“A COMPARATIVE STUDY TO FIND OUT THE EFFECT OF ULTRASOUND THERAPY AND MUSCLE ENERGY TECHNIQUES VERSUS ULTRASOUND ALONE IN PATIENTS WITH ADHESIVE CAPSULITIS OF SHOULDER JOINT”

SUBMISSION OF SYNOPSIS FOR THE REGISTRATION OF THE

DISSERTATION FOR MASTER OF PHYSIOTHERAPY

SUBMITTED TO RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

SUBMITTED BY

SHIVESH KUMAR

RV COLLEGE OF PHYSIOTHERAPY

BANGALORE

KARNATAKA

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

ANNEXURE – II

PROFORMA FOR THE REGISTRATION OF SUBJECT OF

DISSERTATION

1 / NAME OF THE
CANDIDATE / SHIVESH KUMAR
R V COLLEGE OF PHYSIOTHERAPY, JAYANAGAR 4TH BLOCK, BANGALORE 11,KARNATAKA
2 / NAME OF THE
INSTITUITION / RV COLLEGE OF PHYSIOTHERAPY,JAYA
NAGAR 4TH BLOCK,BANGALORE-
11,KARNATAKA
3 / COURSE OF STUDY
AND SUBJECT / MASTER OF PHYSIOTHERAPY IN MUSCULO-SKELETAL DISORDER AND SPORTS PHYSIOTHERAPY
4 / DATE OF ADMISSION
TO COURSE / 13 AUGUEST 2012
TITLE OF THE TOPIC
“A COMPARATIVE STUDY TO FIND OUT THE EFFECT OF ULTRASOUND THERAPY AND MUSCLE ENERGY TECHNIQUES VERSUS ULTRASOUND ALONE IN PATIENTS WITH ADHESIVE CAPSULITIS OF SHOULDER JOINT”
6. / RESEARCH QUESTION
Does muscle energy techniques are better effect compared with ultrasound therapy in patient with adhesive capsilitis of shoulder joint.
6.1 / BRIEF RESUME ON THE INTENDED WORK
The term “frozen shoulder” was first introduced by Codman in 1934. He described frozen shoulder as a painful shoulder condition of insidious onset that was associated with stiffness and difficulty sleeping on the affected side. Codman also identified the marked reduction in forward elevation and external rotation that are the hallmarks of the disease. Long before Codman, in 1872, the same condition had already been labeled “peri-arthritis” by Duplay. In 1945, Naviesar coined the term “adhesive capsulitis”. Frozen shoulder is a specific condition that has a natural history of spontaneous resolution and requires a management pathway that is completely different from such distinct shoulder conditions as a rotator cuff tear or osteoarthritis1.
Frozen shoulder is defined as an idiopathic condition of the shoulder characterized by the spontaneous onset of pain in the shoulder with restriction of movement in every direction2. Prevalence of frozen shoulder was found to be 3.06% in a regional community based study2.
Frozen shoulder is a discrete clinical diagnosis for painful restriction of shoulder motion that results from capsular fibrosis. Its etiology, although unclear, is associated with the interaction of constitutional and extrinsic factors among patients who, notably are between 40 and 60 years of age. Stages of freezing, frozen, and thawing characterize the natural history of Frozen shoulder, and the condition is self-limiting within one to three years. By applying appropriate treatment techniques in a creative and judicious manner, the physical therapist can do much to enhance the speed and degree of recovery from frozen shoulder. More controlled studies, however, are needed comparing the combined effects of different forms of treatment.3
Ultrasound is one of the modalities used to treat adhesive capsulitis,it can elevate tissue temperature to depths of 5cm or more. The physiologic response due to ultrasound therapy includes increased collagen tissue extensibility,pain threshold and enzymatic activity, along with changes in nerve conduction velocity, contractile activity of skeletal muscle.3
Muscle energy technique helps is increasing shoulder range of motion. An additional tool for the physical therapist’s ‘manual therapy toolbox’, Muscle Energy Techniques (MET) can help to release and relax muscles, and promote the body’s own healing mechanisms. MET is unique in its application as the client provides the initial effort while the practitioner facilitates the process. The primary force originates from the contraction of soft tissue, which is then utilized to assist and correct the presenting musculoskeletal dysfunction. MET is generally classified as a direct technique – as opposed to indirect –because the muscular effort is from a controlled position, in a specific direction ,against a distant counter force(usually the practitioner). One of the main uses of this method is to normalize joint range, rather than increase flexibility, and techniques can be used on any joints with restricted range of motion (ROM) identified during the passive assessment4.
6.2 / HYPOTHESIS
NULL HYPOTHESIS (H0)
There is no significance difference between ultrasound therapy and muscle energy techniquesin improving functional abilities of patients with adhesive capsulities.
ALTERNATE HYPOTHESIS (H1)
There is a significant difference between ultra sound therapy and muscle energy techniques in improving functional abilities of patients with adhesive capsulitis.
6.3 / REVIEW OF LITERATURE
  • Stephanie D.Moore, Launder KG et al (2011)5 has done a study on muscle enrgy technique .The study included 61 basketball players and they are divided into three groups who received MET for horizontal abductors ,external rotators along with a control group and stated that “a single application of Muscle energy technique for gleno-humeral joint abduction provides improvements in both gleno-humeral joint horizontal adduction and internal rotation range of motion”.
  • John Gibbons (2011)6 in an introduction to Muscle energy technique11 stated that “When used correctly Muscle energy technique can improve joint mobility even when your muscles are initially”.
  • Gonca Bumin , Emine Handan Tuzun et al (2008)7 have done a study to find the reliability and validity of SPADI and concluded that SPADI is a reliable and valid instrument to assess pain and disability in patients with shoulder pathology.
  • F. Angst, J. Goldhahn et al (2006)8 have done a study to find the reliability and validity of SPADI and concluded that SPADI is a practicable, reliable and valid
  • Robertson VJ, Baker KG (2005)9 performed a systematic review of randomized controlled trals in which ultrasound was used to treat people in conditions like musculoskeletal injuries and soft tissue lesions. Each trial was assigned to investigate the contributions of active and placebo ultrasound to the patient’s outcome measured. Thirty-five randomized clinical trials were published. 10 of the 35 RCTS were judged to acceptable methods using criteria based on those developed by Sackett et al. of these RCTS, the results of two trials suggested that therapeutic ultrasound is more effective in treating some clinical problems than placebo ultrasound, and the results of 8 trial suggest that it is not and concluded there is little evidence that active therapeutic ultrasound is more effective than placebo ultrasound for treating people with pain /a range of musculoskeletal injuries/ or for promoting soft tissue healing.
  • Kimberely Hayes et al (2001)10 did a study on “Reliability of five methods for assessing shoulder range of motion”- stated that “goniometry has inter-rater rho (0.64-0.69) and intra rater rho as 0.53-0.65 while assessing shoulder range of motion using goniometry”.
  • Polly E Bijur , Wendy Silver et al(2001)11in their reliability of the visual analog scale for measurement of acute pain Inter class co-efficient of all paired Visual analog scale for pain scores was 0.97[95% CI].This suggests that Visual analog scale is sufficiently reliable to be used to assess acute pain”.
  • Griggs SM, Ahn A, Green A (2000)12 performed a study to evaluate the outcome of patients with idiopathic adhesive capsulitis who were treated with stretching exercises program. Seventy-five consecutive patients with phase II idiopathic adhesive capsulitis were treated with the use of specific four direction of shoulder stretching exercise program and evaluated prospectively and resulted that sixty-four(90%) of the patients reported a satisfactory outcome. There was significant improvement in the scores of pain at rest and pain with activity. Soconcluded that vast majority of patients who have phase II idiopathic adhesive capsulitis can be successfully treated with a specific four-direction shoulder stretching exercise program.
  • Ebenbichler GR, Erdogmus CB, Resch KL et al. (1999)13, Intheir study they selected patients with calcific tendinitis of the shoulder and treated them with pulsed ultrasound (frequency, 0.89 MHz; intensity. 2.5 W/cm2; pulsed mode 1:4) or an indistinguishable sham treatment to the area over the calcification and they found that in patients with symptomatic calcific tendinitis of shoulder, ultrasound treatment helps resolve calcifications and improve function of shoulder.
  • McCormack HM, Horne DJ, Sheather S; (1998):14 In their study “clinical application of visual analog scales” they describe that Visual Analog Scale (VAS) provide a simple technique for measuring subjective experience and it has been established as valid and reliable in a range of clinic and research applications and Visual Analog Scale are one of the most frequently used measurement scale of pain in healthcare research and practice.
  • Zancan A, Gialanella B, Luisa A,et al; (1993)15: the aim of their study was the instrumental evaluation of ultrasonic therapy in patients with periarthiris of the shoulder for their real effectiveness of the anti- inflammatory action of the ultrasound. Two groups of subjects were studied, periarthritis versus normal patients. Results of their study demonstrate a real influence of ultrasound therapy on periarthritis shoulder to improve the functional outcome.
  • Riddle DL, Rothstein JM lamb RL; (1987)16: In their study “goniometric reliability in a clinical setting”, the purpose of their study was to examine the intratester and intertester reliabilities for clinical goniometric measurments of shoulder passive range of motion (PROM) using two different sizes of universal goniometers. Patients were measured without controlling therapists goniometric placement technique or patient position during measurments. They found that goniometric PROM measurments for the shoulder appears to be highly reliable when taken by the same physical therapist, regardless of the size of the goniometer used.

6.4 / OBJECTIVE OF THE STUDY
  1. To find out the effect of ultrasound therapy in patients with adhesive capsulitis of shoulder in improving their pain and functional abilities.
  1. To find out the effect of combination muscle energy techniques and ultrasound therapy in patients with adhesive capsulitis of shoulder in improving their pain and functional abilities.
  1. To compare the effectiveness of ultrasound therapy alone and combination of muscle energy techniques and ultrasound therapy in improving their functional abilities of patients with adhesive capsulitis of shoulder joint.

7. / MATERIALS
  1. VAS chart
  2. Ultrasound therapy unit
  3. Standard Goniometer
  4. Shoulder pain and disability index.

7.1 / SOURCES OF DATA
Periarthritis shoulder of both sexes between age group of 40 – 60 years.
A. / RESEARCH DESIGN
Experimental comparative study without intervention.
B. / SETTING OF STUDY
OPD of RV college of Physiotherapy, Bangalore.
C. / VARIABLES
Dependent variable –
Range of motion of shoulder.
Shoulder pain and disability index.
Pain intensity
INDEPENDENT VARIABLE:
Ultrasound therapy.
Muscle energy techniques
D. / SAMPLING DESIGN
Forty subjects with adhesive capsulitis of shoulder in the age group of 40-60 years will be selected for the study from OPD of R.V.college of physiotherapy, Bangalore. Subjects will be divided in three group(ultrasound therapy alone and ultrasound plus muscle energy techniques). All the subjects will be considered for the study after they sign an institutionally approved consent form.
E. / INCLUSION CRITERIA
  1. Clinically diagnosed adhesive capsulitis (Stage II frozen) patients.
  2. Age group between 40-60 years.
  3. Both male and female.

F. / EXCLUSION CRITERIA
  1. Age group below 40 years and above 60 years.
  2. History of uncontrolled diabetes mellitus.
  3. History of any major trauma or surgery.
  4. Patients under steroid therapy.
  5. Recent fracture or surgery in and around the shoulder joint.
  6. Neuromuscular disorder.
  7. Periarthritis shoulder secondary to Reflex sympathetic dystrophy..
  8. Skin problems.

7.2 / METHODS OF DATA COLLECTION
Primary data will be collected from the samples and 60 samples with adhesive capsulitis of shoulder will be included for the study on the basis of purposeful randomized sampling method.
.
Secondary data is gathered with the help of previous research findings, literature reviews from various journals supporting this study.
7.3 / PROCEDURE
40 subjects with the history of adhesive capsulitis will be selected based the inclusion and exclusion criteria. They will be divided into three equal groups such as Group 1 Group 2 and Group 3. The baseline measurement of pain and ROM of shoulder (External Rotation and Abduction) will be assessed and recorded by VAS Scale and standard goniometer and shoulder pain and disability index before the intervention .
GROUP 1: 20 Subjects in this group will be treated with ultrasound in pulsed mode (1:4) with an intensity of 1.0w/cm2 for duration of 15 minutes.
GROUP 2: 20 Subjects will be treated with ultrasound therapy and muscle energy techniques both.
MET for G.H.joint restricted flexion: Therapist stands in front of the patient and places one hand over the top of the patient’s shoulder at the superior part of the scapula and cup the G.H. joint to palpate for motion .The other hand and forearm support the patient’s flexed elbow and flex the humerus at the G.H . joint in the sagittal plane up to the initial point of resistance. Direct the patient to extend the elbow against your equal counterforce. Maintain the forces for 3-5 seconds, allow the patient to relax for 2 seconds, take up the slack and then repeat.
MET for G.H.joint restricted abduction: Therapist stands in front of the patient, places his one hand over the top of patient’s shoulder, cups the G.H. joint to palpate for motion. Direct the patient to press the elbow towards the body.
MET for G.H.joint restricted external rotation: Therapist stands behind thepatient. Places his hand superior to the patient’s GH joint. Places her forearm of the otherhand medial to the patient’s flexed forearm with her hand supporting the patient’s handand the wrist. Direct the patient to internally rotate the arm by pressing the hand.
Muscle energy techniques for the shoulder joint of 5 repetitions per set, 5 sets per session, 1 session per day, 5 days a week for 4 weeks with each repetition maintained for duration of 7 – 10 seconds.
A. / STATISTICAL TEST
Independent t - testing
7.4
A. / Has the study required any investigation
Or
Interventions to be conducted on animals or human beings / No other investigations
B. / Has ethical clearance obtained / Yes, Ethical clearance is obtained from the institutional ethical committee of RV COLLEGE OF PHYSIOTHERAPY

REFERENCE LIST

  1. Richard Dias, Steven Cutts and Samir Massoud –Clinical review Frozen shoulder BMJ 2005;331;1453-1456.
  2. Prevalence of musculoskeletal disorders in an Italian population sample :a regional community based study.I.The mapping study Clinical and experimental Rheumatology-2005, 23(6)819-828.
  3. Robert A Donatelli, Micheal J and Wooden, Orthopaedic Physical therapy. 3nd ed Churchill Living Stone publication; year 153-158.
  4. S.Brontzman ,Kelvin E. Wilk, Clinical orthopaedics rehabilitation 2nd edition page 227-231,2003.
  5. Stephanie D Moore, Kevin G Launder, Todd A MCLODA, Michael A. Shaffer. The Immediate effects of Muscle Energy Technique on Posterior Shoulder Tightness Journal of orthopaedic and sports physical therapy,–JUNE 2011, vol-41, no -06, 400-407.
  6. John Gibbon. Introduction to muscle energy technique. International Therapist , Issue 97, July 2011,26-28.
  7. Gonca Bumin, Emine Handan Tüzün, Eda Tonga Journal of Back and Musculoskeletal Rehabilitation Vol 28 no 1/2008, Pg 57-62
  8. F. Angst , J . Goldhahn, G Pap, A . Mannoin Cross-cultural adaptation, reliability and validity of the German Shoulder Pain and Disability Index (SPADI) Oxford journals of Medicine Rheumatology vol 46, Issue 1 pg 87-92.
  9. Robertson VJ, Ward AR, Jung P. The effect of heat on tissue extensibility: a comparision of deep and superficial heating. Arch Phys Med Rehab. 2005 Apr; 86(4):819-25.
  10. Kimberely Hayes, Judie R Walton, Zoltan L szomor ,George AC Murrell reliability of five methods in assessing shoulder range of motion , Australian Journal of Physiotherapy 2001 pages 289- 294.
  11. Polly E Bijur, Wendy Silver ,E.John Reliability of visual analog scale for acute,Academic Emergency Medicine- pain ,Vol -8 Issue 12,1153-115
  12. Griggs SM, Ahn A, Green A. An Idiopathic adhesive capsulitis. A prospective functional outcome study of non-operative treatment. J Bone joint Surg Am 2000 Oct 82-A (10); 1398-407.
  13. Ebenbichler GR, Erdogmus Cb, Resch KL, Funovics MA, Kainberger F, Barisani G, et al. Ultrasound therapy for calcific tendinitis of the shoulder. N Engl J Med. 1999 May 20 340(20): 1533-8.
  14. McCormack HM, Horne DJ, Sheather S; “clinical application of visual analog scales:a critical review.Psychol Med.1988 Nov;18(4):1007-19.
  15. Zancan A, Gialanella B, Luisa A,et al; Telethermographic effects and a comparative clinical assessment of the treatment of shoulder periarthritis using ultrasound.G Ital Med Lav 1993 Jan-Jul; 15(1-4) :55-8.

16.Riddle DL, Rothstein JM lamb RLGoniometric reliability in a clinical setting. Shoulder measurements.Phys Ther.1987 May;67(5):668-73.

NAME OF THE
CANDIDATE / SHIVESH KUMAR
SIGNATURE
REMARKS OF THE GUIDE
NAME AND DESIGNATION OF THE GUIDE / DR.P.SENTHIL
PROFESSOR
RV COLLEGE OF PHYSIOTHERAPY, BANGALORE
SIGNATURE OF THE
GUIDE
NAME AND DESIGNATION OF THE CO-GUIDE / DR.G.BALAJI
ASSO.PROF
RV COLLEGE OF PHYSIOTHERAPY, BANGALORE
SIGNATURE OF CO-GUIDE
PRINCIPAL / DR.P.SENTHIL
PRINCIPAL (PROFESSOR)
R.V. COLLEGE OF PHYSIOTHERAPY,BANGALORE
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PRINCIPAL