TAPING WITH ACTIVE EXERCISES VERSUS ACTIVE EXERCISE ALONE IN MANAGEMENT OF SHOULDER IMPINGEMENT SYNDROME SUBJECTS
By
ISHFAQ BASHIR BHAT
Dissertation research proposal submitted to the
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BANGALORE, KARNATAKA
In partial fulfillment of the requirements for the Degree of
MASTER OF PHYSIOTHERAPY (M.P.T)
IN
MUSCULOSKELETAL & SPORTS
Under the guidance of
DR. R DEV ANAND (PT)
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BANGALORE, KARNATAKA
ANNEXURE-ӀI
PROFORMA FOR REGISTERATION OF SUBJECTS FOR
DISSERTATION
1. / Name of the candidate & address / ISHFAQ BASHIR BHATNo.33.80ft Road
Opp. Laggere Ring Road Bridge,
Bangalore-560058
2. / Name of the Institution / HOSMAT COLLEGE OF PHYSIOTHERAPY
No.33.80ft Road
Opp. Laggere Ring Road Bridge,
Bangalore-560058
3. / Course of study and subject / MASTER OF PHYSIOTHERAPY
(Musculoskeletal Disorders and sports Physiotherapy)
4. / Date of Admission to Course / 01/06/2013
5. / Title of The Topic:
“TAPING WITH ACTIVE EXERCISES VERSUS ACTIVE EXERCISE ALONE IN MANAGEMENT OF SHOULDER IMPINGEMENT SYNDROME SUBJECTS”
CONTENTS
6.INTRODUCTION
6.1 Need of study……………………………………………………………04
6.2 Objectives of study……………………………………………………...06
6.3 Hypothesis………………………………………………………………05
6.4 Review of literature……………………………………………………..06
7.MATERIALS AND METHODS…………………………………...... 10
7.1 Study design…………………………………………………………….10
7.2 Study population….……………………………………………………..10
7.3 Sample size………………………………………………………………10
7.4 Source of data……………………………………………………………10
7.5 Sampling method …………………………………...…………………..10
7.6 Study duration…………………………………………………………...11
7.7 Selection criteria………………………………………………………....11
7.8 Outcome measures………………………………………………………12
7.9 Material used…………………………………………………………….12
7.10 Methodology……………………………………………………………12
7.11 Procedure……………………………………………………………….13
7.12 Statistical tools……………………………………………………....…19
7.13 Ethical clearance………………………..…………………………...... 19
8.LIST OF REFERENCES………………………………………….……20
6. BRIEF RESUME OF THE INTENDED WORKS:
6.1Introductionand Need of the study:
Shoulder impingement commonly known as painful arc syndrome refers to compression and abrasion of rotator cuff structures as they pass inferior to acromion and coracoacromialarch during elevation of arm ( primary impingement).1,2Several factors have been attributed to predisposing shoulder impingement syndrome, which include:Altered shoulder kinematic association with dysfunction of rotator cuff and scapular muscles leading to instability of glenohumeral joint.2,3,4
In overhead movements of shoulder co-ordinated movements of scapula and humerus occur through the co-ordination of scapular muscles 5. The dynamic control of shoulder complex is acknowledged essential for normal and efficient functioning of upper limb.6 The upper and lower fibres of trapezius and serratus anterior are paired to form a force couple which controls the scapular upward rotation and posterior tilt.5Altered recruitment pattern and decreased muscle performance of scapula and flexibility deficits influence the kinematics of scapulohumeral rhythm.2 Altered function of serratus anterior and trapezius muscles influence scapular movement , and is associated with poor shoulder function and impingement issues.5Changes in scapular kinematics with shoulder impingement syndrome include increased scapular winging during arm elevation, decreased shoulder upward rotation and posterior tilt (scapular dyskinesis).5
Clinical management of shoulder impingement pathology should address primary underlying causative factors which typically include posture and neuromuscular control.7 Instructions to stabilize the scapula by active motor control exercises or passive means decrease pain, better the scapular position and decrease the signs and symptoms ofshoulder impingement. This is achieved by specific exercises , taping, soft tissue massage , joint mobilizations or passive stretches. 7Active training of specific shoulder musculature aims to increase shoulder function, decrease pain and stabilize scapula. Rotator cuff eccentric training and concentric/eccentric training of scapular stabilizers are routinely incorporated in active strategies.3 Additionally, scapular motor control training; resistance training program for trapezius and serratus anterior; manual scapular upward rotation and stretching of tight musculature (levator scapulae , rhomboids and pectoralis minor) are incorporated in active management strategies.4 Upper quadrant postural awareness plays a vital role in maintenance of the scapular position9
Taping promotes proximal stability of scapula and facilitates the scapular control during movement allowing humeral motion without subsequent pain and help to perform elevating movements of arm while holding the scapula in proper alignment6. It decreases the upper trapezius muscle activity and offers a constant input on the proprioceptive system of upper trapezius muscle activity.5,8Taping improved the lower fiber trapezius activity during 60-30 degree lowering phase of arm scaption and increases the scapular posterior tilt at 30 and 60 degree of arm scaption .5 It increases shoulder range of motion and reduces pain and discomfort. 5
Taping promotes passive support to the scapula in maintenance of ideal position, however, long term effects only due to taping have not been cited in literature. Active training of muscles with taping of scapula may enhance the motor control of scapula during active movements. This study aims to study the effect of taping of scapula and incorporating active exercises to improve the symptoms in shoulder impingement syndrome subjects.
Statement of problem
It is less clear, whether taping scapula with active scapular exercises would be more beneficial than active exercises alone in subjects with shoulder impingement syndrome.
6.2 OBJECTIVES OF THE STUDY
•To determine the effects of taping with active exercises on shoulder function and pain in shoulder impingement syndrome subjects.
•To determine the effects of active exercises only on shoulder function and pain in shoulder impingement syndrome subjects.
•To compare the effects of two interventions on shoulder function and pain in SIS subjects.
6.3HYPOTHESIS
NULL HYPOTHESIS
There is no significant difference in outcome measures between scapular taping and active exercise group and active exercise only group
ALTERNATE HYPOTHESIS
There is a significant difference in pain and shoulder function while performing scapula taping with active exercises than active exercises only group.
Clinical significance
If the study shows significant improvement, active exercises may be incorporated with scapula taped, to enhance motor control of the scapula, in shoulder impingement syndrome subjects.
6.4 REVIEW OF LITERATURE
Pathomechanics
Decreased scapular upward rotation, increased anterior tipping ,increased scapular medial rotation and increased in EMG activity of serratus anterior have been reported as significantly deviant findings in shoulder impingement subjects in comparison to normal subjects.Scapular tipping and serratus anterior muscle function are specifically considered in rehabilitation of SIS.1
The forward head and slouched posture has been associated with an increased in thoracic kyphosis, forward shoulder posture and a scapular that is protracted, elevated, anteriorly tilted and downwardly rotated. This combination of posture has been associated with reduction in gleno-humerl movement and in predisposing shoulder impingement syndrome.11
A normal and abnormal neuromuscular control has been extensively studied using EMG, topographic and magnetic resonance and digital image processing device. A consistence association has been described between inadequate motor control of scapular and patient with SIS syndromes.7
Evidence of imbalance between upper fibres of trapezius (UFT) and lower fibres of trapezius (LFT) in symptomatic population with shoulder impingement syndrome in comparison with asymptomatic subjects provides support for scapular muscle imbalance accompanying shoulder impingement syndrome. Specifically over activity of UFT and under activity of LFT.6
Scapular dyskinesis is present in a high percentage of subjects with shoulder problems and shoulder impingement symptoms.12
Taping
Scapular taping is used as an adjunctive treatment in management of shoulder impingement syndrome.7
Elastic taping results in positive changes in scapular motion and muscle performance and supports its use as a treatment aid in managing shoulder impingement problems.5
Kinesio-taping over lower trapezius muscle improved the lower trapezius muscle activity and increased posterior tilt in baseball players with shoulder impingement syndrome.5
Taping appears to provide a reduction in pain experienced when assessed by both self reported majors or function and on active movements but this benefit occurs only while taping is continued and is not maintained on follow up.7
Combining active correction of posture and taping suggests that there may be a short term improvement in the range of shoulder flexion and scapular plane abduction in shoulder impingement syndrome subjects.11
Shoulder taping is a promising modality in improving the outcomes on pain relief and function improvements in those presenting with symptoms of shoulder impingement syndrome.8
There is altered upper trapezius and lower trapezius muscle activity in subjects with shoulder impingement syndrome and scapular taping technique used is appropriate to reduce UFT activity but not to change LFT activity in shoulder impingement population.6
Scapular taping can be used as an adjunctive technique for promoting proper scapular position and should be used in conjunction with other conservative methods of treatment in shoulder impingement subjects.12
Active strategy
Specific exercise strategy focusing on strengthening eccentric exercises for rotator cuff and concentric/eccentric exercises for scapula stabilizers is effective in reducing pain and improving shoulder function in patients with persistent shoulder impingement syndrome.3
Extension of strengthening exercises for rotator cuff and concentric/eccentric exercises for scapula reduces the need of arthroscopic sub-acromial decompression within the 3 months time frame.3
The integration of key physical examination techniques with evidence with driven rehabilitation concepts to restore optimal range of motion and rotator cuff and scapular strength and stabilization forms basis of clinical rehabilitation of atheletes with shoulder impingement syndrome.2
A 10 week motor control exercise intervention improves function and pain in young adults with shoulder impingement signs and also improves muscle recruitement patterns and scapular kinematics.14
A 3 month specifically tailored progressive strengthening exercise program is more beneficial in improving shoulder function in shoulder impingement syndrome subjects than non specific exercises. 15
Scapular focused treatment approach with motor control exercises, scapular mobilisations and stretching shows promising clinical results in a group of patients with shoulder impingement syndrome. 4
There is a strong evidence of exercise therapy in treatment of shoulder impingement syndrome and it should be the first choice in primary health care. 16
Outcome measures
Shoulder disability questionnaire (SDQ)
SDQ is a self reported questionnaire has been previously used in patients with shoulder impingement syndrome and it covers 16 items to evaluate functional status.
According to the calibrated responsiveness ratio (CRR) and the area under the receiver-operator characteristic curve (AUC) the SDQ discriminates accurately between self-rated clinically stable and improved subjects. The presented results suggest that the SDQ is as responsive as the compared outcome measures, and therefore is ready for use in clinical trials.4,17
While evaluating the responsiveness of SDQ it was seen that SDQ is a useful instrument to assess functional disability in longitudinal studies.18
Lateral scapular slide test
A reliability study of males with and without shoulder pathology concludes that measurement obtained with the lateral scapular slide test and scoliometer are reliable in assessing scapular position or symmetry.19
The reliability of lateral scapular slide test in neutral position is maximum (ICC 0.83-0.97, good to high) in 90 degree of scaption inter-rater and intra-rater reliability were 0.70-0.75 and 0.65-0.83 respectively.20
VAS
The reliability of VAS for acute pain measurement as assessed by the ICC appears to be high. 90% ofthe pain rating were reproducible within 9mm. these data suggest that the VAS is sufficiently reliable to be used to assess acute pain. 21
VAS pain score is believed to be reliable , valid, and sensitive.22
The VAS sensory intensity response to experimental pain, VAS sensory intensity responses to different levels of chronic pain and direct temperature(experimental pain) matches to 3 levels of chronic pain where all internally consistent thereby demonstrating the valid use of VAS for measurement and comparison between chronic pain and experimental pain.23
7. MATERIALS METHODS AND
7.1 STUDY DESIGN
Quasi randomised study
7.2 STUDY POPULATION
Diagnosed SIS subjects reporting to study setting
7.3STUDY SAMPLE SIZE
Study will be done in 30 subjects.
7.4SOURCE OF DATA
Study will be conducted in HOSMAT Hospital, Bangalore and other hospitals in Bangalore.
7.5SAMPLING METHODS
Purposive sampling.
7.6STUDY DURATION
January 2014 to December 2014
7.7SELECTIONCRITERIA
INCLUSION CRITERIA
•Age group- above 18 years
•Sex- male/ female
•Shoulder impingement symptom lasting for more than 1 month
•Unilateral pain and painful arm
•Positive for Hawkin Kennedy test and Neer’s test
•Asymmetry in scapular control (dyskinesis) – Lateral scapular slide test positive
EXCLUSION CRITERIA
•Cervical or thoracic spine involvement
•Stiff shoulder
•Calcific tendinitis confirmed by radiography
•Rheumatoid arthritis, polyarthritis or any degenerative joint disease in shoulder
•History of dislocation and surgery in shoulder or spine
•Any neurological deficit
•Complete rotator cuff tear
•gleno-humeral joint instability determined by positive sulcus sign or positive load and shift test.
7.8Outcome Measurements:
•Shoulder disability (SDQ)
•Scapular instability (LSST)
•Pain (VAS)
7.9 MATERIALSUSED:
•SDQ
•VAS
•Measuring tape
•Goniometer
•Dynamometer
7.10METHODOLOGY
The subjects will be recruited from outpatient department of HOSMAT hospital. The subjects referred to the physiotherapy department with diagnosis SIS will be screened for inclusion-exclusion criteria. The subjects who qualify for the trial will be explained the aim and objective of study. The subjects will be requested to sign the consent form. The subjects will be measured for their baseline outcome measures and then randomised into one of the two groups. Randomization will be done by coin toss method. Head of the coin shall represent Group A and tail shall represent Group B. The consecutive subject will be allocated into the other group, to minimize sample size bias. The subjects will be intervened, as follows.
Group A – Taping with active exercises
Group B – Active exercises only
The subjects will be treated for 1 month duration and final outcome measures will be measured at 4 week duration.
7.11PROCEDURE to measure outcome measures
Primary outcome measures
The primary outcome measures which will be used for our study:
Shoulder disability (SDQ )
the subjects will be given SDQ and asked to score appropriately for the 16 listed items in the questionnaire. The 16 items describe a possible pain provocation during last 24 hours of subjects daily activities .the questionnaire is completed with yes , no, or not applicable response. The score is calculated by adding all yes answers divided by total number of questions and subsequently multiplied by 100. This results in a score between 0 (no disability) to 100 (severe). 4, 19, 20
Scapular instablity(LSST)
The subject will be instructed to undress sufficiently to expose their upper backs (scapula). The inferior angle of scapula and spinous process will be palpated by the researcher. In the resting position, with the arm beside the trunk, the distance between the inferior angle of scapula & nearest vertebral spinosu process shall be measured with an inch tape (in centimetres), bilaterally. The subject will be instructed to abduct the shoulder to 45 & 90 degrees respectively in the coronal plane. The distance between inferior angle & spinous process will be measured again bilaterally. The procedure will be repeated thrice and average values will be used for data analysis.
The subject would be instructed to perform the test actively. However, if the subject perceives severe pain, the arm will be supported by the therapist in the desired positions and the distance will be measured.
PAIN (VAS)
VAS will be used for the assessment of severity of shoulder pain both at rest and shoulder activity which aggravates the symptoms . The VAS is believed to be reliable, valid and sensitive to change.The patient will be given a strip of paper on which there will be a line 10 cm. long. The numbers 0 at one end of the line and “10” will be on the other end of the line. The numbers represent the degree of pain intensity. “0” indicates “no pain” and “10” indicates “maximum pain”. The patients will be asked to mark the number in the line at the point corresponding to the intensity of pain at that very moment.
Secondary outcome measures
RANGE OF MOTION
ROM will be measured by standard goniometer for flexion, scaption and abduction24
FORWARD SHOULDER POSTURE (Acromial distance)
Subject will be positioned in lying and the distance between posterior border of acromion and table in supine position.4The procedure will be repeated three times bilaterally and also when the subject is instructed to retract both the shoulders while keeping thorax fixed against the table.
PECTORALIS MINOR LENGTH(cm)
With the subject supine, the distance between 4th rib and coracoid process will be measured to give the pectoralis minor length. The procedure will be repeated thrice bilaterally and used to calculate the pectoralis minor index.
PMI= distance/height of subject * 100
Pectoralis minor index less than 7.65 refers to shortening of pectoralis minor.4
ISOMETRIC ELEVATION STRENGTH
It will be measured in jobe’s test position using a hand held dynamometer. Subject will be instructed to elevate the arm to 90 degree in the plane of scapula and internally rotated by pointing the thumb. The dynamometer will be placed just above the elbow. The subject is instructed to elevate with maximum strength for a duration of 2 seconds, without breath hold. The test will be performed below the pain threshold level of the subject.
PROCEDURE FOR INTERVENTION
subjects will be allocated into two groups randomly by concealed envelope , the outcome measures will be measured at baseline.
Group A
The treatment protocol for group A will be scapular taping with active intervention.
Taping technique: Taping will be done in the affected side. The subject will be sitting on a table. The shoulder and the scapular area will becleaned with a spirit swab. A cover roll stretch will be used to protect the subject’s skin. The first stripwill be applied pulling proximally from upper trapezius to inferior angle of scapula and the second strip will be applied from the posterior lateral acromion diagonally across the back and ending just lateral to thoracic spinous process.12
The taping will be initiated by applying the first strap over the anterior deltoid muscle and extended posteriorly along the line of scapula terminating before midline.