Rajiv Gandhi University Of Health Sciences
Bangalore
ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1. / Name of the candidate and address / MONIKA BHATGARDEN CITY COLLEGE OF PHYSIOTHERAPY,
16th KM OLD MADRAS ROAD,
VIRGONAGAR POST,
BANGALORE-49
2. / Name of the institution / GARDEN CITY COLLEGE OF PHYSIOTHERAPY
3. / Course of study and subject / MASTER OF PHYSIOTHERAPY
(PHYSIOTHERAPY IN MUSCULOSKELETAL DISORDERS AND SPORTS PHYSIOTHERAPY)
4. / Date of admission to course / 17-05-2007
5. / TITLE OF THE TOPIC: A STUDY ON EFFECTIVENESS OF MULLIGAN MOBILIZATION VERSUS CODMAN PENDULAR EXERCISES IN FROZEN SHOULDER
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8. / BRIEF RESUME OF THE INTENDED WORK:
6.1 NEED FOR THE STUDY
The term frozen shoulder was first introduced by Codman in 1934.He described it as "a painful condition of insidious onset that was associated with stiffness and difficulty sleeping on the effected side."
Long before Codman, in 1872, same condition was termed as ‘periarthritis’ by Duplay . In 1945 Naviesar coined the term adhesive capsulitis1.
Frozen shoulder is a specific condition that has natural history of spontaneous resolution and requires a management pathway that is completely different from such distinct shoulder conditions as rotator cuff tear or osteoarthritis2.
Three phases of clinical presentation3
· Painful freezing phase Duration 10-36 weeks
· Adhesive phase Occurs at 4-12 months.
· Resolution phase Takes 12-42 months
There are increasing numbers of reports espousing the clinical beneficial effects of Mulligan mobilization treatment techniques. The most frequent reported effect is that of an immediate and substantial pain relief accompanied by improvement in function. Prompted by these dramatic effects are questions regarding the mechanisms of action that underpins Mobilization With Movement (MWM ).4
Codman’s pendular exercises are techniques that use effects of gravity to distract the humerus from glenoid fossa5. Hence these are passive movements assisted by gravity. They help relieve pain through gentle traction and oscillating movement and provide early motion of joint structures and synovial fluid6.
Both MWM and Codman exercises are prescribed in case of frozen shoulder and both of them have been successfully administered for managing the frozen shoulder.
Hence the need of this study is to compare Mulligan mobilization technique versus Codman exercises in frozen shoulder patients, and there by find out which one is more appropriate and efficient in improving functional abilities of shoulder.
Not many studies have been done in this field so far.
6.2 REVIEW OF LITERATURE:
1. Yesim Kurtais, et.al(2004) Forty patients who were diagnosed to have periarticular soft tissue disorder of the shoulder were randomly assigned to either a group that received true Ultrasound(US) or a group that received sham Ultrasound(US). Besides true or sham US (10 minutes), superficial heat (10 minutes), electrical stimulation (15 minutes), and an exercise program (15–30 minutes) were administered to both groups 5 days each week for 3 weeks. The results suggest that true US, compared with sham US, brings no further benefit when applied in addition to other physical therapy interventions in the management of soft tissue disorders of the shoulder.7
2. Jing-lan Yang et.al(2007) The purpose of this study was to comparethe use of 3 mobilization techniques—end-range mobilization(ERM), mid-range mobilization (MRM), and mobilization with movement(MWM)—in the management of subjects with frozen shouldersyndrome (FSS) Twenty-eight subjects with FSS were recruited. The authors conclude that in subjects with FSS, ERM and MWMwere more effective than MRM in increasing mobility and functionalability. Movement strategies in terms of scapulo-humeral rhythmimproved after 3 weeks of MWM.8
3. Pamela Teysa, et.al (2006) The objective of this study was to investigate the initial effects of a Mulligan's mobilization with movement (MWM) technique on shoulder ROM in the plane of the scapula and Pain pressure threshold(PPT) in participants with anterior shoulder pain on 24 subjects (11males and 13 females).The results indicate that this specific manual therapy treatment has an immediate positive effect on both ROM and pain in subjects with painful limitation of shoulder movement. Further study is needed to evaluate the duration of such effects and the mechanism by which this occurs.9
4. Adam S. Dowrick, et.al,(2004) This paper reviews instrument designed for patient self-evaluation of musculoskeletal disorders of the upper extremity, and instruments used in an orthopaedic trauma population to assess functional recovery following injury The DASH questionnaire is a regional outcome measure suitable for patients with upper extremity musculoskeletal conditions and consists of 30 items . A study examining the reliability of the DASH in patients with shoulder pain found the internal reliability (Cronbach's alpha) of the questionnaire to be 0.96.10
5. Gulick et.al(2007) The purpose of this case report is to describe a novel approach to help a patient with a medical diagnosis of adhesive capsulitis. The patient was a 64-year-old female with adhesive capsulitis. Outcome variables were the Shoulder Pain and Disability Index (SPADI), internal rotation (IR) and external rotation (ER) ROM, and rotational lack. Twelve treatments of moist heat, analgesic nerve block electrical stimulation, contract/relax exercises for shoulder IR/ER, and Pendulum/Codman exercises were administered. After both 2 and 4 weeks of treatment, the patient demonstrated marked improvements in all areas. Overall, there was a 78-106% increase in ROM (IR and ER) and a 50-83% improvement in functional mobility (rotational lack & SPADI.11
6. D Y Bulgen, et.al,(1984)Forty-two patients with frozen shoulder were taught Pendular exercises and randomly allocated to one of four treatment groups:(a) intra-articular steroids,(b) mobilisations ,(c) ice therapy,(d) no treatment. This study has shown that there is little long-term advantage in any of the treatment regimens but that steroid injections may benefit pain and range of movement in the early stages of the condition.12
6.3 OBJECTIVE OF THE STUDY
· . To study the effects of Mulligan mobilization on frozen shoulder.
· To study the effects of Codman exercises on frozen shoulder.
· To compare the effectiveness of Mulligan mobilization techniques versus Codman’s Pendular exercises in frozen shoulder.
HYPOTHESIS
Null Hypothesis:
The effects of Mulligan mobilization and Codman exercises on performance of shoulder are not different.
Alternate Hypothesis:
The effects of Mulligan mobilization and Codman exercises on performance of shoulder are different.
MATERIALS AND METHODS:
7.1 SOURCE OF DATA
Data for the study will be obtained from :
ITI General hospital and Outpatient department of Garden City College of Physiotherapy.
7.2 METHOD AND COLLECTION OF DATA
· The subjects for the study would be selected by random sampling method.
· The study population would be 30 subjects. In case of any drop out during the conduct of the study the next subject with the same criteria, of selection would be a part of the sample.
STUDY DESIGN
· Experimental study design
INCLUSION CRITERIA
1. Diagnosed as primary idiopathic periarthritis shoulder.
2. Unilateral involvement.
3. Both male and female.
4. Age 40 to 65 yr.
5. No previous physiotherapeutic treatment.
6. Experiencing symptoms of pain & limited ROM for more than 3 months.
7. Second and third stage of frozen shoulder.
EXCLUSION CRITERIA
1. History of major shoulder injury or surgery.
2. Any neurological deficit.
3. Any significant radiological change in shoulder joint.( no changes in cartilegenous joint space or absence of pathological changes other than oesteopenia)
4. Uncooperative patient.
5. Secondary adhesive capsulitis.
6. Any infective diseases/ skin conditions.
7. Signs of acute joint inflammation & muscle spasm
7.3 INTERVENTION / ASSESSMENT TO BE DONE
METHODOLOGY
· Present study intends to compare effectiveness of Mulligan mobilization versus Codman Pendular exercises in frozen shoulder.
· This study includes 30 subjects aged between 40 to 65 yrs.
· The subjects are randomly divided into 2 equal groups.
· All subjects are educated about respective exercise protocols and a prior informed consent is obtained.
· Pretest assessment is done by Disabilities of Arm ,Shoulder and Hand scale .[ DASH] [DASH] OUTCOME QUESTIONAIRE consists of 30 disability/symptoms scale scored 0 (no disability) to 100 (maximum disability ) .
· Common modality for both the groups : - Before resorting to passive mobilization, the thick and contractile capsule can be relaxed and made more stretchable by deep heating using ultrasonics.13Both the groups will receive continuous US operated at a frequency of 1 MHz and at an intensity of 1.5 W/cm2.The treatment duration is 10 minutes7.Ultrasound besides deep heating has the added advantage of increasing extensibility of the contracted soft tissue and therefore preferred.14
· First group is given mulligan mobilization. The treatment condition consists of the application of a postero-lateral glide to the affected shoulder (MWM).The patient is seated and the therapist stands beside the patient on the opposite side to the affected shoulder. One hand is placed over the scapula posterior while the thenar eminence of the other hand is placed over the anterior aspect of head of the humerus. A posterior gliding force is applied to the humeral head. The patient is then asked to raise the affected arm in the plane of the scapula to the point of pain onset while the therapist sustains the gliding force to the humeral head, with care to avoid the sensitive coracoid process. Three sets of 10 repetitions are applied with a rest interval of 30 seconds between each set. The therapist maintains the glide at right angles to the plane of movement throughout the entire range. The participant is instructed that the MWM procedure, including arm elevation, has to be pain free, and must be ceased immediately if any pain is experienced during the application.15
· The Second group is given a series of Pendular exercises. The patient is asked to bend forwards at waist and let the effected side arm hang freely from the ground. He is then instructed to sway back and forth generating small circles with dangling limb. Exercises begin with 2 sets of 10 repetitions in both clockwise and anticlockwise direction.
· All subjects are to exercise under supervision. All are to exercise 5 days a week for 3 weeks. Each subject is assessed at the end of 3 weeks using DASH Questionnaire.
· The duration of the treatment would be 3 weeks.
STATISTICAL TOOL
· Student’s t test will be used for comparing the data.
7.4 ETHICAL CLEARENCE
· Ethical clearance for the study has been obtained from the ethical committee of our institution
LIST OF REFRENCES:
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1. John Ebnezar ,Essentials of orthopaedics for physiotherapists, 2002 reprinted 2nd Ed, page no.226
2. Richard Dias, et.al, Frozen shoulder, BMJ2005; 331:1453-1456(17December).
3. Richard Dias, et.al, Frozen shoulder, BMJ2005; 331:1453-1456(17December).
4. Bill Vicenzino , et.al, Mulligan's mobilization-with-movement, positional faults and pain relief: Current concepts from a critical review of literature, Manual therapy volume 12,issue, May 2007, Pages 98—108.
5. Cailliet, R: Shoulder Pain, ed 3. F A Davis, Philadelphia, 1991.
6. Kisner ,Colby: Therapeutic Exercise, ed 4th ,F A Davis 2002 ,page no 325
7. Yesim Kurtai, et.al, Adding Ultrasound in the Management of Soft Tissue Disorders of the Shoulder .A Randomized Placebo-Controller Trial; Manual Therapy, Vol. 84, No. 4, April 2004, pp. 336-343
8. P Jing lan Yang,et.al, Mobilization Techniques in Subjects With Frozen Shoulder Syndrome: Randomized Multiple-Treatment Trial,Physical Therapy, 2007, 87(10) , 1307-1315.
9. Pamela Teys, Et.al,The initial effects of a Mulligan's mobilization with movement technique on range of movement and pressure pain threshold in pain-limited shoulder, Manual therapy,( in press),received 15 December 2005; received in revised form 10 May 2006; accepted 21 July 2006 .
10. .Adam S.Dowrick, Outcome instruments for the assessment of the upper extremity following trauma: a review, injury, vol 36, issue4, April2005, Pages468-476
Accepted 29 June 2004. Available online 28 November 2004.
11. Dawn T. Gulick ;et.al , Physiotherapy theory and Practice Volume 23, Issue1 January 2007 , pages 57 – 63
12. DA Y Bulgen, et.al Frozen shoulder: prospective clinical study with an evaluation of three treatment regimens, Rheum Dis. 1984 June; 43(3): 353–360.
13.John Ebnezar, Essentials of orthopaedics for physiotherapists,2002reprinted 2nd Ed, page 227
14. Jayant Joshi et.al, Essentials of orthopaedics and applied physiotherapy,1999, page no 475
15. Brian Mulligan. The Painful Dysfunctional Shoulder. A New Treatment Approach Using ‘Mobilisation with Movement’. N Z Journal of PT, Nov 2003, Volume 31(3): 140-142.