CHAP TER-I

INTRODUCTION
Shoulder pain is the third most common musculoskeletal complaint encountered in
clinical practice[1]. Prevalence studies indicate that 16 to 34 percent of the general popula tion
suffers from shoulder pain. In working populations, the incidence of shoulder-related symptoms
may be as high as 14 to 18 percent [2].

One of the most common causes of shoulder pain is rotator cuff (RC) tendinopathy
/shoulder impingement syndrome (SIS)[3]. The syndrome has been described by Neer as
impingement of the rotator cuff tendons against the anterior edge and undersurface of the
anterior third of the acromion, the coracoacromial ligament, and at times the
[1]
acromioclavicularjoint .

1
 Tendons are interposed between muscles and bones, and transmit the force created in the
muscle to the bone which, in turn, enables joint movement[4]. Tendinopathy is a term usually
used for all pain conditions in and around the tendon. The causes of the tendinopathies include,
both the intrinsic (anatomical variants and alterations, muscle tightness/imbalance/weakness,
nutrition, age, joint laxity, systemic disease, vascular perfusion, overweight and all conditions
linked to apoptosis) and the extrinsic factors (occupation, physical load and overuse, technical
errors, inadequate equipment and environmental conditions) which is contributing to the
pathologic processes.[5-7]

Excessive mechanical loading is considered the major cause of rotator cuff tendinopathy.
Tendon injuries in the shoulder account for overuse injuries in sports as well as in jobs that
require repetitive activity. Although tendon problems are very frequent, they are not always easy
to manage[8]. Lesions of the rotator cuff typically start where the loads are presumably the
greatest at the deep surface of the anterior insertion of the supraspinatus.[9] In absence of a total
tear, when the repetitive load exceeds the healing capacity of the tenocyte (overuse), the
tendinopathy occurs.[10]

Overuse may cause damage at both the micro and the macrovasculature[11]. Impaired
metabolic activity including disturbed oxygen transport is likely to be detrimental to molecular
cross- linking and tissue repair. The ageing tendon is characterized by a low rate of metabolism, a
progressive decrease in elasticity and tensile strength and a decreasing tendon blood flow; thus,
age would be regarded as an important predisposing factor in the occurrence of tendinopathy [12].

In most cases, the tendon involved shows no signs of inflammation but instead shows
[13]
fibroblasts, vascular hyperplasia, hyper cellularity, and disorganized collagen . The rotator
cuff consistently show both weakness and muscular imbalance of the external and internal
rotator muscles on the injured extremity in patients with rotator cuff impingement and
glenohumeral joint instability[14].

Chronic pain or repeated tendinopathies could result from the absence of consensus in
treatment. Indeed, if the cause of tendinopathy is the inability of the tendon to bear constraints,
passive treatments, generally purely analgesic and anti- inflammatory, could remain ineffective.

2
 Research has demonstrated moderate evidence for exercise in the treatment of rotator cuff
(RC) tendinopathy. This evidence has primarily addressed traditional concentric-eccentric
resistance training with a lack of rationale for selection of contraction type, dosage, or
progression of resistance. Recent literature has suggested that patients with tendinopathies
respond well to eccentric training[15].

Eccentric strength training, first introduced in 1984 by Stanish et al., have been used
successfully to treat tendinopathies for many years[1].Eccentric training has been proposed as an
effective conservative treatment for the Achilles and patellar tendinopathies [8]. Histological
changes in the supraspinatus tendon have been found to have similarities with those of the
Achilles and patellar tendons[1].

3
 Three basic principles in an eccentric loading regime have been proposed [16].

(1) Length of tendon: the tendon length increases when the tendon is pre-stretched, and
less strain will happen on that tendon during movement

(2) Load: the strength of the tendon should increase by progressively increasing the load
exerted on the tendon

(3) Speed: by increasing the speed of contraction, a greater force will be developed.

It has been suggested that eccentric exercises expose the tendon to a greater load than
concentric exercises[17]. So, the prescription of an eccentric exercise program could be the best
mechanism for strengthening the tendon[18].

First bout of eccentric training could result in damage, including muscle pain,
inflammation, cellular and subcellular alterations, force loss, blood markers of muscle
damage[19]. The damage of eccentric contractions is related to a “mechanical insult”, because as
muscle lengthens, the ability to generate tension increases and a higher load is distributed among
the same number of fibers, resulting in a higher load per fiber ratio and, curiously, a lower
muscle activity[20]

The use of open chain exercise, initially in the modified base position, which is
characterized by the glenohumeral joint elevated 20–30° in the scapular plane position[21-22] and
progressing to 90° abducted training, has been shown to increase multiple parameters of muscle
function[23-24] and also to improve functional performance.

Closed kinetic chain exercises promote cocontraction of rotator cuff musculature which
decreases glenohumeral translation at various levels of elevation. Early in the rehabilitation
process, closed kinetic chain exercises promote safe, functional co-contractions and can
functionally strengthen the rotator cuff[25].

4
1.1 NEED FOR THE STUDY

Eccentric training has been proposed as an effective conservative treatment for the
Achilles and patellar tendinopathies, but less evidence exists about its effectiveness for the
rotator cuff tendinopathy[8].Open chain and closed chain exercises seem to be effective in
bringing about short term changes in pain and disability in patients with rotator cuff
tendinopathy[3].
But there is lack of evidence on the effect of eccentric training combined with open chain
exercise versus eccentric training combined with closed chain exercise in individual with the
rotator cuff tendinopathy. So this study is sought to “Compare the efficacy of open chain
exercise versus closed chain exercise in reducing pain and improving the functional status
in patients with rotator cuff tendinopathy”.

1.2 OBJECTIVE

1. To determine the effects of open chain exercise along with eccentric training in reducing
pain and improving functional status in patients with rotator cuff tendinopathy.
2. To determine the effects of closed chain exercise along with eccentric training in
reducing pain and improving functional status in patients with rotator cuff tendinopathy.
3. To compare the effectiveness of open chain exercise versus closed chain exercise in
reducing pain and improving functional status in patients with rotator cuff tendinopathy .

1.3 HYPOTHESIS

Null hypothesis: There will be no significant difference in pain reduction and functional
improvement in patients with rotator cuff tendinopathy between the groups.
Alte rnative hypothesis: There will be a significant difference in pain reduction and
functional improvement in patients with rotator cuff tendinopathy between the groups.

5
1.4 OPERATIONAL DEFINITION:

Tendinopathy
Tendinopathy is a failed healing response of the tendon, with proliferation of tenocytes,
intracellular abnormalities in tenocytes, disruption of collagen fiber, and a subsequent increase in
the non-collagenous matrix. The term tendinopathy is a generic descriptor of the clinical
condition including both pain and pathological characteristics associated with overuse in and
around tendons.[26]

Eccentric training
The eccentric exercise is the contraction of a muscle for controlling or decelerating a load
while the muscle and the tendon are stretching or remain stretched.[27] The tension in muscle
fibers when lengthening is considerably greater than when muscle fibers are shortening it can
help the healing of the tendon by changing its metabolism and their structural and mechanical
properties[28].

Open kinetic chain exercise

An open kinetic chain is defined as “a combination of successively arranged joints in
which the terminal segments can move freely”.

Closed kinetic chain exercise

Closed Kinetic Chain (CKC) exercises or closed chain exercises are exercises or
movements where the distal aspect of the extremity is fixed to an object that is stationary. With
the distal part fixed, movement at any one joint in the kinetic chain requires motion as well at the
other joints in the kinetic chain therefore, both proximal and distal parts receive resistance
training at the same time.

1.5 PROJECTED OUTCOME

Relaying on the literature review, it is expected that both open chain exercise and closed
chain exercise along with eccentric training will reduce pain and improve the functional status in
patients with rotator cuff tendinopathy.

6
 CHAP TER – II

REVIEW OF LITERATURE

 Stuart R Heron et al (2016) conducted a randomised cross-over trial Comparing three types
of exercise in the treatment of 120 patients with rotator cuff tendinopathy/shoulder
impingement syndrome. Shoulder Pain and Disability Index (SPADI) was used. The outcome
was measured at baseline and six weeks after commencing treatment. They concluded that
Open chain, closed chain and range of movement exercises all seem to be effective in
bringing about short term changes in pain and disability in patients with rotator cuff
tendinopathy.

 Nikos V. Margaritelis et al (2015) this study is to challenge the repeated bout effect always
appears after few eccentric exercise sessions, by exploiting specificity in muscle plasticity.
Seventeen young men were randomly assigned into one of the following groups: the
alternating eccentric-concentric exercise group; and the eccentric-only exercise group. Both
groups performed 8 weeks of resistance exercise using the knee extensors of both legs on an
isokinetic dynamometer. The study concluded that muscle strength was elevated similarly for
both alternating and eccentric-only exercise groups after 13 weeks of training. The
alternating eccentric-concentric exercise scheme, implemented in the present study, has for
the first time successfully overcame the repeated bout effect. The similarity in muscle
strength measurements following the two protocols is against the notion that inflammation
plays an important role in exercise- induced adaptations in muscle.

 Christiana lynneblume (2014) conducted a study to compare the effectiveness of an

eccentric progressive resistance exercise (PRE) intervention to a concentric PRE intervention
in adults with SAIS, to determine if five or eight weeks of intervention was adequate to
achieve significant changes in the shoulder outcome measures and to examine the
correlations between the DASH and the physical measures of shoulder AROM and strength.
The findings of this study indicate that supervised PRE both concentric and ecce ntric
exercise for scapular and rotator cuff muscles performed twice a week for eight weeks may
be beneficial in restoring function in patients with SAIS.

7
 Paula R Camargo, Francisco Alburque rque-Sendín et al (2014) conducted asystemic
review on “Eccentric training as a new approach for rotator cuff tendinopathy” concluded
that the eccentric training should be used aiming improvement of the tendon degeneration,
and usual stretching and strengthening exercises associated with manual therapy techniques
should be used to restore kinematics and muscle activity.

 Adilson J. Meneghel (2013) the present review addresses the issue by bringing up to date
information about the protective effect to physical exercise when performed by untrained
and trained populations. The data indicate that there is a reduction in the magnitude of
indirect markers of muscle damage when the trained population conducts repeated exercise
sessions compared to untrained and/or sedentary individuals. Among the adaptive responses
involved, the neural theory appears to be the main mechanism involved in mitigating the
indirect markers of muscle damage.

 Jeong-Il Kang, Young-Jun Moon et al conducted the study to find the effect on activities,
shoulder muscle fatigue, upper limb disability of two exercise types performed by patients in
the post- immobilization period of rotator cuff repair. The intervention program was
performed by 20 patients from 6 weeks after rotator cuff repair. Ten subjects each were
randomly allocated to a group performing open kinetic chain exercise and a group
preforming closed kinetic chain exercise. Muscle activity and median frequency were
measured by using sEMG and the Upper Extremity Functio n Assessment before and after
conducting the intervention .The Median power frequencies of all these muscles after closed
kinetic chain exercise increased indicating that muscle fatigue decreased. Therefore, research
into exercise programs using closed kinetic chain exercises will be needed to establish
exercise methods for reducing muscle fatigue.

 Philip W McClure, Jason Bialker et al the purpose of this study was to identify changes
that might occur in 3-dimensional scapular kinematics, physical impairments, and functional
limitations. Fifty- nine patients with impingement syndrome were recruited, and 39 patients
successfully completed the 6-week rehabilitation program and follow- up testing. Pain,
satisfaction, and function were measured using the University of Pennsylvania Shoulder
Scale. Range of motion, isometric muscle force, and 3-dimensional scapular kinematic data

8
 also were collected. Subjects were given a progressive exercise program that included
resistive strengthening, stretching, and postural exercises that were done daily at home. The
study concluded that the exercise protocol in the management of shoulder impingement
syndrome may have a positive impact on patients‟ impairments and functional limitations.

 F. Struyf, J. Nijs et al (2012) conducted a study on scapular- focused treatment in patients

with shoulder impingement syndrome: a randomized clinical trial. The purpose of this
clinical trial is to compare the effectiveness of a scapular- focused treatment with a control
therapy in patients with shoulder impingement syndrome. 22 patients with shoulder
impingement syndrome were selected. The primary outcome meas ures included self-reported
shoulder disability and pain. The scapular-focused treatment included stretching and scapular
motor control training. The control therapy included stretching, muscle friction, and eccentric
rotator cuff training. Main outcome measures were the shoulder disability questionnaire,
diagnostic tests for shoulder impingement syndrome, clinical tests for scapular positioning,
shoulder pain (visual analog scale; VAS), and muscle strength.

 John McMullen, Timothy L. Uhl, et al introduced an approach to rehabilitate shoulder

under the topic “A Kinetic Chain Approach for Shoulder Rehabilitation” that integrates the
kinetic chain throughout the rehabilitation. They narrated that the exercises in this approach
are consistent with biomechanical models, apply biomechanical and motor control theory,
and work toward sport specificity. The exercises are designed to stimulate weakened tissue
by motion and force production in the adjacent kinetic link segments. The paradigm of
kinetic chain shoulder rehabilitation suggests that functional movement patterns and closed
kinetic chain exercises should be incorporated throughout the rehabilitation process.

 Salvador Israel Macías-Hernández and Luis Enrique Pére z-Ramíre z conducted a study
to present the overview of the efficacy of eccentric training in tendinopathies and current
evidence of its benefit in rotator cuff tear. Four studies published on eccentric strengthening
for rotator cuff tears were analyzed. There is theoretical evidence abo ut its usefulness in this
pathology, but only a controlled clinical trial has been published with data on improvement
in strength but not in pain or functionality. They concluded that more studies are needed with

9
 better methodological designs in order to generate evidence of their utility and
recommendation.

 Paula R. Camargo et al (2012) conducted a study to evaluate the effects of eccentric

training for shoulder abductors on pain, function, and isokinetic performance during
concentric and eccentric abduction of the shoulder in subjects with SIS. Twenty subjects with
unilateral SIS were selected. Bilateral isokinetic eccentric training for shoulder abductors was
performed for six consecutive weeks, twice a week, on alternate days. The Disabilities of the
Arm, Shoulder and Hand (DASH) questionnaire was used to evaluate functional status and
symptoms of the upper limbs. This study suggests that isokinetic eccentric training for
shoulder abductors improves physical function of the upper limbs in subjects with SIS.

 Aaron Sciascia and Robin Cromwell (2012) purpose of this paper is to present a theoretical
framework which focuses on maximizing kinetic chain utilization and output, accomplished
through improving flexibility of all involved joints and soft tissue, strengthening the lower
extremity and core musculature, optimizing scapular control, and improving muscular
endurance of persons experiencing shoulder pain. The study concluded that rehabilitation of
the throwing athlete‟s shoulder should follow a kinetic chain-based regimen that addresses
specific deficits within individual links which can aid in restoring the natural proximal to
distal muscle activation sequencing.

 Susanne Bernhardsson et al (2011) conducted a study to evaluate the effect on pain

intensity and function of an exercise concept focusing on specific eccentric strength of the
rotator cuff which is a home-based training programme supervised and supported by visits to
physiotherapy clinic in 10 patients with subacromial impingement syndrome. The outcome
was measured using visual analogue scale, Patient-Specific Functional Scale and Western
Ontario Rotator Cuff Index. They concluded that a 12-week eccentric strengthening
programme targeting the rotator cuff and incorporating scapular control and correct
movement pattern can be effective in decreasing pain and increasing function in patients with
subacromial impingement syndrome.

10
 Todd S Ellenbecker, Ann Cools (2010) the purpose of this article is to present an evidence-
based review of the key treatment strategies to rehabilitate and restore shoulder function of
the athlete with rotator cuff impingement. The study concluded that the integration of key
physical examination techniques with evidence-driven rehabilitation concepts to restore
optimal ROM and rotator cuff and scapular strength and stabilization forms the basis of
clinical rehabilitation of the athlete with rotator cuff impingement.

 M Roiget al (2008) this systematic review with meta analysis was conducted to determine if
eccentric exercise is superior to concentric exercise in stimulating gains in muscle strength
and mass. Twenty randomized controlled trial studies met the inclusion criteria. Meta-
analyses showed that when eccentric exercise was performed at higher intensities compared
with concentric training, total strength and eccentric strength increased more significantly.
The study concluded that Eccentric training performed at high intensities was shown to be
more effective in promoting increases in muscle mass measured as muscle girth.

 Anne M. Boonstra, et al (2008) conducted a study to determine the reliability and

concurrent validity of a visual analogue scale (VAS) for disability as a single- item instrument
measuring disability in chronic pain patients was the objective of the study. Concluded that
reliability of the VAS for disability in patients with chronic musculoskeletal pain is good.

 Andre´aDiniz Lopes, et al (2008) this study is to evaluate the validity and reliability of the
Brazilian Portuguese version of the Western Ontario Rotator Cuff Index. Concluded that
Brazilian version of the WORC proved to be a valid and reliable measurement tool for
assessing health-related quality of life in patients with rotator cuff diseases.

11
 CHAP TER III

MATERIALS AND METHODS

3.1 MATERIALS:
1. Theraband
2. Weight cuffs
3. Ball
4. Mat
5. Armed chair
6. WORC questionnaire
7. Pamphlets

3.2 STUDY DESIGN:

Randomized clinical trial study design.

The subjects are randomly allocated into 2 groups (Group A and Group B) by Computer
generated random numbers.
The assessment was taken for all the participants before training session and after the end
of fourth week for statistical analysis and pretest values of both groups were compared with
posttest values in selected parameters over a period of time.

3.3 STUDY SETTING:

The study was conducted in the Department of Orthopedics& Department of Physical
Medicine and Rehabilitation, PSG hospitals, Coimbatore.

3.4 HUMAN PARTICIPATION PROTECTION:

The study was reviewed and approved by institutional human ethics committee at PSG
IMSR.

12
3.5 POPULATION/PARTICIPANTS:
30 individuals with rotator cuff tendinopathy, age group ranging from 30-60 years were
participated. Based on the selection criteria 15 individuals were randomly assigned into each
groups using computer generated randomization method.
Group A: open chain exercise with eccentric training
Group B: closed chain exercise with eccentric training
The above 2 groups will receive warm up, eccentric training and cool down exercise.

3.6 SAMPLING:

Computer based randomized sampling method

3.7 CRITERIA FOR SAMPLE SELECTION

3.7.1 Inclusion criteria:

Age: 30-60years
Shoulder pain for at least 3 months.
3 positive out of 5 following diagnostic test
o Neers impingement test
o Hawkin kennedy impingement test
o Jobes suprespinatus test
o Painful arc between 60-120° during active abduction.
o Tenderness on palpation over supraspinatus or infraspinatus insertio n.
3.7.2 Exclusion Criteria:
Complete tendon rupture
Substantial radiating neck pain
Chronic rheumatic or inflammatory disease
Previous surgery of the affected shoulder
Instability of the shoulder
Osteoarthritis in the acromio-clavicular joint
Adhesive capsulitis
Subacromial corticosteroid injection within the past three months

13
3.8 STUDY DURATION:-
Total duration of 8 months was adopted for this study.

3.9 TREATMENT DURATION:-

3days /week for 4 week

2 sessions per day
45 minutes per session

3.10 INTERVENTION

Based on Stuart R. heron et al the protocol consists of 3 phases of exercise for both the
groups. The 3 phases of exercise include: a warm-up phase, a work phase and a cool down phase
with relaxation activities. The sessions last approximately 45 min, and the loads are adapted to
the possibilities of the subjects to avoid fatigue. A total of 12 sessions are prescribed, on alternate
days, 3 times a week for four weeks[3]. The distributions of the intervention in the groups and the
weekly progression are shown in the Tables below.

The emphasis and relative success of these exercise programmes for the rotator cuff
tendinopathy has been outlined in “Rehabilitation of shoulder impingement syndrome and rotator
cuff injuries: an evidence-based review by Todd S Ellenbecker et al. The weekly progression of
the exercise for both the group was made based on this[29].

14
Exercise protocol
Treatment duration -45 minutes
GROUP-A GROUP-B

10 MINUTES-WARM UP EXERCISE 10 MINUTES WARM UP EXERCISE

Shoulder shrugs Shoulder shrugs

Shoulder bracing Shoulder bracing
Shoulder circles Shoulder circles
Trapezius stretching Trapezius stretching
Pectoralis stretching Pectoralis stretching

20 MINUTES OPEN CHAIN EXERCISE 20 MINUTES CLOSED CHAIN EXERCISE

Shoulder abduction using theraband Wall press up

Shoulder external rotation using theraband Press up in 4 point kneeling
Press up in sitting

10 MINUTES ECCENTRIC TRAINING 10 MINUTES ECCENTRIC TRAINING

Shoulder abduction using weights Shoulder abduction using weights

Shoulder external rotation using weights Shoulder external rotation using weights
Rolling ball on the wall Rolling ball on the wall

5 MINUTES OF COOL DOWN PERIOD 5 MINUTES OF COOL DOWN PERIOD

Shoulder shrugs Shoulder shrugs

Shoulder bracing exercise Shoulder bracing exercise
Shoulder circles Shoulder circles

15
Weekly progression of exercises
WEEK-1 WEEK-2 WEEK-3 WEEK-4

Degree of motion- Degree of motion- Degree of Degree of

0o to 30-45o 0o to 30-45o motion- 0o to full motion- 0o to full

available range available range

OPEN
1 set of 10 1 set of 15 2 set of 10 2 set of 15
CHAIN
repetition repetition repetition repetition
EXERCISE

2 sessions per day 2 sessions per day 2 sessions per 2 sessions per

day day

Using both the Using both the Using only the Using only the

hands during hands during affected hands affected hands

exercise exercise during exercise during exercise

CLOSED
1set of 10 1set of 15 2 set of 10 2 set of 15
CHAIN
repetition repetition repetition repetition
EXERCISE

2 sessions per day 2 sessions per day 2 sessions per 2 sessions per

day day

3.11 INSTRUMENT& TOOL FOR DATA COLLECTION:

Visual analogue scale[VAS]

Western Ontario rotator cuff index[WORC]

16
3.12 TECHNIQUE OF DATA COLLECTION:

Initial assessment was taken on the first day of intervention by using outcome measures.
After obtaining the informed consent form, the Intervention was given to each group separately
for 4 weeks. Final assessment was taken after the 4 weeks of exercise therapy treatment using
same outcome measures. Comparison of pretest and posttest values within the group and
between the groups was done finally.

3.13 TECHNIQUE OF DATA ANALYSIS &INTERPRETATION:

Data collected from subjects were analyzed using paired„t‟ test to measure changes
between pretest and posttest values of outcome measures within the group. Independent„t‟ test
was used to measure the changes between the groups.

Paired „t‟ test

2
(d d )
SD
n 1

d n
t
SD

d = Calculated Mean Difference of pretest and posttest values

SD = Standard Deviation

n = Number of samples

d = Difference between pretest and posttest values

17
Independent „t‟ test

| x1 x2 |
t
1 1
SD
n1 n2

Where,

(n 1 - 1)SD 12 (n 2 - 1)SD 22
SD
n1 n2 2

X1 = Mean difference in Group A

X2 = Mean difference in Group B

SD = Combined standard deviation of Group A and Group B

n1 = Number of patients in Group A

n2 = Number of patients in Group B

SD1 = Standard Deviation of Group A

SD2 = Standard Deviation of Group B

18
SCHEMATIC REPRESENTATION OF FLOW OF PARTICIPANTS

Individuals with Rotator cuff

tendinopathy

Patient selection

(inclusion & exclusion criteria)

Group allocation
(simple random sampling)

Consent form

Group A Group B
[Open chain exercise] [closed chain exercise]
n=15 n=15

Pretreatment assessment

Measure ment tools :

Western Ontario rotator cuff index

Visual analog scale

Each individual receive 24 treatment sessions (2 sessions /day , 3 days a week

for 4 weeks)

Drop out from Group Post treatment assessment Drop out from Group
A 1 [n=14] B 3 [n=12]
(Same measure ment tools used)

Data Analysis

Results

19
 CHAP TER - IV

STATISTICAL ANALYSIS AND INTERPRETATION

Data analysis is the systemic organization and synthesis of research data and testing of
research hypothesis using these data. Interpretation is the process of making sense of the results
of a study and examining the implication (Polit & Belt, 2004). The pretest and posttest values for
Groups A& B were obtained before and after intervention. The pain reduction and improvement
in functional status was measured using Visual analogue scale [VAS], Western Ontario rotator
cuff index. The mean, standard deviation and Paired “t” test values were used to find out whether
there was any significant difference between pretest and posttest values within the groups.

Independent “t” test is used to find the significant differences between the groups after
intervention.

20
 TABLE: 1

Pre and Post test values of visual analogue scale in Group A (n=14)

S No. Pre test Post test

1. 65 51
2. 51 42

3. 70 40

4. 75 65
5. 82 60
6. 84 61
7. 91 65
8. 90 40
9. 73 51
10. 61 60
11. 75 65
12. 61 30
13. 62 35
14. 65 44

21
 Graph: 1

Pre and Post test values of visual analogue scale in Group A (n=14)

Values of visual analogue scale in Group A

100

90

80

70

60

50 Pre test
Post test
40

30

20

10

0
1 2 3 4 5 6 7 8 9 10 11 12 13 14

22
 Table: 2

PRE AND POST TEST VALUES OF VISUAL ANALOGUE SCALE IN

GROUP B (N=12)

S No. Pre test Post test

1. 80 52

2. 70 43

3. 77 30

4. 75 60
5. 76 55

6. 85 52

7. 60 43

8. 85 65

9. 45 20

10. 71 21

11. 55 25

12. 60 44

23
 Graph: 2

PRE AND POST TEST VALUES OF VISUAL ANALOGUE SCALE IN

GROUP B (N=12)

Values of visual analogue scale in Group B

90

80

70

60

50
Pre test
40 Post test

30

20

10

0
1 2 3 4 5 6 7 8 9 10 11 12

24
 Table: 3

MEAN, MEAN DIFFERENCE, STANDARD DEVIATION AND PAIRED „t‟

TEST VALUES OF VISUAL ANALOGUE SCALE OF GROUPS A AND
GROUP B

Groups Mean Mean Standard „t‟ Value „p‟ Value

(VAS) Difference Deviation

Group A 71.79

Pre-test

Group A 50.64 21.14 12.16 6.50 p<0.01

Post-test

Group B 69.92

Pre-test

Group B 42.50 27.42 11.39 8.34 p<0.01

Post-test

Based on Table 3, the mean difference of group A was found to be 21.14, Standard deviation was
12.16, the „t„ value using the paired „t„ test was 6.50 which was greater than the table value of
3.012 at p<0.01. In Group B the mean difference was 27.42, standard deviation was 11.39, the
„t„value using the paired test was 8.34 which was greater than the table value of 3.012 at p<0.01.
This shows there is a significant reduction in pain for VAS in both groups. The result shows that
pretest and posttest mean difference of VAS of group A and group B have statistically no
significant difference.

25
 GRAPH: 3

MEAN, MEAN DIFFERENCE, STANDARD DEVIATION AND PAIRED „t‟

TEST VALUES OF VISUAL ANALOGUE SCALE OF GROUPS A AND
GROUP B

Mean value of VAS for both group A and B

80

70

60

50
Pre test
40 Post test

30

20

10

0
Group A Group B

26
 TABLE: 4

PRE AND POST TEST VALUES OF WESTERN ONTARIO ROTATOR

CUFF INDEX IN GROUP A (n=14)

S No. Pre test Post test

1 46.6 56.1
2 53.3 75.4

3 30 50.7

4 42.6 50.2
5 26.4 46.9
6 35 55
7 14.2 46.4
8 23.3 61.4
9 35.9 54.4
10 39.5 44.5
11 30.7 45.9
12 50.9 75
13 46.6 65.4
14 46.1 70.9

27
 GRAPH: 4

PRE AND POST TEST VALUES OF WESTERN ONTARIO ROTATOR

CUFF INDEX IN GROUP A (N=14)

Values of western Ontario rotator cuff index in group A

80

70

60

50

40 Pre test
Post test
30

20

10

0
1 2 3 4 5 6 7 8 9 10 11 12 13 14

28
 TABLE: 5

PRE AND POST TEST VALUES OF WESTERN ONTARIO ROTATOR

CUFF INDEX IN GROUP B (N=12)

S No. Pre test Post test

1. 44.5 65.9

2. 41.9 64.5

3. 64.75 92.8

4. 29.5 49.2

5. 31.6 47.6

6. 24.2 46.6

7. 50.4 69.5

8. 19.2 41.1

9. 65.2 86.4

10. 40.9 84.5

11. 40.4 61.4

12. 52.1 72.1

29
 GRAPH: 5

PRE AND POST TEST VALUES OF WESTERN ONTARIO ROTATOR

CUFF INDEX IN GROUP B (n=12)

Values of western Ontario rotator cuff index in group B

100

90

80

70

60

50 Pre test
Post test
40

30

20

10

0
1 2 3 4 5 6 7 8 9 10 11 12

30
 TABLE: 6

MEAN, MEAN DIFFERENCE, STANDARD DEVIATION AND PAIRED „t‟

TEST VALUES OF WORC OF GROUPS A AND GROUP B

Groups Mean Mean Standard „t‟ Value „p‟ Value

(WORC) Difference Deviation

Group A 37.26

Pre-test p<0.01
20.46 8.98 8.53
57.73
Post-test

Group B 42.05

Pre-test
34.10 10.08 11.72 p<0.01
76.15
Post-test

Based on Table 6, the mean difference of group A was found to be 20.46, Standard
deviation was 8.98, the „t„ value using the paired „t„ test was 8.53 which was greater than the
table value of 3.106 at p<0.01. In Group B the mean difference was 34.10, standard deviation
was 10.08, the „t„value using the paired test was 11.72 which was greater than the table value of
3.106 at p<0.01. This shows there is a significant improvement in WORC in both groups. The
result shows that pretest and posttest mean differe nce of WORC of group B is statistically
significant than Group A

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 GRAPH: 6

MEAN, MEAN DIFFERENCE, STANDARD DEVIATION AND PAIRED „t‟

TEST VALUES OF WORC OF GROUPS A AND GROUP B

Mean values of WORC -Group A and Group B

80

70

60

50
pre test
40
post test
30

20

10

0
Group A Group B

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 TABLE: 7

COMPARISON BETWEEN THE GROUP A AND GROUP B

Outcome Mean Standard “t” value “p” value

Measures Difference Deviation

VAS 8.14 12.14 1.51 NS*

WORC 17.59 12.60 3.84 P<0.01

*NS= Non Significant

The Independent „t„ test was performed between Group A and Group B to analyze the
significance between the open chain exercise with eccentric training and closed chain exercise
with eccentric training on pain reduction and functional improvement in patients with rotator
cuff tendinopathy.

The visual analog scale (VAS) between the groups were calculated using independent „t„
test & the „t„ value was 1.51 which was lesser than the table value of 2.779 at p>0.01.
The western Ontario rotator cuff index (WORC) between the group were calculated using
independent „t„ test & the obtained „t‟ value is 3.84 which was greater than that of table value of
2.779 at p<0.01.

Therefore the results of these statistical analyses showed that the Group B is effective on
improving the functional status compared to Group B. And there is no significant difference in
both groups on pain.

33
 GRAPH: 7

COMPARISON BETWEEN THE GROUP A AND GROUP B

COMPARISON OF POST TEST VAULES OF VAS AND WORC

BETWEEN THE GROUPS

80

70

60

50
GROUP A
40 GROUP B
30

20

10

0
VAS WORC

34
 CHAP TER V

RESULTS AND DISCUSSION

The aim of this study was to compare the efficacy of open chain exercise versus closed chain
exercise in reducing pain and improving the functional status in patients with rotator cuff
tendinopathy.

A total of 30 patients diagnosed with rotator cuff tendinopathy in the age group of 30-60 years
participated in this study. The participants who satisfied the selection criteria were randomly
assigned into two groups. Baseline measurements were taken using the visual analogue score
(VAS) and Western Ontario rotator cuff index (WORC) for both groups. One group received
open chain exercise combined with eccentric training and the other group received closed chain
exercise combined with eccentric training for4 weeks. At the end of 4 weeks, participants were
again evaluated and measurements were taken using same outcome measures. Statistical analysis
for the present study was done using SPSS (version 16).

No two individual with rotator cuff tendinopathy have similar impairment and thus same
functional limitation. Both males and females are affected equally. Dropout rate was higher in
closed chain exercise group than the open chain exercise group.

The drop-out rate was higher than anticipated; three participants from closed chain exercise
dropped the intervention program. The greater drop-out rate in the CC group may be due to
patient‟s lack of knowledge and importance about the exercise protocol. Three participants dis-
engaged from closed chain exercise treatment protocol totally. One participant dropped out
choosing the surgical repair to correct rotator cuff tear following a fall on outstretched hand.

One participant from open chain exercise group failed to complete the intervention and did not
provide follow up data. It is plausible that a key component in successful rehabilitation of RC
tendinopathy in open chain exercise group is patient compliance.

Participants were selected cautiously not to generalize these results to younger or older patients.
All participants in this study were between 30 and 60 years old a typical age group for the
condition. In older patients, degenerative changes in the rotator cuff tendons are a contributory

35
factor. In younger patients, impingement is often secondary to instab ility, requiring different
treatment

The WORC index score item related to Physical Symptoms, Sports/Recreation, Work and
Lifestyle were the major issue for the patient and this was addressed and found significant
improvement after the treatment. It takes four minutes to complete and is one of the easiest and
quickest tools available to assess function and an excellent way to monitor individual patient
progress. The Patient-Specific Functional Scale was selected in order to measure relevant and
meaningful activities for each patient and because it is sensitive to individual change over time.

Tendon injuries are known to require a long healing time, and our results suggest that complete
resolution of symptoms may not be expected within 4 weeks of eccentric training combined with
open and closed chain exercise. The anatomical and functional complexity of the shoulder joint
may require a more diversified rehabilitation program involving other muscles, and/or a longer
treatment period.

Moncrief et al[30] have demonstrated the efficacy of these exercises in a 4-week training
paradigm, and measured 8–10% increases in isokinetically measured internal and external
rotation strength in healthy subjects.

The data from group A and B for VAS were analyzed using paired„t‟ test and independent„t‟ test.
The calculated value of paired ‟t„ test for group A is 6.50 and for group B is 8.34 which is greater
than the table value indicating there is a significant difference within both the group. The value
of independent t test for both groups are 1.51 which is less than the table value indicating there is
no significant difference between the groups. Hence the null hypothesis is accepted, alternate
hypothesis is neglected.

The data from group A and B for WORC were analyzed using paired‟t‟ test and independent „t‟
test. The calculated value of paired‟t„test for group A is 8.53 and for group B is 11.72 which is
greater than the table value indicating there is a significant difference within both the group. The
value of independent „t‟ test for both groups are 3.84 which is greater than the table value
indicating there is significant difference between the groups. Hence the alternate hypothesis is
accepted, null hypothesis is neglected.

36
The principal finding of the present study was that both Group A and group B was significantly
effective in reducing pain and improving functional status. Group B was more effective
compared to Group A in improving functional status. And both groups show no more difference
in pain.

Repeated activation of the RC following the exercise protocol may have reduced peripheral and
central neurological sensitivity, this resulted in reductions in biochemical driven nociception.
The mechanical loading stimulates the healing response of the tendon as it accelerates tenocytes
metabolism and may speed repair. Gradual exposure to increasing use of the shoulder may have
reduced psychological risk factors; it is also possible that changes in psychosocial factors may
have contributed to the improvements observed in pain and functional status.

Eccentric training is a “tendon-strengthening” program. Eccentric exercises expose the tendon to

a greater load than concentric exercises[31]thus strengthening the tendon[32]. High frequency
oscillations are produced by eccentric contractions in the tendon and these fluctuations in force
provide an important stimulus for the remodeling of the tendon these are the reasons behind the
pain reduction and functional improvement.

Patients who completed the training program improved to the extent that they did not need
surgery.

5.1 LIMITATIONS OF THE STUDY:

• All participants in this study were between 30 and 60 years.

• The study measures only pain and functional status.
• No blinding was done.
• There was a lack of long term follow up of patients to find out the carry over effects of
the intervention

5.2 SUGGESTIONS FOR FUTURE RESEARCH:

• In future studies long term follow-up can be done to determine the effect of intervention.

• The study can also emphasize that scapular control and relearning program to correct
movement pattern in the early phase of rehabilitation in future studies.

37
• The study can be conducted with control group to rule out that the natural maturation of
the syndrome which would influence the results.
• Further research is needed in the clinical setting to avoid the some patients dis-engaging
from treatment.
• The Further studies can be done in large samples because if more the sample size used,
greater would be the significance.
• The study can be conducted with bilateral rotator cuff tendinopathy individuals.
• The future studies can be added with other outcome measures to assess the
strength, Pain and other functional status in rotator cuff tendinopathic individuals.

38
 CHAP TER VI

SUMMARY AND CONCLUSION

This study was conducted to compare the efficacy of open chain exercise versus closed
chain exercise in reducing pain and improving the functional status in patients with rotator cuff
tendinopathy.

Thus the statistical analysis of data concluded that “Closed chain exercise group shows
statistically significant improvement on functional status compared to Open chain exercise
group, whe reas there was statistically no significant diffe rence in both Closed chain
exercise and Open chain exercise group on pain”

39
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