MIRM Versus PIRT in Athletes With Glenohumeral Internal Rotation Deficit
Condition: Glenohumeral Internal Rotation Deficit; Rotator Cuff Impingement; Internal Rotation Contracture-shoulder
MeSH terms: Contracture; Shoulder Impingement Syndrome
Study type: Interventional

Summary: 
      Glenohumeral internal rotation deficit (GIRD) is common physical deficiency found both
      teenager and overhead many sports for example baseball, cricket, and tennis. GIRD is
      generally categorized as simultaneous deficits of internal rotation (IR) and total arc of
      motion in the dominant side. GIRD causes increase muscle stiffness, capsular changes (
      hyperplasia) , muscle imbalance leads to humeral retroversion. The objective of the study
      will be to Compare the effects of Mulligan internal rotation Mobilization and post isometric
      relaxation technique on Pain, Range of motion and function in athletes with Glenohumeral
      Internal Rotation Deficit

      This study will be a Randomise Control trial and will be conducted Pakistan cricket board
      acedmy and in outpatient department of physical therapy, AL REHMAN Hospital Lahore . The
      study will be completed within the time duration of six months . Convenient sampling
      technique will be used to collect the data. A sample size of 14 patients will be taken in
      this study Comparison of Mulligan internal rotation Mobilization and post isometric
      relaxation technique on Pain and function in athletes with Glenohumeral Internal Rotation
      Deficit. Patients will be divided into two groups. (Group A will be treated with mulligan MWM
      AND Sleeper stretch whereas Group B will be treated with post isometic relaxtion technique
      and sleeper stretch ). SPADI score will be used to ask some questions related to patients
      symptoms and daily activities and Numeric pain rating scale will be used to measure pain
      intensity. UNIVERSAL GONIOMETER will be used to measure ROM of shoulder joint All
      participants of the study will fill the SPADI score and Numeric pain rating scale on day 1 as
      pre treatment values and at the end of week 2 as post treatment values respectively . The
      collected data will be analyzed on SPSS 25.
    

Detailed description: 
      Glenohumeral internal rotation deficit (GIRD) is common physical deficiency found both
      teenager and overhead many sports for example baseball, cricket, and tennis. GIRD is
      generally categorized as simultaneous deficits of internal rotation (IR) and total arc of
      motion in the dominant side.

      Tight posterior glenohumeral capsule and posterior muscles such as the posterior deltoid,
      infraspinatus, and teres minor muscles can leads to GIRD although mechanism is not clear yet.
      Few research authors propose that repetitive tensile stress to posterior structures in the
      follow-through phase in throwing movements could lead to inflammation, scar formation, and
      following tightness in posterior tissues, resulting in PST and GIRD.

      Tightness of the posterior shoulder may be a common factor in many shoulder conditions,
      including impingement syndrome, rotator cuff tears, and labral lesions.Posterior shoulder
      tightness may cause alterations in shoulder motion or muscle flexibility that are thought to
      increase risk of injury in athletes.

      GIRD causes increase muscle stiffness, capsular changes ( hyperplasia ) , muscle imbalance
      leads to humeral retroversion.Due to the influence of tightness of the posterior glenohumeral
      soft tissues on glenohumeral and shoulder kinematics stretching of the posterior glenohumeral
      tissues to restore glenohumeral IR ROM is a common aspect of shoulder rehabilitation.

      GIRD can be measured as the difference in the maximum humeral internal rotation angle between
      the dominant (throwing) and non-dominant (non-throwing) limbs. A difference of 10-17 degree
      of internal rotation is common in the dominant arm of throwing athletes who have not suffered
      any shoulder injury. GIRD greater than 25° has been associated with injuries such as superior
      labral lesions, subacromial impingement, and pathological internal impingement in the
      throwing shoulder in dictating a need for investigation of preventative and corrective
      interventions to restore GHJ internal rotation ROM.

      Manual Physical thearpy approaches are very effective in treatment of many musculoskeletal
      issues. Mulligan manual techniques Introduced by Brain mulligan are very useful treating and
      correcting joint dysfunction. The mobilization with movement technique has its own parameter.
      It is done with both therapist patient participation i.e. passive glide is done by
      physiotherapist at peripheral joint meanwhile patient performs pain free physiologic
      movement. The stamp of mobilization with movement (MWM) technique is pain should be decreased
      after the application of technique.

      Muscle energy techniques are basically soft tissue osteopathic manipulation which is
      performed precisely and in controlled manners, patient do isotonic or isometric contractions
      , they are very useful in function and reduce the pain . MET are mostly indicated in to
      decrease pain, stretch tight muscles and fascia, reduce muscle tonus, improve local
      circulation, strengthen weak musculature and mobilize joint restrictions . This leads to
      improved postural alignment and the restoration of proper joint biomechanics and functional
      movement.

      As per as researcher's Knowledge most of the studies were conducted on over all mobility of
      shoulder, only few studies worked purely on internal rotation deficit. so this study will be
      benficient for GIRD.The rationale of this study will be to check the additive effects of
      Mulligan internal roation mobilization on Pain, Range of motion and function in athletes with
      Glenohumeral Internal Rotation Deficit beside the application of sleeper stretch a
      conventional protocol.

      In 2018 Sreenivasu Kotagiri and his colleagues conduced a study on effectiveness of
      Mobilization with Exercise V/S Mulligan Internal Rotation MWM with Stretching in Patient with
      Glenohumeral Internal Rotation Deficit .They founded mulligan mobilization with posterior
      capsule stretching is more effective in improving range of motion and function when compared
      to mobilization with shoulder stabilization exercises alone.

      In 2016 Sonakshi Sehgal and her colleague conducted a study to measure the effect muscle
      energy technique(MET) for the glenohumeral joint external rotators to improve the range of
      motion and strength of internal rotators in athletes with glenohumeral internal rotation
      deficit (GIRD). They found that MET can be used to treat limited glenohumeral internal
      rotation in athletes with GIRD. The study concluded that the treatment showed remarked
      improvement in the range of motion and strength of internal rotators in athletes with GIRD.
      Therefore the technique can be used in acute cases of posterior shoulder tightness to prevent
      the occurrence of other shoulder injuries.

      In 2010 Robert C. Manske, and his colleagues worked on Comparison of Stretching Versus
      Stretching and Joint Mobilization for Posterior Shoulder Tightness Measured by Internal
      Rotation Motion Loss they concluded cross-body stretch and cross-body stretch plus joint
      mobilization ,both may be beneficial for those with limited internal rotation range of
      motion.

      In 2013 Hafiz Sheraz Arshad and his colleagues worked on comparison of Mulligan Mobilization
      with Movement and End-Range Mobilization Following Maitland Techniques in Patients with
      Frozen Shoulder in Improving Range of Motion, they concluded that end range mobilization
      following maitland are equally effective as that of mobilization with movement exercises.
      Effectiveness of end range mobilization following maitland for increasing range of motion and
      improving pain. This supported their usefulness in improving quality of life due to shoulder
      dysfunction such as frozen shoulder.

      As per as researcher's Knowledge most of the studies were conducted on over all mobility of
      shoulder, only few studies worked purely on internal rotation deficit. so this study will be
      benficient for GIRD.The rationale of this study will be to check the additive effects of
      Mulligan internal roation mobilization on Pain, Range of motion and function in athletes with
      Glenohumeral Internal Rotation Deficit beside the application of sleeper stretch a
      conventional protocol.
    

Intervention name(s): Mulligan Internal Rotation Mobilization; Post Isometric Relaxation Technique
Intervention type(s): Other; Other
Intervention description(s): Mulligan Internal Rotation Mobilization (MIRM) Sleeper Stretch The therapist places a web of his one hand around patient's axilla and thumb of another hand in the bent elbow and the glide will be applied to the head of the humerus down in the glenoid fossa using thumb while stabilizing the scapula with another hand. Therapist will ensures that the other hand is stabilizing up and inwards. While this distraction is taking place the patient internally rotated his shoulder with the help of another hand, at the same time his affected upper arm will abduct by therapist abdomen distracting the head of the humerus laterally. The hand in axilla acts as a fulcrum. Mulligan MWM will be applied for 3 days alternate days by following the rule of 3; Post Isometric Relaxation Technique (PIRT) Sleeper Stretch The subject will be positioned supine on the treatment table with the shoulder and elbow, at 90 degree of abduction and flexion. The shoulder will be stabilized at the acromion process with one hand, and the other hand will be used to passively move the arm into internal rotation until the first barrier of motion will reached. The subject will be then instructed to perform a 5second isometric contraction of approximately 25% maximal effort in the direction of external rotation, against an opposing force provided at the distal forearm. Following the contraction, the subject will be instructed to internally rotate the arm toward the ground as a 30-second active assisted stretch will be applied. The subject will be instructed to relax, and a new movement barrier will then engage.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Participant, Investigator)
Primary purpose: Treatment