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IJCRR - 7(14), July, 2015

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EFFECTIVENESS OF END-RANGE MOBILIZATION AND INTERFERENTIAL CURRENT OR STRETCHING EXERCISE AND MOIST HEAT IN TREATMENT OF FROZEN SHOULDER- A RANDOMIZED CLINICAL TRIAL

Author: Dhara N. Panchal, Charu Eapen

Category: Healthcare

Abstract:Background: Frozen shoulder, one of the leading causes of shoulder pain with incidence of 2% in India is frequently treated by physiotherapist. Very few studies have emphasized combination of modalities or comparison of combined treatments for frozen shoulder till date. Thus, there is a need to evaluate the effectiveness of combined treatments for better implications in clinical practice. This study was aimed at comparing the efficacy of end range mobilization (ERM) and interferential current therapy (IFT) with moist heat and stretching on pain, range of motions and disability of shoulder in acute stage of frozen shoulder. Methodology: This clinical trial includes 43 subjects in the acute stage of frozen shoulder with SPADI score > 30. Group 1 (n=22) received treatment including moist heat application and shoulder stretching exercises whereas group 2 (n=21) received end range mobilisation with interferential current therapy. Follow up was taken at 6th day of treatment using SPADI, ROM and VAS for pain. Results: Between Group comparison showed no statistically significant improvement (p=0.41) on VAS Score. However, Abduction (p=0.006), Flexion (p=0.03), and Internal Rotation (p=0.03) were statistically and clinically significant in group 2. Improvement was not observed for external rotation (p=0.8) and SPADI scale (p=0.57). Conclusion: The results demonstrated that the end range mobilization can be used for better improvement in ROM in acute stage of frozen shoulder. Both the treatment strategies can be equally useful for pain management.

Keywords: Frozen shoulder, Rehabilitation, Mobilisation, End range stretch, IFT, Moist heat.

Full Text:

INTRODUCTION

Among different causes of musculoskeletal conditions, Shoulder pain is the third most commonly experienced condition exceeded only by low back and neck pain. 1-3 Shoulder pain is associated with significant impairment and disability which leads to the loss of mobility of this joint and significant morbidity.4,5 A number of causes for shoulder pain exist. Among them, frozen shoulder is the significant one with incidence of 2% in general population in India.6-8 Clinically, it progresses through four phases, acute-painful phase, freezing phase, frozen phase and thawing phase.9,10 The duration of acute phase comprises from 0 to 3 months along with pain and stiffness in more than two directions.9 Treatment of frozen shoulder in this stage can prevent the further progression to more disabling stage.10 The management with respect to physiotherapy consists of various methods to addresses pain and stiffness. For pain the different strategies used are heat11 or ice applications12, ultrasound13, interferential therapy14,15, transcutaneous electrical nerve stimulation16, and pulsed electromagnetic field therapy5 .To correct the stiffness active and passive range of motion exercises17, mobilization and manipulation techniques18-23 are used A recent systematic review concluded that interferential therapy is beneficial in reducing pain in musculoskeletal condition when used as an adjunct to other treatments.14Moist heat has been proven beneficial in the treatment of shoulder impingement and frozen shoulder.11,12 Studies regarding early implication of stretching exercises showed significant improvement in patients’ functional status.17,22Studies comparing the effects of various joint mobilization techniques for frozen shoulder suggested that end range mobilization and movement with mobilization are better for improving pain and function.18-23Thus modalities such as interferential therapy and manual therapy have been shown to be effective when used as an adjunct, the efficacy of other modalities has not been proven. Few studies on combination of modalities or comparison of combined treatments showed beneficial short-term effects.11, 16, 18,24Thus, there is a need to evaluate the effectiveness of combined treatments in better implications for clinical practice. There is a lack of randomized trials for strong evidence of treatment because of heterogeneity in inclusion criteria; inadequate treatment follow-up and variable methodology for specific clinical conditions like frozen shoulder. Therefore, there is a need recommended by Cochrane review to evaluate effectiveness of physiotherapy modalities used in combination. Hence, the aim of the study was to compare the efficacy of end range mobilization (ERM) and interferential current therapy (IFT) with moist heat and stretching on pain, range of motion and disability of shoulder in the acute stage of frozen shoulder.

MATERIAL AND METHODOLOGY

This study was a randomized clinical trial to compare efficacy of two different physiotherapy intervention strategies for frozen shoulder. The study was conducted at the Physiotherapy department, in a Tertiary care hospital. Total duration of the study was of nine months and each subject was treated for 6 daily sessions. The inclusion criteria was subjects between 40 to 65 years of age , with insidious onset of symptoms between last one to three months, significant night pain, significant limitations of shoulder motion in more than one plane with end ranges painful.9 and SPADI scores ≥30 points.25,26 Subjects who had pain due to acute severe trauma such as fractures, dislocation; cervical radiculopathy; subjects suffering from myocardial infarction, hyper and hypothyroidism; and subjects with hypermobility and instability were excluded.23 The study protocol was approved by the Scientific Committee and Time Bound Research Ethics Committee of the KMC, Manipal University. Subjects who were diagnosed for frozen shoulder referred by consultant to the physiotherapy were taken for the study. The total numbers of subject assessed were 59. Among them who fulfilled the inclusion criteria were taken for the study (N=43).The purpose of the study was explained to the subjects and an informed consent was obtained. The demographic information of the included subjects was taken. During the initial evaluation session, the patient was interviewed and an upper quarter screening examination was conducted to rule out cervical and elbow pathology. The baseline data of ROM with goniometer, VAS for pain and SPADI (shoulder pain and disability index) were taken by an observer who was blinded to the study. The same observer recorded the outcome measure after the completion of treatment session. After that, they were randomized into 2 groups, with block randomization.

In-Group 1, the intervention was given as follow.

1) Moist heat

Moist pack was wrapped in towel with three to four folds over the affected shoulder for 10 to 15 minutes. [Moist Heat Therapy Unit –MNE, India]

2) Stretching exercises

Shoulder stretching exercises include; Forward flexion, External rotation, Horizontal adduction, internal rotation.

In-Group 2, the intervention was given as follows,

1) End range Mobilization.-

At the start of each intervention session, the physical therapist examined the patient’s ROM in all directions to obtain information about the end-range position and the end-feel of the glenohumeral joint. Then, 10- 15 repetitions of intensive mobilization were given for flexion, abduction, internal rotation and external rotation Figures 1 and 2).18, 19

2) Interferential therapy

Interferential current therapy was given. [Current applied at 4000 Hz carrier frequency, Amplitude Modulated Frequency will be 0 to 250 Hz. Treatment time was 10 to 15 minutes].27 Patients were re-examined after 6 days of treatment for evaluation of outcomes, i.e. ROM, SPADI and VAS for pain.

RESULTS

Table1 shows baseline value of variables in both the groups. Both the groups had similar baseline values of characteristics for pain and disability and no significant difference was seen between groups. Table 2 shows the comparison of improvements in outcome measures between group 1 and group 2.Pain on visual analogue scale was not statistically significant (p=0.41) between the two groups. Both the group showed similar improvement on VAS. There were significant changes seen in ROMs between the groups. Abduction was statistically highly significant (p=0.006), while flexion (p=0.03) and internal rotation (p=0.03) range were also significant for group 2. However no statistically significant difference was seen in external rotation (p=0.8) between the groups. There was also no significant difference in SPADI scale between groups (p=0.57), which indicates improvement in disability was similar for both the groups.

DISCUSSION

Present study compared two different treatment strategies in patients with acute stage of frozen shoulder. The result of the study was in agreement with hypothesis that combination of End range mobilization and IFT will produce better improvement. The reasons could be attributable to: end-range mobilization and its specific mechanical effects on connective tissue which might have increased ROM.22 This difference in therapeutic responses measured through changes of joint mobility compared to pain and disability were noted previously in other studies.15-18

Range of Motion

The between-group mean difference for ROM of flexion (group 1-14.59, group 2-23.04), and abduction (group1- 11.27, group 2-21.38) was greater than the MCID reported 7 degree for flexion and 16 degree for abduction. The between –group mean difference for ROM for internal rotation (group1-6.27.group2-10.61) and external rotation (group 1- 9.22, group 2- 9.76) was lesser than the MCID reported 11 degree for internal rotation and 14 degree for external rotation.28 The possible mechanism for increase in ROM as suggested by Kelley M et al9 that, specific joint mobilization techniques are believed to selectively stress certain parts of the joint capsule. Yang et al22 said that, this mobilization performed in specific plane close to end range improve the extensibility of periarticular structure. However, the results of the previous studies 18, 19, 29 also showed significant improvement in shoulder external range of motion, which was not statistically significant in the present study. The probable reason of this could be capsular pattern of shoulder joint described by Cyrix in which external rotation was the most limited and hence, difficult to treat and in order to improve external rotation of shoulder long time treatment protocol is mandatory. In-group 1with conventional therapy, the stretching exercises prescribed also did not address specific to rotator cuff interval. Therefore, in both the groups it was lacking .Few studies with follow-up of 12 and 15 years in frozen shoulder patients showed deficiency in external rotation range even after successful treatment.30,31 So, this is in agreement that it is difficult to gain improvement in external rotation in a short period of time.

Pain on VAS score: The MCID value of VAS score is 3 mm.5 In the present study, group 1 showed mean improvement of 2.61mm and group 2 showed 2.92mm. Therefore, none of group has reached at MCID, which give inferences that either IFT or moist heat can be used for pain relief.

SPADI score In the present study, we have used shoulder Pain and Disability Questionnaire in order to document the level of disability with frozen shoulder patient. This scale has been used in previous studies with various shoulder pathology.32, 33 The improvement noted in-group 1 was (14.99±9.03) and group 2 was (16.44±7.09) which was greater than the MCID of this scale. Here, both the group showed similar improvement. Tvieta et al26 had reported the responsiveness of SPADI scale in-patient with frozen shoulder. Point estimates (1.45) for between group changes in disability not exceeded the reported MCIDs. In addition, using MCID of 13 point for SPADI scale, NNT was calculated. The NNT (Number needed to treat) is 5. This means that 5 patients are required in order to say our intervention is effective.

CONCLUSION

The results of present study demonstrated that patients treated with end range mobilization showed greater improvement in range of motion when compared with the group treated with moist heat and stretching exercises. Improvement in pain severity and disability was similar with both the treatments. Therefore, end range mobilization can be used for better improvement in range of motion particularly in acute stage of frozen shoulder. Both the treatment strategies were equally effective for pain management.

ACKNOWLEDGEMENTS

The authors thank Dr Vivek Ramanandi for support in making manuscript. Special gratefulness are extended to Dr P. Senthil Kumar (PT) and Dr Prem Kotian (MS, Ortho) for their support and guidance throughout this study. Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors /publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.

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A Study by Juna Byun et al. entitled "Study on Difference in Coronavirus-19 Related Anxiety between Face-to-face and Non-face-to-face Classes among University Students in South Korea" is awarded Best Article for Vol 12 issue 16
A Study by Sudha Ramachandra & Vinay Chavan entitled "Enhanced-Hybrid-Age Layered Population Structure (E-Hybrid-ALPS): A Genetic Algorithm with Adaptive Crossover for Molecular Docking Studies of Drug Discovery Process" is awarded Best article for Vol 12 issue 15
A Study by Varsha M. Shindhe et al. entitled "A Study on Effect of Smokeless Tobacco on Pulmonary Function Tests in Class IV Workers of USM-KLE (Universiti Sains Malaysia-Karnataka Lingayat Education Society) International Medical Programme, Belagavi" is awarded Best article of Vol 12 issue 14, July 2020
A study by Amruta Choudhary et al. entitled "Family Planning Knowledge, Attitude and Practice Among Women of Reproductive Age from Rural Area of Central India" is awarded Best Article for special issue "Modern Therapeutics Applications"
A study by Raunak Das entitled "Study of Cardiovascular Dysfunctions in Interstitial Lung Diseas epatients by Correlating the Levels of Serum NT PRO BNP and Microalbuminuria (Biomarkers of Cardiovascular Dysfunction) with Echocardiographic, Bronchoscopic and HighResolution Computed Tomography Findings of These ILD Patients" is awarded Best Article of Vol 12 issue 13
A Study by Kannamani Ramasamy et al. entitled "COVID-19 Situation at Chennai City – Forecasting for the Better Pandemic Management" is awarded best article for Vol 12 issue 12
A Study by Muhammet Lutfi SELCUK and Fatma entitled "Distinction of Gray and White Matter for Some Histological Staining Methods in New Zealand Rabbit's Brain" is awarded best article for Vol 12 issue 11
A Study by Anamul Haq et al. entitled "Etiology of Abnormal Uterine Bleeding in Adolescents – Emphasis Upon Polycystic Ovarian Syndrome" is awarded best article for Vol 12 issue 10
A Study by entitled "Estimation of Reference Interval of Serum Progesterone During Three Trimesters of Normal Pregnancy in a Tertiary Care Hospital of Kolkata" is awarded best article for Vol 12 issue 09
A Study by Ilona Gracie De Souza & Pavan Kumar G. entitled "Effect of Releasing Myofascial Chain in Patients with Patellofemoral Pain Syndrome - A Randomized Clinical Trial" is awarded best article for Vol 12 issue 08
A Study by Virendra Atam et. al. entitled "Clinical Profile and Short - Term Mortality Predictors in Acute Stroke with Emphasis on Stress Hyperglycemia and THRIVE Score : An Observational Study" is awarded best article for Vol 12 issue 07
A Study by K. Krupashree et. al. entitled "Protective Effects of Picrorhizakurroa Against Fumonisin B1 Induced Hepatotoxicity in Mice" is awarded best article for issue Vol 10 issue 20
A study by Mithun K.P. et al "Larvicidal Activity of Crude Solanum Nigrum Leaf and Berries Extract Against Dengue Vector-Aedesaegypti" is awarded Best Article for Vol 10 issue 14 of IJCRR
A study by Asha Menon "Women in Child Care and Early Education: Truly Nontraditional Work" is awarded Best Article for Vol 10 issue 13
A study by Deep J. M. "Prevalence of Molar-Incisor Hypomineralization in 7-13 Years Old Children of Biratnagar, Nepal: A Cross Sectional Study" is awarded Best Article for Vol 10 issue 11 of IJCRR
A review by Chitra et al to analyse relation between Obesity and Type 2 diabetes is awarded 'Best Article' for Vol 10 issue 10 by IJCRR.
A study by Karanpreet et al "Pregnancy Induced Hypertension: A Study on Its Multisystem Involvement" is given Best Paper Award for Vol 10 issue 09

List of Awardees

A Study by Ese Anibor et al. "Evaluation of Temporomandibular Joint Disorders Among Delta State University Students in Abraka, Nigeria" from Vol 13 issue 16 received Emerging Researcher Award

A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" from Vol 13 issue 06 received Emerging Researcher Award

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