Rajiv Gandhi University of Health Sciences, Karnataka Bangalore

ANNEXURE II

1. Name of the Candidate and Address (in block letters)

VAIBHAVI SURYAKANT ADATEDR M.V. SHETTY COLLEGE OF PHYSIOTHERAPYVIDYANAGARKULOOR, MANGALORE.

2. Name of the Institution DR. M.V.SHETTY COLLEGE OF PHYSIOTHERAPY

3. Course of Study and Subject

MASTERS OF PHYSIOTHERAPY (MUSCULO SKELETAL-DISORDERS AND SPORTS PHYSIOTHERAPY)

4. Date of Admission to Course 22nd JUNE, 2011.

5. Title of the Topic EFFICACY OF MAITLAND MOBILISATION AND LOW LEVEL LASER THERAPY WITH CAPSULAR STRETCH IN MANAGEMENT OF PATIENTS WITH ADHESIVE CAPSULITIS.

6. Brief Resume of the Intended Work6.1) Introduction and Need of the study: The shoulder is considered the most mobile joint in the human body.1, 2 The synchronous motion of the entire shoulder girdle working in concern with the spine provides tremendous mobility. Shoulder rehabilitation specialists focus on restoring and maintaining normal range of motion at the shoulder girdle.3

Adhesive capsulitis is characterised by insidious and progressive onset of pain and loss of active and passive mobility of glenohumeral joint. The term adhesive capsulitis,periarthritis of shoulder are used at times with a meaning synonymous with frozen shoulder . It was first described by Duplay in 1972 and named frozen shoulder by Codman in 1934.The incidence of frozen shoulder has been estimated to be from 3-5% in general population with a significant incidence amongst diabetics in order of 10-20%. It appears to be most common in adults between the age group of 40-70yrs. Women are at a greater risk(4:1) and non dominant arm is most commonly affected.idiopathic frozrn shoulder is most commonly associated with diabetes mellitus.4, 5,6,7

Adhesive capsulitis has been divided into two types 1)primary adhesivecapsulitis which refers to idiopathic form of a painful and stiff shoulder. 2) secondary adhesive capsulitis indicated as a loss of motion resulting from many disposing factors such as trauma,stroke,upper extremity fractures or surgery with mobilization8,9

.Pain particularly in the first phase of adhesive capsulitis of the shoulder,i.e-freezing phase often keeps patients from performing activities of daily living. In the second phase,i.e-frozen phase there are restrictions in active motion which limit the patient in personal care, ADL, or occupational activities. In the third phase,i.e-thawing phase there is slow increase in the mobility, which leads to full or almost full recovery.The first phase lasts for 2 1/2 -9 months, second phase for 4-12 months and third phase for 5-26 months.10,11,12,13

Various physiotherapy approaches have been suggested for shoulder musculoskeletal disorders, including manual therapy,electrotherapy,acupuncture and exercise therapy.14

Mobilisation techniques are an important part of intervention in physical therapy.Mobilisation techniques can be performed as physiological movements or accessory movements.Physiological movements at the glenohumeral joint are movements of humerus in cardinal planes (eg -flexion,extension,abduction,internal rotation,external rotation.) Accessory movements are the movements passively induced by the therapist and they consist of rolling,gliding,(or sliding),spinning, and distraction within the joint. 15,16The intensity of the mobilization technique with rhythmic oscillatory movements usually is categorized according to 5-grade classification of Maitland.17,18

In frozen shoulder the joint capsule tends to be contracted,thickened and closely adherent to the humeral head contributing to limitation of movement.19In frozen shoulder limitation of external rotation with the arm in abduction typically is associated with an antero-inferior capsular restriction whereas limited internal rotation and cross body adduction are associated with posterior capsular restriction.The capsular pattern is designated by a hard end feel at the end limitation of all 3 passive movements in fixed proportions.Therefore stretching for anterior,inferior,and posterior shoulder should be performed.20

The word LASER is acronym for light amplification by stimulated emission of radiation. The laser is based on the principle of stimulated emission.Effects of laser are reduction of pain and acceleration of repair.21

NEED OF THE STUDY: Studies have proved that Maitland mobilization is effective in reducing pain and increasing both active and passive joint mobility in patients with adhesive capsulitis.22,23,24

Studies have also proved that use of Low Level Laser therapy in painful shoulder conditions causes significant reduction in pain,decreased level of disability and improved range of motion.31

Capsular stretching also causes significant reduction in pain and improvement in function in patients with adhesive capsulitis.28

Many combination of treatments have been used in the past for the treatment of adhesive capsulitis and they have been found to be effective.

But no studies have been done in the past to study the effectiveness of Maitland mobilization and Low level laser therapy with Capsular stretch in patients with Adhesive capsulitis and their effectiveness in reducing pain,increasing joint mobility and functional activities.

RESEARCH QUESTON: Is there any significant difference in reducing pain,increasing joint mobility and function following combined application of Maitland Mobilisation and Low Level Laser therapy with Capsular Stretching in management of patients with Adhesive Capsulitis.

HYPOTHESIS:

Alternate hypothesis: There will be significant difference in shoulder pain,increase in joint mobility and function following combined application of Maitland Mobilisation and Low Level Laser with Capsular Stretching in patients with Adhesive Capsulitis.

Null hypothesis: There will be no significant difference in shoulder pain,increase in joint mobility and function following combined application of Maitland Mobilisation and Low Level Laser with Capsular Stretching in patients with Adhesive Capsulitis.

6.2)REVIEW OF LITERATURE: Jing-Lan Yang, Chein-Wei Chang et al. (2007) conducted a Randomized multiple clinical trial. The purpose of the study was to compare the use of 3 mobilization techniques--End range mobilization (ERM), mid range mobilization (MRM) and mobilization with movement (MRM) in the management of subjects with frozen shoulder syndrome. 28 subjects with frozen shoulder syndrome were recruited for the study. The duration of each treatment was 3 weeks for a total of 12 weeks. The result of the study shows that end range mobilization(ERM) and mobilization with movement(MWM) is more effective than Mid range Mobilization (MRM) in increasing mobility and functional ability in subjects with frozen shoulder syndrome.22

Heuricus M Vermeulen, Piet M Rozing et al.(2006) conducted a Randomised clinical trial.The purpose of the study was to compare the effectiveness of high-grade mobilization techniques (HGMT) with that of low-grade mobilization techniques (LGMT) in subjects with adhesive capsulitis of the shoulder. 100 subjects with unilateral adhesive capsulitis lasting 3 months or more and greater than or equal to 50% decrease in passive joint mobility relative to the non affected side were enrolled in this study which was randomly divided into two groups. The duration of treatment was a maximum of 12 weeks (24 sessions) in both groups.The result of the study shows that HGMTs appear to be more effective in improving glenohumeral joint mobility and reducing disability than LGMT in subjects with Adhesive capsulitis .23

Heuricus M Vermeulen, Piet M Rozing et al.(2000) conducted a study.The purpose of the study was to describe the use of End-range Mobilization techniques in the management of patients with adhesive capsulitis.7 patients with adhesive capsulitis of the glenohumoral joint were treated with end range mobilization techniques twice a week for three months. The result of the study shows that therewas an increase in glenohumoral mobility but in the absence of a control group in the patients of adhesive capsulitis24

Garvice G. Nicholson conducted a study. The purpose of the study was to determine the effects of passive mobilization and active exercises in patients with painfully restricted shoulders.20 patients with painful glenohumoral restrictions were included in the study. They were divided in two groups. The experimental group received mobilization and active exercise 2 to 3 times per week for 4 weeks. The controlled received only active exercise (pendular exercise). The result of the study shows that joint mobilization and exercise are clinically effective in the treatment of painfully stiff shoulders.25

Sarah Jackins has conducted a study on capsular stretching in the non operative treatment of rotator cuff injuries. Capsular stretching of the shoulder was performed five times a day.Each stretch was performed to the point where the patient felt a pull against the shoulder tightness, but not to the point of pain for one minute and the results showed a beneficial effect in improving range of motion.26

Mantone et al have conducted a study on the importance of stretching exercises for anterior,posterior and inferior shoulder capsule as a part of motion programme to improve joint range of motion in stiff shoulder.26

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 2 months patients demonstrated a reduction in pain scores and improvement in active range of motion.27

Umit Bingol did a study on the effect of low power gallium arsenide laser treatment on patients with shoulder pain.This study included 40 patients randomly assigned in to 2 groups. Patients in first group received laser treatment of 2000Hz using a Ga As. Diode laser and an exercise protocol.Patients in second group received placebo laser and same exercise protocol.Patients were evaluated according to parameters of pain,palpation sensitivity,algometric sensitivity and shoulder range before and after treatment.The results showed superior results in laser treatment group compared to control group.28

Apostolos Sterioulos ,2007,performed a study on the effectiveness of low level laser treatment in patients with frozen shoulder.The study included 63 patients with shoulder pain randomly assigned into 2 groups.One group received active laser therapy and second group received placebolaser treatment.The patients in each group received 12 sessions of laser or placebo.The results suggested that laser treatment was more effective in reducing pain and disability scores than placebo group at the end of treatment period.29

Karabegovic A,2009, conducted a study whose aim was to determine effects of laser therapy and TENS.The study was conducted on 70 subjects who were divided into 2 groups of 35 each. The first group received laser therapy and second group received TENS.The laser group showed better results in reducing pain,swelling,disability and improvement of independency.30

Dan L Riddle, Jules M Rothstein et al. (1987) conducted a study. The purpose of the study was to examine the intratester and intertester reliabilities for clinical goniometric measurements of shoulder passive range of motion (PROM) using two different sizes of universal goniometers. The results of the study shows that Goniometric PROM measurements for the shoulder appear to be highly reliable when taken by the same physical therapist, regardless of the size of the goniometer used. The degree of intertester reliability for these measurements appears to be range of motion specific.31

Brain Tilpady, Stephen H. D. Jackson et al. (1998) conducted a study. The purpose of the study was to find the validity and sensitivity of Visual Analogue Scale in young and older healthy subjects. A total of 100 subjects (50 young and 50 old) were included in the study.The results of the study support the validity of the use of Visual Analogue Scale in both the groups.32

Einar Kristian Tveitå, Ole Marius Ekeberg et al. (2008) conducted a study. The objective of the study was to investigate the reproducibility and responsiveness of the SPADI in patients with adhesive capsulitis. Responsiveness was assessed by exploring baseline and follow-up data recorded in a recently reported clinical trial regarding hydro dilatation and corticosteroid injections in 76 patients with adhesive capsulitis. The results of the study support the use of SPADI as an outcome measure in similar settings. 33

6.3) OBJECTIVES OF STUDY :

To determine the efficacy of Maitland Mobilisation and Low Level Laser therapy with Capsular Stretching in relieving pain,increasing joint mobility and function in management of patients with Adhesive Capsulitis.

MATERIALS AND METHODS :7.1) STUDY DESIGN : Experimental design

7.2)SOURCE OF DATA : Patients suffering from Adhesive Capsulitis within the age group of 45-65 years diagnosed and referred by physician or orthopedic surgeon in and around Mangalore.

7.2 (I) Definition of Study Subjects :

60 subjects suffering from Adhesive Capsulitis in the age group of 45 to 65 yrs will be recruited for this study.

7.2 (II) Inclusion and exclusion criteria:

INCLUSION CRITERIA:

-Age group between 45-65 years.-Both males and females.-unilateral involvement.-Painful stiff shoulder for at least 3 months.-Restriction of more than 50% in shoulder range of motion compared to other side. EXCLUSION CRITERIA:

- Diabetes mellitus - History of surgery on the particular shoulder. -Rotator cuff rupture. -Painful stiff shoulder after a serious trauma. - Fracture of the shoulder complex -Presence of osteoarthritis, or signs of bony damage. -Inflammatory diseases such as rheumatoid arthritis. -Tendon calcification

7.2 (III) Study Sampling Design, Method and Size:

Sample design:

Stratified random sampling Method of collection of data From M.V Shetty surgical nursing home, Govt district Wenlock hospital and different physiotherapy and orthopaedic clinics in and around Mangalore.

Sample size: Total 60 subjects with 30 subjects in each group.

7.2 (IV) Follow up: A post treatment test will be conducted on VAS for shoulder pain, Goniometer for active and passive external rotation range of motion of the shoulder joint and Shoulder Pain and Disability Index (SPADI) for disability after 4 weeks of treatment.

7.2 (V) Parameters used for comparison and statistical analysis used: ‘t’ test . 7.2 (VI) Duration of study:

10-12 months approximately.

7.2 (VII) Methodology:

60 subjects with adhesive capsulitis meeting the inclusion criteria will be recruited and randomly divided into two groups, i.e. Group A (experimental group) and Group B( control group), each group containing 30 subjects. Informed consent will be obtained from the subjects

Pre-test will be conducted on Group A and Group B by VAS for assessing pain, goniometer for assessing Glenohumoral active and passive range of motion and SPADI for assessing disability.

Group A will receive Maitland mobilization for glenohumeral joint,i.e, A-P glide,P-A glide, lateral glide,distraction, inferior glide with low level laser therapy and shoulder pendular exercises 2times a week for a period of 4 weeks(8 sessions).

Group B subjects will receive shoulder Pendular exercise 2 times a week for a period of 4 weeks (8 sessions).

Post-test will be conducted on Group A and Group B by VAS for assessing pain, goniometer for assessing Glenohumoral active and passive range of motion and SPADI for assessing disability

The results will be recorded and analyzed statistically.

PROCEDURE:GROUP A(MAITLAND MOBILISATION,LOW LEVEL LASER THERAPY AND CAPSULAR STRETCH AND PENDULAR EXERCISES)Maitland mobilization technique- Posterio anterior glide for glenohumeral joint

The patients were positioned in supine lying in supine with his elbow flexed and his forearm was positioned against a pillow on his trunk.

The researcher kneeled laterally and superiorly to the patients shoulder and positioned the two thumbs, back to back, with the tips in contact with the posterior surface of the head of the humerus adjacent to the acromion process and pointing towards the ceiling. The fingers of the one hand were spread over the clavicular area and those of the hand were spread over the deltoid. The oscillatory movement was produced by the researcher arm, not through researcher thumb flexors.

Antero posterior movement for glenohumeral jointPatients were positioned in supine lying the researcher stood by the patient’s upper

arm facing across his body and supported the lower end of patient’s humerus posteriorly from the medial side with one hand and then rested his forearm on the researcher forearm. The researcher raised the patient’s upper arm approximately 200 anteriorly to the coronal plane to the trunk so that the head of the humerus would not impinge against the inferior surface of the acromion process posteriorly. The researcher placed the cupped heel of another hand anteriorly over the head of the humerus, with the fingers extending superiorly and posteriorly over the acromion process and anteroposterior oscillation was performed. The researcher fingers were cupped loosely around the acromion process, and did not apply pressure at all, but assisted in feeling the movements.

Caudal glide for gleno humeral jointPatients were positioned in supine lying the researcher stood beyond the patient’s

head at the affected side and placed researcher’s pads of thumbs against the head of the humerus immediately adjacent to the anterior and lateral borders of the acromion process so that caudal movement of the head of the humerus was felt in relation them, while direct pressure was used, against the head of the humerus. The entire technique performed with the patient’s arm by his side or with his arm in abduction or flexion in any angle.

Distraction for gleno humeral joint

Patient positioned in supine lying with elbow slightly flexed. The therapist stands on the lateral side of the couch and places the 1st web space in the upper part on the arm near to axilla and with the other hand stabilizes the lateral aspect of the humeral head.The lateral side of the elbow is also stabilized with the therapists pelvis n distraction is applied from medial to lateral side according to maitland gradings.

Low Level Laser Therapy-

Infrared diode laser(904nm), with the following parameters- maximum power-60W, peak power per pulse-27W, pulse frequency-1280Hz, avg point region:2-8J, dose/point:3-4J, total energy density-24J/cm2. Scanning method is used over tender areas of shoulder with appropriate amplitude,frequency and position of beam. Duration of treatment-3min/session for 9 sessions of treatment for 3 weeks.34,35

Capsular stretching for shoulder-

Patients will be treated with a four direction shoulder stretching exercise program that includes passive forward elevation,passive external rotation,passive internal rotation and passive horizontal adduction.The patients will be instructed to stretch the shoulder to the point of tolerable discomfort five times a day.28

Pendular exercise.

Basic Pendular Exercise

Patient will need a chair or table for this exercise. Patient will lean forward so that his back is parallel to the floor and his hands are on the back of the chair. The patient will firmly grip the chair with the non affected hand and slowly bring the affected arm down so it is hanging

freely. Once in this position, the patient will slowly swing his affected arm forward, backward and from side to side. These exercises should be done in repetition of eight times by the affected hand.

Pendular Circles

This exercise will again require the use of the table or chair. Patient will get into the position from the basic pendular exercise, leaning against the back of the chair with his affected arm hanging down. Instead of the back and forth movement, this time the patient will slowly move his affected arm in a clockwise circle. His circles should be as wide as they can be without pain. Will make several circles with his arm, then stop and switch directions to a counter-clockwise direction. These exercises should be done in repetition of 10 times in each direction.

GROUP B-(CONTROL GROUP) PENDULAR EXERCISE.

Subjects in this group will receive basic pendular exercise and pendular circles exercise,the procedure of which is the same as mentioned for group A.

7.3) Does the study require any investigations to be conducted on patients or other Human or animal? if so, please describe briefly: Yes

1) Visual analogue scale 18 to assess pain.

2) Goniometer17 for assessing glenohumoral active and passive range of motion..3) Shoulder Pain and Disability Index19 for assessment of functional ability.

7.4) Has ethical clearance been obtained from your institution in case of 7.3?

Yes

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