Journal of Population Therapeutics

& Clinical Pharmacology

RESEARCH ARTICLE
DOI: 10.47750/jptcp.2023.30.08.031

Impact of PNF, Active Release Technique and Conventional Physiotherapy on

the physical ability of subjects with Periarthritis Shoulder
G.Yuvarani1*, Jibi Paul2, M. Manoj Abraham3, N. Harikrishnan4
1Associate Professor, Faculty of Physiotherapy, Dr.MGR Educational and Research Institute,

Chennai, Tamil Nadu, India

2Professor, Faculty of Physiotherapy, ACS Medical College and Hospital Campus, Dr.MGR.
Educational and Research Institute, Chennai, Tamil Nadu, India
3Principal, KG College of Physiotherapy, Coimbatore, Tamil Nadu, India

4Principal, Faculty of Pharmacy, Dr.MGR Educational and Research Institute, Chennai, Tamil Nadu,

India
*Corresponding author: G.Yuvarani , Associate Professor, Faculty of Physiotherapy, Dr.MGR
Educational and Research Institute, Chennai, Tamil Nadu, India,
Email : yuvarani.physio@drmgr.du.ac.in

Submitted: 10 February 2023; Accepted: 14 March 2023; Published: 07 April 2023

ABSTRACT
The term Periarthritis and adhesive capsulitis was coined in 1945 by Neviaser. The exact etiology
remains unclear. The presentation is like an inflammatory condition followed by fibrosis and collagen
deposition. Periarthritis (PA) is a "catch-all diagnosis" that frequently refers to a variety of shoulder
issues. The goal of this study was to see how Neuromuscular Facilitation and Active Release
Technique improves pain, range of motion, and shoulder function in periarthritic patients. Based on
the criteria for selection, the investigation was carried out at the ACS Medical College and Hospital's
Outpatient Department of Physiotherapy. They were divided into Group A (n = 12), Group B (n = 12)
and Group C (n = 12) using the simple random lottery procedure. This study used a pre- and post-test
comparison design. Simple random sampling was used to choose the study's 36 participants, who were
both male and female, aged 40 to 60, with second-stage periarthritis of the shoulder. Pre- and post-test
scores were kept for the outcome measure, which included the Visual Analog Scale, Goniometry,
Shoulder Pain and Disability Index Scale. Six weekly sessions of the treatment were given over the
course of four weeks. The Dependent variable is Pain, ROM, shoulder function, the Independent
variables are Neuromuscular Facilitation and Active Release Technique. The present study provided
evidence to prove that proprioceptive neuromuscular facilitation is more effective than the active
release technique with P<0.001, in periarthritic patients in terms of lowering discomfort, enhancing
range of motion, and functional capacity. According to the study, periarthritic individuals who
underwent the proprioceptive neuromuscular facilitation have pain relief, improved range of motion,
and improved functional abilities.

Keywords: Periarthritis; Adhesive capsulitis; SPADI; Active release technique; PNF

J Popul Ther Clin Pharmacol Vol 30(8):e291–e297; 07 April 2023.

This article is distributed under the terms of the Creative Commons Attribution-Non
Commercial 4.0 International License. ©2021 Muslim OT et al.

e291
Impact of PNF, Active Release Technique and Conventional Physiotherapy on the physical ability of subjects with
Periarthritis Shoulder

INTRODUCTION movement patterns in response to a variety of

Adhesive capsulitis (AC) was initially identified stimuli while following the therapist's
in 1872 as periarthriti scapulohumerale and then instructions. All PNF techniques are carried out
in 1934 as frozen shoulder. It is a typical in accordance with fundamental guidelines, and
musculoskeletal condition.[1] That affects the performing rotational patterns of movement is
glenohumeral joint and characterized by one of their key elements. To increase muscle
escalating joint capsule inflammation and strength and flexibility, various techniques can be
ensuing shoulder stiffness. Because the frozen used, including rhythmic initiation, repeated
shoulder is incapacitating and frequently causes contractions, rhythmic stabilization,
such intense pain, patients often find it difficult combinations of isotonics, dynamic reversals,
to cope. The prevalence of AC is about 4% in the hold-relax, and contract-relax. The
general population, but it can affect up to 36% of neurophysiology of reciprocal innervation, post-
diabetic patients. Usually between the 5th and 7th isometric relaxation (autogenic inhibition),and
seventh decade of life, female patients are most stress-relaxation is the foundation for hold-
frequently affected. There are two types of frozen relax,contract-relax techniques[4]
shoulder: primary (idiopathic) cases and Stretching and strengthening exercises,
secondary cases. Primary frozen shoulder's electrotherapy modalities, or mobilisation may
etiology is still unknown. The symptoms in the be used in conjunction with physiotherapy
first group appear gradually and develop slowly, treatment. Among a wide range of exercises, joint
and there is no clear trigger mechanism. mobilisation is a type of passive movement used
Secondary cases typically result from trauma or to treat sore and stiff synovial joints. There are
prolonged immobility, which may be caused by a various types of mobilisation, and terminology
variety of pathologies [2] varies between authorities. The oscillatory
"Freezing, frozen, and thawing" are the three motions will be in the direction of the accessory
phases that are typically experienced as frozen motions of the joint, which are minute rolling,
shoulder progresses. A gradual preliminary onset gliding, spinning, or distracting motions that take
over days or weeks characterizes these stages, place between joint surfaces and are necessary
which last for about two years. It takes about for normal mobility. Movement of the humeral
three months to get through phase (freezing), head inferiorly as it moves on the glenoid fossa
which is characterized by intense pain. A during normal abduction is an example of an
significant amount of stiffness and pain at the accessory motion at the shoulder. For the larger
limits of movement characterize the frozen tuberosity of the humerus to pass beneath the
(adhesive) phase, which lasts for 3–9 months. coracoacromial arch and enable complete arm
The thawing (resolution) phase, which lasts 9–18 elevation, this gliding action is required. When an
months and is comparatively painless, sees a examiner moves one articular surface passively
steady improvement in stiffness. Frozen shoulder while stabilising the other, accessory movements
is a self-limiting condition that goes away in 12 in healthy synovial joints can be seen. [5]
to 36 months, according to several authors. [3] Active release technique is also one of the
Adhesive Capsulitis can be treated surgically or treatment options considered now a days by
conservatively. Studies have also shown that many health practitioners for the treatment of
rehabilitation is highly effective in enhancing frozen shoulder. Active release technique helps
ROM, reducing pain, and enhancing function. to break the adhesions formed around the
Early in the 1950s, Kabat and Knott developed shoulder joint. It also releases and stretches the
the PNF treatment method. The general exercises connective tissue around the shoulder, restores
are carried out as typical physiological joint vascular and lymphatic circulation, and increases
movements in one plane, such as abduction, the range of motion [6]. Dierks et al described a
rotation, or flexion. PNF aims to improve joint prospective study of 77 patients that compared
coordination, movement control, and mobility. exercise within the limits of pain with intensive
This can be accomplished by rotating diagonal physiotherapy in patients with frozen shoulder.
J Popul Ther Clin Pharmacol Vol 30(8):e291–e297; 07 April 2023.
This article is distributed under the terms of the Creative Commons Attribution-Non
Commercial 4.0 International License. ©2021 Muslim OT et al.

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Impact of PNF, Active Release Technique and Conventional Physiotherapy on the physical ability of subjects with
Periarthritis Shoulder

They found better results with exercise Based on inclusion and exclusion criteria, the
performed within the limits of pain (64% reached study was carried out at the ACS Medical
near normal, painless shoulder movements at 12 College and hospital's Outpatient Department of
months and 89% at 24 months) than with Physiotherapy. Participants were divided into
intensive physiotherapy (63% achieved a similar Group A (n-12), Group B (n-12) and Group C (n-
result at 24 months).[7] 12) using the simple random lottery method.
From the patient, comprehensive demographic
Many conditions can cause symptoms similar to
information and past medical history were
those of adhesive capsulitis, including full- and
gathered. Informed consent was gained once the
partial-thickness rotator cuff tears, calcific
treatment process was thoroughly explained.
tendinitis, glenohumeral or acromioclavicular
Before and after the therapy, the outcome
arthritis, and cervical radiculopathy. -An accurate
measure, which included the Visual Analog
diagnosis of adhesive capsulitis can reduce
Scale, Goniometry, Shoulder Pain and Disability
patient morbidity by shortening pain duration
Index Scale, was recorded as a pre- and post-test
through physical therapy and intra-articular
score. Six sessions per week for two weeks were
steroid injections. Radiologic findings could play
used for the treatment. Pain, range of motion, and
an important role in adhesive capsulitis diagnosis
shoulder function are the dependent factors.
during the early stages or when clinical features
Neuromuscular Facilitation, and Active Release
are atypical. In this regard, characteristic
Technique are the independent variables.
ultrasound findings and cutoff values for
Neuromuscular Facilitation was applied to Group
adhesive capsulitis parameters could be useful
A, Active Release Technique to Group B, and
for creating a differential diagnosis between
Conventional Exercise to Group C.
adhesive capsulitis and other diseases that mimic
adhesive capsulitis. The natural course of Group A (Neuromuscular Facilitation): Scapular
adhesive capsulitis can be divided into 4 stages PNF was applied to the PNF group by a
based on clinical presentation and arthroscopic professional therapist in two diagonals, anterior
appearance: pre freezing, freezing, frozen, and elevation and posterior depression and anterior
thawing [8] elevation and posterior depression, each with 20
repetitions. While therapists stood in the
direction of the desired motion, patients were
METHOD AND MATERIAL lying on their unaffected side. The therapist
The present randomised control trial study was started off by giving instructions in advance.
carried out with the approval of the Institutional Before giving instructions for the intended
Review of ACS Medical College and Hospital, action, the therapist pushed the scapula to an
Velappanchavadi, Chennai, India. This was a extended position at the beginning of the pattern.
comparative study with pre- and post-testing. The All of the patterns employed rhythmic initiation
study included 36 subjects with periarthritis and facilitation techniques that involved repeated
shoulder who met the inclusion criteria: clinically contractions. The best PNF agonistic technique
diagnosed case of periarthritis shoulder (second for scapular facilitation is this method. The
stage), both male and female, age group 40-60 patient's motion is normalised by the rhythmic
years, and both dominant and non-dominant initiation technique, which also relaxes the
hand. Any recent shoulder joint surgery, patient, improves coordination, and teaches the
pacemakers, or other medical conditions should patient's motion. Utilizing a series of
be disclosed. Subjects on medications, recent contractions, the patient's motion is directed in
steroid injection around shoulder joint Biceps the desired direction and their active range of
tendinitis and other intrinsic shoulder diseases, motion and strength are improved. A 20 second
Parkinsonism, rotator cuff tears Rheumatoid rest period was included in between each
arthritis, cervical radiculopathy was ruled out of repetition.
the study. .

J Popul Ther Clin Pharmacol Vol 30(8):e291–e297; 07 April 2023.

This article is distributed under the terms of the Creative Commons Attribution-Non
Commercial 4.0 International License. ©2021 Muslim OT et al.

e293
Impact of PNF, Active Release Technique and Conventional Physiotherapy on the physical ability of subjects with
Periarthritis Shoulder

Group B (Active Release Technique) releasing the trigger point with the thumb and
The humerus was abducted to 45 degrees, the holding the elbow using the other hand. During
elbow was externally rotated (20–25 degrees) to ART, a particular muscle is shifted from a
the midline, and the flexion was at 90 degrees shortened to a lengthened position, or vice versa.
when the subjects were positioned supine. The The procedure lasted between eight and fifteen
muscle in the axilla was palpated in order to minutes.
identify any areas that had taught bands, trigger
points, or myofascial mobility restriction. The
therapist carefully places their palm in the lower Group C (Conventional exercises)
axilla of the patient, close to the latissimus dorsi Exercises for the shoulder that are commonly
muscle mass. performed include the thumb ladder, wand
exercise, mariner’s wheel and codman's pendular
The therapist presses on the muscle while feeling
exercise.
for trigger points or localised tenderness and
triggering referred pain. The therapist will
actively abduct the subject's shoulder while Data Analysis and Interpretation

TABLE 1: Comparison of VAS score between Group A, B, C using Analysis of Variance

*p>0.05(NS), **p<0.05
Groups Pre Test Post Test
MEAN SD MEAN
GROUP A 6.41 .514 2.91 .514
GROUP B 6.50 .522 3.75 .753
GROUP C 6.50 .522 4.08 .900
F VALUE .103 .103 17.79 17.79
SIGNIFICANCE .958* .958* .000** .000**

When the post-test mean VAS scores for the significant. The post-test mean VAS score values
various groups (Group A(PNF), Group B(ART), showed that Group A (PNF) fared better than
Group C(CV),Group A(PNF) 2.91 showed Group B (ART), which scored 3.75. Group
higher significance than Group B(ART) 3.75, the B(ART) 3.75 outscored Group C(CV) 4.08 in
difference between the two groups was terms of post-test mean VAS score comparisons.

TABLE 2: Comparison of SPADI score between Group A, B, C using Analysis of Variance

Groups Pre Test Post Test
MEAN SD MEAN SD
GROUP A 70.33 4.43 36.16 2.58
GROUP B 69.08 3.55 48.91 4.79
GROUP C 68.08 2.53 60.01 3.47
F VALUE .929 .929 187.36 187.36
SIGNIFICANCE .435* .435* .000** .000**
*p>0.05(NS), **p<0.05

Comparing the post test mean values of SPADI On comparing the post test mean values of
score between Group A(PNF), Group B(ART), SPADI score between Group B(ART) 48.91 has
Group C(CV), Group A (PNF) 36.16 revealed shown better results than Group C(CV) 60.01
better significance than Group B(ART) 48.91.

J Popul Ther Clin Pharmacol Vol 30(8):e291–e297; 07 April 2023.

This article is distributed under the terms of the Creative Commons Attribution-Non
Commercial 4.0 International License. ©2021 Muslim OT et al.

e294
Impact of PNF, Active Release Technique and Conventional Physiotherapy on the physical ability of subjects with
Periarthritis Shoulder

TABLE 3: Comparison of ROM (ABDUCTION) score between Group A, B, C using Analysis of

Variance
Group Pre Test Post Test
MEAN SD MEAN
GROUP A 83.16 6.99 122.91 6.31
GROUP B 82.25 5.20 100.66 5.10
GROUP C 84.16 12.93 97.33 5.95
F VALUE .063 .063 95.89 95.89
SIGNIFICANCE .959* .959* .000** .000**
*p>0.05(NS), **p<0.05

The post test mean values of ROM The post test mean values of ROM
(ABDUCTION) score between Group A (PNF), (ABDUCTION) score between Group B(ART)
Group B(ART), Group C(CV), Group A(PNF) 100.66 has shown better results than Group C
122.91 has shown better significance than Group (CV) 97.33
B(ART) 100.66.

TABLE 4: Comparison of ROM (INTERNAL ROTATION) score between Group A, B, C using

Analysis of Variance
Groups Pre Test Post Test
MEAN SD MEAN
GROUP A 35.41 8.00 56.83 8.07
GROUP B 36.58 5.36 48.75 5.98
GROUP C 37.00 4.80 44.16 4.80
F VALUE .146 .146 17.00 17.00
SIGNIFICANCE .932* .932* .000** .000**
*p>0.05(NS), **p<0.05

On comparing the post test mean values of ROM On comparing the post test mean values of ROM
(Internal Rotation) score between Group A (Internal Rotation) score between Group B
(PNF), Group B (ART), Group C (CV), Group A (ART) 48.75 has shown better results than Group
(PNF) 56.83 has shown better significance than C (CV) 44.16
Group B (ART) 48.75.

TABLE 5: Comparison of ROM (External Rotation) score between Group A, B, C using Analysis
of Variance
Groups Pre Test Post Test
MEAN SD MEAN SD
GROUP A 27.41 2.15 45.91 5.69
GROUP B 27.91 7.75 37.00 9.64
GROUP C 26.16 5.50 32.58 5.79
F VALUE .569 .569 24.72 24.72
SIGNIFICANCE .638* .638* .000** .000**
*p>0.05(NS), **p<0.05

J Popul Ther Clin Pharmacol Vol 30(8):e291–e297; 07 April 2023.

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Commercial 4.0 International License. ©2021 Muslim OT et al.

e295
Impact of PNF, Active Release Technique and Conventional Physiotherapy on the physical ability of subjects with
Periarthritis Shoulder

On comparing the post test mean values of ROM Both Groups had notable differences and post-
(External Rotation) score between Group A treatment gains, according to Narayan,
(PNF), Group B (ART), Group C (CV), Group A Anupamaet al. With lower SPADI scores, Group
(PNF) 45.91 has shown better significance than A of the experimental group performs better than
Group B (ART) 37.00. Group B of the control group, which suggests that
there is a substantial difference between the post-
On comparing the post test mean values of ROM
test scores of the two groups. Conclusion: When
(External Rotation) score between Group B
treating adhesive capsulitis, the neuromuscular
(ART) 37.00 has shown better results than Group
facilitation has a significant positive impact on
C (CV) 32.
the shoulder's functional capacity. Sami S.
Almureef et al. came to the conclusion that
RESULT combining a mobilisation programme with
When the post-test mean VAS values of the traditional therapy for treating frozen shoulder
different groups were compared, Group A (PNF) can be more effective at restoring shoulder range
demonstrated a significantly greater of motion and lowering pain[5].
improvement than Group B(ART), and Group Michael.G.Mertens et al. came to the conclusion
C(CV) at p0.05. that ROM, function, and pain can all be improved
with exercises alone or in combination with other
When the post-test mean SPADI values of the programmes, but that there is little to no
different groups were compared, Group A (PNF) difference between the two for ROM and pain
demonstrated a significantly greater and that the data for function is conflicting.[11].
improvement than Group B(ART), and Group According to Neeti Mishra et al., combining
C(CV) at p0.05. traditional physical therapy exercises with
Group A (PNF) shown a significantly greater scapular proprioceptive neuromuscular
improvement than Group B(ART), and Group facilitation helps patients with adhesive capsulitis
C(CV) at p0.05 when comparing the post-test experience less discomfort and disability[12]. In
mean values of ROM(Abduction) between order to improve range of motion (ROM) in
groups. chronic PA shoulders, Manobhiram nellutla et al.
came to the conclusion that PNF movement
Group A (PNF) significantly outperformed
pattern exhibits greater results[13]. End range
Group B(ART), and Group C(CV) in terms of
mobilisation is more effective in lowering pain
post-test mean values of ROM (Internal rotation),
with improvements in joint range and functional
with a p-value of 0.05.
performance, according to Anitha, J. Sridevi, and
colleagues[14]
DISCUSSION PNF, traditional exercise, and physiotherapy
The aim of the study was to compare the impact modalities all demonstrated immediate effects on
of various physiotherapy modalities on shoulder adhesive capsulitis, according to Nilay comuk
function in individuals with periarthritis. The [15]
mean and standard deviation values of the pre-
and post-test scores of the VAS, SPADI, and
ROM (flexion, abduction, internal rotation, and CONCLUSION
external rotation) were computed, and they The current study provided proof that
showed an improvement in terms of lowering proprioceptive neuromuscular facilitation is
pain, improving range of motion, and increasing superior to active release technique, and
ability in three groups. When the results from the conventional treatment for periarthritic patients
three groups were compared, it became clear in minimizing pain, enhancing range of motion,
from the study's findings that neuromuscular and improving functional capacity.
facilitation outperformed active release
technique, and standard exercise.

J Popul Ther Clin Pharmacol Vol 30(8):e291–e297; 07 April 2023.

This article is distributed under the terms of the Creative Commons Attribution-Non
Commercial 4.0 International License. ©2021 Muslim OT et al.

e296
Impact of PNF, Active Release Technique and Conventional Physiotherapy on the physical ability of subjects with
Periarthritis Shoulder

Ethical clearance 10.1136/bmj.331.7530.1453. PMID: 16356983;

Institutional ethical clearance has been obtained PMCID: PMC131565
from ACS Medical College and hospital, 8. Do JG, Hwang JT, Yoon KJ, Lee YT. Correlation
Chennai to conduct this study. of ultrasound findings with clinical stages and
impairment in adhesive capsulitis of the shoulder.
Orthopaedic Journal of Sports Medicine. 2021
May 10;9(5):23259671211003675.
Conflict of Interest
9. Sonu punia, Jaspreet kaur, Varun singh, Manoj
There is no conflict of interest to conduct and malik, PRIYNKA, "Efficacy Of Proprioceptive
publish this study Neuromuscular Facilitation And Joint
Mobilization In Management Of Frozen
Shoulder", IJRAR - International Journal of
Fund for the study Research and Analytical Reviews (IJRAR), E-
The fund for the study was taken by the ISSN 2348-1269, P- ISSN 2349-5138, Volume.6,
researcher Issue 1, Page No pp.868-873, March 2019.
10. Cho CH, Bae KC, Kim DH. Treatment Strategy
for Frozen Shoulder. Clin Orthop Surg. 2019
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Commercial 4.0 International License. ©2021 Muslim OT et al.

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