RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
ANNEXURE II
Proforma for registration of subjects for dissertation
1 / Name and address of candidate / SHYLESH. B Alva’s College of Physiotherapy,Moodbidri,
DK-574227.
2 / Name of institution / Alva’s College of Physiotherapy,
Moodbidri,
DK-574227.
3 / Course of study and subject / Master of Physiotherapy
(Musculoskeletal and Sports Physiotherapy)
4 / Date of admission to the course / 02/08/2010
5 / Title of study
A comparative study on the effectiveness of sleeper stretch versus cross body stretch on Posterior shoulder tightness and shoulder internal rotation
6. BRIEF RESUME OF THE INTENDED WORK
Shoulder disorders affect up to 67% of the population at some point in their lifetime20. Posterior capsule tightness of the shoulder has been suggested as a causative or perpetuating factor in shoulder impingement syndrome and labral lesions14,16,17,23,24,25,30. The selective tightening of the posterior portion of the shoulder capsule causes anterior and superior translation of the humeral head with passive shoulder flexion. This abnormal humeral head motion can result in a decrease in the subacromial space during overhead activities. This approximation of the humeral head and acromion can lead to compression of tissues in that region and may be associated with limited shoulder flexion, internal rotation, and horizontal adduction 29. Clinically much attention has been given to the effect of tight posterior shoulder tissues on normal glenohumeral joint surface motion 19.
In throwers a tightened posterior-inferior capsule pushes the humeral head superiorly and posteriorly with the arm in the cocked throwing position, such as decreased internal rotation, increased external rotation, and increased posterior shoulder tightness (limited glenohumeral [GH] horizontal adduction). Such alterations have been linked empirically to bony8-12 and soft tissue13,14 adaptations that result from the large rotational and distractive forces acting on the GH joint during the throwing motion.
Some of the reasearchers have alternative explanation for this tightness of posterior capsule. According to Harryman et al26 selective tightening of the posterior portion of the shoulder capsule causes anterior and superior translation of the humeral head with passive shoulder flexion. The abnormal humeral head motion can result in a decrease in the subacromial space during overhead activities. This approximation of the humeral head and acromion can lead to compression of tissues in that region and may be associated with limited shoulder flexion, internal rotation, and horizontal adduction 29.
Then Myers et al31 mentioned that throwing athletes with symptomatic internal impingement had reduced glenohumeral internal rotation and also reduced glenohumeral adduction reflecting posterior shoulder tightness compared to matched asymptomatic subjects. According to Pappas A et al32 the structures of the posterior shoulder include the muscles, ligaments, nerves, and soft tissue. The posterior deltoid, infraspinatus, teres minor, and teres major may play a role in posterior shoulder tightness.
6.1. NEED FOR STUDY
These literatures show that prevention of posterior shoulder shoulder tightness could prevent further complications like impingement, superior labral lesion etc.
The main need of the study is to compare the effectiveness of two type of stretching procedures i.e, sleeper stretch and cross body stretch, which one is more effective in posterior shoulder tightness to reduce further complications.
According to Kevin G et al27 based on their study and results sleeper stretch produce a statistically significant acute increase in posterior flexibility and internal rotation. Then Philip et al27 and Robert c et al39 they concluded that cross body stretching is effective in reducing posterior shoulder tightness and improve internal rotation.
Hence in this study an attempt will be made to prevent posterior shoulder tightness through sleeper stretch and cross body stretch. Their effects will be compared to find out which method gives better results.
6.2. OBJECTIVES OF STUDY
i. To assess the effect of cross body stretching in reducing posterior shoulder tightness and increasing internal rotation of shoulder
ii. To assess the effect of sleeper stretch in reducing posterior shoulder tightness and increasing internal rotation of shoulder
iii. To compare the effect of cross body stretch versus sleeper stretch in reducing posterior shoulder tightness and increasing internal rotation of shoulder
HYPOTHESIS
Null hypothesis
H01 - There is no significant effect of cross body stretch in reducing posterior shoulder tightness and
increasing shoulder internal rotation than sleeper stretch
H02 - There is no significant effect of sleeper stretch in reducing posterior shoulder tightness and
increasing shoulder internal rotation than cross body stretch
H03 - The cross body stretch and sleeper stretch are equally significant in reducing posterior
shoulder tightness and increasing shoulder internal rotation
Experimental hypothesis
H1 - There is a significant effect of cross body stretch in reducing posterior shoulder tightness and
increasing shoulder internal rotation than sleeper stretch.
H2 - There is a significant effect of sleeper stretch in reducing posterior shoulder tightness and increasing
shoulder internal rotation than cross body stretch
H3 - The cross body stretch and sleeper stretch are not equally significant in reducing posterior shoulder
tightness and increasing shoulder internal rotation
6.3. REVIEW OF LITERATURE
Kevin G et al27 (2008) carried a study to detect the effect of ‘sleeper stretch’ in posterior shoulder tightness on 33 National Collegiate Athletic Association Division I baseball players. The main outcome measures are Internal and external glenohumeral rotation ROM and posterior shoulder motion (glenohumeral horizontal adduction). Based on their results, the sleeper stretches produced a statistically significant acute increase in posterior shoulder flexibility.
Philip et al (2007)28 conducted a study to detect the effect of stretching procedures on unilateral posterior shoulder tightness for 4 weeks. In which they applied 5 repetitions of 30 second holding time for each groups. They found a positive response in increase of shoulder internal rotation and horizontal adduction in this.
Carolyn Kisner, Lynn Allen Colby (2007)6 in their book ‘Therapeutic exercise : foundation and technique, 5th edition , during passive stretching both longitudinal and lateral force transduction occurs. Where tension of series elastic connective tissue component rises sharply. After a point there is mechanical disruption (influenced by neural and biochemical changes ) of the cross bridges as the filaments slides apart, leading to abrupt lengthening of the sarcomere occurs. If more permanent (plastic) length increases are to occure, the stretch force must be maintained over an extended period of time. Inhibition of the contractile protein of the muscle by the Golgi Tendon Organ(GTO) contribute to reflexive muscle relaxation during a stretching maneuver enabling a muscle to be elongated against less muscle tension. If a low intensity, slow stretch force is applied to muscle, the stretch reflex is less likely to be activated as the GTO fires and inhibit tension in the muscle, allowing the parallel elastic component (the sarcomere) of the muscle to remain relaxed and to lengthen. Low magnitude loads usually in the elastic range and applied for long periods, increase in the deformation of the connective tissue and allow gradual re-arrangement of collagen fiber bonds (remodeling) & redistribution of water to surrounding tissues.
Grossman M G et al37(2005) have done a study on Ten cadaveric shoulders, were tested with a custom shoulder-testing device. Humeral rotational range of motion, the position of the humerus in maximum external rotation, and glenohumeral translations in the anterior, posterior, superior, and inferior directions were measured with the shoulder in 90 degrees of abduction. They found that a posterior capsular contracture with decreased internal rotation does not allow the humerus to externally rotate into its normal posteroinferior position in the cocking phase of throwing.
Jacquelyn M. Downar, Eric L. Sauers33(2005 ) have done a study to evaluate clinical measures of shoulder mobility in professional baseball players in order to examine differences between the throwing and the non-throwing shoulders and to describe chronic adaptations to throwing. They selected 27 professional baseball players with no previous history of shoulder or elbow injury. They recorded scapular upward rotation at 4 levels of humeral elevation in the scapular plane (rest, 600, 90o, 1200); posterior shoulder tightness; and passive, isolated glenohumeral joint internal and external range of motion. Here they concluded as the throwing shoulder exhibited significant differences in scapular and glenohumeral mobility compared with the non-throwing shoulder.
Burkhart et al5,7(2003) suggest that contracture of the posterior-inferior glenohumeral capsule, evidenced by a lack of internal rotation with the arm abducted to 90°, is an essential cause of superior labral lesions. This assertion was based on a large series of throwers i.e, n=124 with arthroscopically proven superior labral lesion, all of whom demonstrated at least a 25° lack of shoulder internal rotation compared to the non-throwing side.5,7-a
Robert c et al 39(2003) have done a study on 39 college asymptomatic participants. They were randomly assigned into two group; ‘cross body’ stretching only (n, 20) and ‘cross body’ stretching plus posterior joint mobilizations (n, 19). All had a between-shoulder difference of internal rotation of 10° or more. Shoulder internal and external rotation was measured before and after a 4-week intervention. Internal rotation increased in both groups. Inclusion of joint mobilization in a rehabilitation program created trends toward increased shoulder internal rotation mobility.
Bandy WD et al3 (2001) in ‘Therapeutic Exercise: Techniques for Intervention’ suggested that ‘cross-body stretch’ where the shoulder is elevated to approximately 90° of flexion and pulled across the body into horizontal adduction with the opposite arm will stretch the posterior shoulder.
Timothy F: Tyler et al25 (1999) done a study to find out a new method to measure posterior shoulder tightness. Five repeat measurements were made using a standardized protocol on 21 non-impaired subjects to determine intratester reliability. To determine intertester reliability, 2 testers (blinded to their measurement) each performed 1 measurement on 49 shoulders. Twenty-two intercollegiate baseball pitchers were measured once by 1 tester to evaluate the construct validity of the measurement. With the subject in the side-lying position, the test arm was placed in 90 degrees of abduction with the humerus in neutral rotation. The scapula of the test arm was stabilized in the fully retracted position, then the primary tester passively lowered the humerus into horizontal adduction. The humerus was lowered with the scapula stabilized in retraction until motion ceased or humeral rotation occurred. A second tester used a standard carpenter’s square to measure the distance (in centimeters) from the treatment table to the medial epicondyle. Increased distance from the treatment table to the medial epicondyle indicates a less flexible posterior capsule. Side-to-side differences were used for the analysis of the results, and no standardization was used for subject size or arm length. A second measure was obtained before testing the contra-lateral shoulder, and the average of the 2 trials was used in the data analysis. The intra-tester reliability of the measurement was found to be high in dominant (ICC = 0.92) and non-dominant shoulders (ICC = 0.95). Inter-tester reliability was good (ICC = 0.80).
Cynthia C. Norkin et al 4(1998) in ‘measurement of joint motion: a guide to goniometry’ suggested that universal goniometer is simple, reliable and versatile method to measure range of motions of shoulder joint motions both actively and passively. The normal range of shoulder internal rotation (medial rotation), lateral rotation (external rotation) is 4,40 is 900
Harryman et al36(1997) have done a study to investigate the relationship of these translations to the position of the glenohumeral joint and to applied torques and forces in seven isolated glenohumeral joints from fresh cadavera, using a six-degrees-of-freedom position sensor and a six-axis force and torque transducer have shown that selective tightening of the posterior portion of the shoulder capsule causes anterior and superior translation of the humeral head with passive shoulder flexion.
Morrison et al35(1997) suggest that adequate flexibility of the posterior capsule is important prior to beginning a strengthening program.
Warner et al34(1990) carried a study, they evaluated 53 subjects: 15 asymptomatic volunteers, 28 patients with glenohumeral instability, and 10 patients with impingement syndrome. Range of motion was evaluated by goniometric technique in all patients with glenohumeral instability and impingement. They found that patients with shoulder impingement syndrome were limited in passive internal rotation range of motion (ROM) compared to healthy subjects and attributed this limitation to posterior capsular tightness.
7. METHODOLOGY AND MATERIALS
7.1 SOURCE OF DATA
· Out Patient Department (OPD), Alva’s College of Physiotherapy, Moodbidri.
· Alva’s Physiotherapy clinic (Extension unit), Karkala.
· Alva’s Physical Education College, Moodbidri.
7.2 METHODS OF COLLECTION OF DATA
Research design – Experimental clinical trial
Sampling design – convenient sampling
Sample Size
Total sample – 50 subjects with decreased internal rotation greater than 100 from normal
GROUP A (25) – cross body stretching is to be given
GROUP B (25) – sleeper stretch to be given
Selection Criteria
Inclusion Criteria
· Athletes involved in throwing activities27
· aged between 18 and 30 years
· Subjects with a 10° or greater difference between sides in unilateral shoulder internal rotation measured at 90° abduction 28
Exclusion Criteria
· History of shoulder surgery
· Shoulder symptoms requiring medical care within the past year
· Presenting with shoulder muscle strain , joint instability .
Procedure
50 subjects are going to participate in the study, where as those subjects with more than a 10° or greater difference in unilateral shoulder internal rotation measured at 90° abduction using goniometer will be randomly assigned to 2 groups, the GROUP A (cross-body stretch) (n = 25) and the GROUP B (sleeper stretch) (n = 25)
The therapist has to provide subjects in the 2 stretching groups (GROUP A and GROUP B)
stretching exercises on the more limited side only, to perform stretching exercises to a point of mild discomfort once daily for 5 repetitions, holding each stretch for 30 seconds28.
Shoulder internal rotation ROM, with the arm abducted to 90° and scapula motion prevented, will be measured before and after a 4-week intervention period (pre-test and post-test measurements) . Each and every week also have to take post- test measurements of internal rotation using universal goniometer to assess the improvement in range of motion. Primary measure of posterior shoulder tightness will be passive and active internal rotation of the glenohumeral joint with the arm abducted to 90° in the frontal plane using universal goniometer, careful to prevent scapular substitution by watching the anterior aspect of the shoulder during the measurement. Accordingly, the end point for internal rotation measurement will be the angle just prior to the anterior aspect of the shoulder moving anteriorly, indicating scapular motion1.