Comparison of Spencer muscle energy technique and conventional physiotherapy on pain and disability in shoulder adhesive capsulitis: a quasi-experimental study (2025)

Background

Frozen shoulder, or adhesive capsulitis, causes severe shoulder discomfort and limited range of motion (ROM). The present study aims to evaluate the effectiveness of the Spencer muscle energy technique (SMET) in reducing pain and improving functional disability in patients diagnosed with adhesive capsulitis.

Methods

This quasi-experimental study (pre- and post-test) randomly assigned 60 patients to SMET or standard physiotherapy interventions. Group A (control group) received conventional therapy, including 3-MHz ultrasound therapy at 1.5 W/cm² for 5–7min per session, active and active-assisted range-of-motion exercises with 5 repetitions, 10-s isometric exercises, and Codman’s pendulum exercises for 1min. Group B (intervention group) underwent a 7–10-min application of a heating pack, followed by seven Spencer technique procedures. Five repetitions with a 5-s hold during isometric contractions comprised each step. Rhythmic, passive movements with slight resistance mobilized shoulder joints and stretched contracted tissues. The shoulder function was evaluated using the Disability of the Arm, Shoulder, and Hand (DASH) score, the Shoulder Pain and Disability Index, and the Numeric Pain Rating Scale (NPRS). The major outcomes were assessed at baseline, the third week, and the sixth week. The data was analyzed using SPSS 24 (IBM Corp., Armonk, NY). A paired t-test was used to examine DASH and SPADI within-group differences. The 95% CI and p value < 0.05 indicated statistical significance.

Results

The SMET group showed significant reductions in pain and disability levels by week 6 compared to the control group (p < 0.001). By week 6, NPRS scores in the SMET group decreased from 8.00 ± 1.11 to 1.67 ± 0.92, while in the control group, they dropped from 8.17 ± 1.09 to 4.03 ± 1.07. DASH scores differed between the SMET and control groups, with the SMET group improving from 62.92 ± 16.02 to 11.14 ± 6.98 and the control group from 67.74 ± 15.10 to 23.70 ± 11.20. The SMET group increased more in SPADI scores, from 101.07 ± 14.80 to 17.87 ± 8.82, whereas the control group improved from 103.60 ± 13.67 to 50.30 ± 16.02.

Conclusion

In conclusion, demographic analysis showed no significant age or gender differences between groups, assuring baseline comparability (p > 0.05). These findings indicate that SMET is more effective than conventional physical therapy in treating adhesive capsulitis pain and impaired function.

Adhesive capsulitis (AC) or frozen shoulder is a prevalent musculoskeletal condition impacting roughly 2–5% of the general population, primarily in adults aged 40 to 60 years [1]. This condition is marked by pain and a gradual reduction in both active and passive shoulder mobility, potentially resulting in considerable functional disability and decreased quality of life [2]. The condition is frequently idiopathic; however, it has been linked to several risk factors, including diabetes mellitus, thyroid problems, and prior shoulder injuries [3,4,5]. The clinical presentation of adhesive capsulitis entails fibrosis and inflammation of the shoulder capsule, resulting in adhesion development and a corresponding decrease in joint capacity [2, 6].

Several methods of treatment have been utilized for treating adhesive capsulitis, including physical therapy, corticosteroids injections, and surgical treatments [7, 8]. Manual therapy approaches, like the Spencer muscle energy technique (SMET), have garnered attention for their potential advantages in rehabilitating shoulder function and mitigating discomfort [9, 10]. SMET entails the utilization of muscular contractions against an opposing force to augment joint mobility and alleviate muscle tension, thus enhancing range of motion and diminishing pain.

Prior research has demonstrated that muscular energy methods (MET) can significantly enhance shoulder function and alleviate discomfort in individuals with adhesive capsulitis [11]. Nonetheless, the lack of robust randomized controlled trials particularly investigating the impact of SMET on this condition remains [12].

The present study is aimed to compare the effectiveness of SMET and conventional shoulder management in alleviating pain and enhancing functional results in individuals with adhesive capsulitis, thus complementing the current literature on viable treatment approaches for this painful disorder.

Study design and setting

A quasi-experimental study (pre- and post-test) was done in several hospitals in Gujranwala and Daska. These hospitals were Jinnah Memorial Trust Hospital, Wapda Hospital, DHQ/Teaching Hospital, Siddique Sadiq Memorial Trust Hospital, and Hameeda Bashir Hospital. We completed the study over 12 months between June 2023 and May 2024.

Sample selection

A simple random sampling method was employed to ensure unbiased participant allocation. The sample size was calculated using an effect size of 0.8 (Cohen’s d) based on SPADI score differences from prior studies and using the EPI tool with a 95% confidence interval and 80% power. The expected mean and standard deviation for SPADI scores were 21.84 ± 4.37 for group A and 32.93 ± 6.60 for group B. Accounting for a 20% dropout rate, each group comprised 33 participants.

Inclusion and exclusion criteria

To be eligible, participants had to be between the ages of 35 and 70, male or female, have been diagnosed with adhesive capsulitis, have shoulder pain and stiffness that started on their own, and have limited active and passive ranges of motion for at least three months. Exclusion People who had recently had shoulder surgery, rotator cuff rupture, cervical spine disorders, rheumatoid arthritis, osteoporosis, cancer, pregnancy, or previous shoulder manipulation while under anesthesia were not allowed to participate.

Randomization and allocation

We randomly assigned patients to one of two groups using a coin flip method. Group A received conventional therapy, and Group B underwent Spencer's Muscle Energy Technique (SMET). As illustrated in the Fig.1. Participants’ flow chart, each group included 30 participants who were eligible based on the inclusion and exclusion criteria.

Group A (control group)

Group A received conventional therapy, which included ultrasound therapy administered at a frequency of 3 MHz and an intensity of 1.5 W/cm² for 5–7 min per session. Exercise therapy consisted of active and active-assisted range-of-motion exercises with one set of five repetitions; isometric exercises performed with a 10-s hold; Codman’s pendulum exercises for 1 min; shoulder wheel exercises involving ten circular motions; and scapular stabilization exercises lasting 3 min. Each session for group A lasted approximately 20–25 min. The home exercise program (HEP) was instructed to the participants to replicate these exercises thrice a week for 6 months.

Group B (intervention group)

Group B underwent SMET, which included the application of a heating pack for 7–10 min, followed by the execution of seven standardized steps of the Spencer technique. Each step involved five repetitions with a 5-s hold during isometric contractions. We performed the movements in a rhythmic, passive manner with slight resistance to mobilize the shoulder joint and stretch the contracted tissues. Each session for group B took approximately 25–30 min, including heating in the form of hot packs and SMET.

The interventions were administered 3 ×/week for 6 weeks. Home exercises (HEP) were performed twice daily and the patients were instructed.

The Spencer Muscle Energy Technique comprises seven sequential steps: Fig. 2. Step 1 – shoulder extension with elbow flexion; Fig.3. Step 2 – shoulder flexion with elbow extension; Fig. 4 Step 3 – circumduction with compression; Fig. 5 Step 4 – circumduction with distraction; Fig. 6 Step 5 – shoulder abduction and internal rotation with elbow flexion; Fig. 7 Step 6 – shoulder adduction and internal rotation with elbow flexion; and Fig.8 Step 7 – stretching of tissues and pumping of fluids with the arm extended.

The study utilized three validated tools to assess outcomes. Pain intensity was measured using the Numeric Pain Rating Scale (NPRS), which rates pain on a scale of 0 (no pain) to 10 (worst pain imaginable). Functional disability was evaluated using the Shoulder Pain and Disability Index (SPADI), which includes 13 items divided into pain and disability subscales, and the Quick Disabilities of the Arm, Shoulder, and Hand (Quick DASH) questionnaire, a 30-item scale assessing physical function and symptoms.

1. 1.

   Numeric Pain Rating Scale (NPRS).

The NPRS is a numerical version indicating segments of the visual analog scale in which a subject chooses a whole number (0–10 integers) in accordance with the intensity of his/her pain. It consists of a horizontal bar or line, which consists of three segments of whole numbers, which indicates mild, moderate, and severe conditions of pain [13].

1. 2.

   Quick Disability of the Arm, Shoulder, and Hand Questionnaire (Quick DASH Questionnaire).

In the disability scale, every item consists of five response options. At least 27 out of 30 items complete the scale score that extends from 0 (no disability) to 100 (most severe disability) and can be measured. It consists of a 30-item disability/symptom scale [14].

1. 3.

   Shoulder Pain and Disability Index (SPADI).

We utilized a tool—the Shoulder Pain and Disability Index—to identify individuals with shoulder pain and disability in an outpatient setting. It has 13 items organized into subscales of pain and disability. A 5-item subscale measures pain and an 8-item subscale measures disability. We use visual analog scales to rate the data and calculate the means. The combination of the two subscales yields a total score that ranges from 0 (best) to 100 (worst) [15].

Data collection procedure

The outcome measures were recorded at baseline (zero), three weeks (mid-interventional), and six weeks (post-interventional) to evaluate the interventions' early and mid-term impacts with follow-up assessments. Clinical recommendations and earlier research showing tangible progress usually takes place within this time range for adhesive capsulitis led to the selection of these time points. The data collection conformed to the Consolidated Standards for Reporting of Trials (CONSORT) criteria. An impartial physiotherapist, unaware of the intervention, performed all assessments.

Statistical analysis

The data was analyzed utilizing SPSS software version 24 (IBM Corp., Armonk, NY). We conducted a comparison of within-group differences in DASH and SPADI utilizing a paired t-test. The p value of less than 0.05, along with a 95% confidence interval, was considered statistically significant.

Table 1 shows the demographic distribution that shows balanced gender representation (58.3% female, 41.7% male) and a concentration of participants in the 35–45 age group (56.7%). The lack of significant differences in baseline characteristics (p > 0.05) ensures group comparability for subsequent analysis.

Table 2 illustrates the treatment group that showed substantial improvement in DASH scores, decreasing from a mean of 62.92 ± 16.02 at baseline to 11.14 ± 6.98 at 6 weeks (p < 0.001). In contrast, the control group showed limited improvement. This highlights the intervention’s effectiveness in reducing disability.

Table 3 reveals the treatment group which exhibited a marked reduction in pain intensity, with NPRS scores decreasing from 8.00 ± 1.11 at baseline to 1.67 ± 0.92 at 6 weeks (p < 0.001). The control group showed smaller reductions, indicating the intervention’s significant impact on pain management.

Table 4 shows the SPADI scores for the treatment group decreased from 101.07 ± 14.80 at baseline to 17.87 ± 8.82 at 6 weeks (p < 0.001). The control group experienced less pronounced changes, emphasizing the superior efficacy of the treatment in improving shoulder pain and disability.

This study demonstrated that Spencer’s muscle energy technique (SMET) significantly reduces pain and improves shoulder function in adhesive capsulitis more effectively than standard therapy. By the 3rd week of intervention, the therapy group had already begun to show greater improvements than the control group across all outcome measures. Notable reductions were observed in DASH, NPRS, and SPADI scores, indicating decreased disability and pain levels. These early gains further strengthened by week 6, where the therapy group showed markedly better outcomes compared to the control group. Thereby, balanced demographic characteristics and comparable baseline values suggest these results stem from the intervention itself. SMET emerges as a more effective approach for managing pain, disability, and improving functional outcomes in patients with AC.

The improvements might be because the technique can make joints more mobile and lower muscle stress by making it easier for muscles to contract against a counterforce [5, 9]. This aligns with previous research indicating the efficacy of MET in addressing shoulder problems [10, 11]. The current study results also back up the work of Gasibat et al., who found that SMET greatly improved the range of motion and eased the pain of people with frozen shoulder in which SMET’s pain reduction may reflect mechano-transduction effects on capsular fibrosis that is supported with greater DASH score improvements [9].

Moreover, combining SMET with regular physiotherapy might have a synergistic effect that makes results better than with normal therapies alone [10, 12]. The study by Ghaffar et al. underscores the necessity of integrating functional rehabilitation into the management of adhesive capsulitis, indicating that early interventions centered on exercises and manual techniques can markedly improve functionality for patients with frozen shoulders [10]. The reason why time spent in each group is unequal time duration because the control (group A) did not received the hot pack and the inclusion of heat therapy in the intervention (group B) may have contributed to improved ROM by promoting tissue extensibility; however, the substantial functional gains observed are more likely attributed to SMET’s mobilization effects.

A comparison study of Spencer’s muscular energy method and passive stretching revealed a lower NPRS score in the SMET group relative to the passive stretching group. In the same way, another study showed that the SMET group had lower NPRS scores (p < 0.001) than the groups that did regular deep heating and passive stretching. Kuchera et al. stated that impaired functioning often limits individuals with adhesive capsulitis in their ability to engage in activities of daily living (ADLs) [16]. Zreik et al. revealed that the SMET group had a greater enhancement in shoulder functionality and a reduction in discomfort. Previously presented evidence yielded results consistent with the current study [17].

The results of this study are consistent with those of Iqbal et al., who found that Spencer’s muscular energy technique worked better than passive stretching for people with adhesive capsulitis which assessed the outcomes of SMET compared to passive stretching techniques in frozen shoulder patients with those who underwent SMET experienced more significant improvements in pain relief and range of motion [18]. The technique was shown to assist in releasing joint restrictions and enhancing shoulder movement and these results advocate for the use of SMET as a key component in treating adhesive capsulitis.The previous study demonstrated that Maitland Mobilization, both independently and in conjunction with Spencer Muscle Energy Techniques,markedly enhanced pain, range of motion, and functionality in patients with frozen shoulder. Nonetheless, the integrated method demonstratedenhanced results, signifying increased clinical efficacy [19]. Based on this notion, in this present study SMET significantly reduced pain anddisability compared to conventional therapy (p 0.001), with greater improvements in NPRS, DASH, and SPADI scores by week six.

The results of present study are also similar with those who explored the impact of SMET on individuals diagnosed with adhesive capsulitis in which the results demonstrated a noticeable reduction in pain levels and functional limitations after applying SMET on the patients receiving this treatment exhibited better progress than those undergoing standard physiotherapy and hence the findings suggest that SMET is an effective intervention for improving shoulder mobility and managing symptoms [20].

Limitations

This study faced several limitations that may have influenced its outcomes and interpretations. Firstly, the sample size was limited, which could restrict the generalizability of the findings and reduce the statistical power of the results. Additionally, the assessment follow-ups were limited, potentially hindering the ability to observe long-term effects or trends over time. Another notable limitation was the variation in baseline NPRS (Numeric Pain Rating Scale) scores among subjects in both groups. This difference could introduce bias, as it may affect the comparability of the interventions’ effects.

Recommendations

To address these limitations and enhance future research, several recommendations are proposed. Longer follow-ups and extended time durations should be incorporated to better evaluate the sustained effects of the interventions. Furthermore, it is crucial to standardize the severity and stages of adhesive capsulitis across groups to ensure an accurate comparison of outcomes. Equal distribution of gender should also be considered to minimize potential gender-related biases in results. Lastly, age-based distribution can be incorporated to explore the influence of age on treatment efficacy and outcomes. These steps will contribute to more robust and reliable research findings in the future.

ROM:

Range of motion

SPADI:

Shoulder pain and disability index

DASH:

Disability arm shoulder hand

SMET:

Spencer’s muscle energy technique

NPRS:

Numeric pain rating scale

Authors and Affiliations

1. Department of Physical Therapy, Gujranwala Institute of Rehabilitation Sciences, Gujranwala, Pakistan, 52250, Punjab

   Aisha Amin,Zainab Zafar Awan,Faiza Almas,Rabia Talab Hussain&Qurat-ul-ain Zahra

2. Department of Physical Therapy, Riphah International University, Lahore, Pakistan

   Ramsha Malik

3. Quality & Monitoring Directorate, Indus Hospital & Health Network, KRG Campus, Karachi, Pakistan

   Sajjan Iqbal Memon

Contributions

AA, RM, and ZZA: conceptualization, study design, manuscript writing, and data analysis. RM, SIM, and FA: data collection, intervention implementation, and statistical analysis. SIM, RTH, and QZ: literature review and critical revision of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Sajjan Iqbal Memon.

Ethics approval and consent to participate

This study was approved by the Ethics Committee of the Gujranwala Institute of Rehabilitation Sciences affiliated with the University of Sargodha on 06/10/2023 (Approval number: GIRS-00890–17/01). Written informed consent was obtained from all participants before their inclusion in the study.

Consent for publication

Not applicable. This manuscript does not contain any individual person’s data in any form (including individual details, images, or videos).

Competing interests

The authors declare that they have no competing interests.

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