Rajiv Gandhi University of Health Sciences, Karnataka s5

Rajiv Gandhi University of Health Sciences, Karnataka Bangalore Annexure II1. Name of the Candidate and Address JYOTI CHOUDHARY (in block letters) DR.M.V.SHETTY COLLEGE OF PHYSIOTHERAPY VIDYANAGAR, KULOOR, MANGALORE-5750132. Name of the Institution DR.M.V.SHETTY COLLEGE OF PHYSIOTHERAPY3. Course of Study and Subject MASTERS OF PHYSIOTHERAPY (MPT) MUSCULOSKELETAL AND SPORTS 4. Date of Admission to Course 30th October 20095. Title of the Topic A COMPARATIVE STUDY ON THE EFFECTIVENESS OF MOVEMENT WITH MOBILIZATION WITH CAPSULAR STRETCH AND MOVEMENT WITH MOBILIZATION ALONE IN ADHESIVE CAPSULITIS. 1 6 BRIEF RESUME OF THE INTENDED WORK6.1) Introduction and Need of the Study: The shoulder is the most movable but unstable joint in the body because of the range of motion it allows. It is easily subjected to injury because the ball of the upper arm is larger than the socket that holds it. To remain stable, its muscles, tendons and ligaments must anchor the shoulder1.Some of the more common terms that are synonyms for frozen shoulder are adhesive capsulitis, periarthritis, stiff and painful shoulder, periarticular adhesions, Duplay’s disease, scapulohumeral periarthritis, tendinitis of the short rotators, adherent subacromial bursitis, painful stiff shoulder, bicipital tenosynovitis, subdeltoid bursitis, humeroscapular fibrositis, shoulder hand syndrome, bursitis calcarea, supraspinatus tendinitis, periarthrosis humeroscapularis,and a host of foreign language terms2.To regain the normal extensibility of the shoulder capsule and tight soft tissue, passive stretching of the shoulder capsule and soft tissue by means of mobilization techniques has been recommended. Mid-range mobilization (MRM), end-range mobilization (ERM), and mobilization with movement(MWM)technique have been advocated by Maitland, Kaltenborn and Mulligan3.The treatment of adhesive capsulitis should initially be conservative, with the emphasis on passive stretching of the capsular structures. Stretching for the anterior, inferior and posterior shoulder should be performed by the patient as a part of the motion programme. Stretching a shoulder can be painful but stretching slightly past the point of pain is necessary to make forward progression in range of motion4The aim of study is to investigate the effects of Movement with mobilization with capsular stretch and movement with mobilization alone in the treatment of patients with adhesive capsulitis.Need of Study: Studies have proved that both Movement with mobilization and capsular stretch are used in the treatment of adhesive capsulitis.But no studies have been previously conducted to compare the effectivness of movement with mobilization with capsular stretch and movement with mobilization alone.Hence it has not been proved which of the above two treatment protocols are superior in the treatment of adhesive capsulitis.Therefore a need arises to determine the effectiveness of Movement with mobilization with capsular stretch and Movement with mobilization alone in the treatment of adhesive capsulitis.2 Research Question:Is there any significant difference between movement with mobilization with capsular stretch and movement with mobilization alone in the treatment of adhesive capsulitisHypothesis: Null hypothesis:There is no significant difference between Movement with mobilization with capsular stretch and Movement with mobilization alone in the treatment of adhesive capsulitis.Alternate hypothesis:There will be a significant difference between Movement with mobilization with capsular stretch and Movement with mobilization alone in the treatment of adhesive capsulitis.6.2) REVIEW OF LITERATURE: Jing -Ian Yang ,Chein –Wei Chang, Shiau -Yee Chen ,Shwu -Fen wang and Jin- Jenq lin in their study on mobilization techniques in subjects with frozen shoulder concluded that end range mobilization is more effective in the treatment of frozen shoulder3 Bill Vicenzino, B et al had done a critical review of literature to synthetise and evaluate the claims of the effectiveness of MWM. They found trends in the data that support the clinical claims of the rapid ameliorative effects on pain and function during and initially after a single treatment session and also after a course of intervention5.Brian Mulligan had described a technique for shoulder gridle that appears to be clinically effective.He has given a set of guidelines for the application of MWM to shoulder girdle6.BenzaminA.Goldberg et.al anterior capsule tightens during external rotation and the posterior capsule tightens with internal rotation and cross body adduction7Robert J. Neviaser & Thomas J. Neviaser have mentioned the use of gentle stretching exercise into elevation, external rotation and internal rotation under the supervision of a physician and a knowledgeable therapist in the treatment of frozen shoulder8.M.A.Harrast, Anita G.Rao , have mentioned the use of a typical exercise program of active and passive stretching with the goal of maintaining and regaining range of motion in frozen shoulder. The basis of this program is four-quadrant stretching of shoulder joint capsule which includes forward flexion, internal rotation, external rotation and cross-body adduction9. Mc cormac HM,Horne DJ,Sheather S in their study of critical review of clinical 3 application of visual analogue scale stated that visual analogue scale is established as valid and reliable in range of clinical and research application10 Boonstra,Anne M.;Schiphorst Preuper,Henrica R.;Reneman,Michiel F et al did a study to determine the reliability and validity of the visual analogue scale for disability in patients with chronic musculoskeletal pain and they concluded that reliability of the VAS for disability is moderate to good and a strong correlation with the VAS for pain11.Dan L Riddle,Jules M Rothstein and Robert L Lamb examined the intratester and intertester reliabilities of clinical goniometric measurement of shoulder passive range of motion and concluded that the degree of intertester reliability appears to be range of motion specific12Mac Dermid J.C. et al performed a study on the cross sectional and longitudinal validity of shoulder pain and Disability Index in a group of 129 community volunteers with shoulder pain.They found that it is a valid measure to assess pain and disability in community based patients reporting shoulder pain due to musculoskeletal pathology13.Griggs et al reported that following a physical therapy programme consisting of passive stretching exercises (forward elevation, external rotation, horizontal adduction and internal rotation) at a mean follow-up of 22 months, patients demonstrated a reduction in pain score from 1-57 to1-16 in a range from one to five points, improvements in active range of motion, and 64 patients (90%) reported a ‘satisfactory outcome.146.3) OBJECTIVES OF STUDY:1. To evaluate the effectiveness of Movement with mobilization with capsular stretch in relieving pain and improving function in subject with adhesive capsulitis. 2. To find the effectiveness of movement with mobilization alone in relieving pain and improving function in subject with adhesive capsulitis. 3. To compare the effectiveness between Movement with mobilization with capsular stretch and Movement with mobilization alone in relieving pain and improve function in subject with adhesive capsulitis.MATERIALS AND METHODOLOGY:7.1) STUDY DESIGN: Experimental Study. 4 7.2) SOURCE OF DATA:60 Patients suffering from acute adhesive capsulitis coming for physiotherapy referred by physician or orthopaedic surgeon in and around mangalore. 7.2 (I) Definition of Study Subjects:60 subjects suffering from adhesive capsulitis from past 3 months will be recruited for this study. 7.2 (II) Inclusion and Exclusion Criteria: INCLUSION CRITERIA:1. Males and Females. 2. Age group of 40-50yrs. 3. Painful shoulder for atleast 3 months. 4. Limited ROM of a shoulder joint (ROM losses of 25% or greater compared with the noninvolved shoulder in at least 2 of the following shoulder motions: glenohumeral flexion,abduction, or medial and lateral rotation) 5. Informed consent.EXCLUSION CRITERIA:1. Patients with diabetes mellitus. 2. Painful stiff shoulder after a serious trauma. 3. Inflammatory disease such as rheumatoid arthritis 4. A history of surgery on affected shoulder. 5. Fracture of the shoulder joint. 6. Rotator cuff rupture. 7. Tendon calcification.7.2 (III) Study, Sampling Design, Method and Size:SAMPLE DESIGN:Purposive samplingMETHOD OF COLLECTION DATA From different physiotherapy and orthopaedic clinics in and around Mangalore.SAMPLE – SIZE:Total 60 subjects5 7.2 (IV) Follow Up: A post treatment examination will be done to asses pain ,range of motion and functional ability in order to compare the results with pretest examination done to assess the same using VAS, Goniometer , Shoulder pain and Disability index(SPADI)7.2 (V) Parameters used for comparison and statistical analysis used:. Collected data will be analysed by paired and unpaired t- test. 7.2 (VI) Duration of study:The study will be conducted over a duration of 10-12 months.7.2 (VII) Methodology:Subjects meeting the inclusion and exclusion criteria will be recruited for the study after obtaining the informed consent from the patient. All subjects will undergo a pre-treatment examination to assess pain, range of motion and functional ability with the help of visual analogue scale, goniometer, SPADI. Subjects will be randomly assigned into 2 groups A and B respectively30 in each group and the treatment will be given twice a week for 3 weeks.GROUP A: After a brief description about Movement with mobilization and Capsular stretch, subjects in this group will first be given Movement with mobilization followed by Capsular stretch.PROCEDURE: Movement with mobilizationThis technique combines a sustained application of a manual technique "gliding" force to a joint with concurrent physiologic (osteo-kinematic) motion of the joint, either actively performed by the subject or passively performed by the therapist. The manual force, or mobilization, is theoretically intended to cause repositioning of bone positional fault. The aim of MWM is to restore pain-free motion at joints that have painful limitation of range of movement. The subject will be in a relaxed sitting position, a belt will be placed around the head of the humerus to glide the humeral head appropriately, as the therapist's hand will be used over the appropriate aspect of the head of the humerus. A counter pressure also will be applied to the scapula with the therapist's other hand. The glide well be sustained during slow active shoulder movements to the end of the pain-free range and released after return to the starting position. Three sets of 10 repetitions will be applied, with 1 minute rest between sets.6 Capsular stretchTo stretch the anterior capsule the subject will be positioned either in side lying with the affected arm upwards or in high sitting. The shoulder and arms will be brought backwards into extension and this stretch will be maintained for a minimum of 30 seconds and maximum duration up to the point of pain experienced by the patient. Posterior capsule stretching will be performed with the subject in supine position and therapist performing cross body adduction.GROUP B :Subjects in this group will also be given a brief description of Movement with mobilization ,after which they will receive Movement with mobilization alone.On the same assessment parameters ,post- treatment examination will be done to assess pain, range of motion and functional ability at the end of 3 weeks for both the groups for comparison with pre-treatment examination results.7.3) Does the study require any investigations to be conducted on patients or other human or animal? If so, please describe briefly.YES1)Visual analogue scale to assess pain10 2)Goniometer for assessing range of motion12 3)SPADI for assessment of functional ability137.4) Has ethical clearance been obtained from your institution in case of 7.3?7 Yes.8 8 LIST OF REFERENCES: 1. Lori B. Siegel, Norman J. Cohen and Eric P. Gall. Adhesive capsulitis: A sticky issue, American Family Physician 1999:59:7.2. Robert A. Donatelli, Physical therapy of the shoulder 3rd edition, Churchill Livingstone, New York 19973. Jing-Ian Yang,Chein – Wei Chang, Shiau- Yee Chen, Shwu -Fen Wang and Jin-Jenq Lin.Mobilization technique in subjects with frozen shoulder syndrome,randomized multiple- treatment trial,phys ther vol 87,no 10,oct 2007,pp 1307 – 1315. 4. Rookwood C,Matsen f the shoulder vol.2. Philadelphia,Saunders,1998.5.Bill Vicenzino,Aatit Paungmali,Pamela Teys Mulligan’s mobilization with movement,positional faults and pain relief:current concepts from a critical review of literature manual therapy 12(2007)98-108.6.Brain Mulligan,The painful dysfunctional Shoulder.A new treatment approach using Mobilization with Movement newzeland journal of physiotherapy-nov 2003.vol 31,3.7.Benzamin A goldbergrius M. Scarlat & Douglas T. Harryman II. Management of the stiff shoulder. Journal of Orthopaedic Science 1999;4: 462-471.8. Robert J. Neviaser and Thomas J. Neviaser. Frozen shoulder Diagnosis & Management. Current Orthopaedics & Related Research 1987;223:53-649.Mark A. Harrast & Anita G. Rao. The stiff shoulder. Physical Medicine & Rehabilitation clinics of North America 2004; 15:557-57310.Mc Cormac HM,Horne DJ,Sheather S.Clinical applications of visual analogue scale:A critical review;phycol med.1998;18(4):1007-19.11.Boonsrta Anne M,Schiphorst preuper HR,Reneman MF.Reliability and validity of the visual analogue scale for disability in patients with chronic musculoskeletal pain.Int J Rehabil:l Res.2008;31(2):165-9.12.Dan L Riddle,Jules M Rothstein and Robert L Lamb.Goniometric reliability in a clinical setting.1987;67(5):673.13.Mac Dermid JC, Solomon P and Prkachin k,”The shoulder pain and Disability Index demonstrate factor construct and longitudinal validity” BMC Musculoskeletal Disorder 2006,7:12.14.Sean M. Griggs, Anthony Ahn and Andrew Green. Idiopathic Adhesive capsulitis. A perspective functional outcome study of non-operative treatment. The journal of Bone & Joint Surgery 2000: 82-A: 1398-1407.9 10

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