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Outcomes from the Malaysian Arm of The International Survey Informing Greater Insights in Opioid Dependence Treatment (INSIGHT) Project

George P

Med J Malaysia, 2015 Apr;70(2):117-24.
PMID: 26162395 MyJurnal

BACKGROUND: Opioid dependence (OD) is a chronic, relapsing condition representing a significant societal burden in Asia. Opioid maintenance treatment (OMT) in combination with psychosocial treatment is considered to be the most effective strategy to treat opioid dependence. In Malaysia, about 52,000 patients reported receiving OMT in December 2012.
OBJECTIVE: The International Survey Informing Greater Insights in Opioid Dependence Treatment (INSIGHT) project aimed to assess aspects of OMT access and quality of care by surveying patients and users with opioid dependence, and healthcare professionals treating opioid-dependent patients.
MATERIALS AND METHODS: Using a structured questionnaire, 50 patients who were currently receiving OMT (or had received OMT in the past 3 months) and 77 physicians were surveyed in Malaysia regarding the provision and quality of OMT.
RESULTS: Patients were predominately male and in their thirties. Nearly all patients (98%) reported currently receiving methadone liquid; almost half (48%) reported ever having received psychosocial counselling and only 14% had ever received buprenorphine-naloxone in the past. Most physicians reported they were treating their patients with OMT (77% on methadone and 15% on buprenorphine-naloxone), and 3% used psychosocial counselling alone. Although methadone maintenance doses were close to levels recommended by WHO guidelines, induction doses of methadone, and both induction and maintenance doses of buprenorphine were well below these levels in Malaysia.
CONCLUSIONS: The findings suggest that OMT implementation in Malaysia can be improved by providing patients with more education on treatment options, better access to available treatments, including abuse-deterrent formulations, and psychosocial support.
Fulltext A forgetful and angry old lady

Mah, S.L., George, P.

Malaysian Family Physician, 2018;13(2):26-28.
MyJurnal

Dementia is typically characterized by the deterioration of cognitive abilities and is a common disorder
among the elderly in Malaysia. However, behavioral and psychological symptoms are also present
in approximately 90% of dementia patients.1 We report the manifestation of these symptoms in an
elderly woman with dementia and the treatment thereof.
Fulltext Current trends in the management of schizophrenia

George PP

Med J Malaysia, 2002 Mar;57(1):128-31; quiz 132.
PMID: 14569733

Schizophrenia is a common and devastating illness. Patients with schizophrenia may develop many disabilities both due to the disease process as well as due to side effects of the medication used. There are many advances in the treatment of schizophrenia, which can effectively reduce many of these disabilities. Treatment of schizophrenia is a primary health care responsibility and thus all health care personnel need to equip themselves with the latest knowledge on management issues. This article outlines the current management issues in schizophrenia.
Common cultural medical complaint presenting as a delusion

George P, Ramasamy P

Malaysian Journal of Psychiatry, 2006;14(1):41-42.
MyJurnal

Symptoms presented by patients suffering from Schizophrenia can be influenced by cultural factors. A case of Schizophrenia presenting with a common cultural medical complaint as a delusion, is described here. The appropriate assessment, identification and treatment have led to an improved out.
Fulltext Bilateral fracture of prostheses post-hip replacement

Surinder S, George P

Med J Malaysia, 2017 02;72(1):71-72.
PMID: 28255148 MyJurnal

Fracture of hip prostheses is a rare occurrence. A case of bilateral hip prostheses fracture is described here. The need to follow-up and remain vigilant post hip replacement is highlighted.
Fulltext Patient health questionnaire for screening psychiatric disorders in secondary healthcare

Barua A, Jacob GP, Mahmood SS

Indian J Psychiatry, 2013 Apr;55(2):125-30.
PMID: 23825844 DOI: 10.4103/0019-5545.111448

BACKGROUND: The adult population often suffers from a number of physical and mental problems. This study was conducted to determine the proportion of mental illnesses in adult population visiting the outpatient departments at Dr. TMA Pai Rotary Hospital, Karkala and to study the socio-demographic correlates of psychiatric disorders.
MATERIALS AND METHODS: A cross-sectional study was conducted during March 2004 among 193 adult individuals of 18 years and above at Dr. TMA Pai Rotary Hospital, Karkala, Karnataka. Data was analyzed by the statistical package for social sciences version 10.0 for windows and results were expressed in terms of proportions and their 95% confidence intervals (CI). Chi-square test, multiple logistic regression with adjusted odds ratio and its 95% CI.
RESULTS: The proportion of psychiatric disorders in adult population was determined to be 39.9%. Proportion of psychiatric morbidity among males and females were 36.2 and 42.2%, respectively.
CONCLUSION: This study revealed that socio-demographic correlates like age group of 50 years and above, unemployed or housewives, living alone, and a history of psychiatric illness in the family were independently associated with psychiatric disorders in adult population.
KEYWORDS: Adult population; patient health questionnaire; psychiatric disorders; screening; socio-demographic correlates
Fulltext Patients that benefit from buprenorphine-naloxone on medically assisted treatment for opioid dependence in Malaysia

George P, Ramasamy P, Thurairajasingam S, Shah Z

Med J Malaysia, 2015 Aug;70(4):251-5.
PMID: 26358024 MyJurnal

INTRODUCTION: Opioid dependence is recorded as the most common drug of abuse in Malaysia. Currently, the preferred substitution therapy for most Government treatment centres is methadone used as substitution therapy for opioid dependence. There are, however patients who may benefit from being on the combined buprenorphine-naloxone formulation as substitution therapy instead. We discuss six cases of opioid dependence of varied backgrounds that were treated with buprenorphinenaloxone therapy and their outcomes.

DISCUSSION: All of the reported patients improved after the induction of buprenorphine- naloxone. Two of the cases highlighted the transfer of patients on methadone to buprenorphine-naloxone due to the adverse effect and interactions of methadone with other medications. During the transfer there were no major adverse reactions noted, and patients were safely able to continue with the maintenance therapy of buprenorphine- naloxone.

CONCLUSION: Buprenorphine-naloxone is a safe and effective drug substitution therapy for opioid dependence. It has fewer interactions with other medications, and has similar efficacy to methadone. Being a partial agonist, it has a less sedating effect making patients more functional.
Fulltext A forgetful and angry old lady

Mah SL, George P

Malays Fam Physician, 2018;13(2):26-28.
PMID: 30302180

Dementia is typically characterized by the deterioration of cognitive abilities and is a common disorder among the elderly in Malaysia. However, behavioral and psychological symptoms are also present in approximately 90% of dementia patients.1 We report the manifestation of these symptoms in an elderly woman with dementia and the treatment thereof.
Materialism and life satisfaction: the role of religion

Rakrachakarn V, Moschis GP, Ong FS, Shannon R

J Relig Health, 2015 Apr;54(2):413-26.
PMID: 25811060

This study examines the role of religion and religiosity in the relationship between materialism and life satisfaction. The findings suggests that religion may be a key factor in understanding differences in findings of previous studies regarding the inverserelationship found in the vast majority of previous studies. Based on a large-scale study in Malaysia—a country comprised of several religious subcultures (mainly Muslims, Buddhists, and Hindus), the findings suggest that the influence of religiosity on materialism and life satisfaction is stronger among Malays than among Chinese and Indians, and life satisfaction partially mediates the relationship between religiosity and materialism. The paper discusses implications for theory development and further research.
Materialism and Life Satisfaction: The Role of Religion

Rakrachakarn V, Moschis GP, Ong FS, Shannon R

J Relig Health, 2013 Nov 15.
PMID: 24233840

This study examines the role of religion and religiosity in the relationship between materialism and life satisfaction. The findings suggests that religion may be a key factor in understanding differences in findings of previous studies regarding the inverse relationship found in the vast majority of previous studies. Based on a large-scale study in Malaysia-a country comprised of several religious subcultures (mainly Muslims, Buddhists, and Hindus), the findings suggest that the influence of religiosity on materialism and life satisfaction is stronger among Malays than among Chinese and Indians, and life satisfaction partially mediates the relationship between religiosity and materialism. The paper discusses implications for theory development and further research.
Covid-19, not your normal flu: A case report on Covid-19 psychosis and mania in a Malaysian hospital

Wong RPY, George P

Malays Fam Physician, 2022 Nov 30;17(3):144-148.
PMID: 36606171 DOI: 10.51866/cr1369

Evidence suggests that acute severe coronavirus disease 2019 (COVID-19) may be associated with neuropsychiatric symptoms. This is a case report of a patient who had recently been infected with COVID-19 and had no history of psychiatric disorders presenting a few days after inpatient discharge from COVID-19 treatment with acute onset of psychosis and manic symptoms. This case illustrates the psychiatric presentation, possible causes, and management of post-COVID-19 psychosis.
What Do Students in Pharmacy and Medicine Think About Pharmacogenomics and Personalized Medicine Education? Awareness, Attitudes, and Perceptions in Malaysian Health Sciences

Siamoglou S, Koromina M, Moy FM, Mitropoulou C, Patrinos GP, Vasileiou K

OMICS, 2021 01;25(1):52-59.
PMID: 33170085 DOI: 10.1089/omi.2020.0178

This study reports on the attitudes and perceptions toward pharmacogenomics (PGx) and personalized medicine (PM) education among pharmacy and medical students in Malaysian health sciences. Importantly, the survey was developed through a codesign approach, with field pretesting/design with users before the actual survey, and based on collaboration between institutions in Greece and Malaysia. The study addressed eight key areas of interest to education in health sciences: (1) General awareness about genetics and PGx, (2) Attitude toward genetic testing usefulness, (3) Benefits of direct-to-consumer personal genome testing as a "diagnostic" tool, (4) Concerns (risks) about genetics, (5) Effectiveness of genetic testing in PM, (6) Benefits of PGx on disease management, (7) Benefits of PGx on drug management, and (8) Attitudes toward genetic testing public endorsement. We observed that Malaysian students appear aware of the term PGx, but there are areas of critical knowledge gap such as the need for greater familiarity with the concept of PGx implementation science, and the availability of genetic testing in clinical practice. This is one of the first studies on perceptions and attitudes toward PGx testing in Southeast Asia. The present findings provide a map of the views and perspectives of medicine and pharmacy students regarding PGx and implementation of PM in Malaysia and should assist toward facilitating the integration of genomics into the medical decision-making process. To this end, it is necessary to enhance collaboration between universities, health care institutions, and governing bodies to incorporate further training and additional education topics related to PGx and genetic testing. This is the first study that assesses the level of PGx and genomics knowledge of pharmacy and medicine students in Southeast Asia, Malaysia in particular, and thus paves the way to guide future global PGx implementation science.
Advancing Global Precision Medicine: An Overview of Genomic Testing and Counseling Services in Malaysia

Balasopoulou A, Mooy FM, Baker DJ, Mitropoulou C, Skoufas E, Bulgiba A, et al.

OMICS, 2017 12;21(12):733-740.
PMID: 29173101 DOI: 10.1089/omi.2017.0136

Precision medicine, genomic and diagnostic services are no longer limited to developed countries. This broadening in geography of biomarker applications and omics diagnostics also demands empirical study of implementation, diagnostic testing, and counseling practices in the field. For example, the Malaysian population has large ethnic diversity and high prevalence of genetic disorders such as hemoglobinopathies and metabolic disorders. Increased morbidity and mortality from such diseases have a direct impact on society and health system sustainability and for this, decision-making becomes of outmost importance. We report here on our findings on the landscape of genomic testing and genetic counseling services in Malaysia. We first defined the framework of all Malaysian stakeholders that offer genomics services and next, we identified the related information gaps, as depicted through the service providers' online websites. Our research framework revealed that there is a very diverse spectrum of genomics services in Malaysia, in which wet- and dry-laboratory services integrate. Moreover, we identify the current gaps and possible remedies to improve the quality of genomic and predictive analytics, not to mention considerations to ensure robust ethics and responsible innovation. To our knowledge, this is the first such study to be performed for a Southeast Asian country. Our genomics and precision medicine services mapping strategy presented in this study may serve as a model for field assessment at regional, national, and international levels as precision medicine is expanding globally and new governance challenges and opportunities continue to emerge for smart implementation science.
Fulltext Presence of telomerase activity with undetectable p16 gene mutation in Malaysian patients with brain tumor

Jafri AM, Sarina S, George PJ, Nizam IM

Med J Malaysia, 2004 Oct;59(4):480-5.
PMID: 15779580 MyJurnal

Recent study has shown that activation of the telomerase and p16 gene mutation are both necessary for tumorigenesis. Our objectives were to detect telomerase activity and investigate the possibility of p16 gene mutations in various types of brain tumor. We analyzed 23 tumor tissues collected in 2000 to 2002. Telomerase activity was detected by a TRAP assay using a TRAPEZE Telomerase Detection Kit (Intergen, Co). PCR-SSCP (Single Strand Conformation Polymorphism) analysis was performed to screen for p16 gene mutation at exon 1 and 2. The activity was detected in 26.1% of the brain tumor samples and mostly present in high-grade tumors. There was a significant association between telomerase activity status and tumor grade but not with patient criteria. Telomerase activity was detected in the analyzed tumors, supporting the fact that activation of telomerase is an important feature for tumorigenesis. There was no mobility shift of p16 gene using SSCP and suggested no mutation at exon 1 and 2 occurred in all samples. These results suggest that another mechanism of p16 gene alterations could be involved and associated with detectable telomerase activity in the progression of tumors.
Management of gag reflex for patients undergoing dental treatment

Prashanti E, Sumanth KN, Renjith George P, Karanth L, Soe HH

Cochrane Database Syst Rev, 2015.
PMID: 26423025 DOI: 10.1002/14651858.CD011116.pub2

Gag reflex is an involuntary defence mechanism to protect the pharynx and throat from foreign objects. Gagging is a common problem encountered during dental treatment, which makes therapeutic procedures distressing and often difficult or even impossible to perform. Various interventions can be used to control the gag reflex; for example, anti-nausea medicines, sedatives, local and general anaesthetics, herbal remedies, behavioural therapies, acupressure, acupuncture, and prosthetic devices.
Fulltext Epitope Presentation of Dengue Viral Envelope Glycoprotein Domain III on Hepatitis B Core Protein Virus-Like Particles Produced in Nicotiana benthamiana

Pang EL, Peyret H, Ramirez A, Loh HS, Lai KS, Fang CM, et al.

Front Plant Sci, 2019;10:455.
PMID: 31057572 DOI: 10.3389/fpls.2019.00455

Dengue fever is currently ranked as the top emerging tropical disease, driven by increased global travel, urbanization, and poor hygiene conditions as well as global warming effects which facilitate the spread of Aedes mosquitoes beyond their current distribution. Today, more than 100 countries are affected most of which are tropical Asian and Latin American nations with limited access to medical care. Hence, the development of a dengue vaccine that is dually cost-effective and able to confer a comprehensive protection is ultimately needed. In this study, a consensus sequence of the antigenic dengue viral glycoprotein domain III (cEDIII) was used aiming to provide comprehensive coverage against all four circulating dengue viral serotypes and potential clade replacement event. Utilizing hepatitis B tandem core technology, the cEDIII sequence was inserted into the immunodominant c/e1 loop region so that it could be displayed on the spike structures of assembled particles. The tandem core particles displaying cEDIII epitopes (tHBcAg-cEDIII) were successfully produced in Nicotiana benthamiana via Agrobacterium-mediated transient expression strategy to give a protein of ∼54 kDa, detected in both soluble and insoluble fractions of plant extracts. The assembled tHBcAg-cEDIII virus-like particles (VLPs) were also visualized from transmission electron microscopy. These VLPs had diameters that range from 32 to 35 nm, presenting an apparent size increment as compared to tHBcAg control particles without cEDIII display (namely tEL). Mice immunized with tHBcAg-cEDIII VLPs showed a positive seroconversion to cEDIII antigen, thereby signifying that the assembled tHBcAg-cEDIII VLPs have successfully displayed cEDIII antigen to the immune system. If it is proven to be successful, tHBcAg-cEDIII has the potential to be developed as a cost-effective vaccine candidate that confers a simultaneous protection against all four infecting dengue viral serotypes.
Fulltext Generic Cost-Effectiveness Models: A Proof of Concept of a Tool for Informed Decision-Making for Public Health Precision Medicine

Snyder SR, Hao J, Cavallari LH, Geng Z, Elsey A, Johnson JA, et al.

Public Health Genomics, 2018;21(5-6):217-227.
PMID: 31189173 DOI: 10.1159/000500725

BACKGROUND/AIMS: Economic evaluation is integral to informed public health decision-making in the rapidly growing field of precision and personalized medicine (PM); however, this research requires specialized expertise and significant resources. Generic models are a novel innovation to efficiently address a critical PM evidence shortage and implementation barrier by enabling use of population-specific input values. This is a generic PM economic evaluation model proof-of-concept study for a pharmacogenomic use case.
METHODS: An 8-step generic economic model development process was applied to the use case of human leukocyte antigen (HLA)-B*15:02genotyping for prediction of carbamazepine-induced cutaneous reactions, with a user-friendly decision-making tool relying on user-provided input values. This generic model was transparently documented and validated, including cross-validation comparing cost-effectiveness results with 3 country-specific models.
RESULTS: A generic pharmacogenomic use case cost-effectiveness model with decision-making tool was successfully developed and cross-validated using input values for 6 populations which produced consistent results for HLA-B*15:02 screening at country-specific cost-effectiveness threshold values. Differences between the generic and country-specific model results were largely due to differences in model structure and assumptions.
CONCLUSION: This proof on concept demonstrates the feasibility of generic models to provide useful PM economic evidence, supporting their use as a pragmatic and timely approach to address a growing need.
Fulltext Success stories in genomic medicine from resource-limited countries

Mitropoulos K, Al Jaibeji H, Forero DA, Laissue P, Wonkam A, Lopez-Correa C, et al.

Hum Genomics, 2015 Jun 18;9:11.
PMID: 26081768 DOI: 10.1186/s40246-015-0033-3

In recent years, the translation of genomic discoveries into mainstream medical practice and public health has gained momentum, facilitated by the advent of new technologies. However, there are often major discrepancies in the pace of implementation of genomic medicine between developed and developing/resource-limited countries. The main reason does not only lie in the limitation of resources but also in the slow pace of adoption of the new findings and the poor understanding of the potential that this new discipline offers to rationalize medical diagnosis and treatment. Here, we present and critically discuss examples from the successful implementation of genomic medicine in resource-limited countries, focusing on pharmacogenomics, genome informatics, and public health genomics, emphasizing in the latter case genomic education, stakeholder analysis, and economics in pharmacogenomics. These examples can be considered as model cases and be readily replicated for the wide implementation of pharmacogenomics and genomic medicine in other resource-limited environments.
Interventions for the management of taste disturbances

Nagraj SK, Naresh S, Srinivas K, Renjith George P, Shrestha A, Levenson D, et al.

Cochrane Database Syst Rev, 2014 Nov 26.
PMID: 25425011 DOI: 10.1002/14651858.CD010470.pub2

BACKGROUND: The sense of taste is very much essential to the overall health of the individual. It is a necessary component to enjoying one's food, which in turn provides nutrition to an individual. Any disturbance in taste perception can hamper the quality of life in such patients by influencing their appetite, body weight and psychological well-being. Taste disorders have been treated using different modalities of treatment and there is no consensus for the best intervention. Hence this Cochrane systematic review was undertaken.
OBJECTIVES: To assess the effects of interventions for the management of patients with taste disturbances.
SEARCH METHODS: We searched the Cochrane Oral Health Group Trials Register (to 5 March 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2014), MEDLINE via OVID (1948 to 5 March 2014), EMBASE via OVID (1980 to 5 March 2014), CINAHL via EBSCO (1980 to 5 March 2014) and AMED via OVID (1985 to 5 March 2014). We also searched the relevant clinical trial registries and conference proceedings from the International Association of Dental Research/American Association of Dental Research (to 5 March 2014), Association for Research in Otolaryngology (to 5 March 2014), the US National Institutes of Health Trials Register (to 5 March 2014), metaRegister of Controlled Trials (mRCT) (to 5 March 2014), World Health Organization's International Clinical Trials Registry Platform (WHO ICTRP) (to 5 March 2014) and International Federation of Pharmaceutical Manufacturers and Associations (IFPMA) Clinical Trials Portal (to 5 March 2014).
SELECTION CRITERIA: We included all randomised controlled trials (RCTs) comparing any pharmacological agent with a control intervention or any non-pharmacological agent with a control intervention. We also included cross-over trials in the review.
DATA COLLECTION AND ANALYSIS: Two authors independently, and in duplicate, assessed the quality of trials and extracted data. Wherever possible, we contacted study authors for additional information. We collected adverse events information from the trials.
MAIN RESULTS: We included nine trials (seven parallel and two cross-over RCTs) with 566 participants. We assessed three trials (33.3%) as having a low risk of bias, four trials (44.5%) at high risk of bias and two trials (22.2%) as having an unclear risk of bias. We only included studies on taste disorders in this review that were either idiopathic, or resulting from zinc deficiency or chronic renal failure.Of these, eight trials with 529 people compared zinc supplements to placebo for patients with taste disorders. The participants in two trials were children and adolescents with respective mean ages of 10 and 11.2 years and the other six trials had adult participants. Out of these eight, two trials assessed the patient reported outcome for improvement in taste acuity using zinc supplements (RR 1.45, 95% CI 1.0 to 2.1; very low quality evidence). We included three trials in the meta-analysis for overall taste improvement (effect size 0.44, 95% CI 0.23 to 0.65; moderate quality evidence). Two other trials described the results as taste acuity improvement and we conducted subgroup analyses due to clinical heterogeneity. One trial described the results as taste recognition improvement for each taste sensation and we analysed this separately. We also analysed one cross-over trial separately using the first half of the results. None of the zinc trials tested taste discrimination. Only one trial tested taste discrimination using acupuncture (effect size 2.80, 95% CI -1.18 to 6.78; low quality evidence).Out of the eight trials using zinc supplementation, four reported adverse events like eczema, nausea, abdominal pain, diarrhoea, constipation, decrease in blood iron, increase in blood alkaline phosphatase, and minor increase in blood triglycerides. No adverse events were reported in the acupuncture trial.None of the included trials could be included in the meta-analysis for health-related quality of life in taste disorder patients.
AUTHORS' CONCLUSIONS: We found very low quality evidence that was insufficient to conclude on the role of zinc supplements to improve taste perception by patients, however we found moderate quality evidence that zinc supplements improve overall taste improvement in patients with zinc deficiency/idiopathic taste disorders. We also found low quality evidence that zinc supplements improve taste acuity in zinc deficient/idiopathic taste disorders and very low quality evidence for taste recognition improvement in children with taste disorders secondary to chronic renal failure. We did not find any evidence to conclude the role of zinc supplements for improving taste discrimination, or any evidence addressing health-related quality of life due to taste disorders.We found low quality evidence that is not sufficient to conclude on the role of acupuncture for improving taste discrimination in cases of idiopathic dysgeusia (distortion of taste) and hypogeusia (reduced ability to taste). We were unable to draw any conclusions regarding the superiority of zinc supplements or acupuncture as none of the trials compared these interventions.
Fulltext Functional Outcome and Complications in Management of Proximal Humerus Fractures Operated with Proximal Humerus Locking Plate

George PK, Dasgupta B, Bhaladhare SM, Reddy B, Jain A, Jogani AD

Malays Orthop J, 2021 Jul;15(2):47-54.
PMID: 34429822 DOI: 10.5704/MOJ.2107.008

Introduction: Controversies exist in treatment of proximal humerus fractures as treatment options vary greatly from conservative management, closed pinning, stacked intramedullary nails, plating and hemi-arthroplasty. The purpose of this study is to study the fracture patterns of each case and document the functional outcome and complications post-operative in the management of proximal humerus fractures operated with proximal humerus plate.
Material and Methods: Thirty five patients with closed proximal humerus fractures, above 18 years old, admitted in our tertiary care hospital during the study period were enrolled. Patients underwent open reduction internal fixation with proximal humerus locking plate under general anaesthesia. Post-operative patients were assessed using Constant and DASH scores. Complications were recorded.
Results: In our study the absolute Constant score of the study population increases at three months and six months and was found to be significant. Mean Constant score for 4-part fractures was 45.6 which were inferior as compared to 2-part and 3-part fractures (43.1 and 44.6, respectively). The mean Constant score at six months was 51.80 +/- 6.71. All three types of proximal humerus fractures showed significant improvement in the mean DASH score over our study period of six months and was found to be significant. Mean DASH score at six months was 27.97+/-12.84. Out of the 35 cases in the study two had complications. One had implant failure (Neer's type 3, 60-year-old female) and one had varus collapse (Neer's type 3, 45-year-old male).
Conclusion: Due to angular stability and effective maintenance of the intraoperative fracture reduction during follow-up period, early post-operative mobilisation is possible which helps the patient to attain better shoulder range of motion and return to activity faster.

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