four phases defined by Neviaser et al., and Hannafin et al., [12,13]. The first phase, known as the painful phase, is characterised by the slow development of symptoms. Deltoid insertion discomfort and the difficulty to sleep on the afflicted side are the only symptoms that last longer than three months. In certain cases, patients may notice a little restriction in range of motion, but this is usually remedied by the use of a local anaesthetic. Confirmed by biopsies, the arthroscopic image reveals hypertrophic, vascularised synovitis devoid of adhesions and capsular contracture. The second phase is often referred to as “freezing” (14). In this stage there is considerable loss of active and passive ROM which has persisted for three to nine months. Arthroscopic examination reveals perivascular synovitis with increased thickness. In the third phase, known as the “frozen phase”, pain is less but shoulder stifness persist even after an year. In the end, we reach the thawing phase. Because of capsular remodelling, there is often very little discomfort and a steady increase in range of motion (14).

Niel-Asher technique: The Niel-Asher technique is a hands-on manual therapy approach that makes use of body’s inherent healing mechanism to treat shoulder adhesive capsulitis. A five-step therapy regimen is followed to manipulate the glenohumeral joint’s musculoskeletal system in a precise, planned order (15). This technique is effective because it helps to release the adherent structures around the shoulder joint and it also stimulates a certain neural pathway at two different levels: the cortex level and the spinal reflex level (15).

Positional release technique: In 1955, Dr. Lawrence Jones pioneered PRT, also known as Strain Counter Strain Technique (SCST). It is an osteopathic manual therapy technique which helps to restore normal resting muscle tone (16). In this technique the tender points in the hypertonic muscles, that causes the musculoskeletal dysfunctions are identified (16). Then the origin and the insertion of the hypertonic muscles are approximated (16). Analgesia, increased mobility, and resolution of musculoskeletal dysfunction may be achieved by maintaining constant pressure at the tender point and a position of comfort (ease) for 90 seconds (17). The results are due to the inhibition of the activated muscle spindle in the hypertonic muscle, which leads to decrease in the afferent impulses to the brain and thus efferent impulses to the muscle is decreased (16). The efferent impulses were protecting the muscle tissue from being over stretched. By interrupting this pathway the patients muscle is allowed to relax and regain a normal muscle tone.(16) Precise skill to assess and find the primary tender point is essential in PRT, since it the most important step that helps to alleviate or eliminate spasm. Spindle resetting, decreased nociceptive sensitivity, and improved circulation are hypothesised to be the underlying causes for the improvement in patients treated with PRT (17).

Conventional physiotherapy: Hot packs for 10 minutes, Codman’s exercise, finger ladder exercises, wand exercises, active exercises, and capsular stretching are all part of the conventional physiotherapy treatment programme (18).

Hence, the study was conducted to compare the effectiveness of Niel-Asher technique and PRT on pain, Range of Motion (ROM) and functional ability in patients with adhesive capsulitis in Indian population.

Material and Methods

This was a pre and postexperimental study conducted at Santosh Medical College and Hospital, Ghaziabad, India, from January 2021 to January 2023 on the subjects diagnosed as primary adhesive capsulitis. Ethical clearance was taken before the start of the study from Institutional Ethical Committee {F.NO.SU/2021/092(21)}. An informed written consent was taken from the included subjects.

Inclusion criteria: Subjects, within the age group of 40-65 years, diagnosed with primary adhesive capsulitis of shoulder joint based on a referral from an orthopaedician, those having limitation of passive ROM for atleast three months in gleno-humeral joint compared with unaffected side and more than 30 degrees restriction for at least two of these three movements: flexion, abduction or external rotation were included in the study.

Exclusion criteria: Patients with systemic illness like diabetes mellitus, thyroid disorders, rheumatoid arthritis, those with rotator cuff tears, shoulder ligament injuries, malignancies in the shoulder region, subjects with neurological disorders, previous surgery or manipulation under anesthesia of the affected shoulder were excluded from the study.

Sample size calculation: Using N master Software with power of 80% and alpha error 5%, shoulder flexion values-98.4 degrees with Standard Deviation (SD)-16.9 degrees, the authors arrived at the sample size as 51 per group. Since the present study is follow-up study, attrition of participants is predicted and the effective sample size has been approximated for each group as 55.

n=Z2×SD2/ L2

Z=95% Significance level
L=Precision level

The participants in the research were divided into two groups using the systematic random sampling approach i.e. roughly 20 to 30 primary adhesive capsulitis patients come each month. If the data was collected for 12 months, the total population size is 240 (20 patients×12 months). Since 240/110=2, 2 is the sample interval k. As a result, every second patient who meets the inclusion criteria is included in the trial and randomly assigned to either group A or group B.

Study Procedure

The total of 110 participants included in the study were divided into group A and group B with 55 patients each. Conventional physiotherapy treatment and Niel-Asher technique were provided to group A patients for three sessions a week, for six weeks. For patients in group B, were treated with conventional physiotherapy and positional release techniques for three sessions a week, for six weeks. Using a Visual Analog Scale (VAS), shoulder pain and disability index, and goniometry, pre-test measures were made before the intervention. Mid-test was taken at the end of week 3 and post-test at week 6 for both groups of patients. The improvement in the VAS, the Shoulder Pain and Disability Index (SPADI) and the ROM of the shoulder joint at the mid-test and the post-test were compared.

Niel-Asher technique: In Niel-Asher technique, the patient was made to lie sideways and several deep strokes with your hand, from elbow to humeral head were applied. Apply sustained pressure over the embedded nodules or over the fibrous band which you may feel when you move upwards. Apply deep sustained pressure on the tender point over the posterior joint capsule area (teres minor). Perform circumduction of shoulder with bent elbow repeatedly several times from small to large complete circles. Release the fascia up the long head biceps tendon and move upwards only. Pause on the nodules along the tendon; these are fascial tetherings and may be inflamed. As you approach the shoulder, near biceps tendon joins the capsule, hold the trigger point for upto three minutes until it is completely pain free. In supine lying position, the middle fingers of your hand, presses deeply on the trigger point in the middle of the shoulder blade (infraspinatus) (Table/Fig 1).

Positional release technique: Firstly, surrounding and opposing tissues were palpated to locate tender point for shoulder flexion, abduction, internal and external rotation. Then one or two finger pads were used to apply pressure over tender points. The shoulder position were adjusted with rotation to find the position of comfort. Hold the position of comfort until pain decreases significantly or ceases. The average positions hold time with pressure is 90 secs and then release the tender point or joint slowly and reassess (Table/Fig 2).

Conventional physiotherapy: This technique consists of 10-minute hot packs, Codman’s exercise, finger ladder exercise, wand exercise, active activity, capsular stretching and home exercises.

Pretreatment data was gathered using a VAS, goniometry measures, and the SPADI score, with follow-ups after three and six weeks.

Statistical Analysis

In order to analyse the data, non parametric tests were performed. Within group, data was analysed using the Wilcoxon signed-rank test. Comparing the data from the two groups was done with the use of the Mann-Whitney U Test. Statistical Package for the Social Sciences (SPSS) software version 17.0 was used for the analysis of tabulated data.

Results

A total of 110 patients with adhesive capsulitis met the inclusion criteria, with a mean age of 52.05±7.80 years divided equally into group A and group B. There was no significant difference in the demographic characteristics of the participants (Table/Fig 3).

Group A had a mean pre-test VAS score of 6.67, whereas group B’s score was 6.6. The average scores on the visual analogue scale at post-test were 2.27 and 3.51. While there was no statistically significant difference between groups A and B on the pre-test, there was a statistically significant difference (p-value <0.05) on the mid-test and post-test. When comparing Niel-Asher technique with positional release technique for the treatment of adhesive capsulitis, the authors observed that the former is superior in lowering pain (Table/Fig 4).

The mean SPADI score before treatment was 104.84 (group A) and 104.29 (group B) . The average SPADI score after the exam was 67.09 and 78.87. While there was no statistically significant difference between groups A and B on the pre-test, there was a difference (p-value <0.05) on the mid-test and post-test. The authors observed that Niel-Asher technique, when compared to the positional release technique for the treatment of adhesive capsulitis, is more beneficial in reducing functional disability (Table/Fig 5).

The average range of motion in flexion, before treatment, for group A and group B was 106.55 degrees and 103.67 degrees respectively. Postintervention, the average flexion ROM was 162.91 and 138.87 degrees. While there was no statistically significant difference between groups A and B on the pre-test, there was a significant difference (p-value <0.05) on the mid-test and post-test.

Mean Abduction ROM at pre-test was 86.47 degrees for group A and 86.09 degrees for group B. The average post-exercise abduction range of motion was 129.53 and 110.64 degrees. While there was no statistically significant difference between Groups A and B on the Pre-Test, there was a difference (p-value <0.05) on the Mid-Test and Post-Test. Internal rotation range of motion was 29.24 for group A and 29.13 for group B in the pre-test. Post-testing revealed a mean Internal Rotation Range of Motion (ROM) of 51.00 degrees for Group A and 41.80 degrees for Group B. While there was no statistically significant difference between Groups A and B on the Pre-Test, there was a difference (p-value <0.05) on the Mid-Test and Post-Test. The average external rotation range of motion (ROM) at the pre-test was 18.00 for group A and 18.31 for group B. In a post-treatment evaluation, the average number of degrees of freedom for external rotation in group A was 57.33 and for group B, it was 41.78. While there was no statistically significant difference between groups A and B on the Pre-test, there was a difference (p-value <0.05) on the Mid-test and Post-test [Table/Fig-6a,b,c,d].

When comparing Niel-Asher technique with positional release technique for the treatment of adhesive capsulitis, the authors observed that the former is superior in terms of increasing shoulder flexion ROM.

Discussion

Shoulder ACS, or adhesive capsulitis, is a common self-limiting disorder characterised by painful, progressive loss of active and passive shoulder motion due to fibrosis and rigidity of the joint capsule. The main objective of this study was to compare the results of the Niel-Asher technique with those of the positional release technique for the management of adhesive capsulitis of shoulder joint in Indian population. The present study findings suggest that although both the Niel-Asher technique and the positional release technique are beneficial for patients with adhesive capsulitis, the former yielded more significant improvement in terms of pain reduction, range of motion and functional ability. In this study the ROM and functional ability in Niel-Asher group was increased, which supports the results of the study conducted by Weis J et al., a randomised placebo controlled trial conducted in association with the Rheumatology Research Unit at Addenbrooke’s Hospital, Cambridge, United Kingdom (UK), the Niel-Asher technique was compared to a standard physiotherapy protocol (with exercise) and placebo in the Outpatient Department (19). These above results can be due to the effects of mobilisation techniques on joint mobility such as releasing adherent and fibrosed soft tissues, relaying of collagen, gliding of fibres causing capsular remodelling (20).

Adhesive capsulitis is characterised by inflammation and fibrosis, both of which are closely linked to the presence of cytokines. Interleukin (IL)-1a, IL-1b, tumour necrosis factor (TNF)-a, cyclooxygenase (COX)-1, and COX-2 were all found in capsular and bursal tissues of patients with adhesive capsulitis at much greater than normal levels (21). The nervous system goes into a “holding pattern,” or stiffness, in response to painful stimuli, to protect the already injured tissues from further harm. The ‘holding pattern’ occurs when the painful sensation is received by the central nervous system through the afferent fibres, which causes some peripheral and central somatisation (15). In this study the ROM and functional ability in Niel-Asher group is increased, which supports the results of the study conducted by Niel-Asher S et al., (15). The above results can be due to the effects of mobilisation techniques on muscle spindle. The muscle spindle is the main sensory unit for the sensation of joint position (22). The function of muscle spindles has been demonstrated to be decreased with immobility. Anderson J et al., demonstrated a decrease in muscle spindle sensitivity after hind limb suspension in rats (23). The investigators attributed this decrease to the decrease in stiffness of the muscle-tendon complex in series with the muscle spindle. Conversely, Kaya D showed that regular training can increase the signal from the muscle spindles, which can produce plastic alterations in the central nervous system, such as strengthening of synaptic networks and/or structural alteration in the structure and numbers of networks amid neurons (24). These repetitive and regular signals from the mechanoreceptors can produce plastic adjustments in the cortex; over time, the cortical maps of the body are altered by increasing the cortical representation of the joints, which causes enhancement of joint proprioception and joint function. Thus, alteration in the muscle spindle, due to the repeated sequence of mobilisation and movements in the Niel-Asher technique produces an alteration in the ‘holding pattern.’

Most studies have demonstrated that activation of these capsuloligamentous receptors is most intense at the limits of the ROM, when both the muscle and the tendon are stretched [25,26]. These mechanoreceptors provide proprioceptive data in the form of sensory signals modulated by the activation of the peripheral mechanoreceptors in the muscles, joints and skin. These peripheral mechanoreceptors provide the central nervous system with sensory information about joint position and movement to adjust motor action (26). In Niel-Asher technique, activation of the peripheral mechanoreceptors provide the central nervous system with sensory information about joint position and movement to adjust motor action. Thus reduced pain and disability, and increased function as observed in the present study as well.

In the present study the ROM and functional ability improved by application of positional release technique in adhesive capsulitis patients. This improvement can be attributed to neurophysiological effects as said by Jones LH, who proposed in a study that when a muscle is strained by a sudden unexpected force, its antagonist attempts to stabilise the joint, resulting in a counter strain 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 trigger point development (27). The application of positional release technique relaxes the muscle-spindle mechanism of the counterstrained tissue, decreasing afferent gamma and alpha neuronal activity, thereby breaking the sustained contraction (27).

Other studies conducted on PRT also proposed that, by decreasing the tone of the muscles and facial tightness positional release therapy improves range of motion and localised blood flow (28).They theorised that putting patients in a relaxed posture might aid in the delivery of fluids (such as blood and lymph) to the injured areas and the elimination of sensitising inflammatory mediators (29). The neurophysiological impact is a result of the simultaneous activation of peripheral mechanoreceptors and inhibition of nociceptors (30). The goal of positional release therapy, an indirect myofascial technique, that focuses on the neurologic component of somatic strain, is to improve a muscle’s pliability by keeping the muscle in the shortened position, as opposed to stretching it, to induce relaxation (31). On comparison in the present research, pain reduction, functional performance, range of motion in flexion, extension, adduction and rotation and, internal and external rotation all reveal statistically significant differences amongst the two techniques. Clinically Niel-Asher technique improves ROM, reduces pain and improves functional ability more effectively than PRT in adhesive capsulitis patients.

Limitation(s)

The present study was a single-centre study done on small sample, larger sample size may provide better results.

Conclusion

The present study results drew the inference that when comparing the Niel-Asher technique to positional release for the treatment of adhesive capsulitis, the Niel-Asher technique resulted in a much faster rate of recovery in terms of restoring pain-free range of motion and boosting functional activity. When compared to other mobilisation techniques, application of this technique was found to be easy, gave faster results and was reproducible.

References

1.
Andrew S. Neviaser, Robert J. Neviaser; Adhesive Capsulitis of the Shoulder; J Am Acad Orthop Surg. 2011;19(9):536-42. [crossref][PubMed]
2.
Duplay S. Periarthritis of the glenohumeral joint in the shoulder. Rev Pract D Trav de Med. 1896;53:226.
3.
Codman EA. The shoulder. Boston: Thomas Todd 1934.
4.
Lundberg BJ. The frozen shoulder. Clinical and radiographical observations. The effect of manipulation under general anesthesia. Structure and glycosaminoglycan content of the joint capsule. Local bone metabolism. Acta Orthop Scand Suppl. 1969;119:01-59. http://dx.doi.org/10.3109/ort.1969.40.suppl-119.01. [crossref]
5.
Bunker T. Time for a new name for frozen shoulder-contracture of the shoulder. Shoulder Elbow. 2009;1(1):04-09. [crossref]
6.
Nevaiser TJ. Adhesive capsulitis of the shoulder: A study of the pathological findings in periarthritis of the shoulder. J Bone Joint Surg. 1945;27(2):211-22.
7.
Mittal P, Goel Y, Dutta S, Giri S, Verma S, Gadre S, et al. A study on prevalence of adhesive capsulitis in patients with diabetes mellitus. Journal of Current Medical Research and Opinion. 2022;5(6):1216-34.
8.
Bunker TD, Anthony PP. The pathology of frozen shoulder. A Dupuytren-like disease. J Bone Joint Surg Br. 1995;77(5):677-83. [crossref]
9.
Huang YP, Fann CY, Chiu YH, Yen MF, Chen LS, Chen HH, et al. Association of diabetes mellitus with the risk of developing adhesive capsulitis of the shoulder: A longitudinal population-based follow-up study. Arthritis Care Res (Hoboken). 2013;65(7):1197-202. http://dx.doi.org/10.1002/acr.21938. [crossref][PubMed]
10.
Lundberg BJ. The frozen shoulder: Clinical and radiographical observations the effect of manipulation under general anesthesia structure and glycosaminoglycan content of the joint capsule local bone metabolism. Acta Orthop Scand. 1969;119:01-59. https://doi.org/10.3109/ort.1969.40.suppl-119.01. [crossref]
11.
Bulgen DY, Binder AI, Hazleman BL, Dutton J, Roberts S. Frozen shoulder: A prospective clinical study with an evaluation of three treatment regimens. Ann Rheum Dis. 1984;43(3):353-60. [crossref][PubMed]
12.
Neviaser RJ, Neviaser TJ. The frozen shoulder: Diagnosis and management. Clin Orthop Relat Res. 1987;223:59-64. PMID: 3652593. [crossref]
13.
Hannan JA, Dicarlo EF, Wickiewicz TL. Adhesive capsulitis: Capsular fibroplasia of the glenohumeral joint. J Shoulder Elbow Surg. 1994;3(Suppl 5):435-40.
14.
Reeves B. The natural history of the frozen shoulder syndrome. Scand J Rheumatol. 1975;4(4):193-96. [crossref][PubMed]
15.
Niel-Asher S, Hibberd S, Bentley S, Reynolds J. Adhesive capsulitis: Prospective observational multi-center study on the Niel-Asher technique (NAT). International Journal of Osteopathic Medicine. 2014;17(4):232-42. [crossref]
16.
Joshi R, Rathi M. Effect of muscle energy technique versus positional release technique on pain and functions in patients with trapezitis-a comparative study. International Journal of Science and Research. 2015;6(5):2113-15. https:// www.semanticscholar.org/paper/Effect-of-Muscle-Energy-Technique-versus- Positional-Joshi-Rathi/c303e8440a25159aff6cea0618d277db213c1c6e.
17.
Diwadkar P, Khatri S. Immediate effectiveness of positional release therapy in acute ankle sprain. Indian J Phys Ther. 2013;1(1):36-40. https://www. researchgate.net/profile/Ashish-Kakkad/publication/355779770_Arthrogryposis_ Multiplex_Congenita_AMC_A_case_report/links/617d6e32a767a03c14d1b1ab/ Arthrogryposis-Multiple.
18.
Naz SS, Amjad F, Khawar S, Arslan SA, Ahmed A. Comparative effects of active release technique and muscle energy technique on pain, range of motion and functional disability in adhesive capsulitis patients with trigger points. Biomedical Journal of Scientific & Technical Research. 2022;44(4):35697-706. [crossref]
19.
Weis JT, Niel-Asher S, Latham M, Hazleman B, Speed CA. A pilot randomised placebo controlled trial of physiotherapy and osteopathic treatment for frozen shoulder. Rheumatology. 2003;42;145-55. https:// www.researchgate.net/publication/285730231_Apilot_randomised_placebo_ controlled_trial_of_physiotherapy_and_osteopathic_treatment_for_frozen_ shoulder/citation/download.
20.
Frank C, Akeson WH, Woo SL, Amiel D, Coutts RD. Physiology and therapeutic value of passive joint motion. Clin Orthop Relat Res. 1984;(185):113-25. [crossref]
21.
Hannafin JA, Chiaia TA. Adhesive capsulitis: A treatment approach. Clinical Orthopaedics and Related Research®. 2000;(372):95-109. [crossref]
22.
Mohamed AA, Yih KJ, El Sayed WH, Wanis MEA, Yamany AA. Dynamic scapular recognition exercise improves scapular upward rotation and shoulder pain and disability in patients with adhesive capsulitis: A randomized controlled trial. Journal of Manual & Manipulative Therapy. 2020;28(3):146-58. [crossref][PubMed]
23.
Anderson J, Almeida-Silveira MI, Perot C. Reflex and muscular adaptations in rat soleus muscle after hin-dlimb suspension. J Exp Biol. 1999;202(19):2701-07. [crossref][PubMed]
24.
Kaya D. Exercise and Proprioception. In:Proprioception: The Forgotten Sixth Sense. Foster City, USA: OMICS Group; 2016. p. 234-255. https://www. semanticscholar.org/paper/Proprioception%3A-The-Forgotten-Sixth-Sense- Kaya/e22645948d2a9d2552821b614a23b636b9dfc170.
25.
Steinbeck J, Brüntrup J, Greshake O, Potzl W, Filler T, Liljenqvist U. Neurohistological examination of the inferior glenohumeral ligament of the shoulder. J Orthop Res. 2003;21(2):250-55. [crossref][PubMed]
26.
Lephart SM, Fu FH. Proprioception and neuromuscular control in joint stability. Champaign, IL: Human Kinetics; 2000.
27.
Jones LH. Spontaneous release by positioning. D.O. 1964;1:109-116.
28.
D’Ambrogio KJ, Roth GB. Positional release therapy: Assessment and treatment of musculoskeletal dysfunction. J Can Chiropr Assoc. 1998;42(3):188-89.
29.
Bailey M, Dick L. Nociceptive considerations in treating with counterstrain. J Am Osteopath Assoc.1992;92(3):334-41. [crossref][PubMed]
30.
Maitland GD. Peripheral Manipulation, Butterworth-Heinemann, 2 nd edition, 1991.
31.
Thaker S, Dave Y, Patel SR. A study to compare the effect of muscle energy technique and positional release technique on pain and cervical rom in patients with chronic upper trapezitis. International Journal of Scientific Research. 2019;8(6);13-17. https://www.worldwidejournals.com/international-journal-of-scientific-research- (IJSR)/article/a-study-to-compare-the-effect-of-muscle-energy-technique-and-positional-release-technique-on.

DOI and Others

DOI: 10.7860/JCDR/2023/63082.17700

Date of Submission: Jan 24, 2023
Date of Peer Review: Feb 22, 2023
Date of Acceptance: Mar 25, 2023
Date of Publishing: Apr 01, 2023

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

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