Curriculum Development Cell
Registration No. / :
Name of the Candidate / : Ms ANKITA VINAYAK PANDEY
Address / :SDM College of Physiotherapy, Manjushree nagar,
sattur-Dharwad
Name of the Institution / :SDM College of Physiotherapy, Dharwad
Course of Study and Subject / :MPT(Masters in musculoskeletal disorders and
sports)
Date of Admission to Course / :6th JUNE 2012
Title / :A STUDY TO COMPARE THE EFFECTIVENESS OF MULLIGAN’S MOBILIZATION WITH MOVEMENT AND KINESIO TAPING IN SUBJECTS WITH PAINFUL SHOULDER(ROTATOR CUFF INJURY-PARTIAL TEAR AND IMPINGEMENT SYNDROME)
Brief resume of the intended work / : Attached
Signature of the Student / :
Guide Name / : Dr. RAJEEV LAL
Signature of the Guide
Remarks of Guide
Co-Guide Name
Signature Of Co-Guide / : RECOMMENDED FOR REGISTRATION
:
HOD Name / : Dr. RAVI SAVADATTI
Signature of HOD / :
Principal Name / :Dr.RAVI SAVADATTI
Principal E-mail ID
Remarks of Principal
Principal Signature / :
:
:
A)BRIEF RESUME OF THE STUDY
INTRODUCTION:
The shoulder complex, comprises of the clavicle, scapula, and the humerus, is an intricately designed combination of three joints linking the upper extremity to the thorax.1 These three bones articulate with one another to give the shoulder a unique feature of freedom of movement.2 The articular structures present in the shoulder complex serves a primary function of mobility, allowing us to move and position the hand through a wide range of space.1Muscle forces serve a primary mechanism for securing the shoulder girdle to the thorax and providing a stable base of support for upper extremity movements.1
Common conditions around the shoulder include: Tendinitis, Rotator cuff injuries, Adhesive capsulitis, shoulder instability, shoulder fractures, shoulder dislocation, shoulder subluxation, Impingement syndrome, SLAP lesions etc.Most common cause of shoulder pain is secondary to sub acromial impingement and often involves lesions to the rotator cuff, long head of the biceps, or may be due to sub acromial bursitis, glenohumeral, and acromioclavicular osteoarthritis.3 The major symptoms include pain over the shoulder area (frequently irradiating along the ipsilateral arm), restricted range of motion (ROM), and impeded activities of daily living. Without proper treatment, symptoms can last several months or longer and are prone to chronicity.3,4Shoulder pain is an extremely common and disabling problem.9 A systematic review of studies shows that 1 month prevalence population wise is 18% to 31% with some studies showing a lifetime incidence of up to 67%. It is more frequently reported by female patients, especially those over age of 65 years, than male patients. Increased rates of shoulder disorders and disability have been correlated with occupational exposures such as carrying heavy weights, working with the arms above shoulder level, repetitive actions, working in cold and damp environment; and also been associated with performing monotonous work and having a high reported stress level at work.9
Rotatorcuff comprises of supraspinatus, infraspinatus, subscapularis, and teres minor to some extent.5 Fine adjustments of the humeral head within the glenoid is achieved by co-ordinated activity of these four inter related muscles arising from the scapula and is called the ‘Rotator cuff’.6 The Rotator cuff stabilises the glenohumeral joint, while the deltoid elevates the arm.5 The tendinousfibers of the Rotator cuff muscles at or their insertion into the tuberosity undergo degenerative changes. The typical/most significant symptom of Rotator cuff disease is dull aching pain on the lateral side of the shoulder that is worsened by overhead activities and while lying on the affected side.7
GRADES OF ROTATOR CUFF TEARS: Rotator cuff tears can be classified either acute or chronic and as partial (articular or bursal side) or complete.
Complete tears can be classified based on size of the tear: small(0-1cm2), medium(1-3cm2), large(3-5cm2) or massive(>5cm2)27.
Shoulder impingement, defined as compression and irritation of the rotator cuff structures as they pass beneath the coracoacromial arch during elevation of the arm.8 Impingement is thought to be due to inadequate subacromial space for clearance of the rotator cuff tendons as the arm is elevated. People with impingement syndrome present weakness of scapulohumeral muscles and improper control of the glenohumeral and scapulothoracic movements during arm elevation.8 This abnormal muscle control is most likely associated with reduction of the subacromial space leading to impingement.8
Various approaches are being practiced for the management of painful shoulder. Medical approach includes non-steroidal anti-inflammatory drugs, local corticosteroid injections and sometimes even surgical repair. Physiotherapy includes manual therapy, electro therapy, exercise therapy and acupuncture. Manual therapy includes massage, joint mobilization and manipulation.
The goals of manual therapy of painful shoulder are to decrease inflammation, to allow healing thereby facilitating muscles contraction to restore pain free shoulder ROM and hence function.
The concept of MWM developed by Brian Mulligan10,11 is a class of manual therapy techniques widely used in management of musculoskeletal pain. It involves the manual application of sustained glide by a therapist to a joint while a concurrent movement of the joint is actively performed by the patient.10,3 During the technique, the therapist must continually monitor the patient to ensure that no pain is recreated. The principles for this type of joint mobilization are based on analyzing and correcting any positional fault in the joint, which according to MWM theory12 occurs due to various soft and/or bony tissue lesions in/around the joint. The principles of MWM include accessory glide, physiologic movement, pain free or pain alteration, immediate or instantaneous effect, and over pressure.13 It is considered that further improvement in pain reduction can be achieved through the application of pain-free passive over pressure at the end of ROM during the MWM procedure.13,14 The glide in a shoulder pain MWM treatment is oriented in a posterior or postero-lateral direction.3
In recent years, the use of K taping has become increasingly popular.15 K taping is a technique developed by Dr. KenzoKasein the 70’s.16 This technique claims: to normalize muscular function, lymphatic and vascular flow, to diminish pain and aid in correction of possible articular malalignments. This taping technique is frequently applied for pathologies in the musculoskeletal system, in the field of sports injuries.16Kinesio Tape has roughly the same thickness as the epidermis and can be stretched between 30 and 40% of its resting length longitudinally.15 Kinesio Taping can be applied to any joint or musculoskeletal region, which results in improving proprioception, stability and reducing pain in various kinds of musculoskeletal conditions and in different age group.15,17It is believed that Kinesio taping may be helpful in reduction of soft tissue inflammation, muscle weakness and postural alignment by improving the position of the glenohumeral and scapulothoracic joints. Kinesio Taping has been found to be more effective than the local modalities as well.3,18
The visual analogue scale (VAS) is a measurement instrument consisting of 10cm line with zero on one end representing no pain and ten on the other end representing worst pain ever experienced. The patient marks on this scale to indicate the severity of his or her pain.19
The Shoulder Pain and Disability Index (SPADI) is a self-administered questionnaire that consists of two dimensions, one for pain and the other for functional activities. The pain dimension consists of five questions regarding the severity of an individual's pain. Functional activities are assessed with eight questions designed to measure the degree of difficulty an individual has with various activities of daily living that require upper-extremity use. The SPADI takes 5 to 10 minutes for a patient to complete and is the only reliable and valid region-specific measure for the shoulder.20
Standardized goniometric measurements have been shown to have good intrarater reliability and validity.3
NEED FOR THE STUDY:
As per the review of literature, we have found many studies mentioning the positive effectiveness of Mulligan’s Mobilization with movement3,10,21,22,23 and Kinesio taping14,16,18,24 as well, either separately or in combination for the management of painful shoulder.
At the same time there is hardly any study which has compared the effectiveness of both the tehniques. Moreover if we consider Mulligan’s Mobilization with Movement technique, here patient visits the therapist more frequently which means more time (for both the patient and the therapist) and money investment. On the other hand if we consider Kinesio taping technique, here if the tape is applied once can stay for 3 to 5 days, hence less time consuming and is cost effective.
Considering these points in mind I feel there is a strong need for this study, as it will help the clinicians with a stronger hand in managing painful shoulder.
REVIEW OF LITERATURE:
Pamela Teys et al,10 conducted a study with an objective to investigate the initial effects of Mulligan’s mobilization with movement (MWM) technique on shoulder ROM in the plane of the scapula and PPT in participants with anterior shoulder pain. A randomized-controlled trial with a crossover design was conducted with 24 subjects. ROM and PPT were measured before and after the application of MWM, sham and control conditions. Significant and clinically meaningful improvements in both ROM (15.3%, F (2,46) ¼ 16.31 P ¼ 0:00) and PPT (20.2%, Fð2; 46Þ ¼ 3:44, P ¼ 0:04) was observed immediately post treatment. The results indicated that this specific manual therapy treatment had an immediate positive effect on both ROM and pain in subjects with painful limitation of shoulder movement.
A study21 done on 33 subjects by Kachingwe AF et al, to compare the effectiveness of four physical therapy interventions in the treatment of primary shoulder impingement syndrome: 1) supervised exercise only, 2) supervised exercise with glenohumeral mobilizations, 3) supervised exercise with a mobilization-with-movement (MWM) technique, or 4) a control group receiving only physician advice. The MWM and mobilization groups had a higher percentage of change from pre- to post-treatment on all three pain measures (VAS, Neer, Hawkins-Kennedy). The three intervention groups had a higher percentage of change on the SPADI. The MWM group had the highest percentage of change in AROM, and the mobilization group had the lowest.
A study by Olivera C. Djordjevic et al,3 compared the efficacy of Mobilization with Movement (MWM) andkinesiotaping (KT) techniques with a supervised exercise program in participants with patients with shoulder pain. 20 subjects with shoulder pain were included in their studies which were randomly assigned to 1 of 2 groups. Group 1 was treated with MWM and K taping techniques, whereas group 2 was treated with a supervised exercise program. The main outcome measures were activepain-free shoulder abduction and flexion ROM tested on days 0, 5, and 10 with a universal goniometer. Standardized goniometric measurements have been shown to have good intrarater reliability and validity. Improvement in active pain-free shoulder range of motion was significantly higher in the group treated with MWM and K taping.
A systematic review done by Lori A. Michener et al,22with a purpose to examine the evidence for rehab interventions for SAIS. Randomized clinical trials that investigated physical interventions used in the rehabilitation of patients with SAIS with clinically relevant outcome measures of pain and quality of life were selected. The search resulted in 635 potential studies, where 12 samples met the inclusion criteria. In their research Various treatments were evaluated: exercise in six trials, joint mobilizations in two trials, laser in three trials, and ultrasound in two trials. The evidence currently available suggests that exercise and joint mobilizations are efficacious for patients with SAIS.
A study conducted by James camarions et al,23identified the effectiveness of manual therapy to the glenohumeral joint across all painful shoulder conditions. Outcomes measures were range of motion, pain, function, and/or quality of life. Quality assessment was performed using the PEDro scale with subsequent data extraction. The average PEDro score was 7.86, meeting the cutoff score for high quality. Five studies demonstrated benefits utilizing manual therapy for mobility, and four demonstrated a trend towards decreasing pain values. Functional outcomes and quality-of-life measures varied greatly among all studies. Manual therapy appears to increase either active or passive mobility of the shoulder. A trend was found favoring manual therapy for decreasing pain and improving mobility.
As per one of the case report16 on treatment of myofacial pain conducted by the authors FranciscoGarcı´a-Muro Angel L.et al, documents the results achieved with Kinesio Taping as the exclusive therapeutic procedure for the treatment of a patient with shoulder pain of myofascial origin. Results of this case report showed an objective improvement in the range of motion after treatment. Active abduction scored 107", and active flexion 50".
According to one of the studies conducted by the authors Erkan Kaya, et al,18 determined and compared the efficacy of Kinesio tape and physical therapy modalities in patients with shoulder impingement syndrome. Patients (n=55) were treated with kinesio tape (n=30) three times by intervals of 3days or a daily program of local modalities (n=25) for 2weeks. Response to treatment was evaluated with the Disability of Arm, Shoulder, and Hand scale. The rest, night, and movement median pain scores of the Kinesio taping group were statistically significantly lower at the first and second week examination as compared with the physical therapy group. Results of this study showed that Disability of Arm, Shoulder, and Hand scale scores of the Kinesio taping group were significantly lower at the second week as compared with the physical therapy group.
One of the studies conducted on baseball players by authors Yin Hsin Hsu Wen-Yin Chenet al,24 aimed to investigate the effect of elastic taping on kinematics, muscle activity and strength of the scapular region in baseball players with shoulder impingement.In their study Seventeen baseball players with shoulder impingement were treated with TexTM and the placebo taping (3M Micropore tape) over the lower trapezius muscle. They measured the 3-dimensional scapular motion, electromyographic (EMG) activities of the upper and lower trapezius, and the serratus anterior muscles during arm elevation. Strength of the lower trapezius was tested prior to and after each taping application. The results of the analyses of variance (ANOVA) with repeated measures showed that the elastic taping significantly increased the scapular posterior tilt at 30° and 60° during arm raising and increased the lower trapezius muscle activity in the 60–30° arm lowering phase (p0.05) in comparison to the placebo taping. And they concluded that the elastic taping resulted in positive changes in scapular motion and muscle performance.
A study conducted by Mark D Thalenet al,14was to determine the short-term clinical efficacy of Kinesio Tape (KT) when applied to 42 college students with shoulder pain, as compared to a sham tape application. The Subjects were asked to wear the tape for 2 consecutive 3-day intervals. Self-reported pain and disability and pain-free active range of motion (ROM) were measured at multiple intervals to assess for differences between groups. KT group proved to be more beneficial in terms of immediate improvement.
The Visual Analogue Scale (VAS) is a measurement instrument consisting of a 10 cm line with zero on one end representing no pain and 10 on the other end representing worst pain ever experienced. The patient marks on this scale to indicate the severity of his or her pain. A study was done to assess the reliability of VAS in patients with musculoskeletal pain. Results showed an intraclass correlation co-efficient (ICC) of 0.97 (CI= 0.96-0.98) based on which they concluded that reliability of VAS for musculoskeletal pain appears to be high.19
In a study Shoulder pain and Disability Index (SPADI) hashigh internal consistency (0.86 to 0.95) observed overall, and moderate test-retest reliability was reported (ICC = 0.65).25
In a study the active ROM for shoulder was measured using the universal goniometer. Standardized universal goniometric measurements have been shown to have good intrarater reliability and validity.3
RESEARCH HYPOTHESIS:
Null hypothesis (Ho): There will not be any significant difference in the outcome measures between MWM and Kinesio Taping groups in managing subjects of painful shoulder.
Alternate hypothesis (H1): There will be significant difference in the outcome measures between MWM and Kinesio Taping groups in managing subjects of painful shoulder.
OBJECTIVE OF THE STUDY:
To compare the effectiveness of Mulligan’s mobilization with movement and Kinesio taping techniques in the subjects with painful shoulder (rotator cuff injury-partial tear and impingement syndrome).
B)PROCEDURE, MATERIALS AND METHODS:
SOURCE OF DATA COLLECTION:
Outpatient department of physiotherapy, SDM college of medical sciences and hospital, Dharwad.
METHOD OF DATA COLLECTION:
Ethical clearance has been obtained from S. D. M. College of Medical Sciences and Hospital, Dharwad. Patient will be referred by orthopedic surgeon to Physiotherapy department of S. D. M. College of Medical Sciences and Hospital, Dharwad. Patient will be briefed about the study, if he or she agrees then a written consent will be taken and a routine method of evaluation will be done. This will involve history, evaluation of pain, ROM and shoulder disability .The outcome measures are Visual Analogue Scale for pain, ROM measurement by using universal goniometerand shoulder pain and disability index, which will be assessed on day one (pre intervention) and on 3rd day (post intervention).
MATERIAL:
1) Data collection sheet