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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION
1.
KAVAN TK, 26, KSRP OFFICERS
NAME OF THE CANDIDATE AND
ADDRESS
QUARTERS, GODAVARI SANKIRNA,
KORAMANGALA, BANGALORE
[KARNATAKA]
2.
NAME OF THE INSTITUTION
KRUPANIDHI COLLEGE OF
PHYSIOTHERAPY, BANGALORE
COURSE OF THE STUDY AND
SUBJECT
MASTER OF PHYSIOTHERAPY IN
MUSCULOSKELETAL DISORDERS
AND SPORTS PHYSIOTHERAPY
DATE OF ADMISSION TO THE
COURSE
TITLE OF THE TOPIC:
19th MAY 2011
3.
4.
5.
MULTI -MODAL TREATMENT APPROACH FOR
CHRONIC SHOULDER IMPINGEMENT SYNDROME - A
RANDOMIZED CONTROL TRIAL
6
BRIEF RESUME OF THE INTENDED WORK
INTRODUCTION
Chronic shoulder pain is a term that refers to pain that occurs for duration longer than four to
six months1. An estimated 20 percent of the population in the world suffers from shoulder pain
during their lifetime2.
Shoulder pain is second only to low back pain in patients seeking care for musculoskeletal
ailments3. Shoulder pain is responsible for approximately 16% of all musculoskeletal
complaints4, with a yearly incidence of 15 new episodes per 1,000 patients seen in the primary
care setting5.
The prevalence of shoulder pain in the general population ranges from 6.9% to 34%. For
people greater than 70 years of age, the prevalence of shoulder pain was reported to be 21% in
one study. Forty percent of the population probably will suffer from shoulder pain at some
point of their life time6.
The four most common conditions that lead to chronic shoulder pain are1:

Rotator cuff tears,

Shoulder impingement syndrome (SIS)

Frozen shoulder and

Shoulder arthritis.
Shoulder impingement is among the most common function-limiting disorders of the
musculoskeletal system7-8. The point prevalence of shoulder symptoms has been reported to
range from 20 to 33%9, and the incidence of shoulder complaints in the general population
is increasing10. Furthermore, several authors have reported low rates of perceived recovery
(patient reports of ‘being cured’) for patients with a new episode of shoulder pain10 -13. Less
than 25% of patients with a first episode of shoulder pain may recover and be symptom free
after 3 months5. Recovery rates at 18 months have been reported only between 49% and
59%11, 12, 14, and 25% of patients with shoulder or neck pain experience at least one episode of
recurrence within 12 months15. These findings suggest that shoulder pain can be recurrent and
frequently progresses to the chronic stage.
The rotator cuff muscles of the shoulder are sandwiched between the arm bone and the top
of the shoulder (acromion). This unique arrangement of muscle between bone leads to the
condition of impingement syndrome (shoulder bursitis, rotator cuff tendinitis) 16.
Neer first introduced the concept of rotator cuff impingement in 1972. He described the
syndrome as a mechanical impingement of the rotator cuff tendons beneath the anteriorinferior portion of the acromion occurring when the shoulder is placed in the forwardly flexed
and internally rotated position17. It is important to remember that the function of the rotator
cuff, in addition to generating torque, is to stabilize the glenohumeral joint; thus, stronger
rotator cuff muscles result in better glenohumeral joint stabilization and less impingement18.
Conservative management for chronic shoulder pain involves specific strengthening program
for the rotator cuff for the prevention of future injuries. The motions of the rotator cuff that are
emphasized for strengthening the internal rotation, external rotation and abduction. Patients
may require a formal physical therapy program18. Thus, the shoulder exercises should be done
with a fixed weight rather than a variable weight such as a thera band. Repetitions are
emphasized, and a relatively light weight is used. Sometimes, sports-specific techniques are
useful, particularly when strengthening the throwing motion, the serving motion or swimming
motions. In addition, physical therapy modalities such as electro galvanic stimulation,
ultrasound treatment and transverse friction massages can also be helpful.
Some authors routinely advocate the usage of ultrasound in conjunction with other modalities
and report positive outcomes19, 20, 21. The physiologic benefits of ultrasound have been
attributed to its thermal actions; these involve an increase in peripheral blood flow, increased
tissue metabolism and greater tissue extensibility22.
In addition to this transverse friction massage has been advocated by a number of authors in
the management of shoulder disorders. Hammer describes friction massage as a technique
where an involved muscle, tendon or ligament is massaged by applying pressure with a
reinforced finger. The transverse motion across the involved tissue and the resultant
hyperaemia are said to be the chief healing factors of friction massage. The transverse action is
said to prevent the formation of scar tissue while longitudinal friction effects the transportation
of blood and lymph23, 24.
The goals of manual therapy of subacromial impingement are to decrease subacromial
inflammation, to allow healing and strengthening of a dysfunctional rotator cuff
and to restore pain-free shoulder function18.
Studies have also shown that incorporation of joint mobilizations to treat shoulder
impingement results in superior outcomes compared with therapeutic exercise alone25, 26, 27.
Some researchers propose that a mobilization force can be selectively directed to a specific
area of the capsule to restore capsular extensibility26, 28. Studies have found that individuals
with shoulder impingement often have a tight posterior capsule resulting in altered
glenohumeral arthrokinematics29, 30 and a decrease in glenohumeral internal rotation range of
motion (ROM) 31, 32, 30.
Many studies have reported the effectiveness of exercise therapy programs in treatment of
chronic shoulder impingement syndrome as a non surgical intervention, research on the
combination of multimodality treatment in treating a shoulder impingement syndrome is
insufficient. Mario Pribicevic and Henry Pollard reported that there is a significant
improvement in pain, range of motion and in functions of those individuals who were been
diagnosed with shoulder impingement syndrome using a multi- modal treatment approach like
therapeutic ultrasound, soft tissue release, joint mobilization and exercise therapy33.
It seems reasonable to suggest that multimodality treatment in treating a shoulder impingement
syndrome may be helpful in the management of shoulder impingement that do not respond to
conservative management. Unfortunately, there is little evidence on the efficacy of these types
of interventions for patients with chronic subacromial impingement syndromes not responding
to conservative management.
Thus, the aims of this study were to investigate the effectiveness of a combination of multimodal therapy which includes therapeutic ultrasound, soft tissue release, spinal and peripheral
mobilization and exercise therapy on pain, function and Range of motion of chronic shoulder
impingement syndrome patients and if beneficial, to develop a more effective intervention
protocol.
6.1 NEED FOR THE STUDY
Various studies in the past showed that conventional therapy approaches in treating
impingement syndrome was more effective than patient opting for surgery.
Studies have also suggested that multiple modality treatment approach is helpful in reducing
pain, improving ROM and restoring functional activities.
Limited randomized control studies have been conducted on chronic shoulder impingement
syndrome and also on limited number of patient samples.
Thus, the proposed study intends to find the efficacy of a multi-modal treatment approach for
chronic shoulder impingement on a larger group of randomized targeted population.
6.2
OBJECTIVES OF THE STUDY
(A) OBJECTIVES:

To investigate the effectiveness of multi-modal treatment approach to reduce pain in
chronic shoulder impingement syndrome.

To investigate the effectiveness of multi-modal treatment approach to restore the lost
range of motion in chronic shoulder impingement syndrome.

To investigate the effectiveness of multi-modal treatment approach to restore lost
functional activities in chronic shoulder impingement syndrome.
(B) HYPOTHESIS
NULL HYPOTHESIS:
There is no significant effect of multimodal treatment approach in treating chronic shoulder
impingement syndrome.
EXPERIMENTAL HYPOTHESIS:
I.
There is a significant effect of multimodal treatment approach in reducing pain in
chronic shoulder impingement syndrome.
II.
There is a significant effect of multimodal treatment approach in restoring the lost
range of motion in chronic shoulder impingement syndrome.
III.
There is a significant effect of multimodal treatment approach in restoring lost
functional activities in chronic shoulder impingement syndrome.
6.3 REVIEW OF LITERATURE
1. Phil Page (2011) suggested that Subacromial impingement is a frequent and painful
condition among athletes, particularly those involved in overhead sports such as baseball and
swimming. There are generally two types of subacromial impingement: structural and
functional. While structural impingement is caused by a physical loss of area in the
subacromial space due to bony growth or inflammation, functional impingement is a relative
loss of subacromial space secondary to altered scapulohumeral mechanics resulting from
glenohumeral instability and muscle imbalance.
2. Carel Bron, et al (2011) suggested that patients who received 12-week comprehensive
treatment of myofacial trigger point release technique in shoulder muscles reduces the number
of muscles with active myofacial trigger points and is effective in reducing symptoms and
improving shoulder function in patients with chronic shoulder pain.
3. Hidalgo-Lozano A, Fernández-de-las-Peñas C, (2011) suggested that twelve patients
diagnosed with unilateral shoulder impingement attended four sessions for 2 weeks received
trigger point pressure release and neuromuscular interventions showed that manual treatment
of active muscle trigger points can help to reduce shoulder pain and pressure sensitivity
in shoulder impingement syndrome.
4. Jeffrey A. Fleming (2010) suggested that exercise is beneficial for reducing pain and
improving function in individuals with rotator cuff impingement syndrome. The effects of
exercise might be augmented with implementation of manual therapy. In addition, supervised
exercise might not be more effective than a home exercise program.
5. F. Angst, J. Goldhahn (2009) suggested that the German Shoulder Pain and Disability
Index (SPADI) is a practicable, reliable and valid instrument, and can be recommended for the
self assessment of shoulder pain of shoulder pain and function.
6. Aimie F. Kachingwe (2008)39 suggested that patients diagnosed with shoulder
impingement syndrome received physical therapy interventions of glenohumeral mobilizations
and MWM in combination with a supervised exercise program showed significant decrease in
pain and improved function compared to the patients who were only managed by supervised
exercise and control groups. Hence suggesting that manual therapy techniques can be an
important adjunct to supervised exercise in the treatment of individuals with shoulder
impingement syndrome.
7. Gamze Senbursa, Gul Baltac, Ahmet Atay (2007) suggested that patients diagnosed with
impingement syndrome treated with manual physical therapy applied by experienced physical
therapists combined with supervised exercise in a brief clinical trial showed improvement of
symptoms including increasing strength, decreasing pain and improving function earlier than
with exercise program.
8. Joy C MacDermid (2006) suggested that Shoulder Pain and Disability Index (SPADI) is a
valid measure to assess pain and disability in community-based patients reporting shoulder
pain due to musculoskeletal pathology.
9. Kenneth Hing-Sum Tsui (2005) suggested that impingement syndrome is common in
clinical practice. Knowledge of basic anatomy of the shoulder and mechanism of the disease
process is essential for management. Non-steroidal anti-inflammatory drug has only very
limited evidence of effectiveness. Subacromial steroid injection has some evidence of
effectiveness but the optimal type of steroid, dosage, frequency and timing of injection is still
unclear. Structured and supervised exercise programs have been shown to offer long-term
benefit. Weight pendulum exercise and other simple exercises could be recommended to
patients in the clinic setting. Orthopedic surgery is indicated for refractory cases of shoulder
impingement syndrome.
10. Karen A. Ginn and Milton L. Cohen (2005) suggested that patients who underwent
individually-tailored exercise therapy which was aimed at restoring dynamic joint stabilizing
mechanisms and muscle coordination or a combination of various physical modalities and
ROM exercises is equally effective in the short term improvement in chronic shoulder pain.
11. Per Jonsson et. al (2004) suggested a specially designed painful eccentric training model
for the supraspinatus and deltoideus muscles showed promising short-term clinical results on a
small group of patients with severe pain from impingement of the shoulder.
12. Wing K. Chang (2004) suggested that Shoulder impingement syndrome and rotator cuff
disease are increasingly more common in athletes whose sports involve repetitive overhead
motions. The increased forces and repetitive overhead motions can cause attritional changes in
the distal part of the supraspinatus tendon, which is most at risk due to its poor blood supply.
No commercial party having a direct financial interest in the results of the research.
13.Markus Walther,Andreas Werner,Theresa Stahlschmidt,Rainer Woelfel,
Frank Gohlke,(2004) suggested that patients with subacromial impingement syndrome of the
shoulder treated with guided self-training program and by conventional physiotherapy or a
functional brace, showed a significant improvement in shoulder function as well as a
significant reduction in pain.
14. E.John Gallagher, Polly E. Bijur, Clarke Latimer, Wendy Silver,(2001) suggested that
VAS is a methodologically sound instrument for quantitative assessment of acute abdominal
pain and for detecting clinically important changes in such pain.
15. Review of goniometry emphasizing reliability and validity by richard l. gajdosik and
richard w. bohannon (1987): Clinical measurement of range of motion is fundamental
evaluation procedure with ubiquitous application in physical therapy. The purpose of this
article is to review the related literature on the reliability and validity of goniometric
measurements of the extremities. They conclude that clinicians should adopt standardized
methods of testing and should interpret and report goniometric results as ROM measurements
only, not as measurements of factors that may affect ROM.
16. Griffin et al [41] (1967) showed in his comparative study the effectiveness between
phonophoresis and ultrasound in patients suffering from shoulder impingement syndrome that
patients receiving phonophoresis showed significant improvement in range of motion and
pain as compared to the patients receiving ultrasound group.
7.MATERIALS AND METHOD
7.1 SOURCE OF DATA
(A) POPULATION:
Patients diagnosed with shoulder impingement syndrome.
(B) SAMPLE SIZE:
30 subjects who fulfill inclusion criteria will be recruited from the population given above and
divided into two groups- 15 subjects in each group.
GROUP 1: Experimental group; Multimodality treatment approach.
GROUP 2: Control group; Conventional physiotherapeutic approach.
MATERIALS USED FOR THE STUDY:
1. Universal goniometry
2. Assessment chart
3. Therapeutic Ultrasound
4. Couch
5. Mobilization belt
6. Cold packs
7.2 METHOD OF COLLECTION OF DATA:
(A) SAMPLING TECHNIQUES:
Simple random sampling.
(B) TOOLS:

Standard universal goniometry for range of motion (ROM).

Subjective/objective visual analog scale (VAS) for pain assessment.

Shoulder pain and disability index scale (SPADI) for function.
(C) METHODOLOGY:
(I) STUDY DESIGN:
Randomized control trial.
(II) INCLUSION CRITERIA:
In order to participate in this study, subjects will have to fulfill following criteria’33

A positive clinical Neer’s test

Shoulder pain resistant to rest

Shoulder pain resistant to anti-inflammatory drugs

Shoulder pain resistant to subacromial steroid injections

Shoulder pain resistant to conventional physiotherapy with a minimum history of three
months
(III) EXCLUSION CRITERIA:

Glenohumeral or acromioclavicular arthritis’33

Glenohumeral instability

Total rupture of the rotator cuff

Cervical syndrome

Adhesive capsulitis

Neuropathy of the shoulder region
(IV) PROCEDURE and INTERVENTION:
Subjects who fulfill the selection criteria will be included in the study. They will be taken in to
the research once they sign the informed consent.
A total of 30 subjects will be selected and divided into 2 groups of 15 subjects each by simple
randomization.
The study will be carried out in three stages-
a) Pre- intervention measurement
b) Intervention
c) Post-intervention measurement.
a) Pre- intervention measurement
Here the subjects are measured for pain, range of motion and function.

Pain measurement using subjective/objective visual analog scale
The visual analog scale (VAS) is a tool widely used to measure pain. A patient is asked to
indicate his/her perceived pain intensity (most commonly) along a 100 mm horizontal line, and
this rating is then measured from the left edge. The VAS score correlates well with acute pain
levels34.
Hawkins test involves positioning the arm at 90 degrees of flexion with subsequent internal
rotation.
Neer's impingement test is performed with the patient sitting as the practitioner stands behind
the patient with one hand supporting the scapula to prevent scapula rotation and the other hand
holding the forearm. The shoulder is brought into maximum flexion with a small degree of
internal rotation. The test is considered positive if there is pain in the last 10–15 degrees of
flexion. Pain is produced because the greater tuberosity is compressed against the anterior
acromion or coracoacromial ligament, hence this test may aggravate an inflamed bursa
(subacromial), the supraspinatus tendon or the anterior structures of the coracoacromial arch33.
Pain will also be measured at rest, motion and at night pre and post intervention18.

Joint range of motion using universal goniometer
Universal goniometer measurements A 12-inch, 3601 goniometer, marked in 11
increments, with two adjustable overlapping arms was used. Shoulder flexion ROM was taken
by asking the patient to raise their arm straight over-head as far as possible. Standard
measurement positioning was used by placing the stationary arm parallel to the midline of the
thorax, and the moving arm aligned with the shaft of the humerus and lateral epicondyle.
Shoulder ER was taken by passively placing the patient’s arm in 90degree abduction with the
elbow flexed 90degree and asking the patient to rotate their arm backward as far as possible so
that their palm was facing the ceiling. Standard goniometric positioning was used by placing
the stationary arm perpendicular to the floor, and the moving arm was aligned with shaft of the
ulna and styloid process.
Shoulder IR was taken by passively placing the patients arm in 90degree abduction with the
elbow flexed 90degree and asking the patient to rotate their arm forward as far as possible so
that their palm was facing the floor. Positioning of the goniometer for measurement was also
used in a standardized fashion (Norkin and White, 1988)35.

Functional assessment using Shoulder pain and disability index (SPADI)
The Shoulder Pain and Disability Index (SPADI) is a self-administered questionnaire that
consists of two dimensions, one for pain and the other for functional activities. The pain
dimension consists of five questions regarding the severity of an individual's pain. Functional
activities are assessed with eight questions designed to measure the degree of difficulty an
individual has with various activities of daily living that require upper-extremity use. The
SPADI takes 5 to 10 minutes for a patient to complete and is the only reliable and valid
region-specific measure for the shoulder.
Scoring instructions
To answer the questions, patients place a mark on a 10cm visual analogue scale for each
question. Verbal anchors for the pain dimension are ‘no pain at all’ and ‘worst pain
imaginable’, and those for the functional activities are ‘no difficulty’ and ‘so difficult it
required help’. The scores from both dimensions are averaged to derive a total score36.
b) Intervention
GROUP 1: Experimental group; Multimodality treatment approach.
The subject will be given multi modal treatment which includes soft tissue release
technique, ultrasound therapy, peripheral joint mobilization and therapeutic exercises. The
treatment would be given for a week period, with each subject in groups 1 and 2 receiving
respective interventions one time a day. The subjects would be tested at approximately same
time each day. During this period, the subjects will be asked to refrain from any kind of sports
activity or exercise. Pre- test measurement will be taken on 1st day and intervention will be
carried out for 5 days in the week with post-test measurement taken on 5th day. 6th day will be
a resting day and on the 7th day measurement will be taken to check maintenance of gained
ROM.
All of the patients receive soft tissue therapy that involves the application of ischaemic
pressure to the supraspinatus and infraspinatus muscles, as well as the rhomboids, upper
trapezius and levator scapulae. The application involves palpating the muscle bellies and
applying a sustained pressure into areas of muscle spasm until a release of the barrier of
resistance was felt. Release meaning the relaxation of the point of muscle spasm with a
decrease in the sensitivity and muscle tone after re-palpating the area. Care was taken not to
cause increased discomfort to the patient (to the level of pain tolerance).
Longitudinal and transverse friction massage will be applied to the posterior tenomuscular
junction of the infraspinatus muscle, the coracoacromial ligament (postero-inferior aspect) and
the insertion of the supraspinatus on the greater tuberosity of the humerus. The friction
massage application will be achieved by palpating the capsular or tendinous adhesions and
frictioning over its surface with the practitioner's index finger. This will be maintained until
friction anaesthesia is achieved and till the patient could not feel any discomfort. A new point
will be chosen and the process repeated. Once again care will be taken to not cause excessive
discomfort to the patient. At the end of the treatment sessions ice application is advised at a
frequency of three applications of 15 minutes with two 20-minute breaks.
Ultrasound phonophoresis will be applied to the areas that previously underwent friction
massage with a topical corticosteroid [1%]. Ultrasound was applied with a continuous wave
form for 7 minutes at a setting of 2.2 W/cm2 to the rotator cuff insertion on the anteriorinferior aspect of the humerus and posterior inferior aspect of the acromioclavicular joint.
Peripheral thrust manual manipulation will be applied to the glenohumeral joints in external
rotation (progressive) and inferiorly to the acromioclavicular joint and anterior to posterior to
the sternoclavicular joint in all of the patients where a likely motion restriction was detected.
Diversified spinal manipulations were used to manipulate the thoracic and cervical spines at
the level of T3/4 and C5/6. All patients will be given a basic exercise program with initial
emphasis on isometric strengthening of the supraspinatus and infraspinatus muscles. This was
implemented once a reduction in pain and improved range of motion was noted at a frequency
of 4 sets of 10 repetitions, 2–3 times per day. Theraband (extendable elastic) exercises were
also implemented at the same frequency after the initial isometric strengthening period. This
also included shoulder shrugs, wall push-ups and scapula retraction exercises33.
GROUP 2: Control group; Conventional physiotherapeutic approach.
The subjects will be instructed with self training program which includes active range of
motion exercises, stretching and strengthening exercise program including rotator cuff
muscles, rhomboids, levator scapulae and serratus anterior with an elastic band at home at least
seven times a week for 10–15 min and the exercises were taught by physio.therapist. Same
exercise program will be given to each patient as shoulder exercise brochure37, 18.
C) Post- intervention measurement
Post-intervention measurement will be performed in the same manner as pre intervention
measurement for pain, range of motion and function. These measurements will be taken after 1
week of treatment and even after one month post treatment.
8. LIST OF REFERENCES:
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physiotherapy, sydney and the university of Sydney neuroscience research Australia(Neura),
Randwick, Australia
37. )Baltac G (2003) Approaches in athletes with subacromial impingement syndrome:
prevention and exercise programs. Acta Orthop Traumatol Turc 37(1):128–138.
38) Griffin JE, Echternach JL, Price RE, and Touchstone JC: Patients treated with ultrasonic
driven hydrocortisone and with ultrasound alone. Phys Ther 1967, 47:594-60.
39) Aimie F. Kachingwe, Comparison of Manual Therapy Techniques with Therapeutic
Exercise in the Treatment of Shoulder Impingement: A Randomized Controlled Pilot Clinical
Trial, the journal of manual & manipulative therapy n volume 16 n number 4, 2008 , 238-248
9.
SIGNATURE OF
CANDIDATE
SD/(KAVAN TK)
10.
REMARKS OF GUIDE
PRESENTED TO THE RESEARCH
COMMITTEE AND APPROVED
11.
11.1 NAME AND
DESIGNATION OF GUIDE
DR.MARITTA BABY THOMAS
( ASSISTANT PROFESSOR)
MPT (ORTHOPAEDIC AND MANUAL
THERAPY)
11.2 SIGNATURE
SD/-
11.3 CO-GUIDE (if any)
11.4 SIGNATURE
11.5 HEAD OF THE
DEPARTMENT
DR.MASIH MUHAMMAD KHAN
MPT (MUSCULOSKELETAL DISORDERS AND
SPORTS PHYSIOTHERAPY)
11.6 SIGNATURE
SD/-
12
12.1 REMARKS OF THE CHAIRMAN AND PRINCIPAL
APPROVED AND FORWARDED
12.2 SIGNATURE
SD/-