RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA.
ANNEXURE-II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
01 / Name of the candidate & address / PATEL VIBHUTIBEN MADHUSUDANSRINIVAS COLLEGE OF PHYSIOTHERAPY AND RESEARCH CENTER,
MANGALORE.
02 / Name of the Institution / SRINIVAS COLLEGE OF PHYSIOTHERAPY AND RESEARCH CENTER,
MANGALORE.
03 / Course of study and subject / MASTER OF PHYSIOTHERAPY
(MUSCULOSKELETAL DISORDERS AND SPORTS PHYSIOTHERAPY)
04 / Date of admission to the course / 01-04-2013
05 / Title of the topic
“COMPARISON OF MODIFIED SLEEPER STRETCH WITH AND WITHOUT TAPING ON GLENOHUMERAL INTERNAL ROTATION DEFICT IN OVER HEAD THROWERS- A RANDOMIZED CLINICAL TRAIL.”
06 / Brief resume of intended work:
6.1 Need for the study:
Throwing shoulder typically exhibits increased external rotation and decreased internal rotation when compared to the non-throwing shoulder. This loss of internal rotation in the throwing shoulder is defined as the glenohumeral internal rotation deficit (GIRD).1
There is a wide range of causes which lead to the glenohumeral internal rotation deficit. The causes are muscle fatigue , muscle weakness, strength imbalance, loss of motion, soft tissue flexibility, alteration in throwing mechanics and poor static stabilty2
To classify the subject in the GIRD category these are the following criteria.
GIRD 1:- More than 200 of difference in internal rotation of throwing and non throwing shoulder.
GIRD 2:- The difference between internal rotation of the throwing shoulder and the non throwing shoulder was greater than 10% of the total rotation (internal rotation + external rotation) of the non-throwing shoulder.
GIRD 3:- The difference between internal rotation of the throwing shoulder and the non-throwing shoulder was greater than 20% of the internal rotation of the non-throwing shoulder.3
The over head throwing athletes is a unique and complicated sports medicine patient , who has repetitive micro traumatic stress on the throwing shoulder with excessive stress and high angular velocities at the end range of motion.4
Sports such as baseball, cricket, swimming, volleyball, basketball, javelin, water polo and tennis are examples of overhead sports that subject the shoulder to extreme ranges of motion, forces and accelerations/decelerations over many repetitions.5
Over head throwing athletes generally have limitation in internal rotation and increase in range in external rotation in their dominant arm.6
It is a well reported that overhead athletes and specifically baseball undergo an increase in external rotation and decrease in internal rotation. These changes are mainly due to bony and soft tissue adaptation 7
Repetitive throwing at high velocities leads to altered range of motion and over time leads to chronic adaptation to soft and osseous tissues in the glenohumeral joint.8,9 These anatomic adaptation likely lead to difference in range of motion when shoulders are compared bilaterally. Investigators attributed the change in arc of motion to soft tissue adaptations including stretching of anterior capsular structures with a corresponding tightening of posterior capsule.
The modified sleeper stretch is performed with the athlete in a side lying position, trunk rolled posteriorly 20° to 30°, and shoulder elevated to 90°. In this position, passive internal rotation is performed using the opposite arm.12
Taping is done in sitting position. The first piece of the tape was applied+ from the anterior aspect of the humeral head, just lateral to the acromion process to finish at the inferior angle of scapula. The second piece of tape commenced on the anterior aspect of the humeral head over the acromion. The opposite hand lifted the humeral head up and back during the application of the tape.13
Over head athletes generally have limitation of range in internal rotation and increase in external rotation in dominant arm. There are studies showing that taping has significant effect in improving internal rotation ROM in over head athletes.14
The overhead athletes such as baseball, softball, tennis etc. present with posterior shoulder tightness. Therefore an easy, applicable, and specific stretching technique is essential to ensure proper shoulder ROM, kinematics and kinetics and to rehabilitate athletes with disorders associated with this tightness. Studies showing that sleeper stretch are effective in improving internal rotation ROM in over head athletes.15
There are lack studies done by comparing the effect of taping on sleeper stretch on improving glenohumeral internal rotation range of motion in overhead athletes. Hence the purpose of the study is to compare the effect of sleeper stretch with and without taping on shoulder internal rotation range of motion in over head throwers
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Research question:
Will there be any significant difference between modified sleeper stretch and modified sleeper with taping in improving GIRD over head athlete?
6.2 Review of Literature:
1) John Shaji , Chachra Rohit.(2010) conducted a study to compare effect of stretching and mobilization on posterior shoulder tightness in 45 male cricketers who were randomly allocated to 3 groups of 15 each namely group A,B,C receiving stretching, posterior glide mobilization and combination of both respectively. Results showed that group c had maximal improvement in internal rotation and horizontal adduction followed by group A and group B. They concluded that combination of mobilization and stretching is most effective in rehabilitation of posterior shoulder tightness and can also be used individually.16
2) Renato Rangel Torres, Joao Luiz Ellera Gomes(2009) conducted a study to find the existence of glenohumeral rotation deficit in different over head sports. Glenohumeral internal and external rotation of both dominant and non dominant shoulder of 54 male asymptomatic subjects(tennis players, swimmers and control group) were measured and found that the dominant limbs showed less glenohumeral internal rotation than the non dominant limbs in all groups, with the deficit in the group of tennis players about twice the deficit found for swimmers.17
3) Corrao, Melissa, Kolber, Morey J, Wilson, Stanley H.(2009) conducted a study to provide evidence based recommendations for prescription of posterior shoulder stretching, applicable to both asymptomatic and injured population and concluded that exercise techniques designed to address flexibility of posterior shoulder structures may serve as preventive tools for maintaining normal mobility, and the stretching exercises recommended are designed to isolate the posterior structures while preventing compensatory scapular movements.18
4) Charles Ruotolo, Eric Price, Anand Panchal (2006) conducted a study to determine the loss of total arc of motion in relation to shoulder pain in overhand athletes. Internal rotation and external rotation of the glenohumeral joint, measured at 90° of abduction, and total arc of shoulder motion were compared between dominant and non- dominant extremities in athletes with and without shoulder pain and found that college-level baseball players with shoulder pain have a significant decrease in total arc of shoulder motion and internal rotation compared with their non dominant shoulder and with pain-free athletes.19
5) Jiu-jenq Ling, Jing-Lan Yang.(2006) conducted a study to examine the intra-tester and inter-tester reliability of below chest abduction and cross body adduction with an inclinometer as a measurement of posterior shoulder tightness and to assess the validity of these tests by determining the relation between shoulder tightness and shoulder range of motion. They concluded that below chest abduction and cross chest adduction tests are reliable measures (intratester reliability with ICC – 0.84 and 0.91 respectively and intertester reliability with ICC- 0.82 and 0.89 respectively).20
6) T C Bell-Janje , J Gray.(2005) conducted a retrospective study in national academy cricket players to identify injury risk factors that predispose the elite cricketer to injury or re- injury of the shoulder obtained from a postural and biomechanical assessment and concluded that previous shoulder injury was significant risk factor for shoulder injuries in elite cricketers. It may be as a result of inadequate or inappropriate rehabilitation or insufficient rest, further risk factors include player specially, weak scapular stabilizers , postural abnormalities, scoliosis and a limb length discrepancy greater than 1.0cm.21
7) K D Aginsky,L Lategan , R A Stretch.(2004) conducted a study to investigate the relationship between shoulder flexibility and isokinetic strength as possible predisposing factor for shoulder injuries in 21 fast bowlers who were classified into front on, semi front on and side on bowling action. They indicated that presence of possible dysfunction in shoulder rotators, combined with a front on bowling action and external rotation hyper-mobility were predisposing factors for chronic shoulder injuries in cricket fast bowlers.22
8) Lee Herrington (1998) conducted a study to assess differences in glenohumeral rotatory movements between throwing and non throwing arm in a group of ten senior international javelin throwers. Results showed that both arms had significantly greater degrees of external than internal rotation (p<0.01), and the throwing arm had significantly greater range of external rotation than the non-throwing arm. They concluded that the presence of an excessive range of external rotation in the throwing shoulder has the potential to increase eccentric load on the rotator cuff muscles and strain on the passive restraints of the glenohumeral joint.23
9) Todd S. Ellenbecker, E Paul Roetert, Patty A Piorkowski, David A Schulz (1996) conducted a study to determine the existence of significant differences between dominant and non dominant arm in active internal and external rotation range of motion in 203 elite junior tennis players and found no significant differences in males or females between the dominant and non dominant arm in external rotation. The loss of dominant arm internal rotation (AROM) has clinical application for both the development of rehabilitation and preventative flexibility/range of motion programs.24
6.3 Objective of the study:
1) To evaluate the effects of modified sleeper stretch in improving GIRD in over head athlete.
2) To evaluate the effects of modified sleeper stretch with taping in improving GIRD in over head athlete.
3) To compare the effects of modified sleeper stretch and modified sleeper stretch with taping to improve GIRD in over head athlete
6.4 Hypothesis:
Null Hypothesis:
There will be no significant difference between modified sleeper stretch and modified sleeper stretch with taping on improving GIRD in over head athlete
Experimental Hypothesis:
There will be significant difference between modified sleeper stretch and modified sleeper stretch with taping on improving GIRD in over head athlete.
07 / Materials and Methods:
7.1 Source of the data: 60 asymptomatic over head athlete from Mangla stadium Mangalore, bowlers from Nehru Cricket Ground Mangalore
Sample design: Convenient sampling
Sample size: 60 over head throwers
Study design: randomized clinical trail.
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Inclusion criteria:
1) Over head athlete with GIRD.
2) Bilateral comparison of TROM showing asymmetry of 5°.
3) Athletes one year of regular practice.
4) Males and females
Exclusion criteria:
1) Non-players.
2) Players with h/o shoulder pain or fracture or dislocation in less than twelve months.
3) Any nerve lesions of the upper limb.
4) Allergy to tape.
5) Fragile skin around shoulder joint.
7.2 Methods of collection of data:
All subjects will be asked to sign the written consent form station the voluntary acceptance in this study. Subjects who fulfil inclusion criteria will be allotted in to subject group based on block randomization.
Materials to be used:
· Goniometer
· Kinesio Tapes
· Pre-Post assessment form
· Pen.
Outcome measures:
Goniometer
Procedure
MODIFIED SLEEPER STRETCH
The modified sleeper stretch is performed with the athlete in a side lying position, trunk rolled posteriorly 20° to 30°, and shoulder elevated to 90°. In this position, passive internal rotation is performed using the opposite arm.
KINESIO-TAPING
Taping is done in sitting position. The first piece of the tape was applied from the anterior aspect of the humeral head, just lateral to the acromion process to finish at the inferior angle of scapula. The second piece of tape commenced on the anterior aspect of the humeral head over the acromion. The opposite hand lifted the humeral head up and back during the application of the tape.
Description of treatment:
Group 1: : After ruling out the GIRD , the athlete will be assessed baseline ROM of shoulder and then give modified sleeper stretch for five sessions per week of 30 seconds followed by 30seconds rest in between. Range of motion will be measured at the end of every five sessions for one month.
Group 2:
After ruling out the GIRD , the athlete will assess the baseline ROM of shoulder and modified sleeper stretch will be given for five sessions of 30 seconds followed by 30seconds rest in between. In addition to it kinesio taping will be done as mentioned above and then the ROM will be measured at the end of every five sessions for one month.
FINAL FOLLOW UP: It will be carried out at end of one month.
Statistical analysis:-
Test: Paired t-test .
7.3 Does the study require any investigations or interventions to be conducted on patients or other humans or animals?
Yes. The study involves interventions given to the human subjects.
7.4 Has ethical clearance been obtained from your institute in case of 7.3?
Yes.
08 / List of References:
1. Litner D, Mayol M, Uzodinma O, Jones R, Labossiere D. Glenohumeral internal rotation deficits in professional pitchers enrolled in an internal rotation stretching program. American Journal of Sports Medicine. 2007; 35(4); 617-621.
2. Renold.M, Gill.T. Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes, part 1:Physical characteristics and clinical examination. Sports Physical Therapy.2010;2:39-50.
3. Aldridge . R , Guffey. J, Whitehead. M. The effects of a daily stretching protocol on passive glenohumeral internal rotation in over head throwing collegiate athelete. International Journal of Sports Physical Therapy.2012;7(4):365-371.
4. Fleisig GS, Barrentine SW, Escamilla RF, Andrews JR. Biomechanics of over-hand throwing with implications for injuries. Sports Med. 1996;21(6):421-437.
5. Pincent.C , Rae.L,Palmer.J. Return to activity guidelines for the overhead athlete after shoulder injury.Unpublished Master of science in physical therapy thesis. Faculty of rehabilitation medicine.Edmonton,Alberta.University of Alberta; 2010.
6. Dwelly.P et al . Glenohumeral Rotational Range of Motion in Collegiate Overhead-Throwing Athletes During an Athletic Season. Journal of Athletic Training. 2009;44(6):611–616.
7. Crockett.H et al.Osseous Adaptation and Range of Motion at the Glenohumeral Joint in Professional Baseball Pitchers. American Journal of Sports Medicine.2002;30(1): 20-26.
8. Osbahr.D, Cannon.D ,Speer.K. Retroversion of the humerus in the throwing shoulder of college baseball pitchers.The American Journal of Sports Medicine.2002;30(3):346-353.
9. Bukhrat.S, Morgan.C, Kibler.W. The Disabled Throwing Shoulder: Spectrum of Pathology Part I: Pathoanatomy and Biomechanics. The Journal of Arthroscopic and Related Surgery. 2003;19(4): 404-420.
10. Borsa.P,Dover.G,Wilk.K,Reinold.M.Glenohumeral range of motion and stiffness in professional baseball pitchers of Exercise Med Sci Sports.2006;38(1):21-26.
11 Meister.K et al. Rotational motion changes in the glenohumeral joint of the adolescent/Little League baseball player.American Journal of Sports Medicine.2005;33(5):693-698.
12 Wilk.K, Hooks.T, Macrina.L. The modified sleeper stretch and modified cross body stretch to increase shoulder Internal rotation range of motion in the overhead throwing athlete.
13 Ai Ujino. et al.The effects of kinesio tapes and stretching on shoulder range of motion.International Journal of Athleteic therapy and training.2013;18(2):24-28.
14 Thelen.M , Dauber.J , Stoneman.P. The clinical efficacy of kinesio tape for shoulder pain: A randomized,double blinded clinical trial.Journal of Orthopaedic and sports physical therapy.2008;38(7):389-395.
15 McConnel.J , McIntosh.B. The effect of tape on glenohumeral rotation range of motion in elite junior tennis players.Clinical Journal of Sports Medicine.2009;19(2):90-94.
16 Shaji.J, Rohit.C. Comparative analysis of stretching vs mobilization on posterior shoulder tightness in cricketers. Indian Journal of Physiotherapy and Occupational Therapy. 2010; 4:(1).
17 Torres.R and Gomes.J. Measurement of Glenohumeral Internal Rotation in Asymptomatic Tennis Players and Swimmers. American Journal of Sports Medicine.2009;37:1017
18 Corrao.M , Kolber.M ,Wilson.S . Addressing Posterior Shoulder Tightness in Athletic population. Strength and Conditioning Journal.2009;31(6):61-65.
19 Ruotolo.C, Price.E, Panchal.A. Loss of total arc of motion in collegiate baseball players. Journal of Shoulder and Elbow Surgery 2006;15;67-71.
20 Lin.J, Yang.J. Reliability and Validity of Shoulder Tightness Measurement in Patients with Stiff Shoulder. Manual Therapy. 2006(11):146-152.
21 Jenje,T, Gray.J. Incidence, Nature and Risk Factors in Shoulder Injuries of National Academy Cricket Players Over 5 Years – a retrospective study. South African Journal of Sports Medicine 2005;17(4):22-28.
22 Aginsky.K, Lategan.L Stretch.R. Shoulder injuries in provincial male fast bowlers- predisposing factors. Journal of Sports medicine 2004;16(1):25-28.
23 Herrington.L. Glenohumeral joint: Internal and external rotation range of motion in javelin throwers. British Journal of Sports Medicine 1998;32:226–228.
24 Ellenbecker.T, Roetert.E, Piorkowski.P, Schulz.D. Glenohumeral Internal Rotation and External Rotation Range of Motion in Elite Junior Tennis Players. Journal Of Orthopaedics and Sports Physical Therapy 1996;24:336.
09 / Signature of the candidate / PATEL VIBHUTIBEN MADHUSUDAN
10 / Remarks from the guide / Study is feasible and valid.
11 / Name and designation
11.1 Guide
11.2 Signature / DR. PITCHAIAH . A
Associate Professor in Physiotherapy
11.3 Co-Guide
11.4 Signature / DR. M. RATHISH
Assistant Professor in Physiotherapy
11.5 Head of the Department
11.6 Signature / DR.S.RAJASEKAR
Associate Professor & Principal in Physiotherapy
12 / 12.1 Remarks of Chairman and Principal
12.2 Signature / Accepted by scientific and ethics committee reviewers.
DR.S.RAJASEKAR
Associate Professor & Principal in Physiotherapy
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