DISSERTATION SYNOPSIS



DISSERTATION SYNOPSIS

SUBMITTED TO

RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA

BANGALORE

TOWARD PARTIAL FULFILMENT OF

MASTER OF PHYSIOTHERAPY DEGREE COURSE

By

NAIR PREMA

UNDER THE GUIDANCE OF

V S SARAVANAN

VIKAS COLLEGE OF PHYSIOTHERAPY

MARYHILL, KONCHADY, MANGALORE-575006

2010-12

RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA

BANGALORE

REGISTRATION OF SUBJECTS FOR DISSERTATION

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|1. |Name of the Candidate |NAIR PREMA |

| |and Address |VIKAS COLLEGE OF PHYSIOTHERAPY |

| | |AIRPORT ROAD |

| | |MARYHILL, KONCHADY |

| | |MANGALORE – 575008 |

| | | |

|2. |Name of the Institution |VIKAS COLLEGE OF PHYSIOTHERAPY |

| | |Mangalore. |

| | | |

|3. |Course of study and subject |Master of Physiotherapy (MPT) |

| | |Physiotherapy in Musculoskeletal Disorders and Sports Physiotherapy |

| | | |

| | | |

|4. |Date of admission to Course |17-03-2010 |

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|5. |Title of the Topic |

| |A COMPARATIVE STUDY BETWEEN THE EFFICACY OF DEEP HEATING WITH ACTIVE EXERCISE VERSUS DEEP HEATING WITH MANUAL MOBILIZATION |

| |ON PATIENTS WITH FROZEN SHOULDER. |

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|6 |BRIEF RESUME OF THE INTENDED WORK |

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| |6.1) Need for the study |

| | |

| |Frozen shoulder, medically referred to as adhesive capsulitis, is a disorder in which the shoulder capsule, the connective |

| |tissue surrounding the glenohumeral joint of the shoulder, becomes inflamed and stiff, and grows together with abnormal |

| |bands of tissue, called adhesions, greatly restricting motion and causing chronic pain. Shoulder specialist Dr Robert Codman|

| |first described 'Frozen Shoulder' in 1934, although this painful shoulder condition had frustrated patients and doctors for |

| |centuries before this. The fact that Frozen Shoulder merely describes what the patient experiences, is evidence that the |

| |condition was still poorly understood. In 1945, Nevasier used the term Adhesive Capsulitis and described the pathology as |

| |being characterized by adhesions and contractures of the fibrous capsule that surrounds the shoulder joint. (1) While other |

| |conditions can produce a stiff shoulder and shoulder pain, frozen shoulder is characterized by adhesions of the capsule. |

| |Frozen shoulder syndrome is a condition of uncertain etiology characterized by a progressive loss of both active and passive|

| |shoulder motion. (2-4) Clinical syndromes include pain, a limited range of motion and muscle weakness from disuse. (2, 3,5) |

| |The natural history is uncertain .Abnormal bands of tissue grow between the joint surfaces, restricting motion. There is |

| |also a lack of synovial fluid, which normally helps the shoulder joint move by lubricating the gap between the humerus and |

| |the socket in the scapula. It is this restricted space between the capsule and ball of the humerus that distinguishes |

| |adhesive capsulitis from a less complicated, painful, stiff shoulder. People with diabetes, stroke, lung disease, rheumatoid|

| |arthritis, Cervical disk disease, Degenerative arthritis and heart disease, or who have been in an accident are at a higher |

| |risk for frozen shoulder. The condition rarely appears in people under 40 years old and (at least in its idiopathic form) is|

| |much more common in women than in men. Cyriax (6) suggested that tightness in a joint capsule would result in a pattern of |

| |proportional motion restriction (a shoulder capsular pattern in which external rotation would be more limited than |

| |abduction, which would be more limited than internal rotation. Based on the absence of a significant correlation between |

| |joint-space capacity and restricted shoulder ROM, contracted soft tissue around the shoulder may be related to restricted |

| |shoulder ROM. (7) Vermeulen and colleagues (4,8) indicated that adherent axillary recess hinders humeral |

| |Head mobility, resulting in diminished mobility of the shoulder. To regain the normal extensibility of the shoulder capsule |

| |and tight soft tissues, passive stretching of the shoulder capsule and soft tissues by means of mobilization techniques has |

| |been recommended, but limited data supporting the use of these techniques are available. (4,16-23) Midrange mobilization |

| |end-range mobilization and mobilization with movement techniques have been advocated by Maitland, (17) |

| | |

| |Frozen Shoulder Signs & Symptoms |

| |People complain that the stiffness and pain worsen at night. Pain due to frozen shoulder is usually dull or aching. It can |

| |be worsened with attempted motion, or if bumped. A physical therapist may suspect the patient has a frozen shoulder if a |

| |physical examination reveals limited shoulder movement. Frozen shoulder can be diagnosed if limits to the active range of |

| |motion are the same or almost the same as the limits to the passive range of motion. An arthrogram or an MRI scan may |

| |confirm the diagnosis, though in practice this is rarely required. |

| |The normal course of a frozen shoulder has been described as having three stages |

| |Stage one: The "freezing" or painful stage, which may last from six weeks to nine months, and in which the patient has a |

| |slow onset of pain. As the pain worsens, the shoulder loses motion. |

| |Stage two: The "frozen" or adhesive stage is marked by a slow improvement in pain but the stiffness remains. This stage |

| |generally lasts from four to nine months. |

| |Stage three: The "thawing" or recovery, when shoulder motion slowly returns toward normal. This generally lasts from 5 to 26|

| |months. (1) |

| |Deep heating can be effective to help pain relief, depending on personal preference. A study found that heat can provide a |

| |significant amount of pain relief. The main aim of physiotherapy treatment is to gently stretch the shoulder joint. Specific|

| |frozen shoulder exercises is to offer graduated stretching. For this, mobilizing techniques are given by which patient |

| |respond very well for acquiring full range by properly guided simple and specific Frozen shoulder exercises which ensures |

| |relaxed graduated stretching of the contracted capsule. Hence Frozen shoulder exercises also plays an important role to |

| |reduce pain, to increase extensibility of the thickened and contracted capsule of the joint at the anteroinferior border and|

| |at the attachment of the capsule to the anatomical neck of humerus ,to improve mobility of the shoulder. |

| |Due to above factors further studies are necessary to evaluate the effects of passive manual mobilization and active |

| |exercise along with deep heating in patient with frozen shoulder. Hence a prospective randomized study is necessary to test |

| |the hypothesis that in patients with Frozen shoulder. |

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| |6.2) Review of Literature |

| | |

| |1. Diercks et al. conducted a study on a convenience sample of Seventy-seven patients with idiopathic frozen shoulder |

| |syndrome were included in a prospective study to compare the effect of intensive physical rehabilitation treatment, |

| |including |

| | |

| |passive stretching and manual mobilization versus supportive therapy and exercises within the pain limits. There were no |

| |significant differences in age, sex; time elapsed since onset, and disease severity at inclusion. All patients were followed|

| |up for 24 months after the start of treatment. In the patients treated with supervised neglect, 89% had normal or |

| |near-normal painless shoulder function at the end of the observation period. In contrast, of the group receiving intensive |

| |physical therapy treatment, only 63% reached a Constant score of 80 or higher after 24 months. Both the level of the |

| |Constant score at the end of the study and the moment a Constant score of 80 or higher was reached confirm that supervised |

| |neglect yields better outcomes than intensive physical therapy and passive stretching in patients with frozen shoulder.(9) |

| | |

| |2. Desmeules et al. conducted a randomized controlled trial evaluating the effectiveness of therapeutic exercise and |

| |orthopedic manual therapy for the treatment of impingement syndrome. Two independent observers reviewed the methodological |

| |quality of the studies using an assessment tool developed by the Cochrane Musculoskeletal Injuries Group. |

| |Differences were resolved by consensus. Seven trials met our inclusion criteria. It suggested some benefit of therapeutic |

| |exercise or manual therapy compared with other treatments such as acromioplasty, placebo, or no intervention. There is |

| |limited evidence to support the efficacy of therapeutic exercise and manual therapy to treat impingement syndrome.(10) |

| | |

| |3. Shaffer et al. conducted a study for Frozen shoulder- A long-term follow-up with Sixty-two patients who had been treated|

| |non-operatively for idiopathic frozen shoulder were evaluated subjectively and objectively at two years and two months to |

| |eleven years and nine months of follow-up. Thirty-one of these patients still had either mild pain or stiffness of the |

| |shoulder, or both. Thirty-seven of the sixty-two patients still demonstrated some restriction of motion as compared with |

| |study-generated control values. Ten patients had restriction of forward flexion; eight, of forward elevation; seventeen, of |

| |abduction; twenty-nine, of external rotation; and ten, of internal rotation. However, when the motion of each affected |

| |shoulder of thirty-seven patients who had unilateral involvement was compared with that of the unaffected contra lateral |

| |shoulder, eleven demonstrated some restriction. None of these patients had restriction of forward flexion; two had |

| |restriction of forward elevation; two, of abduction; seven, of external rotation; and seven, of internal rotation. The |

| |patients who had substantial restriction in three planes or more were thirteen times more likely to be men. Marked |

| |restriction, when it was present, was most commonly in external rotation. Only seven patients reported mild functional |

| |limitation.(11) |

| | |

| |4. Walmsley et al. conducted a study to differentiate early stage of primary adhesive capsulitis from other commonly seen |

| |shoulder disorders with the potential to cause pain and limited range of movement. They involved in the diagnosis and |

| |treatment of adhesive capsulitis completed the 3 rounds of questionnaires. Following round 3, descriptive statistics were |

| |used to screen the data into a meaningful subset. Consensus was achieved on 8 clinical identifiers. These identifiers |

| |clustered into 2 discrete domains of pain and movement. For pain, the clinical identifiers were a strong component of night |

| |pain, pain with rapid or unguarded movement, discomfort lying on the affected shoulder, and pain easily aggravated by |

| |movement. For movement, the clinical identifiers included a global loss of active and passive range of movement, with pain |

| |at the end-range in all directions. Onset of the disorder was at greater than 35 years of age. This is the study to |

| |establish clinical identifiers indicative of the early stage of primary adhesive capsulitis. Although limited in |

| |differential diagnostic ability, these identifiers may assist the clinician in recognizing early-stage adhesive |

| |capsulitis.(12) |

| | |

| |5. Jewell et al. conducted a study to determine whether physical therapy interventions predicted meaningful short-term |

| |improvement in 4 measures of physical health, pain, and function for patients diagnosed with adhesive capsulitis. Data were |

| |examined from 2,370 patients who had completed an episode of outpatient physical therapy. None of the patients achieved a |

| |50% or greater improvement. After Discussion Conclusions were These results are consistent with findings from randomized |

| |clinical trials that demonstrated the effectiveness of joint mobilization and exercise for patients with adhesive |

| |capsulitis. Ultrasound, massage, iontophoresis, and phonophoresis reduced the likelihood of a favorable outcome, which |

| |suggests that use of these modalities should be discouraged. (13) |

| | |

| |6. Mengiardi et al. conducted a study to evaluate the magnetic resonance arthrographic findings in patients with frozen |

| |shoulder. Preoperative MR arthrograms of 22 patients with frozen shoulder treated with arthroscopic capsulotomy were |

| |compared with arthrograms of 22 age- and sex-matched control subjects without frozen shoulder. The thicknesses of the |

| |coracohumeral ligament and the joint capsule, as well as the volume of the axillary recess, were measured. Patients with |

| |frozen shoulder had a significantly thickened CHL and a thickened joint capsule in the rotator cuff interval but not in the |

| |axillary recess. The volume of the axillary recess was significantly smaller in patients with frozen shoulder than in |

| |control subjects. Synovitis-like abnormalities at the superior border of the subscapularis tendon were significantly more |

| |common in patients with frozen shoulder than in control subjects. Thickening of the CHL and the joint capsule in the rotator|

| |cuff interval, as well as the subcoracoid triangle sign, are characteristic MR arthrographic findings in frozen shoulder. |

| |(14) |

| | |

| |7. Dodman et al. a test on personality on frozen shoulder with Fifty-six patients with frozen shoulder have had their |

| |personality profiles investigated by means of the Middlesex Hospital Questionnaire. Females showed significantly increased |

| |somatic |

| |anxiety compared with controls. It is suggested that this may be important both to aetiology and treatment. Males and |

| |females should be assessed separately in future studies of frozen shoulder.(15) |

| | |

| |8. Binder et al. found that the natural history of frozen shoulder is poorly documented, a prospective study of 40 |

| |patients followed up for 40-48 months (mean 44 months) is described. The range of movement was significantly less than age- |

| |and sex-matched controls. Objective restriction was severe in five patients and mild in a further 11. Patients were often |

| |unaware that shoulder range was impaired. Dominant arm involvement, manual labour, and mobilization physiotherapy were |

| |associated with a less satisfactory outcome. We conclude that, while objective restriction persists, there is little |

| |functional impairment in the late stage of frozen shoulder. (21) |

| | |

| |9. Placzek et al. conducted a study on Long term effects of glenohumeral joint translational manipulation on range of |

| |motion, pain, and function in patients with adhesive capsulitis . Thirty-one patients underwent brachial plexus block |

| |followed by translational manipulation of the glenohumeral joint. Changes in range of motion and pain were assessed before |

| |manipulation with the patient under anesthesia, immediately after manipulation with the patient still under anesthesia, at |

| |early follow |

| |up and at long term follow up. Passive range of motion increased significantly for flexion, abduction, external rotation, |

| |and internal rotation. Significant decreases in visual analog pain scores between initial evaluation and the follow up |

| |assessments also occurredTranslational manipulation provides a safe, effective treatment option for adhesive capsulitis.(24)|

| | |

| | |

| |6.3 Objectives of the study |

| | |

| |The objective of this study is to determine the effects of deep heating with active exercise versus deep heating with manual|

| |mobilization in patients with frozen shoulder in a randomized and a prospective way. Specifically, to determine |

| | |

| |The effects of deep heating with active exercise on patients with frozen shoulder. |

| | |

| |The effects of deep heating with manual mobilization on patients with frozen shoulder. |

| | |

| |To compare the effects of deep heating with active exercise and deep heating with manual mobilization on frozen shoulder |

| |patients. |

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| |7. Materials and methods |

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| |7.1 Source of data |

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| |Data will be collected from patients, who are referred to the outpatient physiotherapy department of vikas college of |

| |physiotherapy, Mangalore, with diagnosis of Frozen Shoulder after obtaining informed consent. |

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| |7.2 Method of collection of data |

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| |Hypothesis |

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| |1. Null hypothesis (Ho) |

| |There is no significant difference between the effects of deep heating with active exercise and deep heating with manual |

| |mobilization on frozen shoulder patients. |

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| |2 Alternative hypothesis (H1) |

| |There is significant difference between the effects of deep heating with active |

| |exercise and deep heating with manual mobilization on frozen shoulder patients. |

| | |

| |Research Design |

| |Pre and post tests experimental study will be used. |

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| |Sampling method |

| |Random sampling method |

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| |Methodology |

| |30 Patients who are diagnosed to have frozen shoulder will be recruited for the study after obtaining informed consent. |

| |Subjects who fulfill the following inclusion and exclusion criteria will be randomly assigned to one of two groups. |

| | |

| |Inclusion Criteria |

| | |

| |30 years to 50 years |

| |Both sex |

| |having a painful stiff shoulder for at least 3 months, |

| |having a limited ROM of a shoulder joint (ROM losses of 25% or greater compared with the noninvolved shoulder in at least 2 |

| |of the following shoulder motions: glenohumeral flexion, abduction, or medial/lateral rotation), and |

| |the consent of the patient’s physician to participate in the study |

| |. |

| |Exclusion Criteria |

| | |

| |Rheumatoid arthritis |

| |diabetes mellitus |

| |a history of surgery on the particular shoulder |

| |a painful stiff shoulder after a severe trauma |

| |fracture of the shoulder complex |

| |rotator cuff rupture |

| |Tendon calcification. |

| |Each group will consist of 15 patients of both genders, within the age group of 30 to 50 years. Group I will be treated with|

| |deep heating with active exercise and Group II will be treated with deep heating with manual mobilization. |

| | |

| |Interventions: |

| | |

| |Both groups will be trained for 1 session a day for 3 weeks, each session will be of 30 minutes. |

| | |

| |Group 1: |

| |This will consist of 15 patients of both gender and they will be treated with deep heating and active exercises. Exercise is|

| |a very important part of the treatment. Exercises will help break up the scar tissue in the shoulder and should be done |

| |twice a day. With all exercises, the patient should warm up before attempting to do them. Exercise equipment required: |

| |.stick |

| |.theraband |

| |.sandbag or weight cuff |

| |.sling and spring |

| |.auto-pulleys |

| |.shoulder wheel |

| | |

| |The following active exercises are: |

| |(1) Pendulum- lean forward with support. Let arm hang down, swing arm a)forward and back b)side to side c)around the circle|

| |(both ways) Repeat 5-10 times each movement |

| |(2) Twisting outwards.-sitting holding a stick, keep elbow into your side throughout ,push with unaffected arm so hand of |

| |problem is moving away from mid line, repeat 5-10 times. |

| |(3)Arm over head, lying on your back, support problem arm at wrist and lift it up |

| | |

| | |

| |Over head can start with elbow bend, Repeat 5-10 times. |

| |(4) Twisting outwards/ arm overhead-Lying on your back, knees bend and feet flat, place your hand behind your neck or head, |

| |elbow up to ceiling, let elbow fall |

| |Outwards Repeat 5-10 times. |

| |(5) Hand behind back-standing with arm by side. Grasp wrist of problem arm |

| |a) Gently stretch hand towards your opposite buttock. |

| |b) slide your arm up your back, can progress and use a towel |

| |(6) Kneeling on all fours- keep your hands still and gently sit back towards your heels. To progress take your knees further|

| |away from your hands. Repeat 5-10 times. |

| |(7) Stretching the back of the shoulder-Take hand of your problem shoulder across body towards opposite shoulder. Give |

| |gentle stretch by pulling your uninvolved arm at the elbow. Repeat 5 times. |

| |(8)Sit or stand-Try and set up a pulley system with pulley or ring above you, pull down with your better arm to help the |

| |stiff arm up. Repeat 10 times. |

| | |

| | |

| |Group 2: |

| |This will consist of 15 patients of both gender and they will be treated with deep heating and manual mobilization. |

| |Mobilization is a therapeutic movement of the |

| |Joint. The most urgent need in treatment is to mobilize joints before contractures develop. Early mobilization, which |

| |frequently will shorten the period of convalescence and prevent the formation of a rigid frozen shoulder. Mobilization can |

| |be used to stretch the shoulder capsule and soft tissues. Different mobilization technique use: |

| | |

| |For glenohumeral joint |

| |- anterior glide |

| |- posterior glide |

| |- inferior glide |

| |- lateral glide |

| |Scapular : |

| |- superior ,inferior glide |

| |- rotation |

| |- Protraction ,retraction |

| | |

| |The goal is to restore normal joint motion and rhythm. Manual mobilization method was performed once a day for three weeks. |

| |The sessions lasted 30 minutes. |

| |. |

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| | |

| |Outcome measures: |

| | |

| |Outcomes of the treatment were measured based on patient report of function and motion analysis. All the patients will be |

| |evaluated in the following outcome |

| | |

| | |

| |measures after 3 weeks. The primary outcome measure of the study was the recovery rate with the normal ROM of the shoulder |

| |at the end of the third week in the two different treatment programs. The secondary end points of the study were: the degree|

| |of improvement in ROM and decrease in pain scores between the groups at the end of the first, second and third week of |

| |treatment. Subjects in both group improved over the 3 weeks. |

| | |

| | |

| |Statistical tests: |

| | |

| |The following statistical tests will be used to analyze the collected data |

| | |

| |In Pre-treatment and post-treatment ROM the measurements are obtained with a standard goniometer. Reliability of measurement|

| |of anterior and posterior shoulder tightness in patients with stiff shoulders and to assess construct validity by |

| |determining the relations between shoulder tightness, shoulder range of motion (ROM), and self-report measures of functional|

| |limitation. The construct validity of the abduction and adduction tests is also performed. Pain values are compared within |

| |each group with a paired t test or Wilcoxon signed rank test. Comparisons of the improvement in ROM and goniometer between |

| |the two therapy groups. Scores on the visual analogue scale, Ashworth Scale and passive range of shoulder are also analysed.|

| | |

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| |7.3 The study requires non-invasive investigations and interventions to be conducted on patients. The investigations to be |

| |conducted include general physical examination like inspection, palpation, measurement of JROM, and MMT, and measurement of |

| |vital signs. |

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| |7.4 Ethical clearance has been obtained from the ethical committee of our institutions to carry out the investigations and |

| |interventions on patients necessary for this study. |

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|8 |REFERENCES: |

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| |(1) Functional outcome and general health status in patients after arthroscopic release in adhesive capsulitis. Baums MH, |

| |Spahn G, Nozaki M, Steckel H, Schultz W, Klinger HM. Knee Surg Sports Traumatol Arthrosc. 2007 May;15(5):638-44 |

| | |

| |(2) Neviaser TJ. Adhesive capsulitis. Orthop Clin North Am. 1987; 18:439-443. |

| | |

| |(3) Neviaser RJ, Neviaser TJ. The frozen shoulder: diagnosis and management. Clin Orthop.1987;223:59-64. |

| | |

| |(4) Vermeulen HM, Obermann WR, Burger BJ, et al. End-range mobilization techniques in adhesive capsulitis of the shoulder |

| |joint: a multiple-subject case report. PhysTher.2000;80:1204-1213. |

| | |

| |(5) Reeves B. The natural history of the frozen shoulder syndrome. Scand J Rheumatol. 1975;4:193-196 |

| | |

| |(6) Cyriax J. Textbook of Orthopedic Medicine, Vol 1: Diagnosis of Soft Tissue |

| |Lesions.7thed.NewYorkMacmillanPublishingCo;1978. |

| | |

| |(7) Mao C, Jaw W, Cheng H. Frozen shoulder: correlation between the response to physical therapy and follow-up shoulder |

| |arthrographY. ArchPhys Med Rehabil. 1997;78:857-859. |

| | |

| |(8) Vermeulen HM, Rozing PM, Obermann WR, et al. Comparison of high-grade and low-grade mobilization techniques in the |

| |management of adhesive capsulitis of RCTPhysTher.2006;86:355-368. |

| | |

| |(9) Bunker TD. Frozen shoulder: unravelling the enigma. Ann R Coll Surg Engl 1997;79:210-3. |

| | |

| |(10) van der Windt DA, Koes BW, de Jong BA, et al. Shoulder disorders in general practice: incidence, patient |

| |characteristics, and management. Ann Rheum Dis. 1995;54:959–964. |

| | |

| |(11) Bassey, E. J.; Morgan, K.; Dallosso, H. M.; and Ebrahim, S. B. .1.: Flexibility of the shoulder joint measured as range|

| |of abduction in a large representative sample of men and women over 65 years of age. European I App!. Physiol., 58: 353-360.|

| |1989. |

| | |

| |(12) Codman EA. The Shoulder: Rupture of the Supraspinatus Tendon and Other Lesions in or About the Subacromial Bursa. |

| |Boston, MA: Thomas Todd; 1934. |

| | |

| | |

| |(13) Dias R, Cutts S, Massoud S. Frozen shoulder. BMJ. 2005;331:1453–1456. |

| | |

| |.(14) Codman EA. Tendinitis of the short rotators. In: Codman EA, ed. Ruptures of the supraspinatus tendon and other |

| |lesions on or about the subacromial bursa. Boston,Mass: Thomas Todd, 1934. |

| | |

| |(15) CODMAN, E. A. (1934) In 'The Shoulder; Rupture of the Supraspinatus Tendon and Other Lesions in or about the |

| |Subacromial Bursa'. Todd, Boston, Mass |

| | |

| |(16) Griggs SM, Ahn A, Green A. Idiopathic adhesive capsulitis: a prospective functional outcome study of nonoperative |

| |treatment. J Bone Joint Surg Am. 2000;82:1398–1407. |

| | |

| |(17) Shaffer B, Tibone JE, Kerlan RK. Frozen shoulder: a long-term follow-up. J Bone Joint Surg Am. 1992;74:738–746. |

| | |

| |(18) Vad VB, Hannafin JA. Frozen shoulder in women: evaluation and management. J Musculoskel Med. 2000;17:13–28. |

| | |

| | |

| |(19) Bigliani, L. U.; Morrison, D. S.; and April, E. W.: The morphology of the acromion and its relationship to rotator |

| |cuff tears. Orthop.Trans., 10: 228,1986. |

| | |

| |(20) Brown, A. R.; Weiss, R.; Greenberg, C; Flatow, E. L.; and Bigliani, L. U.: Interscalene block for shoulder |

| |arthroscopy: comparison with general anesthesia. Arthroscopy, 9:295-300,1993. |

| | |

| |(21) Hazleman B L. The painful stiff shoulder. Rheumatol Rehabil 1972; 11: 413-21. |

| | |

| |(22) Simmonds F A. Shoulder pain with particular reference to the frozen shoulder'. J Bone Joint Surg 1949; 31B: 426-32. |

| | |

| |(23) Clarke G R, Willis L A, Fish W W, Nichols P J R. Preliminary studies in measuring range of motion in normal and painful|

| |stiff shoulders. Rheumatol Rehabil |

| |1975; 14: 39-46. |

| | |

| | |

| |(24) Norkin CC, White DJ. Measurement of Joint Motion: A Guide to Goniometry. 2nd ed. Philadelphia, Pa: FA Davis Co;1995 |

| |:26–37 |

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|9. |Signature of the candidate : |

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|10. |Remarks of the Guide |

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|11. |Name and Designation of |

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| |Guide : V S SARAVANAN M.P.T. |

| |Assoc Professor |

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| |Signature : |

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| |Co-Guide : - |

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| |Signature : - |

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| |Head of the Department : Prof. S. NATARAJAN M.P.T. |

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| |Signature : |

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|12. |12.1 Remarks of the Chairman and Principal |

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| |12.2 Signature : |

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