Shoulder disorders are the 3rd commonest among musculoskeletal conditions. Its prevalence is
estimated 7-26% at one point of time and 67% of the individuals experience shoulder pain once
in their life. Subacromial impingements (SAIS) are the frequent diagnosis accounting for
45-65% of all shoulder disorders. It is defined as "a condition in which the tendons of the
rotator cuff muscles, long head of the biceps or the subacromial bursa are entrapped between
the humeral head inferiorly and anterior acromion superiorly.
Multiple researchers have studied interventions which affect the shoulder range of motions.
Thoracic spine manipulation improves the shoulder range of motion. Similarly, Stretching the
pectorallis minor muscles improve shoulder kinematics. Manual intervention for subscapularis,
infra spinatus, and serratus anterior are non-existent to investigators' knowledge.
Modification to stretch the posterior capsule in a pragmatic manner is described and
recommended but trials are nonexistent. Acromioclavicular joint being the part of the
scapolo-glenohumeral complex has a role to play in the kinematics of the shoulder but trials
on its mobilization with respect to shoulder range of motion are not been studies. These gaps
in research in relation to understanding of the mechanism of shoulder pathology and
subsequent intervention are also identified but trials and interventions are non-existent.
The understanding of the complex relations of the intrinsic and extrinsic factors
necessitates the development of manual therapy interventions to address the factors which are
adversely affect range of motion of shoulder joint. The purpose of this research is to
develop and propose manual therapy interventions for shoulder joint which can effectively
address the limitations in shoulder joint ranges of motion in both healthy subjects and
subjects with shoulder pathology having decrease range of motion through a series of
primitive trials.
AIMES AND OBJECTIVES The primary purpose of this study is to evaluate the short term effects
of Pragmatic manual interventions on range of motion of the shoulder joint in healthy
individual and individuals with shoulder pathology who have restricted ranges of motion .The
aims of this study are therefore to
To evaluate the effects of pragmatic interventions in healthy asymptomatic subjects with
respect to the changes in shoulder joint restricted range of motion
To evaluate the effects of interventions in symptomatic shoulder individual with
restriction in their shoulder range of motion and short term change in the shoulder
related quality of life and pain MATERIAL AND METHOD A single group quasi-experimental
(pretest-posttest) design will be used for all the trials in this study. It will be
conducted at Helping Hand Institute of Rehabilitation Sciences, Mansehra. The study will
be composed of 4 trials in the first phase on healthy subject with respect to each of
the proposed pragmatic (novice) intervention consistent with the first objective and
exploratory in nature. Subjects will be randomly allocated to the initial four groups.
The initial 4 trials on healthy subjects are chosen since the effects of each of the
proposed pragmatic interventions is not been studied but advocated. Healthy subjects
with restriction in shoulder ROM are deemed appropriate since other confounding factors
such as pain is absent and objectives could be achieved. In Phase 2, trial on patient
with shoulder pathology will be conducted after evaluating the effects on range of
motion in healthy individual. Each trial will recruit 30 subjects. subjects in trial 5
with shoulder pathology will be assessed through Urdu version of shoulder pain and
disability index at baseline, after one week and 5 weeks of pragmatic interventions. A
sample size of 30 for each trial ( a total of 150 subject) is deemed appropriate after a
pilot trial on 5 healthy subject which produced a meaningful difference of 15 degree
change in abduction, and 3 cm difference in reaching up behind the back and using
standard deviation estimates from previous studies. Finally, The urdu translated and
validated version of SPADI will used to measure shoulder related pain and Disability.
Ethical approval will be sought from REC Isra university and Ethical committee of HHIRS.
Subjects consent will be taken in writing (annex 2) and full study information will be
given (annex 3). Each of Phase 1 and phase 2 of this study will be completed in 6 months
(a total of 1 year) from August 2019 to August 2020.
SUBJECTS ASSESSMENT PROCEDURE For healthy subject of the initial 4 trials, subjects willing
to participate will be screened against the inclusion and exclusion criteria. Each
participant for trial 5 with shoulder pathologies will be assessed thoroughly and screened
against the inclusion and exclusion criteria. Demographic information, information related to
history of the presenting complaint, past medical and surgical history, hobbies, occupation,
drug history and social history will be collected from all the eligible subjects in trial 5.
Additional information in relation to date of onset, behavior of symptoms, aggravating,
easing factors, previous treatment including injection and other surgical interventions,
relevant investigation will be collected.
A detailed objective examination process will be followed for participants in trial 5.
Examination process will include inspection of the shoulders, cervical spine and thoracic
spine from the front, each side and back. Any abnormality seen will be documented.
Inspection will be followed by ruling out any pathology of the neck by asking the patient to
perform active neck rotation to each side, side flexion, extension and flexion and any pain,
discomfort and paraesthesia will be noted. These quick movements are assumed sufficient to
rule out any pathology of the neck. Neck movements will be followed by the active elevation
(flexion and abduction) of the shoulder joint and any pain, restriction in range and
willingness to movement will be noted. Active reaching behind the back will be performed and
any limitation in comparison with the asymptomatic side noted. Limitation will be measures
from the respective posterior superior iliac spine though measuring tape. Active elation of
the arm is followed by the passive movements of abduction, flexion, and medial rotation. Any
limitation of range, end feel and pain will be noted during each of the passive movement.
Active resisted movement of abduction, medial rotation, later rotation of shoulder and
flexion and extension of elbow are followed and strength/pain will be noted. The systematic
procedure of assessment followed from Cyriax and has been found highly reliable(39) and
assessment procedure including similar procedures Special test such as Neer's sign, Hawkin
kennedy test, scarf test, speed test, O'brien's test will be administered to determine SAIS.