ORIGINAL ARTICLE EFFICACY OF SCAPULAR MOVEMENT WITH MOBILIZATION IN PATIENTS WITH SHOULDER IMPINGEMENT

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1 ORIGINAL ARTICLE EFFICACY OF SCAPULAR MOVEMENT WITH MOBILIZATION IN PATIENTS WITH SHOULDER IMPINGEMENT Dr Ajit S Dabholkar 1 (Associate Professor), Dr Sujata Yardi 3 (Professor and Director) Dr Tejashree Dabholkar 2 (Asstt Professor) Department of Physiotherapy, Pad. Dr. D. Y. Patil University, Nerul, NaviMumbai. Corresponding Author: Dr Ajit S Dabholkar 1 (Associate Professor), Haware s Green Park, B-2/603,Sector-22,Kamothe address:ajitdabholkar78@yahoo.co.in Abstract Background & Purpose of the study: Scapular kinematic alterations have been demonstrated in subjects with impingement syndrome. These scapula movement alterations are believed to decrease the subacromial space by failing to move the acromion away from the humeral head during arm elevation resulting in increased compressive loads on the tendons of rotator cuff or long head of the biceps muscle. Mulligan s movement with mobilization (M.W.M) hypothesize that positional malalignment can be corrected with appropriate gliding. Thus this research investigates the efficacy of scapular movement with mobilization in patients with shoulder impingement. Aim: Efficacy of scapular movement with mobilization in patients with shoulder impingement Objective: Assess immediate effect of scapular movement with mobilization in shoulder impingement Research design: Exploratory study Methodology: Scapula M.W.M was given to the patient, 10 repetitions thrice were repeated.

2 Outcome measures: Visual analogue scale was used to assess pain, Range of Motion in Scaption plane was assessed by using Goniometer, Supraspinatus strength assessment was assessed in Scaption plane,shoulder pain and disability index(spadi) was assessed Data collection and analysis: Baseline data recorded for the outcome measures and post intervention data was statistically analyzed for the level of significance. Paired t-test was done for the same. Results: Significant differences were observed with respect to various outcome measures studied. Visual analogue scale Mean difference is 2.880,Standard deviation difference is 1.447,95% confidence interval difference is to 3.477,(p<0.0001).Range of motion Mean difference is 21.28,Standard deviation difference ,95% confidence interval difference is to , (p<0.0001). Supraspinatus strength Mean difference is 4.40kgs,Standard deviation difference is 1.528,95% confidence interval difference is to (p<0.0001) and Shoulder pain and disability index score(spadi) Mean difference is ,Standard deviation difference is 7.840,95% confidence interval difference is to ,(p<0.0001). Conclusion: Scapular movement with mobilization proved to be effective in patients with shoulder impingement Key words: Impingement shoulder, scapular alteration, Movement with mobilization Introduction: Shoulder impingement was described by Neer in Shoulder impingement is one of the most common conditions that affect the shoulder and accounts for 44 65% of all cases of shoulder pain 2. Impingement usually refers to compression and mechanical abrasion of the rotator cuff tendons, subacromial bursae, or long head of the biceps tendon beneath the anterior undersurface of the acromion, coracoacromial ligament, or undersurface of the acromioclavicular joint during elevation of the arm. Another possible mechanism of impingement can be attributed to intrinsic breakdown of the rotator cuff tendons as a result of tension overload 3. Serratus anterior and lower trapezius are the most susceptible to the effects of inhibition and are most frequently involved in early phases of shoulder pathology 4 The scapula serves many roles in order for proper shoulder function to occur (W. Ben Kibler, Br J Sport Med 2010).Scapular kinematic alterations have been demonstrated in subjects with impingement syndrome 5..

3 MRI study by Solem Bertoft et al revealed that anterior opening of the subacromial space narrowed as the shoulder moved from a retracted to a protracted position 6 Mulligan s movement with mobilization(m.w.m) hypothesize that positional malalignment can be corrected with appropriate gliding. Thus this research investigates the efficacy of an innovative method i.e. Scapular movement with mobilization in patients with shoulder impingement. Material and methodology: Fig: 1 Materials: Goniometer, Push-Pull Dynamometer(Baseline),Visual Anolgue scale Pen,Paper Study Design: Exploratory, one group pretest and posttest study Inclusion Criteria: Patients with impingement of shoulder, Hawkin s Kennedy and Neer s test was positive. Scapula repositioning/scapula retraction test positive Exclusion Criteria: Rotator cuff tear, Frozen shoulder, Shoulder instability Methodology: Institutional ethics committee approval was taken to start the study. Written consent was taken from all the subjects who participated in the study. 30 subjects were selected according to the inclusion criteria as mentioned above.

4 Outcome measures: Visual analogue scale was used to assess pain, Range of Motion in Scaption plane was assessed by using Goniometer, Supraspinatus strength assessment was assessed in scaption plane, Shoulder pain and disability index(spadi) was assessed. Procedure for scapular movement with mobilization as shown in Fig 2 & 3(Innovative method): The patient was made to sit on a stool. The therapist stands behind the patient on the affected side. The therapists left hand holds the scapula in a way that the fingers are on the medial border of the scapula, web space on inferior border and the thumb on the lateral border of the scapula. The right hand is on the superior part of the clavicle. The right hand thumb is on the spine of the scapula and the fingers anterior to the clavicle. The patient is told to do the offending movement in the scaption plane with the thumb facing up. The therapists moves/assists the scapula in upward rotation (left hand) and posterior tilting the scapula(right hand) as the patients goes into the end range of motion actively elevating the shoulder. Scapula M.W.M was given to the patients, 10 repetitions thrice were repeated ( 48 hour follow up was studied) FIGURE 2 & 3 Data collection and Analysis: Baseline and Post intervention data was recorded for the outcome measures and statistically analyzed for the level of significance. Paired t-test was done for the same

5 Results and Observations: Outcome Mean Mean Std Dev Std Dev P VALUE pre post pre post VAS <0.0001* SUPRASPINATUS STRENGTH <0.0001* SCAPTION ROM <0.0001* SPADI <0.0001* *Indicates Extremely significant Discussion: Alterations in scapula positions and motions occur in 68% to 100% of patients with shoulder injury (W.Ben Kibler).Visible alterations in scapular position and motion patterns have been termed scapular dyskinesis. Several investigators 8-14 have studied 3-D (3-dimensional) shoulder kinematics during arm elevation, including how abnormal motion may relate to shoulder impingement. It has been described that during elevation of the arm in healthy subjects the scapula should upwardly rotate and posteriorly tilt 15,16 In subjects with impingement less serratus anterior muscle activation and greater upper and lower trapezius activation were found with less scapular upward rotation and posterior tilt(lin JJ et al,j.electromyography Kinesiology2005,Sports Exs Med 2008) Studies have demonstrated that subjects with shoulder impingement may present with decreased scapular upward rotation and posterior tilt, and increased scapular internal rotation during arm elevation. 17,18. Nociceptive input may influence peripheral and central motor control (Pain 2001). Studies demonstrated difference in EMG activity in particular upper and lower trapezius between people with SIS and healthy controls (BMC Musculoskeletal Disorders 2010) Correctional mobilisation(a repositioning) is sustained, pain free function is restored and several repetitions will begin to bring lasting improvements(mulligan)

6 Inman, Saunders and Abbott 19 stated that coordinated activity in scapular muscles for smooth movement of the scapula during arm motions. They studied raw EMG data from various muscles and described trapezius and lower serratus anterior as the prime movers for scapular upward rotation. Overall, trapezius has been found to be more active during abduction as compared to flexion, 20. consistent with less scapular internal rotation present in scapular plane abduction as compared to flexion 21,22 The middle and lower serratus anterior are aligned with a substantial mechanical advantage for scapular upward rotation 23, in combination with the ability to posteriorly tilt and externally rotate the scapula The middle and lower serratus anterior are the only scapulothoracic muscles with the capability to both upwardly rotate and posteriorly tilt the scapula on the thorax. Their line of action will also directly approximate the scapula to the thorax, which can serve as a stable base. The functions of serratus anterior make its contribution to normal scapular kinematics during arm elevation very significant in reducing risk for scapular alterations identified with shoulder impingement symptoms, including reduced upward rotation or posterior tilting, or increased scapular internal rotation. Force couples are preprogrammed to interact with glenohumeral muscle to provide scapular position and stability for arm motion (Jnl Biomech1995) Position and control of the scapula on the thorax play a critical role in normal function of the shoulder. Stabilization is provided through the scapulothoracic musculature by approximating or compressing the scapula to the thorax. Scapular motions on the thorax align the glenoid fossa with the humeral head maximizing joint congruency and providing a stable base for humeral motion 7. Normal External rotation of scapula during scaption coordinated action of all parts of trapezius and serratus anterior.(muscle and Nerve 2006 Correction of asynchronous muscle activity, improve dynamic stability and thereby decrease pain and increase function(michener et al, J of Hand Th 2004,Desmeule SF et al, Sports Med 2003)

7 FIGURE 4 : ALIGNMENT-IMPAIRMENT MODEL As shown in the above Model, Alignment deviation leads to impairment. Therefore, selecting Mulligan s M.W.M for correcting the positional malalignment would give lasting benefits. According to the present study, pain was alleviated improving range of motion and supraspinatus strength, thus decreasing the disability in patients of shoulder impingement. Normal kinematics of the shoulder are believed critical to preserving the subacromial space and preventing impingement during arm elevation. The length-tension relationship and load of the rotator cuff and scapular muscles and tendons are also believed to be influenced by normal kinematics. Conclusion: Scapular movement with mobilization proved to be effective in patients with shoulder impingement Clinical Implications : Scapular movement with mobilization can be used in patients with impingement shoulder demonstrating abnormal behaviour. Acknowledgement : None Funding : NIL Conflict of Interest : None

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