Rajiv Gandhi University of Health Sciences, Karnataka

Bangalore

ANNEXURE II

1. / Name of the Candidate and Address (in block letters) / POOJA
DR.M.V.SHETTY COLLEGE OF PHYSIOTHERAPY
VIDYANAGAR
KULOOR,MANGALORE-575013
2. / Name of the Institution / DR.M.V.SHETTY COLLEGE OF PHYSIOTHERAPY
3. / Course of Study and Subject / MASTER OF PHYSIOTHERAPY (MPT)
MUSCULOSKELETAL DISORDERS AND SPORTS PHYSIOTHERAPY
4. / Date of Admission to Course /

13th JULY 2011

5. / Title of the Topic / THE EFFECTIVENESS OF DEEP FRICTION MASSAGE AND LOWER LEVEL LASER THERAPY
IN THE TREATMENT OF SUPRASPINATUS TENDINITIS
BRIEF RESUME OF THE INTENDED WORK:
6.1) INTRODUCTION AND NEED OF THE STUDY:
Supraspinatus tendinitis or painful arc syndrome occurs in shoulder joint1.Is often associated with shoulder impingement syndrome.Supraspinatus is one of the four mucles which abducts the arm at the shoulder. It also assist in stabilizing the shoulder joint firmly supporting the head of the humerus against the scapula2,3.
Supraspinatus tendinitis is often associated with shoulder impingment syndrome.The common belief is that impingment of supraspinatus tendon leads to supraspinatus tendonitis (inflammation of supraspinatus ,rotator cuff tendon,or the contigous pretendinous soft tissue),which is known a stage of shoulder impingment syndrome (stage second) as described originally by Neer in 19724.
The shoulder joint owes its stability to rotator cuff muscles which are the four small muscles
located around the shoulder joint which helps with movement,the importantly their tendons
stabilize the head of the humerus within the joint capsule1.
Sometimes wear and tear of supraspinatus tendon results,which is commonly associated with
inflammation of bursa subacromial bursitis.There may be even little tears in tendon fibres –partial
tears or sometimes even complete tears1.Typically seen in people aged 25-604
Around 70%of the patients with tendinitis will improve over 5-20 days,mobilize the joint themselves, through the treatment with physiotherapy will help5
It is usually treated by anti- inflammatory drugs local injections,physiotherapy or low does irradiation.6 Various physiotherapy treatments modalities such as TENS, Ultrasound, laser treatment Range of motion and strengthening exercises will help with the recovery from painful shoulder.7
Liz Saunders suggest that the dose of laser therapy improves the symptons of supraspinatus tendinitis8
The word LASER is a acronym for “Light amplification by stimulated emmission of radiation” The operation of laser consisting of emmitted light phonotic and may be visible or invisible Portion of electromagnetic spectrum depending on its wavelength.LASER emission is based on Principle of absorption ,spontaneous,stimulated emmission of radiation.General characterstices of laser are coherence,collimation,and divergence ,monochromaticity, power ,and power density and polarazation.Specific characterstices which are particular to the type of laser used are frequency,power,and emmision mode.According to the power ,lasers are divided into high-power
medium power and soft or cold laser.(lower level laser therapy)9
Lower level laser therapy has recently emerged as a distinct therapeutic modality in a control of both acute and chronic pain.Lower level laser therapy is a type of phototherapy and non invasive technique ,include light source (wavelength 632-1064) treatment that generates light of a single wavelength.Lower level laser therapy emits no thermal effect ,sound or vibration and may act via
nonthermal and photochemical reactions in the cells ,also reffered to a photobiology or biostimulation.The device used in this application usually produces either infrared or visible red radiation and include the gallaium arsenide or gallium aluminium arsenide infrared or helium neon semiconductor9
Various researchers had been done to evaluate the effect of LASER on various tendintis condition (supraspinatus tendinitis,lateral epicondilytis planter faciatis etc,) and found that LASER therapy can reduce pain in acute, subacute and chronic tendinopathy with optimal treatment procedure/ Parameters8,10,11,12.Low power laser treatment has been described as having a stimulative effect on human tissue at a local or general systemic level,or both by accleration of photobiological or photochemical process.
Transverse friction massage has been advocated by a number of authors in the management of shoulder disorders. Hammer describes friction massage as a technique where an involved muscle tendon or ligament is massage by applying pressure with a reinforced finger.18,19.
The transverse motion across the involved tissue and resultant hyperaemia are said to be chief healing factors of friction massage. The transverse action is said to prevent the formation of scar tissue while longitudinal friction effects the transportation of blood and lymph.18,19
NEED OF STUDY:
-Previous studies says that lower level laser therapy is helpful in reducing pain and tenderness.it also helps to reduce weakness in supraspinatus tendinitis.
-Previous studies says that deep friction massage stimulates fiber orientation in regenerating fiber connective tissue.Prevents adhesion formation and rupture unwanted adhesion formation.
-In some way studies have also been proved the Lower level laser therapy has a beneficial effect
on tissue healing and relief pain.There is a lack of evidence on the combined benefit of deep
Friction massage and lower level laser therapy in the treatment of supraspinatus tendinitis.hence
a need arises.
Research Question:
Whether the treatment of deep friction massage and lower level laser therapy is effective in the treatment of Supraspinatus tendinitis or not?
Hypothesis:
Alternative hypotheses:
There will be significant effect of deep friction massage and lower level laser therapy in the treatment of Supraspinatus tendinitis.
Null hypothesis:
There will be no effect of deep friction massage and lower level laser therapy in the treatment of supraspinatus tendinitis
6.2) REVIEW OF LITERATURE:
Liz saunders compare the effectiveness of lower level laser therapy ,ultrasound and control group in the treatment of supraspinatus tendinitis and concluded that laser therapy should be treatment of choice for supraspinatus tendonosis rather than ultrasound8.
Bansal k Shitiga, Padamkumar S studied the effectiveness of ultrasound and deep friction massage in treatment of supraspinatus tendonitis and concluded that both the intervension reduce pain and increase abduction range of motion but deep friction massage has slight edge over ultrasound13
Scand J Rheumato says that active laser therapy produced significant improvement over drug therapy for all these objectives measures (active extension,flexion and abduction of the shoulder)and pain.Naproxen sodium significantly improved only movement and function compared to dummy laser14
Tumilty S, Munn J, assess the clinical effectiveness of lower laser therapy in the treatment of tendinopathy.Lower level laser therapy can potentially be effective in treating tendinopathy when recommended dosages are used .12 positive studies provide strong evidence that positive outcomes are associated with the use of current dosage recommendations for the treatment of tendinopathy15
Liz saunders also reviewed the efficacy of lower level laser therapy in supraspinatus tendinitis.Here in this a low power laser using a 820 nm,40mw probe operating at 5000 htz to produce a dose of 30 J/cm2 was used to treat one group (laser) other group was treated with a similar but dummy laser (DL).The data revealed that the LASER had less pain (p<0.05) after the treatment than before.No such changes occurred in DL group;indeed ,secondary weakness and tenderness increased slightly in the latter group after the treatment16
Mario Pribicevic, Henry pollard described the deep friction massage in the management of shoulder disorder. The transverse motion across the involved tissue and resultant hyperaemia and are said to be chief healing factors of deep friction massage.18,19
Shrode LW,reviewed the treatment of shoulder impingment syndrome using the supraspinatus synchronization exercises. The case presented in this report responded quiclky to conservative treatment using the supraspinatus synchronization exercises20
Boonstra AM et al performed a study to determine the reliabilty and validity of VAS for disability in patients with chronic musculoskeletal pain and they concluded that the reliability of the VAS for the disability is moderate to good and strong corelation with the VAS for pain21.
B Gimblett PA,Saville J,Ebrall reviewed range of motion exercises, phonophoresis followed by cross friction massage to supraspinatus tendon. They involved appoximately 20 sesssions of phonophoresis, range of motion exercises, cross friction massage to the supraspinatus tendon the calcific deposits in supraspinatus tendon clearly seen in the previous radiograph were no longer visible and symptons were resolved22.
6.3) OBJECTIVES OF STUDY
To compare the effectiveness of deep friction massage and lower level laser therapy in the treatment of supraspinatus tendinitis.
MATERIALS AND METHODS :
7.1) Study Design:
Experimental study design ( Comparative )
7.2) Source of data:
Patient suffering from Supraspinatus tendinitis referred to physiotherapy by Physician or
Orthopaedic surgeon in and around Mangalore.
7.2(I) Definition of Study Subjects:
patients aged 18 – 50 years.
7.2(II) Inclusion and Exclusion Criteria:
Inclusion Criteria:
1)  25 subjects with supraspinatus tendinitis assigned randomly assigned.
2)  Both male and female.
3)  Age 20-60.
Exclusion Criteria:
1)  Subjects with bilateral supraspinatus tendinitis.
2)  History of shoulder fracture /dislocation.
3)  Subjects with impingment syndrome.
4)  Subjects with frozen shoulder.
5)  Subjects with bicipital tendinitis.
6)  Any deformity in shoulder
7)  Non-coperative patients
7.2(III) Study Sampling Design, Method and Size:
Sample design:
Randomly sampling method.
Method of collection of data
Subjects in the age of 20-60 with supraspinatus tendinitis will be selected in and around
Mangalore for the study.
7.2(IV) Follow Up:
It is one time study.
7.2(V) Parameters used for comparison and statistical analysis used:
Collective data will be analyzed by unpaired ‘t’- test and by paired ‘t’ – test.
7.2(VI) Duration of study:
Data will be collected over a period of 10-12 months.
7.2(VII) Methodology:
Subjects meeting the inclusion and exclusion criteria will be recruited for study. Informed consent will be obtained from the patients. Then the patients will be randomly assigned into two groups , A and B respectively, having 25 subjects in each group.
Pre-treatment assessment of pain and abduction of shoulder will be noted for both the groups.
visual analouge scale (VAS) and Goniometer will be used to measure pain and range of motion
respectively.

GROUP –A received deep friction massage and Lower level laser therapy

PROCEDURE-

Group A patients first subjected to longitudinal and transverse friction massage apply to the posterior tenomuscular junction of the infraspinatus muscle.the coracoacromial ligament (posterior-inferior aspect) and the insertion of supraspinatus on the greater tubrosity of the humerus.the friction massage application is achieve by palpating the capsular or tendinous adhesions and frictioning over its surface with practioner’s index finger. This is maintain until friction anasthesia is achieved and patient could not feel any discomfort.Care is taken not to cause excessive discomfort to the patient (3 sessions per week x 3 weeks).Then patients subjected to lower level laser therapy using a 829 nm ,40 Mw probe operating at 5000 htz to produce a dose of nine treatment,identical advice and educational material (3 sessions per week x 3 weeks)

GROUP-B received Range of motion exercises-

PROCDURE-

Group B is subjected to basic exercise programme on isometrics strengthning of supraspinatus
and infraspinatus muscle at a frequency of 4 sets of 10 repititions per day.
7.3) Does the study require any investigations to be conducted on patients or other human or animal? If so, please describe briefly.
YES,
Ø  Clinical tests for Supraspinatus tendinitis - 1. Empty can test.16
2. Apley scratch test.16
3. Hawkins test.17
Ø  Visual Analogue Scale – Pain assessmentqq
Ø  Goniometer – Range of motion of shoulder
7.4) Has ethical clearance been obtained from your institution in case of 7.3.
YES

LIST OF REFERENCES

1.  Collier,J. Longmore., Brown TD, Oxford.Handbook of clinical specialities 5th edition.
2.  “Physical therapy of shoulder”; Robert donatelli ; 2003.
3.  “Shoulder injuries in sport: Evaluation, Treatment and rehab”; Jerome V.Ciulo; 1996
4.  Kumar P,Clark M.CLINICAL MEDICINE .WB Saunders 2002;
5.  Murtagh, J.General Practice . Second Ed. McGraw-hill,1998.
6.  Strahlenther Onkol 2003 feb; 179(2): 129-30;
7.  Ferri:Ferri’s clinical Advisor : Instant diagnosis and treatment, 2004 ed; Copyright 2004
Mosby,Inc.
8.  Saunders L. “The efficacy of lower level laser therapy in supraspinatus tendinitis”.
Clinical Rehabilitation 1995; 9(2);126-34
9.  David GB , Diamantopolous C, O’Kanes, Dolores TS .Therapeutic lasers.theory and
practise. Churchill Livingstone ,United .K.
10.  Stergioulas A. effects of lower level laser therapy and plyometric exercise in the treat-
-ment of ;lateral epicondilitis.Photomed laser surgery 2007 jun ; 25(3);205-13
11.  Bjordal JM, Coupee C, Ljunggren E.Low level laser therapy for tendino pathy:Evidence
of a dose response pattern. Physical Therapy Surgery 2007 jun; 25(3); 205-13
12. Kiritisi O. Tsitas K, Malliaropolilos N, Mikroulis G .Ultrasonographic evaluation of
platar faciatis after Lower level laser therapy ;results of a double-blind ,randomised
placebocontrolled trial lasers med sci 2009 .
13.Indian journal of physiotherapy and occupational therapy,Year;2001,vol:5 issue:2.
A comparative study between the efficacy of therapeutic ultrasound and soft tissue
massage (deep friction massage) in supraspinatus tendinitis.Bansal K.Shitija,
Padamkumar S.
14.Scand J Rheumatol 1989;18(6):427-37.Low power laser therapy of shoulder tendinosis
England S ,Farrell AJ,Coppock JS ,Struthers G,Bacon PA.
15..Photomed laser surg:2010 feb;28(1):3-16.Lower level laser therapy treatment of tendinopathy:a systemic review with meta analysis.Tumiltys,Munnj,McDonoughS,Hurley DA,Basford JR,Baxter GD.
16.The painful shoulder:part first,Clinical evaluation Thomas W.Woodward,M.D and Thomas
M.best,M.D,PH.D,University of wisconsin Medical school ,Madison.Arm Fam Physician
.2000 may 15;61(10):3079-3088
17.Hawkins RJ,Kennedy JC.Impingment syndrome in athletes .Amj.Sports med.1980;8:151-7
18. Hammer WI: The use of the transverse friction massage in the management of chronic
bursitis of the hip or shoulder ,J Manipulative physiol Ther 1993,16;107-711
19. Hammer WI: friction massage : from functional soft tissue examination and treatment by
manual methods .Gaithersbery:Aspen ;1999:463-478
20. J Manipulative Physiol Ther.1994 jan;17(1):treating shoulder impingment using the
supraspinatus synchronization exercise.Shrode LW.
21. Boonstra AM,Schiphorst Preuper HR,Reneman MF.Reliability and vaildity of the visual
analouge scale for disability in patients with chronic musculoskeletal pain.lut J Rehab
Res.2008;31?(2):165-9.

22. J Manipulative physiol ther.1999 nov-dec;22(9):6227.A conservative management protocol
For calcific tendinitis of shoulder.J Gimblett PA.Saville J,Ebrall P.