RAJIVGANDHIUNIVERSITY OF HEALTH SCIENCES, KARNATAKA
BANGALORE
ANNEXURE II
1. / Name of the Candidate & Address:(in block letters) / B. MYTHILI,
Dr. M.V. SHETTY COLLEGE OF PHYSIOTHERAPY, VIDYA NAGAR, KULOOR POST, MANGALORE, KARNATAKA 575013
2. / Name of the Institution: / Dr. M.V. Shetty College of Physiotherapy
3. / Course of Study & Subject: / Master of Physiotherapy (MPT)
4. / Date of admission: / 9.6.2007
5. / Title of the Topic: / EFFECTS OF MULLIGAN’S MWM AND EXERCISES VERSUS MULLIGAN’S MWM AND EXERCISES WITH SCAPULAR TAPING IN INDIVIDUALS WITH SHOULDER IMPINGEMENT SYNDROME.
6. / Brief Resume of the Intended Work
6.1) Introduction & Need of the Study:
Shoulder is one of the most dynamic joints in the body. It is a very mobile joint & its large range of motion comes at the expense of stability. Shoulder disorders can lead to considerable disability, reduction in health-related quality of life, absenteeism from work & substantial utilization of health care resources1.
Shoulder impingement syndrome is believed to be the most common cause of shoulder pain. Individuals at highest risk for shoulder impingement are laborers & jobs that require repetitive overhead activity. It is also common in sports involving throwing activities. Shoulder impingement has been defined as compression & mechanical abrasion of the rotator cuff structures as they pass beneath the coracoacromial arch during elevation of the arm.2,3
Multiple theories exist as to the primary etiology of shoulder impingement, including anatomic abnormalities of the coracoacromial arch, tension overload, ischaemia or degeneration of rotator cuff tendons & shoulder kinematic abnormalities.4,5Several factors contribute to shoulder impingement such as posture, muscle force, range of motion & scapular dysfunction.
NEED OF THE STUDY:
Mulligan’s Mobilisation with Movement (MWM) has been shown to have immediate positive effects on correcting the positional faults & reducing the pain & increasing the range of motion for painful shoulder6. But the long term effects of this intervention & also its effect on reducing the disability have not yet been tested.
Exercises for scapular stabilizers & rotator cuff muscles have shown improvement in the functions of the shoulder disorders7. Scapular taping improves the resting position of the scapula, correctsthe faulty scapulothoracic movement in shoulder impingement syndrome8.
This study proposes to combine the effects of Mulligan’sMWM, scapulartaping & exercises as the treatment approach for the reduction of pain, increasing the pain free range of motion & improving the functional skills in patients with shoulder impingement syndrome.
RESEARCH QUESTION:
Will there be any significant difference following the application of MWM and exercises with scapular taping (Group B)compared to the MWM and exercises (Group A) aloneinindividuals with shoulder impingement syndrome?
HYPOTHESIS:
ALTERNATE HYPOTHESIS
There will be significant difference in the outcome measures following the application of Mulligan’s MWMand exercises with scapular taping and Mulligan’s MWM and exercisesin individuals with shoulder impingement syndrome.
NULL HYPOTHESIS
There will be no significant difference in the outcome measures following the application of Mulligan’s MWM and exercises with scapular taping and Mulligan’s MWM and exercises in individuals with shoulder impingement syndrome.
6.2)REVIEW OF LITERATURE:
1.Philip W McClure et al (2006) found that in patients with subacromial impingement syndrome had decreased ROM & could exert lesser muscle force & postulated that the impingement conditions can be corrected by focusing on strengthening & restoring flexibility9.
2. Ann M. Cools et al (2007) has conducted a controlled laboratory study on selecting exercises for shoulder rehabilitation and has given a preference to the exercises with high activation of lower and middle trapezius and low activity of upper trapezius10
3. David M Selkowitz (2007) by EMG analysis of scapular muscles concluded that scapular taping decreased upper trapezius activity in people with suspected shoulder impingemeny during overhead task11.
4. H H Host(1994)found that an intervention of scapular taping & exercises appeared to be effective in relieving symptoms in patients with shoulder impingement syndrome. But the suggestion was based on a single case study & a controlled experimental study was recommended8.
5. Brian Mulligan(2003) has stated that the concept of MWM appears to be clinically effective in treating painful shoulder conditions & is therefore an important addition to the existing repertoire of MWM techniques12.
6. Joy C Mac Dermid et al (2005) studied cross sectional and longitudinal validity of Shoulder Pain And Disability Index and found that it is a valid measure to assess pain and disability in patients reporting shoulder pain due to musculoskeletal pathology13.
7. Pamela Teys et al (2006) studied the initial effects of Mulligan’s mobilization with Movement on Shoulder range of motion & pain-pressure threshold in participants with anterior shoulder pain found any immediate & significant improvement in both the outcomes pre to post intervention when compared to sham or control conditions. It was recommended that further studies should emphasize on the time course of these effects & also on a measure of function or disability6.
6.3) OBJECTIVES OF THE STUDY:
- To evaluate the effectiveness of Mulligan’s MWM and exercises on patients with shoulder impingement syndrome.
- To evaluate the effectiveness of Mulligan’s MWM and exercises with scapular taping on patients with shoulder impingement syndrome.
- To determine whether the Mulligan’s MWM and exercises with scapular taping shows significant improvement than Mulligan’s MWM and exercises on patients with shoulder impingement syndrome.
7) /
MATERIALS & METHODS:
7.1) STUDY DESIGN:Quasi experimental study design
7.2) SOURCE OF DATA:
Patients attending the out patient department of Dr. M.V. Shetty Surgical Nursing Home, GovernmentDistrictWenlockHospital & Dr.M.V.ShettyCollege of Physiotherapy with the diagnosis of impingement syndrome will be taken into the study.
7.2. I) DEFINITION OF STUDY SUBJECTS:
Subjects with the diagnosis of shoulder impingement syndrome by an orthopaedician will be included in the study. After a due consideration of the inclusion and exclusion criteria more than 50 subjects will be recruited in the study. The subjects will be divided into two groups,25 in each group.
7.2. II) INCLUSION & EXCLUSION CRITERION:
Inclusion criterion:
- Diagnosis of shoulder impingement syndrome with the duration of symptoms more than 1 month and less than 1year supported by plain x-ray.
- Aged over 18 years
- Subjects presenting any 3 of the following
Positive Hawkins test
Pain on active shoulder elevation
Pain on palpation of rotator cuff tendon
Pain on isometric resisted abduction.
Exclusion criterion:
- History of shoulder impingement syndrome more than 1 year
- History of any fractures around the shoulder
- Rotator cuff tear with acute inflammation (resting pain)
- Cervical radiculopathy
- Acromioclavicular joint dysfunction
- Positive sulcus sign
- Glenohumeral arthritis
- Brachial plexus neuropathy
- Calcified deposits
- Neoplasm
- Adhesive capsulitis
- Reflex symphathetic dystrophy
SAMPLE DESIGN:
Purposive sampling design
METHOD OF COLLECTION OF DATA:
Afterdue consideration of inclusion and exclusion criteria, an informed consent will be obtained from the subjects. Subjects will be assessed before the treatment (baseline) and are assigned randomly in to 2 groups. In both the groups
Pre and post test will be conducted.
1. Pre test:
Painfree ROM Elevation of Shoulder by Goniometry (Flexion and abduction)
Function SPADI12
2. Post test:
Pain free ROM and Function measured after 4 weeks of intervention
SAMPLE SIZE:
50 subjects equally divided into
Group A will receive MWM and exercises
Group B will receive MWM and exercises with scapular taping
7.2 IV) FOLLOW UP:
There will be a follow up assessment using the above mentioned outcome measures after 4 weeks of intervention.
7.2 V) PARAMETERS USED FOR COMPARISON & STATISTICAL TESTS:
The following statistical tools will be used to compare the effects of Mulligan’s MWM and exercises versus Mulligan’s MWM and exercises with scapular taping on the patient with shoulder impingement syndrome.
The paired ‘t’ test will be used to compare the pre versus post test values of Goniometeric measurementfor ROM & SPADI score for shoulder functional status for group A & B respectively.
The unpaired ‘t’ test will be used to compare the mean difference values of ShoulderRange of motion & SPADI scores between the groups A & B.
7.2 VI)DURATION OF THE STUDY:
Period of 1 year.
7.2 VII) METHODOLOGY:
After screening for the inclusion & exclusion criterion with the informed consent pre test evaluation will be conducted for both the groups with the help of measuring tools and data will be recorded. Brief demonstration will be given prior to the treatment session.
GROUP A will receive MWM first with the patient sitting in a chair or stool. The therapist stands on the opposite side of the involved limb. While the therapist is giving sustained posterior glide & the patient is asked to do active abduction in the plane of scapula for 3 sets of 10 times each session6. Then exercises to the strengthen rotator cuff muscles and scapular stabilizers of the shoulder will be given7,12.The exercises will be supervised at the clinic & the patient will be asked to continue at home. The number of treatment sessions will be 3 per week for a period of 4 weeks.
GROUP B will receive the MWM and exercises as per the same methodology as described above. Scapular taping technique aims to encourage a retracted & depressed scapular posture & thoracic extension11. There will not be any activity limitations.
Post test assessment will be done using the above mentioned outcome measures for both the groups at the end of 4 weeks the results compared by the above mentioned statistical tests.
7.3) Does the Study require any Investigations to be conducted on patients or other human or animal? If so, please describe briefly.
Yes. Neer Impingement Test
Hawkin’s Impingement Test
SPADI
Range of motion of shoulder.
7.4) Has ethical clearance been obtained from your institution in case of 7.3
Yes
8) /
LIST OF REFERENCES:
1. Smith KL, Harryman DT, 2nd, Antoniou J, Campbell B, Sidles JA, Matsen FA, 3rd: Aprospective, multipractice study of shoulder function and health status in patients withdocumented rotator cuff tears. J Shoulder Elbow Surg 2000, 9(5):395-402.2. Matsen FA, Arntz CT. Subacromial impingement. In: RockwoodCA,
Matsen FA, eds. The Shouder. Philadelphia, Pa: WB Saunders Co;
1990:623–646.
3.Neer CS Jr. Impingement lesions. Clin Orthop. 1983;173:70 –77.
4. Fu FH, Harner CD, Klein AH. Shoulder impingement syndrome: a
critical review. Clin Orthop. 1991;269:162–173.
5. Jobe FW, Bradley JP. The diagnosis and nonoperative treatment of
shoulder injuries in athletes. Clin Sports Med. 1989;8:419–438.
6. Pamela Teys, Leanne Bisset & Bill Vicenzino, “ The initial effects of Mulligan’s Mobilisation with Movement technique on range of movement & pressure pain threshold in pain limited shoulders, Manual therapy, 2006
7. Bang MD, Deyle GD: Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. Journal of Orthopaedic & Sports Physical Therapy 2000, 30(3):126-137.
8. HH Host, “Scapular Taping in the treatment of Anterior Shoulder Impingement”, Physical Therapy/Volume 75, Number 9/September 1995 pages 803 – 812.
9. .McClure PW, Michener LA, Karduna AR. Shoulder function and
3-dimensionalscapular kinematics in people with and without shoulder impingementsyndrome. Phys Ther. 2006;86:1075–1090
10. Ann M. Cools , Vincent Dewitte, Frederick Lanszweert, Dries Notebaert, Arne Roets, Barbara Soetens, Barbara Cagnie, Erik E. Witvrouw. Rehabilitation of Scapular Muscle Balance: Which Exercises to Prescribe? The American Journal of Sports Medicine .Oct 2007 v35 i10 p1744(8).
11. David M Selkowitz, Casey Chaney, Sandra J. Stuckey et al, “the effect of scapular taping on surface electrmyographic signal amplitude of shoulder girdle muscles during upper extremity elevation in individuals with suspected shoulder impingement syndrome” Journal of Orthopedic & sports physicaltherapy, Epub, July 2007.
12. Brain Mulligan, “The Painful dysfunctional shoulder. A new treatment approach using Mobilization With Movement”, Newzealand Journal of Physiotherapy November 2003, 31(3): 140-142
13. Joy C MacDermid, Patty Solomon, and Kenneth Prkachin, The Shoulder Pain and Disability Index demonstrates factor, construct and longitudinal validity, BMC Musculoskeletal Disorders, 2006, 7:12.