Original Research Article EFFECT OF CERVICO … · Original Research Article EFFECT OF CERVICO-THORACIC MOBILIZATION ON HEMIPLEGIC SHOULDER PAIN WITH SUPRASPINATUS TENDONITIS DUE

Int J Physiother Res 20164(3)1510-17 ISSN 2321-1822 1510

Original Research Article

EFFECT OF CERVICO-THORACIC MOBILIZATION ON HEMIPLEGICSHOULDER PAIN WITH SUPRASPINATUS TENDONITIS DUE TOIMPINGEMENT SYNDROME AN EXPERIMENTAL STUDYSnehanjali Jena Monalisa Pattnaik Patitapaban Mohanty

Swami Vivekanand National Institute of Rehabilitation Training and Research Olatpur CuttackOrissa India

Introduction Biomechanically cervical and thoracic spine is involved in impingement syndrome in hemiplegiaAim of the study is to find the effect of cervico-thoracic mobilization on hemiplegic shoulder pain withsupraspinatus tendonitis due to impingement syndromeMaterials and Methods The selected subjects were randomly assigned in to experimental and control groupswith 15 subjects each Experimental group received conventional exercises along with manual therapy ieMaitlandrsquos rhythmic oscillatory central PA mobilization of cervico-thoracic spine (C7-T4 vertebra) as toleratedby patient for a periods of 4 weeks Control group received conventional exercises (stretching of internalrotators supraspinatus muscle weight bearing exercise weight shifting exercises strengthening and scapularmobilization) Total duration of treatment was 5 days per week for 4 weeksResults Result of the study suggested that both the control group and experimental group had a significantimprovement in pain ROM and disability in hemiplegic subjects with supraspinatus tendonitis causingimpingement syndrome after treatment for 4 weeks However the experimental group showed greater change ascompared to control groupConclusion The study demonstrates that cervicondashthoracic mobilization has better effect in improving painROM and function compared to conventional treatment in hemiplegic subjects with supraspinatus tendonitisdue to impingement syndromeKEY WORDS Supraspinatus Tendonitis Impingement Syndrome Hemiplegic Shoulder Pain Mobilization

ABSTRACT

INTRODUCTION

Address for correspondence Dr Patitapaban Mohanty PhD PT Assoc Professor SwamiVivekanand National Institute of Rehabilitation Training and Research Olatpur P O Bairoi CuttackOrissa 754010 India E-Mail ppmphysiorediffmailcom

International Journal of Physiotherapy and ResearchInt J Physiother Res 2016 Vol 4(3)1510-17 ISSN 2321-1822

DOI httpdxdoiorg1016965ijpr2016122

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Access this Article online

International Journal of Physiotherapy and ResearchISSN 2321- 1822

wwwijmhrorgijprhtml

DOI 1016965ijpr2016122

Received 30-03-2016 Peer Review 30-03-2016 Revised None

Accepted 22-04-2016Published (O) 11-06-2016Published (P) 11-06-2016

Subluxation Impingement syndrome (Rotatorcuff injury Bicipital tendinitis) CRPS ndash 1Brachial plexopathy Axillary neuropathySubscapular neuropathy Myofascial painSpasticity Soft tissue contracture [1]Biomechanically possible causes of HSP due toimpingement syndrome 1 Inadequate externalrotation of humerus due to hypertonicity and

Shoulder pain is a common complication afterstroke that can inhibit recovery and reducequality of life Incidence of hemiplegic shoulderpain (HSP) varies from 34 - 84- [1] Shoulderpain by itself can result in significant disability(Najenson et al 1971 Poduri 1993) Causes ofhemiplegic shoulder pain are Capsulitis


Snehanjali Jena Monalisa Pattnaik Patitapaban Mohanty EFFECT OF CERVICO-THORACIC MOBILIZATION ON HEMIPLEGIC SHOULDERPAIN WITH SUPRASPINATUS TENDONITIS DUE TO IMPINGEMENT SYNDROME AN EXPERIMENTAL STUDY

shortening of internal rotator during abductionlead to impingement of greater tuberosityagainst coracoacromial arch during passivemovement and causes pain [2] 2 Loss ofscapulohumeral rhythm During arm abductionscapula and humerus moves in a ratio of 12Normally scapula moves in forward and upwarddirection during abduction In hemiplegiadelayed scapular rotation due to increase tonein muscles leading to retraction and depressionIf the patientrsquos scapula doesnrsquot move sufficientlywhen his arm is being lifted passively traumaoccurs and patient experience pain at shoulder[2] 3 Lack of downward movement of head ofhumerus in glenoid fossa [2] Because of thesebiomechanical changes during passiveactiveabduction greater tuberosity impinges withacromion leading to Supraspinatus tendinitisSubacromial bursitis Rotator cuff tear [1]Involvement of cervical and thoracic spine inimpingement syndrome Well in 1988 found thatsupraspinatus tendonitis and capsulitis havefrequently their origin totally or part from cervicalor upper most thoracic spine Any lesion ofnervous system can lead to increase tensionwithin the system as a whole Hemiplegicpatient have abnormal tension of nervoussystem and loss of adaptive lengthening ofneural structures A sensitive cervical nerve rootcould possibly alter the mobility of glenohumeraljoint and shoulder as a whole and mimic as atrue glenohumeral condition With stiff upperthoracic spine extension the rib may subluxatesuperiorly on fixed thoracic spine and result inpain and dysfunction around shoulder [2]Increased thoracic kyphosis tend to abduct thescapula and downwardly rotate it altering thescapulohumeral relationship which leads tomuscle weakness and decreased ROM resultingin impingement syndrome [3]Thoracic spine forms a key link in the kinematicsequence of arm elevation Thoracic sidebending and rotation are caused by unilateralhumeral motions The relationship betweenreduced mobility of the cervicothoracic spine andshoulder pain could be explained by thisreflexogenic mechanism Thoracic jointmanipulation improves spinal mobility and alsoassisted in decreasing distal and autonomicsymptoms [4] Painful hemiplegic shoulder can

be very limiting and has the potential to furtheradd to the disability seen with hemiplegia Thedevelopment of painful hemiplegic shoulder isassociated with severe stroke and poorfunctional outcome [5] Management of thepainful hemiplegic shoulder once the conditionhas developed is difficult and response totreatment is frequently unsatisfactory Currentmanagement for HSP are positioning ofhemiplegic shoulder slings and other aidsstrapping the hemiplegic shoulder activetherapies electrical stimulation surgerybutulinium toxin injection steroid injectionaromapathy and acupuncture subscapularnerve block segmental neuromyotherapyrelieving anxiety general activities increasingrange of passive movement self assisted armactivities scapular mobilization [5] Asdescribed biomechanically cervical and thoracicspine is involved in impingement syndrome inhemiplegia Thoracic kyphosis also found to beincreased in hemiplegics which is associatedwith hemiplegic shoulder pain3 Cervical andthoracic central posterior to anterior mobilizationincrease the sympathetic activity of upper limb[6] reduce the stiffness of spine [7] reducethoracic kyphosis [8] and improve posture [910]thereby reduce shoulder pain in hemiplegics Nostudy could found the effect of cervico-thoracicmobilization in HSP with supraspinatustendonitis due to impingement syndromeAim of the StudyTo find the effect of cervico-thoracic mobilizationon hemiplegic shoulder pain with supraspinatustendonitis due to impingement syndrome

MATERIALS AND METHODS

Study design Pre test and post testexperimental study design Subjects A total of30 subjects with hemiplegia due to strokediagnosed clinically as supraspinatusimpingement syndrome who met inclusion andexclusion criteria were recruited from theoutpatient and in-patient department ofSVNIRTAR and a written consent was obtainedfrom each subject Group Assignment Theselected subjects were randomly assigned toexperimental and control groupInclusion criteria Complain of shoulder painage- 25ndash65 years tenderness over supraspin-



atus tendon with positive Hawkins Kennedyimpingement sign and Neerrsquos impingement testExclusion criteria Complete rotator cuffrupture Adhesive capsulitis Bicipital tendinitisGlenohumeral instability Labral tears OAaround shoulder complex Acute fractureCervical nerve root pathology Tumor activesystemic disease Spinal hypermobility Historyof shoulder pain before stroke Cardiacsymptoms Any other contraindication to manualtherapy techniqueIndependent variables Maitlandrsquos rhythmicoscillatory central PA mobilization of cervico-thoracic spine (C7 ndash T4 vertebra) as tolerated bypatient Shoulder rehabilitation programmeincluding stretching of internal rotatorsupraspinatus muscle weight bearing exerciseweight shifting exercises strengtheningscapular mobilizationDependent variables Shoulder pain anddisability index (SPADI) The SPADI is a selfadministered questionnaire that consists of twodimensions one for pain and other for functionalactivities The pain dimension consists of fivequestions regarding the severity of individualrsquospain Functional activities are assessed with 8questions designed to measure the degree ofdifficulty an individual has with various activitiesof daily living that require upper extremity useIt was used to assess the pain and functionallevel of the subjectsVisual analogue scale (VAS) Visual analoguescale was used to measure subjective painintensity This is a card with an uncalibratedscale ranging from 0-10 on one side (with lsquo0rsquorepresenting no pain and lsquo10rsquo representing worstpain in life) and corresponding 10 cm ruler onother side (with each cm representing pain level1)Pain free ROM Standard universal goniometerwas used to measure passive glenohumeralinternal rotation external rotation and shouldercomplex abduction with elevation ROMProcedure All subjects after meeting inclusionand exclusion criteria were asked to fill theconsent form and then randomly divided into 2groups Experimental group -15 subjectsControl group - 15 subjects Before initiatingtreatment subjects were assessed for baseline

RESULTS

Fig 1 Change in SPADI score

Figure 1 illustrates that there was improvementin TOTAL SPADI score in both the group following4 weeks of intervention However experimentalgroup showed better improvement in postmeasurement compared to control groupThere was a main effect of time F (1 28 005) =383870 p = 0000 There was main effect forgroup also F (1 28 005) =5740 p= 0024 Themain effect were qualified to Time times Groupinteraction also F (1 28 005) = 69671p = 0000 Tukeyrsquos post hoc analysis showsstatistical significant improvement in total SPADIscores in both the groups after 4 weeks ofintervention However the improvement inexperimental group is significantly more

values of all the dependent variables Therapywas started the day after the measurement wastaken Experimental group received conventio-nal exercises ie shoulder rehab programmealong with manual therapy for a period of 4weeks Control group received conventionalexercises for a period of 4 weeksTotal duration of treatment was 5 days per weekfor 4 weeksData Collection Measurements were taken priorto the beginning of treatment (pretest) and wererepeated after completion of four weeks (post-test)Data Analysis The dependent variables wereanalyzed using a 2times2 ANOVA repeatedmeasures on second factor There was onebetween factor (group) with two levels (groupsexperimental control) and one within factor(time) with two levels (time pre post) Post-hoc analysis was done using a 005 levelsignificance



Fig 2 Change in VAS score

Figure 2 illustrates that there was improvementin VAS score in both the group following 4 weeksof intervention However experimental groupshowed greater improvement in postmeasurement compared to control groupThere was a main effect of time F (1 28 005) =612500 p = 0000 There was main effect forgroup also F (1 28 005) =13033 p= 0001 Themain effect were qualified to Time times Groupinteraction also F (1 28 005) = 162000p = 0000 Tukeyrsquos post hoc analysis showsstatistical significant improvement in VAS scoresin both the groups after 4 weeks of interventionHowever the improvement in experimentalgroup is significantly more

Fig 3 Change in EXTERNAL ROTATION range

Figure 3 illustrates that there was improvementin pain free external rotation ROM score in boththe group following 4 weeks of interventionHowever experimental group showed greaterimprovement in post measurement compared tocontrol groupThere was a main effect of time F (1 28 005) =3345067 p = 0000 There was main effect forgroup also F (1 28 005) = 749067 p= 0000The main effect were qualified to Time times Groupinteraction also F (1 28 005) = 426667p = 0000Tukeyrsquos post hoc analysis statistical

Fig 4 Change in INTERNAL ROTATION range

Figure 4 illustrates that there was improvementin PAIN FREE INTERNAL ROTATION ROM scorein both the group following 4 weeks ofintervention However experimental groupshowed greater improvement in postmeasurement compared to control groupThere was a main effect of time F (128005) =2244817 p=0000 There was main effect forgroup also F (1 28 005) =13028 p= 0001 Themain effect were qualified to Time times Groupinteraction also F (1 28 005) = 289243 p =0000 Tukeyrsquos post hoc analysis showsstatistical significant improvement in internalrotation ROM score in both the groups after 4weeks of intervention However the improvem-ent in experimental group is significantly more

significant improvement in pain free externalrotation ROM score in both the groups after 4weeks of intervention However theimprovement in experimental group issignificantly more

Fig 5 Change in ABDUCTION range

Figure 5 illustrates that there was improvementin ABDUCTION WITH ELEVATION ROM score inboth the group following 4 weeks of intervention



DISCUSSION

However experimental group showed betterimprovement in post measurement compared tocontrol groupThere was a main effect of time F (1 28 005) =549924 p = 0000 There was main effect forgroup also F (1 28 005) =14904 p= 0001 Themain effect were qualified to Time times Groupinteraction also F (1 28 005) = 99400p = 0000 Tukeyrsquos post hoc analysis statisticalsignificant improvement in SPADI DISABILITYscore in both the groups after 4 weeks ofintervention However the improvement inexperimental group is significantly more

The Overall result of the study suggested thatboth the control group (conventional therapy likescapula mobilization strengthening stretchingof internal rotator and supraspinous weightbearing exercises) and experimental group(conventional exercise along with cervico-thoracic mobilization) had a significantimprovement in pain ROM and disability inhemiplegic subjects with supraspinatustendinitis causing impingement syndrome aftertreatment for 4 weeks However theexperimental group showed greater change ascompared to control groupPain Abduction without scapular upwardrotation leads to impingement [2] Basmajain(1979 1981) reported that restoration ofscapular posture to normal result in restorationin passive but effective function of shoulder joint[1112] Mobilisation of scapula in to fullelevation and protraction might have helped inrestoration of scapular posture and pain freepassive movement thereby decrease theimpingement [2]The shoulder fails to rotate externally becauseof the hypertonous and short internal rotatorShoulder abduction without adequate externalrotation causes impingement of soft tissue andgives rise to pain Sustained stretch throughpositioning modifies or reduces the toneimproves the external rotation range therebydecreases the impingement and pain [13]Subjects also received passive supraspinatusstretching in sitting with hand behind the backposition Heng Zhao et al (2008) [14] on

ultrasonic evaluation had found change inbiomechanical property hysteresis length ofmuscle following stroke Stretching realign thescar tissue fibres so that they can heal correctlyThis might have reduced the pain alsoHemiplegic subjects demonstrate weakness ofexternal rotator as part of their impairmentImbalance between rotator cuff and deltoid isanother cause of impingement Resistanceexercise helps in increasing strength andendurance in these subjects In this study onlythe shoulder external rotators werestrengthened as internal rotators were found tobe spastic So active free and active assistedmanual strengthening was encouraged in sittingposition with the arm by the side (infraspinatus)arm abducted to 75deg (teres minor) and abductionin scapular plane (supraspinatus) Leviseth G(1994) had found that in painful shoulderreduced muscle endurance and fatigue can leadto important changes in rotator cuff as well asin deltoid muscle [15] Strengthening might haveimproved endurance and increase Na Kconcentration there by reduction of pain haveachieved [15] Strengthening is an importanttreatment which gives nutrition to thedegenerated inflamed tendon so alsorestructuring of the collagen tissue haveachieved in the plane of stressControl group had also received weight bearingand weight shifting through the affected upperextremity Sustained stretching through weightbearing also modifies or reduces tone [13] Inthis study the subjects were positioned in sittingposition and arm is gently taken in to extensionslight abduction and externally rotated positionThis position might have reduced the tone ofinternal rotator thereby improved the externalrotation range Weight shifting with maximumphysical support minimum resistance andminimum speed are the key to inhibit spasticitywhere the distal end of the extremity was keptin contact with the couch and the proximal endmoved in small range [16]Besides this conventional treatment experime-ntal group had taken an additional cervicondashthoracic central PA mobilization Well in 1988[17] found that supraspinatus tendonitis andcapsulitis in hemiplegics have frequently theirorigin totally or part from cervical or upper most


thoracic spine The effect of cervico-thoracicmobilization can be attributed to theirmechanical neurological reflexogenic andpsychological effect Increase thoracic kyphosistends to abduct the scapula and downwardlyrotate it altering the scapulohumeralrelationship which leads to muscle weaknessand reduced ROM [3] As a result shoulderimpingement may present Adequate thoracicextension creates a more optimal rib cagesurface to allow the scapula to move Thoracickyphosis and stiffness make the overheadmotion difficult and lead to subacromialimpingement [18] Many a reasearcher foundrelationship between scapular position andshoulder dysfunction [19] So position of scapulaon thoracic spine has a greater influence onposture and shoulder pain Some authors havealso advocated that cervical and thoracic spinehas a strong influence on the position andmobility of the scapula and glenohumeral joint[2021] Therefore in this study Mobilization ofthe stiff thoracic spine might have reducedstiffness altered the position of scapulaimproved the posture and thereby reduceimpingement and painWright A 1995 Vecenzino et al 1995 [2223] hadproposed that manual therapy relieves pain bymodification of chemical environment ofperipheral nociceptors activation of segmentalpain inhibitory mechanism activation ofdescending pain control system In a studySterling et al had found sympathetic activity ofupper limb with Grade III PA mobilization to C5C6 motion segment [24] Sympathetic neuronsin the upper limb arise from T2-T5 spinalsegments (grey anatomy) Hence thecorresponding spinous processes C7-T4 weremobilized [25]Wainner et al (2001) [26] has proposed themechanism that effect of thoracic manipulationin shoulder patients is based on regionalinterdependence If one area such as thoracicspine is dysfunctional that may also affect themobility of shoulder and create shoulder painThe reduction of pain following mobilization inexperimental group might be due to placeboeffect Zusman 1986 2004 and Katavich 1998[27-29] had found the placebo effect of spinalmanual therapy Both the groups have taken

conventional treatments which were supervisedas well as hands on But the experimental grouphad received an additional cervico-thoracicmobilization which was more hands ontreatment and had a placebo effect from lyingon of hands hence shown better resultExternal Rotation ROM Both the groupsstretching of internal rotator and strengtheningof external rotator was done that might haveimproved the external rotation range But theexperimental group was treated with additionalcervicothoracic mobilizations that haveincreased more the external rotation range inthis group Joseph et al (2009) [30] in their studyfound 30deg increase total rotation (external andinternal) range of motion following thoracicmanipulation in shoulder pain subjects In thisstudy we found 393 degree improvement incombined external and internal rotation ROMAnother study by Creighton University (2012)[31] had found thoracic mobilization improvesshoulder external rotation ROM in normalindividuals Furthermore experimental grouphad shown better reduction of pain As the painsubsided these individuals might have doneexternal rotator strengthening exercisesadequately without fatigue and pain that mighthave an effect on external rotation rangeAbduction ROM The limiting factors for thereduced abduction ROM are limited externalrotation inflamed thickened supraspinatustendon and the fear of pain It has already beendiscussed that strengthening improves the bloodflow to the supraspinatus muscle and reduce theinflammation In a review of articlesBovendrsquoEerdt et al in 2008 had found stretchingin short term reduce the spasicity [32] So hereSustained stretching of internal rotators mighthave reduces the spasticity of internal rotatorsand increase the external rotation ROMScapular mobilization also might have improvedshoulder girdle mobility so abduction ROM getincreased Abduction ROM increased parallelwith the reduction in pain in both the groupsTherefore both the control and experimentalgroup had an improvement in abduction ROM Thoracic spine forms a key link in the kinematicsequence of arm elevation Mcclure 1999 [33]had found thoracic spine position significantlyaffect the scapular kinematics during scapular



plane abduction McClatchie et al (2008) [34]had found increase shoulder abduction painfularc following mobilization of the asymptomaticcervical spine McCormack 2012 Strunce 2009[3536] had found improved active abductionROM following thoracic mobilization in normalindividuals with adhesive capsulitis and shoulderpain respectively Another mechanism is that inboth the group pain has reduced significantlybut in the experimental group significantly morethan control that might have improved theshoulder abduction ROMInternal Rotation ROM Warner JJ 1990 [37]had found that patients with shoulderimpingement syndrome often have limitedinternal rotation ROM In both the groupssubjects were positioned in sitting with handbehind the back and are maintained passivelyby the therapist for 2 minutes This positionstretches the supraspinatus muscle This maybe one of the reasons why both the groups haveimproved internal rotation ROM Anotherpossible mechanism may be pain was thelimiting factor for ROM restriction In a study byCreighton University had found increasedshoulder internal rotation ROM followingthoracic manipulation Pain referred fromcervical region might be causing spasm aroundthe shoulder musculature Cervical mobilizationreduce pain thereby spasm get subsided andinternal rotation ROM had improved Already ithas been discussed that cervical and thoracicmobilisation has a hypoalgesic effect that mighthave improved the ROMSpadi Disability There was statisticalsignificant improvement in both the groups after4 weeks of treatment There was 2497improvement in experimental group and only1063 improvement in conventional groupHemiplegics have weakness of muscles of upperlimb as part of their impairment In addition toit another factor that makes them disable is painBoth the groups improved significantly butcompared to control group experimental grouphave better improvement in pain that is beingreflected in the disability score As the painreduced they might have done strengtheningexercises without pain and fatigue that hadimproved the strength which is also reflectedby disability score Bang and Deyle 2000 [38]

reported improvement in strength function andpain when manual therapy to the shouldercervical spine and thoracic spine is added withexercise therapy in patients with shoulderimpingement Another possible mechanism maybe the increased abduction external andinternal rotation ROMs have improved somefunctionCONCLUSION

The study demonstrates that cervico-thoracicmobilization has better effect in improving painROM and function compared to conventionaltreatment in hemiplegic subjects withsupraspinatus tendonitis due to impingementsyndromeLimitations Smaller sample size Strength ofshoulder muscles has not been measuredFuture Suggestion Follow up is necessary toestablish the efficacy of cervico-thoracicmobilization in management of supraspinatustendonitis due to impingement syndrome inhemiplegics

Conflicts of interest None

REFERENCES

[1] Randall L Braddom Physical medicine andrehabilitation Saunders 4th edition (December 212010)

[2] Davies Patricia M Steps to follows-thecomprehensive treatment of patients withhemiplegia ISBN 978-3-642-57022-3

[3] Jaraczewska E Long C Kinesioreg taping in strokeimproving functional use of the upper extremity inhemiplegia Topics in Stroke rehabilitation 2006Jul13(3)31-42

[4] Treatment protocol for hemiplegic shoulder paintoronto rehabilitation institute NCT01232218 July2012

[5] Swati Mehta PhD (cand) Robert Teasell MD NorineFoley MSc Painful hemiplegic shoulder evidencebased review of stroke rehabilitation httpwwwebrsrcomevidence-review11-painful-hemiplegic-shoulder

[6] M sterling G Jull A Wright cervical mobilizationconcurrent effect on pain sympathetic activiyu andmotor activitymanual therapy20016(2)72-81

[7] GD Maitland Maitlandrsquos vertebral manipulation7th edition

[8] Ivan Bautmans Judith Van Arken Mike VanMackelenberg and Tony Mets rehabilitation usingmanual mobilization for thoracic kyphosis inelderly postmenopausal patients withosteoporosis J Rehabil Med 201042129-135



[25] Henry Gray thoroughly rev and re-edited by WarrenH Lewis Anatomy of the human body 20th ed

[26] Wainner RS Whitman JM Cleland JA Flynn TWRegional interdependence a musculoskeletalexamination model whose time has come J OrthopSports physther 200737658-660

[27] Zusman M Spinal manipulative therapy review ofsome proposed mechanisms and a new hypothesisAustralian Journal of Physiotherapy 198632 89-99

[28]Zusman M Mechanism of musculoskeletalphysiotherapy Physical Therapy Reviews2004939ndash49

[29]Katavich L Differential effects of spinalmanipulative therapy on acute and chronic musclespasm a proposal for mechanisms and efficacyManual Therapy 19983132-9

[30] Snels I A Dekker J H van der Lee J H LankhorstG J Beckerman H amp Bouter L M Treating patientswith hemiplegic shoulder pain American journalof physical medicine amp rehabil itation200281(2)150-160

[31] Effect of thoracic mobilization on shoulder rangeof motion Creigton university clinical trialgovidentifier 2012

[32] Bovend lsquoEerdt TJ Newman M Barker K DawesH Minelli C Wade DT The effects of stretching inspasticity a systematic review Arch Phys MedRehabil 2008 Jul89(7)1395-406 Doi 101016japmr200802015 Epub 2008 Jun 13

[33] Kebaetse M mcclure P Pratt NA Thoracic positioneffect on shoulder range of motion strength andthree-dimensional scapular kinematics Arch PhysMed Rehabil 1999 Aug80(8)945-50

[34] Lynda mcclatchie Judi Laprade Shelley MartinSusan B Jaglal Denyse Richardson Anne AgurMobilizations of the asymptomatic cervical spinecan reduce signs of shoulder dysfunction in adultsManual Therapy xxx 20081ndash6


[36]Joshua R mccormack Use of thoracic spinemanipulation in the treatment of adhesivecapsulitis a case report J Man Manip Ther 2012Feb20(1)28ndash34

[37] Warner JJ micheli LJ arsalian LE kennedy J kennedyR patterns of flexibilitylaxity and strength innormal shoulder and shoulders with instability andimpingementAM j sports med 199018366-375

[38] Bang MD Deyle GD Comparison of supervisedexercise with and without manual physical therapyfor patients with shoulder impingement syndromeJ Orthop Sports Phys Ther 2000 Mar30(3)126-37

[39] Najenson T Yacubovich E amp Pikielni S S Rotatorcuff injury in shoulder joints of hemiplegic patientsScandinavian journal of rehabilitation medicine19713(3)131

[9] Saharmann S A does postural assessmentcontribute to patient care journal of ortho sportsphy therapy 200232(8)376-379

[10] Gimsby O amp gray JC interrelationship of the spineto shoulder girdle in ram Dontalli (ed) clinics inphysical therapy physical therapy of the shoulder3rd edition new York Churchill Livingstone 1997pp95e129

[11] Basmajian J V 1979 muscle alive Their functionrevealed by electromyography 4th edition Williamand Wilkins Baltymore

[12] Basmajian JV Biofeedback in rehabilitation Areview of principles and practices Archives ofPhysical Medicine and Rehabilitation 198162469-475

[13] Susan B OrsquoSullivan Thomas J Schmitz PhysicalRehabilitation 4th edition

[14] Heng ZhaoYupeng RenYi-Ning WuShu Q Liu and Li-Qun Zhang Ultrasonic evaluations of Achillestendon mechanical properties poststroke J ApplPhysiol (1985) 2009 Mar106(3)843-849

[15] G Leviseth Changes in muscle fibre cross sectionalarea and concentration of NaK-Atpase in deltoidmuscle in patients with impingement syndrome Jortho sports phy ther199419146

[16] Carr E K amp Kenney F D Positioning of the strokepatient a review of the literature Internationaljournal of nursing studies 199229(4)355-369

[17] Well C Manipulative procedure I M wells CESramppom V Dowsher D(ebs) painmanagementand control in physiotherapy Heimemannphysiotherapy London 1998

[18] Dr Dan Pope Shoulder impingement part- 4 Thethoracic spine and rib cage role in impingement fitness pan free

[19] Carla Benton Thoracic manipulation with shoulderdysfunction physiopedia

[20] Culham EPeat M functional anatomy of theshoulder complex J of ortho sports physicaltherapy 199318342-450

[21] Magarey ME and Jones MA Specific evaluation ofthe function of force couples relevant forstabilization of the glenohumeral joint ManualTherapy 2003b8247-53

[22] Wright A Hypoalgesia post-manipulation therapya review of a potential neurophysiologicalmechanism Manual Therapy 1995111ndash6

[23]V icenzino B Gutschlag F Collins D et al Aninvestigation of the effects of spinal manualtherapy on forequarter pressure and ARTICLE INPRESS 498 J Perry A Green Manual Therapy 13(2008) 492ndash499Author rsquos personal copythermalpain thresholds and sympathetic nervoussystem activity in asymptomatic subjects apreliminary report In Shacklock M editor Movingin on pain Conference proceedings AdelaideAustralia Sydney Butterworth-Heinemann 1995P 185ndash93

[24] M sterling G Jull A Wright cervical mobilizationconcurrent effect on pain sympathetic activiyu andmotor activitymanual therapy 20016(2)72-81


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shortening of internal rotator during abductionlead to impingement of greater tuberosityagainst coracoacromial arch during passivemovement and causes pain [2] 2 Loss ofscapulohumeral rhythm During arm abductionscapula and humerus moves in a ratio of 12Normally scapula moves in forward and upwarddirection during abduction In hemiplegiadelayed scapular rotation due to increase tonein muscles leading to retraction and depressionIf the patientrsquos scapula doesnrsquot move sufficientlywhen his arm is being lifted passively traumaoccurs and patient experience pain at shoulder[2] 3 Lack of downward movement of head ofhumerus in glenoid fossa [2] Because of thesebiomechanical changes during passiveactiveabduction greater tuberosity impinges withacromion leading to Supraspinatus tendinitisSubacromial bursitis Rotator cuff tear [1]Involvement of cervical and thoracic spine inimpingement syndrome Well in 1988 found thatsupraspinatus tendonitis and capsulitis havefrequently their origin totally or part from cervicalor upper most thoracic spine Any lesion ofnervous system can lead to increase tensionwithin the system as a whole Hemiplegicpatient have abnormal tension of nervoussystem and loss of adaptive lengthening ofneural structures A sensitive cervical nerve rootcould possibly alter the mobility of glenohumeraljoint and shoulder as a whole and mimic as atrue glenohumeral condition With stiff upperthoracic spine extension the rib may subluxatesuperiorly on fixed thoracic spine and result inpain and dysfunction around shoulder [2]Increased thoracic kyphosis tend to abduct thescapula and downwardly rotate it altering thescapulohumeral relationship which leads tomuscle weakness and decreased ROM resultingin impingement syndrome [3]Thoracic spine forms a key link in the kinematicsequence of arm elevation Thoracic sidebending and rotation are caused by unilateralhumeral motions The relationship betweenreduced mobility of the cervicothoracic spine andshoulder pain could be explained by thisreflexogenic mechanism Thoracic jointmanipulation improves spinal mobility and alsoassisted in decreasing distal and autonomicsymptoms [4] Painful hemiplegic shoulder can

be very limiting and has the potential to furtheradd to the disability seen with hemiplegia Thedevelopment of painful hemiplegic shoulder isassociated with severe stroke and poorfunctional outcome [5] Management of thepainful hemiplegic shoulder once the conditionhas developed is difficult and response totreatment is frequently unsatisfactory Currentmanagement for HSP are positioning ofhemiplegic shoulder slings and other aidsstrapping the hemiplegic shoulder activetherapies electrical stimulation surgerybutulinium toxin injection steroid injectionaromapathy and acupuncture subscapularnerve block segmental neuromyotherapyrelieving anxiety general activities increasingrange of passive movement self assisted armactivities scapular mobilization [5] Asdescribed biomechanically cervical and thoracicspine is involved in impingement syndrome inhemiplegia Thoracic kyphosis also found to beincreased in hemiplegics which is associatedwith hemiplegic shoulder pain3 Cervical andthoracic central posterior to anterior mobilizationincrease the sympathetic activity of upper limb[6] reduce the stiffness of spine [7] reducethoracic kyphosis [8] and improve posture [910]thereby reduce shoulder pain in hemiplegics Nostudy could found the effect of cervico-thoracicmobilization in HSP with supraspinatustendonitis due to impingement syndromeAim of the StudyTo find the effect of cervico-thoracic mobilizationon hemiplegic shoulder pain with supraspinatustendonitis due to impingement syndrome

MATERIALS AND METHODS

Study design Pre test and post testexperimental study design Subjects A total of30 subjects with hemiplegia due to strokediagnosed clinically as supraspinatusimpingement syndrome who met inclusion andexclusion criteria were recruited from theoutpatient and in-patient department ofSVNIRTAR and a written consent was obtainedfrom each subject Group Assignment Theselected subjects were randomly assigned toexperimental and control groupInclusion criteria Complain of shoulder painage- 25ndash65 years tenderness over supraspin-




RESULTS

















DISCUSSION













REFERENCES











































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RESULTS

















DISCUSSION













REFERENCES











































How

to c

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DISCUSSION













REFERENCES











































How

to c

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EFF

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Res

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64(

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DISCUSSION













REFERENCES











































How

to c

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a e

t all

EFF

ECT

OF

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Res

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REFERENCES











































How

to c

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REFERENCES











































How

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How

to c

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a e

t all

EFF

ECT

OF

CERV

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-THO

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Res

201

64(

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Documents

Original Research Article EFFECT OF CERVICO … · Original Research Article EFFECT OF CERVICO-THORACIC MOBILIZATION ON HEMIPLEGIC SHOULDER PAIN WITH SUPRASPINATUS TENDONITIS DUE