IJOT : Vol. XXXVI : No. 2 August - November 200437

†PASSIVE EXERCISES COUPLED WITH THERAPEUTIC ACTIVITIES — ACOMPARATIVE STUDY IN THE MANAGEMENT OF FROZEN SHOULDER.* MANISH SAMNANI, M.O.Th.-I* Dr. Rajendra Jain Hospital,Bhilai (C.G).

Clinical observations show that all motions increasesignificantly when treated with therapeutic activities exceptmedial rotation and hence to achieve functional hand-to-back.Nicholson(1985) through a study stated that medialrotation did not improve significantly when shoulders withperiarthritis were treated with active exercises alone.

This study seeks to find out whether the use of passive ROMexercises could produce more significant results to achievemedial rotation & hence functional hand-to-back when givenin conjunction with the therapeutic activities.

METHODA same subject experimental design was used for the study.

INCLUSION CRITERIA

1. Diagnosed primary idiopathic periarthritis of shoulder.

2. Unilateral involvement.

3. Previous treatment by analgesics only.

4. Experiencing symptoms of pain & limited ROM for notlonger than 3 months.

EXCLUSION CRITERIA

1. Any significant radiological finding.

2. Signs of acute joint inflammation & muscle spasm.

3. Any neurological deficit.

20 such patients,9 male and 11 female were included for thestudy.All the subjects were aged between 35-60years.Writteninformed consent was taken from the subjects beforeparticipating in the study.

Correspondence:* Dr. Manish SamnaniOccupational TherapistDepartment of Rehabilitation Sciences,5th floor,Central Library Building,Jamia Hamdard, Hamdard Nagar,New Delhi-110 062.E-mail: msamnani@rediffmail.com† Presented in the 41st Annual National Conference of AIOTA at NewDelhi, in the year 2004.

INTRODUCTIONFrozen shoulder or Periarthritis is a distinct clinical syndromeassociated with pain and restricted range of active and passiveglenohumeral motion.

Patients having no positive findings in their history,clinicalexamination,or radiographic review that could explain theirpain and and a decrease in shoulder motion are classified ashaving Primary Idiopathic Frozen Shoulder.

The non-traumatic stiff shoulder is usually limited in alldirections but the two functionally important movements tothe patient are flexion and the combined movements ofglenohumeral extension,adduction,medial rotation whichenables to get hand behind the back.

Limitation in ROM occurs due to structural changes in theperiarticular tissues.These changes include shortening ofcapsule,ligament or muscle as well as adhesion formation.

Treatment of limited ROM and function is geared towardsapplying tensile forces in an effort to cause elongation of therestricting tissues.

The Indian Journal of Occupational Therapy : Vol. XXXVI : No. II (August-November ‘04)

AbstractTo test the effectiveness of using passive exercises coupled with therapeutic activities to improve functional hand-to-backin Frozen Shoulder.A standardize test of functional hand-to-back served as a pre-test and post-test to compare two groups (n=20) comprisingboth male and female diagnosed of having Frozen Shoulder. The therapeutic activities program was the same for bothgroups, but the treatment group was given passive exercise while the control group was not.The degree of improvement was significantly higher in the treatment group to achieve functional hand-to-back ascompared to control group.The study supports a passive exercise program alongwith therapeutic activities as a means for the improvement offunctional hand-to-back in Frozen Shoulder.

IJOT : Vol. XXXVI : No. 2 August - November 200438

The subjects were randomly allocated to one of the twogroups,A & B of 10 each.

The outcome variable,functional hand-to-back was measuredusing an ordinal scale as follows:

Dorsum of hand to lateral thigh : 0

Dorsum of hand to buttock : 2

Dorsum of hand to lumbosacral region : 4

Dorsum of hand to waist (L3 level) : 6

Dorsum of hand to 12th dorsal vertebra : 8

Dorsum of hand to interscapular region : 10

PROCEDUREEach subject was asked to take his or her hand to theback,keeping arm adducted,at a position that he or she isable to hold.The score of the assessment at baseline,for each subjectwas thus noted using the scale.The patients belonging to control group ‘A’ receivedtherapeutic activity program & active exercises as follows:1. Codman Pendulum Exercises.2. Pulley Exercises.3. Shoulder Wheel.4. Active ROM Exercises using dowel.5. Finger stepping and corner stretch.6. Reaching out tasks.The treatment was given for a period of 45min.,6 times aweek.The subjects belonging to group ‘B’ were treated with thesame therapeutic activities as given to subjects of group ‘A’but they were also given Passive ROM Exercises as follows:1.Patient in supine:

Passive ROM to the shoulder by the therapist from neutralposition to maximal flexion available.

2.Patient in supine:Passive ROM to the shoulder by the therapist from neutralposition to maximal adduction available.

3.Patient in supine:Shoulder abducted to less than or equal to 90 degree, elbowflexed 90 degree:Passive ROM to the shoulder by the therapist from thisinitial position to maximal internal rotation available.

4.Patient in supine:Shoulder abducted to less than or equal to 90 degree, elbowflexed 90 degree:

Passive ROM to the shoulder by the therapist from thisinitial position to maximal external rotation available.

5.Patient in supine:Shoulder flexed to less than or equal to 90 degree, elbowflexed 90 degree:Passive circumductory ROM to the shoulder.

6.Supraspinatus stretching.Passive exercises were given for a period of 15min. afterthe therapeutic activities,6 times a week.

The scores for performing functional hand-to-back wasreassessed for each subject of group ‘A’ & ‘B’ after 6 weeksof therapy and data was recorded.The data collected was then statistically analyzed to comparethe functional outcome scores after using the two treatmentprotocols.

RESULTSThe mean pretest scores for the subjects of control group‘A’ was 1.6 while the post-test score for the same subjectgroup was 2.6 (t=0.29,p=0.77).

The mean pretest scores for the subjects of control group‘B’ was 1.8 while the post-test score for the same subjectgroup was 5.8 (t=4.5,p=0.002).

The mean difference in the pre and post-test scores for group‘A’ was 1.0 while that for group ‘B’ was 4.0

Thus the results were found to be very significant for thegroup ‘B’ treated with passive exercises (p=0.002).

These results suggest that there is more improvement toachieve functional hand-to-back when treated with passiveexercises along with therapeutic activities than when treatedwith therapeutic activities alone.

TABLE - I

Baseline Characteristics of Study SubjectsControl ExperimentalGroup Group(Active (Active +Alone) Passive)

Total no. OfSubjects 10 10

SEX

Male 6 3 X² =0.81,p=0.17

Female 4 7

MEAN AGE 42.7(9.0) 42.9(6.5) t =0.05,p=0..95(S.D.)

IJOT : Vol. XXXVI : No. 2 August - November 200439

TABLE - II

Comparison of Pre and Post Therapy Scores

Scores Control Group Experimental Group(Active Alone) (Active + Passive)

Pre Therapy 1.6(1.57) 1.8(1.4) t =0.29,p=0..77

Post Therapy 2.6(0.9) 5.8(1.9) t =4.57,p=0.002

Difference of Pre 1.0(1.05) 4.0(2.1) t=4.12,p=0.0008and Post Therapy

GRAPH-I

Comparison of Means of Pre and Post TherapyScores

0

1

2

3

4

5

6

PRE-THERAPYPOST THERAPY

CONTROL EXPERIMENTAL

GRAPH – II

Comparison of Means of Difference of Pre and PostTherapy Scores

0

1

2

3

4

5

DIFF IN PRE-THERAPY DIFF IN POST THERAPY

DISCUSSION The ability to achieve functional hand-to-back improvessignificantly when treated with a program consisting of passiveexercises alongwith other therapeutic activities.

Nicholson(1985),also found that all ranges improvedsignificantly when treated with passive joint mobilization.

According to Carolyn Wordsworth passive exercises havemultiple benefits. Gentle passive exercises short of pain andthe pathologic limit of motion reduce pain.Theoretically thispain reduction occurs because of a neuromodulation effecton the mechanoreceptors within a joint.Often reflex musclespasm prevents a patient from performing activeexercise,whereas a therapist can passively guide the limbfurther into the range without eliciting spasm or a stretchreflex.Also because many patients are reluctantpsychologically to perform regular appropriate activeexercises,passive exercises may become the treatment ofchoice.

According to McClure,Flowers periarticular tissues remodel overtime based on the forces applied to those tissues.

CONCLUSIONThe study supports a passive exercise program alongwiththerapeutic activities as a means for the improvement offunctional hand-to-back in Frozen Shoulder.

ACKNOWLEDGEMENTI extend my sincere thanks to Dr.Rajendra Jain for allowing me toconduct the study in his hospital and Dr.R.M.Pandey for conductingthe Statistics.

REFERENCES1. Jones M.A.,Magarey M.E.,Clinical reasoning in the use of

manual therapy techniques for the shoulder girdle.In: Evaluationand Treatment of the Shoulder,Philadelphia,F.A.DavisCompany:2001:317-346.

2. Saidoff D.C.,McDonough A.L.,Stiff and painfulshoulder.In:Critical Pathways in therapeuticintervention,Mosby:1997:153-164.

3. Constant C.R.,Murley A.H.G., A clinical method of functionalassessment of the shoulder.Clinical Orthopaedics & RelatedResearch,1987:214:160-164.

4. Wardsworth C.T., Frozen Shoulder, Physical Therapy: 1986: 66(12) :1878-1883.

IJOT : Vol. XXXVI : No. 2 August - November 200440

5. Maitland G.D.,Treatment of the glenohumeral joint by passivemovement,Physiotherapy:1983:69(1):3-7.

6. McClure P.W.,Flowers K.R.,Treatment of limited shoulder motionusing an elevation splint.Physical Therapy:1992:72(1):57-62.

7. Callinan N.,McPherson S. et al,Effectiveness of hydroplastyand therapeutic exercise for treatment of frozen shoulder,Journalof Hand Therapy:2003(July-September):219-224.

8. Lastago P.C., Jaffe R.,Continuous passive motion after repair ofthe rotator cuff.The Journal of Bone & Joint Surgery:1998:80-A(7):1002-1011.

9. Salter R.B.,The Physiologic Basis of Continuous Passive Motionfor Articular Carti lage Healing and Regeneration,HandClinics:1994:10(2):211-219.

10. Nicholson G.G. , Effect of Joint Mobilization on Pain andHypomobility Associated with Patients Suffering with AdhesiveCapsulit is,Journal of Orthopaedics & Sports PhysicalTherapy:1985:238-246.

l