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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
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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.
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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.
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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
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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).
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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.
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 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.
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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

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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).
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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.
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(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.
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(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.
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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.
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:
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
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