RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA

ANNEXURE- II

PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

1 NAME OF CANDIDATE & ADDRESS

P.SUNITHANo 16, 2nd cross Gumaiah layout , Padmanabha Nagar,Bangalore- 70

2 NAME OF THE INSTITUTION THE OXFORD COLLEGE OF PHYSIOTHERAPY J P Nagar 1st phase Bangalore-78

3 COURSE OF THE STUDY & SUBJECT

MASTER OF PHYSIOTHERAPY(Physiotherapy in musculoskeletal Disorders and Sports Physiotherapy)

4 DATE OF ADMISSION 5th MAY, 2007

5 TITLE OF THE STUDY:

“A STUDY TO ANALYSE THE EFFECTIVENESS OF SELF-ASSISTED CROSS BODY STRETCH VS STANDING SLEEPER STRETCH AT 90o ON THE POSTERIOR SHOULDER TIGHTNESS IN CRICKET BOWLERS.”

6 BRIEF RESUME OF THE INTENDED WORK

6.1 NEED FOR THE STUDY:

Studies show that dominant shoulder of overhead athletes are highly

stressed joints and likely to have more structural abnormalities seen on

magnetic resonance imaging scans. 93% of throwing shoulders had abnormal

magnetic resonance imaging findings and 37% were symptomatic.1 MRI

abnormalities consistent with internal impingement and superior labral lesions

can be seen in asymptomatic throwing shoulder but not in non- throwing

shoulder.2 Asymptomatic pitchers had labral lesions with about 40 degree loss

of internal rotation in the throwing shoulder.3

Studies have shown that throwers have a prevalence of posterior shoulder

tightness in dominant arm occurring in response to repetitive loading of the

posterior shoulder structures during different phases of throwing.4 The culprit in

the development of dead arm in throwers is the tight posterior inferior capsule.5

Tightening of the posterior shoulder structures (capsule, rotator cuff) has been

suggested as a causative factor for shoulder impingement. It was demonstrated

that throwing athletes with symptomatic internal impingement had reduced

glenohumeral internal rotation reflecting posterior shoulder tightness compared

to matched asymptomatic subjects.6

A posterior capsular contracture with decreased internal rotation does

not allow the humerus to externally rotate into its normal posterior-inferior

position in the cocking up phase instead , the humeral head is forced

posteriosuperiorly, which leads to type II superior labrum anterior to posterior

lesions in overhead athletes.7

Selective tightening of the posterior capsule of the shoulder causes

anterior and superior translation of the head of humerus with passive shoulder

flexion.8 The abnormal translation associated with posterior capsular tightness

and loss of internal rotation will cause subsequent impingement of the tissues

in the subacromial region due to decrease in subacromial space during

overhead activities as in throwing which is associated with pain.9,10

Posterior shoulder stretching is advised to improve the flexibility of the

posterior capsule in the beginning of the strengthening programme.11 Several

types of stretching techniques are advised to address the posterior shoulder

tightness like the sleeper stretch in standing, sleeper stretch in lying, cross body

stretch standing against the wall, but the effectiveness of the various stretching

procedures on posterior shoulder tightness in cricket bowlers is yet to be

identified.

Cross body stretch in standing with lateral border of scapula pressed

against the wall and standing sleeper stretch with shoulder and at 90 degree and

lateral border of scapula against the wall are two stretching procedures in which

no assistance is required from the therapist to stabilize the scapula as

stabilization is obtained from compression against the wall.12,13 Hence this

study is intended to analyse the effectiveness of cross body stretch and

standing sleeper stretch at 900 on posterior shoulder tightness in cricket

bowlers.

6.2 REVIEW OF LITERATURE:

Jost B,- 20051 as per this study shoulder of throwing athletes are highly

stressed joints and likely to have more structural abnormalities seen on

magnetic resonance imaging scans. 93% of throwing shoulders had abnormal

magnetic resonance imaging findings and 37% were symptomatic.

Hal brecht JT-19992 this study showed the prevalence of internal

impingement and superior labral lesions in asymptomatic throwing shoulder

through MRI findings.

Miniaci A- 2002 3 as per this study asymptomatic pitchers had labral lesions

with about 40 degree loss of internal rotation in the throwing shoulder.

Sakiko oyama-2006 4as per this study there is prevalence of posterior

shoulder tightness in dominant arm of throwers. This occurs as a response to

repetitive loading of the posterior shoulder structures during different phases of

throwing.

Stephen.S. Burkhart etal 2003 5as per this study the main culprit in the

development of dead arm in throwers is the tightness of the posterior inferior

capsule.

Meyers etal-20066 according to this study throwing athletes with pathologic

internal impingement demonstrated significantly greater glenohumeral internal

rotation deficits and posterior shoulder tightness compared to control subjects

and no significant external rotation gains. These findings indicate that a

tightening of the posterior shoulder elements (capsule, rotator cuff) contributes

to impingement. Injury management include stretching to restore flexibility to

the posterior shoulder.

Grossman etal 2005 7stated that posterior capsular contracture with

decreased internal rotation does not allow the humerus to externally rotate into

its normal posterior inferior position in the cocking phase of throwing but it is

forced poster superiorly which explains the etiology of type II superior labrum

anterior to posterior lesions in overhead athletes.

Harry man etal 19908 stated that operative tightening of the posterior portion

of the capsule increased the anterior and superior translation with flexion of the

glenohumeral joint and cross body movement and this occurred earlier in the

arc of motion compared with the intact glenohumeral joint. Such translations

are associated with motions in sports such as the translation between the late

cocking and early acceleration phases of pitching a baseball. These lead to

posterior labral tears and calcification of posterior capsule in throwers and are

due to abnormal humeral translations due to posterior capsule tightness.

H. Gregory etal 20069 stated that posterior shoulder tightness is the common

cause for pain due to impingement and decreased internal rotation range in

shoulder and reproduction of pain. Increased anterosuperior translation of the

humeral head occurs with forward flexion and can mimic the pain reported

with impingement syndrome. The abnormal translation can lead to dead arm

syndrome leading to superior labral lesion and possibly rotator cuff tear.

Sumant.G Krishnan etal 200411 – posterior shoulder stretching is incorporated

in the rehabilitation of subacromial impingement in overhead athletes

Candice.P. schucker 200712 as per this study performing posterior shoulder

stretch for 3 repetitions with 30 seconds hold with proper scapular stabilization

can significantly increase the internal range of motion and decrease posterior

shoulder tightness. Stretches compared are standing sleeper stretch at 45o and

90o and cross body stretch. In all types the lateral border of scapula is stabilized

against the wall.

Philip Mc clure etal 200713 stated that cross body stretch is effective than

sleeper stretch in normal individuals with posterior shoulder tightness to

increase internal rotation range of motion after 4 weeks intervention with 5

repetitions 30sec hold.

Jacquelyn M Downar etal 200514 stated that the throwing shoulder had

significant decrease in internal rotation range than no throwing shoulder.

Timothy .F. tyler etal 200015 stated that measuring shoulder internal rotation

range of motion is a reliable and valid clinical measurement for identifying

posterior shoulder tightness.

Riddle DL etal 198716 stated that the intratester interclass correlation

coefficient for all passive range of motion for shoulder using universal

goniometer is .87 to .99.

Rachel .E. Valentine etal 200617 stated that single measure intraobserver

interclass correlation coefficient was .82 to .98 with highest standard error of

measurement values of 5.3 degree for angular measurements and 1.6 cms for

linear measurements of shoulder.

6.3 OBJECTIVES OF THE STUDY:

To compare the effectiveness of cross body stretch and standing

sleeper stretch at 90o on passive internal, external and total rotation

range of motion of the dominant shoulder in cricket bowlers with

posterior shoulder tightness.

6.4 HYPOTHESIS:

a) Null hypothesis:

There is no significant difference in cross body stretch vs standing

sleeper stretch at 90o on posterior shoulder tightness.

b) Alternate hypothesis:

There is significant difference between cross body stretch vs standing

sleeper stretch at 90o on posterior shoulder tightness.

Dependent variable:

Passive internal rotation range of motion of dominant shoulder

measured in supine with shoulder in 90o abduction.

Passive external rotation range of motion of dominant shoulder

measured in supine with shoulder in 90o abduction.

Total range of rotation of dominant shoulder.

Independent variable:

Cross body stretch in standing with shoulder in 90o flexion and lateral

border of scapula pressing against the wall for stabilization.

Standing sleeper stretch at 90o shoulder and elbow flexion and lateral

7

border of scapula stabilised against the wall.

MATERIALS AND METHODS:

7.1 STUDY DESIGN AND SETTING:

7.1.1 Study design:

A comparative efficacy study.

7.1.2 Source of data:

Cricket clubs in Bangalore.

7.2 METHODOLOGY:

7.2.1 POPULATION:

Healthy cricket bowlers of age 15 to 30 years.

7.2.2 SELECTION CRITERIA:

a) INCLUSION CRITERIA

Cricket bowlers participating for > 3 years

Subjects with an asymmetry of not less than 10o internal

rotation range of motion in the dominant arm defined by the

primary limb with which they throw measured at 90o abduction.

Age group between 15 to 30 years

Subjects willing to participate

Subjects who are able to understand and do the stretch properly.

b )EXCLUSION CRITERIA:

Bowlers with a history of shoulder surgery

Bowlers with a history of neurologic disease, arthritis and connective

tissue disease.

Subjects with shoulder pain.

Shoulder symptoms requiring medical care within past one year.

7.2.3 SAMPLING:

a) SAMPLING METHOD:

Simple random sampling

b) SAMPLE SIZE:

N= 30 Subjects

7.2.4 PROCEDURE

A total of 30 subjects fulfilling the inclusion criteria would participate

in this study. The subjects will be randomly allotted to the 2 groups of 15

subjects each (cross body stretch and standing sleeper stretch at 90o). The

primary measurement is the passive internal and external rotation of the

dominant shoulder using the universal goniometer. The subject in supine lying

with shoulder in 90o abduction and elbow flexion. The fulcrum is marked at the

olecranon process, stable arm perpendicular to the floor and movable arm

parallel to the mid axis of forearm. The shoulder is passively taken to internal

rotation and scapular substitution is prevented by stopping the internal rotation

when the anterior aspect of shoulder starts moving. Then the range is measured.

The passive external rotation range is also measured using the same procedure

by passively externally rotating the shoulder. The total rotation is measured by

adding the measured passive internal and external rotation of the dominant

shoulder. The intervention procedure is as follows.

Cross body stretch- the subjects in this group stand with the dominant shoulder

and elbow flexed to 90o with the lateral border of the scapula pressed against

the wall. Passive horizontal adduction would be applied by the non dominant

hand to the dominant elbow. The end point is the feeling of a mild discomfort.

Standing sleeper stretch at 90o- the subjects in this group stand with the

dominant shoulder and elbow flexed to 90o with the lateral border of the

scapula pressed against the wall. The dominant shoulder would be moved into

internal rotation by having the non-dominant hand slowly press the forearm

down. The end point is the feeling of a mild discomfort.

Both the stretching would be performed once daily for 5 repetitions, holding

each stretch for 30 seconds. Subjects in both the stretching group would be

shown the assigned stretching, which they would be asked to demonstrate. The

intervention period would be 4 weeks after which the passive internal, external

and total rotation of the dominant shoulder is measured.

a) Duration and follow up

3 months( including data collection intervention and evaluation)

No follow up.

b) Materials used

Universal goniometer.

7.3 OUTCOME MEASURES AND STATISTICAL

ANALYSIS:

7.3.1 OUTCOME MEASURES:

Passive internal rotation of dominant shoulder.

Passive external rotation of dominant shoulder.

Total rotation of the dominant shoulder.

7.3.2 STATISTICAL ANALYSIS:

Mann Whitney U test.

Wilcoxon Signed test.

Effect Size- due to Hedge.

7.4

a) Does the study require any intervention to be conducted on patients or

other humans or animals?

Yes, it requires intervention i.e. giving shoulder stretches and assessing

the passive internal and external rotation of dominant shoulder using

universal goniometer before and after intervention.

c) Has ethical consent for the study has been obtained from the institution

in case.

Yes, it has been obtained from my institution.

Ethical clearance form is attached as appendix (I).

The informed consent will be obtained prior to the study from each

subject in their native language is attached as appendix (II).

8.

REFERENCES:

1. Jost B, Zumstein M etal “MRI findings in throwing shoulders;

abnormalities in professional hand ball players.” Cli orthop Relat Res 2005

May (434) 130-7.

2. Hal brecht JL, etal “Internal impingement of the shoulder;

comparisons of findings between throwing and non throwing shoulders of

college baseball pitchers.” Arthroscopy. 1999 Apr 15(3) 253-8.

3. Miniaci A, Mascia AT etal “Magnetic resonance imaging of the

shoulder in asymptomatic professional baseball pitchers.” Am J sports Med.

2002 Jan- Feb 30(1) 66-73.

4. Sakiko Oyama BS “profiling physical characteristics of the

swimmers shoulder comparison to baseball pitchers and non overhead

athlete.” University of Pittsburgh 2006 .

5. Stephen .S Burkhart, Craig D Morgan etal “The disabled throwing

shoulder: Spectrum of pathology part I : Pathoanatomy & Biomechanics” The

J of Arthroscopic & Related Surg 2003 (19) No 4, April, 404- 420.

6. Meyers JB Laundner etal “glenohumeral range of motion deficits

and posterior shoulder tightness in throwers with pathologic internal

impingement” Am J sports Med 2006; 34;385-391.

7. Grossman MG, Tibone JE etal “A cadaveric model of the throwing

shoulder : possible etiology of superior labrum anterior to posterior lesions.”

J Bone Joint Surg Am; 2005; 87; 824-831.

8. Harry man DT,2nd, Sidles JA etal “ Translation of the humeral head

on the glenoid with passive glenohumeral motion” J Bone Joint Surg Am

1990; 72;1334-1343.

9. H.Gregory Bach, Goldberg BA “Posterior Capsular Contracture of

the shoulder” J.Am Acad Orthop Surg 2006 ;14 ;265-277

10. Michael.C. Koester MD, Michael S.George MD, etal “Shoulder

impingement syndrome” The Am J of Med; 2005;118;452-455.

11. Suman T.G. Krishnan, Richard J Hawkins etal “The shoulder and

overhead athlete” 2004 Pg 151.

12. Candice .P. Schucker BS, ATC “Evaluation of three on the field non

assisted posterior shoulder stretches in collegiate baseball pitchers.”

University of Pittsburgh, 2007.

13. Philip McClure, Jenna Balaicius etal “Randomized controlled

comparison of stretching procedures for posterior shoulder

tightness”.J.orthop sports Phy Therp 2007;37(3); 108-114.

14. Jacquelyn M Downar MS, ATC, CSCS “Clinical measures of

shoulder mobility in the professional baseball player” J Ath train, 2005 Jan –

mar 40(1) 23- 29.

15. Timothy F Tyler, MS, PT, ATC, Stephen. J .Nicholas MD etal

“Quantification of posterior capsule tightness and motion loss in patients with

shoulder impingement.” The Am J of Sports Med, 28, 668-673 (2000).

16. Riddle DL, Rothstein JM etal “Goniometric reliability in a clinical

setting. Shoulder measurements” Phys Therapy 1987, May 67(5) 668-673.

17. Rachel E Valentine, Jeremy. S. Lewis “ Intraobserver reliability

of 4 physiologic movements of the shoulder in subjects with and without

symptoms” Arch Phy Med Rehb 87(9) 1242-1249.Sept 2006..

9.

10.

11.

12.

Signature of the candidate

Remarks of the guide

NAME AND DESIGNATION OF

11.1 Guide

11.2 Signature

11.3 Co-Guide

11.4 Signature

11.5 Head of the Department

11.6 Signature

12.1 Remarks of Chairman and Principal

12.2 Signature

Mr.K.G. Kirubakaran MPT

Principal

Mr.K.G. Kirubakaran MPT

Principal

Appendix ITHE OXFORD COLLEGE OF PHYSIOTHERAPY

I PHASE, J.P. NAGAR, BANGALORE-560078

Review Board on ethics for Research

We hereby declare that the project entitled, “A STUDY TO ANALYSE

THE EFFECTIVENESS OF SELF ASSISTED CROSS BODY

STRETCH VS STANDING SLEEPER STRETCH AT 90o ON

POSTERIOR SHOULDER TIGHTNESS IN CRICKET

BOWLERS ”Carried out by Mrs. P. Sunitha of I year M.P.T. has been brought forward for

scrutiny to the board members. After analyzing the Objectives, subjects involved

and the methodology of the project, the following conclusions were drawn.

The project does not have any mental or physical harm to the subjects

involved. The performance of the study procedure will not cause any injury to the

subjects. The board has evaluated and confirmed that the experimenter is trained

and qualified in giving the intervention and /or measuring outcome. The informed

consent from the prepared ensures that, the experimenter explains the procedure

of the study to the patients, their voluntary participation is confirmed and the

identification of the subjects is maintained confidential.

Further, more the findings of the study will benefit similar subjects, the

profession and the society.

Hence, the review board has no objections on the conduct of the study.

Chairman of Departmental Review Board Project Guide

Principal APPENDIX III PROFORMA

Name: Group:

Age: Serial No:

Sex: Date of assessment:

Address:

INCLUSION CRITERIA: Is the subject a cricket bowler participating for > 3 years (Y/N)

Subject with an asymmetry of not less than 10o

internal rotation range of motion in the dominant arm. (Y/N)

Is the age group between 15 to 30 years (Y/N)

Is the subject able to understand and do the stretch properly? (Y/N)

EXCLUSION CRITERIA:

Has a history of shoulder surgery. (Y/N)

Has a history of neurologic disease, arthritis and

connective tissue disease.

(Y/N)

Do you have pain in your shoulders. (Y/N)

Has shoulder symptoms requiring medical care within past one year. (Y/N)

Group A-------Cross body stretch group

Range of motion

Non- dominant shoulder Dominant shoulder

preintervention preintervention postintervention

1)Internalrotation

2)external rotation

3) Total rotation

Group B------Standing sleeper stretch group

Range of motion

Non- dominant shoulder Dominant shoulder

preintervention preintervention postintervention

1)Internal rotation

2)external rotation

3) Total rotation

Signature of the subject:

Signature of Witness:

Signature of Investigator:

Date:APPENDIX – II

CONSENT FORM

TITLE: “A STUDY TO ANALYSE THE EFFECTIVENESS OF

SELF-ASSISTED CROSS BODY STRETCH VS STANDING

SLEEPER STRETCH AT 90o ON THE POSTERIOR SHOULDER

TIGHTNESS IN CRICKET BOWLERS.”

INVESTIGATOR: Mrs. P. Sunitha

PURPOSE OF RESEARCH:

I ____________ have been informed that this study is carried to know the effect of self-

assisted cross body stretch vs standing sleeper stretch at 900 on cricket bowlers with posterior

shoulder tightness.

PROCEDURE:

I have been explained that this study is conducted by using self-assisted standing sleeper

stretch at 900 and cross body stretching techniques. I am aware that I have to follow the

researcher’s instruction as has been told to me.

RISK AND COMFORT:

I understand that there is no potential risk associated with this study and this study will not

produce any harm to me by participating. I understand that there won’t be any discomfort

throughout the study. I am aware that Mrs. P.Sunitha will help me for better understanding of

the procedures.

BENEFITS:

I understand that this study helps to know the efficacy of self-assisted cross body stretch vs

standing sleeper stretch at 900 on cricket bowlers with posterior shoulder tightness.

ALTERNATIVES:

I understand the procedure being studied is the standard way than compared to other studies

which can be conducted by using other tools.

CONFIDENTIALITY:

All the data recorded will be kept in strictest confidence apart from the researcher no one will

ever access to the data without your permission. If the data are used for publication in the

medical literature or for the teaching purpose, no names will be used.

PHOTOGRAPHY CONSENT:

Mrs. P.Sunitha has explained to me that photographs are required in order to illustrate various

aspects of the study for the thesis and other articles, and at presentations or conferences. These

images may also be converted to electronic formats for use in multimedia presentations and

documents accessible to others by computers for the purpose of sharing the results of the study

and for promoting this research. By giving my consent I authorize Mrs. P.Sunitha to use any of

the photographs taken of me in printed format, in slides for presentation, and in electronic

format.

REQUEST FOR MORE INFORMATION:I understand that I may ask any questions of the study at any time, Mrs.P.Sunitha is available

to answer my questions, and copy of this consent form will be given to me to keep for my

careful reading.

REFUSAL OR WITHDRAWAL OF PARTICIPATION:

I understand that my participation is voluntary and I may refuse to withdraw consent and

discontinue participation at anytime. I also understand that she may not include my

participation in the study at any time after he has explained the reason for doing so.

INJURY STATEMENT:

I understand that, in the unlikely event of the injury resulting directly/indirectly from my

participation in this study, medical treatment will be available but no further compensation will

be provided. I understand that my agreement to participation in this study and I am not waiver

any of my legal right, I explained to ___________ the purpose of the research, the

procedure required and the possible risk and benefits to the best of my ability.

Investigator: Mrs P.Sunitha

Investigator Signature Date:

I confirm that Mrs.P.Sunitha has explained me the purpose of research study, the procedure

and the possible risk and benefits that I may experience, I have read and I have understood this

consent to participate as a subject in this research project.

Candidate’s Signature Date:

Witness Signature Date: