DISSERTATION SYNOPSIS
SUBMITTED TO
RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA
BANGALORE
TOWARD PARTIAL FULFILMENT OF
MASTER OF PHYSIOTHERAPY DEGREE COURSE
By
NAIR PREMA
UNDER THE GUIDANCE OF
V S SARAVANAN
VIKAS COLLEGE OF PHYSIOTHERAPY
MARYHILL, KONCHADY, MANGALORE-575006
2010-12
RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA
BANGALORE
REGISTRATION OF SUBJECTS FOR DISSERTATION
1. / Name of the Candidateand Address / NAIR PREMA
VIKAS COLLEGE OF PHYSIOTHERAPY
AIRPORT ROAD
MARYHILL, KONCHADY
MANGALORE – 575008
2. / Name of the Institution / VIKAS COLLEGE OF PHYSIOTHERAPY
Mangalore.
3. / Course of study and subject / Master of Physiotherapy (MPT)
Physiotherapy in Musculoskeletal Disorders and Sports Physiotherapy
4. / Date of admission to Course / 17-03-2010
5. / Title of the Topic
A COMPARATIVE STUDY BETWEEN THE EFFICACY OF DEEP HEATING WITH ACTIVE EXERCISE VERSUS DEEP HEATING WITH MANUAL MOBILIZATION ON PATIENTS WITH FROZEN SHOULDER.
6 / BRIEF RESUME OF THE INTENDED WORK
6.1) Need for the study
Frozen shoulder, medically referred to as adhesive capsulitis, is a disorder in which the shoulder capsule, the connective tissue surrounding the glenohumeral joint of the shoulder, becomes inflamed and stiff, and grows together with abnormal bands of tissue, called adhesions, greatly restricting motion and causing chronic pain. Shoulder specialist Dr Robert Codman first described 'Frozen Shoulder' in 1934, although this painful shoulder condition had frustrated patients and doctors for centuries before this. The fact that Frozen Shoulder merely describes what the patient experiences, is evidence that the condition was still poorly understood. In 1945, Nevasier used the term Adhesive Capsulitis and described the pathology as being characterized by adhesions and contractures of the fibrous capsule that surrounds the shoulder joint. (1) While other conditions can produce a stiff shoulder and shoulder pain, frozen shoulder is characterized by adhesions of the capsule. Frozen shoulder syndrome is a condition of uncertain etiology characterized by a progressive loss of both active and passive shoulder motion. (2-4) Clinical syndromes include pain, a limited range of motion and muscle weakness from disuse. (2, 3,5) The natural history is uncertain .Abnormal bands of tissue grow between the joint surfaces, restricting motion. There is also a lack of synovial fluid, which normally helps the shoulder joint move by lubricating the gap between the humerus and the socket in the scapula. It is this restricted space between the capsule and ball of the humerus that distinguishes adhesive capsulitis from a less complicated, painful, stiff shoulder. People with diabetes, stroke, lung disease, rheumatoid arthritis, Cervical disk disease, Degenerative arthritis and heart disease, or who have been in an accident are at a higher risk for frozen shoulder. The condition rarely appears in people under 40 years old and (at least in its idiopathic form) is much more common in women than in men. Cyriax (6) suggested that tightness in a joint capsule would result in a pattern of proportional motion restriction (a shoulder capsular pattern in which external rotation would be more limited than abduction, which would be more limited than internal rotation. Based on the absence of a significant correlation between joint-space capacity and restricted shoulder ROM, contracted soft tissue around the shoulder may be related to restricted shoulder ROM. (7) Vermeulen and colleagues (4,8) indicated that adherent axillary recess hinders humeral
Head mobility, resulting in diminished mobility of the shoulder. To regain the normal extensibility of the shoulder capsule and tight soft tissues, passive stretching of the shoulder capsule and soft tissues by means of mobilization techniques has been recommended, but limited data supporting the use of these techniques are available. (4,16-23) Midrange mobilization end-range mobilization and mobilization with movement techniques have been advocated by Maitland, (17)
Frozen Shoulder Signs & Symptoms
People complain that the stiffness and pain worsen at night. Pain due to frozen shoulder is usually dull or aching. It can be worsened with attempted motion, or if bumped. A physical therapist may suspect the patient has a frozen shoulder if a physical examination reveals limited shoulder movement. Frozen shoulder can be diagnosed if limits to the active range of motion are the same or almost the same as the limits to the passive range of motion. An arthrogram or an MRI scan may confirm the diagnosis, though in practice this is rarely required.The normal course of a frozen shoulder has been described as having three stages
· Stage one: The "freezing" or painful stage, which may last from six weeks to nine months, and in which the patient has a slow onset of pain. As the pain worsens, the shoulder loses motion.
· Stage two: The "frozen" or adhesive stage is marked by a slow improvement in pain but the stiffness remains. This stage generally lasts from four to nine months.
· Stage three: The "thawing" or recovery, when shoulder motion slowly returns toward normal. This generally lasts from 5 to 26 months. (1)
Deep heating can be effective to help pain relief, depending on personal preference. A study found that heat can provide a significant amount of pain relief. The main aim of physiotherapy treatment is to gently stretch the shoulder joint. Specific frozen shoulder exercises is to offer graduated stretching. For this, mobilizing techniques are given by which patient respond very well for acquiring full range by properly guided simple and specific Frozen shoulder exercises which ensures relaxed graduated stretching of the contracted capsule. Hence Frozen shoulder exercises also plays an important role to reduce pain, to increase extensibility of the thickened and contracted capsule of the joint at the anteroinferior border and at the attachment of the capsule to the anatomical neck of humerus ,to improve mobility of the shoulder.
Due to above factors further studies are necessary to evaluate the effects of passive manual mobilization and active exercise along with deep heating in patient with frozen shoulder. Hence a prospective randomized study is necessary to test the hypothesis that in patients with Frozen shoulder.
6.2) Review of Literature
1. Diercks et al. conducted a study on a convenience sample of Seventy-seven patients with idiopathic frozen shoulder syndrome were included in a prospective study to compare the effect of intensive physical rehabilitation treatment, including
passive stretching and manual mobilization versus supportive therapy and exercises within the pain limits. There were no significant differences in age, sex; time elapsed since onset, and disease severity at inclusion. All patients were followed up for 24 months after the start of treatment. In the patients treated with supervised neglect, 89% had normal or near-normal painless shoulder function at the end of the observation period. In contrast, of the group receiving intensive physical therapy treatment, only 63% reached a Constant score of 80 or higher after 24 months. Both the level of the Constant score at the end of the study and the moment a Constant score of 80 or higher was reached confirm that supervised neglect yields better outcomes than intensive physical therapy and passive stretching in patients with frozen shoulder.(9)
2. Desmeules et al. conducted a randomized controlled trial evaluating the effectiveness of therapeutic exercise and orthopedic manual therapy for the treatment of impingement syndrome. Two independent observers reviewed the methodological quality of the studies using an assessment tool developed by the Cochrane Musculoskeletal Injuries Group.
Differences were resolved by consensus. Seven trials met our inclusion criteria. It suggested some benefit of therapeutic exercise or manual therapy compared with other treatments such as acromioplasty, placebo, or no intervention. There is limited evidence to support the efficacy of therapeutic exercise and manual therapy to treat impingement syndrome.(10)
3. Shaffer et al. conducted a study for Frozen shoulder- A long-term follow-up with Sixty-two patients who had been treated non-operatively for idiopathic frozen shoulder were evaluated subjectively and objectively at two years and two months to eleven years and nine months of follow-up. Thirty-one of these patients still had either mild pain or stiffness of the shoulder, or both. Thirty-seven of the sixty-two patients still demonstrated some restriction of motion as compared with study-generated control values. Ten patients had restriction of forward flexion; eight, of forward elevation; seventeen, of abduction; twenty-nine, of external rotation; and ten, of internal rotation. However, when the motion of each affected shoulder of thirty-seven patients who had unilateral involvement was compared with that of the unaffected contra lateral shoulder, eleven demonstrated some restriction. None of these patients had restriction of forward flexion; two had restriction of forward elevation; two, of abduction; seven, of external rotation; and seven, of internal rotation. The patients who had substantial restriction in three planes or more were thirteen times more likely to be men. Marked restriction, when it was present, was most commonly in external rotation. Only seven patients reported mild functional limitation.(11)
4. Walmsley et al. conducted a study to differentiate early stage of primary adhesive capsulitis from other commonly seen shoulder disorders with the potential to cause pain and limited range of movement. They involved in the diagnosis and treatment of adhesive capsulitis completed the 3 rounds of questionnaires. Following round 3, descriptive statistics were used to screen the data into a meaningful subset. Consensus was achieved on 8 clinical identifiers. These identifiers clustered into 2 discrete domains of pain and movement. For pain, the clinical identifiers were a strong component of night pain, pain with rapid or unguarded movement, discomfort lying on the affected shoulder, and pain easily aggravated by movement. For movement, the clinical identifiers included a global loss of active and passive range of movement, with pain at the end-range in all directions. Onset of the disorder was at greater than 35 years of age. This is the study to establish clinical identifiers indicative of the early stage of primary adhesive capsulitis. Although limited in differential diagnostic ability, these identifiers may assist the clinician in recognizing early-stage adhesive capsulitis.(12)
5. Jewell et al. conducted a study to determine whether physical therapy interventions predicted meaningful short-term improvement in 4 measures of physical health, pain, and function for patients diagnosed with adhesive capsulitis. Data were examined from 2,370 patients who had completed an episode of outpatient physical therapy. None of the patients achieved a 50% or greater improvement. After Discussion Conclusions were These results are consistent with findings from randomized clinical trials that demonstrated the effectiveness of joint mobilization and exercise for patients with adhesive capsulitis. Ultrasound, massage, iontophoresis, and phonophoresis reduced the likelihood of a favorable outcome, which suggests that use of these modalities should be discouraged. (13)
6. Mengiardi et al. conducted a study to evaluate the magnetic resonance arthrographic findings in patients with frozen shoulder. Preoperative MR arthrograms of 22 patients with frozen shoulder treated with arthroscopic capsulotomy were compared with arthrograms of 22 age- and sex-matched control subjects without frozen shoulder. The thicknesses of the coracohumeral ligament and the joint capsule, as well as the volume of the axillary recess, were measured. Patients with frozen shoulder had a significantly thickened CHL and a thickened joint capsule in the rotator cuff interval but not in the axillary recess. The volume of the axillary recess was significantly smaller in patients with frozen shoulder than in control subjects. Synovitis-like abnormalities at the superior border of the subscapularis tendon were significantly more common in patients with frozen shoulder than in control subjects. Thickening of the CHL and the joint capsule in the rotator cuff interval, as well as the subcoracoid triangle sign, are characteristic MR arthrographic findings in frozen shoulder. (14)
7. Dodman et al. a test on personality on frozen shoulder with Fifty-six patients with frozen shoulder have had their personality profiles investigated by means of the Middlesex Hospital Questionnaire. Females showed significantly increased somatic
anxiety compared with controls. It is suggested that this may be important both to aetiology and treatment. Males and females should be assessed separately in future studies of frozen shoulder.(15)
8. Binder et al. found that the natural history of frozen shoulder is poorly documented, a prospective study of 40 patients followed up for 40-48 months (mean 44 months) is described. The range of movement was significantly less than age- and sex-matched controls. Objective restriction was severe in five patients and mild in a further 11. Patients were often unaware that shoulder range was impaired. Dominant arm involvement, manual labour, and mobilization physiotherapy were associated with a less satisfactory outcome. We conclude that, while objective restriction persists, there is little functional impairment in the late stage of frozen shoulder. (21)
9. Placzek et al. conducted a study on Long term effects of glenohumeral joint translational manipulation on range of motion, pain, and function in patients with adhesive capsulitis . Thirty-one patients underwent brachial plexus block followed by translational manipulation of the glenohumeral joint. Changes in range of motion and pain were assessed before manipulation with the patient under anesthesia, immediately after manipulation with the patient still under anesthesia, at early follow
up and at long term follow up. Passive range of motion increased significantly for flexion, abduction, external rotation, and internal rotation. Significant decreases in visual analog pain scores between initial evaluation and the follow up assessments also occurredTranslational manipulation provides a safe, effective treatment option for adhesive capsulitis.(24)
6.3 Objectives of the study
The objective of this study is to determine the effects of deep heating with active exercise versus deep heating with manual mobilization in patients with frozen shoulder in a randomized and a prospective way. Specifically, to determine
The effects of deep heating with active exercise on patients with frozen shoulder.
The effects of deep heating with manual mobilization on patients with frozen shoulder.
To compare the effects of deep heating with active exercise and deep heating with manual mobilization on frozen shoulder patients.
7. Materials and methods
7.1 Source of data
Data will be collected from patients, who are referred to the outpatient physiotherapy department of vikas college of physiotherapy, Mangalore, with diagnosis of Frozen Shoulder after obtaining informed consent.