Original Article
EFFICACY OF ULTRASOUND W ITH M AITLAND M OBILIZATION OVER
SHORT WAVE DIATHERM Y W ITH M AITLAND M OBILIZATION IN
IM PROVING THE FUNCTIONAL PERFORM ANCE OF PATIENTS W ITH
PERIARTHRITIS SHOULDER
J.M ahendran, M .PT (Ortho)
* 1, A.N.Sundaresan M .PT (Ortho)
2, Gowrishankar Potturi
M .PT(Neuro)
3, P.D. Karthikeyan M .PT (Neuro)
4.
* 1,3,4 Lect urer, School of Physiot herapy, Allianze Universit y college of M edical Sciences, Kepala Batas,
Penang, M alaysia.
2 Senior Lect urer, School of Physiot herapy, Allianze Universit y college of M edical Sciences, Kepala
Batas, Penang, M alaysia.
Objective: To invest igat e t he effect iveness of ult rasound w it h M ait land m obilizat ion over Short w ave diat hermy w it h M ait land m obilizat ion in im proving t he f unct ional perform ance of pat ient s w it h Per iart hrit is of shoulder
Design: A sim ple random ized cont rolled clinical t rail
Sett ing: The st udy w as conduct ed in t he depar t m ent of physiot herapy in Ganga Hospit al Coim bat ore (India), Vinayaka M ission Hospital Salem (India).
Subject s: 30 pat ient s w ere select ed random ly from t he populat ion using sim ple random sam pling procedure (Lott er y M et hod) and w ere divided int o t w o equal groups.
Intervention : The experim ental group (n=15) w ere given Ult rasound w it h M ait land m obi lizat ion w it h 1 M Hz in
frequency, cont inuous m ode and 1.5 W/ cm2 of int ensit y w it h 5cm2 sized t ransducer for 10 m inut es of t reat m ent
durat ion .The cont rol group (n=15) w ere given Short w ave diat hermy w it h M ait land m obi lizat ion for period of 15 m in w it h cont ra planar t echnique.
Outcome m easures: The funct ional perform ance w as m easured using Shoulder Pain and Disabilit y Index (SPADI) scale.
Results: In Group-A (Exper im ent al Group ) and Group-B (Cont rol Group), all data w as expressed as m ean ± , SD and w as stat ist ically analysed using paired ‘t ’ t est and independent ‘t ’ t est t o det erm ine t he stat ist ical difference am ong t he param et ers at 0.5% level of significance. Stat ist ical data of SPADI show ed t hat , Group-A is significant ly dif ferent from Group-B w it h p<0.05; i.e 95% of significance.
Conclusion: The post ult rasound M ait land m obilizat ion is found m ore effect ive and beneficial t han post SWD M ait land m obilizat ion on shoulder f unct ions in periart hrit is.
KEYW ORDS: M ait land m obilizat ions, Short w ave diat hermy, Ult rasound, Periart hrit is, Glides.
Quick Response code
Access this Article online
International Journal of Physiotherapy and Research
ISSN 2321- 1822
w w w.ijmhr.org/ ijpr.html
Received: 18-06-2014 Accepted: 07-07-2014
Published: 11-08-2014
ABSTRACT
INTRODUCTION
Address for correspondence: J.M ahendran, M .PT (Ort ho), Lect urer, School of Physiot herapy, Allianze Universit y college of M edical Sciences, Kepala Batas, Penang, M alaysia-13200
E-M ail: jayamahendran@gmail.com
International Journal of Physiotherapy and Research, Int J Physiother Res 2014, Vol 2(4):621-25. ISSN 2321-1822
Peer Review : 18-06-2014
The shoulder is a complex anat omical joint t hat allow s movement in many planes. M ult i-plane w ide arcs of movement s are t he result s of t he
M AITLAND M OBILIZATION IN IM PROVING THE FUNCTIONAL PERFORM ANCE OF PATIENTS WITH PERIARTHRITIS SHOULDER.
for a w ide range of cont rolled purposeful daily act ivit ies like washing hair, washing back, put-t ing an objecput-t on a high shelf.
Periart hrit is is a common disabling and painful condit ion characterized by act ive and passive lim it at ion of t he shoulder range of m ot ion (ROM ).The term “ Periart hritis” first described by a French doct or ES Duplay in 18721. Shoulder
m o t i o n an d d ai ly act i v it i es ar e r est r i ct ed gradually, causing disabilit y. Alt hough t he ROM varies depending upon w hich stage t he pat ient present s, yet he or she st ill has limit at ions of p assi v e ROM i n a cap su lar pat t er n . Approxim ately 7% t o 21% of t he populat ion su f f er s f r om pain f u l or st if f sh ou ld er 2. It
commonly affect s w omen more frequent ly t han m en and p eak age is 56 years 3. Bi lat eral
involvement occurs in 40% t o 50% 4. Pat ient s
w it h diabetes have high prevalence rate of 20% t han t he normal populat ion. 5
Various convent ional treatments like Analgesics, Nonsteroidal ant i-inflammat ory (NSAIDS) drugs, physiot herapy modalit ies, exercises and advices are available t o t reat t his condit ion. They mainly aim at relieving pain and im proving range of mot ion (ROM ).
Short-w ave diat hermy (SW D) is a deep t issue heat ing elect rot herapeut ic m odalit y, w hich produces an oscillat ing elect romagnet ic field in t he frequency range of 27.12 M Hz. Therapeut ic effects of t hese oscillat ions proven in t heir abilit y t o decrease t issue viscosit y and w it h t hese m uscu lar an d t en d in o u s co nt r act u r es. Additionally, the deep heating effect also induces an an t i -i nf lam m at or y resp on se, st im ul at e connect ive t issue repair, reduce joint st iffness, m uscle spasm , pain and prepare t issue for passive st retching. 6
Ult rasound (US), w hich is a deep t issue heat ing modalit y, can elevate t issue temperat ure. The physiologic response due t o ult rasound t herapy includes increased collagen t issue extensibilit y, pain t hreshold and enzymat ic activit y, along w it h ch anges i n ner ve con duct ion vel oci t y and cont ract ile act ivit y of skeletal muscle 7. A recent
evidence-based guidelines conclude t hat t he t herapeut ic US was effect ive in t he t reat ment of calcific tendonit is of t he shoulder, t here was no evidence that it was beneficial for ot her forms
of shoulder pain (e.g. capsulit is, bursit is, and tendonit is). 8
M ait l and m ob i l izat io n is a w i d el y used t herapeut ic technique used to treat various intra art icular and periarticular disorders. Grades I and II of M ait land m obi lizat ion t echniques are primarily used for t reat ing joint s limited by pain. The oscillat ion may have an inhibit ory effect on t he percept ion of painful st imuli by repet it ively st i m ul at i n g m ech ano r ecept o rs t hat b l ock nocicept ive pat hways at t he spinal cord or brain stem levels. These nonst retch mot ions help t o move synovial fluid t o improve nut rit ion t o t he cart ilage w hereas Grades III and IV are primarily used as st retching manoeuvres9. Appropriate
select io n of m ob i l izat i on t ech n iq u e f o r t reat ment can only take place after a t horough assessment and examinat ion.
Aim for study:
To find t he effect iveness of ult rasound w it h M ai t l an d m o b i li zat i o n o v er sh or t w av e d i at h er m y w i t h M ai t l an d m o b i l i sat i o n i n improving funct ional performance of pat ient s w it h periart hrit is shoulder.
Objectives:
1. To find t he effect iveness in applicat ion of ultrasound combined w it h M ait land mobilisation in improving funct ional performance of pat ient s w it h periart hrit is shoulder.
2. To find t he effect iveness in applicat ion of short wave diat hermy combined w it h M ait land m obilisat ion in im proving funct ional perfor-mance of pat ient s w it h periart hrit is shoulder. 3. To compare t he effect iveness of ult rasound w it h M ait land m obi lizat ion over short w ave d iat h -er m y w i t h M ait lan d m o b i l isat i on i n improving funct ional performance of pat ient s w it h periart hrit is shoulder.
M ATERIALS AND M ETHODS
J.M ahendran, M .PT (Ort ho), et .al.. EFFICACY OF ULTRASOUND W ITH M AITLAND M OBILIZATION OVER SHORT WAVE DIATHERM Y WITH M AITLAND M OBILIZATION IN IM PROVING THE FUNCTIONAL PERFORM ANCE OF PATIENTS WITH PERIARTHRITIS SHOULDER.
Inclusion Criteria:
1. Unilateral periart hrit is 2. Pat ient s age bet w een 40-60 3. Bot h sexes w ere included Exclusion Criteria:
1. Hist ory of uncont rolled diabetes mellit us 2. Pat ient s w it h skin disorders
3. Pat ient s under steroid t herapy
4.Hist ory of any major t rauma or surgery M aterials:
1. Consent forms 2.Evaluat ion format
3.Ult rasound machine and conduct ion gel 4.Shortwave diat hermy machine, elect rodes and pads
5. Pillow s and t ow els
Treatment and assessment technique:
30 p at ien t s w i t h con f i r m ed di agno si s o f periarthrits w ere selected based on inclusion and exclusion criteria. They w ere divided int o t w o equal groups consist s of 15 pat ient s by simple random sampling procedure (Lottery M et hod). The p at i ent s w er e exp lai n ed abo u t t h e t reat ment and assessment procedure and w ere taken t heir consent before group division. Group A w as given Ult rasound and M ait land mobilisat ion 5 sessions per w eek for a period of 2 successive w eeks.
Procedure:
Application of Ultrasound
The pat ient s posit ioned comfortably t o receive t herapeut ic ult rasound w it h parametric settings of 1 M Hz in frequency, continuous mode and 1.5 W/ cm2 of intensit y w it h 5cm2 sized t ransducer
for 10 minutes of treatment durat ion. After coat-ing the skin w it h couplcoat-ing media (Aquasonic gel), Ult rasound was delivered by moving t he t reat-m ent head over t he ant erior, super ior and posterior regions of t he affected joint in slow, circular and overlapping fashion. 10
Application of M aitland M obilisation 9
Passive Accessory M ovements
The follow ing passive accessory m ovem ent s w ere tested and t reated accordingly.
Gleno-Humeral Joint : · Antero –Posterior glide · Postero – Anterior glide · Caudal glide
· Dist ract ion or Lateral glide Sterno – Clavicular Joint : · Antero – Posterior glide · Postero – Anterior glide · Caudal glide
· Cephalad glide
Acromio – Clavicular Joint · Antero – Posterior glide · Posterior – Anterior glide · Caudal glide
· Cephalad glide
Passive Physiological M ovements
The follow ing passive physiological movement s w ere tested and t reated accordingly
· Flexion · Extension · Abduct ion
· Internal and External rotat ion
Group B was given Short wave diat hermy and M ait land mobilisat ion for t w o w eeks
Application of Shortwave
Before start t he t reat ment t he t herapist evalu-at ed t he safet y m easures of t he shor t w ave diat hermy device. Pat ient ’s t hermal sensat ion of t he t reat ment part was evaluated and all metal obj ect s, m at er ials, cl ot hing and elect ronic devices from t reat m ent part w ere rem oved. Pat ient was posit ioned in supine lying and short wave diat hermy pads w ere applied in cont ra-planner (AP) met hod for 20 minutes on affected shoulder11. The spacing bet w een t he pads and
t reat ment part is maintained by t he placing of eight folded t ow els. Intensit y was maintained and adjusted t o produce comfortable warmt h based on pat ient ’s feedback.
OUTCOM ES M EASURES:
M AITLAND M OBILIZATION IN IM PROVING THE FUNCTIONAL PERFORM ANCE OF PATIENTS WITH PERIARTHRITIS SHOULDER.
The SPADI is a disease specific, self – adminis-t raadminis-ted scale adminis-t haadminis-t measures adminis-t he impacadminis-t of shoul-der pat hology in terms of pain and disability. The scale consist of 13 items int o t w o subscales: pain (5 items) and disabilit y (8 Items). The t otal score was calculated out of 100.
RESULTS AND TABLES
This st udy is t o analyse t he effect of Ult rasound over Short w ave diat hermy in combined w it h M ait land m obilisat ion im proving funct ional performance in periart hrit is shoulder.
In Group-A (Experimental Group ) and Group-B (Experimental Group ), all data was expressed as mean ± , SD and w as st at ist ically analysed using paired ‘t ’ test and independent ‘t ’ test t o determine t he stat ist ical difference among t he parameters at 0.5% level of significance.
Paired ‘t ’ test was used t o examine t he changes in dependent variables from baseline t o after complet ion of intervent ion in each group. The pre-test mean value of SPADI in Group-A is 70.73 (SD=10.92) and p o st -t est is 19.26 (SD=3.78). ‘t ’ value = 22.59, p<0.05.
The pre-test mean value of SPADI in Group-B is 70.26 (SD=11.46) and post-test is 28.8 (SD=6.06). ‘t ’ value =24.53, p<0.05.
The independent ‘t ’ test is done t o calculate t he signi f i cance o f di f f er en ce i n SPADI sco res bet w een Group-A and Group-B. The mean of differences in SPADI scores bet w een pre and post- test in Group-A is 51.86 (SD=8.74) and in Group B is 41.8 (SD=6.47), t = 3.58.
Thus from above statistical data of SPADI, Group-A is significant ly different from Group-B w it h p<0.05; i.e 95% of significance. Hence w e reject t he null hypot hesis.
Table 1: Com parison of Pre and Post-t est values of SPADI scores in Group A and Group B.
M ean SD P value M ean SD P value Pre test 70.73 10.92 70.26 11.46
Post test 19.26 3.78 28.8 6.06 T value
SPADI score Group A Group B
<0.05 <0.05
22.59 24.53
Table 2: Com parison of Pre t est and Post t est dif ferences in SPADI scores in Group A and Group B.
M ean of differences in SPADI scores
Pre test and Post t est M ean SD T value P value
Group A 51.86 8.74
Group B 41.8 6.47 3.58 <0.05
Graph 1: Show ing t he Pre-t est and Post-t est dif ferences in SPADI scores in Group A and Group B.
DISCUSSION
In this study efficacy of ult rasound with M aitland m obilisat ion over Short w ave Diat hermy w it h M ait l and m ob i l isat io n in i m p r o vi n g t h e funct ional perform ance of t he pat ient s w it h periart hrit is shoulder t he result s show n t hat Ultrasound w it h M aitland mobilisat ion was more effect ive and beneficial.
The beneficial effect of Ult rasound in improving sh ou l d er f un ct io n al p er f o r m an ce can b e at t r i but ed t o t he non -t her m al ef fect s and t hermal effect s.
Cyt okines play a vital role in regulat ion of injury r ep ai r and st i m ul at in g t issue h eal in g an d r em o d ell i n g. The n on -t her m al ef f ect o f ult rasound result s in increase in release of cyt okines by bot h vasodilatat ion and act ivat ion of adhesion molecules by signal t ransduct ion pat hways.12-16
A number of report s have demonst rated t hat ult rasound has been proven for it s beneficial ef f ect s b y m o du l at i n g vasod i l at at io n , lymphocyte adhesion, mast cell degranulat ion, phagocyt ic proliferat ion of T-cells, ost eoblast s and a n um b er of pr ot ein associ at ed w it h inflammat ion and repair. 17-20
It also helps in breaking of t he adhesions w hich are leading to joint rest riction by the mechanical energy w it hin t he Ult rasound w ave and t he shearing force of t he wave combined to produce mechanical propert ies t hat effect t he molecular st ruct ures w it hin t he cell.
M any r esearch st u d ies hav e p r o ven t h at ult rasound m ay int eract w it h one or m ore co m p o n en t s o f in f l am m at io n an d al so accelerates fibrinolysis.21-22
J.M ahendran, M .PT (Ort ho), et .al.. EFFICACY OF ULTRASOUND W ITH M AITLAND M OBILIZATION OVER SHORT WAVE DIATHERM Y WITH M AITLAND M OBILIZATION IN IM PROVING THE FUNCTIONAL PERFORM ANCE OF PATIENTS WITH PERIARTHRITIS SHOULDER.
struct ures t o produce its thermal or non-t hermal effect s23, by t he t hermal effect of Ult rasound it
increases t he collagen and tendon extensibilit y t hereby it increases t he range of m ot ion in pat ient w it h adhesive capsulit is24. Vermeulen
HM et al (2000) d escr i b ed t hat M ai t lan d M obi lisat ion plays m ajor role in decreasing sympt oms of perirt hrit is of shoulder25 and if t he
t herm ot herapy applied prior t o joint m obili-sat i o n can i n cr ease t he ext en si b i li t y o f connec-t ive t issue leading t o increased range of m ot i on2 6.Resear ch es pr o v ed t h at b y t h e
applicat ion of short wave diathermy increase the blood supply and increases t issue extensibilit y.27
CONCLUSION
In t his st udy, w e conclude t hat applicat ion of M ait land mobilisat ion can be combined w it h Ult rasound t han Short wave diat hermy t o give greater funct ional performance in pat ient s w it h periart hrit is of shoulder.
Conflicts of interest:None
REFERENCES
-tat ion in ad hesive capsulit is, Sw iss M ed Weekly 2004 ; 134 : 353 – 358.
12. Hogg N, Landis RC. Ad hesion m olecules i n cell i n t e r act i o n s. Cu r r Op i n I m m u n o l . 1 99 3 Jun;5(3):383-90.13. Pardi R, Inverardi L, Bender JR. Regulat or y m echanism s in leukocyt e ad hesion: f l exi b le r ecep t o r s f o r so p h ist i cat ed t r avel er s. Im m unol Today. 1992 Jun;13(6):224-30.
14. Chokshi SK, Rongione AJ, Freem an I, Gal D, Grunw ald AM , Al l i ge r H. U l t r aso n i c e n er gy p r o d u ces endot helium -dependent vasom ot or relaxat ion in vit ro (abst r.). Circulat ion 1989; (Suppl II): II: 565. 15. Fi sch el l TA1, Ab bas M A, Grant GW, Si egel RJ.
Ult rasonic energy. Ef fect s on vascular funct ion and int egrit y. Circulat ion. 1991 Oct ;84(4):1783-95. 16. M axw ell L, Collecutt T, Gledhi ll M , Sharm a S, Edgar
S, Gavi n JB. Th e au gm e n t at i o n o f l eu co cy t e ad h esi o n t o en d o t h e l i u m b y t h e r ap e u t i c ult rasound. Ult rasound M ed Biol. 1994;20(4):383-90.
1 7. An d e r so n DW, Bar r et t JT. De p r essi o n o f phagocyt osis by ult rasound. Ult rasound M ed Biol. 1981;7(3):267-73.
18. Doan N, Reher P, M eghji S, Harris M . In vit ro ef fect s of t herapeut ic ult rasound on cell proliferat ion, pr ot ein synt h esi s, an d cyt o ki ne pro duct i on by hum an fi broblast s, ost eoblast s, and m onocyt es. J Or al M axi l lo f ac Su r g. 1999 Ap r ;57(4):409-19; discussion 420.
19. Young SR, Dyson M . M acrophage responsiveness t o t herapeut ic ult rasound. Ult rasound M ed Biol. 1990;16(8):809-16.
20. Lennart D. Johns , Nonthermal Effect s of Therapeutic Ult rasound: The Frequency Resonance Hypot hesis, J At hl Train. 2002 Jul-Sep; 37(3): 293–299.
21. Har paz D, Chen X, Francis CW, M arder VJ, M elt zer RS. Ult rasound enhancem ent of t hrom bolysis and r ep er f u si o n i n vi t r o . J Am Co l l Car d i o l . 1993 M ay;21(6):1507-11.
22. C W Francis, P T Onundarson, E L Carst ensen, A Blinc, R S M elt zer, K Schw ar z, and V J M arder, Enhancem ent of f ibrinolysis in vit ro by ult rasound. J Clin Invest . Nov 1992; 90(5): 2063–2068.
23. Young S. Ult rasound t herapy. In: Kitchen S, Bazin S, eds. Elect ro t herap y: Evid en ce-Based Pract i ce. China: Churchill Livingst one; 2002:211–230. 24. Basford JR. Therapeut ic physical agent s. In: DeLisa
JA, edit or. Physical m edicine and rehabi lit at ion. Principles and pract ice. Phi ladelphia: Lippincot t W illiam s & W i lkins; 2005. p. 251-70.
25. Ver m eulen HM , Oberm ann WR, Burger BJ, Gea J Kok, Piet M Rozing, and Cornelia HM van den Ende. End-range m obi lizat ion t echniques in ad hesive capsulit is of t he shoulder joint : a m ult iple-subject case report ; Phys Ther 2000; 80:1240-1213. 26. Br ukner P, Khan K. Clinical Sport s M edicine. (2ED).
(2001). M cGraw Hi ll.
27. Goat s GC. Cont inuous short-w ave (radio-frequency) diat herm y. Br J Sport s M ed. 1989;23:123–127. 1. Duplay ES. DE 1a Perat hrit e Scapulahum erale et
d es r ai d eu r s d e 1 ’ e p au l e q u i e n so n 1 a consequence. Arch gen M ed 1872; 20:513-542. 2. Chard , M D, hazelm an, R.Hzlem an, BL.King, RH and
Reiss, BB (1991). Shoulder disorders in elderly: A com m unit y survey Art hrit is and Rheum at ism , 34, 766-769.
3 . Hace r Do gr u , Si b e l Basar an , Tu n ay Sar p e l (2008).Effect iveness of t herapeut ic ult rasound in adhesive capsulit is. Joint Bone Spine. 75, 445-450. 4. Greene W B. Essent ials of m usculoskeletal care. 2. Rosem ont , IL: Am erican Academy of Ort hopedic Surgeons; 2001.
5. Robert C. M anske Æ Daniel Prohaska, Diagnosis and m anagem ent of adhesive capsulit is, Curr Rev M usculoskelet M ed (2008) 1:180–189.
6. Curett e S. Adhesive capsulit is. Research advances frozen in t im e. J.Rhum at ol 2000. 27, 1329-1331. 7 . Ro b er t A Do n at el l i , M i ch e al J an d Wo o d en ,
Ort hopaedic Physical t herapy. 3rd ed Churchill Living
St one publicat ion; year 153-158. ISBN: 0443079935 8. Philadelphia Panel M em bers. Philadelphia panel evid ence-based cl in ical pract ice guid el ines on select ed rehabilit at ion int ervent ions for shoulder pain. Phys Ther 2001;81:1719-30.
9 . G. D. M ai t l an d , Pe r i p h e r al M an i p u l at i o n , But t erw ort h- Heinem ann, 2nd edit ion, 1991 1 0. Hace r Do gr u Si b e l Basar an , Tu n ay Sar p el .
Effect iveness of therapeut ic Ult rasound in Adhesive capsulit is; Joint Bone Spine (75); 2008; 445-450. 11. Fusun Guler-Uysal, Er kan Kozanoglu, Com parison
of t he early response t o t w o m et hods of rehabi li- Ho
