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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
KARNATAKA, BANGALORE
Annexure II
Proforma For Registration Of Subject For Dissertation
1.
Name
of
candidate
Address (In
letters)
the
KHAN MISBAH ABU SAQUIB
and
‘F’ WING,GRD FLR ROOM NO-‘02’,TANWAR
Block
COMPLEX.KAUSA MUMBRA,DIST THANE: 400612
2.
Name of institution:
3.
Course of study and MASTERs OF PHYSIOTHERAPY (MPT) 2 YEARS
DEGREE COURSE
IN MUSCULOSKELETAL
Subject:
DISORDERS AND SPORTS
4.
Date of Admission to
26/7/2013
course:
CITY
COLLEGE
MANGALORE
OF
PHYSIOTHERAPY,
COMPARISION OF RECRUITMENT OF LOWER
TRAPEZIUS AND SERRATUS ANTERIOR IN
FROZEN SHOULDER, IMPINGEMENT SYNDROME
AND ASYMPTOMATIC SUBJECTS
5.
Title of the topic:
6.
Brief resume of the intended work:
6.1) Introduction and need of the study
Shoulder pain is a common problem with upto half of the population experien
cing atleast one episode per year.the morbidity associated with shoulder pain is com
monly encountered in primary care and physiotherapy.
The shoulder joint complex consists of the sternoclavicular (SC),
Acromioclavicu lar (AC) and the glenohumeral (GH) joints. It enjoys greater range
of motion than any other joint in the body. However, this high mobility results in
challenges to the static and dynamic stabilizing structures of the shoulder complex.1
Shoulder muscles are largely responsible for the dynamic stability and joint
motion of the glenohumeral joint.When the shoulder muscles fatigue, joint
mechanics become altered, thus possibly leading to pathologies such as tendonitis,
impingement,and even subluxations or dislocations.In addition,shoulder fatigue
directly affects the way in which the scapula moves concomitantly with the
1
humerus.2Since the kinematics of the shoulder depend largely upon the surrounding
muscles, fatigue in any of the muscles could lead to an alteration in the
scapulohumeral rhythm.Demonstrated that as shoulder muscles fatigue,there is a
resultant destabilization of the scapula and decrease in the scapulohumeral
rhythm.2,3
The upper trapezius,lower trapezius,serratus anterior muscles are considered
to be the upwards rotators of scapula.these muscles plays an integral part in scapula
movement during scapula humeral rhythm along with upper and lower trapezius
muscles,serratus anterior forms a force couple that upwardly rotates the scapula and
also elevate the acromion.The most common scapula muscles which will go for
weakness or inhibition are lower stabilizers of scapula(serratus anterior,rhomboids,
middle and lower trapezius).This problem manifests itself through decreased
shoulder abduction and secondary impingement scapulo humeral rhythm or
scapular position may be altered with different condition that include increase
loading,muscle fatigue,impingement syndrome instability of glenohumeral joint or
postural changes.5,6
The scapulothoracic gliding mechanism is not a true joint but is the riding of
the concave anterior surface of the scapula on the convex posterolateral surface of
the thoracic cage. The thorax and scapula are separated by the supscapularis and
serratus anterior muscles, which glide over each other during movements of the
scapula.The scapula is held in close approximation to the chest wall by muscular
attachments.In movements of the shoulder complex, the scapula can be protracted,
retracted, elevated, depressed, and rotated about a variable axis perpendicular to its
flat surface.7,8 The muscles connecting the scapula with the axial skeleton shows
that all except for the upper fibers of the trapezius and pectoralis minor muscles are
inserted near or on the medial border of the scapula.These include the upper and
lower digitations of the serratus anterior muscle,the levator scapulae muscle,the
rhomboid major and minor muscles,and the lower fibers of the trapezius muscle.6
Considering the forces and moments developed about the base of the scapular spine
during the early stages of abduction of the arm, a consistent mechanical pattern is
seen.The major influence of the upper fibers of the serratus anterior muscle and the
abduction force applied to the scapula by the rotator cuff muscles are balanced by
the rhomboid,levator scapulae,and lower fibers of the trapezius muscles.This
influence stabilizes the root of the spine of the scapula,which is the center of
rotation for movement up to 100 degrees of abduction.As rotation of the scapula
progresses past this point,the principal source of activity is the lower part of the
serratus anterior muscle.The upper part of the trapezius muscle primarily opposes
the pull of the deltoid muscle, and it has limited influence on scapular rotation .The
serratus anterior muscle is an essential factor in stabilizing the scapula in the early
phase of abduction, in addition to upwardly rotating the scapula. The lower fibers
of the serratus anterior muscle are oriented to exert moments effectively about both
the root of the scapular spine and the acromioclavicular joint during the initial and
later phases of abduction. The serratus anterior muscle has the longest moment arm
of the relevant muscles. Reduced activity of serratus anterior muscle has been
demonstrated in both neurological and soft tissue lesions affecting the shoulder
complex. The majority of the literature on the influence of the scapulohumeral,
axioscapular, and axiohumeral muscles of the shoulder complex has dealt with the
"action" of the muscles.5,8,9
Serratus anterior and lower trapezius are important muscles in scapular
stability, however in shoulder pain these muscles are prone to be inhibited thus
2
offsetting the force couple.11Thus to study the recruitment of serratus anterior and
lower trapezius in patients with frozen shoulder and impingement syndrome.This
insight into muscle recruitment patterns will optimize therapeutic interventions.
Need of the study
The scapula plays a major role in facilitating optimal shoulder function.
Scapular anatomy and bio-mechanics interact to produce efficient movement .In
normal upper quarter function the scapula provides a stable base from which
glenohumeral mobility occurs.Stability at scapulothoracic joint depends on
surrounding musculature.Many muscles serve to stabilize the scapula, the main
stabilizers are the levator scapulae, rhomboids major and minor, serratus anterior
and trapezius.12 The upper trapezius, lower trapezius and serratus anterior muscles
are considered to be the upwards rotators of scapula. These muscles play an integral
part in scapula movement during scapulo humeral rhythm.13 Along with upper and
lower portion of trapezius muscle, serratus anterior forms a force couple that
upwardly rotates the scapula and also elevate the acromion.14
The most common scapula muscles which will go for weakness or inhibition
are lower stabilizers of scapula (serratus anterior, rhomboids, middle and lower
trapezius). This problem manifests itself through decreased shoulder abduction and
secondary impingement.10,15,16
Scapulo humeral rhythm or scapular position may be altered with different
condition that include increase loading,muscle fatigue, impingement syndrome,
instability of glenohumeral joint or postural changes.15,17The kinematic alteration in
scapular motion have been linked to decrease in serratus anterior muscle activity,
increase in upper trapezius muscle activity ,or imbalance of forces between the
upper trapezius and lower part of the trapezius muscles.18,19Abnormal scapulo
humeral rhythm or decrease in upwards rotation of scapula during humeral
elevation have been linked to ‘imbalance’ in force production of the upper and
lower portion of trapezius and serratus anterior muscles.18,20,21.Inadequate upwards
rotation during the painful arc of motion is believed to be potential contributor to
development or progression of impingement syndrome .22
Serratus anterior and lower trapezius are important muscles in scapular
stability, however in shoulder pain these muscles are prone to be inhibited thus
offsetting the force couple.23,And as these muscles goes into more weakness,so to
find out the how much is the muscle recruited,and which muscle goes into more
weakness.And thus these study is carried on to find the muscle recruitment of
serratus anterior and lower trapezius in patients with frozen shoulder and
impingement syndrome.This insight into muscle recruitment patterns will optimize
therapeutic interventions.
Research question
Will there be differences in the muscle recruitment of serratus anterior and lower
trapezius in frozen shoulder,impingement syndrome and normal?
Hypothesis.
Alternate Hypothesis – To find out the significant co-activation between lower
trapezius and serratus anterior in frozen shoulder,impingement syndrome and
normals,while performing three movements (flexion,extension and abduction).
Null hypothesis- There is no significant co-activation between lower trapezius and
3
serratus anterior in frozen shoulder,impingement syndrome and normals,while
performing three movements (flexion,extension and abduction).
6.2) REVIEW OF LITERATURE
1.
Matilal et al., (2006); conducted a study on muscle activity of serratus
anterior,upper trapezius, and lower trapezius during arm abduction in
multidirectional instability, who found altered scapular movement due to
decreasd activity of lower part of trapezius and serratus anterior muscles.the
muscles activity imbalance observed in lower trapezius muscle could not be
related to shoulder instability.3
2.
Ann M.cool et al., (2007) did a study on EMG activity of 3 trapezius parts
and the serratus anterior muscle in 45 healthy subject in 12 commonly used
trapezius strengthing exercises which are used in the treatment for trapezius
muscle imbalance and concluded that in case of trapezius muscle imbalance 3
exercises were selected like side lying external rotation,side lying forward
flexion, prone horizontal abduction with external rotation and prone extension
found to be the most appropriate to restore trapezius muscle balance.26
3.
Joseph caroline et al., (2012); conducted a study which shows a significant in
muscle activation and co activation between is and healthy controls.there we
were three main posture(flexion,abduction,scaption),where in isometric the
middle trapezius,lower trapezius,anterior,middle and posterior deltoid had
significantly lower activity in individuals with IS compared to control
individuals.In isometric scaption,anterior deltoid had lower activation,while
middle deltoid had greater activation.in isometric flexion,the serratus anterior
and anterior deltoid had lower activation,while in upper trapezius and posterior
deltoid had greater activation in individuals with IS compared to control
individuals.12
4. Paula M Ludewig et al., (2000) conducted a study to find out the alterations
in shoulder kinematics and associated muscle activity in people with symptoms
of shoulder impingement on 52 subjects from a population of workers with
routine exposure to overhead activity and concluded that scapular
tipping(rotation about a medial to lateral axis) and serratus anterior muscle
function are important to consider in the rehabilitation of patient with
symptoms of shoulder impingement related to occupational exposure to over
head work.2
5.
Robert A.Mccabe et al., (2007) did a study on emg analysis of lower trapezius
muscles during exercise performed below 90 degree of shoulder elevation in
15 healthy subjects and concluded that press up and scapular retraction have
high ratio of lower trapezius to upper trapezius activity.27
6.
Hardwick DH et al., (2006) did a comparative study of serratus anterior
muscle activation during wall slide exercise and other traditional exercise on
20 healthy subject and they found that wall slide is an effective exercise to
activate the serratus anterior muscle at and above 90 degree of shoulder
4
elevation.28
7.
Ann M. Cool et al., (2006) did a study to find out trapezius muscle latency on
39 overhead athletes with shoulder impingement syndrome and compared with
30 over head athletes without impingement syndrome during sudden
downward falling movement of the arm and concluded that overhead athletes
with impingement symptoms show abnormal muscle recruitment timing in
trapezius muscle.29
8. Lin JJ, Wu YT et al., (2005) compared the upper trapezius and lower trapezius
muscle activity between 15 patients suffering from unilateral frozen shoulder
syndrome and 15 normal subjects during maximum static arm elevation at 6
different positions :60 and 120 degree of flexion,abduction in frontal and
scapular plane and they found that the increased trapezius muscle activity
may contribute to scapular substitution movement in compensation for
impaired glenohumeral motion in patient with frozen shoulder syndrome. The
insufficiency of the increased lower trapezius muscle activity should be an
important consideration in the rehabilitation of patient of frozen shoulder
syndrome.34
9.
Richard A Ekstrom et al., (2003) did a study on EMG analysis of exercises
for the trapezius and serratus anterior activity in 30 healthy subjects and
concluded that for upper trapezius unilateral shoulder shrug exercise, for
middle trapezius the shoulder horizontal extension with external rotation, for
lower trapezius overhead arm raise in the line of trapezius muscle in prone and
for serratus anterior shoulder abduction in the plane of scapula above 120
degree and a diagonal exercise with combination of shoulder flexion,
horizontal flexion and external rotation produced maximum EMG activity.12
10. Michael J Decker et al., (1999) did a study to document the EMG activity
and applied resistance associated with 8 scapulo humeral exercises performing
below shoulder height on 20 healthy subjects and concluded that serratus
anterior punch, scaption, dynamic hug, knee push up plus and push up plus
exercises consistently elicited serratus anterior muscle activity greater than 20
% of maximum voluntary isometric contraction.30
11. J Bruce Moseley et al., (1992) conducted a study on EMG analysis of scapula
muscles during a shoulder rehabilitation programme on 9 healthy subjects to
find out which exercises most effectively used in scapular muscles and they
found that 4 exercises like scaption, rowing push up with a plus , and press up
showed to make up the core of scapula muscle strengthening programme.31
12. Peat and Grahame et al., (1998) investigated trapezius, serratus anterior and
deltoid EMG in people with and without shoulder pathology. They found that
the upper trapezius showed an increased activity during arm elevation and
lowering and decreased activity in serratus anterior at some humeral elevation
angles in patients as compared to healthy controls.32
13. Bagg and Forrest et al., (2000) studied the EMG activity in the three parts of
trapezius and serratus anterior during scapular plane elevation in 20 healthy
5
male subjects. They averaged integrated EMG signal collected from the
muscles during 5 trials performed at a predetermined speed of arm
elevation.They plotted the EMGsignal across the range of motion to analyze
muscular activity.They found that the muscle s show an increase in activity of
upper and middle fibers of trapezius and serratus anterior.33
14.
Lin and colleagues et al., (2005).studied the upper and lower fibers of
trapezius muscle in people with and without frozen shoulder syndrome during
static elevated arm posit ions. They found increase ed upper trapezius activity
across all planes and angles (60° and 120° ) and increased lower trapezius
activity only at 120° of elevation during the make test in the patient group as
compared to controls.34
15. Lin,jiu-jenq et al (2005)the aim of this study was to characterize upper and
lower trapezius muscle activity for patients experiencing frozen shoulder
compared to asymptomatic subjects.there were 15 patients of frozen shoulder
and 15 were asymptomatic subjects,data were collected by using emg activity
obtained from upper and lower trapezius muscles during maximal static arm
elevation at six different testing position. They found that there is insufficiency
of the increased lower trapezius muscle activity should be important
consideration in the rehabilitation of patients experiencing frozen shoulder.34
6.3) OBJECTIVES OF THE STUDY
1. To find out the muscle recruitment of serratus anterior and lower trapezius in
frozen shoulder patients.
2. To find out the muscle recruitment of serratus anterior and lower trapezius in
impingement syndrome patients.
3. To find out the muscle recruitment of serratus anterior and lower trapezius in
normals.
7.
MATERIAL AND METHODS
7.1. STUDY DESIGN
Cross sectional study
7.2. SOURCE OF DATA
Data will be collected from patients, who are referred to outpatient physiotherapy
department of city hospital research and diagnostic centre, Mangalore.
7.2(I) Definition of study subjects
Patients aged 40-70 years who were diagnosed as frozen shoulder,impingement
syndrome and fulfilling the criteria of the study.
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7.2 (II) Inclusion and Exclusion criteria
INCLUSION CRITERIA







Age group of 40 -70 years.
Patients with frozen shoulder.
Patients with impingement shoulder.
Normals.
Any previous injury which leads to frozen shoulder.
Idiopathic.
Patients who were willing for the study,under criteria
EXCLUSION CRITERIA






Patients with rotator cuff tear,bicipital tendinitis.
Any other pathology around shoulder joint.
Any neurological impairments.
Patients without any vascular disorder.
Patients with visual and hearing impairments.
Non co-operative patients.
7.2 (III) STUDY SAMPLING DESIGN, METHOD AND SIZE:
SAMPLE – DESIGN
Non- probability convenient sampling was used
METHOD OF COLLECTION OF DATA
Patients fulfilling the inclusive and exclusive criteria would only be recruited.
Patients will be assessed. Patients will be scored using shoulder pain and disability
index.
SAMPLE – SIZE
The sample consists of 30 patients,which is divided in three groups frozen
shoulder,impingement syndrome and normals, satisfying the inclusion and
exclusion criteria and referred to the physiotherapy department.
7.2(IV) Follow Up
One time study
7.2(V) Parameters and statistical tests used.
Non parametric anova test,kruskal-wallis test.
7.2 (VI) Duration of study
7
The study will be conducted over a duration of 6 months
.
7.2 (VII) Methodology
The demographic data recorded from the participants were age, height ,weight,
occupation,medical history and shoulder evaluation was done.Prior to the
commencement of data collection the subjects were asked to fill the consent form.
Patients were explain about the procedure and were asked to perform three move
ments flexion, abduction and in scaption during each session( on 5 secs beat with
metronome). All sites for electrode placements are prepared by cleaning the area
with spirit.
Electrode placement :
For the lower trapezius, the shoulder is passively flexed to 90 degree, electrode
were placed obliquely,one superior and other inferior to a point 5cm, infero lateral
from the root of spine of scapula.
For serratus anterior, the shoulder is passively abducted to 90 degree, electrode
were placed vertically along the mid axillary line at the rib levels 6 through 8.
7.3 Does the study require any investigation to be conducted on patients or
other human or Animal? If so, please describe briefly.
Yes
7.4 Has ethical clearance been obtained from your institution in case of 7.3
Yes
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32. Peat M, Grahame RE. Electromyographic analysis of soft tissue lesions
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33. Lin JJ, Wu YT, Wang SF, Chen SY. Trapezius muscle imbalance in individuals
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SIGNATURE OF THE CANDIDATE
10 REMARKS OF GUIDE
NAME AND DESIGNATION (in
11
Block Letters)
MRS. RASHMI. B
(ASSISTANT PROFESSOR)
11.1 GUIDE
11.2 SIGNATURE
11.3 CO GUIDE (If any)
NA
11.4 SIGNATURE
-------------------
11.5 HEAD OF THE DEPARTMENT
11.6 SIGNATURE
NA
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12.1 REMARKS OF THE
TOPIC IS APPROPRIATE AND HAS
CLINICAL APPLICATIONS.
RECOMMENDED.
CHAIRMAN AND PRINCIPAL
12.2 SIGNATURE
11