RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
ANNEXURE-II
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1 / NAME OF THE CANDIDATE AND ADDRESS / Mr. M. PALANIVELUNo.204, 1st ‘A’ BTS Road
8th Main, Sunkal Farm Layout,
Bangalore - 560030.
2 / NAME OF THE INSTITUTION / THE OXFORD COLLEGE OF PHYSIOTHERAPY
Survey No.6/9 & 6/11, 1st Cross,
Begur Road,Hongasandra,
Bangalore-560068.
3 / COURSE OF THE STUDY AND SUBJECT / MASTER OF PHYSIOTHERAPY
(MUSCULOSKELETAL DISORDERS AND SPORTS)
4 / DATE OF THE ADMISSION TO THE COURSE / 12-06-2009
5. / TITLE OF THE STUDY
“TO COMPARE THE EFFECTIVENESS OF ANTERIOR AND INFERIOR VERSUS
POSTERIOR AND INFERIOR GLIDE JOINT MOBILIZATIONS ON FUNCTIONAL
OUTCOME IN PATIENTS WITH SHOULDER ADHESIVE CAPSULITIS”.
6. / BRIFE RESUME OF INTENDED WORK:
6.1. NEED OF THE STUDY:
Adhesive capsulitis is caused by inflammation of the joint capsule and synovium that eventually results in the formation of capsular contractures.1 Physical therapy is commonly prescribed for this condition. Dianne v Jewell et al found that Ultrasound, massage, iontophoresis and phonophoresis not had much significance in reducing pain, increasing ROM and function.2
Mobilization has been recognized increasingly by physiotherapist for its value in the treatment on adhesive capsulitis.3 Very less studies have been conducted to check the functional outcomes.
According to concave-convex rule, the anterior directed mobilization is selected to manage hypo mobility in external rotation.5 When the external rotation of the shoulder taking place the head of the humerus will automatically move anteriorly as per concave-convex rule. So as per joint surface motion therapist use to do anterior glide to do external rotation.
Asymmetrical tightening of the capsule during the humeral rotation, resulting in translation of the humeral head in the direction opposite to the tightened capsule. The humeral head initially translates the direction opposite to the motion, due to the joint surface geometry. Then increasing moment angle of rotation the humeral head changes as the capsular tightens.6
In adhesive capsulitis, capsular contractures develop usually in the area of rotators cuff interval.7 A tight rotary cuff interval may not only limit the ROM, it produce unwanted obligate anterior superior translation thus limiting the posterior translation associated with external rotation.8
By manipulating the humeral head posteriorly it might have increased total allowable excusrion of the capsule thus improving external rotation.9
The presumed pathology of underlying capsular restrictions, a treatment focus on managing external rotation, abduction are based on the impairment level. The ability to perform various activity of daily living is part of shoulder function. This implies that the ability to perform ADL activities reflects, among other factors, the range of motion of the shoulder. The inability to carry out the activities of daily living, correlate significantly with the range of motion of the shoulder.11
Shoulder range of motion is generally measured in terms of flexion, external rotation, abduction but in functional activities these pure motions are rarely seen and the shoulder presence large range of motion, movements are coupled and multiplanar motion occur in the activity.4
Rajendran et al demonstrated automatic external rotation of the humerus is an essential component of active as well as passive elevation of the arm through abduction.8 So, Interior glide included in the study for functional outcome.
The purpose of this study is to compare the effectiveness of anterior and inferior
versus posterior and inferior glide joint mobilizations on functional outcome in patients with
shoulder adhesive capsulitis
6.2 REVIEW OF LITERATURE:
1. G.C.R. HAND, ET AL (2007) revealed that the capsule was characterized by presence of fibroblast, proliferating fibroblast and chronic inflammatory cells.
2. DIANNE V JEWELL, ET AL(2009) conducted the study whether physical therapy intervention predicted meaningful short-term improvement in pan, function and found out that electro modalities are not having significant reduction pain and in improving ROM.
3. JING-LAN YANG ET AL(2007) conducted an investigation to find the effect of mobilization treatment and found mobilization techniques improved the normal extensibility of shoulder capsule.
4. MARGARETA NORDEN, ET AL(2001) – Basic Biomechanics of the musculoskeletal system, Third edition, Lippincott Williams & Wilkins, Page-319.
5. G.D.MAITLAND(1991) - Peripheral manipulation –3rd ed. Butterworth Heinemam;p 149.
6. NOVOTNY JE, ET AL(1998) studied the normal kinematics of the unconstrained glenohumeral joint under coupled moment loads and found out that when increasing moment and angle of rotation, translation changed the direction and moved with the primary motion.
7. UITVLUGT G, ET AL(1993) studied arthroscopic observations before and after manipulation of frozen shoulder and found that there was synovial and capsular hemorrhage indicative of tearing from manipulation.
8. HARRYMAN DT, ET AL(1990) studied translation of humeral head on the glenoid with passive glenohumeral motion and found out imbrications of posterior part of capsule increase the resistance to inferior and posterior translation.
9. ROUBAL PJ, ET AL(1996) conducted study on glenohumeral gliding manipulation following interscalene brachial plexus block in patients with adhesive capsulitis and found out that effective gliding manipulation can be carried out under regional blockade and performed in an office setting by practioners knowledge in manipulation techniques.
10. RAJENDRAN ET AL (1991) demonstrated automatic external rotation of the humerus is essential component for elevation of the arm through abduction.
11. PAUL D.TRIFFITT, (1998) studied the relationship between motion of the shoulder and the stated ability to perform Activities of daily living and found out the ability to carry out activities of daily living particularly those that are performed regularly by most patients, correlate significantly with range of motion of the shoulder.
OUTCOME MEASURES:
12. BEATON DE, ET AL (2001) evaluated the reliability, validity and responsiveness of DASH outcome measure in different regions of the upper extremity and concluded that DASH had validity, reliability and responsiveness in both proximal and distal disorders, confirming its usefulness across the whole extremity
13. BOT SD, ET AL (2004) studied Clinimetric evaluation of shoulder disability questionnaires: a systemic review of the literature and found out the DASH received the best ratings for its clinimetric properties.
14. RIDDLE DL, ET AL (1987) studied goniometric reliability in clinical setting. Shoulder measurements. And found out the degree of intertester reliability for these measurements appears to be range of motion specific.
6.3 OBJECTIVES OF THE STUDY:
1. To find out the effectiveness of anterior and inferior glide on functional outcome in patients with shoulder adhesive capsulitis.
2. To find out the effectiveness of posterior and inferior glide on functional outcome in patients with shoulder adhesive capsulitis.
3. To compare the effectiveness of anterior and inferior glide versus posterior and inferior glide on functional outcome in patients with shoulder adhesive capsulitis.
6.4 HYPOTHESES
Research Hypothesis: There is a significant difference between anterior and inferior glide and posterior inferior glide mobilization on functional outcome in patients with shoulder adhesive capsulitis.
Null Hypothesis: There is no significant difference between anterior and inferior glide and posterior inferior glide mobilization on functional outcome in patients with shoulder adhesive capsulitis.
7.MATERIALS AND METHODS
7.1 STUDY DESIGN AND SETTING
7.1.1 STUDY DESIGN
· Simple Random Sampling Method
7.1.2 SOURCE OF DATA
Samples for the study will be collected from
· OPD in Oxford College of Physiotherapy
· Sanjay Gandhi Trauma & Orthopedics Centre, Bangalore
· Spine and Orthopedic Centre, Bangalore
7.2 METHODOLOGY
7.2.1 POPULATION:
Both male and female subjects diagnosed with adhesive capsulitis with age group of 45 to 60 who satisfy the selection criteria, form the population of study.
7.2.2 SELECTION CRITERIA:
a) INCLUSION CRITERIA.
In order to participate in the study, subjects must satisfy the following criteria.
1. Patients at 2nd stage of adhesive capsulitis that lasts anywhere 4 to 12 months
2. Age group between 45 to 60 years
3. Dominant shoulder involvement
4. External rotation ROM restriction that decrease with shoulder abduction
5. Abduction ROM < 80 deg, Flexion < 100 deg, External Rotation < 45 deg
b) EXCLUSION CRITERIA:
Subjects will be excluded from this study if any of following criteria apply
1. Degenerative disorders of joint
2. Rotator cuff pathologies
3. Any neurological deficits (stroke, Parkinson's disease)
4. Contra-indicated to ultrasound therapy
5. Recent fracture of upper limb
6. Cardiac origin shoulder pain
7. Manipulation under anesthesia
7.2.3 SAMPLING METHOD AND SAMPLE SIZE
· Simple Random Sampling Method
· Sample size consists of 120 patients with 40 patients in each group
7.2.4 PROCEDURE
The people who fulfilled the inclusion criteria will be selected for the study and they will be informed about the purpose of the study, procedure and effects of intervention. Informed consent will be obtained.
Pre and Post functional outcome will be obtained by DASH questionnaire and ROM of Shoulder flexion, abduction and external rotation using Universal Goniometer for all subjects.
Subjects are divided into 3groups:
Group A) Experimental Group 1
Group B) Experimental Group 2
Group C) Control Group
Group A:
EXPERIMENTAL GROUP: 1
Ultrasound will be given at the beginning of intervention as it helps to alter Viscoelastic properties of the connective tissue and maximize the effectiveness of the stretch mobilization.15
Anterior and Inferior Maitland grade III joint mobilization technique will be followed by ultrasound therapy. i.e. large amplitude movement performed into resistance or up to the limit of the range.
The subjects will be advised to do shoulder ROM and pendulum exercises.
ANTERIOR AND INFERIOR GLIDE MOBILIZATION TECHNIQUE:
ANTERIOR GLIDE:
The patient is positioned supine and the therapist stands away from the patients shoulder facing across his body. Patient arm is abducted and stabilized by holding his forearm against therapist right side. The palmar surface of the index fingers contact the back of the head of the humerus, Therapist padded surface of thumb hold around the humerus to form an encompassing grasp.
The slack of scapular movement is taken up by lifting the head of the humerus. So that any further oscillatory movement will be associated with the postero-anterior gleno humeral movement. The direction of the postero-anterior movement is parallel to the inferior surface of the acromian process.
INFERIOR GLIDE:
Patient positioned in supine and the heel of the hand is placed against the head of the patient humerus immediately adjacent to the acromian process and therapist finger spread over his shoulder towards his neck.
The movement is produced entirely by the pressure of the therapist hand against the head of humerus from the superior extent of the glenoid cavity to its inferior extent.
Stretch hold is held for at least one minute. Sustained stretch at end range will be performed at least 15 minutes per session. Treatment duration of per session is 30 minutes.
Pre and Post functional outcome will be obtained from both the experimental groups by DASH questionnaire and ROM of Shoulder flexion, abduction and external rotation using goniometer for all subjects.
EXPERIMENTAL GROUP: 2
Ultrasound will be given at the beginning of intervention as it helps to alter Visco elastic properties of the connective tissue and maximize the effectiveness of the stretch mobilization.
Posterior and Inferior Maitland grade III joint mobilization technique will be followed by ultrasound therapy. i.e. large amplitude movement performed into resistance or up to the limit of the range.
The subjects will be advised to do shoulder ROM and pendulum exercises.
POSTERIOR GLIDE AND INFERIOR GLIDE MOBILIZATION TECHNIQUE:
POSTERIOR GLIDE
The therapist stands by the patients shoulder facing his feet and supports the distal end of his humerus posteriorly from the medial side with the hand, abducts his arm then rests his flexed forearm on therapist forearm. The cupped heel of the hand placed anteriorly against the head of the humerus with therapist finger extended medially across the adjacent clavicular area.
The oscillatory movement is produced by pressure against the head of the humerus with the hand.
INFERIOR GLIDE
Patient positioned in supine and the heel of the hand is placed against the head of the patient humerus immediately adjacent to the acromian process and therapist finger spread over his shoulder towards his neck.
The movement is produced entirely by the pressure of the therapist hand against the head of humerus from the superior extent of the glenoid cavity to its inferior extent.
Stretch hold is held for at least one minute. Sustained stretch at end range will be performed at least 15 minutes per session. Treatment duration of per session is 30 minutes.
Group C:
CONTROL GROUP
In this group they will receive ultrasound therapy, shoulder ROM and pendulum exercises.
DURATION OF STUDY
Treatment for both the experimental groups and control group will receive 3 sessions per week for about 3 weeks.
MATERIALS REQUIRED
1 Universal Goniometer
2 Ultrasound therapy unit (1 megahertz)
3 DASH Questionnaire
7.3. OUTCOME MEASURES AND STATISTICAL ANALYSIS
7.3.1 OUTCOME MEASURES
DASH Questionnaire
Range of Motion
7.3.2. STATISTICAL ANALYSIS
ANOVA used as the statistical test to analyze significant variability between the groups for every test considered for the study.
7.4 a. Does the study require any interventions to be conducted on patients or other humans or animals?
Yes. The study requires intervention on functional outcome in
patients with shoulder adhesive capsulitis
7.4 b. Has the ethical consent for the study has been obtained from the institution in case?
Yes, it has been obtained from the institution. Ethical clearance form is attached as appendix I. An informed consent will be obtained prior to study from each subject in their native language (appendix II)
REFERENCES:
1. G.C.R.Hand, N.A.Athanasou, T.Mathews, A.J.Carr. The pathology of frozen shoulder JBJS 2007; issue 7: Vol 89-B: 928-932.
2. Dianne V Jewell, Daniel L Riddle and Leroy R Thacker. Interventions associated with an increased or decreased likelihood of pain reduction and improved function in patients with adhesive capsulitis: A retrospective cohort study. phys ther 2009; may: 89(5): 419-429
3. Jing-lan yang, Chein-wei Chang, Shiau-yee Chen, Shwu-Fen Wang and Jiu-jenq Lin. Mobilization Techniques in Subjects With Frozen Shoulder Syndrome: Randomized Multiple-Treatment Trial. phys ther 2007; oct; vol.87(10): 1307-1315
4. Margareta Nordin, Victor H.Frankel, Basic Biomechanics of the musculoskeletal system. 3rd ed, Lippincott Williams & willkins.2001; p.319.
5. Maidland.Peripheral manipulation. 3rd ed. p149.
6. Novotny JE, Nichols CE, Beynnon BD. Normal kinematics of the unconstrained glenohumeral joint under coupled moment loads. J shoulder elbow surg 1998; Nov-Dec 7(6): 629-39
7. Uitvlugt J, Detrisac DA, Johnson LL, Austin MD, Johnson C. Arthroscopic observations before and after manipulation of frozen shoulder Arthroscopy 1993; vol 9: issue 2: 181-185
8. Harryman DT, Sidles JA, Clark JM, MC/Quade KG, Gibb TD, Matsen FA. Translation of the humeral head on the glenoid with passive glenohumeral motion J Bone J Surg 1990; 72(9): 1334-1343
9.Roubal PG, Dobritt D, Placzek JD Glenohumeral gliding manipulation following interscalene brachial plexus block in patients with adhesive capsulitis J.ortho p sports phys ther 1996; Aug; 24(2): 66-77
10. K.Rajendran. The rotary influence of articular contours during passive Gleno humeral abduction.singapore med J 1992; vol 33: 493-495
11. Paul D.Triffitt.The relationship between motion of the shoulder and the stead ability to perform Activities of Daily living.JB & JS 1998; 80: 41-6
12. Beaton DE, Katz JN, Fossel AH, Wright JG, Tarasuku, Bombardier C.Measuring the whole or the parts? Validity, reliability, and responsiveness of the disabilities of the arm, shoulder and hand outcome measure in different regions of the upper extremity. J hand ther 2001 Apr-Jun; 14(2): 128-46
13. Bot SD, Terwee CB, Vander windt DA, Bouter LM, Dekker J, de vet HC. Clinimetric evaluation of shoulder disability questionnaires: a systematic review of the literature Ann Rheum disses 2004; Apr; 63(4); 335-41.
14. Riddle DL, Rothstein JM, Lamb RL. Goniometric reliability in a clinical setting. Shoulder measurements Phy Ther; 1987 may;67(5): 668-73.
15. Claudia A Knight, carie R Rutledge, michael E cox, martha A Costa and Susan J Hall. Effect of superficial heat, Deep heat and Active exercise warm-up on the Extensibility of the plantar flexors Phys ther 2001; June; vol 81, no.6: 1206-1214.
9. / Signature of the candidate
10. / Remarks of the guide
11. / NAME AND DESIGNATION OF THE
GUIDE / Mr.K.G.Kirubakaran ,
Principal
11.1 / Signature
11.2 / Co-guide / Mr.T.Sathiyaselvam
Asst.Professor
11.3 / Signature
12. / Remarks of chairman
and principal
12.1 / Signature
APPENDIX-I