DISSERTATION SYNOPSIS
SUBMITTED TO
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA
BANGALORE
TOWARDS PARTIAL FULFILLMENT OF
MASTER DEGREE COURSE
BY
POOJA DINKAR RAO
UNDER THE GUIDANCE OF
V. SARAVANAN
VIKAS COLLEGE OF PHYSIOTHERAPY
MARYHILL, KONCHADY, MANGALORE-575006
2011-13
RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES,KARNATAKA
BANGALORE
REGISTRATION OF SUBJECTS FOR DISSERTATION
1. / Name of the Candidateand Address / POOJA DINKAR RAO
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 / 18-06-2011
5. / Title of the Topic THE EFFECTIVENESS OF MANUAL THERAPY IN SUPRASPINATUS TENDINOPATHY
6.
7.
8. / BRIEF RESUME OF INTENDED WORK:
6.1) Need for the study
Shoulder pain accounts for about 16% to 26% of all musculoskeletal problems and is most common complaint in shoulder disorders. The rotator cuff consists of four muscles in the shoulder responsible for securing the arm into the shoulder joint: infraspinatus, supraspinatus, teres minor and subscapularis. The tendon most commonly injured is supraspinatus muscle because it is subject to more stress than any other muscle. Supraspinatus tendinopathy is a term used to describe problems involvingthe tendon of the muscle.1,2
Subacromial impingement syndrome (SIS) is the most common cause of shoulder pain, constituting 16-40% of all cases.3 This problem is frequently seen in the general population and a predisposing factor is resistive overuse.3,4 Supraspinatus is the most frequently involved tendon.The aim of the rehabilitation in SIS is to provided a stable and pain-free shoulder joint with full rangeof motion. The mobilization techniques minimize the joint inflammation, edema and pain by improving the circulation and releasing the adhesions. These modalities will also help to reduce voluntary and reflex joint stiffness of the patients.5-7 However, the mobilization methods are not widely used because of their economic costs and impracticality. 8
Supraspinatus tendinopathy occurs commonly from overloading the shoulder with repetitive or heavy weighted activities, especially overhead activities. In a study by Miller, Wei, Molly, Bovar and Murrel (2008), it was hypothesised that an increase in the amount and duration of load on a tendon leads to activation of stress activated protein kinases, oxygen free radicals and apotic (programmed cell death) mediators. The persistent activity of these substances may cause the tendon to undergo excessive apoptosis, leading to weakened tendon structure, therefore increasing the amount of tendon degeneration and the tendon becomes more vulnerable to rupture. A change in the sport or gym programme or starting a new sport may also make a person more susceptible to sustaining a supraspinatus injury.1,2
Supraspinatus tendinopathy are injuries that result from many gradual tiny tears (microtears) in the tendon of the supraspinatus muscle over time. The microtears usually occurs at the point of insertion.2
The goals of the acute phase are to relieve pain and inflammation, prevent muscle atrophy without exacerbating the pain, reestablish nonpainful range of motion, and normalize the arthrokinematics of the shoulder complex. This includes a period of active rest, eliminating any activity that may cause an increase in symptoms.
Range-of-motion exercises may include pendulum exercises and symptom-limited, active-assisted range-of-motion exercises. Strengthening exercises should be isometric in nature and work on the external rotators, internal rotators, biceps, deltoid, and scapular stabilizers (ie, rhomboids, trapezius, serratus anterior, latissimus dorsi, pectoralis major). Neuromuscular control exercises also may be initiated.
Modalities that also may be used as an adjunct include cryotherapy, transcutaneous electrical nerve stimulation, high-voltage galvanic stimulation, ultrasound, phonophoresis, or iontophoresis.
Patient education regarding activity; pathology; and the avoidance of overhead activity, reaching, and lifting is particularly important for this acute phase. The general guidelines to progress from this phase are decreased pain or symptoms, increased range of motion, painful arc in abduction only, and improved muscular function. The addition of an initial manual therapy may improve the results of the rehabilitation with exercise.1
Therefore the aim of this study is to assess the efficacy of manual therapy in the treatement of patients with sympomatic supraspinatus tendinopathy.
6.2) Review of literature:
1.Gamze senbursa, Gul Baltaci et al did a study to assess the efficacy of manual therapy in the treatment of patients with symptomatic supraspinatus tendinopathy.All patients had rehabilitation for 12 weeks.Pain level was evaluated with a visual analogue scale (VAS) and range of motion was measured usin goniometer.All patients were evaluated before , and at the 12th week of rehabilitation. Supervised exercise, supervised manual therapy, and home based exercise are all effective and promising methods in the rehabilitation of the patients with subacromial impingement sndrome. The addition of manual therapy may improve the results of the rehabilitation with exercise. 9
2.Brosseau L, Casimiro et al involved patients with tendinopathy and were administered with deep transverse friction massage with rest, stretching exercises, cryotherapy and therapeutic ultrasound. This was compared to other group of patients with rest, stretching exercises, cryotherapy and therapeutic ultrasound only. Reviewers conclusion was that deep friction massage combined with other physiotherapy modalities did not show consistent benefit over the control of pain, or improvement of strength and functional stats for patients.10
3. Sole G, Munn J et al conducted research to determine the effectiveness of manual therapy techniques for the management of musculoskeketal disorders of the shoulder. Results were analysed within diagnostic subgroups (adhessive capsulitis, shoulder impingement syndrome, non specific shoulder pain/ dysfunction) and a qualitative analysis using levels of evidence different treatment efective was applied. For shoulder impingement syndrome, there was no clear evidence to suggest additional benefits of manual therapy to other interventions. Manual therapy was not shown to be more effective than other conservative interventions for adhesive capsulities, however massage and mobilization with movement may be usefull in comparision to no treatement for short term outcomes of shoulder dysfunction.11
4.Yang J L, Jan M H et ak examined the effectivenessof the end range mobilization? Scapular mobilization treatement approach in a sub group of frozen shoulder syndrome. Subjects in a group who were given end range mobilization/scapular mobilization treatement experienced greater improvement in outcomes compared with
other group of patients. Therefore this treatement is more effective than a standardised physical therapy programme.12
5.Bang MD, Deyle GD did a comparative study on effectiveness of 2 physical therapy treatement approaches for impingement syndrome of shoulder. Two groups were made and were randomly assigned to 1 of the 2 treatment. Subjects in both groups experienced decrease in pain and increase in function, but ther was significantly more improvement in the manual therapy group compared to he exercise group.13
6. Lombardi and Troxel on a study on rotator cuff tendon injuries during resistive exercises, found that 13% of the cases had rotator cuff injuries during exercise, with 27% occurring during home-based programs.14
7. Michener et al., in their study comparing exercises, joint mobilization, laser, ultrasound and acupuncture in the treatment of SIS, emphasized the importance of
mobilization and exercises.15
8. Bang and Deyle,16 had the best results for pain relief, functional recovery and muscle strength in patients who had manipulative therapy in addition to an exercise program. The manipulative therapy was also found to be useful in the treatment of frozen shoulder.17,18
9. Kolber MJ, Fuller G et al conducted this study and investigated thereliabilityand concurrent validity of activeshoulderelevation in the scapular plane (scaption) using a digital inclinometer andgoniometer. Two investigators used a goniometerand digital inclinometer to measure scaption on 30 asymptomatic participants in a blinded repeated measures design. The concurrent validity between goniometry and digital inclinometry was excellent with and ICC value of 0.94 for both raters. The 95% limits of agreement suggest that the difference between these two measurement instruments can be expected to vary by up to ±11 degrees. The results support the interchangeable use of goniometry and digital inclinometer for measuring scaption. Clinicians and researchers should consider the minimal detectable values presented when interpreting change during subsequent measurement sessions.19
10. VAS is used for pain association. This scale involves ahorizontal line, 10 cms, such that 0 defines “no pain” and 10 defines “unbearable pain”. The patient is asked to mark the strength of his/ her pain at rest, during activity and at time on the horizontal line. The reliability of VAS was determined by Clark et al, who found r = 0.79 re test = 0.97. 20
6.3) Objectives of the study
The objective of this study is to investigate, in a randomized, prospective controlled study, the effectiveness of manual therapy in supraspinatus tendinopathy .
MATERIALS AND METHODS
7.1) Source of data
Data will be collected from patients who attend the out patient clinic of Vikas College of Physiotherapy, Mangalore, with diagnosis of Supraspinatus tendinopathy after obtaining informed consent.
7.2) Method of collection of data
Hypothesis
There is significant reduction in pain imposed by supraspinatus tendinopathy after administration of manual therapy.
Null Hypothesis
There is no significant reduction in pain imposed by supraspinatus tendinopathy after administration of manual therapy.
Research Design
Single factor experimental design will be used for this study.
Sampling method
Purposive sampling method
Tools used
1. Couch
2. Pillows
3. Powder
4. Goniometre
5. Towel
METHODOLOGY
30 patients diagnosed with supraspinatus tendinopathy within the age group of 30-60 years of both gender will be recruited and asked to complete a medical history questionnaire. To be eligible for the study the subjects should fulfill the following inclusion and exclusion criteria.
Inclusion Criteria
Patients with partial supraspinatus tear (Stage 1) and/or subacromial impingement
syndrome (SIS) diagnosis were included in this study, diagnosed by clinical
examination and magnetic resonance imaging (MRI).
Exclusion criteria:
1. Patients with shoulder trauma
2. Patients with shoulder instability
3. History of frozen shoulder
4. Patients with acromioclavicular and glenohumeral joint problems
5. Patients with calcified tendonitis
6.History of shoulder surgery and/or with a history of disease in hand, wrist or in the cervical region
7. Patients who had had a physical therapy and rehabilitation program wuthin the last two years.
Study Design
The subjects who fulfill the inclusion and exclusion criteria and willing to participate in the study will be randomly assigned one of two groups after obtaining written informed consent.
Group 1: This group will consist of 15 subjects (N=15) of both gender and they will undergo manual therapy ie joint and soft tissue mobilization three times a week. (Experimental group)
Group 2: This group will consist of 15 subjects (N=15) of both gender and they will be given glenohumeral and scapulothoracic exercises. (Control group)
Interventions:
Both groups will undergo rehabilitation for 12 weeks.
Manual therapy consisted of deep friction massage
on the supraspinatus muscle, scapular mobilization, glenohumeral joint mobilization.
Deep friction massage
The action of friction massage is by just struming back and forth over the inflamed tendon at the point of greatest tenderness.The strokes areperpendicularto the fibres of the tendon.
Gentle to moderate pressure with the pads of fingers or a thumb is given. It is finished by icing the massage site with raw ice for a maximum of two minutes, or until it is numb, whichever comes first. The complete treatment should take about 3-6 minutes, and is repeated at least once per day, and a maximum of three times per day.
Glenohumeral joint mobilization
The patient is is supine lying position, shoulde off plinth in abduction, elbow flexed to 90 degree.Graded AP mobilization is applied through your mobilizing arm against the humeral head.Caudal glides is applied through mobilizing humeral head caudally.
Outcome measurements:
All patients were evaluated before the treatment and on 12th week. Night pain, rest pain and pain with movement were assessed with a 10-cm visual analogue scale (VAS). VAS measurements were repeated before the treatment, and 12th week follow-ups. The shoulder range of motion (ROM) was measured with a goniometer and degrees of restriction were recorded.21
7.3) Statistical Analysis
The data collected will be analyzed using non-parametric tests as the data are ordinal
in nature. The intra group pre and post-test data will be analyzed using T test.
7.4)Ethical Clearance
Ethical clearance has been obtained from the ethical committee of our institution to carry out the investigations and interventions on subjects necessary for this study.
REFERENCES
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14. Lombardi VP, Troxel RK. Update on US resistance training injuries and deaths. Med Sci Sports Exerc 2005;37: S12.
15. Michener LA, Walsworth MK, Burnet EN. Effectiveness of rehabilitation for patients with subacromial impingement syndrome: a systematic review. J Hand Ther 2004; 17:152 -64.
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17. Diercks RL, Stevens M. Gentle thawing of the frozen shoulder: a prospective study of supervised neglect versus intensive physical therapy in seventy-seven patients with frozen shoulder syndrome followed up for two years. J Shoulder Elbow Surg 2004;13:499-502.
18. Güler-Uysal F, Kozano¤lu E. Comparison of the early response to two methods of rehabilitation in adhesive capsulitis. Swiss Med Wkly 2004;134:353-8.