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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. 6 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 LIST OF REFERENCES 1. McClure PW, Michener LA, Sennett BJ, Karduna AR. Direct 3-dimensional Measurement of scapular kinematics during dynamic movements in vivo.J Should er Elbow surg. 2001;10(3):269-277. 2. Ludewig PM, Cook TM. Alterations in shoulder kinematics and associated musc le activity in people with symptoms of shoulder impingement.Phys Thr.2000 ;80 (3):276- 291 3. McClure PW, Michener LA, Karduna AR. Shoulder function and 3dimensional scapular kinematics in people with and without shoulder impingement syndrome. Phys Ther. 2006;86(8):1075-1090 4. Matsen FAI, Arntz CT. Subacromial impingement. In: Rockwood C, Matsen F, eds. The Shoulder. Philadelphia: W.B. Saunders Co; 1990:623-646 5. Neer CS, 2nd. impingement lesions. Clin Orthop Relat Res. 1983;(173):70-77. 6. Lukaseiwicz AC, McClure P, Michener L, Pratt N, Sennett B. Comparison of 3dimensional scapular position and orientation between subjects with and without shoulder impingement. J Orthop Sports Phys Ther. 1999;29(10):574583. 7. Ludewig PM, Cook TM, Nawoczenski DA. Three-dimensional scapular orienta tion and muscle activity at selected positions of humeral elevation. J Orthop 8 Sports Phys Ther. 1996;24(2):57-65. 8. Koester MC, George MS, Kuhn JE. Shoulder impingement syndrome. Am J Med 2005;118(5):452-455. 9. Lin JJ, Wu YT, Wang SF, Chen SY. Trapezius muscle imbalance in individuals suffering from frozen shoulder syndrome. Clin Rheumatol. 2005;24(6):569-575. 10. Scibek JS, Mell AG, Downie BK, Carpenter JE, Hughes RE. Shoulder kinemat ics in patients with full-thickness rotator cuff tears after a subacromial injection. J Shoulder Elbow Surg. 2008;17(1):172-181. 11. Kuhn JE. Exercise in the treatment of rotator cuff impingement: A systematic review and a synthesized evidence-based rehabilitation protocol. J Shoulder Elbow Surg. 2009;18(1):138-160. 12. Ludewig PM, Hoff MS, Osowski EE, Meschke SA, Rundquist PJ.Relative bala balance of serratus anterior and upper trapezius muscle activity during push-up exercises. Am J Sports Med. 2004;32(2):484–493. 13. Cools AM, Dewitte V, Lanszweert F, et al. Rehabilitation of scapular muscle balance: Which exercises to prescribe? Am J Sports Med. 2007;35(10):17441751 14. Wadsworth DJ, Bullock-Saxton JE. Recruitment patterns of the scapular rotator muscles in freestyle swimmers with subacromial impingement. International journ al of sports medicine. 1997;18(8):618-624. 15. Bagg SD, Forrest WJ. A biomechanical analysis of scapular rotation during arm abduction in the scapular plane. Am J Phys Med. 1988;67(6):238-245. 16. Doody SG, Freedman L, Waterland JC. Shoulder movements during abduction in the scapular plane. Arch Phys Med Rehabil. 1970;51(10):595-604. 17. McQuade KJ, Smidt GL. Dynamic scapulohumeral rhythm: The effect of external resistance during elevation of the arm in the scapular plane. Journal of Orthope dic sports physical therapy. 1998;27:125-133. 18. Ludewig PM, Behrens SA, Meyer SM, Spoden SM, Wilson LA. Threedimensional clavicular motion during arm elevation: Reliability and descriptive data. J Orthop Sports Phys Ther. 2004;34(3):140-149. 19. Ebaugh DD, McClure PW,Karduna AR. Three-dimensional scapula thoracic motion during active and passive arm elevation. Clin Biomech. 2005;20:700709. 20. Bagg SD, Forrest WJ. Electromyographic study of the scapular rotators during arm abduction in the scapular plane.Am J Phys Med. 1986;65(3):111-124. 21. Ludewig PM, Hoff MS, Osowski EE, Meschke SA, Rundquist PJ.Relative 9 balance of serratus anterior and upper trapezius muscle activity during push-up exercise Am J Sports Med. 2004;32(2):484–493. 22. Voight ML, Thomson BC. The role of the scapula in the rehabilitation of should er injuries. J Athl Train. 2000;35(3):364–372. 23. Lewis JS, Wright C, Green A. Subacromial impingement syndrome:the effect of changing posture on shoulder range of movement. J Orthop Sports Phys Ther. 2005;35(2):72–87 24. Decker MJ, Hintermeister RA, Faber KJ, Hawkins RJ. Serratus anterior muscle activity during selected rehabilitation exercises. Am J Sports Med. 1999;27(6):784-791. 25. Ann M Cool. Rehabilitation of scapula muscle balance. The American Journal of Sports Medicine 2007; 35:1744-1751. 26. Robert A Mccabe, Karl F, Orishimo. Surface EMG analysis of the lower trapezius muscle during exercises performed below 90 degree of shoulder elevation in healthy subject. (cited 2007 November 26 ) Available from: http://najspt.org/artical/24. 27. Hardwich DH. Beebe J A. A comparison of Serratus anterior muscle activation during wall slide exercise and other traditional exercises. Journal of Orthopedics and Sports Physical Therapy. 2006, 36; (12): 903-910. 28. Ann M Cool. Trapezius muscle latency with and without impingement syndrome. The American Journal of Sports Medicine 2003; 31(4):542-549. 29. Lin JJ WU YT. Trapezius muscle imbalance in individuals suffering from frozen shoulder. Clinical Rheumatology .2005; 24 (6):569-579 30. Michael J Decker. Serratus anterior muscle activity during selected rehab ilitation exercises. The American journal of sports medicine.1999; 27:784-791. 31.J Bruce Moseley.EMG analysis of scapular muscles during a shoulder rehabilitation programme. The American Journal of Sports Medicine 1992; 20 (2):128-134. 32. Peat M, Grahame RE. Electromyographic analysis of soft tissue lesions affecting shoulder function. Am J Phys Med. 1977;56(5):223-240. 33. Lin JJ, Wu YT, Wang SF, Chen SY. Trapezius muscle imbalance in individuals suffering from frozen shoulder syndrome. Clin Rheumatol. 2005;24(6):569-575 34. Bagg SD, Forrest WJ. Electromyographic study of the scapular rotators during arm abduction in the scapular plane. Am J Phys Med. 1986;65(3):111-124. 10 9 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 ------------------- 12.1 REMARKS OF THE TOPIC IS APPROPRIATE AND HAS CLINICAL APPLICATIONS. RECOMMENDED. CHAIRMAN AND PRINCIPAL 12.2 SIGNATURE 11