Additional Effects of Thoracic Mobilization Versus Manipulation Along With Standard Physical Therapy in Adhesive Capsulitis

The intervention will be conducted over a period of 4 weeks, with three treatment sessions per week. Participants will be divided into two groups, and both groups will receive the same conventional physical therapy treatment program, while the additional thoracic intervention will differ between the groups. At the beginning of each treatment session, TENS and hot pack therapy will be applied for 10 minutes prior to the therapeutic exercises and manual therapy. Stretching exercises will be performed for the levator scapulae, upper trapezius, pectoralis minor, and pectoralis major muscles. During the first week, each stretch will be held for 10 seconds and followed by a 10-second rest period, with five repetitions performed for each muscle per session. In the second week, the stretching duration will be increased to a 15-second hold with five repetitions per muscle. During the third week, stretching will be performed with a 15-second hold for six repetitions per muscle, while in the fourth week, the hold duration will be increased to 20 seconds with six repetitions per muscle. Strengthening exercises will be performed for the middle and lower trapezius and rotator cuff muscles. During the first week, strengthening will be initiated using manual resistance with a 10-second hold, five repetitions, and two sets per muscle. In the second week, six repetitions will be performed for two sets with a 10-second hold. During the third week, strengthening will progress to six repetitions for three sets with a 10-second hold, and during the fourth week, six repetitions for three sets with a 12-second hold. Resistance will be progressed to TheraBand and dumbbells as tolerated. Glenohumeral joint mobilization will also be performed throughout the intervention using anteroposterior, posterior-anterior, and inferior glides with Grade III and IV techniques. During the first week, 10 repetitions will be performed for one set; during the second week, 15 repetitions will be performed for one set; and during the third and fourth weeks, 20 repetitions will be performed for two sets. Group A will receive thoracic manipulation in addition to the conventional treatment program. The target thoracic segment between T1 and T7 will be identified through posterior-to-anterior assessment. The participant will be positioned prone, and the therapist will preload the tissues before delivering a quick, controlled high-velocity, low-amplitude (HVLA) thrust at the end of the participant's full exhalation. The thoracic manipulation will be performed three sessions per week throughout the intervention period. Group B will receive thoracic mobilization along with the same conventional treatment program. Central posterior-to-anterior oscillatory mobilization will be performed with the participant in the prone position. The joint-sign segment, defined as the most painful or stiffest thoracic segment, will be identified using the Passive Accessory Intervertebral Motion (PAIVM) test. If no joint sign is present, mobilization will be applied at the T6-T7 segment. The thoracic mobilization will progress across the four-week intervention period. During the first week, Grade I and II thoracic spine mobilization will be performed; during the second week, Grade II and III mobilization will be applied; during the third week, Grade III and IV mobilization will be used; and during the fourth week, Grade IV mobilization will be performed. The thoracic mobilization will be provided three sessions per week. The conventional physical therapy program will therefore remain consistent in its core components for both groups, including TENS, hot pack therapy, stretching, strengthening, and glenohumeral joint mobilization, while the additional thoracic intervention will differ between the groups. This intervention protocol will allow comparison of thoracic manipulation and progressive posterior-to-anterior thoracic mobilization when combined with standard physical therapy in participants with adhesive capsulitis.

Inclusion criteria

• Age range between 40 and 60 years.
• Both male and female patients with unilateral or bilateral shoulder pain.
• Pain persisting for at least 3 months.
• Decreased shoulder ROM, including external rotation, abduction, internal rotation, and flexion, with both active and passive ROM reduced by more than 50%.
• Clinically diagnosed with Stage 2 or Stage 3 adhesive capsulitis.

Exclusion criteria

• History of fracture, surgery, or dislocation in the affected shoulder.
• Shoulder pain resulting from systemic diseases such as rheumatoid arthritis, infection, or tumors, or conditions such as myelopathy (positive Hoffman's sign).
• Neurological conditions such as stroke or cervical radiculopathy (positive Spurling's test).
• Thoracic Outlet Syndrome (positive Roos test).
• Uncontrolled hypertension or cardiac instability, including unstable angina, recent myocardial infarction, or other cardiovascular conditions.