Cyriax Friction Massage Technique Health And Social Care Essay

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1st Jan 1970 Health And Social Care Reference this

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INTRODUCTION

Shoulder girdle is a complex series of articulations that is crucial to many activities of daily living. This condition can impact on working life, leisure and general quality of life .A global decrease in shoulder function is called Periarthritis, referring to the actual adherence of the shoulder capsule to the humeral head.

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Periarthritis (frozen shoulder) is an insidious painful condition with gradual restriction of all planes of movement in the shoulder. The causes of frozen shoulder are not fully understood. It can be due to idiopathic or post-traumatic causes .Factors associated with adhesive capsulitis include female gender , age older than 40 years , trauma , immobilization , diabetes ,thyroid disease , stroke , myocardial infarction , the presence of autoimmune diseases , cervical spine disorders , reflex sympathetic dystrophy syndrome. Idiopathic (primary) adhesive capsulitis is characterized by fibrosis of the capsule resulting with progressive, painful loss of active and passive shoulder motion.

In Periarthritis shoulder, adhesions (abnormal bands of tissue) grow between the joint surfaces, restricting motion. There is also a lack of synovial fluid, which normally lubricates the gap between the bone and socket to help the shoulder joint move. The loss of movement is greatest for lateral rotation than for abduction and medial rotation (Cyriax’s capsular pattern, Cyriax 1978

The natural course of a frozen shoulder is usually self-limiting. It is a disease that improves over an 18 to 24 month period. Multiple studies have demonstrated an improvement with different types of treatment. Dominant arm involvement has been shown to have a good prognosis; associated

Intrinsic pathology or insulin – dependent diabetes of more than 10 years are poor prognostic indicators.

STAGES OF PERIARTHRITIS SHOULDER

Reeve’s has described three stages of the disease:

STAGE 1(PAINFUL STAGE)

This stage is mainly characterized by pain usually lasting 2-9months.

Generalized ache that is difficult to pinpoint.

Muscle spasms in the trapezius also commonly occur during this phase.

Increasing pain at night and at rest.

The condition progresses to one of severe pain accompanied by stiffness and decreased range of motion.

STAGE 2(FROZEN STAGE)

Pain gradually subsides or less pain.

Stiffness is marked lasting 4-12 months.

Restriction of movement.

Decreasing pain at night and at rest.

Discomfort felt at extreme ranges of movement.

STAGE 3(RECOVERY STAGE)

Decreased pain

Marked restriction with slow, gradual increase of range of motion.

Recovery is spontaneous but frequently incomplete.

Frozen shoulder occurs much more commonly in individuals with diabetes, affecting 10% to 20% of these individuals. Other medical problems associated with increased risk of frozen shoulder include Hypothyroidism, Hyperthyroidism, Parkinson’s disease, cardiac disease or surgery. Frozen shoulder can develop after a shoulder is injured or immobilized for a period of time. Attempts to prevent frozen shoulder include early motion of the shoulder after it has been injured

Pain due to frozen shoulder is usually dull or aching. It can be worsened with attempted motion. The pain is usually located over the outer shoulder area and sometimes the upper arm. The predominant feature of this disorder is restricted motion or stiffness in the shoulder. Patients suffering from this condition cannot move the shoulder normally .Motion is also limited when someone else attempts to move the shoulder for the patient.

PATHOLOGY

Synovial hypertrophy.

Reduced volume with a tight capsule.

Neo vascular proliferation.

Hyper vascular synovitis.

Capsular contraction and thickening.

No synovitis is seen and decrease in the thickness of the capsule.

Decreased volume of the gleno humeral joint with restricted ROM.

Although the glenohumeral joint synovial capsule is involved, much of the disease process involves structures outside the shoulder joint, including the coracohumeral ligament, rotator interval, subscapularis musculotendinous unit, and the subacromial burse.

Although recovery is usually spontaneous, treatment with Intra-articular corticosteroids and gentle but persistent physical therapy may provide a better outcome, resulting in little functional compromise. Physiotherapy treatments used for acute adhesive capsulitis include local heat, SWD, TENS, Ultrasound, Mobilizations and exercises.

NEED FOR THE STUDY

Periarthritis shoulder or frozen shoulder is among the common afflictions of shoulder joint, affecting as much as 2% of general population .Pain is the most disturbing factor and it leads to functional impairments, include difficulty in dressing.

There was a need to study about the effects of cyriax manipulation and shortwave diathermy on painful stage of the periarthritis shoulder

STATEMENT OF THE PROBLEM

To study the: ” Efficacy of cyriax friction massage technique and conventional therapy in patients with painful stage of unilateral periarthritis shoulder”

OBJECTIVE OF THE STUDY

The objective of the study was to evaluate the effectiveness of Cyriax friction massage technique and conventional therapy in patients with painful stage of unilateral periarthritis shoulder”

HYPOTHESIS

Null Hypothesis:

The study was carried out on the basis of the null hypothesis which could be stated as “There is no significant improvement in pain and functional activities between cyriax friction massage technique and conventional physical therapy in patients with painful stage of unilateral periarthritis shoulder “

Alternate Hypothesis:

The alternate hypothesis states have “There is a significant improvement in pain and functional activities between cyriax friction massage technique and conventional physical therapy in patients with painful stage of unilateral periarthritis shoulder”

REVIEW OF LITERATURE

Leah Steele, Hannah Lade, Stephanie McKenzie, and Trevor G. RussellInt J Telemed Appl. 2012; Physiotherapists often assess and treat clients with shoulder pain, and there exists considerable evidence of effective physiotherapy treatments for many shoulder disorders, with conservative physiotherapy management shown to provide up to an 88% improvement in shoulder function in the long term.

Jing-lan Yang, Shiau-yee Chen, Ching-Lin Hsieh, BMC Musculoskeletal Disorder. 2012; 13: 46. Clinical approaches like mobilization, stretching, and/or massage may decrease shoulder tightness and improve symptoms in subjects with stiff shoulders.

Nicola Crichton, D. Gould et al.2012. Visual Analogue Scale (VAS) is a measurement instrument that tries to measure a characteristic or attitude that is believed to range across a continuum of values and cannot easily be directly measured.

Jose Orlando Ruiz .J Man Manip Ther. 2009; 17(1): 58-63. Various treatment approaches have been described for limited shoulder passive range of motion (ROM)5. These approaches include different forms of manual therapy, electrotherapy, active exercise, and several forms of passive stretching5. The use of passive stretching of the shoulder capsule and soft tissues by means of mobilization techniques has been recommended.

Jenna Godfry, Richard Humman(2009) the simple shoulder test

demonstrated overall acceptable performance of shoulder.

U.-D. Reips and F. Funke (2008) there is evidence showing that visual analogue scales have superior metrical characteristics than discrete scales, thus a wider range of statistical methods can be applied to the pain measurements.

James P. Tasto, MD and David W. Elias, MD (Sports Med Arthrosc Rev 2007; 15:216-221). The term ‘frozen shoulder” is defined as a clinical condition with restricted active and passive range of motion (ROM) in

all directions, including flexion, abduction, and rotation

Pajareyak, et al, 2004, concluded that physical therapy is effective for patients with adhesive capsulitis.

Fusun Guler – Uysal, Erhankozanagils, Swiss medical weekly 2004 : 134 : 353 – 358 , indicates daily mobilizations exercises provides faster and better response in the early phase of treatment in periarthritis shoulder.

Gules-Ursal F , Kozanoglu E , Swiss Med WKY.2004 Jun 12;134(23-24);353A randomized , comparative study on the early response of two methods of rehabilitation (cyriax approach Vs conventional physiotherapy) in adhesive capsulitis concluded that the cyriax methods of rehabilitation provides as faster and better response than conventional physical therapy methods in the early phase of treatment in adhesive capsulitis.

Joshua Cleland , Christoper J Durall, and physical therapy for adhesive capsulitis , physiotherapy Aug 2002 : 88 : 8 : 450 -457 , proposes that 6 months of physical therapy , Codman’s exercises ,and strengthening exercises shows significant improvements in active range of motion in patients with adhesive capsulitis.

Levy O, Rath E, A tar D 2001, concluded that when pain and limitation of passive range of motion persist, gentle manipulation dramatically shortens the debilitating process.

Griggs SM, Ab n A, Green A, 2000, proved that patients with idiopathic Periarthritis shoulder can be successfully treated with a specific four direction stretching exercise program.

MATERIALS & METHODOLOGY

Materials:

Mobilization bed and towel

Simple shoulder test

Visual Analogue Scale

Shoulder assessment form

Shortwave Diathermy unit

SELECTION CRITERIA

Inclusion criteria:

Age group between 40-60 years.

Shoulder pain of minimum 2 months duration with no major shoulder trauma.

Marked loss of active and passive shoulder motion.

Pain with motion and a minimum visual analogue scale (VAS) score of 3 cm.

Normal findings on anteroposterior and axillary lateral radiographs of the glenohumeral joint.

Willingness to participate in study.

Exclusion criteria:

Adhesive capsulitis secondary to rotator cuff tear.

Patient with OA and RA shoulder.

Dislocation and fracture in and around shoulder joint.

Chronic case of adhesive capsulitis.

Patients with history of intra articular steroid injectionas.

Poly arthritis or neurological disease or cervical neuropathy.

Medical conditions such as cardiac disease, infections, coagulations disorders.

Tumors around shoulder region.

Cervical rib.

Cervical Brachialgia

Cervical Spondylosis.

Parameters

Visual analog scale

Simple shoulder test

METHODOLOGY

STUDY DESIGN:

A pre-test and post-test experimental study design.

SAMPLE SIZE:

Thirty patients with adhesive capsulitis (Stage 1) who comes under inclusion criteria were taken for the study.

Group 1 (Experimental Group): Patients treated with cyriax friction massage technique.

Group2: (Control Group): Patients treated with shortwave diathermy.

Both groups concluded their treatments with daily home exercise program.

SAMPLING:

The subjects for this study were selected through a convenient sampling technique.

STUDY SETTING:

The study was conducted in Department of Physiotherapy, Sri Ramakrishna Hospital, Coimbatore. All the participants were interviewed and examined to ensure that the selection criteria were fulfilled. Such eligible subjects were selected and they took part in the study after obtaining informed consent.

Study duration:

The study was carried out for 6 months.

Treatment duration:

Both groups received treatment, for 1 month.

Experimental Group: Once in alternative days/week.

Control Group: Everyday once except weekends.

Demographic data of Experimental group:

Age group

Males

Females

Total

40-50

02

03

05

50-60

01

01

02

60-70

01

03

04

70-80

02

02

04

Total

06

09

15

Side Involved

Number

Right

08

Left

07

Total

15

Demographic data of Control Group:

Age group

Males

Females

Total

40-50

01

03

04

50-60

01

02

03

60-70

02

04

06

70-80

01

01

02

Total

05

10

15

Side Involved

Number

Right

06

Left

09

Total

15

STATISTICAL TOOLS

Independent t test was used to show the effectiveness of treatment between Group1 and Group2.

Independent “T” test =

S=

Where,

S = Combined standard deviation

= difference of mean of experimental group

= difference of mean of control group

= number of subjects in experimental group

= number of subjects in control group

INTERVENTION TECHNIQUE

CYRIAX MANIPULATION

Principle

Cyriax introduces transverse deep friction massage for soft tissue injury and lesions.

Effects of cyriax friction massage

Traumatic hyperaemia which help evaluate pain triggering metabolites. Movement of the affected structure which prevents or destroy the adhesion and helps to optimize the quality of scar tissue. Stimulation of the mechano receptor for which produces a quality of afferent impulse that stimulate the temporary analgesia and also help the patient in movement exercises.

Technique

Patient position should be in supine or high sitting.

Therapist stands treatment side of the patient and holds the patient arm with one hand .Applying the friction force to the treatment area by using the Middle and Index finger of the therapist. Before and during the friction massage therapist should give a mild traction by pulling the patients arm. No movement should occur between skin and finger.

SHORT WAVE DIATHERMY

Definition

Diathermy is the application of high -frequency electromagnetic energy that is primarily used to generate heat in body tissues.

Dosage

SWD with 220 V/50 Hz power source and 27.12 MHz oscillation frequency was applied to the therapy region.

Position of the patient

Patient’s position should be in supine and pad electrode should place antero-posteriorly in contra planar method .

In the 15 minute treatment duration , we should ask to the patient about heat and their comfortable oftenly.

FREE EXERCISES

Definition:

Free exercises are those which are performed by the patient’s own muscular efforts without the assistance or resistance of external force, other than that of gravity.

Objective exercises – in which patient aims to attain particular goal (Wall climbing exercises /finger ladder exercise ) :

Face a wall about three quarters of an arm length away from it. Using only your fingers (not your shoulder muscles), raise your arm up to shoulder level. Perform sets of 10 to 20 exercises at each session

Over head pulleys:

Instruct the patient to hold one end of the rope by normal hand and other end by the affected hand, with the normal hand pull the rope and lift the involved extremity forward (flexion), out to the side (abduction). The patient should not shrug the shoulder or lean the trunk. The patient position may be sitting, standing, or supine.

Patient using a wand for self assisted shoulder rotation:

T-Bar Abduction

Loosely grasp end of T-bar with involved hand and hold longer end with uninvolved hand .Use uninvolved hand to lift involved arm outward to side of body as far as tolerable, hold, then slowly return to start. Repeat 30 times.

T-Bar Extension

Loosely grasp end of T-bar with involved hand and hold longer end with uninvolved hand. Use uninvolved hand to lift involved arm backward behind body as far as tolerable, hold, then slowly return to start. Repeat 30 times.

T-Bar Flexion

Loosely grasp end of T-bar or broom stick with involved hand and hold longer end with uninvolved hand. Use uninvolved hand to lift involved arm upward in front of body as high as possible, hold, and slowly lower. Involved arm may assists pain allows .Repeat 30 times.

Codman’s exercises ( Pendular exercises ) :

For gentle distraction, no weight is used. The subject standing with the trunk flexed at the hip about 90 degree. The arm, hangs loosely downward in a position between 60 degree and 90 degree flexion .A pendulum or swinging motion of the arm is initiated by having the patient move the trunk slightly back and forth. Motions of flexion, extension, and horizontal abduction, adduction and circumduction can be done .Increase the arc of motion as tolerated.

Mariners wheel exercises:

This height – adjustable, wall -mounted wheel is designed to exercise the whole arm: the shoulder, the forearm, and the wrist. The user grasps the wheel’s horizontal handle and their arm goes through 360° of rotation with the wheel. This device has a resistance control so as the user’s strength and range of motion improves the difficulty of the exercise can be increased for progressive rehabilitation. The exercise also encourages lateral movement in the arm.

Towel stretch:

Take a 3 foot long towel, grasp it with both hands, and hold it in the horizontal position. Use the upper, good arm, to pull the affected arm toward the lower back. This can be repeated with the towel at a 45° angle. Perform sets of 10 to 20 stretches at each session.

Shoulder bracing exercises

Shoulder 90° of abduction, elbow 90° flexion ask the patient to

Protract and retract the shoulder, full arm should move front and back.

SIMPLE SHOULDER TEST FOR GROUP i

S.No

Pre test

Post test

Difference

1

19

63

44

2

33

71

38

3

38

84

48

4

29

71

42

5

25

69

44

6

30

75

45

7

29

75

46

8

19

70

51

9

33

84

51

10

31

82

51

11

30

80

50

12

38

84

46

13

4o

84

44

14

36

82

46

15

26

80

54

SIMPLE SHOULDER TEST FOR GROUP ii

s.no

Pre test

Post test

Difference

1

22

49

27

2

33

50

17

3

35

55

20

4

29

58

29

5

30

59

29

6

30

58

28

7

29

58

29

8

26

53

27

9

33

61

28

10

35

60

25

11

30

59

29

12

38

58

20

13

35

60

25

14

28

55

27

15

19

42

23

VISUAL ANALOGUE SCALE FOR GROUP 1

S.NO

Pre test

Post test

Difference

1

6

2

4

2

8

4

4

3

8

3

5

4

7

3

4

5

9

5

4

6

7

4

3

7

7

4

3

8

6

2

4

9

9

5

4

10

8

3

5

11

8

4

4

12

6

3

3

13

7

2

5

14

6

2

4

15

6

2

4

VISUAL ANALOGUE SCALE FOR GROUP 2

S.NO

Pre test

Post test

Difference

1

6

2

4

2

8

6

2

3

7

5

2

4

7

5

2

5

9

7

2

6

8

5

3

7

6

4

2

8

9

7

2

9

8

6

2

10

9

7

2

11

7

4

3

12

6

4

2

13

6

4

2

14

8

6

2

15

7

5

2

Data Analysis and Interpretation

ANALYSIS OF PRE TEST VALUES OF SIMPLE SHOULDER TEST

TEST

Cyriax friction massage Vs Short wave diathermy with free exercise

Pre test

Mean value

Group 1

Group 2

30.4

30.13

Independent t test

0.18

P value and its

significance

P value˃0.05 is insignificance

The calculated pre test’t’ value between group1 and group2 was 0.18 and the critical value was 1.701, which states that there is a no significant difference between two groups.

ANALYSIS OF PRE TEST VALUES OF SIMPLE SHOULDER TEST

ANALYSIS OF POST TEST VALUES OF SIMPLE SHOULDER TEST

TEST

Cyriax friction massage Vs Short wave diathermy with free exercise

post test

Mean value

Group 1

Group 2

76.93

55.66

Independent t test

2.083

P value and its

significance

P value˃0.05 is insignificance

The calculated post test ‘t’ value between group1 and group2 was 2.083 and the critical value was 1.701which states that there exists a significant difference between two groups.

ANALYSIS OF POST TEST VALUES OF SIMPLE SHOULDER TEST

ANALYSIS OF SIMPLE SHOULDER TEST WITH CYRIAX AND FREE EXERCISE

TEST

Group1

Cyriax friction massage with free exercise

Pre test mean value

Post test mean value

30.4

76.93

Independent t test

18.44

P value and its

significance

P value˃0.05 is insignificance

The student’t’ test value for group1 (Cyriax friction massage with free exercise) was 43.09 and the critical value was 1.761 which states that there exists significant difference the pre test and post test value group1.

ANALYSIS OF SIMPLE SHOULDER TEST WITH CYRIAX AND FREE EXERCISE

ANALYSIS OF SIMPLE SHOULDER TEST WITH SHORT WAVE DIATHERMY AND FREE EXERCISE

TEST

Group2

Short wave diathermy with free exercise

Pre test mean value

Post test mean value

30.13

55.66

Independent t test

14.67

P value and its

significance

P value˃0.05 is insignificance

The student’t’ test value for group1 (short wave diathermy with free exercise) was 25.66 and the critical value was 1.761 which states that there exists significant difference between the pre test value and post test value group2.

ANALYSIS OF SIMPLE SHOULDER TEST WITH SHORT WAVE DIATHERMY AND FREE EXERCISE

ANALYSIS OF VISUAL ANALOGUE SCALE OF PRE TEST OF TWO GROUP

TEST

Cyriax friction massage Vs Short wave diathermy with free exercise

Pre test

Mean value

Group 1

Group 2

7.46

7.73

Independent t test

0.77

P value and its

significance

P value˃0.05 is insignificance

The calculated pre test’t’ value between group1 and grou2 was 0.77and the critical value was 1.701, which states that there is no significant difference between two groups.

ANALYSIS OF VISUAL ANALOGUE SCALE OF PRE TEST OF TWO GROUP

ANALYSIS OF VISUAL ANALOGUE SCALE OF POST TEST OF TWO GROUP

TEST

Cyriax friction massage Vs Short wave diathermy with free exercise

Post test

Mean value

Group 1

Group 2

3.46

5.46

Independent t test

5.68

P value and its

significance

P value˃0.05 is insignificance

The calculated post test’t’ value between group1 and grop2 was 5.68 and the critical value was 1.701 which states that there exists a significant difference between two groups.

ANALYSIS OF VISUAL ANALOGUE SCALE OF POST TEST OF TWO GROUP

ANALYSIS OF VISUAL ANALOGUE SCALE OF GROUP 1

TEST

Group 1

Cyriax friction massage with free exercise

Pre test mean value

Post test mean values

7.46

3.46

Independent t test

24.18

P value and its

significance

P value˃0.05 is insignificance

The student’t’ test value for group2(Cyriax friction massage with free exercise ) was 24.18 and the critical value was 1.761, which states that there exists significant difference between the pre test and post test value of group.

ANALYSIS OF VISUAL ANALOGUE SCALE OF GROUP 1

ANALYSIS OF VISUAL ANALOGUE SCALE OF GROUP 2

TEST

Group 2

Short wave diathermy with free exercise

Pre test mean value

Post test mean value

7.73

5.46

Independent t test

14.83

P value and its

significance

P value˃0.05 is insignificance

The student’t’ test value for group1 (Short wave diathermy with free exercise ) was 14.83 and the critical value was1.761, which states that there exists significant difference between the pre test and post test value of group 2.

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ANALYSIS OF VISUAL ANALOGUE SCALE OF GROUP 2

RESULTS

Effectiveness of Group1(Cyriax friction massage with free exercise ) is elicited by comparing the pre test and post test value Group2(shoulder function) using paired ‘t’ test , the calculated value is 18.44 , where the critical value is 1.761.Since the calculated value is greater than the critical value , there exists a significant difference between the pre test and post test value ofGroup2

Effectiveness of Group2( Short wave diathermy with free exercise )is elicited by comparing the pre test and post test of Group1(shoulder function) using paired ‘t’ test; the calculated value is 14.67,where the critical value is 1.761.Since the calculated value is greater than the critical value , there exists a significant difference between the pre test and post test value of Group2

While comparing the post test value of Group1 and Group2 using independent’t’ , the calculated value is ,2.083 where the critical value is 1.761 , which shows that there exists a significant difference between the pre test and post test value of two groups

When comparing the mean value of both the post test, mean value of Group1, 76.93 is greater than the post test mean value of Group2, 55.66 which confirms that Group1 shows a significant improvement than Group 2

Effectiveness of Group1 (Cyriax friction massage with free exercise) is elicited by comparing the pre test and post test value Group2(visual analogue scale) using paired ‘t’ test , the calculated value is 24.18 , where the critical value is 1.761.Since the calculated value is greater than the critical value , there exists a significant difference between the pre test and post test value ofGroup1

Effectiveness of Group2 (Short wave diathermy with free exercise) is elicited by comparing the pre test and post test of Group2(visual analogue scale) using paired ‘t’ test; the calculated value is 14.83,where the critical value is 1.761.Since the calculated value is greater than the critical value , there exists a significant difference between the pre test and post test value of Group2

While comparing the post test value of Group1 and Group2 using independent’t’ , the calculated value is ,5.68 where the critical value is 1.761 , which shows that there exists a significant difference between the pre test and post test value of two groups

When comparing the mean value of both the post test, mean value of Group1, 3.46 is less than the post test mean value of Group2, 5.46 which confirms that Group1 shows a significant improvement than Group 2

This study is fiend out the effectiveness of cyriax friction massage technique and free exercise is improving the pain relief and functional activities as evidenced by visual analogue scale and simple shoulder test in painful stage of unilateral periarthritis shoulder”

DISCUSSION

This study compares the effectiveness of Cyriax technique and short wave diathermy in subjects with painful stage of unilateral periarthritis shoulder”

Both groups were aimed reducing pain and increasing functional activities of shoulder joint. This study involves the pre test and post test with 15 patients. The variables taken in this study includes ,

VAS

SIMPLE SHOULDER TEST

This study was carried out on the basis of null hypothesis which could be stated as there is no significant difference in pain and function activities between Cyriax friction massage and short wave diathermy in patients with painful stage of periarthritis of shoulder joint.

Group 1 patients were treated with Cyriax approach and Group 2 patients were treated with Short wave diathermy. And both group also receive the free exercise. Pre test and post test values of VAS and SIMPLE SHOULDER TEST were assessed.

The intra group analysis shown that calculated ‘t’ value of group1 is grea

INTRODUCTION

Shoulder girdle is a complex series of articulations that is crucial to many activities of daily living. This condition can impact on working life, leisure and general quality of life .A global decrease in shoulder function is called Periarthritis, referring to the actual adherence of the shoulder capsule to the humeral head.

Periarthritis (frozen shoulder) is an insidious painful condition with gradual restriction of all planes of movement in the shoulder. The causes of frozen shoulder are not fully understood. It can be due to idiopathic or post-traumatic causes .Factors associated with adhesive capsulitis include female gender , age older than 40 years , trauma , immobilization , diabetes ,thyroid disease , stroke , myocardial infarction , the presence of autoimmune diseases , cervical spine disorders , reflex sympathetic dystrophy syndrome. Idiopathic (primary) adhesive capsulitis is characterized by fibrosis of the capsule resulting with progressive, painful loss of active and passive shoulder motion.

In Periarthritis shoulder, adhesions (abnormal bands of tissue) grow between the joint surfaces, restricting motion. There is also a lack of synovial fluid, which normally lubricates the gap between the bone and socket to help the shoulder joint move. The loss of movement is greatest for lateral rotation than for abduction and medial rotation (Cyriax’s capsular pattern, Cyriax 1978

The natural course of a frozen shoulder is usually self-limiting. It is a disease that improves over an 18 to 24 month period. Multiple studies have demonstrated an improvement with different types of treatment. Dominant arm involvement has been shown to have a good prognosis; associated

Intrinsic pathology or insulin – dependent diabetes of more than 10 years are poor prognostic indicators.

STAGES OF PERIARTHRITIS SHOULDER

Reeve’s has described three stages of the disease:

STAGE 1(PAINFUL STAGE)

This stage is mainly characterized by pain usually lasting 2-9months.

Generalized ache that is difficult to pinpoint.

Muscle spasms in the trapezius also commonly occur during this phase.

Increasing pain at night and at rest.

The condition progresses to one of severe pain accompanied by stiffness and decreased range of motion.

STAGE 2(FROZEN STAGE)

Pain gradually subsides or less pain.

Stiffness is marked lasting 4-12 months.

Restriction of movement.

Decreasing pain at night and at rest.

Discomfort felt at extreme ranges of movement.

STAGE 3(RECOVERY STAGE)

Decreased pain

Marked restriction with slow, gradual increase of range of motion.

Recovery is spontaneous but frequently incomplete.

Frozen shoulder occurs much more commonly in individuals with diabetes, affecting 10% to 20% of these individuals. Other medical problems associated with increased risk of frozen shoulder include Hypothyroidism, Hyperthyroidism, Parkinson’s disease, cardiac disease or surgery. Frozen shoulder can develop after a shoulder is injured or immobilized for a period of time. Attempts to prevent frozen shoulder include early motion of the shoulder after it has been injured

Pain due to frozen shoulder is usually dull or aching. It can be worsened with attempted motion. The pain is usually located over the outer shoulder area and sometimes the upper arm. The predominant feature of this disorder is restricted motion or stiffness in the shoulder. Patients suffering from this condition cannot move the shoulder normally .Motion is also limited when someone else attempts to move the shoulder for the patient.

PATHOLOGY

Synovial hypertrophy.

Reduced volume with a tight capsule.

Neo vascular proliferation.

Hyper vascular synovitis.

Capsular contraction and thickening.

No synovitis is seen and decrease in the thickness of the capsule.

Decreased volume of the gleno humeral joint with restricted ROM.

Although the glenohumeral joint synovial capsule is involved, much of the disease process involves structures outside the shoulder joint, including the coracohumeral ligament, rotator interval, subscapularis musculotendinous unit, and the subacromial burse.

Although recovery is usually spontaneous, treatment with Intra-articular corticosteroids and gentle but persistent physical therapy may provide a better outcome, resulting in little functional compromise. Physiotherapy treatments used for acute adhesive capsulitis include local heat, SWD, TENS, Ultrasound, Mobilizations and exercises.

NEED FOR THE STUDY

Periarthritis shoulder or frozen shoulder is among the common afflictions of shoulder joint, affecting as much as 2% of general population .Pain is the most disturbing factor and it leads to functional impairments, include difficulty in dressing.

There was a need to study about the effects of cyriax manipulation and shortwave diathermy on painful stage of the periarthritis shoulder

STATEMENT OF THE PROBLEM

To study the: ” Efficacy of cyriax friction massage technique and conventional therapy in patients with painful stage of unilateral periarthritis shoulder”

OBJECTIVE OF THE STUDY

The objective of the study was to evaluate the effectiveness of Cyriax friction massage technique and conventional therapy in patients with painful stage of unilateral periarthritis shoulder”

HYPOTHESIS

Null Hypothesis:

The study was carried out on the basis of the null hypothesis which could be stated as “There is no significant improvement in pain and functional activities between cyriax friction massage technique and conventional physical therapy in patients with painful stage of unilateral periarthritis shoulder “

Alternate Hypothesis:

The alternate hypothesis states have “There is a significant improvement in pain and functional activities between cyriax friction massage technique and conventional physical therapy in patients with painful stage of unilateral periarthritis shoulder”

REVIEW OF LITERATURE

Leah Steele, Hannah Lade, Stephanie McKenzie, and Trevor G. RussellInt J Telemed Appl. 2012; Physiotherapists often assess and treat clients with shoulder pain, and there exists considerable evidence of effective physiotherapy treatments for many shoulder disorders, with conservative physiotherapy management shown to provide up to an 88% improvement in shoulder function in the long term.

Jing-lan Yang, Shiau-yee Chen, Ching-Lin Hsieh, BMC Musculoskeletal Disorder. 2012; 13: 46. Clinical approaches like mobilization, stretching, and/or massage may decrease shoulder tightness and improve symptoms in subjects with stiff shoulders.

Nicola Crichton, D. Gould et al.2012. Visual Analogue Scale (VAS) is a measurement instrument that tries to measure a characteristic or attitude that is believed to range across a continuum of values and cannot easily be directly measured.

Jose Orlando Ruiz .J Man Manip Ther. 2009; 17(1): 58-63. Various treatment approaches have been described for limited shoulder passive range of motion (ROM)5. These approaches include different forms of manual therapy, electrotherapy, active exercise, and several forms of passive stretching5. The use of passive stretching of the shoulder capsule and soft tissues by means of mobilization techniques has been recommended.

Jenna Godfry, Richard Humman(2009) the simple shoulder test

demonstrated overall acceptable performance of shoulder.

U.-D. Reips and F. Funke (2008) there is evidence showing that visual analogue scales have superior metrical characteristics than discrete scales, thus a wider range of statistical methods can be applied to the pain measurements.

James P. Tasto, MD and David W. Elias, MD (Sports Med Arthrosc Rev 2007; 15:216-221). The term ‘frozen shoulder” is defined as a clinical condition with restricted active and passive range of motion (ROM) in

all directions, including flexion, abduction, and rotation

Pajareyak, et al, 2004, concluded that physical therapy is effective for patients with adhesive capsulitis.

Fusun Guler – Uysal, Erhankozanagils, Swiss medical weekly 2004 : 134 : 353 – 358 , indicates daily mobilizations exercises provides faster and better response in the early phase of treatment in periarthritis shoulder.

Gules-Ursal F , Kozanoglu E , Swiss Med WKY.2004 Jun 12;134(23-24);353A randomized , comparative study on the early response of two methods of rehabilitation (cyriax approach Vs conventional physiotherapy) in adhesive capsulitis concluded that the cyriax methods of rehabilitation provides as faster and better response than conventional physical therapy methods in the early phase of treatment in adhesive capsulitis.

Joshua Cleland , Christoper J Durall, and physical therapy for adhesive capsulitis , physiotherapy Aug 2002 : 88 : 8 : 450 -457 , proposes that 6 months of physical therapy , Codman’s exercises ,and strengthening exercises shows significant improvements in active range of motion in patients with adhesive capsulitis.

Levy O, Rath E, A tar D 2001, concluded that when pain and limitation of passive range of motion persist, gentle manipulation dramatically shortens the debilitating process.

Griggs SM, Ab n A, Green A, 2000, proved that patients with idiopathic Periarthritis shoulder can be successfully treated with a specific four direction stretching exercise program.

MATERIALS & METHODOLOGY

Materials:

Mobilization bed and towel

Simple shoulder test

Visual Analogue Scale

Shoulder assessment form

Shortwave Diathermy unit

SELECTION CRITERIA

Inclusion criteria:

Age group between 40-60 years.

Shoulder pain of minimum 2 months duration with no major shoulder trauma.

Marked loss of active and passive shoulder motion.

Pain with motion and a minimum visual analogue scale (VAS) score of 3 cm.

Normal findings on anteroposterior and axillary lateral radiographs of the glenohumeral joint.

Willingness to participate in study.

Exclusion criteria:

Adhesive capsulitis secondary to rotator cuff tear.

Patient with OA and RA shoulder.

Dislocation and fracture in and around shoulder joint.

Chronic case of adhesive capsulitis.

Patients with history of intra articular steroid injectionas.

Poly arthritis or neurological disease or cervical neuropathy.

Medical conditions such as cardiac disease, infections, coagulations disorders.

Tumors around shoulder region.

Cervical rib.

Cervical Brachialgia

Cervical Spondylosis.

Parameters

Visual analog scale

Simple shoulder test

METHODOLOGY

STUDY DESIGN:

A pre-test and post-test experimental study design.

SAMPLE SIZE:

Thirty patients with adhesive capsulitis (Stage 1) who comes under inclusion criteria were taken for the study.

Group 1 (Experimental Group): Patients treated with cyriax friction massage technique.

Group2: (Control Group): Patients treated with shortwave diathermy.

Both groups concluded their treatments with daily home exercise program.

SAMPLING:

The subjects for this study were selected through a convenient sampling technique.

STUDY SETTING:

The study was conducted in Department of Physiotherapy, Sri Ramakrishna Hospital, Coimbatore. All the participants were interviewed and examined to ensure that the selection criteria were fulfilled. Such eligible subjects were selected and they took part in the study after obtaining informed consent.

Study duration:

The study was carried out for 6 months.

Treatment duration:

Both groups received treatment, for 1 month.

Experimental Group: Once in alternative days/week.

Control Group: Everyday once except weekends.

Demographic data of Experimental group:

Age group

Males

Females

Total

40-50

02

03

05

50-60

01

01

02

60-70

01

03

04

70-80

02

02

04

Total

06

09

15

Side Involved

Number

Right

08

Left

07

Total

15

Demographic data of Control Group:

Age group

Males

Females

Total

40-50

01

03

04

50-60

01

02

03

60-70

02

04

06

70-80

01

01

02

Total

05

10

15

Side Involved

Number

Right

06

Left

09

Total

15

STATISTICAL TOOLS

Independent t test was used to show the effectiveness of treatment between Group1 and Group2.

Independent “T” test =

S=

Where,

S = Combined standard deviation

= difference of mean of experimental group

= difference of mean of control group

= number of subjects in experimental group

= number of subjects in control group

INTERVENTION TECHNIQUE

CYRIAX MANIPULATION

Principle

Cyriax introduces transverse deep friction massage for soft tissue injury and lesions.

Effects of cyriax friction massage

Traumatic hyperaemia which help evaluate pain triggering metabolites. Movement of the affected structure which prevents or destroy the adhesion and helps to optimize the quality of scar tissue. Stimulation of the mechano receptor for which produces a quality of afferent impulse that stimulate the temporary analgesia and also help the patient in movement exercises.

Technique

Patient position should be in supine or high sitting.

Therapist stands treatment side of the patient and holds the patient arm with one hand .Applying the friction force to the treatment area by using the Middle and Index finger of the therapist. Before and during the friction massage therapist should give a mild traction by pulling the patients arm. No movement should occur between skin and finger.

SHORT WAVE DIATHERMY

Definition

Diathermy is the application of high -frequency electromagnetic energy that is primarily used to generate heat in body tissues.

Dosage

SWD with 220 V/50 Hz power source and 27.12 MHz oscillation frequency was applied to the therapy region.

Position of the patient

Patient’s position should be in supine and pad electrode should place antero-posteriorly in contra planar method .

In the 15 minute treatment duration , we should ask to the patient about heat and their comfortable oftenly.

FREE EXERCISES

Definition:

Free exercises are those which are performed by the patient’s own muscular efforts without the assistance or resistance of external force, other than that of gravity.

Objective exercises – in which patient aims to attain particular goal (Wall climbing exercises /finger ladder exercise ) :

Face a wall about three quarters of an arm length away from it. Using only your fingers (not your shoulder muscles), raise your arm up to shoulder level. Perform sets of 10 to 20 exercises at each session

Over head pulleys:

Instruct the patient to hold one end of the rope by normal hand and other end by the affected hand, with the normal hand pull the rope and lift the involved extremity forward (flexion), out to the side (abduction). The patient should not shrug the shoulder or lean the trunk. The patient position may be sitting, standing, or supine.

Patient using a wand for self assisted shoulder rotation:

T-Bar Abduction

Loosely grasp end of T-bar with involved hand and hold longer end with uninvolved hand .Use uninvolved hand to lift involved arm outward to side of body as far as tolerable, hold, then slowly return to start. Repeat 30 times.

T-Bar Extension

Loosely grasp end of T-bar with involved hand and hold longer end with uninvolved hand. Use uninvolved hand to lift involved arm backward behind body as far as tolerable, hold, then slowly return to start. Repeat 30 times.

T-Bar Flexion

Loosely grasp end of T-bar or broom stick with involved hand and hold longer end with uninvolved hand. Use uninvolved hand to lift involved arm upward in front of body as high as possible, hold, and slowly lower. Involved arm may assists pain allows .Repeat 30 times.

Codman’s exercises ( Pendular exercises ) :

For gentle distraction, no weight is used. The subject standing with the trunk flexed at the hip about 90 degree. The arm, hangs loosely downward in a position between 60 degree and 90 degree flexion .A pendulum or swinging motion of the arm is initiated by having the patient move the trunk slightly back and forth. Motions of flexion, extension, and horizontal abduction, adduction and circumduction can be done .Increase the arc of motion as tolerated.

Mariners wheel exercises:

This height – adjustable, wall -mounted wheel is designed to exercise the whole arm: the shoulder, the forearm, and the wrist. The user grasps the wheel’s horizontal handle and their arm goes through 360° of rotation with the wheel. This device has a resistance control so as the user’s strength and range of motion improves the difficulty of the exercise can be increased for progressive rehabilitation. The exercise also encourages lateral movement in the arm.

Towel stretch:

Take a 3 foot long towel, grasp it with both hands, and hold it in the horizontal position. Use the upper, good arm, to pull the affected arm toward the lower back. This can be repeated with the towel at a 45° angle. Perform sets of 10 to 20 stretches at each session.

Shoulder bracing exercises

Shoulder 90° of abduction, elbow 90° flexion ask the patient to

Protract and retract the shoulder, full arm should move front and back.

SIMPLE SHOULDER TEST FOR GROUP i

S.No

Pre test

Post test

Difference

1

19

63

44

2

33

71

38

3

38

84

48

4

29

71

42

5

25

69

44

6

30

75

45

7

29

75

46

8

19

70

51

9

33

84

51

10

31

82

51

11

30

80

50

12

38

84

46

13

4o

84

44

14

36

82

46

15

26

80

54

SIMPLE SHOULDER TEST FOR GROUP ii

s.no

Pre test

Post test

Difference

1

22

49

27

2

33

50

17

3

35

55

20

4

29

58

29

5

30

59

29

6

30

58

28

7

29

58

29

8

26

53

27

9

33

61

28

10

35

60

25

11

30

59

29

12

38

58

20

13

35

60

25

14

28

55

27

15

19

42

23

VISUAL ANALOGUE SCALE FOR GROUP 1

S.NO

Pre test

Post test

Difference

1

6

2

4

2

8

4

4

3

8

3

5

4

7

3

4

5

9

5

4

6

7

4

3

7

7

4

3

8

6

2

4

9

9

5

4

10

8

3

5

11

8

4

4

12

6

3

3

13

7

2

5

14

6

2

4

15

6

2

4

VISUAL ANALOGUE SCALE FOR GROUP 2

S.NO

Pre test

Post test

Difference

1

6

2

4

2

8

6

2

3

7

5

2

4

7

5

2

5

9

7

2

6

8

5

3

7

6

4

2

8

9

7

2

9

8

6

2

10

9

7

2

11

7

4

3

12

6

4

2

13

6

4

2

14

8

6

2

15

7

5

2

Data Analysis and Interpretation

ANALYSIS OF PRE TEST VALUES OF SIMPLE SHOULDER TEST

TEST

Cyriax friction massage Vs Short wave diathermy with free exercise

Pre test

Mean value

Group 1

Group 2

30.4

30.13

Independent t test

0.18

P value and its

significance

P value˃0.05 is insignificance

The calculated pre test’t’ value between group1 and group2 was 0.18 and the critical value was 1.701, which states that there is a no significant difference between two groups.

ANALYSIS OF PRE TEST VALUES OF SIMPLE SHOULDER TEST

ANALYSIS OF POST TEST VALUES OF SIMPLE SHOULDER TEST

TEST

Cyriax friction massage Vs Short wave diathermy with free exercise

post test

Mean value

Group 1

Group 2

76.93

55.66

Independent t test

2.083

P value and its

significance

P value˃0.05 is insignificance

The calculated post test ‘t’ value between group1 and group2 was 2.083 and the critical value was 1.701which states that there exists a significant difference between two groups.

ANALYSIS OF POST TEST VALUES OF SIMPLE SHOULDER TEST

ANALYSIS OF SIMPLE SHOULDER TEST WITH CYRIAX AND FREE EXERCISE

TEST

Group1

Cyriax friction massage with free exercise

Pre test mean value

Post test mean value

30.4

76.93

Independent t test

18.44

P value and its

significance

P value˃0.05 is insignificance

The student’t’ test value for group1 (Cyriax friction massage with free exercise) was 43.09 and the critical value was 1.761 which states that there exists significant difference the pre test and post test value group1.

ANALYSIS OF SIMPLE SHOULDER TEST WITH CYRIAX AND FREE EXERCISE

ANALYSIS OF SIMPLE SHOULDER TEST WITH SHORT WAVE DIATHERMY AND FREE EXERCISE

TEST

Group2

Short wave diathermy with free exercise

Pre test mean value

Post test mean value

30.13

55.66

Independent t test

14.67

P value and its

significance

P value˃0.05 is insignificance

The student’t’ test value for group1 (short wave diathermy with free exercise) was 25.66 and the critical value was 1.761 which states that there exists significant difference between the pre test value and post test value group2.

ANALYSIS OF SIMPLE SHOULDER TEST WITH SHORT WAVE DIATHERMY AND FREE EXERCISE

ANALYSIS OF VISUAL ANALOGUE SCALE OF PRE TEST OF TWO GROUP

TEST

Cyriax friction massage Vs Short wave diathermy with free exercise

Pre test

Mean value

Group 1

Group 2

7.46

7.73

Independent t test

0.77

P value and its

significance

P value˃0.05 is insignificance

The calculated pre test’t’ value between group1 and grou2 was 0.77and the critical value was 1.701, which states that there is no significant difference between two groups.

ANALYSIS OF VISUAL ANALOGUE SCALE OF PRE TEST OF TWO GROUP

ANALYSIS OF VISUAL ANALOGUE SCALE OF POST TEST OF TWO GROUP

TEST

Cyriax friction massage Vs Short wave diathermy with free exercise

Post test

Mean value

Group 1

Group 2

3.46

5.46

Independent t test

5.68

P value and its

significance

P value˃0.05 is insignificance

The calculated post test’t’ value between group1 and grop2 was 5.68 and the critical value was 1.701 which states that there exists a significant difference between two groups.

ANALYSIS OF VISUAL ANALOGUE SCALE OF POST TEST OF TWO GROUP

ANALYSIS OF VISUAL ANALOGUE SCALE OF GROUP 1

TEST

Group 1

Cyriax friction massage with free exercise

Pre test mean value

Post test mean values

7.46

3.46

Independent t test

24.18

P value and its

significance

P value˃0.05 is insignificance

The student’t’ test value for group2(Cyriax friction massage with free exercise ) was 24.18 and the critical value was 1.761, which states that there exists significant difference between the pre test and post test value of group.

ANALYSIS OF VISUAL ANALOGUE SCALE OF GROUP 1

ANALYSIS OF VISUAL ANALOGUE SCALE OF GROUP 2

TEST

Group 2

Short wave diathermy with free exercise

Pre test mean value

Post test mean value

7.73

5.46

Independent t test

14.83

P value and its

significance

P value˃0.05 is insignificance

The student’t’ test value for group1 (Short wave diathermy with free exercise ) was 14.83 and the critical value was1.761, which states that there exists significant difference between the pre test and post test value of group 2.

ANALYSIS OF VISUAL ANALOGUE SCALE OF GROUP 2

RESULTS

Effectiveness of Group1(Cyriax friction massage with free exercise ) is elicited by comparing the pre test and post test value Group2(shoulder function) using paired ‘t’ test , the calculated value is 18.44 , where the critical value is 1.761.Since the calculated value is greater than the critical value , there exists a significant difference between the pre test and post test value ofGroup2

Effectiveness of Group2( Short wave diathermy with free exercise )is elicited by comparing the pre test and post test of Group1(shoulder function) using paired ‘t’ test; the calculated value is 14.67,where the critical value is 1.761.Since the calculated value is greater than the critical value , there exists a significant difference between the pre test and post test value of Group2

While comparing the post test value of Group1 and Group2 using independent’t’ , the calculated value is ,2.083 where the critical value is 1.761 , which shows that there exists a significant difference between the pre test and post test value of two groups

When comparing the mean value of both the post test, mean value of Group1, 76.93 is greater than the post test mean value of Group2, 55.66 which confirms that Group1 shows a significant improvement than Group 2

Effectiveness of Group1 (Cyriax friction massage with free exercise) is elicited by comparing the pre test and post test value Group2(visual analogue scale) using paired ‘t’ test , the calculated value is 24.18 , where the critical value is 1.761.Since the calculated value is greater than the critical value , there exists a significant difference between the pre test and post test value ofGroup1

Effectiveness of Group2 (Short wave diathermy with free exercise) is elicited by comparing the pre test and post test of Group2(visual analogue scale) using paired ‘t’ test; the calculated value is 14.83,where the critical value is 1.761.Since the calculated value is greater than the critical value , there exists a significant difference between the pre test and post test value of Group2

While comparing the post test value of Group1 and Group2 using independent’t’ , the calculated value is ,5.68 where the critical value is 1.761 , which shows that there exists a significant difference between the pre test and post test value of two groups

When comparing the mean value of both the post test, mean value of Group1, 3.46 is less than the post test mean value of Group2, 5.46 which confirms that Group1 shows a significant improvement than Group 2

This study is fiend out the effectiveness of cyriax friction massage technique and free exercise is improving the pain relief and functional activities as evidenced by visual analogue scale and simple shoulder test in painful stage of unilateral periarthritis shoulder”

DISCUSSION

This study compares the effectiveness of Cyriax technique and short wave diathermy in subjects with painful stage of unilateral periarthritis shoulder”

Both groups were aimed reducing pain and increasing functional activities of shoulder joint. This study involves the pre test and post test with 15 patients. The variables taken in this study includes ,

VAS

SIMPLE SHOULDER TEST

This study was carried out on the basis of null hypothesis which could be stated as there is no significant difference in pain and function activities between Cyriax friction massage and short wave diathermy in patients with painful stage of periarthritis of shoulder joint.

Group 1 patients were treated with Cyriax approach and Group 2 patients were treated with Short wave diathermy. And both group also receive the free exercise. Pre test and post test values of VAS and SIMPLE SHOULDER TEST were assessed.

The intra group analysis shown that calculated ‘t’ value of group1 is grea

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