material and methodology

8/6/2019 Material and Methodology

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Material &methodology MATERIAL AND METHODOLOGY

This study was an observational cross sectional study with sample size of 61 patients

who were having cerebovascular accident and reported in our study setup which was

medicine ward, Acharya Vinoba Bhave Rural Hospital and Department Of

Physiotherapy, Sawangi (Meghe) Wardha.

Method of sampling used was convenient sampling.

Inclusion criteria:

1. stroke hemiplegics patients(acute, subacute, chronic)

2. Patients having preserved cognitive and communication skills.

Exclusion criteria:

1 Patient suffering from shoulder pain due to any other primary pathology in

shoulder than that due to stroke.

Procedure

After getting institutional ethical committee approval 100 patients were selected on the

basis of selection criteria and a written signed consent was obtained from the subjects

who willingly volunteered for the study. Out of 100 selected patients only 61 reported for

the study, each of these subjects was interviewed and examined. Each assessment was

performed by single therapist.

The subjects were interviewed for self-report of existing shoulder pain. The interview

also included recording of pain intensity by visual analogue scale. To rate neglect,

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Material &methodology

NIHSS neglect item was used. Voluntary control and Shoulder strength in flexion,

abduction, and elbow flexion was assessed by using voluntary control grading and

medical research council scale for muscle strength. Hypertoincity in shoulder flexors,

abductors, and elbow flexors was measured using modified ashworth scale.

Hypertonicity was present if the tested muscle group had score of atleast 1 on modified

ashworth scale. Physical examination of the affected shoulder began with a structured

musculoskeletal examination to identify the site of tenderness on palpation,

Specific sites were palpated:

Anteriorly, tendon of long head of biceps was palpated between greater and lesser

tuberosity of humeral head. Supraspinatus tendon was palpated anteriorly over its

insertion at the greater tuberosity of humerus with arm at 30 of shoulder extension.

Subacromial area was examined by palpating the gap between the acromion process

and head of humerus on superolateral aspect of shoulder. Pain in subacromial region is

usually attributed to the inflammation of subacromial bursa.

Acromioclavicular joint, coracoid process and surrounding soft tissues were also

examined for any localized or diffuse tenderness.

The subjects were tested on five physical diagnostic maneuvers as stated below:

1. Neer impingement test : The subject is in sitting position and subjects arm is

elevated through forward flexion in the scapular plane by the examiner passively

bringing the greater tuberosity against the anteroinferior border of acromion. Anabnormal finding is provocation of pain which is indicative of impingement of

rotator cuff or injury to supraspinatus muscle.

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2. Speed test : Examiner actively resisted elevated shoulder in forward flexion at the

plane of scapula in a completely extended elbow with forearm medially rotated by

patient. Pain in the bicipital groove is said to be indicative of biceps tendon

involvement.

3. Acromioclavicular shear test : It is said to be indicative of inflammation of

acromioclavicular joint. This test is performed by subject sitting. The examiner

cups his/her hand anteriorly on the clavicle and posteriorly on the spine of

scapula. By squeezing the heel of hands tougher elicits pain in the presence of

acromioclavicular joint inflammation.

4. Rowes test : To show multidirectional instability in the shoulder. The patient

was seated in bed with waist flexed at 45 angle, while examiner held the head of

the humerus by placing one hand over shoulder so that the index and middle

finger sat over the anterior aspect of the humeral head. The examiner then exerted

anterior and posterior force to elicit instability in either direction. For inferior

instability traction was applied vertically to elicit sulcus sign.

5. Lippman test : The patient sits or stands while examiner holds the arm flexed to

90 with one hand, with other hand examiner palpates the biceps tendon 7 to 8 cm

below the glenohumeral joint and moves the biceps tendon side to side in bicipial

groove. A sharp pain indicates bicipital tendonitis.

The entire diagnostic test used could be administered without active performance from the patient except speed test (which requires active forward flexion

of shoulder by the subject). As an alternative for speed test another special test

namely lippman test which does not require any active performance from the subject

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was also used to identify the involvement of biceps tendon in patients with voluntary

control grading/manual muscle strength less than grade 3.

The data obtained from above physical diagnostic tests as well as from self-reported

shoulder pain was recorded and documented to determine the frequency and

characteristics with respect to structures involved causing hemiplegic shoulder pain

syndrome.

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material and methodology

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