EFFECT OF SHOCKWAVE THERAPY ON PAIN IN DIABETIC FROZEN SHOULDER

EFFECT OF SHOCKWAVE THERAPY ON PAIN IN DIABETIC FROZEN SHOULDER

Mostafa O.A.B. Mohammed¹; Akram A. Sayed²; Hany E. Obaya³

andYoussef S. Sweify⁴

¹Physiotherapist at Elsahel Teaching Hospital

²Assistant Professor of Physical Therapy for Cardiovascular / Respiratory Disorder and Geriatrics, Faculty Of physical Therapy, Cairo University

³Assistant Professor of Physical Therapy for Cardiovascular / Respiratory Disorder and Geriatrics, Faculty Of physical Therapy, Cairo University

⁴Professor of Internal Medicine, Elsahel Teaching Hospital, General Organization of Teaching Hospitals and Institutes

Key Words:Diabetes type 2, frozen shoulder, Shock wave therapy.

ABSTRACT:

Background:Shoulder disorders are one of the most common complications in patients with diabetes, and yet it receives relatively little attention. One of the most common shoulder disorders is frozen shoulder, also known as ‘adhesive capsulitis’. Frozen shoulder causes severe pain, restricts joints’ range of motion, and disturbs sleep when the pain is severe, all of which disrupt patients’ daily lives. Recently, radial extracorporeal shockwave therapy was presented as a new way to treat frozen shoulder. Purpose: The aim of this study was to determine the effect of shockwave therapy on pain in diabetic frozen shoulder in diabetic patients’ type 2. Subjects: Forty diabetic patients of both genders were selected from Elsahel Teaching Hospital. The patient’s age ranged from 45 to 60 years. They were randomly assigned into two groups equal in number. Group (A) who received radial extracorporeal shockwaves and home routine. Group (B) who received traditional physiotherapy (composed of ultrasound and aerobic, range of motion and mobility exercises). The treatment program continued for two weeks (3 sessions per week). Visual analogue scale was used in the assessment of level of shoulder pain before and after the course of treatment. Results: There was a significant decrease in the value of visual analogue scale in group (A) than group (B). Conclusions:radial extracorporeal shockwaves decreased pain in diabetic frozen shoulder in type 2 diabetic patients.

1. INTRODUCTION

Diabetes mellitus (DM) is defined as a heterogeneous metabolic disorder characterized by hyperglycemia resulting from defects in insulin secretion, insulin action or both. Hyperglycemia is the key determinant for the development of complications in diabetes. (Zubin et al., 2018).

DM is associated with high morbidity and mortality. Chronic hyperglycemia can be damaging to different organ systems such as kidneys and blood vessels. DM is the leading cause of kidney failure, lower-limb amputations, and blindness and is among the top causes of death worldwide. Diagnosing and treating diabetes effectively is the key to prevent these complications. (Stephanie et al., 2014).

Diabetic patients are commonly classified into two broad categories: type 1 diabetes mellitus (T1DM), which is caused by β-cell destruction, usually leading to absolute or near absolute insulin deficiency, or type 2 diabetes mellitus (T2DM), which is characterized by progressive insulin secretory defect on the background of insulin resistance. (Solis-Herrera,et al., 2015).

Complications of diabetes are usually grouped into microvascular and macrovascular diseases, with the former having much higher prevalence than the latter. Microvascular diseases include retinopathy, nephropathy and neuropathy. Macrovascular complications concern cardiovascular disease, such as coronary artery disease, cerebrovascular disease, and peripheral artery disease.(Konstantinos et al., 2018).

Frozen shoulder, also known as adhesive capsulitis, is characterized by pain and significant restriction of both active and passive shoulder range of motion (ROM).The incidence of adhesive capsulitis is higher in diabetics than in the general population. Frozen shoulder is estimated to affect 11–30% of diabetic patients and 2–10% of non-diabetics. Frozen shoulder appears at an earlier age in diabetic patients. Diabetic patients with frozen shoulder were found to have greater level of disability compared to people who do not have diabetes. Moreover, functional outcomes as measured by shoulder pain and disability index were reported to be worse in diabetics compared to non-diabetics with frozen shoulder. (Mohammad et al., 2014).

Conservative treatments for frozen shoulder include nonsteroidal anti-inflammatory drugs (NSAIDs), intra-articular injections of glucocorticoids and physiotherapy. Physiotherapy has been shown to beeffective in reducing shoulder pain and increasing functional activities. Using NSAIDs in conjunction with physiotherapy were found to be more effective as compared to using NSAIDs alone. Similarly, various studiesfound that outcomes of using intra-articular injections in combination with physiotherapy were much better as compared to intra-articular injections alone. (Hui et al., 2017).

The interest in applying extracorporeal shockwave therapy (ESWT) to musculoskeletal diseasesbegan with observational studies of osteoblastic response pattern in animals in the mid-1980. In the past years, ESWT had emerged as the treatment of choicefor many orthopedic disorders including plantar fasciitis, tennis elbow, shoulder calcific tendinopathies and non-united fractures of long bones. Recently, ESWT application had expanded to the treatment of sports injuries such asjumper's knee and Achilles tendinopathy. (Ching-Jen, 2012).

2. Subjects

This study was carried on forty volunteer cases of both genders with T2DM, suffering from diabetic frozen shoulder. They were randomly selected from Elsahel Teaching Hospital.  Their age ranged from 45 – 60 years old. This study was conducted from December 2018 to July 2019.

Inclusion criteria:

• All patients had Type 2 diabetes mellitus for more than 5 years.
• Thereage ranged from 45 to 60 of both sexes.
• All patients were medically stable and under full medical supervision (diagnosed as diabetic patients using fasting blood glucose test).
• The only cause of frozen shoulder was diabetes mellitus.
• No history of shoulder trauma.
• All patients were free from cerebrovascular or pulmonary disorders.

Exclusion criteria:

All patients had been subjected to full clinical history and examination to exclude the following:

• Patients with T1DM.
• Hypertensive patients.
• Cardiac, pulmonary or cerebrovascular diseases.
• Osteoporosis.

Design of the study:

1) Group A:

This group consisted of twenty patients(13 females and 7 males) with T2DM and suffered from diabetic frozen shoulder. They received radial extracorporeal shockwave therapy(rESWT) and home routine 3 times per week for 2 weeks.

2) Group B:

This group consisted of twenty patients (11 females and 9 males) with T2DM and suffered from diabetic frozen shoulder. They received traditional physiotherapy (ultrasound and aerobic, ROM and mobility exercises) and home routine 3 times per week for 2 weeks.

METHODS:

a)Evaluative Procedure:

The visual analogue scale (VAS), a subjective assessment, was used to assess pain before and after the course of the treatment. The scale was explained clearly for every patient chosen for the study.

b)Treatment Procedures:

Group A:

1. Shockwave application:
   1. Patient lay flat in supine position.

   2. 24Egypt. J. of Appl. Sci., 35 (1) 2020

      The area of treatment was then cleaned with alcohol.

1. Sufficient amount of gel was applied to the area of treatment, which was necessary to transfer the shock waves efficiently and smoothly. 
2. The shockwave applicator was applied perpendicular to the anterior aspect of the shoulder. The applicator was slightly pushed against the shoulder and the start button was pressed.
3. Treatment was administered three times a week for 2 weeks (a total of six sessions). Patient received 2000 pulses at a frequency of 20 Hz per session with submaximal pressure between 0.12 and 0.38 mJ/mm2 (1.6 and 5.0 bar), increased gradually, depending on the level which the patient could tolerate without local anesthetics.

Group B:

1. Ultrasound application:
   1. Patient lay flat in supine position.
   2. The area of treatment was then cleaned with alcohol.
   3. Sufficient amount of gel was applied to the area of treatment, which was necessary to transfer the ultrasound (US) waves efficiently and smoothly. 
   4. The US head was applied perpendicular to the anterior aspect of the shoulder, with firm pressure to ensure good contact with the skin.
   5. Patient received 7 minutes of US at of frequency of 1 MHz (to ensure deep penetration) and intensity ranging from 1 to 2 W/cm² according to the tolerance of the patient.
2. Therapeutic Exercise:

Exercises included aerobic, ROM and mobility exercises. Each exercise was performed 10 times.

1. Pendulum Stretch: the patient leaned over slightly, from standing position, allowing the affected arm to hang down. The patient then started to swing the arm in small circles. As the patient progressed in treatment, the pendulum stretch effect was increased by holding a light weight (three to five pounds) in the swinging arm.
2. Wall-bar Stretching Exercise: the patient stood about an arm-length from wall-bar. The patient then held onto the highest bar that could be reached and started to move forward and downward until a stretch was felt in the upper shoulder and back. The patient held the position for 30 seconds to 1 minute according the level of pain.
3. Glenohumeral distraction in different angles of abduction and flexion: the patient was positioned side lying at the edge of the table. The hand of the therapist was placed on the humeral head just below the acromion while the patient's arm rested in the therapist's arm. The other hand of the therapist was placed on the lateral border on the scapula. The therapist attempted to move the arm in different angles of abduction and flexion while pushing the scapula in medial rotation.

4. Egypt. J. of Appl. Sci., 35 (1) 2020                                        25

   External Rotation Stretch: the patient was positioned supine lying with the elbow flexed at a right angle. The therapist held the hand of the patient and attempted to move it out word, within the limit of pain, while maintaining the elbow in right angle position.

Home Routine for Both Groups:

Home routine exercises for group A and B included:

1. Shoulder mobilization exercises in all directions: (flexion, abduction and external rotation), either as free exercise or by using light weight (one kilogram). The patient performed this exercise from standing position. The patient moved the shoulder forward in flexion for 10 repetitions, then moved it outward in abduction for 10 repetitions, and then externally rotated it for 10 repetitions.
2. Finger walk: the patient faced the wall while in standing position. The patient then reached out and touched the wall with the fingertips of the affected arm, and then slowly walked up the wall with the fingers, as far as the pain allowed. The patient performed this exercise 10 times and regularly measured the maximum elevation as biofeedback for improvement.

Patients were instructed to perform these exercises three times per week at free session days as home program.

Statistical analysis:

The mean and standard deviation of different clinical data were calculated for all patients. Paired t-test was used to determine the significance of difference between the results before and after the course of treatment within each group.

3. RESULTS

- General Characteristics:

Age:

The current study was conducted on 40 participants (24 females and 16 males). They were assigned into two equal groups. Group (A) consisted of 20 participants (13 females and 7 males) with mean age value of 51.55±3.17 years. Group (B) consisted of 20 participants (11 females and 9 males) with mean age value of 50.85±3.16 years. As indicated by the independent t test, there were no significant differences (p>0.05) in the mean values of age between both tested groups (Table 1).

Table (1): Physical characteristics of participants in both groups (A&B):

*SD: standard deviation, P: probability, S: significance, NS: non-significant.

Fig. 1: Mean values of age between both groups

Sex distribution:

The sex distribution of group A revealed that there were 13 females with reported percentage of 65 % and 7 males with reported percentage of 35 %. The sex distribution of group B revealed that there were 11females with reported percentage of 55 % and 9 males with reported percentage of 45 % as shown in table (2). Chi square revealed there was no significant differences between both groups in sex distribution (p>0.05).

Table (2): Distribution of sex in both groups:

Fig. 2: Frequency distribution of sex in group A

Fig. 3: Frequency distribution of sex in group B

- Effect of Shockwave on VAS:

a-Within groups:

As presented in table (3) and illustrated in figure (4), within group's comparison the mean ± SD values ofVASin the "pre" and "post" tests were8.75±0.96 and 2.25±1.29respectively in the group (A). Multiple pairwise comparison tests (Post hoc tests) revealed that there was significant reduction of VASat post treatment in compare to pre-treatment (P-value =0.0001*). While, the mean ± SD values of VASin the "pre" and "post" tests were 9.05 ±0.99 and 4.65±1.69 respectively the group (B). Multiple pairwise comparison tests (Post hoc tests) revealed that there was significant reduction of VASat post treatment in compare to pre-treatment (P-value =0.0001*).

b- Between groups:

Considering the effect of the tested group (first independent variable) on VAS, Multiple pairwise comparison tests (Post hoc tests) revealed that the mean values of the "pre" test between both groups showed no significant differences with (P=0.34). As well as, multiple pairwise comparison tests (Post hoc tests) revealed that there was significant difference of the mean values of the "post" test between both groups with (p=0.0001*) and this significant reduction in favour to group A than group B.

Table (3): Mean ±SD and p values of VAS pre and post-test at both groups.

*Significant level is set at alpha level <0.05    

SD: standard deviation

MD: Mean difference

p-value: probability value

Fig. 4: Mean values of VAS at different measuring periods at both groups

4. DISCUSSION

The present study was conducted to identify the effect of shockwave therapy on pain in diabetic frozen shoulder.

Forty patients of both genders with T2DM, suffering from diabetic frozen shoulder, participated in this study. They were randomly assigned into two equal groups, each group consisted of 20 patients, group A and group B. Group A received rESWT in addition to home routine. Group B received traditional physiotherapy (US and aerobic, ROM and mobility exercises) in addition to home routine.

In the present study, there was a significant improvement in VAS in both groups -in favor of group A.

Physical therapy modalities for treating frozen shoulder include cryotherapy, electrotherapy, and exercises. ESWT has recently drawn great attention as a non-invasive method of treatment. ESWT promotes healing process of connective tissues, including tendons and bones through improvement of neovascularization which helps reducing pain and improves shoulder mobility and function. (Sangho et al., 2017).

The physiological effect of ESWT could be explained by transformation of mechanical signals into biologic or biochemical signals. ESWT modulates the transmission of pain signal by producing extracellular cavitations when passing through tissues that may damage local nerve endings, activating the small-diameter fibers and the serotonergic system and eventually, the gate-control theory (Babak et al., 2013).

In agreement with this study, Babak et al., (2014) found that ESWT has positive effects on acceleration of the healing process of adhesive capsulitis. Considering the hazards of other therapies such as surgery, patients with adhesive capsulitis can benefit from ESWT because of its noninvasive nature, low costs, no need for hospitalization, and the lack of adverse effects during the treatment.

This study is in agreement with (Sung et al., 2016) as they stated that VAS scores improved post-intervention and at the second and fourth weeks of follow-up in the intervention group.

This study was supported by the study of (Sangho et al., 2017) as they conducted a study on two groups of patients. The experimental group received ESWT and conservative physiotherapy, while the control group was treated with hot packs, US, and interference current therapy. They stated that both groups (experimental and control groups) experienced statistically significant declines in their degree of pain as measured by the VAS score. The inter-group comparison after the treatment showed that the experimental group recorded statistically significant lower VAS scores than the control group.

In agreement with this study, Mohamed et al., (2018) found that ESWT and therapeutic exercises were effective in reducing the shoulder pain for patients with diabetic frozen shoulder.

Wei et al., (2017)also agreed with this study as they stated that ESWT showed great efficacy in relieving shoulder pain with regard to Numeric Rating Scale (NRC) scoreas measured at 4 weeks (P < .05) and 8 weeks (P < .01) after treatment.

Muthukrishnan et al., (2019) agreed with this study, as they found that ESWT significantly reduced pain in patients with diabetic frozen shoulder in comparison with the control group.

CONCLUSION

From the findings of the current study, this study concludes that rESWT is effective in decreasing pain in diabetic frozen shoulder in type 2 diabetic patients.

REFERENCES

Babak,  V. ;  F.  Alizadeh;  A.  Moayednia;  M.   Emadi ;M.H. Khorami and S. Haghdani  (2013): Efficacy of Extracorporeal Shock Wave Therapy for the Treatment of Chronic Pelvic Pain Syndrome: A Randomized, Controlled Trial; ISRN Urol.; 972601.

Babak, V. ;  P. Taheri ;  A.Z. Zade and S. Moradian (2014): Efficacy of Extracorporeal Shockwave Therapy in Frozen Shoulder; Int J Prev Med.; 5(7): 875–881.

Ching-Jen, W. (2012): Extracorporeal shockwave therapy in musculoskeletal disorders; J OrthopSurg Res.; 7(11):1-8.

Hui, Bin Yvonne Chan ; P.Y. Pua and C.H. How (2017): Physical therapy in the management of frozen shoulder; Singapore Med J.; 58(12): 685–689.

Konstantinos, P. ; M. Banach ; E. Bekiari ; M. Rizzo and M. Edmonds (2018): Complications of Diabetes 2017; J Diabetes Res.; 3086167.

Mohamed, K. Seyam ;Ezzat E. Moubarak and Abdul Rahim Shaik (2018): The Effect of Extracorporeal Shock Wave Therapy for Patients with Diabetic Frozen Shoulder; Majmaah Journal of Health Sciences ; 6(2):40-49.

Mohammad, M. Uddin ;Aminuddin A. Khan ;  Andrew J. Haig and Mohammad K. Uddin (2014): Presentation of frozen shoulder among diabetic and non-diabetic patients; J ClinOrthop Trauma; 5(4): 193–198.

Muthukrishnan, R. ; A.A. Rashid and F Al-Alkharji (2019): The effectiveness of extracorporeal shockwave therapy for frozen shoulder in patients with diabetes: randomized control trial; J PhysTher Sci.; 31(7):493-497.

Sangho, L. ;S. Lee ;M. Jeong ;H. Oh andK. Lee (2017):The effects of extracorporeal shock wave therapy on pain and range of motion in patients with adhesive capsulitis; J PhysTher Sci.; 29(11): 1907–1909.

Solis-Herrera, C. ; C. Triplitt ; C. Reasner ; R.A. DeFronzo and E. Cersosimo (2015): Classification of Diabetes Mellitus; MDText.com, Inc.

Stephanie, A. Stein ; Kristin L. Maloney and Toni I. Pollin (2014): Genetic Counseling for Diabetes Mellitus; Curr Genet Med Rep.; 2(2): 56–67.

Sung, H. Kim ; Kang W. Ha ; Yun H.Kim ; Pyong-HwaSeol ; Ho-Jun Kwak ; Seung-Wan Park and Byung-JuRyu (2016): Effect of Radial Extracorporeal Shock Wave Therapy on Hemiplegic Shoulder Pain Syndrome; Ann Rehabil Med.; 40(3): 509–519.

Wei, Li ; Shou-Xiang Zhang ; Qi Yang ; Bao-Lin Li ; Qing-Gang Meng and  Zheng-GuiGuo (2017):Effect of extracorporeal shock-wave therapy for treating patients with chronic rotator cuff tendonitis; Medicine (Baltimore); 96(35): e7940.

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تأثیر الموجات التصادمیة على الکتف المتجمد السکری

مصطفى عمر الفاروق بدیع محمد، أکرم عبد العزیز سید،

هانی عزت عبیة ، یوسف صباح سویفی

 -1 أخصائی العلاج الطبیعی بمستشفى الساحل التعلیمی،

2- أستاذ مساعد بقسم العلاج الطبیعی لاضطرابات الجهاز الدوری التنفسی والمسنین، کلیة العلاج الطبیعی - جامعة القاهرة،

3- أستاذ مساعد بقسم العلاج الطبیعی لاضطرابات الجهاز الدوری التنفسی والمسنین، کلیة العلاج الطبیعی - جامعة القاهرة،

4- أستاذ الباطنة، مستشفى الساحل التعلیمی، الهیئة العامة للمستشفیات والمعاهد التعلیمیة.

هدف هذه الرسالة هو تقییم ومقارنة تأثیر الموجات التصادمیة على الکتف المتجمد السکری فی مرضى السکر من النوع الثانی. تمت الدراسة على أربعین مریضا بالسکر النوع الثانی، تم اختیارهم من مستشفى الساحل التعلیمی، تتراوح أعمارهم ما بین 45 - 60 عاماً، وتم تقسیمهم عشوائیا إلى مجموعتین متساویتین فی العدد. المجموعة (أ) تلقت جلسات الموجات التصادمیة، بجانب المواظبة على التمرینات المنزلیة، والمجموعة (ب) تلقت العلاج الطبیعی التقلیدی المکون من الموجات فوق الصوتیة والتمرینات العلاجیة، بجانب المواظبة على التمرینات المنزلیة. وقد استمر البرنامج العلاجی لمدة أسبوعین بمعدل ثلاثة جلسات أسبوعیا. وقد تم عمل قیاس لمستوى الألم (باستخدام مقیاس النظیر البصری) وقیاس لمدى حرکة مفصل الکتف (باستخدام جهاز قیاس المیل الیدوی) لکل مریض داخل المجموعتین. وأظهرت النتائج وجود زیادة غیر ذات دلالة إحصائیة فی قیاس مدى حرکة مفصل الکتف فی المجموعتین، ووجود نقص فی مقیاس مستوى الألم ذو دلالة إحصائیة کبیرة فی مجموعتی الاختبار وکانت أفضل النتائج فی المجموعة الأولى بالنسبة لنقص مستوى الألم. یستنتج من هذه الدراسة أن الموجات التصادمیة لها تأثیر أفضل من العلاج الطبیعی التقلیدی على مستوى الألم فی الکتف المتجمد السکری بمرضى السکر النوع الثانی.

الکلمات الدالة: السکری النوع الثانی، الکتف المتجمد، الموجات التصادمیة