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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION 1 NAME AND ADDRESS OF Aakanksha THE CANDIDATE Department of Physiotherapy Florence College of Physiotherapy 2 NAME OF THE INSTITUTION Department of Physiotherapy Florence College of Physiotherapy 3 COURSE OF STUDY AND Master of Physiotherapy SUBJECT (Musculoskeletal disorders and Sports Physiotherapy) 4 23rd July 2012 DATE OF ADMISSION TO COURSE 5 TITLE OF THE STUDY “The Effectiveness of Progressive Resistance Training on Shoulder Impingement Syndrome” 1 6. BRIEF RESUME OF THE INTENDED WORK 6.1 Need for the study The Upper limb performs a number of functions related to activities of daily living and labor. The shoulder pain is a very common musculoskeletal complaint and individuals with shoulder pain comprise a significant percentage of patients seeking medical attention. Shoulder Impingement Syndrome (SIS) is considered the most common intrinsic causes of shoulder pain and disability. In 1972, Neer first introduced the concept of shoulder impingement syndrome to the literature, stating that “it result from mechanical impingement of the rotator cuff tendon beneath the antero inferior portion of the acromion, especially when the shoulder is placed forward flexed and internally rotated position”2. Shoulder Impingement Syndrome is a condition in which there is impingement (mechanical surmountable obstruction) between the coracoacromial arch and the content of the sub-acromial space (rotator cuff, sub-acromial bursa, long head of biceps tendon) during abduction of the shoulder3. Shoulder impingement syndrome may results from acute trauma due to a fall or severe blow to the shoulder or a single heavy lift that strain the soft tissue of the joint. It may also caused by chronic strains such as repeated overhead work, repeated sports movements (weight lifting and throwing), prolonged static arm positions (computer work), sleeping habits (lying on same arm each night)4. Most of the chronic causes are related to postural habits creating muscle imbalance of the shoulder joint. Some of the muscles get tight and shortened while others get weak and over stretched. This may produce a typical pain during the mid range abduction of shoulder, joint stiffness, decreased range of movement (ROM), decreased muscle strength and decreased function of the shoulder joint6. The treatment of shoulder impingement syndrome can consists of Rest, Ice, NSAIDS, local heat, avoidance of activities that increase pain, stretching exercise, steroid injection in the sub-acromial space and in refractory cases, anterior 2 acromioplasty with sub-acromial decompression with or without rotator cuff repair. Out of which Progressive Resistance Training (PRT) appears to be safe and effective form of intervention for patients with muscle strength deficit5. Progressive Resistance Training (PRT), is a system of dynamic resistance training in which a constant external load is applied to the contracting muscle by some mechanical means (usually a free weight or weight machine) and incrementally progressed. The Repetition Maximum (RM) is used as the basis for determining and progressing the resistance . The concept of PRT was introduced by DeLorme, who originally used the term heavy resistance training, to describe a new system of strength training. DeLorme proposed and studied the use of three sets of 10RM with progressive loading during each set8. Progressive resistance training is the gradual increase of load. Tolerance to exercise should be monitored by health care professionals and adopted to the individual. The following items should be considered in order to achieve and increase strength, improved resistance and muscle hypertrophy. 1. An increase in local resistance. 2. Number of repetitions. 3. Speed of repetitions. 4. Rest period and, 5. Volume of training (number of repetitions x resistance and number of repetitions x sets and number of sets per exercise). DeLorme method of progressive resisted training is such form of intervention for improving muscle strength and hypertrophy in patients with shoulder impingement syndrome. A number of systematic reviews on study involving shoulder intervention have fond little evidence of exercise used in the treatment of shoulder impingement syndrome. Furthermore, there is a lack of detailed description regarding such exercises. 3 As the shoulder impingement syndrome is the most common case, hence the need of the study arises to find out the effectiveness of progressive resistance training on shoulder impingement syndrome. HYPOTHESIS: Null Hypothesis: There is no significant effectiveness in the application of progressive resistance training on shoulder impingement syndrome. Alternate Hypothesis: There is a significant effectiveness in the application of progressive resistance training on shoulder impingement syndrome. 4 6.2 REVIEW OF LITERATURE Paula M Ludewig et. al.,(2011) 16 (1) : 33-39 They conducted an experimental study on 35 patients with shoulder impingement syndrome for a period of 2 months. The study concluded that the application of progressive resistance training twice a week for 2 months is effective in relief of pain and improve joint ROM. Mc Clure.et.al (2010) 40(8):474-93 Conducted a standardized case series treatment programme on 10 patients with shoulder impingement syndrome. The purpose of the study was to find out the effectiveness of progressive strengthening programme. It was assessed by disabilities of the arm shoulder and hand. The result shows significant increase in the strengthening of rotator cuff and scapular muscles. Imperio Lombardi Jr et.al.,(2008) 15 : 59 (5):615-22 Conducted an experimental study on 60 patients with shoulder impingement syndrome (8 repetitions, twice a week) for 2 months. The purpose of study was to findout the effectiveness of Progressive Resistance Training on shoulder impingement syndrome. The main outcome measures examined were pain intensity (assessed using a Visual Analogue Scale), joint range of motion (using Goniometer), muscle strength, function and quality of life for the treatment effect. The result concluded that the patients who underwent progressive resistance training exhibited improvement regarding pain and function. Kim Bennel et. al.,(2007) 31:8:86 Conducted an randomized controlled trial on 200 participants with shoulder impingement syndrome and the precipitating factors. This study aimed to investigate the effectiveness of progressive resistance training in the treatment of shoulder impingement syndrome. The study concluded that progressive resistance training is more effective in relieving pain and increasing joint ROM. Timothy F. Tyler et. al., (2005) 14(6)570-4 They conducted an randomized controlled study on 54 patients of both sexes between the ages of 25 to 55 years. The purpose of the study was to find out the effectiveness of progressive resistance training on shoulder impingement syndrome. The study finally concluded that the management of shoulder impingement syndrome 5 by progressive resistance training is effective by means of relieving pain and increase joint ROM. Eril Sauers et. al., (2005) 40(3) 221-23 Studied 84 patients of both sexes between the ages of 40-45years with chronic shoulder impingement syndrome. The purpose of the study was to find out the effectiveness of progressive resistance training on shoulder impingement syndrome. The main outcome measures examined were pain intensity (using VAS), joint ROM (using Goniometer), joint function for the treatment effect. They concluded that management of shoulder impingement syndrome by progressive resistance training is effective. Desmeules et. al . ,(2003) 13 (3): 176-82 Conducted an experimental study on 39 patients for 60 days in both sexes between the ages of 18 to 55 years with shoulder impingement syndrome. The study aimed to investigate the effectiveness of progressive resistance training on shoulder impingement syndrome. The result showed that progressive resistance training is most effective in easing pain and increasing the joint ROM. 6.3 Objective of the Study: To assess the “Effectiveness of Progressive Resistance Training on Shoulder Impingement Syndrome” with Visual Analogue Scale (VAS) for pain and increase in range of motion (using Goniometer). 6 7. MATERIALS AND METHODOLOGY 7.1 Methodology : Method of Sampling : Simple purposive random sampling Type of the study : Experimental study Proposed sample size : 30 Procedure of data collection: An ethical clearance will be obtained from the ethical committee of Florence College of Physiotherapy both male and female patients satisfying the inclusion criteria and exclusion criteria will be selected for the study. Purpose of the study will be explained and an informed consent will be obtained from the subjects. Initially, a brief physical assessment will be done, which will include demographic data and assessment of pain by using Visual Analogue Scale (VAS) and Range of Motion (ROM). A complete orthopedic evaluation will be done. Inclusion criteria: Age : between 18 to 65 years of age. Gender : both male and female. Symptoms associated with overhead activities. Diagnosis of shoulder impingement syndrome as evidence by all 3 criteria: Reproduction of symptoms with impingement test: either HawkinsKennedy or Neer test. Pain during active shoulder elevation at or above 60 degrees. Weakness of rotator cuff or pain during the empty can test or during resisted shoulder external rotation. Able to understand, write and speak. Exclusion criteria: Severe pain : pain is > 7/10 on VAS Previous shoulder surgery on the same side. Traumatic shoulder dislocation within the past 3 months on the same side. Reproduction of shoulder pain with active or passive cervical motion. Systemic inflammatory joint disease. Global loss of passive shoulder ROM, indicative of adhesive capsulitis. 7 Full-thickness rotator cuff tear, as evidenced by any one of the following; Markedly reduced shoulder external rotation strength. Drop arm test. External rotation lag sign. Lift off test. Positive findings on MRI or Ultrasonography. Statistical method: t-test Materials used: 1. Examination table. 2. Bed sheet. 3. Pillow. 4. Chair. 5. Multi-pulley muscle – building equipment. 6. Visual analog scale. 7. Goniometer OUTCOME MEASURES VISUAL ANALOG SCALE: Patients were provided with a visual analog scale and were asked to mark their pain status on a line provided with 0 to 10 cms, where 0 represents no pain and 10 represents maximum pain, at the first session, at the sixth session and at the end of the last session of the treatment program. 0 10 No Pain Maximum Pain RANGE OF MOTION : By using Goniometer, shoulder flexion, extension, abduction , medial (internal) rotation, lateral (external) rotation measured at the first session, at the sixth session and at the end of the last session of the treatment program. 8 SHOULDER EXTENSION Test position Subject prone Shoulder no abduction, adduction or rotation (note: to measure gleno – humeral motion, stabilize, stabilize scapula) Goniometer Alignment Fulcrum center of humeral head near acromion process Stationary arm – parallel mid – axilliary line Moving arm – aligned with midline of humerus (lateral epicondyle) Normal range (for shoulder complex motion) 40° – 60° Normal End feel SHOULDER FLEXION Test position Normal range (for shoulder complex motion) 160° – 180° Subject supine Flatten lumbar spine (flex knees) Shoulder no abduction, adduction or rotation (note: to measure gleno – humeral motion, stabilize scapula) Goniometer alignment Normal end feel Fulcrum – center of humeral head near acromion process Stationary arm – parallel mid – axillary line Moving arm – aligned with midline of humerus ( lateral epicondyle) Muscle stretch SHOULDER ABDUCTION Test position Normal range Subject supine Shoulder 0°flexion and extension Shoulder laterally (externally) rotated Shoulder abducted Stabilize thorax(note: to measure gleno-humerous motion, stabilize scapula) (for shoulder complex abduction) 160° – 180° Goniometer alignment Capsular or ligamentous Normal end feel Fulcrum center of humeral head near acromian process Stationary arm – parallel to sternum Moving arm – aligned with midline of humerus 9 Muscle strecth SHOULDER MEDIAL (INTERNAL) ROTATION Test position Normal Range 60° – 70° Subject supine Shoulder 90° abduction Forearm neutral Elbow flexed 90° Stabilize arm Goniometer alignment Normal End Feel Fulcrum – olecranon process of ulna Stationary arm – aligned vertically Moving arm – aligned with ulna (styloid process) Capsular SHOULDER LATERAL (EXTERNAL) ROTATION Test Position Normal Range 80° – 100° Subject supine Shoulder 90° abduction Forearm neutral Elbow flexed 90° Stabilize arm Goniometer Alignment Normal End Feel Axis – olecranon process of ulna Stationary arm – aligned vertically Moving arm – aligned with ulna (styloid process) Capsular PROCEDURE: A total of 30 subjects suitable to inclusion and exclusion criteria were selected randomly with informed consent of patients. Prior to the treatment program, patient’s pain status by visual analog scale and the Range of Motion by Goniometer and readings were noted. PROGRESSIVE RESISTANCE TRAINING PROCEDURE: The patients in the experimental group participated in the muscle strength assessment using a repetition maximum exercise, in which patients perform 10repetitions with the maximum bearable weight, thereby determining 10 Repetition Maximum (10RM). 10 Once the 10 repetition maximum was determined, training was divided into the following regimen: 3 series of 10 Repetition: 1st series with 50% of the 10 repetition maximum. 2nd series with 75% of the 10 repetition maximum. 3rd series with 100% of the 10 repetition maximum, respecting the patient’s pain threshold; turned another movement. Between the first, second and third series, there was a resting period of 2 minutes, the speed of movement was 2 seconds for both the eccentric and concentric phases. The exercises flexion, extension, medial and lateral rotation of the shoulder was carried out six days a week for a period of 2 weeks. A multi-pulley muscle – building equipment was used for the exercise. Prior to the resistance training, the patients were instructed to perform warm up activities followed by flexibility exercises. To move through full, available and pain free range of motion. To include both concentric (lifting) and eccentric muscle action. To use moderate intensity exercises at least 10 repetitions / set. To use slow to moderate speeds of movement. To use rhythmic controlled non – ballistic movement. Followed by cool down after completion of exercises. MOVEMENTS AT THE SHOULDER JOINT: (1) Flexion: Main muscles: Clavicular head of the pectoralis major. Anterior fibers of deltoid. Accessory muscles: Coracobrachialis. Short head of biceps. Sternocostal head of pectoralis major. 11 (2) Extension: Main muscles: Posterior fibers of deltoid. Latissimus dorsi. Accessory muscles: Teres major. Long head of biceps. (3) Adduction: Main muscles: Pectoralis major. Latissimus dorsi. Accessory muscles: Teres major. Coraco brachialis. Short head of biceps. Long head of triceps. (4) Abduction: Deltoid. Supraspinatus. Serratus anterior. Upper and lower fibers of trapezius. (5) Medial rotation: Pectoralis major. Anterior fibers of deltoid. Latissimus dorsi. Teres major. Subscapularis. 12 (5) Lateral rotation: Posterior fibers of deltoid. InfraSpinatus. Teres minor. To strengthen the flexors of the shoulder: The patient was positioned with his or her back to the equipment and the elbow flexed at 90°; the patient performed the flexion movement of the shoulder from 0° to 90°. To strengthen extensor of the shoulder: The patient faced the equipment with the elbow flexed at 45° and the shoulder at 60° of flexion and 30° of extension. To strengthen the medial and lateral rotators: The patient was positioned alongside the equipment with the elbow flexed at 90°; for the medial rotation, the patient started at 45° of lateral rotation and moved to 45° of medial rotation; for the lateral rotation, the patient began the movement at 45° of Medial rotation and moved to 30° of lateral rotation. 7.2 Ethical Clearance Ethical clearance have been obtained from the Ethical committee of the Institution. 13 8. List of References 1. Cardoso de Souza M. et.al. Progressive Training on Patient with Shoulder Impingement Syndrome, a Literature Review Rheumatism 61 (2) : 84-9, 2009. 2. Carolyn Kisner, a Text Book of Therapeutic Exercise, 4th edition . 3 Cynthia. C. Norkin and Pamela. K. Levangie, Joint Structure and Function, a Comprehensive Analysis, 4th Edition. 4. Eril. Sauers, Effectiveness of Rehabilitation for Patients with Subacromial Impingement Syndrome, Journal of Athletic Training , 40 (3) 221-223, 2005. 5. Imperio Lombardi jr et.al., a Literature of Review of Progressive Resistance training in patient with Shoulder Impingement Syndrome Randomized Control Trial, American Journal of Physiotherapy , 15:59(5):615-22, 2008. 6. Jefrey A. Fleming, Exercise Protocol for the treatment of rotator cuff Impingement Syndrome, Journal of Athletic Training ,45 (5): 483-485, 2010. 7 McClure; Shoulder Function and 3 Dimensional Scapular Kinetics in People with shoulder impingement syndrome, physical therapy, 40(8):474-93, 2010. 8 M. Deena Gardiner – The Principles of Exercise Therapy, 4th Edition. 9 Paul. M. Ludewig, A Literature Review of shoulder Impingement Biomechanical Consideration in Rehabilitation, Journal of the University of Minneosta, 2011. 10 Textbook of Gray’s Anatomy, Peter L Williams, 38th Edition, 1995. 11. Timothy. F. Tyler. et.al, Quantifying Shoulder Rotation Weakness in Patients with Shoulder Impingement Syndrome, Journal of Shoulder and Elbow Surgery, 14 (6) 570-4, 2005. 14 : 9 SIGNATURE OF THE CANDIDATE 10 REMARKS FO THE GUIDE 11 NAME AND DESIGNATION OF THE GUIDE 11.1 SIGNATURE 11.2 CO-GUIDE 11.3 SIGNATURE 11.4 HEAD OF DEPARTMENT 11.5 SIGNATURE 12 REMARKS OF THE CHAIRMAN AND PRINCIPAL 12.1 SIGNATURE 15