Scientific Research Journal of India SRJI Vol 3 Issue 1 Year 2014

Scientific Research Journal of India
(Multidisciplinary, Peer Reviewed, Open Access, Indexed Journal of Science)

ISSN: 2277-1700
Vol: 3, Issue: 1, Year: 2014

Editor in Chief
Mrityunjay Sharma
Editors
Popiha Bordoloi
Kuki Bordoloi
Sudeep Kale
Waqar Naqvi
Piyush Jain
Junior Editor
Jyoti Sharma

Office
Dr. L. Sharma Campus, Muhammadabad Gohna, Mau, U.P., India. Pin- 276403
Website
http://srji.drkrishna.co.in
URL Forwarded to
http://sites.google.com/site/scientificrji
Email
editor.srji@gmail.com
Contact
+91-9839973156
Declaration: The contents of the articles and the views expressed therein are the sole responsibility of the authors, and the
editorial board will not be held responsible for the same.
Copyright 2014 Scientific Research Journal of India
All rights reserved.

CONTENTS

Title Author/s Department Page
Editorial Mrityunjay Sharma i
DOCUMENTATION OF
COMPLICATIONS FOLLOWING
MULTILEVEL SURGERIES IN
CEREBRAL PALSY
Gayatri Ajay Upadhyay,
Ajay Kumar Upadhyay,
Krishna N. Sharma
Physiotherapy 1
INCIDENCE OF MYOFASCIAL
PAIN SYNDROME IN CEREBRAL
PALSY PATIENTS POST
MULTILEVEL SURGERY: A
RETROSPECTIVE STUDY
Gayatri Ajay Upadhyay,
Ajay Kumar Upadhyay,
Krishna N. Sharma
Physiotherapy 9
COMPARISON OF EFFECT OF
HIP JOINT MOBILIZATION AND
HIP JOINT MUSCLE
STRENGTHENING EXERCISES
WITH KNEE OSTEOARTHRITIS
A. Tanvi, R. Amrita, R.
Deepak, P. Kopal
Physiotherapy 15
COMPARISON OF SHOULDER
MUSCLE STRENGTHENING
EXERCISES WITH THE
CONVENTIONAL TREATMENT
OF MECHANICAL NECK PAIN
Dr. Deepak Raghav, Dr.
Sabiha, Dr. Monika, Dr.
Tanvi
Physiotherapy 28
PHYSIOTHERAPY
INTERVENTION IN
MANAGEMENT OF DIZZINESS
Shahanawaz SD Physiotherapy 41
ETHICAL CHALLENGES FOR
OCCUPATIONAL THERAPIST IN
INDIA TO USE SOCIAL MEDIA
Koushik Sau, Sridhar D,
Sanjiv Kumar
Occupational
Therapy
52
STUDY OF EFFECTIVENESS OF
CORTICOSTEROID INJECTION
IN FROZEN SHOULDER
Dr. Pradeep Choudhari, Dr.
Anand Mishra
Orthopaedics/
Physiotherapy
58

ISSN: 2277-1700 Website: http://srji.drkrishna.co.in URL Forwarded to: http://sites.google.com/site/scientificrji
iv

i
FROM EDITOR IN CHIEF

Information is a source of learning. But unless it is organized, processed, and available to the right people in
a format for decision making, it is a burden, not a benefit.
- William Pollard (18281893)

The quote by William Pollard reveals the fact why do we require a journal. Sharing a research is as important
as doing it, and what is better than sharing it for free and benefitting the world. This was the concept behind
starting this open access journal. I was a part of this journal from very beginning and it was really exciting to
learn the basics of researches, editing, and publishing from the honourable editors of this journal. It is the
plateform where I developed the craze for researches. Being just an MBBS STUDENT, I had never thought
of getting the opportunity to lead this journal at this age and stage, but when the editorial board decided to put
this responsibility on my shoulders, I was amazed and overwhelmed to see their trust.

So dear Readers! As the new Editor in Chief, Ild like to welcome you all to the 3
rd
year of this journal. In this
issue: Like previous issue this is also a multidisciplinary and open access journal that contains total 5 papers
in Physiotherapy, 1 paper of Occupational Therapy and 1 from Orthopaedics. I hope youll find these papers
informative.

Be aware that the journal also has a website, http://srji.drkrishna.co.in where subscribers can access the full
content and also submit papers for future publication.

Please send me informal comments directly, or formal letters we can publish, about the journal. I welcome
new ideas about topics (content) and process. Let me know your thoughts.

Thanks for the opportunity, and stay tuned for future editions.

-Mrityunjay Sharma

1

DOCUMENTATION OF COMPLICATIONS FOLLOWING MULTILEVEL
SURGERIES IN CEREBRAL PALSY

*Gayatri Ajay Upadhyay, **Ajay Kumar Upadhyay, ***Krishna N. Sharma

ABSTRACT
Purpose: The aim of the study is to document the complications following multilevel surgeries done in
cerebral palsy in order to determine risk factors that would correlate with the post-operative complications.
Design: Retrospective study. Setting: D.L.S. Institute for Health & Wellness, U.P, India Methodology: One
hundred and ten children with cerebral palsy who underwent multilevel surgeries were studied
retrospectively to document the post-operative complications and determine risk factors that would
correlate with postoperative complications. Except for seven who left the rehabilitation, all of the children
had six months of follow up. Results: Fifteen patients had at least one complication. 56 had myofascial pain
syndrome, 39 patients had post-operative joint stiffness, 23 had osteoporosis, 12 sustained pathological
fractures, 10 had anterior knee pain, 8 suffered meralgia paresthetica, 5 had hypertrophic scar, 3 had bed
sores, 3 had patellar tendinitis, 3 had rickets, 2 had electrical burns, 2 had wound infection, 1 patient had
complex regional pain syndrome, 2 had myositis ossificans, 1 had axillary nerve palsy. All were managed
with appropriate treatment at the centre. Conclusion: In conclusion, documentation can help prevent the
risk of complications after multilevel surgeries in cerebral palsy. A nonambulatory patient is at even
greater risk. Fortunately the fractures and ulcers observed in this series healed uneventfully with no
operative intervention. Clinical relevance of the study: To document the Complications following
Multilevel Surgery in cerebral palsy children which have not yet been done well in the literature.

KEYWORDS: Cerebral palsy, Complications, Multilevel Surgery
2
INTRODUCTION
Orthopedic surgery has a major role to play in
minimizing the impairments and activity
limitations associated with the development of
musculoskeletal pathology in children with
cerebral palsy (CP)
1
. CP can be considered to
be a neuromusculoskeletal disorder
2.
Once the
neurological impairments associated with CP
are expressed, progressive musculoskeletal
pathology develops to some degree in the
affected limbs of the majority of children.
Subtle degrees of muscletendon contractures
seem to be the result of differential growth
impairment of the muscletendon units, in
relation to long-bone growth.
2-4
More severe
contractures are found in more severely
involved children and may be more related to
lack of mobility than to spastic hypertonia.
2
In
addition to soft-tissue involvement, the
prevalence of torsion in long bones, and joint
instability, is also high.
2,5
The secondary
musculoskeletal pathology contributes to gait
impairments, fatigue, activity limitations, and
participation restrictions.
5

Orthopedic procedures have been designed to
address the various components of the
progressive musculoskeletal pathology
including tendon lengthenings, tendon
transfers, rotational osteotomies, and joint
stabilization procedures.
5,6,7
More recently,
single-level surgery has been replaced by the
concept of multilevel surgery in which
multiple levels of musculoskeletal pathology,
in both lower limbs during one operative
procedure, requiring only one hospital
admission and one period of rehabilitation.
5-8

This is variously described as multilevel
surgery, gait-improvement surgery and, most
frequently, single-event multilevel surgery to
distinguish it from the birthday syndrome
approach of the past.
8

The main musculoskeletal problems which
prevent the CP patients from functional
activities, mobility, ADL and gait are
spasticity and lever arm dysfunction. It needs
a complex but goal oriented surgical
procedure followed by a sequenced post-
operative rehabilitation protocol.
Complications with surgical procedures are
common. Since multilevel surgeries are
addressing musculoskeletal problems in
multiple levels, the extent of complications are
also high. The amount of discomfort and
problems following surgery depends on the
type of surgery performed. Sometimes
complications can occur following surgery.
However, individuals may experience
complications and discomforts differently.
Complications following Multilevel Surgery
in cerebral palsy children have not been
documented well in the literature. The goal of
the current study was to document and analyze
the complications following multilevel
surgeries in children with cerebral palsy.
Methods and Methodology
After IRB approval, a retrospective review
was performed to identify all complications
Scientific Research Journal of India Volume: 3, Issue: 1, Year: 2014
3
following multilevel surgeries during the post-
surgical rehabilitation by the authors from
2008-2013. 110 cerebral palsy subjects who
underwent multilevel surgery were studied for
the complications following the surgery. The
present study analyzed the complications
during post-surgical rehabilitation following
multilevel surgery during a period of 5 years
(2008-2013). All 110 children underwent
multilevel surgeries followed by physical
therapy for at least 6 months. For all of the
patients, this therapy was accomplished as
outpatients at the D.L.S. Institute for Health &
Wellness, Mau. The therapists maintained a
very high index of suspicion for any
complication notified. Any erythema or
swelling around the joints was assured if
fracture.
RESULTS
Complications during post-surgical
rehabilitation following multilevel surgeries
during a period of 5 years (2008-2013) were
analyzed. The range of the age of patients who
underwent multilevel surgeries was 3- 20.
The commonest complications was myofascial
pain syndrome and post-operative joint
stiffness. 56 had myofascial pain syndrome,
39 patients had post-operative joint stiffness,
23 had osteoporosis, 12 sustained pathological
fractures, 10 had anterior knee pain, 8 suffered
meralgia paresthetica, 5 had hypertrophic scar,
3 had bed sores, 3 had patellar tendinitis, 3 had
rickets, 2 had electrical burns, 2 had wound
infection, 1 patient had complex regional pain
syndrome, 2 had myositis ossificans, 1 had
axillary nerve palsy. All were managed with
appropriate treatment at the centre.
DISCUSSION
common. Patients with cerebral palsy who
undergo surgical reconstruction with
osteotomies are at significant risk of
complications. The risk of complications
following an osteotomy is significantly greater
in the non-ambulatory population, and in a
recent series a 69 percent complication rate
was noted. Since multilevel surgeries are
multilevel, the extent of complications were
problems following surgery depended on the
complications occurred following surgery.
However, individuals experience
Pain after any orthopedic surgery is a
recognized complication found to have an
adverse impact on patient's quality of life,
increasing psychosocial distress. We have
noted many cases of myofascial pain
syndrome as a cause of postsurgery pain.
Myofascial pain syndrome is a regional pain
syndrome characterized by myofascial trigger
points in palpable taut bands of skeletal
muscle that refers pain a distance, and that can
cause distant motor and autonomic effects. 56
out of the 103 patients with complications
(54.36%) experienced MPS, the majority
4
having onset within the first 6 months after
surgery. This high incidence supports the need
for identifying and treating the often
underdiagnosed and misdiagnosed MPS found
in these patients. Most patients with MPS had
active MTPs in muscles of the shoulder girdle.
This would be expected since the most likely
activation factors in these patients would be
related to positioning of the shoulder during
surgery, maintaining muscles in a shortened
position after surgery, the surgical scar, the
manipulation, and excision of forearm fascia
during surgery or the adaptation of upper
extremity movement after surgery. There are
at least 2 possible reasons to explain the
tightness that is often found in the major
muscle after surgery: (1) Immobilization and
(2) the positioning of the arm in abduction and
external rotation during surgery. The patients
efforts to inhibit movement causing pain
through thoracic flexion and scapular
protraction may account for the high presence
of MTPs in the pectoralis major, upper
trapezius and sternocleidomastoid. The
pectoral tightness pulls the scapula into a
protracted position, and the arm into internal
rotation, increasing the risk of subsequent
MTPs in shoulder rotators, and in scapula
retractors, as well as in back and neck
muscles. The diagnosis of MPS was made by
an Rehabilitation Specialist (>5 years
experience treating MPS) using the Simons
Criteria (Simons et al., 1999), that required 5
major and at least 1 of 4 minor criteria to be
satisfied
12
. Although we achieved very good
results in the control of pain of our patients by
means of a specific physical therapy treatment
of MTPs, the fact that we did not have a
control group to evaluate the effectiveness of
our treatment does not allow any conclusion to
be drawn regarding this issue. Controlled
studies with longer follow-up are needed to
evaluate the effectiveness of different specific
treatments of MPS in these patients to be
certain about the real contribution of MTPs to
their pain.
26

The second most frequent complication was
joint stiffness, which occurred in 39 patients
(37.86%) and was characterized as diminished
ROM after 4 weeks of surgery. Stiffness in
knee and ankle joints is a common
complication after multilevel surgeries. It is
mainly resulting from the post-operative
immobilization, associated muscle and joint
contractures also seen in early phases of
rehabilitation. Very sensitive mobilization and
stretching are essential for the recovery.
Osteopenia and osteoporosis in children, not
as in adults, are not easily defined and a more
preferable term is low bone mass; this is
defined as a bone mineral content or areal
bone mineral density z score that is less than
or equal to -2.0, adjusted for age, gender, and
body size
14
. Many factors may contribute to
poor bone mineralization in children with
cerebral palsy. Duration of immobilization and
some physical problems such as deformities
leads to improper weight bearing and non-
weight bearing may cause deficiency in bone
5
mineralization and leads to factures
14
.
Anticonvulsant medication and limited
sunlight exposure may further cause low
serum vitamin D levels, and thus, calcium
content of bone may be decreased
15
. Sufficient
daily intake of calcium and vitamin D is of
major importance in youth in general and in
children with cerebral palsy in particular
14
.
Weight bearing exercises to the legs reduces
the risk of fracture and improves the bone
strength.
During rehabilitation, there was no instance
when there was a forcible manipulation, a
sudden increase in pain, a visible deformity or
an audible snap that is usually associated with
a fracture. The pathological fracture was found
during a routine X-ray done by the orthopedic
to investigate pain in their legs. A
pathological fracture can very well happen
during transfers at home, for instance.
The factors that may contribute to poor bone
mineralization (Rickets) in children after
multilevel surgeries are duration of
immobilization, poor feeding and oral motor
dysfunction may lead to inadequate caloric,
protein and calcium intake and limited
sunlight exposure may further cause low
serum vitamin D levels. The complications of
rickets in post-surgical children are pain,
delays in the child's motor skills development,
failure to grow and develop normally and
skeletal deformities. Immobilization after
surgery results in endosteal bone loss with
thinning of cortices. These narrow and thin
long bones have increased propensity to
fracture from bending and torsional loads.
Those with impaired mobility, stiff or
contracted joints, quadriplegia or with poor
nutrition are at greater risk of fragility
fracture.
24

Myositis Ossificans is a non-neoplastic,
heterotopic ossification of soft tissues i.e.
skeletal muscle, tendons, aponeurosis and
fascia. Many cases are clearly related to major
or minor trauma. In case of multilevel
surgeries the post-surgical scar may cause the
myositis ossificans. Common area affected are
the distal femoral region and humeral region.
Common symptoms are pain, warmth and
swelling. On diagnosis of myositis ossificans
the manual mobilizations and techniques
should be avoided. Rest and active assisted
exercises should only be encouraged.
Anterior knee pain arising from the
Patellofemoral joint is a relatively uncommon
yet significant problem in the pediatric
cerebral palsy (CP) population. Knee flexion
deformity caused by hamstring contracture
and rectus femoris spasticity increases the
forces across the Patellofemoral joint and
causes Patella Alta in most children with CP.
On examination, all patients had tenderness at
the inferior pole of the patella. Anterior knee
pain is very common in children after
multilevel surgeries.
16
The etiology of anterior
knee pain after multilevel surgeries is
uncertain, although there may be a
combination of factors responsible. In few
6
case reports, the rate of postoperative anterior
knee pain ranged from 4% to more than
40%.
21
Also crouched knee standing position
during post-operative rehabilitation may leads
to this condition. This was treated by using
McConnell regimen for anterior knee pain
17
.
Sachs et al first proposed the association
between anterior knee pain with post-operative
flexion contracture and quadriceps weakness.
22
Later Fisher and Shelbourne documented
their series of arthroscopic scar resection and
restoration of full knee hyperextension in a
group of patients with symptomatic flexion
contracture after reconstructive surgery.
23

After restoration of extension, patients
exhibited significant improvement of
extension, patients exhibited significant
improvement in anterior knee symptoms.
These findings have contributed to the
widespread acceptance of the importance of
obtaining full extension post operatively after
reconstructive surgery to diminish anterior
knee pain.
Meralgia Paresthetica characterized by pain,
paresthesia (abnormal sensation of burning,
tingling, etc.) and numbness on the lateral
surface of the thigh in the region supplied by
the lateral femoral cutaneous nerve. Mainly it
occurs due to scar tissue adhesion in the thigh
and partial tear of the nerve from the incision
of psoas. The usual diagnosis of the condition
is made on the description given by the child.
An examination will check for any sensory
differences between the affected leg and the
other leg. The management of Meralgia
Paresthetica includes sensory desensitization
technique, neural mobilization and
electrotherapeutic modalities like interferential
therapy or TENS.
Hypertrophic scars are firm, raised, and
erythematous and, by definition, remain within
the boundaries of the original wound found
approximately 1 to 2 weeks following injury
16
.
Some of these scars will gradually regress
over time, whereas others may continue to
enlarge and become permanent
19
. Treatments
may include scar mobilization, electrotherapy
modalities such as ultra sound, laser therapy.
Pressure ulcers are a frequent complication in
patients with marked increase in muscle tone.
In patients with spasticity, the pressure ulcers
usually develop at exposed locations,
especially pre sacrally, over the trochanters, or
at the heels. Commonest area after multilevel
surgeries is heels. As a precaution the parents
were instructed to keep glove with water under
the heel to reduce the pressure or to use water
bed. The pressure ulcers occur due to the
weight of the body pressing on the skin or
when the child's skin is repeatedly rubbed
against a surface like a mattress, bedding or
other equipment or when the child's skin is
pulled across a surface in opposite directions.
Moisture can make child's skin more prone to
pressure ulcers. If proper precautions are not
taken the pressure ulcers can retard the speed
of rehabilitation. Proper medical attention,
use of water bed and physiotherapy was given
to heal the condition.
7
After an upper extremity surgery, complex
regional pain syndrome (CRPS) may
complicate recovery, delay return to work,
diminish health-related quality of life, and
increase the likelihood of poor outcomes
and/or litigation. CRPS Type I (CRPS I), is a
pain syndrome characterized by an
exaggerated response to a painful stimulus.
Management of CRPS included both
physiotherapy & medical management. The
treatment protocol used was soft tissue
mobilization followed by myofascial release
therapy, trigger point release, stress loading,
wax bath and finally TENS.
Body-weight supported treadmill training
(BWSTT) is task-dependent training that has
been used successfully in post multilevel
surgeries Cerebral Palsy rehabilitation.
Axillary nerve palsy is an iatrogenic artifact
due to BWSTT when the harness is tight and
supported at the axillary region. Due to
recurrent compression in axilla, nerves get
compressed and leads to axillary nerve palsy.
It was mainly treated with electrical
stimulation and functional exercise
programme.
However, none of the complications were life
threatening or permanent. According to the
observation of our pediatric therapist they
found a co relation between cerebral palsy
patients with speech and language
impairments, mental retardation, of
uneducated parents and aged to suffer more
with complications then others.

REFERENCES
1. Review article Musculoskeletal Aspects of Cerebral Palsy H. Kerr Graham, P. Selber From the Royal
Childrens Hospital, Melbourne, Australia
2. Graham H. Mechanisms of deformity. In: Scrutton D, Damiano D,Mayston M, editors. Management
of the Motor Disorders of Children with Cerebral Palsy. Clinics in Developmental Medicine No 161.
2nd edn. London: Mac Keith Press, 2004, 10529.
3. Cosgrove AP, Graham HK. Botulinum toxin A prevents the development of contractures in the
hereditary spastic mouse. Dev Med Child Neurol 1994; 36: 37985.
4. Ziv I, Blackburn N, Rang M, Koreska J. Muscle growth in normal and spastic mice. Dev Med Child
Neurol 1984; 26: 949.
5. Bache C, Selber P, Graham HK. The management of spastic diplegia. Curr Orthop 2003; 17: 88104.
6. Rodda JM, Graham HK, Nattrass GR, Galea MP, Baker R, Wolfe R. Correction of severe crouch gait
in patients with spastic diplegia with use of multilevel orthopaedic surgery. J Bone Joint Surg Am
2006; 88: 265364.
7. Stout JL, Gage JR, Schwartz MH, Novacheck TF. Distal femoral extension osteotomy and patellar
tendon advancement to treat persistent crouch gait in cerebral palsy. J Bone Joint Surg Am 2008; 90:
247084.
8. Rang M. Cerebral palsy. In: Morrissy R, editor. Lovell and Winters Pediatric Orthopaedics. 3rd edn.
Philadelphia: JB Lippincott Co, 1990, 465506.
9. Matsuo, Takashi; Hara, Hiromichi; And Tada, Shunsaku: Selective Lengthening of the Psoas and
Rectus Femoris and Preservation of the Iliacus for Flexion Deformity of the Hip in Cerebral Palsy
Patients. J. Pediat. Orthop. , 7: 690-698, 1987.
10. Izumi Kondo, Kanoko Hosokawa, Manabu Iwata, Atsushi Oda, Tadao Nomura, Keiichi Ikeda,
Kumamoto, Yoshimi Asagai, Tomokazu Kohzaki, Hitoshi Nishimura: Effectiveness of selective muscle
release surgery for children with cerebral palsy: longitudinal and stratified analysis; Developmental
Medicine & Child Neurology 2004, 46: 540547.
8
11. Gage J. Gait analysis in Cerebral Palsy. London: Mac Keith Press, 1991.
12. Simons, D.G., Travell, J.G., Simons, L.S., 1999. Travell & Simons Myofascial Pain and Dysfunction:
The Trigger Point Manual, second ed. Williams & Wilkins, Baltimore, p. 132.
13. Michal Cohen, Eli Lahat, Tzvy Bistritzer, Amir Livne, Eli Heyman, and Marianna Rachmiel :
Evidence-Based Review of Bone Strength in Children and Youth With Cerebral Palsy; Journal of
Child Neurology 1-9 2009.
14. Bulent Unay, S. Umit Sarycy, Sabahattin Vurucu, Neriman Ynanc, Rydvan Akyn, Erdal Gokcay;
Evaluation of bone mineral density in children with cerebral palsy; The Turkish Journal of Pediatrics
; 45: 11-14;2003.
15. Hakan Senaran, Candice Holden, Kirk W. Dabney, and Freeman Miller ; Anterior Knee Pain in
Children With Cerebral Palsy:Journal of Pediatric Orthopaedic & Volume 27, Number 1,
January/February 2007.
16. McConnell J, Gresalmer R, (1998), The Patella - A Team Approach. Aspen Publications.
17. Tina Alster, Laser Scar Revision: Comparison Study of 585-nm Pulsed Dye Laser With and Without
Intralesional Corticosteroids; Dermatol Surg 29:1:January 2003.
18. Shahram Aarabi, Kirit A. Bhatt, Yubin Shi, Josemaria Paterno, Edward I. Chang, Shang A. Loh,
Jeffrey W. Holmes, Michael T. Longaker, Herman Yee and Geoffrey C. Gurtner; Mechanical load
initiates hypertrophic scar formation through decreased cellular apoptosis ;The FASEB Journal.
2007;21:3250-3261.
19. http://www.ehealthme.com/ds/baclofen/myofascial+pain+syndrome
20. Bach BR Jr, Jones GT, Sweet FA, et al: Arthroscopy-assisted anterior cruciate ligament
reconstruction using patellar tendon substitution: Two to four-year follow-up results. Am J Sports
Med 22: 758767,1994
21. Sachs RA, Daniel DM, Stone ML, et al Patellofemoral problems after anterior cruciate ligament
reconstruction. Am J Sports Med 17 760-765,1989
22. Fisher SE, Shelbourne KD: Arthroscopic treatment of symptomatic extension block complicating
anterior cruciate ligament reconstruction Am J Sports Med 52581-56:4, 1993
23. Pediatric Bone: Biology & Diseases - Francis H. Glorieux, John M. Pettifor, Harald Jppner 2011,
Page 299
24. P. Curley., K. Eyers, V. Brezinova et al. Common Peroneal Nerve Dysfunction after high tibial
osteotomy. Journal of Bone and Joint Surgery, Vol. 72 B, No. 3, May 1990
25. Maria Torres Lacomba, PhD et al. Incidence of Myofascial Pain Syndrome in Breast Cance Surgery:
A Prospective Study, Clinical Journal of Pain 2010, 26: 320 -325.
26. Zhongyu Li et al. Complex Regional Pain syndrome, Hand Clin 26 (2010) 281289.

CORRESPONDENCE
* MPT (Neurology). Email: drmitrphysio@gmail.com, Academics Training and Research Manager, D.L.S.
Institute for Health & Wellness, U.P
** MSPT (Sports and Ortho), Assistant professor, Ayushman College of physiotherapy, Bhopal.
*** MPT (Neurology), PhD, Dean of Studies and Head of Department (Physiotherapy) at St. Louis
University, Cameroon, Africa. Email: dr.krisharma@gmail.com
9

INCIDENCE OF MYOFASCIAL PAIN SYNDROME IN CEREBRAL PALSY
PATIENTS POST MULTILEVEL SURGERY: A RETROSPECTIVE STUDY

*Gayatri Ajay Upadhyay, **Ajay Kumar Upadhyay, ***Krishna N. Sharma

ABSTRACT
Background: Pain after multilevel surgery is a recognized complication found to have an adverse impact of
cerebral palsy patients quality of life, increasing psychosocial distress. There have been case reports about
myofascial pain syndrome emerging as a cause of postsurgery pain. Myofascial pain syndrome characterized
by myofascial trigger points in palpable taut bands of skeletal muscle that refers pain a distance and that can
cause distant motor and autonomic effects. Objective: The goal of the current study was to document
andanalyze MPS following multilevel surgeries in children with cerebral palsy. Design: Retrospective study.
Setting: D.L.S. Institute for Health & Wellness, Mau, U.P, India Methodology: One hundred and ten children
with cerebral palsy who underwent multilevel surgeries were studied retrospectively to document myofascial
pain syndrome post operatively and determine risk factors that would correlate with myofascial pain
syndrome. The diagnosis of MPS was made by a rehabilitation specialist using the Simons Criteria (Simons et
al., 1999), that required 5 major and at least 1 of 4 minor criteria to be satisfied
12
. Results:56 out of the 103
patients with complications (54.36%) experienced MPS, the majority having onset within the first 6 months
after surgery. The commonest complain of pain in post multilevel surgeries cerebral palsy patients were
because of Myofascial Pain Syndrome. Conclusion: Myofascial Pain Syndrome is a potential cause of pain in
cerebral palsy patients undergoing multilevel surgeries having onset within the first 6 months after surgery.

Keywords: Myofascial pain syndrome, incidence, prevalence, cerebral palsy, multilevel surgery, pain
10
INTRODUCTION
Cerebral palsy is common. It affects
approximately 3 per 1000 children. Lever arm
dysfunction and deformities due to muscle
tightness (spasticity) occurs in up to half of the
more severely affected children, and many of
these children require major surgery.
Orthopedic surgery has a major role to play in
minimizing the impairments and activity
limitations associated with the development of
musculoskeletal pathology in children with
cerebral palsy (CP)
1
. Orthopedic procedures
have been designed to address the various
components of the progressive
musculoskeletal pathology including tendon
lengthening, tendon transfers, rotational
osteotomies, and joint stabilization
procedures.
2,3,4
More recently, multilevel
surgery have come up in which multiple levels
of musculoskeletal pathology, in both lower
limbs during one operative procedure,
requiring only one hospital admission and one
period of rehabilitation.
2-5
This is variously
described as multilevel surgery, gait-
improvement surgery and, most frequently,
single-event multilevel surgery to distinguish
it from the birthday syndrome approach of
the past.
5
common. Since multilevel surgeries
multiple levels, the extent of complications are
problems following surgery depends on the
complications can occur following surgery.
However, individuals may experience
After bony surgery the management of pain is
very difficult, as spasticity tends to increase
and causes painful spasms which are difficult
to control. The identification of the level of
pain can be challenging because most of these
children are unable to communicate verbally.
There is a high emotional and financial burden
on the families of these children. Families
describe high levels of emotional distress
around the time of surgery, particularly when
their child is in pain. Difficulty with pain
control post operatively may delay discharge
from hospital and parental return to work. It
causes disrupted sleep for the child and family
and may delay the child's return to school.
Myofascial Pain Syndrome (MPS) following
Multilevel Surgeries in cerebral palsy children
has not been documented in the literature. This
study is the first to describe fully the
myofascial pain experience of children with
cerebral palsy undergoing multilevel surgeries
type of major surgery. The goal of the current
study was to document and analyse MPS
following multilevel surgeries in children with
cerebral palsy.
The MPS is defined as the signs and
symptoms caused by active myofascial trigger
points (MTPs). An MTP can be defined as a
hyperirritable nodule of spot tenderness in a
palpabletaut band of skeletal muscle. The spot
11
is a site of exquisite tenderness to palpation,
that refers pain adistance, and that can cause
distant motor and autonomiceffects.
6
MTPs
are considered to be localized muscle
contractures occurring at dysfunctional motor
endplates.
TABLE 1. Recommended Criteria for
Identifying Myofascial Trigger Points.
7

Palpable taut band
Exquisite spot tenderness of a nodule in a taut
band
Patients recognition of current pain complaint
by pressure on the tender nodule
Painful limit to full stretch range of motion
was assessed in each patient, but was
considered confirmatory, although not
necessary to the diagnosis of MPS
MPS indicates myofascial pain syndrome.

Hence, MPS is classified as a myopathy
associated with disordered neuromuscular
junction function.
6,7
MTPs can be classified as
active (symptom-producing) or latent (not
spontaneously symptomatic).
6,7
Latent MTPs
can be activated by acute or chronic
overload,
6,7
by leaving the muscle in a
shortened position for a long period
oftime,
6,7
by surgical scars
8
or by surgical
drains,
9
among other causes. MTPs can be
identified by the objective tests of magnetic
resonance elastography,
10
by specific
electromyographic (EMG) examination,
11
by
ultrasound technology (grayscale 2D
ultrasound, vibration sonoelastography, and
Doppler),
12
or by sophisticated microdialysis
techniques assaying characteristic biochemical
markers.
13
Central hypersensitization
associated with MTP activation is objectively
visualized on functional magnetic resonance
imaging studies.
14
In the clinical setting,
MTPs are identified by physical
examination.
36
Recent studies have shown that
clinicians with adequate training in muscle
palpation techniques have a high degree of
reliability in identifying MTPs, not only in the
same muscle, but the same trigger point within
the muscle. Thus, the most widely used
diagnostic criteria
7
(Table 1) have shown a
good overall inter rater reliability.
15-17
The
examiner in this study has had extensive
experience in MTP examination and
treatment. The objective of this study was to
assess the incidence of MPS retrospectively 5
years after multilevel surgeries.
METHODS
Design: After IRB approval, a retrospective
review was performed to identify myofascial
pain syndrome as one of the potential cause of
pain following multilevel surgeries during the
post-surgical rehabilitation from 2008-
2013.By means of a specific physical therapy
treatment of MTPs we achieved very good
results in the control of pain of our patients.
Patients: 110 cerebral palsy subjects who
underwent Multilevel Surgeries were studied
12
for the complications following the surgery.
The present study analyzed the complications
during post-surgical rehabilitation following
multilevel surgeries during a period of 5 years
(2008-2013). All 110 children underwent
multilevel surgeries followed by a post-
operative immobilization period varied
between 2 weeks (upper limbs) to 6-10 weeks
(lower limbs) and was followed by physical
therapy for at least 6 months.
Assessment: Each patient underwent pre
operative and post operative assessment
during all the phases of rehabilitation. In
addition to the scheduled assessments each
patient as well as their parents was instructed
to report if they experienced pain. Aphysical
therapists expert in diagnosis of MPS
performed the assessment.
During the pre operative assessment,
demographic data were collected on all
patients including age, sex, type of cerebral
palsy, medical history, bony deformities,
GMFCS Level, GMFM 88 and other details.
Patient were also asked open question about
whether they felt any pain. If they did, a
physical examination was conducted to find
the source of pain, including evaluation of
active MTPs. Location, duration and intensity
of pain were recorded.
In post operative assessment, data were
collected regarding the type of surgery
performed, the duration of immobilization,
any complication if any was noted and
intervened and level of pain. If the patient
complained of pain, the patient was again
examined to determine the cause including
assessment of active MTPs. The diagnosis of
MPS was based on the major criteria proposed
by Simons et al, shown in Table 1.
RESULTS
Complication causing pain during post-
surgical rehabilitation following multilevel
surgeries during a period of 5 years (2008-
2013) was analysed. The commonest
complications causing pain were Myofascial
Pain Syndrome (56, 54.36 %),
Incidence of MPS
The number of cerebral palsy patients with
active MTPs was 56 out of 103 (54.36%).
During these 5 years other pain conditions
were also noted like post operative joint
stiffness, pathological fractures, rickets,
osteoporosis and anterior knee pain. MPS
developed mainly during six months period
after surgery. The active MTPs were mainly
found in Pectoralis Major, Trapezius and
Sternocleidomastoid.
DISCUSSION
This will be the first published study to
address the incidence of MPS among cerebral
palsy post multilevel surgeries. The results of
this study give an insight into incidence of this
unreported pain syndrome in cerebral palsy
patients after multilevel surgeries.
common. Patients with cerebral palsy who
undergo surgical reconstruction with
13
osteotomies are at significant risk of
complications. The risk of complications
following an osteotomy is significantly greater
in the non-ambulatory population, and in a
recent series a 69 percent complication rate
was noted. Since multilevel surgeries
multilevel, the extent of complications are also
high. The amount of discomfort and problems
following surgery depended on the type of
surgery performed. Sometimes complications
occurred following surgery. However,
individuals experience complications and
discomforts differently.
Pain after any orthopaedic surgery is a
recognized complication found to have an
adverse impact on patient's quality of life,
increasing psychosocial distress. We have
noted many cases of myofascial pain
syndrome as a cause of post-surgery pain.
Myofascial pain syndrome is a regional pain
syndrome characterized by myofascial trigger
points in palpable taut bands of skeletal
muscle that refers pain a distance, and that can
cause distant motor and autonomic effects. 56
out of the 103 patients with complications
(54.36%) experienced MPS, the majority
having onset within the first 6 months after
surgery. This high incidence supports the need
for identifying and treating the often
underdiagnosed and misdiagnosed MPS found
in these patients. Most patients with MPS had
active MTPs in muscles of the shoulder girdle.
This would be expected since the most likely
activation factors in these patients would be
related to positioning of the shoulder during
surgery, maintaining muscles in a shortened
position after surgery, the surgical scar, the
manipulation, and excision of forearm fascia
during surgery or the adaptation of upper
extremity movement after surgery. There are
at least 2 possible reasons to explain the
tightness that is often found in the major
muscle after surgery: (1) Immobilization and
(2) the positioning of the arm in abduction and
external rotation during surgery. The patients
efforts to inhibit movement causing pain
through thoracic flexion and scapular
protraction may account for the high presence
of MTPs in the pectoralis major, upper
trapezius and sternocleidomastoid. The
pectoral tightness pulls the scapula into a
protracted position, and the arm into internal
rotation, increasing the risk of subsequent
MTPs in shoulder rotators, and in scapula
retractors, as well as in back and neck
muscles. The diagnosis of MPS was made by a
rehabilitation specialist using the Simons
Criteria (Simons et al., 1999), that required 5
major and at least 1 of 4 minor criteria to be
satisfied
7
. Although we achieved very good
results in the control of pain of our patients by
means of a specific physical therapy treatment
of MTPs, the fact that we did not have a
control group to evaluate the effectiveness of
our treatment does not allow any conclusion to
be drawn regarding this issue. Controlled
studies with longer follow-up are needed to
evaluate the effectiveness of different specific
treatments of MPS in these patients to be
14
certain about the real contribution of MTPs to their pain.
18

REFERENCES
1. H. Kerr Graham, P. Selber. Review article Musculoskeletal Aspects of Cerebral Palsy From the Royal
Childrens Hospital, Melbourne, Australia
2. Bache C, Selber P, Graham HK. The management of spastic diplegia. CurrOrthop 2003; 17: 88104.
3. Rodda JM, Graham HK, Nattrass GR, Galea MP, Baker R, Wolfe R. Correction of severe crouch gait in
patients with spastic diplegia with use of multilevel orthopaedic surgery. J Bone Joint Surg Am 2006; 88:
265364.
4. Stout JL, Gage JR, Schwartz MH, Novacheck TF. Distal femoral extension osteotomy and patellar tendon
advancement to treat persistent crouch gait in cerebral palsy. J Bone Joint Surg Am 2008; 90: 247084.
5. Rang M. Cerebral palsy. In: Morrissy R, editor. Lovell and WintersPediatric Orthopaedics. 3rd edn.
Philadelphia: JB Lippincott Co, 1990, 465506.
6. Simons DG. Review of enigmatic MTrPs as a common cause of enigmatic musculoskeletal pain and
dysfunction. J ElectromyogrKinesiol. 2004;14:95107
7. Simons DG, Travell JG, Simons LS. Myofascial Pain andDysfunction. The Trigger Point Manual. Upper
Half of Body.2nd ed. Baltimore: Williams and Wilkins; 1999.
8. Lewit K, Olsanska S. Clinical importance of active scars: abnormal scars as a cause of myofascial pain.
J Manipulative PhysiolTher. 2004;27:399402.
9. Cummings M. Myofascial pain from pectoralis major following trans-axillary surgery. Acupunct Med.
2003;21:105107.
10. Chen Q, Bensamoun S, Basford JR, et al. Identification and quantification of myofascial taut bands with
magnetic resonance elastography. Arch Phys Med Rehabil. 2007;88: 16581661.
11. Couppe C, Midttun A, Hilden J, et al. Spontaneous needle electromyographic activity in myofascial
trigger points in the infraspinatus muscle: a blinded assessment. J Musculoskelet Pain. 2001;9:716.
12. Sikdar S, Shah JP, Gebreab T, et al. Novel applications ofultrasound technology to visualize and
characterize myofascialtrigger points and surrounding soft tissue. Arch Phys MedRehabil.
2009;90:18291838.
13. Shah JP, Phillips TM, Danoff JV, et al. An in vivomicroanalytical technique for measuring the local
biochemicalmilieu of human skeletal muscle. J Appl Physiol. 2005;99:19771984.
14. Niddam DM, Chan RC, Lee SH, et al. Central modulation ofpain evoked from myofascial trigger point.
Clin J Pain. 2007;23:440448.
15. Gerwin RD, Shannon S, Hong CZ, et al. Interrater reliabilityin myofascial trigger point examination.
Pain. 1997;69:6573.
16. Sciotti VM, Mittak VL, DiMarco L, et al. Clinical precision ofmyofascial trigger point location in the
trapezius muscle. Pain.2001;93:259266.
17. Bron C, Franssen J, Wensing M, et al. Interrater reliability ofpalpation of myofascial trigger points in
three shouldermuscles. J Man ManipTher. 2007;15:203215.
18. Maria Torres Lacomba, PhD et al. Incidence of Myofascial Pain Syndrome in Breast Cance Surgery: A
Prospective Study, Clinical Journal of Pain 2010, 26: 320 -325.

CORRESPONDENCE
* MPT (Neurology). Email: drmitrphysio@gmail.com, Academics Training and Research Manager, D.L.S.
Institute for Health & Wellness, U.P
** MSPT (Sports and Ortho), Assistant professor, Ayushman College of physiotherapy, Bhopal.
*** MPT (Neurology), PhD, Dean of Studies and Head of Department (Physiotherapy) at St. Louis
University, Cameroon, Africa. Email: dr.krisharma@gmail.com
15

COMPARISON OF EFFECT OF HIP JOINT MOBILIZATION AND HIP
JOINT MUSCLE STRENGTHENING EXERCISES WITH KNEE
OSTEOARTHRITIS

*A. Tanvi, **R. Amrita, ***R. Deepak, ****P. Kopal

ABSTRACT
Purpose- The purpose of pre and post experimental study was to determine whether hip joint mobilization and
hip joint muscle strengthening of the hip muscles in patients with knee osteoarthritis are effective in comparison
to the conventional therapy in treatment of knee osteoarthritis. Background- Osteoarthritis is a chronic,
degenerative joint disease mainly affecting weight-bearing joint such as knee. Exercise programs for knee OA
have been described such as general aerobic exercise programs like walking or cycling as well as more specific
programs involving strengthening of particular muscle groups and/or flexibility exercises of lower limb muscle
groups. Method- A total of 30 patients were taken on the basis of inclusion (Kellgren grade 2 or 3) and
exclusion criteria and divided into two groups via convenient sampling. Group A (n=15) received conventional
treatment i.e.US+TENS, Knee range of motion strengthening and stretching exercises and Group B (n=15)
received conventional + hip joint mobilization and hip joint muscle strengthening exercise for six weeks. All the
outcome variables i.e .knee range of motion, pain and functional disability were measured at 0 (pre-test), 10
th

and 21
st
sitting. Result- t-test indicated that Group B (experimental group) demonstrated significant
improvements in knee ROM, pain and functional disability, measurements. Within group analysis was found to
be significantly different. Conclusion- The results of the study suggest that hip joint mobilization and hip joint
muscle strengthening exercises are beneficial in improving knee ROM and functional disability and in reducing
pain.
Keywords: osteoarthritis, hip joint mobilization and hip joint muscle strengthening exercises, WOMAC, knee
16
ROM.

INTRODUCTION
Osteoarthritis (OA) is a degenerative condition
of articular/hyaline cartilage of synovial joints
and is a chronic, localized joint disease
affecting approximately one third if adults with
the diseases predominately affecting the medial
compartment of the tibio-femoral joint. Patients
with knee OA frequently report symptoms of
knee pain and stiffness as well as difficulty
with activities of daily living such as walking,
stair-climbing and housekeeping. Ultimately,
pain and disability associated with the disease
lead to a loss of functional independence and a
profound reduction in quality-of-life.
1
Osteoarthritis of the knee, defined as a Kellgren
and Lawrence grade of two or higher in either
knee, was found in 121 women, a prevalence of
12.5%.
2
Prevalence of OA increases with age
and aging is associated with decreasing
physiological functions.
3
General health status
instruments measure multiple aspects of health,
including, specifically, physical function, social
function, and pain, and are suitable for
comparison of health status between diseases.
5
A variety of exercise programs for knee OA
have been described in the literature. These
have included general aerobic exercise
programs such as walking or cycling as well as
more specific programs involving
strengthening of particular muscle groups
and/or flexibility exercises. Studies
investigating the effects of strengthening in
patients with knee OA have generally focused
on improving quadriceps strength. However,
little attention has been paid to improving the
strength of other lower limb muscle groups
such as the hip abductors and adductors.
1

Reduced hip abductor strength has also been
shown in people with knee pathology and is
most likely to be a consequence of altered
loading during gait to rapidly move body
weight onto the unaffected limb. In contrast,
medial knee OA progressed more slowly in
people with stronger ipsilateral hip abductors
because adequate hip abductor strength may
control weight shift and maintain lateral pelvic
stability during the single-leg stance phase of
gait. Mobilization is one of the most commonly
recommended treatments for this condition.
The goal of mobilization is to restore the
normal arthro-kinematics of a joint, including
spins, rolls and glides, by improving the
extensibility of the ligamento-capsular tissue.
Mobilizations are often combined with
traditional physical therapy modalities as
well.
11
Impaired hip mechanics have been associated
with increased medial compartment knee
loads.
6
Less is known about the hip adductor
muscles in relation to knee OA but they may
also help reduce the knee adduction moment,
particularly in a varus malaligned knee. By
virtue of their attachment to the distal medial
femoral condyle, the adductors could
eccentrically restrain the tendency of the femur
to move further into varus. Yamada et al. found
17
that patients with knee OA demonstrated
stronger hip adductors compared with age-
matched controls, and that those with more
severe OA had even stronger adductors than
their less severe counterparts. They
hypothesized that this increased strength may
be due to greater use of the hip adductors in an
attempt to lower the knee adduction moment.
The purpose of this study was to analyze the
efficacy of hip joint mobilization and hip joint
muscle strengthening exercise to improve knee
ROM, functional disability and improve pain in
knee OA.
METHODOLOGY
Subjects criteria
This study was carried out on 34 patients, out
of which 30 continued the study and other drop
out in between the study and the patient was
collected from R K physiotherapy clinic
Khanpur, Delhi. Their ages ranged from 40-75
years old, according to Kellgren grade 1 or 2
radiologically, predominance of pain over
medial region of knee as well as hip pain,
clinical criteria described by Attman et al for
knee OA, VAS more than 5 on 10cm scale
were included
6,7,8
and was excluded if history
of trauma, surgery of hip, knee and ankle joint,
and peripheral vascular diseases, any
neurological or cardiovascular pathology and
systemic diseases
1,4,8
.
Patients were informed that results drawn out
of study will facilitate them to measure their
performance and help in further enhancing the
variable that improve their performance. A
written consent form was taken from the
patients who volunteered for the study and
fulfilled the inclusion and exclusion criteria of
the study.
Outcome measures
Demographic variables of all subjects, such
as age, height, and weight were recorded. All
subjects underwent a detailed orthopaedic
assessment. A baseline measurement of
dependent variables were taken using
goniometer, WOMAC score and visual
analogue scale.
Knee Range of Motion measured using
universal goniometer which is a commonly
used method for the clinical assessment of
range of motion. The intraclass correlation
coefficients (ICCs) for intratester reliability of
measurements obtained with a goniometer were
.99 for flexion and .98 for extension. Intertester
reliability for measurements obtained with a
goniometer was .90 for flexion and .86 for
extension
10
.
Functional disability was assessed using
WOMAC questionnaire which consists of 3
sections A,B,C i.e. section A for pain and
section B for stiffness and section C for
functional difficulty. Patient is asked to rate
each question out of five grades of severity. the
testretest reliability of the WOMAC was 0.74,
0.58, and 0.92 (ICC) for the pain, stiffness, and
physical function subscales.
20

Pain was assessed using VAS (visual analogue
18
scale), used to measure the average intensity of
pain. In this patient is asked to mark their pain
on a 10 cm line marked with 0 marked on one
side and 10 on other end, where 0 indicated no
pain and 10 indicates maximum pain. The ICC
for all paired VAS scores was 0.97.
9

Treatment
Both the groups received US and TENS at a set
dosage used for pain relief.
32
Group A received set of knee range of motion
exercises, strengthening and stretching
exercises which includes knee in mid flexion to
full extension, knee in mid extension to full
flexion(two 30 s bouts with 3 sec hold), knee
strengthening exercises includes static quad
sets in knee extension (6 sec hold with 10 sec
rest for 10 repetitions), standing terminal
extension (hold for 3 sec for 10
repetitions),seated leg presses(hold for 3 sec
and repeat for 30 sec bouts), knee stretching
exercises includes standing calf stretch ,supine
hamstring stretch, prone quadriceps femoris
stretch (hold for 30 sec and repeat for 3).
Group B received all the exercises in group A
as well as additional exercises for hip joint
which includes all the glides in different planes
(caudal glide, anterior- posterior glide,
posterior anterior glide, posterior to anterior
mobilization in flexion, abduction and external
rotation) and hip muscle strengthening
exercises include abduction and adduction in
side lying, abduction and adduction in standing,
standing wall hip isometric abduction, towel
squeezes ( 3 sets of 10 with 5 second hold).
Data was collected prior to start of treatment
program 0 sitting, at 10
th
sitting and after the
end of treatment session i.e. at 21
st
sitting.
DATA ANALYSIS
The mean and standard deviation of all the
variables were analysed. Data analysis was
done with the help of SPSS for windows in
order to verify the investigations of the study.
Independent t-test was used to compare
between group difference and repeated
ANOVA measures was used to analyze within
group difference for all the dependent
variables. The significance level set for this
study was 95% (p<0.05). The significance of
mean difference within and between the groups
was done by Newman-Keuls post hoc test after
ascertaining normality by Shapiro-Wilks test
and homogeneity of variances by Levenes test.
RESULTS
The age of two groups i.e. Group A who
received conventional treatment along with US
and TENS and Group B who received hip joint
mobilization and hip joint muscle strengthening
are summarized graphically in Fig. 1.1. The
age of Group A and Group B knee OA patients
ranged from 41-70 yrs and 44-68 yrs,
respectively with mean ( SD) 53.93 8.85 yrs
and 57.47 7.46 yrs, respectively. The mean
age of Group B was comparatively higher than
Group A. Comparing the mean age of two
groups, t test revealed similar (p>0.05) age
between the two groups (53.93 8.85 vs. 57.47
19
7.46, t=1.18, p=0.247). In other words,
patients of two groups were age matched and
therefore age may not influence the outcome
measures.
Fig. 1.1 Mean age of two groups
Age (yrs)
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
Group A Group B
Groups
M
e
a
n

Outcome variables
I. ROM
The pre and post treatments ROM levels
(degree) of two groups are summarized in
Table 1.1. which shows that the mean ROM
levels in both groups increased (improved)
after the treatments and at the end of the
treatments, the increase (improvement) was
found higher in Group B than Group A.
Table 1.1: Pre and post treatments ROM levels (Mean SD) of two groups
Groups
0 sitting
(n=15)
10
th
sitting
(n=15)
21
st
sitting
(n=15)
Group A 99.20 9.66 104.87 10.37 111.60 10.52
Group B 94.60 9.75 101.53 8.94 112.00 7.43
p value 0.194 0.344 0.909

Fig. 1.2. Comparative mean ROM levels
within the
groups.

Fig. 1.3. Comparative mean ROM levels
between the groups.

20
Comparing the mean ROM levels within the
groups (Fig.1.2 and Fig. 1.3), the ROM levels
in both groups increased (improved)
significantly (p<0.001) at both 10
th
and 21
st

sittings (post treatment) as compared to 0
sitting (pre-treatment). Further, the mean ROM
levels in both groups also increased
significantly (p<0.001) at 21
st
sitting as
compared to 10
th
sitting.
II. WOMAC
The pre and post treatments WOMAC scores of
two groups are summarized in Table 1.3. which
shows that the mean WOMAC scores in both
groups decreased (improved) after the
treatments and at the end of the treatments, the
decrease (improvement) was found higher in
Group B than Group A.

Table 1.3: Pre and post treatments WOMAC scores (Mean SD) of two groups
Groups
0 sitting
(n=15)
10
th
sitting
(n=15)
21
st
sitting
(n=15)
Group A 65.47 13.26 48.40 14.11 37.80 14.62
Group B 64.27 11.60 48.07 15.25 31.07 13.37
p value 0.813 0.948 0.189

Fig. 1.5. Comparative mean WOMAC scores
within the groups

Fig. 1.6 Comparative mean WOMAC scores
between the groups

21
Comparing the mean WOMAC scores
between the groups (Fig 1.5 and Fig.
1.6), the WOMAC scores of two groups
did not differed (p>0.05) at 0 sitting i.e.
found to be statistically the same. In
others words, WOMAC scores of two
groups were comparable. Further, the
mean WOMAC scores of two groups
also not differed (p>0.05) at 10
th
sitting
and 21
st
sitting,
III. VAS
The pre and post treatments VAS scores of two
groups are summarized in Table 1.5 shows that
the mean VAS scores in both groups decreased
(improved) after the treatments and at the end
of the treatments, the decrease (improvement)
was found higher in Group B than Group A.

Table 1.5: Pre and post treatments VAS scores (Mean SD) of two groups
Groups
0 sitting
(n=15)
10
th
sitting
(n=15)
21
st
sitting
(n=15)
Group A 7.47 0.83 6.07 1.10 4.67 1.59
Group B 7.33 0.98 5.33 0.98 3.60 1.06
p value 0.745 0.078 0.012

Comparing the mean VAS scores within the
groups (Table 1.6), the VAS scores in both
groups decreased (improved) significantly
(p<0.001) at both 10
th
and 21
st
sittings (post
treatment) as compared to 0 sitting (pre-
treatment). Further, the mean VAS scores in
both groups also decreased significantly
(p<0.001) at 21
st
sitting as compared to 10
th

sitting. The comparisons concluded that both
treatments are effective for improving VAS in
patients with knee OA.

Fig. 1.7. Comparative mean VAS scores
within the groups.

22

Fig. 1.8. Comparative mean VAS scores
between the groups.
Comparing the mean VAS scores between the
groups (Fig 1.7 and Fig. 1.8), the VAS scores
of two groups did not differed (p>0.05) at 0
sitting i.e. found to be statistically the same.
The mean VAS scores of two groups also not
differed (p>0.05) at 10
th
sitting. However, the
mean VAS score of Group B at 21
st
sitting was
found significantly (p<0.05) different and
lower as compared to Group A, indicating
Group B is more effective than Group A for
improving VAS in patients with knee OA.
DISCUSSION
The aim of the study was to compare the
effectiveness of hip joint mobilization and hip
joint strengthening of the hip muscles with
conventional therapy in the treatment of
patients with knee osteoarthritis. The result of
the study suggested that hip joint mobilization
and hip joint strengthening exercises are
significantly more effective than conventional
treatment.
This finding supports the view that there are the
positive effects of hip joint mobilization
(Cliborne, et al. 2004)
22
and hip muscle
strengthening on knee load, pain, and function
in people with knee osteoarthritis (Kim L
Bennell, et al. 2007)
33
. It appears that hip joint
mobilization and strengthening exercises are
effective in reducing pain and stiffness, and in
improving knee ROM and physical function in
patients with OA of the knee than conventional
treatment. This finding is in agreement with
Cliborne, et al. (2004)
22
who stated that short
term response of hip mobilization on Knee OA
and of Bennell, et al. (2007) the hip
strengthening exercises were effective on OA
of the knee
33
. The present study while
demonstrating significant difference in the
effect of conventional treatment and hip joint
mobilization and hip joint strengthening
exercises on the selected clinical features of
OA have however shown that the hip joint
mobilization and hip joint strengthening
exercises affected greater pain relief as well as
gains in ROM and improves function. Pain is a
major contributory factor to the disability in the
patient with Knee OA hence it is
understandable that experimental group which
effected greater pain reduction in this study
brought about greater functional improvement.
Among subjects who completed the study,
those in the experimental group had a greater
improvement in WOMAC scores over the 6-
week period (P<.001) than those in the
conventional treatment group.
Impaired hip muscle performance can render
the hip joint susceptible to dysfunction in all
planes. Abnormal motion of the femur can have
23
a direct effect on tibiofemoral joint kinematics
and strain the soft tissue restraints that bind the
tibia to the distal end of the femur. Chang and
colleagues, who reported that the ability to
generate greater hip abductor moments during
walking was protective against ipsilateral
medial compartment osteoarthritis progression
in older adults.
29
Altered knee function as a
result of knee OA may affect the hip and result
in painful impairments.
24
The faulty
biomechanical knee position can be a result of
a tight posterior and posteriorlateral hip
complex, causing the femur to not flex, adduct,
and internally rotate during the loading phase
of gait. This causes the knee to remain
relatively extended, abducted, and externally
rotated, and could lead to medial joint overload
over time.
23
Mechanoreceptors that provide proprioceptive
function are located at the tendons, ligaments,
meniscus, joint capsule and muscle. Pain may
be a factor affecting the evaluation of muscle
strength and proprioceptive acuity.
21
Joint
mobilization which involves low-velocity
passive movements within or at the limit of
joint range of motion reduces pain by
modulating the nervous tissues and increases
joint motion (Maitland 2005; Vicenzino
2001).
16
Joint mobilization has been shown to
induce immediate hypoalgesia in individuals
with knee OA with a concurrent improvement
in function. The positive hypoalgesic affects
are believed to occur through stimulation of
mechanoreceptors and activation of pain
inhibitory cortical systems.
30
Mobilization is
thought to reduce joint pain through the
stimulation of afferent nerve receptors or by
improving joint lubrication. Mobilization of the
hip is also used to help restore joint mobility.
28
Since serotonin and noradrenaline releasing
neurons in the spinal cord originate in
supraspinal sites in the brainstem, these data
support a role for descending inhibitory
pathways in the hypoalgesia produced by joint
mobilization. It has been hypothesized that
mobilization may activate descending pain
inhibitory systems, mediated supraspinally
(Wright, 2002; Souvlis et al., 2004).
31
During mobilization/manipulation, the
capsuloligamentous tissues of a joint are
mechanically stretched. One primary goal of
mobilization is to improve extensibility of
restricted capsuloligamentous tissue;
secondarily, articular mechanoreceptor
activation level is affected. Joint mobilization
has been demonstrated to improve physiologic
and accessory motions to hypomobile
structures. This in turn causes an alteration in
the articular mechanoreceptor resulting by way
of arthrokinetic reflex activity in enhanced
muscle strength.
26
Joint mobilization also
causes physical loading and unloading of joint
cartilage to facilitate the flow of synovial fluid
within the joint. This flow of fliud ensures
adequate nutrition to the articular cartilage.
When compression is combined with
mobilization, there is thought to be even greater
stimulation of synovial fluid flow.
11
Other proposed benefits of manual therapy
24
include mechanical alteration of tissue,
neurophysiologic effects, and psychological
influence.
30
Joint mobilization not only has an
impact on the motor unit activity in muscles
functioning over the joint, but it also has been
shown to affect more remote muscles as well,
including muscles on the contralateral side of
the body.
26
Hip mobilizations are a
noninvasive, relatively inexpensive
intervention that appears to provide short-term
benefit in patients with knee pain and clinical
evidence of knee OA who present any
combination of 2 CPR variables.
24
Chang and colleagues postulated that hip
abductor weakness may result in additional
contralateral pelvic drop, shifting the centre of
mass toward the swing extremity, which
therefore increases forces across the medial
compartment of the stance extremity and
hastens disease progression.
17
The aim of
strengthening exercises in people with OA is
primarily to improve control and stability of the
joint during movement and thus maintain
functional ability. More recent reviews also
indicated a strong evidence base for the
efficacy of strengthening exercises in managing
OA.
13
The beneficial effects of resistive
exercise for individuals with OA may be
attributed to several associated factors such as:
facilitation of endogenous opiates which
creates an analgesic effect to improve a
persons tolerance to pain, decrease in
depression coupled with perceived level of
disability, through associated weight loss, or
mechanically through alteration of the
biomechanics of the joint. Strength training is
presumed to protect the joint from pathologic
stress and loading.
14
People with knee OA demonstrate significant
weakness of the hip musculature compared
with asymptomatic controls.
17
Hip abduction
(HA) exercises have important functional
implications because they enable patients to
regain the muscle strength needed for
performing activities of daily living and
sports.
15
Since muscle strengthening improves
pain and function in knee OA, strengthening
exercise is widely recommended for the
condition.
17
Lower limb strengthening
exercises are an important component of the
treatment for knee osteoarthritis (OA).
Strengthening the hip abductor and adductor
muscles may influence joint loading and/or
OA-related symptoms, but no study has
compared these hypotheses directly.
1
The hip muscles, particularly the abductors,
play an important role in stabilization of the
pelvis and trunk. Indeed, movement of the
contra lateral pelvis or lateral leaning of the
trunk over the stance limb, which may occur as
a result of hip muscle weakness, has been
suggested to adversely influence the magnitude
of the knee adduction moment. Thus, hip
muscle activity appears to be an important, yet
understudied, contributor to knee joint load.
1
The exercises focus on strengthening the hip
abductor muscles, such as the gluteus medius, a
broad, thick, radiating muscle that helps to
25
stabilize the pelvis during ambulation. In
patients with osteoarthritis in the knees, these
muscles tend to be weak, causing the pelvis to
tilt toward the side of the swing leg when
walking, instead of remaining level with the
ground, which increases the load on the knee
joints. Strengthening these muscles helps the
pelvis and the knee remain in better alignment,
and thereby lessens the load.
25
Hip muscles
may stabilize the pelvis during gait in ways to
maintain the center of mass in alignment,
which may have an effect on frontal plane knee
moments as suggested by Bennell.
14
In this
study, as reduction in pain brought significant
improvement in health and physical function
that contribute in improving WOMAC score,
and thus helps in reducing knee disability by
minimizing the load on knee joint during
ambulation and so intervention of the hip may
be indicated in the treatment of patients with
knee OA. Future Research can be done by
extending the duration of the study or including
other exercise protocols. The future study can
be done by using another electrotherapeutic
modality with same protocol. This study has
provided a positive outcome of the
experimental method conducted in order to
treat the proposed condition; still it provides us
with a chance to further modify the
methodology.
Relevance to Clinical Practice
Hip joint mobilization and hip joint muscle
strengthening exercises shows better
improvement in muscle strength and function
and reduction in pain in comparison to
conventional therapy in the patients with knee
osteoarthritis. So Hip joint mobilization and hip
joint muscle strengthening exercises can be use
as clinical practice in the treatment of knee
joint osteoarthritis.
Conclusion
The study concludes by stating that null
hypothesis is rejected as the result of the study
suggests that the hip joint mobilization and hip
joint muscle strengthening exercises are more
effective in decreasing pain and in improving
functional ability and increasing knee ROM in
patients with knee osteoarthritis.

REFERENCES
1. Kim L Bennell, et al. Comparison of neuromuscular and quadriceps strengthening exercise in the
treatment of varus malaligned knees with medial knee osteoarthritis: a randomised controlled trial
protocol BMC Musculoskeletal Disorders 2011, 12:276
2. Kim L Bennell, Michael A Hunt, Tim V Wrigley, David J Hunterand Rana S Hinman The effects of
hip muscle strengthening on knee load, pain, and function in people with knee osteoarthritis: a
protocol for a randomised, single-blind controlled trial BMC Musculoskelet Disord. 2007; 8: 121.
3. Deborah Hart, et al. Defining osteoarthritis of the hand for epidemiological studies: The Chingford
Study Annals of the Rheumatic Diseases 1994; 53: 220-223
4. Duygu Cubukcu, et al. Relationships between Pain, Function and Radiographic Findings in
Osteoarthritis of the Knee: A Cross-Sectional Study Arthritis. 2012; 2012: 984060.
5. Srinivas Mondam, Srikanth Babu V, Raviendra Kumar B and Jalaja Prakash A Comparative
Study of Proprioceptive Exercises versus Conventional Training Program on Osteoarthritis of Knee
26
Research Journal of Recent Sciences Vol. 1(12), 31-35, December (2012).

6. F Angst, A Aeschlimann, W Steiner, G Stucki Responsiveness of the WOMAC osteoarthritis index
as compared with the SF-36 in patients with osteoarthritis of the legs undergoing a comprehensive
rehabilitation intervention Ann Rheum Dis 2001;60:834840
7. David Wallace and Christa Barr The Effect of Hip Bracing on Gait in Patients with Medial Knee
Osteoarthritis Arthritis. 2012; 2012: 240376.
8. Mikhled F. Maayah, et al. Changes In Pain And Range Of Motion In Patients With Osteoarthritis
Of The Knee Living In Jordan By The Effect Of Self-Management Program Versus Routine
Physiotherapy: Randomized Clinical Trial Canadian Journal on Medicine Vol. 3, No. 3, May 2012
9. Gail D Deyle, et al. Physical Therapy Treatment Effectiveness for Osteoarthritis of the Knee: A
Randomized Comparison of Supervised Clinical Exercise and Manual Therapy Procedures Versus
a Home Exercise Program Physical Therapy December 2005 vol. 85 no. 12 1301-1317
10. Polly E. Bijur, et al. Reliability of the Visual Analog Scale for Measurement of Acute Pain
Academic Emergency Medicine December 2001, Volume 8, Number 12, 11531157
11. Michael A Watkins, Dan L Riddle, Robert L Lamb and Walter J Personius Reliability of
Goniometric Measurements and Visual Estimates of Knee Range of Motion Obtained in a Clinical
Setting Phys Ther. 1991; 71:90-96.
12. Effect of mobilization of the Anterior Hip Capsule on Gluteus Maximus Strength The Journal of
Manual & Manipulative Therapy Vol. 10 NO. 4 (2002), 218 -224
13. Dheeraj Lamba, Satish Chandra Pant Comparison of manual physical therapy and conventional
physical therapy programs in osteoarthritis of knee Journal of Physiotherapy and Occupational
Therapy. Jan.-March, 2011, Vol. 5, No.1
14. Ann E Rahmann Exercise for people with hip or knee osteoarthritis: a comparison of land-based
and aquatic interventions Open Access Journal of Sports Medicine 2010:1 123135
15. Kevin James McQuade et al. Effects of Progressive Resistance Strength Training on Knee
Biomechanics During Single Leg Step-up in Persons with Mild Knee Osteoarthritis Clin Biomech
(Bristol, Avon). 2011 August; 26(7): 741748.
16. Lori A. Bolgla, Timothy L. Uhl Reliability of electromyographic normalization methods for
evaluating the hip musculature Journal of Electromyography and Kinesiology 17 (2007) 102111
17. Nor Azlin M.N. & K. Su Lyn. Effects of Passive Joint Mobilization on Patients with Knee
Osteoarthritis. Sains Malaysiana 40(12)(2011): 14611465
18. Rana S. Hinman et al. Hip Muscle Weakness in Individuals With Medial Knee Osteoarthritis
Arthritis Care & Research Vol. 62, No. 8, August 2010, pp 11901193
19. Alan E. Mikesky et al. Effects of Strength Training on the Incidence and Progression of Knee
Osteoarthritis Arthritis & Rheumatism Vol. 55, No. 5, October 15, 2006, pp 690699
20. Cameron W. MacDonald, Julie M. Whitman, Joshua A. Cleland, Marcia Smith, Hugo L. Hoeksma.
Clinical Outcomes Following Manual Physical Therapy and Exercise for Hip Osteoarthritis: A
Case Series J Orthop Sports Phys Ther 2006;36(8):588-599.
21. Sara Mc Connell, et al. The Western Ontario and McMaster Universities Osteoarthritis Index
(WOMAC): A Review of Its Utility and Measurement Properties Arthritis Care & Research
45:453461, 2001
22. N. Shakoor, S. Furmanov, D.E. Nelson, Y. Li, J.A. Block Pain and its relationship with muscle
strength and proprioception in knee OA: Results of an 8-week home exercise pilot study J
Musculoskelet Neuronal Interact 2008; 8(1):35-42
23. Amy V. Cliborne, Clinical Hip Tests and a Functional Squat Test in Patients With Knee
Osteoarthritis: Reliability, Prevalence of Positive Test Findings, and Short-Term Response to Hip
Mobilization J Orthop Sports Phys Ther 2004;34:676-685.
24. Robert T. Bashaw, Edwin M. Tingstad, Rehabilitation of the Osteoarthritic Patient: Focus on the
Knee Clin Sports Med 24 (2005) 101 131
25. Linda L Currier, Paul J Froehlich, Scott D Carow, Ronald K McAndrew, Development of a
Clinical Prediction Rule to Identify Patients With Knee Pain and Clinical Evidence of Knee
Osteoarthritis Who Demonstrate a Favorable Short-Term Response to Hip Mobilization Phys Ther.
2007;87: 11061119.]
26. Laura Thorp Study to assess hip exercises as treatment for osteoarthritis in the knee joints July 16,
2009 - 08:09 Health & Medicine
27
27. Howard Makofsky Immediate Effect of Grade IV Inferior Hip Joint Mobilization on Hip Abductor
Torque: A Pilot Study J Man Manip Ther. 2007; 15(2): 103110.
28. Elizabeth A. Sled et al. Effect of a Home Program of Hip Abductor Exercises on Knee Joint
Loading, Strength, Function, and Pain in People With Knee Osteoarthritis: A Clinical Trial Phys
Ther.2010;90:895904.
29. Michael T. Cibulka and Anthony Delitto, A Comparison of Two Different Methods to Treat Hip
Pain in Runners JOSPT Volume 17 Number 4 April 1993
30. Christopher M. Powers, The Influence of Abnormal Hip Mechanics on Knee Injury: A
Biomechanical Perspective J Orthop Sports Phys Ther 2010;40(2):42-51.
31. Thomas Adams et al. Physical Therapy Management of Knee Osteoarthritis in the Middle-aged
Athlete Sports Med Arthrosc Rev 2013;21:210
32. Penny Moss et al. The initial effects of knee joint mobilization on osteoarthritic hyperalgesia
Manual Therapy 12 (2007) 109118.
33. Naryana C Mascarinet al. Effects of kinesiotherapy, ultrasound and electrotherapy in management
of bilateral knee osteoarthritis: prospective clinical trial BMC Musculoskeletal Disorders 2012,
13:182
34. Kim L Bennell, et al. Comparison of neuromuscular and quadriceps strengthening exercise in the
treatment of varus malaligned knees with medial knee osteoarthritis: a randomised controlled trial
protocol BMC Musculoskeletal Disorders 2011, 12:276

CORRESPONDENCE
*MPT (Musculoskeletal), Assistant professor, Santosh Medical and Dental, college of physiotherapy.
**MPT (Musculoskeletal), Student, Santosh Medical and Dental, college of physiotherapy.
***MPT (Musculoskeletal), Principal, Associate professor, Santosh Medical and Dental, college of
physiotherapy.
****MPT (Sports), Assistant professor, Santosh Medical and Dental, college of physiotherapy.
Corresponding author: Dr. Tanvi Agarwal, MPT (MUSCULOSKELETAL), A48 A- ASHOK NAGAR
GHAZIABAD, drtanviagg@gmail.com
28

COMPARISON OF SHOULDER MUSCLE STRENGTHENING EXERCISES
WITH THE CONVENTIONAL TREATMENT OF MECHANICAL NECK
PAIN

*Dr. Deepak Raghav, **Dr. Sabiha, ***Dr. Monika, ****Dr. Tanvi

ABSTRACT
Background and Purpose: Although there have been previous researches reporting that scapula-thoracic
muscles such as the rhomboids, middle trapezius, and lower trapezius are thought to contribute to postural
stability of the cervical spine and reduce biomechanical loading of cervico-scapular musculature but
currently it is not known whether scapula-thoracic muscle strength is impaired in patients with chronic
neck pain compared to healthy individuals. Thereby this study is being conducted to see the effect of
shoulder muscles Strengthening on Mechanical neck pain. Methods: 30 patients who have been diagnosed
to have postural neck pain have been randomly assigned to one of the two treatment groups. Each group
consisted of 15 patients of both genders. Group A will be administered the traditional treatment protocol
with the addition of shoulder muscle strengthening exercises and Group B will be administered traditional
treatment . Both the groups will be administered 5 sessions per week for 3 weeks Visual analogue scale,
range of motion and neck disability index were the outcome measure and their scores for all groups were
taken prior ,at seventh week and after the training. Results: The pre and post treatments VAS (score) of two
groups showing that the mean VAS in both groups decreased (improved) after the treatments, and at final
evaluation, the decrease (improvement) was evident slightly higher in Group A than Group B. Comparison
between the 2 groups for extension ROM it showed that both the groups were equally effective. For side
flexion the comparison between the 2 groups proved equal effectiveness in both the groups. The pre and
29
post treatments Neck Disability Index (NDI) scores of two groups showing that the mean NDI scores in
both groups decreased (improved) after the treatments and the decrease (improvement) was evident
comparatively higher in Group A (73.9%) than Group B (66.0%). Conclusion: The conclusion of the study
was that the Shoulder Muscle strengthening protocol was equally effective as the conventional treatment
protocol, in case of Mechanical neck pain
Keywords: Strengthening exercises, Mechanical neck pain, Visual analogue scale, Range of motion, Neck
disability index

INTRODUCTION
Neck pain is a common occurrence & some of
disability within the population with a lifetime
include as high as 54%
3
.In the general
population up to 30%-50% of adults
experience neck pain at least once per year
(Martin Scherer et al., 2012)
4
. Non-specific
neck pain has a postural or mechanical basis
and affects about two thirds of people at some
stage, especially in middle age. Acute neck
pain resolves within days or weeks but may
become chronic in about 10% of people
6
.
Bogduk & Mc Guirk et al also suggest that
neck pain maybe subdivided into upper
cervical spinal pain and lower cervical spinal
pain, above and below an imaginary transverse
line through C4. From upper cervical
segments, pain can usually be referred to the
head whereas from the lower cervical
segments pain can be referred to the scapular
region, anterior chest wall, shoulder or upper
limb
7
.
The Bone & Joint Decade 2000-2010 Task
Force on Neck Pain & its associated disorder
describe neck pain as pain located in the
anatomical region of the neck with or without
radiation to head, trunk or upper limbs. The
Australian Acute Musculoskeletal Pain
guidelines group also recommended for neck
pain for no known cause the term Idiopathic
Neck Pain .The Neck Task Force proposed the
term Translatory neck pain instead of acute,
short duration for sub-acute and long duration
for chronic neck pain
7
.
According to several studies of patients, neck
pain may underlie impaired postural balance
(Marie B. Jorgensen et al., 2011)
8
. Most
patients who present with neck pain have non-
specific (simple) neck pain, where symptoms
have a postural or mechanical basis.
Etiological factors are poorly understood and
are usually multi-factorial, including poor
posture, anxiety, depression, neck strain, and
sporting or occupational activities ( Haqberg
et al.,2000)
9,33
. Aberrant activity within the
three portions of the trapezius muscle and
associated changes in scapular posture have
been identified as potential contributing
factors (Sally Wegner et al. 2010)
1
.
Bad posture causes shortening of muscular
fibers around articulation atlanto- occipitalis
and overstretching of muscles around joints
and thus possibly chronic neck pain. Chronic
neck pain is often a widespread sensation with
30
hyperalgesia in the ligaments and muscles
during both passive and active movements. It
has also been stated that forward head posture
may affect not only neck but also the thoracic
spine and shoulder blade, possibly causing
overall imbalance in the musculoskeletal
system (Jung-Ho Kang et al., 2012) .
11

Neck pain causes considerable personal
discomfort due to pain, disability, and
impaired quality of life, and may affect work.
Studies have shown that physical training,
including specific exercises targeting the deep
postural muscles of the cervical spine, is
effective in reducing neck pain for patients
with chronic neck pain. Exercise & vigorous
physical activities have a beautiful effect on
neck pain
12
.
Jensin et al. found that strengthening &
fitness exercise is effective in reducing the
prevalence of neck pain
13
. In addition to
gaining neck muscle strength, neck strength
training has been shown to be effective in
reducing neck pain & the disability associated
with it (Petri K. Salo et al.)
14
. Stretching and
strengthening exercise reduces chronic neck
pain compared with usual care
6
.

METOHDS
Selection and description of participants:
A sample of 50 subjects participated in the
study, out of which 20 subjects could not
complete the study.
SOURCE: Department of Physiotherapy
Santosh Medical & Dental College &
Hospital, Ghaziabad.
Subjects who fulfilled the inclusion criteria
and were ready to attend exercise program
regularly were selected.
To participate subjects had to meet the
inclusion criteria: (i) Subjects with age of 20-
45 years. (ii) Subjects with history of
restriction of movement (iii) neck pain.
(iv)forward head posture. (v) Unilateral
pain.
32, 11,14
Exclusion Criteria for the subjects were: (i)
Tumour. (ii) Infection. (iii) Non mechanical
neck pain. (iv) Herniated disc. (v) spinal
fracture. (vi)Recent cervical surgery.
Technical information:
A pre-post experimental design was used. The
subjects were invited to participate in the
study and were divided accordingly into two
groups. A detailed explanation of the
procedure was given to the patients after
which they signed informed consent.
30 patients who have been diagnosed to
groups traditional treatment of Hot Pack (20
minutes)
88
+ Cervical Isometrics+ Chin Tucks+
Static Stretching (5 reptts,30 seconds)
19,88

exercises will be done. The treatment protocol
was carried out for approximately 40-45
minutes including the application of Moist
heat Pack for 20 minutes
In Group A along with the traditional
treatment have postural neck pain have been
randomly assigned to one of the two treatment
31
groups. Each group consisted of 15 patients of
both genders. Group A will be administered
the traditional treatment protocol with the
addition of shoulder muscle strengthening
exercises and Group B will be administered
traditional treatment . Both the groups will be
administered 5 sessions per week for 3 weeks.
In both the, shoulder muscle strength training
will be done
91
including the muscles- Serratus
Anterior, Supraspinatus, Infraspinatus &
Upper Trapeziu
Statistics
The data were summarized as Mean SD. The
groups were compared by repeated measures
analysis of variance (ANOVA) using general
linear models (GLM) and the significance of
mean difference within and between the
groups was done by Tukeys post hoc test
after ascertaining normality by Shapiro-Wilks
test and homogeneity of variances by
Levenes test. A two-sided (=2) p<0.05 was
considered statistically significant. All
analyses were performed on STATISTICA
(version 6.0) software.

RESULTS
Pre and post treatments VAS score(Mean
SD) of two groups
Pre and post treatments VAS scores (Mean
SD) of two groups showing a gradual decrease
in the score.The pre and post treatments VAS
(score) of two groups showing that the mean
VAS in both groups decreased (improved)
after the treatments, and at final evaluation,
the decrease (improvement) was evident
slightly higher in Group A than Group B.
Pre and post treatments Flexion levels
(Mean SD) of two groups
Pre and post treatments Flexion levels (Mean
SD) of two groups showing an increase in the
Range of motion. The pre and post treatments
Flexion levels (degree) of two groups are
summarized in the table showing that the
mean Flexion levels in both groups increased
(improved) after the treatments, and at final
evaluation, the increase (improvement) was
evident slightly higher in Group B (13.2%)
than Group A (12.0%).
Pre and post treatments Extention levels
mean SD) of two groups
Pre and post treatments Extension levels (Mean
SD) of two groups depicting a similar scale
of improvement in the range. The pre and post
treatments Extension levels (degree) of two
groups are summarized in the table showed that
the mean Extension levels in both groups
increased (improved) after the treatments, and
at final evaluation, the increase (improvement)
was evident slightly higher in Group B (12.2%)
than Group A (11.1%).

Pre and post treatments Side flexion levels
Pre and post treatments Side flexion levels
(Mean SD) of two groups showing the
effectiveness of both the protocols. The pre
and post treatments Side flexion levels
(degree) of two groups are summarized in the
table showing that the mean Side flexion
levels in both groups increased (improved)
32
after the treatments, and at final evaluation,
the increase (improvement) was evident
slightly higher in Group A (12.9%) than
Group B (11.4%).

Pre and post treatments Lateral rotation
levels (Mean SD) of two groups
Pre and post treatments Lateral rotation levels
(Mean SD) of two groups indicating an
increase in the ranges. The pre and post
treatments Lateral rotation levels (degree) of
two groups are summarized in the table
showing that the mean Lateral rotations in
both groups increased (improved) after the
treatments and the increase (improvement)
was evident slightly higher in Group B
(21.2%) than Group A (20.5%).

P Pre and post treatments NDI scores
Pre and post treatments NDI scores (Mean
SD) of two groups. The pre and post
treatments Neck Disability Index (NDI) scores
of two groups are summarized in the table
showing that the mean NDI scores in both
groups decreased (improved) after the
treatments and the decrease (improvement)
was evident comparatively higher in Group A
(73.9%) than Group B (66.0%).

Comparative mean Flexion levels between the
groups.

Comparative mean Extension levels between
the groups.
33

Comparative mean Side flexion levels within
the groups

Comparative mean NDI scores within the
groups.

Comparative mean Lateral rotation levels
within the groups.
DISCUSSION
The aim of the study was to compare the
shoulder strengthening program with the
conventional treatment of postural neck pain.
When the VAS score comparison was made
between the groups it showed similar decrease
indicating that both the groups are equally
effective for improving postural neck pain.
Comparing the two groups against each other
proved that both the groups were equally
effective. As we make comparison between
the 2 groups for extension ROM it showed
that both the groups were equally effective.
For side flexion the comparison between the 2
groups proved equal effectiveness in both the
groups. Comparing Group A v/s Group B for
lateral rotation it was evident that both the
groups had similar improvement. When N.D.I.
scores were compared between the groups it
showed similar improvement in both the
groups.
The net results when observed clearly showed
that in terms of VAS Group A had more
effectiveness than Group B, while in Flexion
range of motion Group B proved to be better
than Group A. In case of Extension range of
motion Group B had better effectiveness but
as of Side Flexion range of motion Group A
proved better & for Lateral Rotation range of
motion Group B was marginally better than
Group A. As we talk of Neck Disability Index
Group A showed a marked better effect when
compared to Group B.
This study was carried out for the reason that
currently it is not known whether scapula-
thoracic muscle strength is impaired in
patients with chronic neck pain compared to
healthy individuals. Katrina Maluf et al.
supports the shoulder muscle strengthening
34
protocol by stating that Scapulo-thoracic
muscles such as the rhomboids, middle
trapezius, and lower trapezius are thought to
contribute to postural stability of the cervical
spine and reduce biomechanical loading of
cervico-scapular musculature
1
.
Years ago, Gordon compared the effects of
strength and endurance training on muscle
proteins. Strength training adds to the portion
of the muscle that generates tension, the
contractile proteins. Connective tissue and
tendons grow in size and toughness when they
are placed under tension. This increased
toughness in tendons may help quiet the
inhibitory influence of the muscle receptor
known as the tendon organ, a receptor
sensitive to stretching. The increase in
thickness of connective tissue contributes
somewhat to the growth or hypertrophy of the
muscle
43
.
The effects of conventional group cannot be
overlooked. Moist heat therapy is known to
have effects on pain and spasm and thus can
attribute to pain relief and improved tissue
extensibility in both the groups
88,89.
Anna Sjors et al stated that neck shoulder pain
remains a major problem in tasks with high
exposure to awkward working positions,
repetitive movements and movements with
high precision demands.
Janda et al described a cervical upper crossed
syndrome to show the effect of a poking chin
posture on the muscles. Forward head posture
(FHP) is one of the most common faulty
postures to be accompanied by the deep neck
stabilizer muscle weakness. Physiotherapists
usually recommend using the chin-tuck
exercises to correct this faulty posture
83
.
The neck retractions for proper posture by
moving the neck backward to a position over
the shoulders, then a cranio-cervical flexion
which is a nodding action to affect the deep
flexors of the neck for which the terminology
is chin tucking exercise. These exercises have
shown an immediate pain reduction response.
These neck exercises also help reverse the ill
effects of poor neck posture, neck related
headaches and the pain of arthritis. They are a
simple and pro-active approach to improve the
coordination and fitness of your neck muscles.
These exercises target the deeper muscles
which guide movements are important for
preventing injury and they often become weak
when you are in pain and thus require specific
therapeutic exercises to activate and train
them. Strength training results in muscle
hypertrophy, an increase in the cross-sectional
size of existing fibers. This is achieved by
increasing the number of myofibrils,
sarcoplasmic volume, protein, supporting
connective tissue. Also strength training
programs increase the intramuscular stores
such as adenosine tri-phosphate (ATP),
creatine phosphate (CP) and glycogen.
The reduction in the pain following static
stretching can be explained on the basis of
inhibitory effects of GTO (which causes a
dampening effect on the motor neuronal
discharges, thereby causing relaxation of the
musculotendinous unit by resetting its resting
35
length) and Pacinian corpuscle
modification.These reflexes will allow
relaxation in musculotendinous unit tension
and decreased pain perception
88
.
The combination of stabilization exercises and
chin-tuck exercises provide not only the better
correction effect for Forward head posture in
neck pain patients, but could be provided a
more effective and stable corrected posture
83
.
The variations in the results occur due to
difference in characteristics

FUTURE RESEARCH
This study has provided a positive outcome of
the experimental method conducted in order to
treat the proposed condition, still it provides
us with a chance to further modify the
methodology and conduct a new study.
Extending the duration of the study will make
up for future prospects.
Future study can be done on another
population.
Also the comparison of other technique with
proposed technique can be done in future.
A larger sample size can be taken up for the
study.
LIMITATION OF STUDY
1. The study has limited sample size and
short period of intervention. Increasing the
sample size would have increased the
statistical power of the study.
2. Duration of the study was limited.
3. Electromyography could not be used due
to unavailability.
4. Less Trials.
5. Instrumental error could not be ruled out.

CONCLUSION
The conclusion of the study was that the
Shoulder Muscle strengthening protocol was
equally effective as the conventional treatment
protocol, in case of Mechanical neck pain,
therefore the null hypothesis is rejected.

REFERENCES
1. SallyWegner , Gwendolen Jull, Shaun O'Leary , Venerina Johnston ; The effect of a scapular postural
correction strategy on trapezius activity in patients with neck pain; Manual Therapy;2010:1-5
2. Bahar Shahidi, Cynthia L Johnson, Douglas Curran-Everett and Katrina S Maluf Reliability and
group differences in quantitative cervicothoracic measures among individuals with and without
chronic neck pain; BMC Musculoskeletal Disorders Vol 3
3. Nicok.H.Raney, Evan J. Peterson, Tracy A. Smith, James E. Cowar, Daniel G. Rendeiro, Gal D.
Dayle & John D. Childs; Development of a clinical prediction rule to identify patients with neck pain
likely to benefit from cervical traction & exercises; ; European Spine Journal 2009 March;18(3);382-
391.
4. Martin Scherer, Helene Schaefer, Eva Blozik, Jean Francois Chenot, Wolfgang Hinumel; The
experience and management of neck pain in general practice-the patients perspective; European
Spine Journal 2010 19(6) 963-971, published online Feb 2012.
5. Petri K. Salo, Arja H. Hakkinen Kantianu & Jari J. Ykinen; Effect of neck strength training on
health related quality of lifein females with chronic neck pain : A randomized controlled 1 year follow
up study; Health & quality of life outcomes 2010;8:48
6. Allan, Binder; Neck Pain; Clinical Evidence 2008; 2008:1103.
36
7. Victoria Misailida, Parasheni Malleiou, Anastesia Beneka, Alexandros Karagiannidis, Georhios
Godolias; Assessment of patients with neck pain: a review of definition, selection criteria &
measurement tools; Journal of Chiropractic Medicine 2010 June;9(2):49-59.
8. Marie B. Jorgensen, Joregen H. Skotte, Andreas Holtermann, Gisele Sjogaard, Nicolas C. Peterson &
Karen Sogaard; Neck Pain and Postural Balance among workers with high postural demands- a
cross sectional study; Biomedcentral musculoskeletal disorders 2011,12:176.
9. Haqberg M, Harms Ringdahl K, Nisell R, Hjelm E.W.; Rehabilitation of Neck shoulder Pain in
women industrial workers: a randomized trial comparing isometric shoulder endurance training with
isometric shoulder strength training ; Arch Physiological Medical Rehabilitation 2000
Aug;8(18):1051-8.
10. Mettek Zebris, Lars L. Anderson, Mogens T Pederson, Peter Motensen, Christoffer H Anderson, Mette
M. Pederson, Marriane Boyser, Kirsten K Rossler, Harald Hannerz, Oles Mortensen & Gisela
Sjogard; Implementation of neck shoulder exercises for pain relief among industrial workers: A
randomized controlled trial; Biomedcentral Musculoskeletal Disorders 2011;12-205.
11. Jung-Ho Kang, Rae-Young Park, Su-Jin Lee, Ja-Young Kim, Seo-Ra Yoon and Kwang-Ik Jung; The
Effect of The Forward Head Posture on Postural Balance in Long Time Computer Based Worker;
Annals of Rehabilitation Medicine 2012 Feburary:36(1):98-104.
12. Inge Ris Hansen, Karen Sgaard, Robin Christensen, Bente Thomsen, Claus Manniche, and Birgit
Juul- Kristensen Neck exercises, physical and cognitive behavioral-graded activity as a treatment for
adult whiplash patients with chronic neck pain: Design of a randomized controlled trial;(This is a
study design presented before the study was conducted)
13. Ekalak Sitthipornvorakul, Prawit Janwantankul, Nithima Purepong, Praneet Pensri & Allard J.
Vander Beck; The association between physical activity and neck and low back pain; European Spine
Journal 2011 May;20(5):677-689.
14. Petri K. Salo,Arja H.. Hakkinan, Hannu Kartianan, Jari J Ylinen, Effect of neck strength training on
healthy related quality of life in females with chronic neck pain : a randomized controlled study : 1
year; Health Quality Life Outcomes 2010; 8:48, published online 2010 May 4.
15. Wim Jorritsma,Grietje E.de Vruis,Pieter U. Dijktstra,Jan H.B. Geertzer, Michael F. Reneman; Neck
Pain & Disability Scale & Neck Disability Index : Validity of Dutch Language versions; ; European
Spine Journal 2012 January ;21(1):93-100
16. Emily R. Howell ; The association between neck pain, Neck Disability Index & Cervical Range of
Motion; Journal of the Canadian Chiropractic Association2011 September:55(3):211-221
17. Ewa Misterska, Roman Jankowski, Maciej Glowacki; Cross cultural adaptation of the Neck Disability
Index & Copenhagen Neck functional Disability Scale for patients with neck pain due to degenerative
& discopathic disorders. Psychometric properties of Polish version;Biomedcentral-musculoskeletal
disorders 2011;12:84, published online 2011 April 29
18. Chantal H.P. Dekoming,J Bartsteal,Bouvian C.M. Smiths-Engelsman & Erik J.M. Hinduls;
Clinimetric evaluation of Active Range of Motion measures in patients with non-specific neck pain:
systematic review; . European Spine Journal 2008 Jul,17(7);905-921,published online 2008 april22.
19. Phil Page; Current concepts in muscle stretching for exercise & rehabilitation; International Journal
of Sports Physical Therapy.
20. Romy Lauche, Holger Cramer, Kyung-Eun Choi, Thomas Rampp, Felix Joyonto Saha, Gustav J
Dobos and Frauke Musial; The influence of a series of five dry cupping treatments on pain and
mechanical thresholds in patients with chronic non-specific neck pain - a randomised controlled pilot
study
21. Bahar Shahidi, Cynthia L Johnson, Douglas Curran-Everett, and Katrina S Maluf; Reliability and
group differences in quantitative cervicothoracic measures among individuals with and without
chronic neck pain; Biomedcentral Musculoskeletal Disorders 2012; 13: 215.
22. Jan Lucas Hoving, Jan JM Pool, Henk van Mameren, Walter JLM Devill, Willem JJ Assendelft,
Henrica CW de Vet, Andrea F de Winter, Bart W Koes, and Lex M Bouter Reproducibility
measurements of the range of motion are an important prerequisite for the interpretation of study
result; BMC Musculoskelet Disord. 2005; 6: 59.
23. Wegner S, Jull G, O'Leary S, Johnston V. The effect of a scapular postural correction strategy on
trapezius activity in patients with neck pain; Manual Therapy. 2010 Dec; 15(6):562-6.
24. Ana Cludia Violino Cunha, Thomaz Nogueira Burke, Fbio Jorge Renovato Frana, and Amlia
Pasqual Marques; Effect of Global Posture Reeducation and of Static Stretching on Pain, Range of
37
Motion, and Quality of Life in Women with Chronic Neck Pain: A Randomized Clinical Trial; ;
Clinics. 2008 December; 63(6): 763770.
25. Ren Fejer, Kirsten Ohm Kyvik, and Jan Hartvigsen; The prevalence of neck pain in the world
population: a systematic critical review of the literature; European Spine Journal 2006 June; 15(6):
834848.
26. Jamie Mansell, Ryan T Tierney,Michael R Sitler, Kathleen A Swanik, and David Stearne; Resistance
Training and Head-Neck Segment Dynamic Stabilization in Male and Female Collegiate Soccer
Players; Journal of Athletic Training 2005 Oct-Dec; 40(4): 310319.

27. S Bot, J M van der Waal, C Terwee, D A W M van der Windt, F Schellevis, L Bouter, and J Dekker;
Incidence and prevalence of complaints of the neck and upper extremity in general practice; Annals
of Rheumatological Disorders 2005 January; 64(1): 118123.
28. Michael Bergin, James M. Elliott, Gwendolen A. Jull; The Case of the Missing Lower Trapezius
Muscle; Journal of Orthopedics Sports Physical Therapy 2011;41(8):614.
29. Marloes Thoomes-de Graaf, Maarten S. Schmitt; The Effect of Training the Deep Cervical Flexors on
Neck Pain, Neck Mobility, and Dizziness in a Patient With Chronic Nonspecific Neck Pain After
Prolonged Bed Rest: A Case Report ; Journal of Orthopedic Sports Physical Therapy
2012;42(10):853-860.
30. Anastasia Gkotsi,1 Dimosthenis Petsas,Vasilios Sakalis,Asterios Fotas, Argyrios Triantafyllidis,
Ioannis Vouros, Evangelos Saridakis, Georgios Salpiggidis,and Athanasios Papathanasiou;Pain
point system scale (PPSS): a method for postoperative pain estimation in retrospective studies; ;
Journal of Pain Research 2012; 5: 503510.
31. Martin Scherer, Eva Blozik, Wolfgang Himmel, Daria Laptinskaya, Michael M. Kochen, and
Christoph Herrmann-Lingen ;Psychometric properties of a German version of the neck pain and
disability scale; European Spine Journal 2008 July; 17(7): 922929.
32. Jasper M. Schellingerhout, Arianne P. Verhagen, Martijn W. Heymans, Bart W. Koes, Henrica C. de
Vet, and Caroline B. Terwee; Measurement properties of disease-specific questionnaires in patients
with neck pain: a systematic review;Quality of Life Research. 2012 May; 21(4): 659670.
33. JOHN D. CHILDS, Joshua A. Cleland , James M. Elliott, Deydre S. Trehen,Robert S Wainner,Julie M
Whitman,Bernard J. Sopky, Joseph J. Godges, Timothy W. Flynn,Clinical Practice Guidelines Linked
tothe International Classification of Functioning, Disability, and Health From the Orthopaedic
Section of the American Physical Therapy Association Journal of Orthopedics Sports Physical
Therapy 2008;38(9):A1-A34.
34. Afsun Nodehi Moghadam, Roghayeh Mohammadi, Amir Massoud Arab, and Anoshirvan
Kazamnajad, The effect of shoulder core exercises on isometric torque of glenohumeral joint
movements in healthy young females
35. Aaron Sciascia and Robin Cromwell; Kinetic Chain Rehabilitation: A Theoretical Framework;
Rehabilitation Research Practical 2012; 2012: 853037.
36. Angela Tate, Gregory N. Turner, Sarah E. Knab, Colbie Jorgensen, Andrew Strittmatter, Lori A.
Michener, Risk Factors Associated With Shoulder Pain and Disability Across the Lifespan of
Competitive Swimmers; Journal of Athletic Training, 2012 Mar-Apr; 47(2): 149158.
37. Selma Cvijetic, Simeon Grazio, Milica Gomzi, Ladislav Krapac, Tomislav Nemcic, Melita Uremovic,
and Jasminka Bobic, Muscle strength and bone density in patients with different rheumatic
conditions: cross-sectional study; Croation Medical Journal 2011 April; 52(2): 164170.
38. Jennifer A Klaber Moffett, David A Jackson, Stewart Richmond, Seokyung Hahn, Simon Coulton,
Amanda Farrin, Andrea Manca, David J Torgerson; Randomized trial of a brief physiotherapy
intervention compared with usual physiotherapy for neck pain patients: outcomes and patients'
preference; BioMedical Journal 2005 January 8; 330(7482):75.
39. Soraya M.V. Costa, Yumi E.T. Chibana, Leandro Giavarotti, Dbora S. Compagnoni, Adriana H.
Shiono, Janice Satie, and Eduardo S.B. Bracher; Effect of spinal manipulative therapy with stretching
compared with stretching alone on full-swing performance of golf players: a randomized pilot trial;
Journal of Chiropractic Medicine 2009 December; 8(4): 165170.
40. Nizar Abd Jalil, Mohammad Saufi Awang,and Mahamarowi Omar; Scalene Myofascial Pain
Syndrome Mimicking Cervical Disc Prolapse: A Report of Two Cases Scalene; The Malaysian
Journal of Medical Sciences2010 Jan-Mar; 17(1): 6066.
41. Afsun Nodehi Moghadam, Roghayeh Mohammadi, Amir Massoud Arab, and Anoshirvan
Kazamnajad, The effect of shoulder core exercises on isometric torque of glenohumeral joint
38
movements in healthy young females; Journal of Research in Medical Sciences 2011 December
16(12): 15551563.
42. Megan M. Heintz and Eric J. Hegedus; Multimodal Management of Mechanical Neck Pain Using a
Treatment Based Classification System; Journal of Manual & Manipulative Therapy 2008; 16(4):
217224.
43. Smith, R., and O. Rutherford. 1995. The role of metabolites in strength training, European journal of
applied physiology and occupational physiology 71:332-36
44. MACKENZIE, B. (2003) Strength comes in many forms - here is how to develop them Available from:
http://www.brianmac.co.uk/articles.
45. David Maggie for spurlings and postural neck pain and upper crossed syndrome.pg 131
46. Carolyn Kisner and Lynn Allen Colby; Therapeutic Exercise Foundation & Techniques; Resistance
Training;4th edition;60-61,80-81
47. Carolyn Kisner and Lynn Allen Colby; Therapeutic Exercise Foundation &
Techniques;Stretching;4th edition,172
48. Beaulieu,JA;Developing a stretching program;The Physician & Sports Medicine 9:59,1981.
49. Hertling D & Kessler, RM: Introduction to Manual Therapy. In Hertling, D and Kessler, RM:
Management of Common Musculoskeletal Disorders, ed 3, Lippincott, Philadelphia,1996, pp 112-132
50. Cynthia norkinns for ROM(chap 1)
51. Cote P, Cassidy JD, Carroll L. The factors associated with neck pain and its related disability in the
Saskatchewan population. Spine. 2000;25:11091117.
52. Cote P, Cassidy JD, Carroll LJ, Kristman V. The annual incidence and course of neck pain in the
general population: a population-based cohort study. Pain. 2004;112:267273.
53. Carroll LJ, Hogg-Johnson S, Velde G, Haldeman S, Holm LW, Carragee EJ, et al. Course and
prognostic factors for neck pain in the general population: results of the Bone and Joint Decade
20002010 Task Force on Neck Pain and Its Associated Disorders. Spine. 2008;33:S75S82.
54. Hogg-Johnson S, Velde G, Carroll LJ, Holm LW, Cassidy D, Guzman J, et al. The burden and
determinants of neck pain in the general population: results of the Bone and Joint Decade 20002010
Task Force on Neck Pain and Its Associated Disorders. Spine. 2008;33(Suppl):S39S51
55. Makela M, Heliovaara M, Sievers K, et al. Prevalence, determinants, and consequences of chronic
neck pain in Finland. Am J Epidemiol1991;134:13561367
56. Bogduk N., McGuirk B. Management of acute and chronic neck pain: an evidence based approach.
Pain research and clinical management. 1st ed. Elsevier
57. Falla D. Unravelling the complexity of muscle impairment in chronic neck pain. Man Ther.
2004;9:125133.
58. Treleaven J. Sensorimotor disturbances in neck disorders affecting postural stability, head and eye
movement control. Man Ther. 2008;13:211
59. Michaelson P, Michaelson M, Jaric S, Latash ML, Sjolander P, Djupsjobacka M. Vertical posture
and head stability in patients with chronic neck pain. J Rehabil Med. 2003;35:229235
60. iield S, Treleaven J, Jull G. Standing balance: a comparison between idiopathic and whiplash-
induced neck pain. Man Ther. 2008;13:183191.
61. Roijezon U. Sensorimotor function in chronic neck pain: objective assessments and a novel method
for neck coordination exercise. Ume University medical dissertations, ISSN. 2009. 0346-6612; 1273;
62. Burgess-Limerick R, Plooy A, Ankrum DR. The effect of imposed and self-selected computer monitor
height on posture and gaze angle. Clinical of Biomechanics (Bristol, Avon) 1998;13:584592.\
63. Silva AG, Punt TD, Sharples P, Vilas-Boas JP, Johnson MI. Head posture and neck pain of chronic
non traumatic origin: a comparison between patients and pain-free persons. Archives of Physical
Medicine Rehabilitation 2009;90:669674.
64. Griegel-Morris P, Larson K, Mueller-Klaus K, Oatis CA. Incidence of common postural
abnormalities in the cervical, shoulder and thoracic regions and their association with pain in two
age groups of healthy subjects. Physical Therapy Journal 1992;72:425431
65. O'Sullivan PB. Lumbar segmental 'instability': clinical presentation and specific stabilizing exercise
management. Manual Therapy 2000;5(1):212.
66. Jull G, Falla D, Treleaven J, Hodges P, Vicenzino B. Retraining cervical joint position sense: the
effect of two exercise regimes. Journal of Orthopedic Research 2007;25(3):404412.
67. Falla D, Jull G, Hodges P, Vicenzino B. An endurance-strength training regime is effective in
reducing myoelectric manifestations of cervical flexor muscle fatigue in females with chronic neck
39
pain. Clinical Neurophysiological journal. 2006;117(4):828837

68. Hayden J, van Tulder MW, Malmivaara A, Koes BW (2010) Exercise therapy for treatment of non-
specific low back pain. Cochrane Database Systemic Review.
69. Henchoz Y, Kai-Lik So A. Exercise and nonspecific low back pain: a literature review. Joint Bone
Spine. 2008;75:533539
70. Jensen I. Neck pain. Best Pract Res Clinical Rheumatological Disorders. 2007;21:93108
71. Liddle SD, Baxter GD, Gracey JH. Exercise and chronic low back pain: what works? Pain.
2004;107:176190.
72. Cote P, Cassidy JD, Carroll L. The factors associated with neck pain and its related disability in the
Saskatchewan population. Spine. 2000;25(9):11091117.
73. Aromaa A, Koskinen S. Health and functional capacity in Finland: Baseline results of the health 2000
health examination survey
74. Bovim G, Schrader H, Sand T. Neck pain in the general population. Spine. 1994;19(12):13071309
75. Guez M, Hildingsson C, Nilsson M, Toolanen G. The prevalence of neck pain: a population-based
study from northern Sweden. Acta Orthopedic Scand. 2002;73(4):455459
76. Hermann KM, Reese CS. Relationships among selected measures of impairment, functional limitation,
and disability in patients with cervical spine disorders. Physical Therapy 2001;81(3):903914
77. Saarni SI, Harkanen T, Sintonen H, Suvisaari J, Koskinen S, Aromaa A, Lonnqvist J. The impact of 29
chronic conditions on health-related quality of life: a general population survey in Finland using 15D
and EQ-5D. Qualitative Life Resources. 2006;15(8):14031414
78. Barton PM, Hayes KC. Neck flexor muscle strength, efficiency, and relaxation times in normal
subjects and subjects with unilateral neck pain and headache. Archives of Physical & Medical
Rehabilitation. 1996;77(7):680687
79. Chiu TT, Sing KL. Evaluation of cervical range of motion and isometric neck muscle strength:
reliability and validity. Clinical Rehabilitation. 2002;16(8):851858
80. Jordan A, Mehlsen J, Ostergaard K. A comparison of physical characteristics between patients
seeking treatment for neck pain and age-matched healthy people. J Manipulative Physical Therapy
1997;20(7):468475
81. Krout RM, Anderson TP. Role of anterior cervical muscles in production of neck pain. Archves of
Physical & Medical Rehabilitation 1966;47(9):603611
82. Silverman JL, Rodriquez AA, Agre JC. Quantitative cervical flexor strength in healthy subjects and in
subjects with mechanical neck pain. Archives of Physical & Medical Rehabilitation 1991;72(9):679
681.
83. Vernon H, Mior S; The Neck Disability Index: a study of reliability and validity; Journal of
Manipulative Physiological Therapy 1992 Jan;15(1)
84. Cynthia J Watson and Margaret Schenkman; Physical Therapy Management of Isolated Serratus
Anterior Muscle Paralysis PHYSICAL THERAPY;1995; 75:194-202.
85. Adaptation of muscle to prolonged length changes; Biomechanics of skeletal muscles;
Biomechanical Principles 61-62.
86. J. L. Andersen, P. Aagaard; Effects of strength training on muscle fiber types and
87. size; consequences for athletes trail for high- intensity sport; Scandinavian Journal of Medical
Science& Sports 2010: 20(5)
88. Rebecca Booth ;The physiological effects of stretching; Stretch Receptors, Stretch Reflex;4-7.
89. Richa Mahajan,Chita Kataria, Kshitija Bansal;Compaitive effectiveness of Muscle Energy technique
and static stretching for subacute mechanical neck pain;International journal of health and related
sciences, vol 1(1)17-21
90. Parmar S, Shyam A, Sabnis S, Sancheti P. The effect of isolytic contraction and passive manual
stretching on pain and knee range of motion after hip surgery: A prospective, double-blinded,
randomized study. Hong Kong Physiotherapy Journal 2011; 29:25-30.
91. Nora Corbett; Treatment based classification approach to neck pain.

CORRESPONDENCE
* MPT (Musculoskeletal), Principal, Santosh Medical College and Hospital, Ghaziabad, Uttar Pradesh
** Student MPT (Musculoskeletal), Santosh Medical College and Hospital, Ghaziabad, Uttar Pradesh
40
*** MPT (Neurology), Assistant Professor, Santosh Medical College and Hospital, Ghaziabad, Uttar
Pradesh.
**** MPT (Musculoskeletal), Assistant Professor, Santosh Medical College and Hospital, Ghaziabad, Uttar
Pradesh.

41

PHYSIOTHERAPY INTERVENTION IN MANAGEMENT OF DIZZINESS

* Shahanawaz SD

ABSTRACT
Purpose: The aim of the study is to know the efficacy of exercise protocol in treating the patients with
dizziness. Design: Pilot study. Setting: RK Physiotherapy Department ,Rajkot, Gujarat, India; Madhuram
Hospital, Rajkot Methodology: Patients had evaluated by physician, Hall pike dix test, caloric test, postural
nyastagmography, Dizziness handicap inventory. Before the treatment patient had an outcome measured
with Dizziness handicap inventory, and Hall pike dix test. After that patient received design treatment
protocol for seven days. And after that all subject has to outcome measure with dizziness handicap
inventory, and Hall pike dix test. Results: Fifteen patients had at least one complication. 56 had myofascial
pain syndrome, 39 patients had post-operative joint stiffness, 23 had osteoporosis, 12 sustained path

KEYWORDS: Dizziness, DHI, Physiotherapy, Protocol

INTRODUCTION
The brain coordinates information from the
eye, the inner ear, and the bodys senses to
maintain balance. If any of these information
sources is disrupted, the brain may not be
able to compensate. Which results in
dizziness. Dizziness is one of the geriatric
problem.
1
According to studies, thirty
percent of older population suffer with
dizziness and this percentage will increases
at the age of 85 years.
2
For physicians
dizziness for older age group became
challenge as it is associated with multicausal.
The vestibular system is integral to balance
42
control. The paired vestibular organs, housed
within the temporal bone, include 3
orthogonal semicircular canals (superior,
posterior, and horizontal) and 2 otolish
organs (utricle and saccule). Together, the
semicircular canals and otolish organs
provides continues input to the brain about
rotational and translationl head motion and
the heads orientation relative to the gravity
This information from the vestibular organs
and their central pathways allows for the
maintenance of gaze and postural stability
via the vestibular ocular reflex and vestibulo
spinal reflex, respectively. Dysfunction of
the peripheral vestibular structures cannot be
directly observed but can be inferred from
assessment of these reflexes.

Background of study:
Dizziness is one of the geriatric problems.
According to studies, thirty percent of older
population suffers with dizziness and this
percentage will increases at the age of 65
years. For physicians dizziness became
challenge as it is associated with multiple
causes. According to National Institutes of
Health 54% of people experience feeling
dizzy at least once during life time.

Aim of study:
The purpose of this study was to Know the
efficacy of exercise protocol in treating the
patients with dizziness.

Hypothesis:
There is significant difference in treating the
patients with designed exercise protocol and
were assessed on Dizziness Handicap
Inventory (DHI) ,
Null Hypothesis:
There is no significant difference in treating
the patients with designed exercise protocol
and were assessed on Dizziness Handicap
Inventory (DHI)

Material:
Couch, stop watch, Goniometre.

Study design:
Pilot study.

Study area:
RK Physiotherapy Department ,Rajkot,
Gujarat, India. Madhuram Hospital ,Rajkot

Population:
Subjects having dizziness.

Inclusion criteria:-
Age group is 18-65
Both Males and Females
Able to experiencing symptoms for longer
period of 3 months
Able to transfer from sitting to standing and
move independently
Able to tolerate the exercise.
1) Physician diagnosed dizziness
2) Hall pike dix test (+ve)
3) Dizziness handicap inventory
4) caloric test (+ve)
43
5) Nyastagmography.

METHODOLOGY
All subjects were explained about the study.
Informed consent forms had sign. Subjects
were examined thoroughly with assessment
format. Assessment format is given in the
annexure. Patients had evaluated by
physician, Hall pike dix test.
3
caloric test,
postural nyastagmography, Dizziness
handicap inventory
4
. Patient who had fulfill
any three inclusion criteria included in the
study. Before the treatment patient had an
outcome measured with Dizziness handicap
inventory, and Hall pike dix test. After that
patient received design treatment protocol
for seven days. And after that all subject has
to outcome measure with dizziness handicap
inventory, and Hall pike dix test.

RESULTS
The mean value of pre treatment is 48.00 and
post treatment is 38.14 .and statistically
assessed by using the Wilcoxon signed ranks
test the table value T=2.7831 and p value is
0.018 .hence it shows a significant
difference.

Findings: Patient with dizziness shown the
significant changes in pre and post DHI
outcome
measured.

Wilcoxon Signed Ranks Test

CONCLUSION
Patient with dizziness shows significant
improvement post exercise protocol .Hence
the null hypothesis is rejected and Alternate
hypothesis is accepted.

DISCUSSION
In this study it has observed that the pre
treatment and post treatment values for the
subject 1 is 60 and 36 which were assessed
by using DHI ,when compare to the other
subjects .It shows the Subject 1 has practiced
more times /day.

Funding:
Self Funding

Conflict of Interest:
My interest is to set a exercise protocol on
dizziness which is cost effective and helpful to
the Indian society.

44
ANNEXURE - 1
PROTOCOL FOR DIZZINESS PATIENTS
No. TASK Repetition Time
1 straight head 3 times 30second
2 Turn your ahead 60 degrees towards right 3 times 30 second
3 Turn your ahead 60 degrees towards left 3 time 30second
4 Close your eyes and imagine blank back ground 1time 30second
5 Close Your Eyes Busy back ground (Checker
Board)
1 time 30 second
6 Single Leg Stance -Right Side 1 time 30 second
7 Single Leg Stance - Left Side 1 time 30second
8 Heel and Toe raises 1 time 30second
9 Perturbation training 1 time 30secomd
10 Hip marching 1 time 30 second
11 Lift up your right knee as high as comfortable.
(Lower your leg,
Alternate lifting your knees)
10,lifts(each
leg)
30 second
12 Sit and straight your right knee 6 times 30second

45

DIZZINESS HANDICAP QUESTIONNAIRE
1). Does looking up increase your problem?
(- ?)
o Yes ()
o Sometimes
( )
o No ()
2). Because of your problem, do you feel frustrated?
( l- l?)
o Yes ()
o Sometimes
( )
o No ()
3). Because of your problem, do you restrict your travel for business or recreation?
(l- , , ?)

o Yes ()
o Sometimes
( )
o No ()
4) Does walking down the aisle of a supermarket increase your problems?
( l- .
o Yes ()
o Sometimes
( )
o No ()
5). Because of your problem, do you have difficulty getting into or out of bed?
(l- ?)
o Yes ()
o Sometimes
46
( )
o No ()
6). Does your problem significantly restrict your participation in social activities
such asgoing out to dinner, the movies, dancing or to parties?
( | ,= ,5= ,= r
?)
o Yes ()
o Sometimes
( )
o No ()
7). Because of your problem, do you have difficulty reading?
( .)
o Yes ()
o Sometimes
( )
o No ()
8). Does performing more ambitious activities such as sports or dancing or
household choressuch as sweeping or putting dishes away increase your problem?
( ,= r , , ?)
o Yes ()
o Sometimes
( )
o No ()
9). Because of your problem, are your afraid to leave your home without having
someoneaccompany you?
(l | ?)
o Yes ()
o Sometimes
( )
o No ()
10). Because of your problem have you been embarrassed in front of others?
o Yes ()
47
( l ?)
o Sometimes
( )
o No ()
11). Do quick movements of your head increase your problem?
(|= l ?)
o Yes ()
o Sometimes
( )
o No ()
12). Because of your problem, do you avoid heights?
(l?)
o Yes ()
o Sometimes
( )
o No ()
13)Does turning over in bed increase your problem?
( l ?)
o Yes ()
o Sometimes
( )
o No ()
14). Because of your problem, is it difficult for you to do strenuous homework or
yard
work?
(l , ?)
o Yes ()
o Sometimes
( )
o No ()
48
15). Because of your problem, are you afraid people may think you are
intoxicated?
(l l?)
o Yes ()
o Sometimes
( )
o No ()
16). Because of your problem, is it difficult for you to go for a walk by yourself?
( ?)

o Yes ()
o Sometimes
( )
o No ()
17). Does walking down a sidewalk increase your problem?
( | ?)

o Yes ()
o Sometimes
( )
o No ()
18). Because of your problem, is it difficult for you to concentrate?
(l|\ - ?)
o Yes ()
o Sometimes
( )
o No ()
19) Because of your problem, is it difficult for you to walk around the house in the
dark?
(l ~ ?
o Yes ()
o Sometimes
( )
49
o No ()
20). Because of your problem, are you afraid to stay at home alone?
(l | ?)
o Yes ()
o Sometimes
( )
o No ()
21). Because of your problem, do you feel handicapped?
( , ?)
o Yes ()
o
Sometimes
)
o No ()
22). Has your problem placed stress on your relationship with members of your
family orfriends?
(l | ? ~ - ?)
o Yes ()
o Sometimes
( )
o No ()
23). Because of your problem, are you depressed?
(l?)
o Yes ()
o Sometimes
( )
o No ()
50

24). Does your problem interfere with your job or household responsibilities?
( lll, l - ?)
o Yes ()
o Sometimes
( )
o No ()
25). Does bending over increase your problem?
( l ?)
o Yes ()
o Sometimes
( )
o No ()

REFERENCES
1. Colledge NR, Wilson JA, Macintyre CC, Mac LennanWJ :The prevalence and characteristics of
dizziness in an elderly community.
2. Tinetti ME, williams CS Gill TM: Dizziness among older adults: A possible geriatric syndrome.
3. Cheryl D Ford-Smith, The Individualized Treatment of a Patient With Benign Paroxysmal Positional
Vertigo,(PHYS THER. 1997; 77:848-855.)
4. Richard A. Clendanie, The Effects of Habituation and Gaze Stability Exercises in the Treatment of
Unilateral Vestibular Hypofunction,(JNPT , Volume 34, June 2010.)
5. Janet OdryHelminski,: Strategies to Prevent Recurrence of Benign Paroxysmal Positional
Vertigo,(ARCH OTOLARYNGOL HEAD NECK SURG/VOL 131, APR 2005)
6. Ahmad H. Alghadir, review article on An update on vestibular physical therapy(Journal of the
Chinese Medical Association 76 (2013) 1e8)
7. Kathleen M Gill-Body, :Relationship Among Balance Impairments, Functional Performance, and
Disability in People With Peripheral Vestibular hypofunction,(PHYS THER. 2000; 80:748-758)
8. Courtney D.Hall , Vestibular-specific gaze stability exercises to standard balance rehabilitation
results in greater reduction in fall risk.(JNPT 2010;34: 6469).
9. Fernando Vaz Garcia :Disequilibrium and Its Management in Elderly Patients(International Tinnitus
Journal, Vol. 15, No. 1, 8390 ,2009)
10. Bara A. Alsalaheen: Vestibular Rehabilitation for Dizziness and Balance Disorders After
Concussion(JNPT 2010;34: 8793)
11. Carol A. Foster a AnnandPonnapan b Kathleen Zaccaro c:A Comparison of Two Home Exercises for
Benign Positional Vertigo:Half Somersault versus Epley Maneuver(Departments of a Otolaryngology
and Audiology, University of Colorado Denver, Aurora, Colo. , USA)

12. Aggrawal NT, Bennett DA, Bienias JL, Mendes de leon CF, Morris MC,EvansDA:The prevalence of
dizziness and its association with functional disability in a biracial community population.JGerontol
(A Biolsci Med sci 2000, 55:M288-)
13. Sloane PD,Coeytaux RR, Beck RS ,DallaJ: Dizziness: State of the science. Ann Intern Med
2001,134:823-832
51
14. Lawson J, Fitzgerald j, Birchall j, Aldren CP, Kenny RA: diagnosis of geriatric patients with severe
dizziness.J AM geriatrSoc 1999, 47:12-17
15. Madlon- Kay DJ: Evaluation and outcome of the dizzy patient. (J FamPract 1985, 21:109-113.)
16. Harvey SA, Wood DJ, Feroah TR: Relationship of the head impulse test and head-shake nystagmus in
reference to caloric testing. (American Journal of Otology)
17. Fujimoto M, Rutka J, Mai M: A study into the phenomenon of head-shaking nystagmus: Its presence
in a dizzy population. (Journal of Otolaryngology)

CORRESPONDENCE
* M.P.T. (Neurology), Ph.D, Assistant Professor, RK University, Rajkot

52

ETHICAL CHALLENGES FOR OCCUPATIONAL THERAPIST IN INDIA
TO USE SOCIAL MEDIA

*Koushik Sau, **Sridhar D, ***Sanjiv Kumar

ABSTRACT
Like other part of the world, usage of social media is growing rapidly among various age groups using
Internet actively in India. Social media has good and bad qualities within it. Occupational therapist can use
social media effectively to promote their professional qualities through media based activities in the virtual
forum. Social media such as Internet based access is cost effective, consumer friendly, communicates faster
and reaches everyone around the world by few clicks but Occupational Therapist should use these media with
utmost cautious. This article is a try to summaries some perception about ethical and legal issues on social
media users among occupational therapy practitioners in India.
KEYWORDS: Social Media, Occupational Therapy, Ethics, Privacy Issue, India

1 INTRODUCTION
Social media (SM) concepts gained more
attention in everyones life as a recent past
1
.
The concept defines SM as mobile phone and
web-based platform that enable individual or
group of people to communicate actively to
interact and exchange of user generated
contents
2
. Though SM become synonymous
with social network site, SM has been more
powerful in terms of consumer technology.
Various types of social media exist in the
present day scenario. Virtual world in social
networking sites like Facebook or Google +,
Blog like BlogSpot, Micro blog like twitter,
collaborative projects like wiki, content
53
communities like YouTube, Virtual social
world like second life, image hosting website
like Flicker, PowerPoint presentation and
document sharing website such as Slide share
and professional networking like LinkedIn
3,4
.
Individuals can shared or obtained information
in different formats like text, picture, video
and audio
4
.
These forms of information offer various
platforms to provide personal statements,
creating an interest group, ensuring
cooperation and sharing information, which is
considered to be an important tool for
communication
2,4
.
2 SOCIAL MEDIA IN INDIA:
Easy access to information and
communication technology (ICT) through
computer and mobile access technology is
growing every year in all regions of the world
and as well as in India. One out of four
persons in the world uses SM
5
and in India,
more than 60 million people are currently
using various SM sites for communication and
exploration
6
. It is estimated in India around 66
million people are going to be a SM user by
the June, 2013
6
.
According to report published by the Internet
and mobile association of India (IAMAI)
2012, 74 % of active Internet users from urban
in India use SM and number of user
increasing every day due to growing Internet
penetration through Smartphones and
consequent mobile internet use
6
. IAMAI
report (2012) revealed that SM usage ranked
second after email and served as the First
time Internet uses by among active Internet
users of India
6
. Though top eight metro cities
contribute 34% of SM users, however, 66% of
users in India belong to other small cities.
Almost one fourth (24%) SM users were from
the small town with population less than two
lakhs
6
.
It is a common belief that young adult rules
SM platform
7
but according to resent findings
showed older men uses SM with 65%
penetration level compare to young adult 84%
penetration
6
level, which is a quite high ratio
in a country like India. Experience and
budding occupational therapists can utilize the
SM site to promote their profession practice
and knowledge. They should be cautious
regarding advantages and disadvantages while
using the social media.

2.1 Benefits of social media:
SM helps people to connect and collaborate
with virtual communities. These communities
offer an opportunity to reach out to their
audience with a stroke of key from any place
at a given time. This form of connectivity
increases more individual and group
interaction between social media user
2
and
also elevates electronic communication like
face-to-face communication
5
. Through SM,
everyone has access to explore other
geographical and physical boundaries with
few clicks via mobile
8
or computer gadgets,
enhances the broadcast of health- related
information to general public
5,9
and also used
54
in teaching and advocacy
9
.

2.2 Problems with social media:
Like other technological inventions, SM can
be used in good or bad ways
7
which is like a
mirror that reflects what best or worst we post
on it
9,10
. Occupational therapists should be
aware about their tweet, blog post, Status
update or photos, video uploads in any social
media not only reflect user, but it also reflects
ones employer and profession
7
.
It can blur the boundary between an
individuals professional and personal life
10, 11
.
Any form of post in the SM site will become
easy accessible for wider audience beyond the
up-loader aim to reach friends and colleagues
of their domain. Once uploaded information is
difficult to control by up-loader and
impossible to delete those content in future
11,
12
.
Sometimes an unwanted post or adverse
comments from individual against
professionals or profession as a whole can ruin
ones image and difficult to control
12, 13
.
Propagation regarding undisclosed
information and frivolous misleading
rumours
2
regarding professional or profession
may create the bad image among others due to
high accessible by others, and precaution can
avoid circumstantial errors.

2.3 Occupational Therapy and social
media:
SM is much more than a tool for
communication, which has widely and
effectively used by occupational therapists for
various purposes in professional practice
4, 7, 12,
13, 14
. Professional bodies of an occupational
therapists in different countries are using SM
for promotion, marketing purposes and, even
encouraging their members to use it for
professional growth
4, 7, 12, 13, 14, 15
, with a
specific SM guidelines for the occupational
therapists
4
. In recent years, Indian
occupational therapists are also using different
SM like BlogSpot, Facebook, and twitter as
one of the daily routines.
According to Kaplan and Haenlei
3
SM has two
major components that are social and media,
and both are important for an occupational
therapy profession. SM is an essential
professional activity for present generation
13,
14
. It helps to develop small and large
communities among other fellows
occupational therapist who has a similar
interest, and specialists discuss the knowledge
base for academic and clinical practice issues
in occupational therapy
14
and also develop
virtual communities with other fellow
professionals, organization to learn and share
the mutual benefits
7, 13, 14
. Occupational
therapist can also be a part of virtual
communities such as Community for stroke
patient older adult Autism and play an
advocacy role as when it required
7, 12
.
Media is another major component in which
occupational therapist can make use of SM for
marketing and promotional activities
4, 13, 15
.
This will helps the individual to access target
audiences and widening the communication
55
range
4
. Now a days, Indian consumers have a
role to select their preferred health care
provider.
To educate consumer regarding occupational
therapy services and its benefits. In this
regard, every occupational therapist should be
in the participatory mode to promote and
market
15, 16
along with their clinical and
academic practice. It also helps to develop
strategic partnerships and collaboration with
other organizations
4, 9
. Media platforms can be
used for political advocacy for the
occupational therapists
7
. It helps the
occupational therapist to provide necessary
information directly to their potential
customers any time frame and place. It is a
time-saving mechanism and economical when
compare to any other form of media that
breaks through geographical barriers in few
clicks
4
.

2.4 Ethical consideration using social media
by the occupational therapist:
Due to the recent high SM growth rate in
India among other professionals, occupational
therapist may not afford to be distant from SM
usage because the report showed that active
Internet user spent more than 28 minutes every
day in India
6
. In this view, the occupational
therapist should use SM in absolute sensitivity
towards customer and profession
5,9
with legal
obligation, which may arise various laws
pertaining to information privacy
2
.

2.5 Customer concern:
World federations of Occupational therapy
(WFOT) code of ethics clearly mention that
confidentiality should not disclose without
consumer consent
17
. All India Occupational
Therapy Associations (AIOTA) in their code
of ethics also declare that occupational
therapist should maintain confidentiality about
consumer information
18
. Occupational
therapist can only disclose private information
of client with his verbal or written consent
19,20
.
Other international occupational therapy
national bodies suggested that if there is any
legal requirement or consumers information
helpful for general public, then it can be
shared
19, 20
. According to 2011 Information
technology rule
23
, any leakage of health-
related information like medical record,
patients history of the physical,
psychological and mental health conditions of
an Indian citizen will be confined to
imprisonment for six months term or a fine up
to rupees one lakh or both
2, 21
.

2.6 Professional Concern:
Occupational therapist should be aware about
the SM norms, ethical obligation and legal
formalities while using this platform with
professional identity. Using social media for
professional related practice issue not only
reflects the individual practitioner but it also
reflects profession and employers
12, 13
. In this
view, the occupational therapist should
scrutinize well before posting in any social
media platform about themselves, others and
profession
9
.
56
3. SUMMARY/CONCLUSION:
SM is a common practice in the modern day
among professionals. Occupational therapist
should understand the appropriate use of SM
is shared responsibility for every individual
9

because each one represents their profession
by some means
13
. One should be aware about
SM, followers and also essential to maintain
separate accounts for professional and
personal usage
4
.
Each one of us should follow organization
policies and ethical obligations to maintain
consumer privacy and confidentiality at all
time. We recommend that occupational
therapist must maintain their dignity and
professional responsibilities while using SM.
In India, there are few guidelines available for
SM usage professionally and not specified to
individual profession, especially like
occupational therapy or any other
disciplines
12
.
In September 2011, the Department of
Information Technology under Government of
India released guidelines for using social
media only for the government organization
2
,
and these guidelines are not made for
occupational therapist or any other health
profession. However, these guidelines can be
adapted for the occupational therapy
11
also.

REFERENCES

1. Tiryakioglu F, Erzurum F. Use of social networks as an education tools. Contemporary
Educational Technology, 2011; 2(2): 135-150.
2. Framework & guideline for use of social media for government organizations [Internet]. New
Delhi, Department of electronics and information technology ministry of Communication &
information technology government of India. 2011, Sep; [cited 2013 Apr 15].

3. Available from:
http://negp.gov.in/pdfs/Social%20Media%20Framework%20and%20Guidelines.pdf
4. Kaplan AM, Haenlein M. Users of the world, unite! The challenges and opportunities of social
media. Business Horizons. 2010; 53: 59-68.
5. Social media strategies & guidance [Internet]. UK: British association of occupational therapists
and college of occupational therapist; 2013 [cited 2013 Apr 16]. Available from:
http://www.cot.co.uk/strategic-plans/social-media-strategy-guidance
6. McNab C. What social media offers to health professional and citizens? Bulletin of the World
Health Organization 2009; 87:566.
7. Social media in India -2012 [Internet]. Mumbai: Internet and mobile association of India 2013,
Feb; [updated 2013 Feb; cited 2013 Apr 16]. Available from:
http://www.iamai.in/Upload/Research/31220132530202/Report-Social-Media%202012_67.pdf .
8. Strzelecki MV. Social media sites How Practitioners can better follow, fan and friend. OT Practice
.2011, March, 8; 16(5):8-11.
9. Practice guideline ethical and responsible use of social media technologies [Internet]. Canada:
Nurses association of new Brunswick ; 2012 [ updated 2012 Oct; cited 2013 Apr 19] Available
from : http://www.nanb.nb.ca/downloads/Practice%20Guidelines-%20Social%20Media-E(1).pdf
10. Greysen SR, Kind T, Chretien KC. Online professionalism and the mirror of social media. J Gen
Intern Med. 2010 Nov; 25(11):1227-9.
11. Using social media: practical and ethical guidance for doctors and medical students [Internet].
London: British Medical Association; Available from: http://bma.org.uk/-
/media/Files/PDFs/Practical%20advice%20at%20work/Ethics/socialmediaguidance.pdf.
12. Visser BJ, Huiskes F, Korevaar DA.A social media self-evaluation checklist for medical
practitioners. Indian J Med Ethics. 2012 Oct-Dec;9(4):245-8
57
13. Wainer L. Social media in OT practice. On the record. 2011 Fall; 11(3): 10-11.
14. Kashani R, Burwash , Hamilton A. To be or not to be on facebook: That is the question.
Occupational Therapy Now. 2010, November; 12(6): 19-22
15. Bodell S, Hook A. using Facebook for professional networking: a modern day essential. BJOT.
2011, Dec; 74(12); 588-590.
16. Share information about occupational therapy on social media sites [Internet]. USA: The American
occupational therapy association; c2012 [cited 2013 Apr 20] Available from:
http://www.aota.org/DocumentVault/News/Social-Media/Social-Media.aspx
17. Morley M, Rennison J. Marketting occupational therapy: everybodys business. BJOT.2011, Aug;
74(8); 406-408.
18. Code of ethics [Internet].World federation of occupational therapy; c2005 [updated 2005; cited
2013 Apr 19] Available from: http://www.wfot.org/ResourceCentre.aspx
19. Bylaws of all India Occupational therapist association [Internet]. India: All India Occupational
therapist association; c 1950[updated 2009; cited 18 Apr]. BYELAW XI: (ARTICLE X SECTION
II) A Code of Ethics for Occupational Therapists;[about 2 screen] Available from :
http://www.aiota.org/pdf/AIOTA_BYLAWS.pdf
20. Code of ethics and professional conduct [Internet]. UK: College of occupational therapy; c 2013
[updated 2010; cited 20 Apr]. Confidentiality; [about 3 screen]. Available from:
http://www.cot.co.uk/sites/default/files/publications/public/Code-of-Ethics2010.pdf
21. Code of ethics and professional conduct of occupational therapist [Internet].Ireland: The
association of Occupational Therapist of Ireland; c 2013 [updated 2006; cited 2013 Apr 20].
Confidentiality; [about 1 screen ] Available from : http://www.aoti.ie/attachments/6e16e2ca-aa53-
4b0c-aa2c-4186067cfaa4.PDF
22. Now, leaking health information may land you in prison [Internet]. The Indian Express [online
edition].2011, Jun, 27[cited 2013 Apr 25[about 2 screens] Available from:
file:///C:/Documents%20and%20Settings/Admin/My%20Documents/Opinion%20on%20IJME/Now
,%20leaking%20health%20information%20may%20land%20you%20in%20prison%20-
%20Indian%20Express.htm

CORRESPONDING AUTHOR:
*Assistant Professor- Senior Scale, Department of Occupational Therapy, School Of Allied Health
Sciences,, Manipal University, Manipal, Karnataka, India. Email: Koushiksau@gmail.com
** Department of Occupational Therapy, School Of Allied Health Sciences,, Manipal University, Manipal,
Karnataka, India.
*** Department of Occupational Therapy, School Of Allied Health Sciences,, Manipal University, Manipal,
Karnataka, India.
58

STUDY OF EFFECTIVENESS OF CORTICOSTEROID INJECTION IN
FROZEN SHOULDER

*Dr. Pradeep Choudhari, **Dr. Anand Mishra

ABSTRACT
Objective: To assess whether intraarticular corticosteroids improve the outcome of a comprehensive home
exercise programme in patients with Frozen Shoulder. Setting: The study was undertaken in the
Department of Orthopedics & Traumatology, Sri Aurbindoo Medical College and Post graduate institute
Indore (SAIMS), M.P. Subjects: Eighty patients with Frozen Shoulder were enrolled in the study.
Interventions: The patients were randomly assigned to two groups: Group 1 patients were given
intraarticular corticosteroid (1 mL, 40mg methylprednisolone acetate) Followed by a 12-week
comprehensive home exercise programme. Group 2 patients were given intraarticular serum physiologic
(1mL solution of 0.9% sodium chloride) followed by a 12-week comprehensive home exercise programme.
Main measures: The outcome parameters were Shoulder Pain and night pain and shoulder Passive range
of motion. Results: Mean actual changes in abduction range of motion, Shoulder Pain and were
statistically different between the two groups at the second week, with the better scores determined in group
1. However, there were no significant differences between the groups at the 12th week. Conclusions:
Intraarticular corticosteroids have the additive effect of providing rapid pain relief, mainly in the first
weeks of the exercise treatment period. In patients with Frozen Shoulder who have pain symptom
predominantly, intraarticular corticosteroid therapy could be advised concomitantly with exercise.

KEYWORDS: Frozen Shoulder, Intraarticular corticosteroids, Home Exercise Programme

59
INTRODUCTION
Frozen Shoulder is a condition characterized
by spontaneous onset of shoulder pain and
gradual loss of active and passive shoulder
motion. It is a common cause of shoulder pain
and disability estimated to affect 25% of the
general population.
1
The aetiology of frozen
shoulder remains unclear; however, the factors
associated with frozen shoulder include
female, trauma, age older than 40 years,
diabetes, prolonged immobility, thyroid
disease, stroke, myocardial infarcts and
presence of autoimmune disease.
2
The natural
history of frozen shoulder goes through three
phases: increasing pain and stiffness, lasting
29 months, a steady-state period from 4 to
20 months, and a spontaneous recovery lasting
between 5 and 26 months.
3
Some authors
believe it is a self-limiting disorder,
4,5
but
others suggest it is a more chronic disorder
leading to longer term disability.
68
In the
recovery stage, approximately 715% of
patients permanently lose their full range of
motion.
8,9
Exercises, physiotherapy
programmes including ultrasound, laser,
transcutaneous electrical stimulation and
iontophoresis, oral non-steroidal anti-
inflammatory drugs and intraarticular
injections to the glenohumeral joint, or their
combinations are used to treat frozen shoulder.
In resistant patients, manipulation or surgical
release may be applied.
10
Van der Heijden et
al. assessed the effectiveness of physiotherapy
for patients with soft tissue shoulder disorders
from randomized controlled trials and showed
that ultrasound therapy seems ineffective in
patients with shoulder disorders when
compared with placebo or another treatment,
and there was insufficient evidence to support
the effectiveness of low level laser, heat, cold,
electrotherapy, exercise and mobilization in
such patients.
11
Green et al. reviewed
randomized clinical trials of efficacy of non-
steroidal anti-inflammatory drugs,
intraarticular and subacromial corticosteroid
injection, oral corticosteroid, physiotherapy,
manipulation under anaesthesia, hydro
dilatation and surgery in patients with
shoulder pain, and reported that there was
little evidence to support or refute the use of
any of the common interventions.
1214

Buchbinder et al. performed a systematic
review of randomized and pseudo-randomized
trials of corticosteroid injections for shoulder
pain. Their conclusion was that intraarticular
steroid injection for frozen shoulder may be
beneficial, although its effect may be small
and not well maintained.
15
A systematic
review of randomized clinical trials on the
effectiveness of corticosteroid injections or
physiotherapy for shoulder pain showed
inconsistent short-term results and limited
evidence for the long-term outcome.
16
Our
objective was to assess whether intraarticular
corticosteroids improve the outcome of a
comprehensive home exercise programme in
patients with frozen shoulder.

MATERIALS AND METHODS
This prospective study was conducted in the
60
Department of Orthopedics & Traumatology,
Sri Aurbindoo Medical College and Post
graduate institute Indore (SAIMS), M.P.
Study included all newly diagnosed frozen
shoulder patients consecutively came to the
Department of Orthopedics outpatient clinic.
Frozen shoulder or adhesive capsulitis was
defined as the presence of shoulder pain with
limitation of both active and passive
movements of the glenohumeral joint of >25%
in at least two directions.
17

The inclusion criteria were as follows: age
between 18 and 70, symptom duration
between six weeks and six months, and no
treatment other than analgesics in the last six
months.
The exclusion criteria were uncontrolled
diabetes mellitus, contraindications of
injections and previous shoulder surgery. A
total of 80 patients with frozen shoulder were
enrolled in this study. All patients were
randomized after initial evaluation by
selecting a sealed unmarked envelope
containing a letter that informed them of their
group. Group 1 patients (n=30) with 40
shoulder involvements were given
intraarticular 1 mL, 40 mg methylprednisolone
acetate followed by a 12-week comprehensive
home exercise programme. Group 2 patients
(n=30) with 40 shoulder involvements were
given intraarticular 1mL serum physiologic
(solution of 0.9% sodium chloride) followed
by a 12-week comprehensive home exercise
programme.
The injections were given intraarticularly via
the posterior approach, with the patient seated,
and the arm on the affected side slightly
rotated internally. The index finger of the
physician was placed on the coracoid process
and the thumb on the angle between the spine
of the scapula and the acromion. The needle
was introduced 1 cm below the thumb and
aimed at the coracoid process. A 1- or 2-mL
syringe, fitted with a 5-cm, 21-gauge needle
was used. All the injections were applied by
the same Doctor, who was informed with
regard to the injection materials, while patients
were unaware of the type of injection. All
patients were assessed at initial evaluation,
and 2nd and 12th weeks of treatment. Initial
evaluation included the recording of
demographic data, medical history, relevant
comorbidities, dominant and affected shoulder
and detailed examination of the shoulder. At
all three evaluations, shoulder passive range of
flexion/abduction and external/internal
rotation, night pain and shoulder disability
were measured. Passive range of motion of the
involved shoulder was measured in all planes
with a long-arm goniometer with patients in
supine position. Shoulder flexion was assessed
in sagittal plane with the arm at the side and
hand pronated, while the shoulder abduction
was measured in the frontal plane with the arm
at the side and the shoulder externally rotated
to obtain maximum abduction. Shoulder
internal and external rotations were measured
in transverse plane with the arm abducted to
90%, the elbow flexed to 90%, the hand
pronated and the forearm perpendicular to the
61
floor. When the arm could not be abducted
90%, the arc was considered to be 0%, and
internal and external rotations were measured
on this plane. Night pain was measured with
visual analogue scale of 0100 mm, ranging
from no pain to very severe pain. Shoulder
pain and disability index was administered to
all patients to evaluate shoulder disability, and
was evaluated in three forms:
(a) Shoulder Pain and Disability Indexpain,
b) Shoulder Pain and Disability Index
disability and
(c) Shoulder Pain and Disability Indextotal.
The five-item pain subscale addresses pain
experienced during activities of daily living,
and each item is anchored by the descriptors
no pain (left anchor) and worst pain
imaginable (right anchor). The eight
disability items address the level of difficulty
in performing activities of daily living. These
items are anchored with descriptors no
difficulty (left anchor) and so difficult it
required help (right anchor). Each item is
scored by measuring the distance from the left
anchor to the mark made by the person.
Subscales are scored in a three-part process.
First, item scores within the subscale are
summed. Second, this sum is divided by the
summed distance possible across all items of
the subscale to which the person responded.
Third, this ratio is multiplied by 100 to obtain
a percentage. Higher scores on the subscale
indicate greater pain and greater disability. To
obtain the Shoulder Pain and Disability Index
total score, pain and disability subscales are
averaged.
18,19
University of California-Los
Angeles end-result score, a 35-point scale, was
used to assess the effectiveness of treatment.
The items measured include pain (10 points),
function (10 points), active forward flexion
(5 points), strength of forward flexion (5
points) and patient satisfaction. A score of
3435 is considered an excellent result, 2933
a good result, and any score less than 28 a
poor result.
20,21
The scale was applied at the
2nd and 12th weeks of the treatment. All
patients were given the same comprehensive
home exercise programme. Initially, pendulum
circumduction and passive shoulder self-
stretching in forward elevation, external
rotation, horizontal adduction and internal
rotation were prescribed. The patient was
instructed to stretch the shoulder to the point
of tolerable discomfort five times a day. The
goal is to stretch the capsule sufficiently to
allow restoration of normal glenohumeral
biomechanics. When the passive shoulder
range of motions reached 90% of normal
ranges, the exercise protocol was followed by
isometric in all planes; theraband exercises
with three different therabands (lowmedian
high resistances); strengthening exercises for
the muscles of scapular stabilizations; and
advanced muscle strengthening exercises with
dumbbells, respectively. All the patients were
invited biweekly to ensure compliance and to
be instructed regarding the new exercise. We
recommended hot pack application before and
cold pack application after shoulder exercises.
Oral paracetamol (1500 mg/day) was
62
recommended to patients when needed. The
same Doctor, who was blinded to the injection
therapy, evaluated all patients measurements.
All patients were informed about the nature of
the study procedure and provided informed
consent prior to beginning the trial was taken.
Data analysis was performed using SPSS for
Windows. Data were shown as mean standard
deviation or median (interquartile range),
where appropriate. Categorical variables were
presented as percentages. Medians were
compared using the Mann Whitney U-test.
Differences among repeated measures were
evaluated by Friedman Two-Way Analysis of
Variance by Ranks. When the P-value from
the Friedman test statistics was statistically
significant, multiple comparison tests were
used to determine pair wise differences
between groups. At the 2nd and 12th weeks,
actual changes in levels according to baseline
were calculated. Between-group comparisons
for actual changes were evaluated by Mann
Whitney U-test. For categorical comparisons,
chi-square or Fishers exact test were used,
where appropriate. A P-value less than 0.05
was considered statistically significant.

RESULTS
The demographic characteristics of the
patients according to group are shown in Table
1.

Table 1 Demographic characteristics of the patients in both groups
Group 1 Group 2 P Value
Age ( Mean in Yrs) 56.9 56.3 0.792
SexMale 25 10 0.105
Female 15 14
Co-morbidities 33 20 1.000
Dominant hand
Right

38

24

Left 4 0 0.288
Affected side
Dominant

27

11
0.145
63
Non-Dominant 13 13

Group 1 included 40 patients, two of whom
had bilateral involvement; thus, a total of 42
shoulder joints were evaluated. Twenty-four
patients of 40 in group 2 completed the study.
Sixteen patients failed to complete the study:
10 had difficulty in attending the clinic
regularly, 2 had intercurrent medical problems
and 4 were lost to follow-up. A consort
diagram of the patients is shown in Figure 1.
There were no differences between the groups
with respect to demographic data (P40.05).
Medians of night pain, all range of motions,
and Shoulder Pain and Disability Index scores
at each evaluation are shown in Table 2 and
Figure 2. University of California-Los
Angeles end-result score at each evaluation is
shown in Table 2. There were no statistical
differences between the two groups in the
initial measurements of night pain, Shoulder
Pain and Disability Index scores and all range
of motions, with the exception of external
rotation (P40.05). Range of motions, night
pain, and Shoulder Pain and Disability Index
scores in both groups differed significantly at
the 2nd and 12th weeks with respect to
baseline values (Table 2). University of
California-Los Angeles end-result score
results improved significantly in both groups
at the 12th week in comparison with the 2nd
week score (P50.05).

Table 2 Medians of night pain, all ranges of motion (ROMs), Shoulder Pain and Disability Index
(SPADI) scores and University of California-Los Angeles end-result scores (UCLA) at each
evaluation
GROUP 1 GROUP 2
Base line
median
2nd week
median
12
th
week
median
Base line
median
2
nd
week
median
12
th
week
median
Night pain 77.5(20.0) 30.0(50.0) 7.5(30.0) 70.0(40.0) 50.0(38.7) 12.5(50)
Flexion 137.5(30.0) 160.0(38.7) 180.0(16.2) 130.0(27.5) 150.0(37.5) 165.0(27.5)
Abduction 107.5(41.2) 137.5(60.0) 180.0(22.5) 90.0(27.50 110.0(46.2) 160.0(57.5)
Int.Rotation 55.0(25.0) 80.0(30.00 90.0(15.00 47.5(10.0) 55.0918.7) 90.0(30.0)
Ext.Rotation 50.0(31.2) 75.0(45.0) 90.0(20.00 40.0(17.5) 50.0(18.70 70.0(37.5)
64
UCLA 26.5(4.5) 32.5(6.2) 23.0(6.5) 31.5(7.7)
SPADI-t 69.4(40.5) 29.9(33.0) 10.9(23.3) 70.5(25.6) 42.5(38.0) 14.5(27.1)
SPADI-p 71.0(39.7) 28.0(32.0) 12.0(32.0) 66.0(25.0) 43.5(48.0) 12.5(26.7)
SPADI-d 63.4(38.1) 26.2(36.0) 10.0(24.2) 70.5(24.8) 44.0930.9) 11.5(31.4)

The mean actual changes in night pain, range
of motions, and Shoulder Pain and Disability
Index scores at the 2nd and 12th weeks and
differences between the two groups are shown
in Tables 3 and 4.

Table 3 Mean actual change in night pain, ranges of motion (ROMs) and Shoulder Pain and
Disability Index (SPADI) scores at the 2nd week from baseline and differences between the groups
Group 1 Group 2 P value
Night pain -36.5(25.1) -26.5(25.1) 0.070
Flexion 22.4(18.5) 13.9(16.5) 0.075
Abduction 36.5(27.1) 18.7(26.8) 0.033
Int.Rotation 16.5(19.1) 9.8(14.9) 0.088
Ext.Rotation 18.4(16.3) 12.9(13.4) 0.173
SPADI total -30.9(19.9) -20.2(15.0) 0.047
SPADI-pain -30.1922.1) -19.0(17.6) 0.041
SPADI-disability -28.8(21.2) -23.1(17.8) 0.301

Table 4 Mean actual change in night pain, ranges of motion (ROMs) and Shoulder Pain and
Disability Index (SPADI) scores at the 12th week from baseline and differences between the groups
Group 1 Group 2 P value
Night pain -53.1(27.8) -51.7(28.1) 0.552
Flexion 36.8(15.9) 33.5(16.1) 0.356
65
Abduction 57.8(27.9) 54.2(29.1) 0.639
Int.Rotation 25.7(19.1) 54.2(29.1) 0.693
Ext.Rotation 27.4(19.5) 31.2(20.1) 0.421
SPADI total -44.4(24.0) -48.2(16.3) 0.407
SPADI-pain -42.4(25.5) -44.8(19.4) 0.684
SPADI-disability -42.2(26.3) -49.8(18.8) 0.156

Mean actual changes in abduction range of
motion, Shoulder Pain and Disability Index
total score and Shoulder Pain and Disability
Indexpain score were statistically different
between the two groups in the 2nd week, with
the better scores determined in group 1. There
was no significant difference between the two
groups with respect to mean actual change in
night pain, Shoulder Pain and Disability Index
scores, and range of motion measurements at
the 12th week. In the 2nd week, group 1
showed 32 (76.2%) poor, 9 (21.4%) good and
1 (2.4%) excellent recovery according to
University of California- Los Angeles scores.
Group 2 showed 23 (95.8%) poor, 1 (4.2%)
good, and 0 (0%) excellent recoveries. In the
12th week, group 1 showed 15 (35.7%) poor,
17 (40.5%) good and 10 (23.8%) excellent
recovery. Group 2 showed 10 (41.7%) poor,
10 (41.7%) good, and 4 (16.7%) excellent
recovery. Medians of University of California-
Los Angeles scores in the 2nd week were
significantly different between the two groups
(P0.002), with better scores in group 1;
however, difference in 12
th
week scores was
insignificant (P0.486). No side-effects were
noted during the drug or exercise therapy
sessions.

DISCUSSION
We aimed in this study to assess whether
intraarticular corticosteroids improve the
outcome of a comprehensive home exercise
programme in patients with frozen shoulder.
Our results show that intraarticular
corticosteroid therapy concomitant with
exercise achieves fast relief of pain and
improvement in disability in the short term.
Exercise therapy is critically important in
frozen shoulder. It is important to educate the
patient regarding the improvement in range of
motion. Stretching should be the focus of the
treatment. It can be taken beyond the limits of
the available range of motion.
2
It has been
demonstrated that there is a significant deficit
in shoulder muscle isometric strength and
endurance.
22
Strengthening of the scapula
musculature and rotator cuff muscles can be
added to increase strength and endurance.
2,22

A 90% improvement can be achieved using
66
only four directional stretching exercises.
23
In
this study, we administered a comprehensive
exercise programme both to the patients
treated with intraarticular placebo and to those
given corticosteroid. Both groups showed the
same improvement at the 12th week.
Comprehensive exercise therapy under close
follow-up is a fundamental choice Steroid
injection therapy has been advised in frozen
shoulder based on the belief that inflammation
plays an important role in the pathogenesis. In
1945, Neviaser introduced the term adhesive
capsulitis and described the inflammatory
process.
24
Cytokines have been implicated
recently in the inflammation and fibrosis
described in frozen shoulder. Cytokines are
involved in the initiation and termination of
repair processes in multiple musculoskeletal
tissues, and their sustained production has
been shown to result in tissue fibrosis.
25
Early
treatment with intraarticular corticosteroid
may provide a chemical ablation of synovitis,
thus limiting the subsequent development of
fibrosis and shortening the natural history of
the disease.
2
There are contradictory findings
in different studies about intraarticular
corticosteroid therapy. Rizk et al. compared
four treatments for frozen shoulder:
(a) Intraarticular methylprednisolone and
lidocaine, (b) intrabursal methylprednisolone
and lidocaine, (c) intraarticular lidocaine, and
(d) intrabursal lidocaine. There were no
significant differences in outcome between
intrabursal injection and intraarticular
injection. Injection of steroid with lidocaine
had the advantage of partial transient pain
relief.
26
Bulgen et al. randomized patients to
treatment with steroid, physical therapy, ice or
benign neglect. The initial response to
treatment was most marked in patients treated
with steroid; however, no significant
difference in final long-term outcome was
reported when treatment groups were
compared.
27
Ryans et al. found that patients
having intraarticular corticosteroid therapy
had better outcome in disability scores but not
in pain and range of motion in the 6th week,
but all the therapy groups had improved to a
similar degree with respect to all outcome
measures at 16 weeks.
28
One trial of
fluoroscopically guided injection with and
without physiotherapy found corticosteroid-
injected patients had less disability and better
range of motion outcome at six weeks
compared with physical therapy alone or
placebo injection.
17
Van Der Windt et al.
compared the effectiveness of corticosteroid
injection with physiotherapy for the treatment
of the painful stiff shoulder. They concluded
that the differences between those who
received injections and those treated with
physiotherapy resulted mainly from
comparatively fast relief of symptoms that
occurs after injections.
29
Similar to the results
of our study, all these studies indicated that
corticosteroid injection is more effective in the
improvement of frozen shoulder in the early
follow-up period; however, this difference
disappears in the late follow-up period. Other
papers evaluating the effectiveness of steroid
67
or exercise or physical therapy found no
difference in all stages in pain, disability and
range of motion between the groups.
30
They
all advised corticosteroid injection as being
less costly to administer. When we assessed
the systematic review of randomized clinical
trials of the effectiveness of corticosteroid
injections for shoulder pain, we found that
intraarticular corticosteroid injection for
frozen shoulder may be beneficial, although its
effect may be small and not well-maintained;
there were inconsistent short-term results and
limited evidence for the long-term
outcome.
15,16
In this study, University of
California-Los Angeles end-result score was
used to assess the effectiveness of treatment of
shoulder disorders. To our knowledge, there is
no study using this score in frozen shoulder
patients. The score included patient
satisfaction, shoulder function, and range and
strength of forward elevation, and our results
were similar with our other findings. This
score can be applied to frozen shoulder
patients in the follow-up of the treatment. One
limitation of our study was the large number
(n16) of lost patients in group 2. Two
patients had intercurrent medical problems, 4
were lost during the follow-up period and 10
did not attend assessment visits regularly and
thus had to be excluded from the study. This
was an unexpected situation for a randomized
study. We assume this may have been due to
the absence of sufficient patient satisfaction,
although better recovery with corticosteroid
supply was observed in the short term in our
results.
In conclusion, intraarticular corticosteroids
have additive effects related to rapid pain
relief, mainly in the first weeks of the exercise
treatment period. The combination of the
corticosteroid injection and therapeutic
exercises was equally effective when
compared with the therapeutic exercises alone
at the end of 12 weeks. In patients with frozen
shoulder who have predominant pain
symptoms, intraarticular corticosteroid therapy
could be advised concomitantly with exercise.

CLINICAL MESSAGES
Intraarticular corticosteroids have the additive
effect of providing rapid pain relief, mainly in
the first weeks of the exercise treatment
period. _ in patients with frozen shoulder who
have pain symptom predominantly,
intraarticular corticosteroid therapy could be
advised concomitantly with exercise.

REFERENCES
1. Wolf JM, Green A. Influence of co morbidity on self assessment instrument scores of patients with
idiopathic adhesive capsulitis. J Bone Joint Surg Am 2002; 84: 116772.
2. Hannafin JA, Chiaia TA. Adhesive capsulitis. Clin Orthop 2000; 372: 95109.
3. Gam AN, Schydlowsky P, Rossel I, Remvig L, Jensen EM. Treatment of frozen shoulder with
distension and glucorticoid compared with glucorticoid alone. Scand J Rheumatol 1998; 27: 42530.
4. Rizk TE, Pinals RS. Frozen shoulder. Semin Arthritis Rheum 1982; 11: 44052.
68
5. Grubbs N. Frozen shoulder syndrome: a review of literature. J Orthop Sports Phys Ther 1993; 18:
47987.
6. Vecchio PC, Kavanagh RT, Hazleman BL, King RH. Community survey of shoulder disorders in the
elderly to assess the natural history and effects of treatment. Ann Rheum Dis 1995; 54: 15254.
7. Croft P, Pope D, Silman A. The clinical course of shoulder pain: prospective cohort study in primary
care. Primary Care Rheumatology Society Shoulder Study Group. BMJ 1996; 313: 601602.
8. Binder AI, Bulgen DY, Hazleman BL, Roberts S. Frozen shoulder: a long term prospective study. Ann
Rheum Dis 1984; 43: 36164.
9. Reeves B. The natural history of the frozen shoulder syndrome. Scand J Rheumatol 1975; 4: 19396.
10. Dias R, Cutts S, Massoud S. Frozen shoulder BMJ 2005; 331: 145356.
11. van der Heijden GJ, van der Windt DA, de Winter AF. Physiotherapy for patients with soft tissue
shoulder disorders: a systematic review of randomised clinical trials. BMJ 1997; 315: 2530.
12. Green S, Buchbinder R, Glazier R, Forbes A Systematic review of randomised controlled trials of
interventions for painful shoulder: selection criteria, outcome assessment, and efficacy. BMJ 1998;
316: 35460.
13. Green S, Buchbinder R, Glazier R, Forbes A Interventions for shoulder pain. Cochrane Database
Syst Rev 2000; 2: CD001156.
14. Green S, Buchbinder R, Glazier R, Forbes A. WITHDRAWN: Interventions for shoulder pain.
Cochrane Database Syst Rev 2007; 3: CD001156.
15. Buchbinder R, Green S, Youd JM. Corticosteroid injections for shoulder pain. Cochrane Database
Syst Rev 2003; 1: CD004016.
16. van der Windt DA, Bouter LM. Physiotherapy or corticosteroid injection for shoulder pain? Ann
Rheum Dis 2003; 62: 38587.
17. Carette S, Moffet H, Tardif J et al. Intraarticular corticosteroids, supervised physiotherapy, or a
combination of the two in the treatment of adhesive capsulitis of the shoulder. Arthritis Rheum 2003;
48: 82938.
18. Roach KE, Budiman-Mak E, Norvarat S, Lertratanakul Y. Development of a Shoulder Pain and
Disability Index. Arthritis Care Res 1991; 4: 14349.
19. Beaton D, Richards RR. Assessing the reliability and responsiveness of five shoulder questionnaires. J
Shoulder Elbow Surg 1998; 7: 56572.
20. Ellman H, Hanker G, Bayer M. Repair of the rotator cuff. End-result study of factors influencing
reconstruction. J Bone Joint Surg Am 1986; 68: 113644.
21. Roddey TS, Olson SL, Cook KF, Gartsman GM, Hanten W. Comparison of the University of
California-Los Angeles Shoulder Scale and Simple Shoulder Test with the pain and disability index:
single-administration reliability and validity. Phy Ther 2000; 80: 75968.
22. Ju rgel J, Rannama R, Gapeyava H, Ereline J, Kolts I, Paasuke M. Shoulder function in patients with
frozen shoulder before and after 4-week rehabilitation. Medicina (Kaunas) 2005; 41: 3038.
23. Griggs SM, Ahn A, Green A. Idiopathic adhesive capsulitis. A prospective functional outcome study of
nonoperative treatment. J Bone Joint Surg Am 2000; 82: 1398407.
24. Neviaser JS. Adhesive capsulitis of the shoulder. A study of the pathological findings in periarthritis
of the shoulder. J Bone Joint Surg 1945; 27: 21122.
25. Border WA, Noble NA. Transforming growth factor beta in tissue fibrosis. N Engl J Med 1994; 331:
128692.
26. Rizk TE, Pinals RS, Talaiver AS. Corticosteroid injection in adhesive capsulitis: investigation of their
value and site. Arch Phys Med Rehabil 1991; 72: 2022.
27. Bulgen DY, Binder A, Hazelman BL, Dutton J, Roberts S. Frozen shoulder: Prospective clinical study
with an evaluation of three treatment regimens. Ann Rheum Dis 1984; 43: 35360.
28. Ryans I, Montgomery A, Galway R, Kernohan WG, Mckane R. A randomizedcontrolled trial of
intraarticular triamcinolone and/ or physiotherapy in shoulder. Rheumatology 2005; 44: 52935.
29. van der Windt DA, Koes BW, Deville W, Boeke AJP, de Jong BA, Bouter LM. Effectiveness of
corticosteroid injections versus physiotherapy for treatment of painful stiff shoulder in primary care:
randomised trial BMJ 1998; 317: 129396.
30. Ginn KA, Cohen ML. Exercise therapy for shoulder pain aimed at restoring neuromuscular control: a
randomized comparative clinical trial J Rehabil Med 2005; 37: 11522.

CORRESPONDENCE
69
*Associate Professor, Dept of Orthopaedics & Traumatology, Sri Aurobindo Medical College & P.G.
Institute, Indore, M.P, India. Address for correspondence: 7/3/3, Ahilaya Mata Colony, Near Charak
Hospital, Rani Sati Gate, Indore-452003, India. Email: pchoudhari@rediffmail.com
**Professor, Dept of Physiotherapy, Sri Aurobindo Medical College & P.G. Institute, Indore, M.P, India.
Address for correspondence: 7/3/3, Ahilaya Mata Colony, Near Charak Hospital, Rani Sati Gate, Indore-
452003, India. Email: Anand5556@rediffmail.com
70

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