International Journal of Medical and Health Research

International Journal of Medical and Health Research

ISSN: 2454-9142
Received: 16-05-2020; Accepted: 17-05-2020; Published: 16-06-2020
www.medicalsciencejournal.com
Volume 6; Issue 6; 2020; Page No. 87-91

Effectiveness of spencer muscle energy technique on periarthritis shoulder

Arul Pragassame S1*, Mohan Raj G2, Aravinth L3
1
Assistant Professor, Division of P.M &R, RMMC & H, Annamalai University, Tamil Nadu, India
2
Professor, School of Physiotherapy, Aarupadai Veedu Medical College and Hospital, Puducherry, India
3
Department of P.M &R, RMMC & H, Annamalai University, Tamil Nadu, India

Abstract
Background: Periarthritis shoulder is characterized by a painful, gradual loss of active and passive gleno-humeral movement.
The Spencer Muscle Energy Technique is unique in its implementation as the client makes the initial effort while being
facilitated by the practitioner. The main uses of this technique are to normalize joint range, rather than increase flexibility.
Objective: To evaluate the effectiveness of the Spencer muscle energy technique on Pain, Shoulder ROM and Functional
disability in patients with Periarthritis Shoulder.
Materials and Methods: In this study, 30 participants were chosen using a random sampling method based on selection
criteria and informed consent was obtained from each participant. Subjects were assigned randomly into two groups. Group A
(N=15) was treated with the Spencer muscle energy technique, ultrasound therapy and Codman’s pendulum exercise. Group B
(N=15) was treated with ultrasound therapy and Codman’s pendulum exercise. The initial evaluation of the pain intensity by
the numerical pain rating scale (NPRS), the shoulder ROM by the universal goniometer, and the functional disability was
scored using the hand behind back (HBB).
Results: Significant improvements observed in patients of Group A and Group B. When comparing the group A and B, NPRS
(Z=3.53, P=0.001), shoulder abduction (Z=3.45, P=0.001), shoulder internal rotation (Z=3.45, P=0.001), shoulder external
rotation (Z=3.44, P=0.001) and hand behind back (Z=3.53, P=0.001) are significantly increased in group A.
Conclusion: The study result concludes that in patients with periarthritis shoulder, the Spencer muscle energy technique group
is effective in decreasing pain, improving ROM, and functional disability.

Keywords: spencer muscle energy technique, periarthritis shoulder, ultrasound therapy, functional disability

1. Introduction Multiple procedures have been defined in the treatment of

The shoulder is considered to be the most mobile joint in the periarthritis shoulder such as cryotherapy, modalities (SWD,
human body. It is better to call the shoulder complex TENS, UST), moist heat, joint mobilization, stretching and
because it takes a series of articulations to position the strengthening exercises are given to restore function by
humerus in space. The main joints are glenohumeral joint, decreasing inflammation and pain and thus enabling normal
sternoclavicular joint, acromioclavicular joint and shoulder mechanics to be restored.
scapulothoracic articulations [1]. The shoulder complex The Spencer muscle energy technique is a standardized
functions in a coordinated way to provide the upper limb sequence of shoulder treatments with extensive diagnosis,
with smoothest and widest range of motion. The motion treatment, and prognosis execution. It was developed in
available to the glenohumeral joint alone cannot account for 1916 by Spencer, D.O. This technique evolved from 1916 to
complete elevation (abduction and flexion) available to the the present in an attempt to identify factors in the
humerus. The scapula on the thorax contributes to the rest of development of manipulative methods [8]. This strategy is a
the range through its sternoclavicular and acromioclavicular well-known manipulative osteopathic technique focusing on
connections [2, 3] mobilizing of the scapulothoracic and glenohumeral joints.
Periarthritis shoulder is a common problem in the shoulder It enables the limited joints, enhances their function, and
between 40 and 60 years. It is reported to affect 2-5 present affects other emotional, social and cognitive regions
of the overall population, increasing to 10-38 % of diabetes positively [9].
and thyroid disease patients. Women are more affected than Spencer muscle energy technique is an articulatory
the men, with the dominant side more involved [4, 5]. technique used in seven different processes to treat shoulder
It is a condition of unclear etiology characterized by a limitation caused by periarthritis shoulder. In this technique,
gradual loss of active and passive movement that happens smooth, passive, rhythmic motion is designed for the
when there is no other known intrinsic shoulder disorder [6]. stretching of contracted muscles, capsules and ligaments.
This condition is defined by the thickening of the synovial Most of the force is applied to the movement end range.
capsule, the contraction of soft tissue and biceps tendon This technique improves pain-free movement by stretching
adhesion and/or axillary fold obliteration secondary to the soft tissues, improving lymphatic flow and stimulating
adhesion resulting in an insidious and gradual loss of active enhanced joint circulation [10]. So the study intends to
and passive mobility in the glenohumeral joint owing to evaluate the effect of the Spencer Muscle Energy Technique
joint contracture [7]. on periarthritis Shoulder.

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2. Materials and methods contact and is held in the therapist’s right hand. The
The present study was an intervention study conducted at therapist’s left hand is performing the medial and lateral
the outpatient Department of Physical Medicine and rotation movement of the shoulder joint with the
Rehabilitation, RMMCH, Annamalai University, Tamil Goniometer and measuring the angle to see the passive
Nadu, India, during September, October and November ROM and the active ROM is measured by the patient
2018. The study was endorsed by the Departmental himself performing the movement [12].
Research Committee (PMR/DRC-7/2018). During the
specified time period, the sample size was selected using a 2.2.3 Hand behind Back
convenient sampling method. Thirty-seven patients with HBB was determined by asking subjects to reach the middle
plantar fasciitis were selected, seven of them were excluded of their spine with their thumb as a feasible measure. The
and the study sample was 30 patients. The inclusion criteria distance between the T1 spinous process and the radial
for the study were (1) Patients with a primary periarthritis styloid process will be measured by the tape measure [13].
shoulder (2) Duration of the condition from 3 to 14 months
(3) One-sided involvement (4) Both male and female (5) 2.3 Treatment procedure
Age group from 40 to 60 years (6) Those willing to take five The treatment procedure was administered five days a week.
consecutive days of treatment. The main exclusion criteria The frequency was one session a day, three sets of 10
were (1) Intra articular injection in the affected shoulder for repetitions with one-minute rest between sets. Before
the last 3 months (2) Any prior surgery on the affected mobilization, all participants were received ultrasound
shoulder. treatment (8 minutes) and were advised to perform the
Codman’s pendulum exercise as a home program.
2.1 Study Procedure
Based on the selection criteria, the subjects were chosen. 2.3.1 Spencer Muscle Energy Technique
The purpose of the study was explained to the subjects and Treatment position:
an informed consent was given in their known language. The patient in lateral lying in the shoulder to be handled
Demographic data were collected. Subjects were randomly away from the table. The therapist standing at the side of the
allocated to two groups. Group A (N=15) received table facing the patient at the level of the patient’s chest [14].
ultrasound therapy, Spencer muscle energy technique and
Codman's pendulum exercise, whereas Group B (N=15) Techniques
received ultrasound therapy and Codman’s pendulum Step 1. Shoulder extension with elbow flexion: The elbow
exercise. Shoulder pain, shoulder ROM and shoulder of patients was kept in a flexed position and the arm was
functional disability measured using NPRS, universal extended to the limited barrier (Figure 1).
goniometer and HBB score for both the groups. The above Step 2. Shoulder flexion with elbow extension: Patients with
evaluation was carried out on the patient first visit before flexed elbows were extended and moved anteriorly into
the beginning of treatment and again on the final day of shoulder flexion until the restricted barrier was reached
treatment at the end of the 5th day. Pre and post treatment (Figure 2).
evaluation was compared and statistically analyzed. Step 3. Circumduction with compression and elbow flexed:
In 90° abduction, grasping the patient’s elbow and shoulder,
2.2 Outcome measures moved the elbow in small clockwise and counter clockwise
2.2.1 Numerical Pain Rating Scale (NPRS) circles with compressive force (Figure 3).
The NPRS was used to measure pain intensity of the Step 4. Circumduction with traction and elbow extended:
subject. The subject sat on a chair and was requested to Therapist maintained the traction of the patients with the
mark the severity of resting pain from 0 as “no pain” to 10 shoulder joint at 90° of abduction and holding either elbow
as “severe pain” on a 10 cm line [11]. or wrist induced small clockwise and counter clockwise
circles (Figure 4)
2.2.2 Goniometer measurement for Shoulder ROM Step 5. Shoulder abduction and internal rotation with elbow
2.2.2.1 Shoulder abduction flexion: The patient was asked to place his hand on the
The patient is in the supine lying position. The axis are therapists forearm for support and then the therapist carried
taken one inch below the acromion process of the scapula. out the abduction and internal rotation of the patients arm
The movable arm is placed over the midline of the anterior internal rotation (90°) (Figure 5)
side of the arm and is held in the right hand of the therapist. Step 6. Internal rotation with arm abducted, hand behind
It is placed on the clavicle horizontally and is held by the back: The therapist’s hands on patient’s shoulder to stabilize
therapist left hand. The therapist’s right hand performs the the clavicle and scapula and move the patient's hand to
shoulder abduction movement with the goniometer and lumbosacral area. Pull elbow anteriorly to internally rotate
measures the angle to see the passive ROM and the active the shoulder into the restrictive barrier (Figure 6).
ROM is measured by the patient himself performing the Step 7. Distraction, stretching tissues and enhancing fluid
movement [12]. drainage with arm extended: The therapist clamps his
fingertips over the deltoid muscle, the patient’s hand is
2.2.2.2 Shoulder internal rotation and external rotation placed over the therapist’s shoulder, and the therapist slowly
Patient in supine lying with shoulder and elbow 90º shifts his arm away from the shoulder and releases it,
position. The olecranon process of the ulna is taken as the repeating it 5–10 times if necessary (Figure 7).
axis. The movable arm is placed over the midline of the
posterior aspect of the forearm and is held in the therapist’s 3. Results
left hand. The stable arm is placed straight line of the The outcome measures used were NPRS, shoulder ROM
moving arm, kept in the air without the patient’s body such as abduction, internal rotation and external rotation and

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HBB. As the NPRS was a discrete variable, a non- plays a part in the descending modulation of pain.
parametric test such as the Wilcoxon signed rank test Nociceptive inhibition take place in the dorsal horn of the
(Before and after treatment) and the Mann Whitney‘U’ test spinal cord, as nociceptive impulses in the dorsal horn are
(Between group comparison) was selected. The other caused by the stimulation of the mechanoreceptor [16].
outcome variables are studied by parametric tests such as As a result, the reduction in HBB (Improvement) is
Paired sample‘t’ test (Before and After treatment) and significantly higher in group A. In Spencer muscle energy
Independent sample ‘t’ test (Between group comparison). technique, passive rhythmic movement restores
The entire statistical procedure is carried out by statistical arthrokinematic gliding and rolls, restoring mobility of the
package of social sciences (SPSS -21). shoulder. Biomechanically, the coracohumeral ligament is
There was a significant difference in NPRS after treatment believed to limit external rotation of the ROM. Other
in both groups. The degree of improvement in group A was potential factors limiting external rotation being the rotator
significantly higher than in group B (2.70±1.06), Therefore interval and the superior glenohumeral ligament, which is
group A was significantly better than group B in reducing more resistant to external rotation ROM. Shoulder
pain of the PA shoulder (Table 1). abduction, is restricted by inferior capsule. The pattern of
Significant improvements in shoulder abduction, internal loss of internal rotation is consistent with the capsular
rotation, and external rotation of the ROM were observed tension in the posterior band of the inferior glenohumeral
following treatment in both groups. The improvement in ligament complex, which restricts the internal rotation
comparison group A was significantly higher than in group ROM.
B. The mean difference was 25.17±13.09. The mean The chronic periarthritis shoulder is characterized by an
difference in the improvement of the internal rotation of the adherent axillary recess, coracohumeral thickness, adhesion
shoulder was 16.33±6.69 and the external rotation was in the rotator intervals and contracted soft tissues which may
17.33±7.96 (Table 2). lead to kinematic alteration of the scapulohumeral and
After treatment, the HBB measurement was significantly scapulothoracic joints, resulting in restricted in capsular
reduced in both groups. The magnitude of reduction in pattern, i.e. more restricted external rotation and abduction,
measurement was higher in group A (Mean =3.07±0.59) and less limited internal rotation and flexion and increased
than in group B (Mean=1.33±0.62). Between group lateral rotation of the scapula. The effects of joint
comparison, it shows that the decrease of the HBB measures mobilization include alleviation of capsular constraints and
was significantly different (Z=4.49, P=0.001). rupture of adhesions, distraction of affected tissue and
Consequently, in group A, improvement in the HBB was normal articular cartilage motion and lubrication. The
significantly higher than in group B (Table 3). results of this study are consistent with the previous study of
There was a significant difference in the magnitude of Grieve GP [17].
improvement between the two groups in all of the outcome Khyathi P, et al [18], says Spencer’s technique of stretching
measures. The mean difference in NPRS was 2.70±1.06. the shoulder capsule and tight soft tissues improves pain-
The mean difference in abduction ROM was 25.17±13.09, free ROM, restoring specific joint movement. When used,
the mean difference in internal rotation was 16.33±6.69, and this technique improves the lymphatic flow from the
the mean difference in external rotation was 17.33±7.96. treatment area. The joint recovers its normal ROM and with
The mean difference in HBB was 2.20±1.06. The this technique resets neural reflex. This technique assists the
improvement was significantly higher in group A (Table 4). limited joints, and favorably affect other emotional, social
and cognitive regions. Passive repetitive movement, traction
4. Discussion or gliding of the translator improves the nutrition,
Spencer's technique is designed to reduce pain by changing circulation and lubrication of the joints. It reverses negative
the circulatory pain biomarkers and improves the pain free changes in the joint, and normalizes arthrokinematic gliding
range of motion by stretching the shoulder capsule and tight and rolling movements. Increased gliding will normalize the
soft tissues, thus restoring specific joint movement. The osteokinematic rotation and allow the mobility of the
result of this study is that, in accordance with the previous shoulder to be restored.
study by Contractor ES et al. [15], the Spencer technique
reduces pain, the possible mechanism includes neurological 4.1 Limitations and Recommendations
and tissue variables such as stimulation of low-threshold  Sample size is limited. In order to further validate these
mechanoreceptors on central pain inhibitory systems and innovative therapeutic techniques for PA shoulder, an
neuronal populations with possible gating effects in the increase in the number of participants may be required.
dorsal horn. Low threshold mechanoreceptors from the  Short duration study (1 week) may increase duration of
joints and muscles project in the mid brain region to the the study.
periaqueductal gray. During isometric contraction, muscle  It is suggested that the patient should be followed up
and joint mechanoreceptors are activated. This results in periodically in the future to find out if the improvement
sympathetic excitation evoked by the somatic efferent and is being maintained or changed for good or bad.
localized activation of periaqueductal gray (PAG), which

Table 1: Shows Group Comparison of NPRS

Group A Group B
2 Related Sample 2 Related Sample
NPRS Mean S. D Mean S. D
Z P Z P
Pre 7.66 1.12 7.13 1.06
3.53 0.001 3.63 0.001
Post 4.00 0.92 5.33 0.82

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Table 2: Shows Group Comparison of ROM

Group A Group B
Shoulder Movement
2 Related Sample 2 Related Sample
(ROM) Mean S. D Mean S. D
Z P Z P
Pre 77.67 28.21 88.33 6.98
Abduction 3.45 0.001 3.46 0.001
Post 114.33 23.51 102.6.76 6.76
Internal Pre 37.67 8.42 50.67 10.15
3.45 0.001 3.63 0.001
Rotation Post 59.33 8.63 61.67 9.94
Pre 34.00 7.37 42.00 14.12
External Rotation 3.44 0.001 3.26 0.001
Post 57.67 8.21 51.67 13.68

Table 3: Shows Group Comparison of HBB

Group A Group B
HBB 2 Related Sample 2 Related Sample
Mean S. D Mean S. D
Z P Z P
Pre 21.67 2.53 21.73 2.05
3.53 0.001 3.58 0.001
Post 18.60 2.16 20.47 2.19
Mean Difference Mean=3.07 S. D=0.59 Mean=1.33 S. D=0.62

Table 4: Pre and Post Difference between Group Comparisons

Independent Sample
Variables Mean Difference S. D
Z P
NPRS 2.70 1.06 4.71 0.001
Abduction 25.17 13.09 4.74 0.001
Internal Rotation 16.33 6.69 4.68 0.001
External Rotation 17.33 7.96 4.66 0.001
HBB 2.20 1.06 4.49 0.001

Fig 3: Circumduction with compression

Fig 1: Shoulder extension

Fig 2: Shoulder flexion with elbow extension Fig 4: Circumduction with traction

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8. Conflicts of Interest: There are no conflicts of interest.

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