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The Efficacy of Rehabilitation of Postural and Muscular Imbalances

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The Efficacy of Rehabilitation of Postural and Muscular Imbalances Powered By Docstoc
					The Efficacy of Rehabilitation of Postural and Muscular Imbalances in
the Chiropractic Management of Shoulder Impingement Syndrome in
                                      Swimmers




 A dissertation submitted to the Faculty Health Sciences, Technikon Witwatersrand, in
partial fulfilment of the requirement for the degree of Master of Technology: Chiropractic
                                           By


                                  Jacqueline Richards
                                 (Student no: 9806711)




_______________________________                         _____________
Dr B Losco (M. Tech. Chiropractic SA)                   Date
(Supervisor)


_______________________________                         _____________
Dr C Lyons (M. Tech. Chiropractic SA)                   Date
(Co-supervisor)
                                    DECLARATION


I declare that this dissertation is my own, unaided work. It is being submitted in partial
fulfilment for the Degree of Master of Technology at the Technikon Witwatersrand,
Johannesburg. It has not been submitted before for any degree or examination in any
other Technikon or University.




__________________________                                      ___________
Jacqueline Richards                                             Date




                                                                                             II
                                        ABSTRACT



The purpose of this unblinded, controlled pilot study was to compare the effectiveness
of Spinal Manipulative Therapy and a shoulder rehabilitation program, focussing on
improving muscular and postural imbalances, verses Spinal Manipulative Therapy alone
in the treatment of sub-acute and chronic shoulder impingement syndrome found in
swimmers.


In executing the comparison, it was anticipated that both treatment protocols would be
effective, but the combined therapy of Spinal Manipulative Therapy and rehabilitation
would be the most effective in treating sub-acute and chronic shoulder impingement
syndrome in swimmers. This treatment           protocol focused on correcting the
biomechanical dysfunction in the cervical spine and thoracic spine coupled with a
rehabilitation program to stretch anterior musculature, strengthen posterior musculature
and strengthen the shoulder in external rotation. These muscular and postural
imbalances are a contributing factor in perpetuating the pathomechanics causing sub-
acute and chronic shoulder impingement syndrome found in swimmers. Shoulder
impingement syndrome of this kind in swimmers is known as Swimmer’s shoulder.


Thirty swimmers between the ages of 18 and 60 with subacute and chronic shoulder
pain were recruited by advertising in the local newspapers. Two groups of fifteen
patients were created. Patients were randomly assigned to one of the groups as they
enrolled for participation. Group A underwent Spinal Manipulative Therapy of the
thoracic and cervical spines in conjunction with shoulder strengthening and postural
corrective exercises. Group B underwent Spinal Manipulative Therapy of the thoracic
and cervical spines. Each patient was treated nine times in three weeks.


A Saunders Digital Inclinometer was used to record objective glenohumeral ranges of
motion and a painful arc was determined as positive between 45 and 120 degrees. The
Supraspinatus Test was performed which was recorded as positive or negative.
Subjective findings were measured with the use of the Visual Analogue Pain Scale and
a questionnaire modified from Athletic Shoulder Outcome Rating Scale and American
Shoulder and Elbow Surgeons’ Shoulder Evaluation Form. Data was collected prior to
the first, fourth, seventh and ninth visit.

                                                                                         III
The results indicated that both groups were effective in treating Swimmer’s shoulder.
Group A showed the most positive results in terms of objective and subjective clinical
findings.


In conclusion, Group A (Spinal Manipulative Therapy and Rehabilitation) was the most
effective treatment protocol for the management of sub-acute and chronic shoulder
impingement syndrome in swimmers. This treatment protocol had a greater benefit with
regard to improvement of shoulder abduction range of motion, painful arc,
Supraspinatus Test and Visual Analogue Pain Scale than Group B (Spinal Manipulative
Therapy only).




                                                                                    IV
                                    DEDICATION


This work is dedicated to my family, Louise, Chris, Nikki and Darren. Thank you for your
      unfailing support, your unconditional love and your unquestionable patience.




   Thank you to my mentor Robert Fuller for his support throughout the course of my
Chiropractic studies. Were it not for his assistance I would not be doing Chiropractic and
 would not be where I am today. Thank you for your tolerance, support and assistance.




                                                                                        V
                               ACKNOWLEDGEMENTS



Thank you to Dr Fuller, Dr Parbhoo, Peter, Enid, Ethne and Patricia for having me at the
practice to complete my clinical trial.


Thank you to the Caxton Local Newspapers for publishing my advert free of charge.
Without your assistance my clinical trial would not have been completed so quickly.


Thank you to Tim and Trish for the use of your lap top computer! Without which I would
have slowly descended into insanity. Your assistance is greatly appreciated.


Thank you to my supervisor, Dr Barrett Losco and co-supervisor Dr Craig Lyons for your
hard work and assistance with this dissertation.


Last, but definitely not least, thank you to all the patients who took part in the study.
Without you I would not have been able to complete this study. Your contribution was
greatly appreciated!




                                                                                            VI
                                 TABLE OF CONTENTS

                                                                 Page

DECLARATION                                                       II
ABSTRACT                                                          III
DEDICATION                                                        V
ACKNOWLEDGEMENTS                                                  VI
TABLE OF CONTENTS                                                 VII
LIST OF FIGURES                                                   XIII
LIST OF TABLES                                                    XV
LIST OF APPENDIX                                                  XVII


CHAPTER 1 INTRODUCTION                                            1


CHAPTER 2 LITERATURE REVIEW                                       3
2.1      Introduction                                             3
2.2      Anatomy and Biomechanics of the shoulder                 3
 2.2.1      The Sternoclavicular Joint (SC)                       4
 2.2.2      The Acromioclavicular Joint (AC)                      4
 2.2.3      Glenohumeral Joint                                    5
 2.2.4      Scapulothoracic Joint                                 6
 2.2.5      Scapulohumeral Rhythm                                 8
 2.2.6      Muscles Acting on the Shoulder and Pectoral Girdle    8
2.3      Impingement                                              10
 2.3.1      Aetiology                                             10
 2.3.1.1      Types of Acromion                                   10
 2.3.2      Primary Impingement                                   11
 2.3.3      Secondary Impingement                                 11
2.4      Swimmer’s Shoulder                                       12
 2.4.1      Definition                                            12
 2.4.2      Incidence and Prevalence                              12
 2.4.3      Aetiology                                             13
 2.4.4      Propulsion and Drag                                   13
 2.4.4.1      Propulsion                                          13


                                                                       VII
 2.4.4.1.1     Form Drag                                                        14
 2.4.4.1.2     Wave Drag                                                        14
 2.4.4.1.3     Fractional Drag                                                  14
 2.4.5     Swimming Strokes                                                     15
 2.4.5.1     Freestyle                                                          16
 2.4.5.2     Backstroke                                                         18
 2.4.5.3     Butterfly                                                          19
 2.4.5.4     Breaststroke                                                       21
 2.4.6     Pathomechanics of Shoulders in Swimming                              22
 2.4.6.1     Humeral Rotation/ Depression                                       22
 2.4.6.2     Hand Placement and Position                                        23
 2.4.6.3     Shoulder Position                                                  23
 2.4.6.3.1     Adduction/ Internal Rotation                                     24
 2.4.6.3.2     Abduction/ Internal Rotation                                     26
 2.4.6.3.3     Abduction/ External Rotation                                     26
 2.4.6.4     Muscular Imbalance                                                 26
 2.4.6.4.1     Relationship Between Pectorals and Scapular Rotators             26
 2.4.6.4.2     Relationship Between Adductor/ Internal Rotators and Abductor/   27
               External Rotators
 2.4.6.5     Instability                                                        28
 2.4.6.6     The Kick                                                           28
 2.4.6.7     Body Role and Rotation                                             28
 2.4.6.8     Head Position and Breathing Pattern                                29
 2.4.6.9     Training Concerns                                                  29
 2.4.6.10 Spinal Concerns                                                       30
 2.4.7     Rehabilitation                                                       30
2.5      Correlation Between Shoulder Girdle and Spine                          32
 2.5.1     Anatomical Correlation                                               32
 2.5.2     Biomechanical Correlation                                            33
 2.5.3     Neurological Correlation                                             34
 2.5.4     Postural Correlation                                                 36
2.6      Spinal Manipulative Therapy                                            37
 2.6.1     Phases of Joint Motion                                               37
 2.6.2     The Adjustment                                                       38
 2.6.3     Success Rate                                                         39

                                                                                VIII
2.7      Differential Diagnosis of Shoulder Pain                     39
2.8      Imaging                                                     40
2.9      Treatment                                                   40
 2.9.1      Conservative Treatment                                   40
 2.9.2      Rehabilitation                                           41
 2.9.3      Invasive Therapy                                         41


CHAPTER 3 METHODOLOGY                                                42
3.1      Sample and Selection Criteria                               42
3.2      Research Criteria                                           42
 3.2.1      Inclusion Criteria                                       42
 3.2.2      Exclusion Criteria                                       43
3.3      Treatment Protocol                                          44
 3.3.1      Randomisation Process                                    44
 3.3.2      Group Treatment Protocol                                 44
 3.3.3      Rehabilitation Program                                   45
 3.3.3.1      The in-doorway Stretch                                 46
 3.3.3.2      Functional Position of the Arm                         47
 3.3.3.3      Lateral Rotation of the Arm at the Shoulder            48
 3.3.3.4      Standing Row                                           49
 3.3.4      Spinal Manipulative Therapy                              51
 3.3.4.1      Posterior Superior Occiput                             51
 3.3.4.2      Superior Condyle                                       52
 3.3.4.3      Cervical Break                                         53
 3.3.4.4      Thumb Cervical Extension                               56
 3.3.4.5      Combination Movement                                   57
 3.3.4.6      Thumb Movement: Bench TM                               58
 3.3.4.7      Crossed Bilateral Body Drop                            59
3.4      Procedure                                                   61
 3.4.1      First Consultation                                       61
 3.4.2      Follow-up Consultations                                  61
 3.4.3      Measurements                                             61
 3.4.3.1      Objective Measurements                                 62
 3.4.3.1.1      Painful Arc and Shoulder Abduction Range of Motion   62
 3.4.3.1.2      Supraspinatus Test (Empty Can Test)                  63

                                                                      IX
 3.4.3.2      Subjective Measurements                                                  63
 3.4.3.2.1      Visual Analogue Pain Scale                                             63
 3.4.3.2.2      Questionnaire                                                          64
3.5      Data Analysis                                                                 64
 3.5.1      Objective Data                                                             64
 3.5.2      Subjective Data                                                            64
 3.5.3      Statistical Analysis                                                       65


CHAPTER 4 RESULTS                                                                      67
4.1      Introduction                                                                  67
4.2      Objective Data                                                                68
 4.2.1      Shoulder Abduction Range of Motion                                         68
 4.2.1.1      Graphical Representation of Pain Free Shoulder Range of Motion           68
 4.2.1.2      Statistical Representation of Pain Free Shoulder Range of Motion         69
 4.2.1.2.1      Intragroup Comparison                                                  69
 4.2.1.2.2      Intergroup Comparison                                                  69
 4.2.2      Painful Arc                                                                71
 4.2.2.1      Graphical Representation of Painful Arc                                  71
 4.2.2.2      Statistical Representation of Painful Arc                                72
 4.2.3      Supraspinatus Test                                                         73
 4.2.3.1      Graphical Representation of Supraspinatus Test                           73
 4.2.3.2      Statistical Representation of Supraspinatus Test                         74
4.3      Subjective Data                                                               75
 4.3.1      Visual Analogue Pain Scale                                                 75
 4.3.1.1      Graphical Representation of Visual Analogue Pain Scale                   75
 4.3.1.2      Statistical Representation of Visual Analogue Pain Scale                 76
 4.3.1.2.1      Intragroup Comparison                                                  76
 4.3.1.2.2      Intergroup Comparison                                                  76
 4.3.2      Questionnaire Scores                                                       78
 4.3.2.1      Question 1: Is your shoulder comfortable with your arm at rest by your   78
              side?
 4.3.2.1.1      Graphical Representation of Question 1 Scores                          78
 4.3.2.1.2      Statistical Representation of Question 1 Scores                        79
 4.3.2.2      Question 2: Does your shoulder allow you to sleep comfortably?           81
 4.3.2.2.1      Graphical Representation of Question 2 Scores                          81

                                                                                            X
 4.3.2.2.2      Statistical Representation of Question 2 Scores                       82
 4.3.2.3     Question 3: Can you reach the small of your back to tuck in your shirt   83
              with your hand?
 4.3.2.3.1      Graphical Representation of Question 3 Scores                         83
 4.3.2.3.2      Statistical Representation of Question 3 Scores                       84
 4.3.2.4      Question 4: Can you place your hand behind your head with the elbow 85
              straight out to the side?
 4.3.2.4.1      Graphical Representation of Question 4 Scores                         85
 4.3.2.4.2      Statistical Representation of Question 4 Scores                       86
 4.3.2.5      Question 5: Can you lift a fill litre container to the level of your    87
              shoulder without bending your elbow?
 4.3.2.5.1      Graphical Representation of Question 5 Scores                         87
 4.3.2.5.2      Statistical Representation of Question 5 Scores                       88
 4.3.2.6      Question 6: Can you wash the back of your opposite shoulder with        89
              the affected extremity
 4.3.2.6.1      Graphical Representation of Question 6 Scores                         89
 4.3.2.6.2      Statistical Representation of Question 6 Scores                       90
4.4      Levels Adjusted at each Visit                                                91
 4.4.1      Visit 1                                                                   91
 4.4.2      Visit 2                                                                   93
 4.4.3      Visit 3                                                                   95
 4.4.4      Visit 4                                                                   97
 4.4.5      Visit 5                                                                   99
 4.4.6      Visit 6                                                                   101
 4.4.7      Visit 7                                                                   103
 4.4.8      Visit 8                                                                   105
 4.4.9      Visit 9                                                                   107
4.5      Tables of Interpretive Data                                                  108
4.6   Swimming Strokes                                                                110



CHAPTER 5 DISCUSSION                                                                  111
5.1   Introduction                                                                    111
5.2   Objective Data                                                                  111
 5.2.1      Shoulder Abduction Range of Motion                                        111


                                                                                       XI
 5.2.2      Painful Arc                                                                113
 5.2.3      Supraspinatus Test                                                         115
5.3      Subjective Data                                                               117
 5.3.1      Visual Analogue Pain Scale                                                 117
 5.3.2      Questionnaire                                                              119
 5.3.2.1      Question 1: Is your shoulder comfortable with your arm at rest by your   119
              side?
 5.3.2.2      Question 2: Does your shoulder allow you to sleep comfortably?           119
 5.3.2.3      Question 3: Can you reach the small of your back to tuck in your shirt   120
              with your hand?
 5.3.2.4      Question 4: Can you place your hand behind your head with the elbow 121
              straight out to the side?
 5.3.2.5      Question 5: Can you lift a full litre container to the level of your     121
              shoulder without bending your elbow?
 5.3.2.6      Question 6: Can you wash the back of your opposite shoulder with         122
              the affected extremity?
5.4      Levels of Manipulation                                                        122
5.5      Tables of Interpretive Data                                                   124
5.6   Swimming Strokes                                                                 125


CHAPTER 6 CONCLUSION AND RECOMMENDATION                                                127
6.1      Conclusion                                                                    127
6.2   Recommendation                                                                   128


CHAPTER 7 REFERENCE                                                                    130




                                                                                        XII
                                   LIST OF FIGURES


Figure 1.    Anterior view of musculature and osteology of the pectoral girdle      7
Figure 2.    Muscles of the rotator cuff                                            9
Figure 3.    Lift force and propulsion while swimming freestyle                     15
Figure 4.    Freestyle stroke pattern                                               18
Figure 5.    Backstroke stroke pattern                                              19
Figure 6.    Butterfly stroke pattern                                               20
Figure 7.    Butterfly arm pattern                                                  21
Figure 8.    Breaststroke stroke pattern                                            22
Figure 9.    Adduction stress in swimmer’s shoulder                                 25
Figure 10.   Vascularity of critical zone                                           25
Figure 11.   Scheme showing the relationship of a cervical nerve and its ganglion
             to a cervical vertebra                                                 35
Figure 12.   Joint manipulation and mobilization                                    38
Figure 13.   The in-door-way stretch                                                46
Figure 14.   Sports specific exercise of the shoulder                               47
Figure 15.   Lateral rotation of the arm at the shoulder                            48
Figure 16.   Standing row                                                           49
Figure 17.   Push-ups with extra                                                    50
Figure 18.   Posterior Superior Occiput                                             52
Figure 19.   Superior condyle                                                       53
Figure 20.   Cervical Break                                                         54,
                                                                                    55
Figure 21.   Thumb Cervical Extension                                               56
Figure 22.   Combination Movement                                                   58
Figure 23.   Thumb Movement: Bench TM                                               59
Figure 24.   Crossed Bilateral Body Drop                                            60
Figure 25.   Comparison of the Means for Shoulder Abduction Range of Motion.        68
Figure 26.   The graph compares the number of positive pain scale readings in       71
             each visit.
Figure 27.   The graph compares the number of positive Supraspinatus test           73
             results.
Figure 28.   Comparison of the Means for the Visual Analogue Pain Scale Scores      75


                                                                                    XIII
Figure 29.   A comparison of the Means for the Questionnaire Question One       78
Figure 30.   Comparison of the Means for the Questionnaire Question Two         81
Figure 31.   Comparison of the Means for the Questionnaire question Three       83
Figure 32.   Comparison of the Means for the Questionnaire Question Four        85
Figure 33.   Comparison of the Means for the Questionnaire Question Five        87
Figure 34.   Comparison of the Means for the Questionnaire Question Six         89
Figure 35.   Pie chart representing the levels adjusted at the first visit.     91
Figure 36.   Pie chart representing the levels adjusted at the second visit.    93
Figure 37.   Pie chart representing the levels adjusted at the third visit.     95
Figure 38.   Pie chart representing the levels adjusted at the fourth visit.    97
Figure 39.   Pie chart representing the levels adjusted at the fifth visit.     99
Figure 40.   Pie chart representing the levels adjusted at the sixth visit.     101
Figure 41.   Pie chart representing the levels adjusted at the seventh visit.   103
Figure 42.   Pie chart representing the levels adjusted at the eighth visit.    105
Figure 43.   Pie chart representing the levels adjusted at the ninth visit.     107




                                                                                XIV
                                LIST OF TABLES


Table 1:    Phases of scapulohumeral rhythm                                      8
Table 2.    Neer Stages of Impingement                                           11
Table 3.    Muscles connecting the upper limb to the spine                       33
Table 4.    Differential Diagnosis of Shoulder pain                              39
Table 5.    Uncommon diagnoses of cervicobrachial pain                           40
Table 6.    Contraindications to Spinal Manipulative Therapy                     43
Table 7.    Contraindications to shoulder rehabilitation                         44
Table 8:    Descriptive statistics for Questionnaire Question 1                  79
Table 9.    Descriptive Statistics for Questionnaire Question 2                  82
Table 10.   Descriptive Statistics for Questionnaire Question 3                  84
Table 11.   Descriptive Statistics for Questionnaire Question 4.                 86
Table 12.   Descriptive Statistics for Questionnaire Question 5.                 88
Table 13.   Descriptive Statistics for Questionnaire Question 6                  90
Table 14.   Table demonstrating the number of times each level was adjusted in   91
            visit 1.
Table 15.   Table demonstrating the number of times each level was adjusted in   93
            visit 2.
Table 16.   Table demonstrating the number of times each level was adjusted in   95
            visit 3.
Table 17.   Table demonstrating the number of times each level was adjusted in   97
            visit 4.
Table 18.   Table demonstrates the number of times each level was adjusted in    99
            visit 5.
Table 19.   Table demonstrating the number of times each level was adjusted in   101
            visit 6.
Table 20.   Table demonstrating the number of times each level was adjusted in   103
            visit 7
Table 21.   Table demonstrating the number of times each level was adjusted in   105
            visit 8
Table 22.   Table demonstrating the number of times each level was adjusted in   107
            visit 9.
Table 23.   Age groups                                                           108


                                                                                     XV
Table 24.   Gender                                     108
Table 25.   Dominance                                  109
Table 26.   Chronicity                                 109
Table 27.   Number of patients and their main stroke   110




                                                       XVI
                               LIST OF APPENDIX

Appendix A:   Advertisement                                         135
Appendix B:   Patient Information and Consent Form                  136
Appendix C:   Soap Note                                             138
Appendix D:   Pertinent Physical Examination                        139
Appendix E:   Cervical Spine Regional Examination                   141
Appendix F:   Shoulder Regional Examination                         147
Appendix G:   Questionnaire                                         155
Appendix H:   Visual Analogue Pain Scale                            156
Appendix I:   Pain Free Shoulder Abduction Range of Motion Scores   157
Appendix J:   Painful Arc Scores                                    158
Appendix K:   Supraspinatus Test Scores                             159
Appendix L:   Visual Analogue Pain Scale Scores                     160
Appendix M:   Questionnaire Score                                   161
Appendix N:   Levels of Adjustment                                  164
Appendix O:   Full Statistical Analysis                             165




                                                                     XVII

				
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