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 Table of Contents  
Year : 2020  |  Volume : 7  |  Issue : 5  |  Page : 79-83

Short-term efficacy of an integrated approach using spencer's mobilization and agnikarma on movement and functional disability in a patient with shoulder impingement syndrome

1 Department of Kinesiology and Movement Sciences, Dr. D. Y. Patil College of Physiotherapy, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
2 Department of Kriya Sharir, Dr. D. Y. Patil College of Ayurveda and Research Centre, Pimpri-Chinchwad, Maharashtra, India
3 Department of Shalyatantra, Dr. D. Y. Patil College of Ayurveda and Research Centre, Pimpri-Chinchwad, Maharashtra, India

Date of Web Publication26-Feb-2020

Correspondence Address:
Dushyant D Patil
Dr. D. Y. Patil College of Ayurveda and Research Centre, D. Y. Patil Vidyapeeth, Sant Tukaram Nagar, Plot No. Bgp/190, Pimpri, Pune - 411 018, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdrr.jdrr_59_19

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Shoulder impingement is one of the major causes of shoulder pain accounting to about almost 30%. It is classified as structural or functional and is commonly seen in patients with repetitive overhead activity. The patient was a 25-year-old active male involved in cricket as a part of his recreational activity. He complained of severe pain every time his arm came near his ear while bowling. As the pain did not subside on its own, he decided to take medical intervention. The patient received a combined intervention of Spencer's mobilization and Agnikarma for three sessions for a period of 1 week. Pre- and posttreatment muscle strength and functional disability were documented. Pre to post intervention showed significant improvement in muscle strength and functional disability. The combined effect of mobilization with Agnikarma is found promising on short-term basis.

Keywords: Agnikarma, impingement, rotator cuff, Spencer's mobilization, swedana

How to cite this article:
Samson A, Patil DD, Patil PD. Short-term efficacy of an integrated approach using spencer's mobilization and agnikarma on movement and functional disability in a patient with shoulder impingement syndrome. J Dent Res Rev 2020;7, Suppl S2:79-83

How to cite this URL:
Samson A, Patil DD, Patil PD. Short-term efficacy of an integrated approach using spencer's mobilization and agnikarma on movement and functional disability in a patient with shoulder impingement syndrome. J Dent Res Rev [serial online] 2020 [cited 2020 Jul 8];7, Suppl S2:79-83. Available from: http://www.jdrr.org/text.asp?2020/7/5/79/278899

Editor: Dr. Pradnya Kakodkar

  Introduction Top

The third-most common frequently occurring musculoskeletal problem with the prevalence of 26% in general is shoulder pain.[1] Rotator cuff tears and subacromial impingement are among the most common causes of shoulder pain and disability.[1] Lewis reports a lifetime danger of up to 30%.[2] With age, the recurrence of rotator sleeve tears increments and full-thickness tears are extraordinary in patients more youthful than 40 years of age. The frequency of rotator sleeve tear in 33% of shoulders was seen in the 50- to 60-year run and in 100% in those over 70 years old, as revealed in a cadaveric study.[3] The rotator sleeve is made out of four muscles; to be specific, the supraspinatus, infraspinatus, teres minor, and subscapularis. These muscles take their root from the collection of scapula and lodges onto the tuberosity of proximal humerus.[4] The rotator sleeve contributes significantly to the glenohumeral stability and mobility. The pivotal role of rotator cuff is for the dynamic stability of shoulder where it has to work against the excessive upward pull of deltoid, thereby facilitating smooth movements.[5] Among the rotator cuff muscles, the supraspinatus is the most commonly impinged structure because of its passage underneath the subacromial roof, causing to rub against the roof repeatedly, thereby causing inflammation to the tendon. Constant irritation can trigger pathologic process and lead to rotator sleeve degeneration and dysfunction. At the point when the four sleeve muscles cannot act in synchrony to keep the humeral head focused in the glenoid, dynamic stability can be compromised.[6] Shoulder impingement has been managed worldwide by surgical and conservative methods. Because of its high success rate, the conservative approach is preferred by many patients. Physiotherapy remains the mainstay of conservative approach, which includes manual therapy interventions such as mobilization, manipulation, electrotherapy modalities, and exercises. There are various kinds of mobilizations that are used by different therapists according to their expertise. Spencer's mobilization is one such technique that has been underused even though its results are promising. The Spencer system is an institutionalized arrangement of shoulder treatment created by Spencer, D.O. in 1916, with wide application in treatment, diagnosis, and prognosis. The advancement of this strategy is followed from 1916 to date in an attempt to recognize factors in the improvement of manipulative techniques. Spencer had first tried this technique in baseball players with shoulder pain due to trauma and had achieved great success. The technique is usually well tolerated as it causes only moderate pain during its application owing to its nature of smooth, rhythmic, and cadenced application.[7] The Ayurvedic literature too holds strong documentation for the conservative management of tendon inflammation. Agnikarma is the most commonly used form of treatment that consists of treating the affected part with medicated oils and heat. Agnikarma is a unique therapeutic procedure because of its preventive, primitive, and prophylactic properties. Agnikarma is found effective in vata vyadhis (forms of arthritis) and has been recommended in various musculoskeletal disorders by Aacharya Sushruta (an ancient Indian physician).[8] As literature is scarce highlighting the combined effects of Ayurveda and physiotherapy intervention for managing shoulder pathology, this study aims to report the impact of these two combined interventions for the same.

  Case Description Top

The patient was a 25-year-old active male who was into cricket for recreation. He presented to the clinic with complaints of pain around the acromion process in his left shoulder. He noticed this pain since 3 weeks after a period of repeated bowling activity, but ignored it as he thought it will subside on its own. The pain was more in severity when his arm came around his ear. As the pain did not subside on its own, he presented to the department as advised by his family orthopedician. He had a history of self-management of the same pain by surfing about physiotherapy on the Internet. As the patient was so young and something beyond physiotherapy was possible, the case was discussed with an Ayurvedic practitioner. The Ayurvedic literature has sufficient evidence in the management of shoulder pathology. Hence, a decision was made to treat the patient conservatively with an interdisciplinary approach. The patient was an active participant in the entire discussion and plan. A thorough physical assessment was taken and documented. The intervention was given after taking necessary consent from the patient. Only a very short-term intervention was possible as the patient was traveling overseas soon.

Physical examination

Physical assessment of the patient uncovered clear shortfalls during perception and clinical testing, which included quality deficiencies, decreased glenohumeral movement range, and agony with specific positions expected during indicative clinical special tests. Cervical pathology, neural association, and systemic reasons for the left arm pain were eliminated at the beginning of screening. The patient exhibited extreme two-sided scapular dyskinesia and an abatement in the active range of motion (AROM) of the involved left shoulder when contrasted with the noninvolved right shoulder by means of observation. Shoulder AROM estimations, both at assessment and posttreatment, are incorporated in [Table 1]. Passive movement (PROM) and joint play evaluation were utilized to preclude intra-articular pathology. PROM measurements are summarized in [Table 2]. Four special tests were performed for the clinical diagnosis of shoulder impingement syndrome (SIS), whereas additional tests for capsular and other soft-tissue involvement were negative. A complete list of special tests and results, at evaluation and discharge, is summarized in [Table 3]. Finally, manual muscle testing revealed noteworthy lopsided characteristics between ipsilateral muscles tested, fundamentally the scapular stabilizers. Strong irregular characteristics are one of the primary etiologies of functional SIS.[9] A total rundown of muscles tested and results are recorded in [Table 4]. The Shoulder Pain and Disability Index scale was taken for evaluating functional disability [Table 5]. The score obtained was 68%. Based on the positive results of the special clinical tests for impingement, the patient was diagnosed as having SIS.
Table 1: Upper extremity active range of motion measurements (degrees)

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Table 2: Upper extremity passive range of motion measurements (degrees)

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Table 3: Clinical special tests and results

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Table 4: Manual muscle testing

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Table 5: Shoulder pain and disability index

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The combined intervention (Spencer's mobilization and Agnikarma) was given for three sessions for a period of 1 week with an aim to restore the range of motion, arthrokinematics of the glenohumeral joint, and functional disability and to reduce pain. Prior to the mobilization, the patient was briefed about the procedure. The patient was made to lie in side-lying position (unaffected upper extremity down) so that all the seven steps of mobilization [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7] could be administered. Step 1 consisted of the therapist stabilizing the shoulder of the patient with one hand and extending the affected arm at the shoulder joint with elbow flexed until the resistance barrier is felt. Once the barrier was found, few gentle oscillations were performed. Step 2 consisted of flexing the shoulder joint with elbow extension till the barrier and oscillations were performed. Step 3 consisted of abducting the shoulder (elbow maintained in flexion) to approximately 90° and then circumduction of the shoulder by applying compression. Step 4 is similar to step 3, in that the shoulder is given traction instead of compression before circumduction. In step 5, the patient's affected side hand (elbow flexed) was placed on the therapist's forearm that was stabilizing the shoulder. The patient's arm was then taken into abduction and internal rotation followed by adduction and external rotation. In step 6, the patient's hand was placed just at the back of the lower ribs, and the shoulder was abducted. The therapist with one hand pulled the shoulder forward against the resistance of the other hand (stabilizing hand) on the front of the shoulder. At the final step, the therapist induced alternating traction and compression on the shoulder's soft tissues.[7] The patient was sent for Agnikarma soon after the mobilization. As with any other procedure, the patient was explained in detail about the procedure and expected response. Prior to Agnikarma, prophylactic tetanus toxoid was given to the patient before the commencement of the intervention. He was treated by Agnikarma with gu′a (jaggery) on the areas of maximum tenderness around the affected shoulder joint for 2 min. It was repeated for 2–3 times [Figure 8]. Three sittings were done for a period of 1 week. The points of subsequent application were different from that of the previous one. Post procedure, Aloe vera pulp and madhuyashti churna were applied over every site.
Figure 1: Step 1 – Spencer's mobilization

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Figure 2: Step 2 – Spencer's mobilization

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Figure 3: Step 3 – Spencer's mobilization

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Figure 4: Step 4 – Spencer's mobilization

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Figure 5: Step 5 – Spencer's mobilization

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Figure 6: Step 6 – Spencer's mobilization

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Figure 7: Step 7 – Spencer's mobilization

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Figure 8: Agnikarma

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  Results and Discussion Top

The findings [Table 1], [Table 2], [Table 3], [Table 4], [Table 5] clearly demonstrate an improvement in pain, range of motion, muscle strength, and functional disability. Only horizontal arm adduction did not show any significant change.

The treatments given in the case report were all based on the current literature focusing on explaining the etiology and treatment strategies for shoulder impingement. However, the authors tried to use an integrated approach combining two different disciplines as both hold strong evidence for managing impingement. Escamilla et al. in their investigation has referenced that the essential focal point of rehabilitation for SIS is to diminish mechanical pressure that might be acting on the rotator cuff tendon and to re-establish vascularity that might be diminished auxiliary to a wide range of etiologies.[10] According to Ayurveda, each Dhatu (tissue) has its own Dhatvagni (obstruction), and when it turns out to be low, infections start to occur. In this condition, Agnikarma works by offering outer warmth, thereby expanding the Dhatvagni which assuages the increased doshas and subsequently lightens the sickness.[11] Sthanik Snehana and swedana works by lubricating the Srotamsi (microcirculatory channels). It also displaces exudates, and thus may relieve tension and pain. It softens muscles, ligaments, and tendons, thus correcting stiffness and rigidity, and induces elasticity in the body. It also prepares smooth passages (microchannels) for the elimination of vitiated Doshas during Swedana therapy.[12] The Spencer's system is expected to diminish pain by modifying the circulatory nociceptive biomarkers. Its passive cadenced movement restores the arthrokinematic rolling and gliding along these lines, re-establishing shoulder mechanics. The Spencer's procedure delivers pain-free range of motion by stretching the shoulder capsule and tight delicate tissues, re-establishing explicit joint movement. This strategy when applied builds the lymphatic stream from the treatment zone and resets neural reflexes.[13] The improvements seen in the patient, even though short term, might be owed to the above physiological mechanisms that operated interchangeably.

The results presented here reported the patient's condition immediately after the treatment was over. However, no follow-up of the case was taken.

  Conclusion Top

The authors of this case report strongly support the combined application of interventions of two disciplines in the management of shoulder pathologies.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Lewis JS, Green AS, Dekel S. The aetiology of subacromial impingement syndrome. Physiotherapy 2001;87:458-69.  Back to cited text no. 1
Lewis JS. Rotator cuff tendinopathy/subacromial impingement syndrome: Is it time for a new method of assessment? Br J Sports Med 2009;43:259-64.  Back to cited text no. 2
Lehman C, Cuomo F, Kummer FJ, Zuckerman JD. The incidence of full thickness rotator cuff tears in a large cadaveric population. Bull Hosp Jt Dis 1995;54:30-1.  Back to cited text no. 3
Chaurasia BD. Human Anatomy. 4th ed. Delhi: CBS Publishers; 2009.  Back to cited text no. 4
Levangie P, Norkin C. Joint Structure and Function: A comprehensive Analysis. 4th ed. Philadelphia: F. A. Davis Company; 2005.  Back to cited text no. 5
Otis JC, Jiang CC, Wickiewicz TL, Peterson MG, Warren RF, Santner TJ, et al. Changes in the moment arms of the rotator cuff and deltoid muscles with abduction and rotation. J Bone Joint Surg Am 1994;76:667-76.  Back to cited text no. 6
Patriquin DA. The evolution of osteopathic manipulative technique: The spencer technique. J Am Osteopath Assoc 1992;92:1134-6, 1139-46.  Back to cited text no. 7
Negi V. Avabahuka vis-a-vis frozen shoulder: A review. WJPR 2018;7:411-22.  Back to cited text no. 8
Zoolinger C, Urfer A, Gerber D. Physical therapy management of an elite rock climber with subacromial impingement syndrome (SIS). Phys Ther Rehabil 2018;5:1-8.  Back to cited text no. 9
Escamilla RF, Hooks TR, Wilk KE. Optimal management of shoulder impingement syndrome. Open Access J Sports Med 2014;5:13-24.  Back to cited text no. 10
Nagnath SR, Critical appraisal of agnikarma and its therapeutic aspects. Int Res Pharm 2013;4:75-7.  Back to cited text no. 11
Rajoria K, Singh SK, Sharma R S, Sharma S N. Clinical study on Laksha Guggulu, Snehana, Swedana & traction in osteoarthritis (knee joint). AYU 2010;31:80-7  Back to cited text no. 12
Khyathi P, Vinod Babu K, Sai Kumar N, Asha D. Comparative effect of spencer technique versus mulligan's technique for subjects with frozen shoulder – A single blind study. Int J Physiother 2015;2:448-58.  Back to cited text no. 13


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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