1. Nepal Medical College and Teaching Hospital (NMC), Nepal: alicechen@gmail.com
2. Nepal Medical College and Teaching Hospital (NMC), Nepal: richasharma@gmail.com

*             Correspondence: alicechen@gmail.com

Keywords: adhesive capsulitis, frozen shoulder, maitland mobilization, kaltenborn-mobilizations

1. INTRODUCTION

Known also as adhesive capsulitis (AC), frozen shoulder (FS) is a self-inflammatory, chronic, progressive pain syndrome that is characterized by stiffness or loss of GH joint movement, capsular pattern limitation, and shoulder joint pain. Adhesive capsulitis is often referred to by the colloquial labels “Per arthritis,” “painful stiff shoulder,” and “shoulder arthrofibrosis” [1]. The humerus, which forms the upper arm, the scapula, or shoulder blade, and the clavicle, often known as the collarbone, are the three bones that make up the shoulder joint. The shoulder joint is surrounded by tissue known as the joint capsule, which keeps everything in place. This tissue thickens and becomes inflammatory in frozen shoulder. The third most frequent MSK problem, shoulder discomfort affects 16–20% of the general population. Idiopathic adhesive capsulitis refers to the condition where there is no clear cause for it to occur. Of the pain complaints, idiopathic adhesive capsulitis (IAC) is the most prevalent. According to a regional community-based investigation, adhesive capsulitis was as common as 3.06% [2, 3]. Research is currently ongoing to determine the precise aetiology of adhesive capsulitis. It is believed that nerve stimulation has a role in the beginning of shoulder pain specific to AC. The hyperresponsiveness of the Alpha-adrenoreceptor, which activates both nociceptive and proprioceptive fibres, is the cause of adhesive-capsulitis shoulder pain. Inflammatory process is another aetiology of adhesive capsulitis. Inflammation brought on by cytokines may cause shoulder synovitis, which may then trigger a fibrotic cascade including growth factors like TGF-beta. The fibroblast cell proliferation provides the histologic appearance that verifies the development of fibrosis in the capsulitis. Adhesive capsulitis patients exhibit increased levels of fibrogenic growth factors and matrix metalloproteinase [4]. It might happen in the absence of any clear risk factors or it can be connected to a number of other systemic or local illnesses [5]. Depending on its cause, adhesive capsulitis can be categorised as primary or secondary. Primary frozen shoulder refers to idiopathic frozen shoulder (IAFS), which develops when the reason is unknown. It is still unknown what causes the idiopathic type of the disease, despite several theories being put forth. If a recognised cause of frozen shoulder exists, secondary frozen shoulder will be considered as well. The research indicates that patients with diabetes mellitus had a much greater prevalence of 10-22 percent for idiopathic adhesive capsulitis, despite the condition being present in 2-4 percent of the general population [6]. The diagnosis of idiopathic adhesive capsulitis is usually made on the basis of clinical findings with characteristics of pain and limited passive ROM, especially the external rotation in most cases most limited movement, if the local shoulder pathology is absent, i.e. Any pathology of rotator cuff, GH arthritis, or supraspinatus tendinitis Five percent of people worldwide have FS, with most affected people being in the 40–70 age range (5).Compared to men, women are more likely to be impacted [7]. Diabetes mellitus is a recognised risk factor for adhesive capsulitis in both men and women. Of the frequent musculoskeletal signs of diabetes, it is the most incapacitating, affecting about 20% of those with the disease. According to a 2016 meta-analysis, people with diabetes are five times more likely to acquire adhesive capsulitis than non-diabetic patients; in contrast, the normal population affected is only 2% and 4%, respectively. The same meta-analysis also found that diabetic patients had a 30% higher prevalence of adhesive capsulitis. Only in females are thyroid conditions non-specific risk factors for adhesive capsulitis. Adhesive capsulitis in hyperthyroidism may be related to sympathetic nervous system activity. However, it is unknown what specifically causes adhesive capsulitis in hyperthyroid individuals. However, According to the study [8], persons with hyperthyroidism had a 1.22 times increased chance of getting adhesive capsulitis compared to the general population. For patients at risk of or exhibiting symptoms of diabetes or thyroid disease, a fasting glucose test, or A1C level, and a TSH measurement may be required [9]. Patients with breast cancer are more likely to develop adhesive capsulitis and its risk factors even after 13 and 18 months following surgery. Cumulative adhesive capsulitis was described as any past history of adhesive capsulitis diagnosis made on the history or interviews with patients, and medical records following mastectomy, even if the patient did not satisfy the current definition of adhesive capsulitis. Therefore, studies on the correlation between adhesive capsulitis and breast cancer will be helpful in raising patient awareness and educating them [10]. Shoulder morbidity was more common in breast cancer survivors (17%) compared to non-survivors [11]. Particular shoulder alignment, as a result of inactivity and actions involving captioning, Clinical signs include pain, reduced range of motion, muscle weakness, and altered scapulohumeral rhythm. Adhesive capsulitis sufferers experience shoulder pain that keeps them awake at night on the afflicted side for months or years, as well as difficulty with dressing, combing, grooming, self-care, and doing overhead chores. Symptoms of adhesive capsulitis might increase medical expenses for the public health and make it harder to work [12]. The disease of the joint capsule can be distinguished from other possible sources of symptoms using the James Cyriax capsular pattern. This capsular pattern shows that there is movement loss in a fixed proportion and that every joint has a different movement loss pattern. Because of the tightness of the joint capsule, the capsular arrangement results in a proportionate restriction in range of motion during passive activities [13]. In adhesive capsulitis, abduction is more restricted than medial rotation, and external rotation is more restricted than abduction [14, 15]. The following are the stages of adhesive capsulitis: Stage 1 (Freezing Stage): the uncomfortable phase that comes with a slow development of symptoms. Aching and referred discomfort to the deltoid insertion are among the symptoms, which also make it difficult to sleep on the affected side for shorter than three months. Individuals may encounter a slight limitation in their range of motion, which is consistently alleviated with the application of a local anaesthetic [16]. The arthroscopic image reveals thickened perivascular synovitis. Histology shows the formation of hypercellular appearance, disorganised collagen fibril deposition, and perivascular and subsynovial scars. The symptoms have been present for 9–14 months. Shoulder stiffness is the most obvious sign, and it might persist overnight or until the end of range of motion. Patchy synovial thickening and atrophy of the axillary recess are visible on arthroscopic examinations; a sample reveals dense, hypercellular collagenous tissue. Stage 3 (Thawing): A chronic stage characterised by severely restricted range of motion and completely developed adhesions. Minimal pain and a progressive increase in range of motion are the characteristics of this syndrome. This time frame may extend to a maximum of 24 months. The relationship between arthroscopy and histological findings has not been studied [17, 18]. Numerous surgical, pharmaceutical, physiotherapeutic, and electrotherapeutic interventional techniques are used to treat frozen shoulder. Manipulation, mobilisation with movement, soft tissue techniques, muscular energy techniques, and other approaches are examples of physical therapeutic procedures. Physical therapy modalities, including heating, acupuncture, TENS, ultrasound (US), and laser, as well as a range of exercise techniques, including patient-initiated stretches, scapular setting exercises, and pendulum exercises, can be employed in conjunction with conservative treatment. Numerous workouts and methods have been used for a long time. Among the preferred therapies is joint mobilisation helps increase and restore the shoulder synovial joint’s range of motion. There exist multiple tiers of mobilisation, including intermediate mobilisation [19]. Clinically, FS impairs both passive and active shoulder range of motion, with external rotation suffering the most. The usefulness of joint mobilisation for patients with FS who suffer from shoulder joint rotational disease has been studied in the past. There are two types of joint mobilisation that are routinely used to treat FS patients: the cautious sustained lengthening approach devised by Maitland and Kaltenborn [20] and the cautionary oscillatory method. MM treats shoulder stiffness and discomfort using a Grade I–IV graded passive oscillatory technique with depth detection. Grade I depth, which is often used in cases of severe discomfort, is a low amplitude depth that is applied at the start of joint range of motion when there may be minimal strain on connective tissue. Grade II, on the other hand, describes a very little amplitude depth that is produced from the joint ROM’s commencement to its centre. Its kilometres are appropriate for pain relief because degrees I and II oscillation stimuli activate the joint’s mechanical receptor, blocking the noxious stimulus from producing the painful sensation that is transmitted to the scared signalling system. Grade III operations are performed at a high amplitude [21]. In contrast, KM assesses articular floor motions and applies them to rectify MacConail’s classification, which asserts that maximum articular surfaces possess convex exterior surfaces and convex interior surfaces. In order to increase joint mobility without suppressing the joint floor, KM uses software that implements a constant passive stretching method. There are three categories for the forces influencing growing joint mobility: I, II, and III. Juvenile deep distraction is used in Grade I; it rarely causes pressure in the pill joint and is frequently applied to relieve discomfort. Grade II pressure is defined as that which lengthens the periarticular tissue; this type of stimulation is colloquially known as “playing the game.” Lastly, grade III pressure, which is typically used to update the ROM, justifies enough distraction or slippage to enable the joint cover to expand sufficiently [22]. The goal of the study is to support physicians in applying Maitland and Kaltenborn Mobilisation Techniques on adhesive capsulitis discomfort and range of motion with an evidence-based approach. in order to ascertain whether treatment is more effective in producing better outcomes for the management regimen. Previous research indicates that there aren’t many studies contrasting these two AC mobilisation procedures in patients with diabetes. Which mobilisation strategy works best for treating AC will be demonstrated by this investigation. Additionally, these two methods have never been considered before in our setting.

2. LITERATURE REVIEW

A systematic review titled “Efficacy of Different Types of Mobilisation Techniques in Patients with Primary Shoulder AC of the Shoulder” was carried out by Hammad, Arsh, et al. We were able to incorporate them by searching PubMed for pertinent studies published prior to November 2014. The reference list’s additional references were carefully chosen. Randomised controlled studies and the English language were used to evaluate the impact of mobility techniques on pain and range of motion in individuals with primary AC. 810 patients were recruited as a result of taking part in 12 randomised controlled trials. The article was reviewed independently by just two reviewers, and the calibre of the technique was evaluated. Those with primary AC of the shoulder improve generally from mobility techniques. The Maitland technique and combination mobilisations seem to be recommended for the time being because early evidence for other mobilisation approaches are scarce [23]. A study titled “Comparative Study on the Effectiveness of Maitland Mobilisation Technique Versus Muscle Energy Technique in Treatment of Shoulder AC” was carried out in 2019 by Ragav [24] and Singh et al. The goal of the study was to determine the best course of care for idiopathic adhesive capsulitis. When comparing the two groups, it was found that both groups’ levels of discomfort and range of motion had considerably improved both before and after therapy. According to the study mentioned above, the Maitland group showed greater ROM improvement, whereas the MET group showed greater pain improvement rating. Therefore, when pain (acute or chronic) interferes with the ability to contract muscles under control, the therapeutic effects of MET antagonists can be used to improve the situation. When the pain disappears, Maitland mobilisation may be used to increase range of motion [25]. A article titled “Comparative study on the efficacy of Maitland technique (grade IV) and Mulligan technique in the treating of frozen shoulder” was published in 2019 by Rathod, Priyanka, and associates. 50 volunteers were randomised to one of two groups at random for the Zia Uddin Hospital trial. Group B received the Mulligan Technique, whereas Group A received the Maitland Technique (Grade IV). The appropriately functioning patient’s capability was ascertained with the SPADI questionnaire, pain was measured using the VAS Score, and range of motion was examined with the Goniometer. It was concluded that, when it came to treating adhesive capsulitis, the Mulligan mobilisation approach outperformed the Maitland mobilisation technique by a significant margin [26].  In a 2019 study, Syed Muhammad Hammad examined the effectiveness of Kaltenborn mobilisation in conjunction with thermotherapy against Kaltenborn mobilisation on its own in patients suffering from adhesive capsulitis. Fifteen (50%) of the thirty patients were allocated to either of the two groups. Group A showed more improvement in disability as compared to group B [27]. In one study, individuals with adhesive capsulitis were compared to see how effective Kaltenborn mobilisation in combination with thermotherapy was vs Kaltenborn mobilisation on its own. Patients with adhesive capsulitis participated in the randomised controlled trial, which took place at the Hayatabad Medical Complex and Habib Physiotherapy Complex in Peshawar, Pakistan, from January to June 2017. Two groups of subjects were randomly assigned to each other. Group B received only Kaltenborn mobilisation, whereas Group A received both Kaltenborn mobilisation and thermotherapy. It was discovered that Kaltenborn mobilisation in conjunction with thermotherapy was more beneficial for patients suffering from adhesive capsulitis than Kaltenborn mobilisation alone. It was discovered that Kaltenborn mobilisation in conjunction with thermotherapy was more beneficial for patients suffering from adhesive capsulitis than Kaltenborn mobilisation alone [26]. Adhesive capsulitis of the shoulder, including pain, severity, and distribution, was investigated by Candela et al. (2017). The objective was to examine the distribution, degree, and kind of pain in patients suffering from adhesive capsulitis of the shoulder. They discovered that women experienced more severe adhesive capsulitis-related shoulder pain. The anterior part of the shoulder is the primary site of adhesive capsulitis pain distribution; it rarely extends to the distal third of the arm [21]. The effectiveness of manual therapy approaches, namely those that target the glenohumeral joint, in the management of adhesive capsulitis is not well-established. In this study, the effectiveness of manual therapy approaches for adhesive capsulitis is assessed. When Kotagiri, Sreenivasu; et al. compared the effectiveness of muscle energy technique and mobilisation to improve the shoulder range of motion in frozen shoulder, they found a larger variation (p=0.001) in post-treatment NPRS between Group A and Group B. The results of the NPRS statistical analysis score showed that the P-value was very significant (0.00) after the treatment and non-significant (0.968) prior to the therapy (2). The results of the current investigation were consistent: Maitland mobilisation is helpful in treating frozen shoulder discomfort [27].  In terms of pain and maximum joint movement, Sumit Ragav, Anshika Singh, et al. compared the effectiveness of the Mulligan ‘MWM’ Technique to the Kaltenborn Mobilisation Technique in patients with adhesive capsulitis. Mulligan’s method was statistically significant when it came to reducing pain and increasing range of motion in the two groups. P < 0.05 According to the current study, individuals with adhesive capsulitis can have significant improvements in pain and range of motion using the mulligan mobilisation approach (p0.05) [28]. The findings of the current investigation support the effectiveness of Kaltenborn mobilisation in treating frozen shoulder discomfort. The impact of Mulligan’s Mobilisation With Movement Techniques on Peripheral Joint Joint movement to promote joint ROM in particular peripheral joint illnesses was studied by Nikolaos StathopoulosPT, MSc, et al. continuously in all moving axes for AC (average gain 12.30o–26.09o, P.02) A significant difference (p0.05) was seen between the groups in the current investigation, indicating the value of different mobilisation strategies for improving range of motion and pain alleviation in adhesive capsulitis [29]. Passive lengthening exercises vs. Mulligan mobilisation with movement for discomfort, range of motion, and function in patients with adhesive capsulitis was the name of the study done by Ankita et al. On the final measurements of pain, disability score, and range of motion, the group receiving passive stretching exercises improved significantly more; p-values of 0.00 for pain, 0.01 for disability score, and 0.04 for total SPADI score indicated significance [30].

3. CONCLUSION

The study found that in order to alleviate pain and range of motion in patients with adhesive capsulitis, both Maitland mobilisation and Kaltenborn mobilisation were equally effective and produced a significant difference in VAS and SPADI scores.

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