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Shimaa N et al.
Journal of medical research and practice
JMRP
Marc
h 2013 Volume no 2 Issue 6
148
Available at www.jmrp.info
Res
Research article
Shock Wave versus Phonophoresis in Treatment of Diabetic Frozen Shoulder
Sahar M. Adel
1
,Shimaa N. Abo ElAzm
2*
,
Neveen A. Abdel-Raoof
1
& Khaled Takey Ahmed
3
Au
t
h
or
Affilations
1
Sahar M. Adel,
Department of Physical Therapy for
Basic Science, Faculty of Physical
Therapy, Cairo University, Giza, Egypt.
2
Shimaa N. Abo ElAzm,
Department of Basic Sciences, Faculty
of Physical Therapy, Misr University
for sciences and technology(MUST),
Giza, Egypt.
1
Neveen A Abdel-Raof ,
Department of Physical Therapy for
Basic Science, Faculty of Physical
Therapy, Cairo University, Giza, Egypt.
3
Khaled Takey Ahmed,
Department of physical therapy for
cardiopulmonary, geriatrics disorders
and its surgery, Misr University for
sciences and technology, Giza, Egypt.
Corresponding Author
Shimaa N. Abo ElAzm.,
Department of Basic Sciences, Faculty
of Physical Therapy, Misr University
for sciences and technology, Giza,
Egypt.
Email:- shimaaaboelazm@yahoo.com
Abstract
The purpose: of this study was to investigate the effects of shock wave
therapy versus phonphoresis in treatment of diabetic frozen shoulder.
Design: 40 Patients were evaluated pre-treatment and post treatment
for shoulder pain intensity, shoulder disability index and range of
motion,. Methods: Patients were randomly distributed into two equal
groups, each group consisted of 20 patients. Group A with a mean age
of 45.33 ± 8.64 years received 4 sessions of shockwave therapy (2000
shocks per session, one session per week for four consecutive weeks
with 022 mJ/mm
2
) and therapeutic exercises (passive stretching
exercises, strengthing exercises, and mobilization exercises for
shoulder joint) 3 times per week, every other day, for 4 consecutive
weeks. Group B with a mean age of 46.26 ± 8.05 years received 12
sessions of phonophoresis (frequency of 3MH, and intensity 1w/cm)
and same therapeutic exercises as group A ( 3 times per week, every
other day, for 4 consecutive weeks). Results: The results revealed
significant difference in all measured variables regarding group A and
B when comparing pre and post treatment mean values ( P<0.0001).
Significant improvement was observed in favour of group A in all
measured variables ( pain intensity, shoulder disability index and
range of motion) Conclusion: Both shock wave and the phonophoresis
had a significant effect on decreasing shoulder pain severity, shoulder
functional disability, increasing in shoulder flexion, abduction and
internal rotation motions . However, the shockwave therapy was more
effective in all measured variables than phonphoresis in treatment of
patients with diabetic frozen shoulder.
Key words: Shoulder; diabetic frozen shoulder; shockwave;
phonophoresis.
Introduction:
Frozen shoulder, is a condition known as adhesive
capsulitis, it represents a clinical syndrome of pain
associated with severely restricted joint range of
movement
1
. It is used in discussing the specific
clinical syndrome that is characterized by
insidious onset of pain with no trauma and
gradual reduction in range of motion. This
syndrome may occur in both genders. The real
cause of this syndrome is unknown but there are
some predisposing factors involved such as
synovial cell hyperplasia, fibrosis of the capsule
due to cytokines or other inflammatory factors
2
. A
link between frozen shoulder and diabetes has
been described by many authors, with the most
accepted values 10-20% incidence of frozen
shoulder in diabetic patients
3
. Shock waves are
sound waves generated by a source that creates
vibration which are then transported through
tissue via fluid and solid particles interaction
4
.
In the last ten years, shock wave therapy has been
successfully employed as an anti-inflammatory
therapy in a number of orthopedic diseases such
as pseudoarthrosis, tendinitis, of the shoulder
epicondylitis, plantar fasciitis, and several
inflammatory tendon diseases
5
. Ultrasound is an
intervention that is frequently used by physical
ISSN NO
-
2162
-
6391(Print)
2162-6375(Online)
Shimaa N et al.
Journal of medical research and practice
JMRP
Marc
h 2013 Volume no 2 Issue 6
149
therapist mainly to soft tissue injuries because of
its presumed effect of accelerating healing of
damaged tissues. Phonophoresis involves the use
of ultrasound energy for the transdermal delivery
of low molecular weight drugs
6
. It has several
advantages. It has a low risk of burning the skin,
no need to ionize the drugs, and its permeability is
approximately 5 cm and its treatment time is
short. The drug is placed on the skin in the form of
a gel, cream, ointment, or liquid and serves as a
medium for the ultrasound transmission. This
procedure is intended to enhance transdermal
penetration of particles of the drug while
providing the therapeutic effects of ultrasound
7
.
Both conservative and surgical treatment aim is
to decrease tightness of the capsule, which may
increase shoulder range of motion
8
. Progressive
resistance training exercises for the scapular and
rotator cuff musculature in patients with frozen
shoulder syndrome are effective in reducing pain
and improving function and quality of life
9
. It has
been reported that, mobilization exercises are
effective in changing characteristics of joint
kinematics during shoulder abduction
10
. The
study aimed to compare clinical outcome of
shockwave and phonopheresis in treatment of
diabetic frozen shoulder.
Materials and methods
Forty diabetic patients (21 females and 19 males)
referred from orthopaedic department at the
Memorial Hospital of MUST University diagnosed
as diabetic frozen shoulder represented the
sample of the study. All patients were referred by
same orthopaedic surgeon who was responsible
for diagnosis of cases based on clinical and
radiological examinations.
Their age ranged between 40-60 years old (mean
age 50.35±3.25 years). Approval for the study was
obtained from the ethical committee of the Faculty
of Physical Therapy, Cairo University. Treatment
was conducted in a private clinic and all
participants received a comprehensive
explanation about the purpose of the study, its
benefits, inherent risks, and expected
commitments with regard to time and their
informed consent was obtained.
Inclusion criteria:
- Diabetic frozen shoulder
- Age 40-60 ( the onset before age of forty is very
uncommon. The peak age is 56 years
11)
.
- Illness time ranging between 2-9 months(phase
1 frozen shoulder; the painful phase
11
.
Exclusion criteria:
• Rotator cuff tears.
• Non diabetic frozen shoulder .
• Glenohumeral or acromioclavicular arthiritis.
• Any previous shoulder surgeries.
• Malignancy.
• Blood coagulation disorders or patients on
anticoagulant drugs.
• Patients who had intra-articular injection.
Group assignment:
Subjects were randomly assigned into two groups
of equal numbers each containing twenty subjects.
The investigator flipped a coin to determine
whether the patients was in the study group or
control group. Group A (N =20) received shock
wave therapy in addition to a program of exercise
therapy and Group B (N =20) received the same
program of exercise in addition to phonophoresis.
Instrumentations
A- For evaluation:
Evaluation was conducted for each patient of the
two groups before and after treatment. The
assessment procedure included the following:
1. Pain assessment:
Pain was assessed by using visual analogue scale
(VAS). This scale allows continuous data analysis
and uses a 10cm line with 0 (no pain) and 10
(killing pain). Patients place a mark along the line
to denote their level of pain
12
.
2- Pain and functional disability
This variable was assessed by using the shoulder
pain and disability index (SPADI) which is a valid
and reliable index for measuring shoulder pain
and disability. It consists of two parts; part one
assesses pain and part two assesses functional
disability. Scores were calculated as follow: in part
one pain scores in all questions were added, and a
mean value was chosen. In part two functional
score of all questions were added and a mean
value was chosen for the purpose of data analysis.
The final scores for each part were statistically
analyzed separately
13
.
3- Range of motion assessment:
An electrogoniometer (Model 01129 Guymon
Goniometry) was used to determine the range of
motion of the shoulder joint. It is a tool used to
Shimaa N et al.
Journal of medical research and practice
JMRP
Marc
h 2013 Volume no 2 Issue 6
150
eliminate the need to manually score each
measurement by storing the information
internally. It has a range of 0° to 360° and is
accurate to +/- 1. It stores up to 80 data points or
80 subject / joint number. The validity and
reliability of electrogoniometer for measurement
of shoulder joint movement was tested and well
documented
14
.
The device was calibrated before treatment at 0
point and shoulder movements were measured.
Shoulder movements including; flexion, abduction
and internal rotation were determined for each
patient from supine lying position. All
measurements were done for three consecutive
times and the mean was calculated and used for
the purpose of data analysis.
Instrumentation used for treatment:
1- Radial Extracorpreal shockwave device
It is a device that provide shock wave its model is
radial spec and serial number is (1107394)
medispec . It is connected to electrical main supply
115/220VA C at frequency 50/60 HZ and 5 A.
2- Pagani ultrasound apparatus pulson 200
It consists of multifrequency head (1 and 3 MHz),
surface area 4 cm², Continuous and pulsed mode
(10 – 20 – 30 – 40 – 50 - 100%), Acoustic contact
control. Mains voltages: 100- 240-VAC, 50/60 Hz,
50/60 HZ +/- 10 %, Maximum power –in
operation: 85 VA, Dimensions (b x h x d): 266 x
100 x 275 mm , Weight: 3,650 kg, Safety class I.
Treatment procedures:
1- G A (Shock wave therapy group):
1- From sitting with shoulder abducted at 45º and
elbow flexed and the forearm rested on flat
surface, the shock wave applicator was applied on
most tender point near the insertion of rotator
cuff at greater tuberosity under the acromion. The
shock wave therapy was administrated using
15mm head applicator. Each patient in the
experimental group A received 4 sessions, one
session per week for four consecutive weeks with
2000 impulses per session, an energy flex density
of 0.22mJ/mm2 , pulse rate 10/sec and frequency
1-15 Hz. The treatment area was prepared with a
coupling gel to minimize the loss of shock wave
energy at the interface between applicator tip and
skin
15
.
2- The exercise program was applied as
follows:
A. Passive stretching exercise for the
posterior shoulder capsule and surrounding
musculature was done for only 3 times with a
holding time 30 seconds and 10 seconds rest
period between repetitions in each session
16
.
B. Strengthening exercises for shoulder
flexion, and horizontal abduction. For each of the
exercises, a 10- repetition maximum was
determined. This determination was based on the
examiner's observation of movement quality and
the subject's responses with regard to fatigue and
pain. Deterioration in movement quality or pain
exceeding a mild discomfort was avoided during
all strengthening exercises by either reducing the
level of resistance or modifying the ROM until the
subject was able to progress. Each exercise was
performed as 3 sets of 10 repetitions with a 60-
seconds rest period between each set. A seated
press-up and the elbow push–up exercises were
also included. Both were performed to fatigue or
for a maximum of 25 repetitions. The quality of all
repetitions of each exercise was continuously
monitored by the investigator of the study
16
.
C. Mobilizing exercises in the following
form: Patients received sustained mobilization
technique with grades (I, II, II, and IV) and
oscillatory mobilization technique in the form of
inferior, anterior, and posterior glide. The
mobilization was done for 2-4 times with a
holding time of 30 seconds and a rest period of 10
seconds. The oscillatory technique is done at the
rate of 5-6 oscillation/second for 20 minutes
17
.
The anterior gliding mobilization technique was
done with the patient lying prone and the
glenohumeral joint abducted 90 degrees in the
scapular plane, one hand stabilize the humerus
above the elbow and the other glide the humeral
head and the applied force was in the
anterolateral direction. This technique was done
to increase extension and external rotation
18
.
The posterior gliding mobilization technique was
done with the patient lying supine and the
glenohumeral joint abducted 90 degrees in the
scapular plane, one hand stabilize the humerus
above the elbow and the other glides the humeral
head and the applied force was done in the
posterolateral direction. This technique was done
to increase the flexion and internal rotation
18
.
The inferior glide was done with the patient lying
supine and the glenohumeral joint abducted 90
degrees in the scapular plane, one hand stabilize
Shimaa N et al.
Journal of medical research and practice
JMRP
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h 2013 Volume no 2 Issue 6
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the humerus above the elbow and the other glides
the humeral head and the applied force was done
inferiorly and laterally. This technique was done
to increase shoulder abduction
19
.
2- G B( Phonophoresis group):
In addition to the exercise program given to GA,
subjects representing the sample of this study
received phonophoresis for 12 sessions, 3
sessions per week as follows:
From sitting position with the affected arm facing
the therapist, continuous ultrasound with a
frequency of 3MH,and intensity 1w/cm was
applied on the affected shoulder at the site of pain
using diclofenac sodium gel for 5 minute
(20)
.
Statistical analysis:
Paired t-test was used to detect difference within
shock wave group and within phonophoresis
group at pain severity, functional disability index
and range of motion
Un paired t-test was used to detect the difference
between both groups (shock wave,
phonophoresis) before and after treatment at pain
intensity, functional disability index and range of
motion.
Results:
The results of the study after the suggested period
of treatment revealed significant improvement in
the measured variables including pain, function,
and range of motion in GA and GB when
comparing the pre and post treatment mean
values. Significant difference was observed in
favour of GA in pain severity; joint function and
shoulder range of motion, when comparing the
post treatment mean values of the two groups.
Subjects:
GA twenty patients (twelve females and eight
males) with diabetic frozen shoulder syndrome
were included in this group that received shock
wave therapy and exercises. The mean (± SD) of
age 45.33 ± 8.64 years, weight 78 ± 5.26 kg, height
168.53 ± 0.04 cm, and BMI 27.54 ± 2.65 kg/m²
GB twenty patients (nine females and eleven
males) with diabetic frozen shoulder syndrome
were included in this group that received
phonohoresis therapy and exercises. The mean (±
SD) of age 46.26 ± 8.05 years, weight 79.06 ± 8.41
kg, height 169.4± 0.06 cm, and BMI 27.60 ± 3.09
kg/m²
Comparing the general characteristics of the
subjects of both groups revealed that there was no
significance difference between both groups in the
mean age, weight, height, or BMI (p > 0.05).
Pain intensity for Group (A) and Group (B) pre
and post treatment
The mean and standard deviation values (SD) of
VAS for GA before application of shock wave was
6.8 ± 1.08, while after application of shock wave
was 0.4 ± 0.5. The mean difference was 6.4 and the
percent of improvement was 94.11 %. There was a
significant difference between pre and post
treatment in VAS (p = 0.0001). (Table 1).
The mean and SD of VAS for GB before application
of phonophoresis was 6.73 ± 1.38, while after
application of phonophoresis was 1.06 ± 0.7. The
mean difference was 5.67 and the percent of
improvement was 84.24 %. There was a
significant difference between pre and post
treatment in VAS (p = 0.0001). (Table 1)
Table 1. Pre and post treatment mean values of VAS for Group (A) and Group (B).
X: Mean, SD: Standard Deviation, MD: mean difference, t value:
Unpaired t value, p value= Probability value , S= significant
Pain between subjects of for Group (A) and Group (B) post treatment
The mean value ± SD of VAS after treatment for group A was 0.4 ± 0.5 and that for group B was 1.06 ± 0.7.
The mean difference between both groups was -0.66. There was a significant difference between GA and
GB in VAS post treatment with t-value=-2.97 (p= 0.006). (figure 1)
VAS
MD
% of
improvement
t
-
value
p
-
value
Sig
X
±SD
Pre
GA
6.8 ± 1.08
6.4
94.11
18.33
0.0001
S
Post
0.4 ± 0.5
Pre
GB
6.73±1.38
5.67
84.24
22.48
0.0001
s
post
1.06±0.7
Shimaa N et al.
Journal of medical research and practice
JMRP
Marc
h 2013 Volume no 2 Issue 6
152
Figure 1. Post treatment mean values of VAS in Group (A) and Group (B)
SPADI for Group (A) and Group (B) pre and post treatment
The mean value ± SD of SPADI after treatment for group A was 0.6 ± 0.5 and that for group B was 1.2 ±
0.67. The mean difference between both groups was -0.6. There was a significant difference between G A
and G B in SPADI post treatment (p = 0.01). (Table 2)
The mean and SD± values of SPADI for group B before application of phonophoresis was 6.6 ± 1.05, while
after application of phonophoresis was 1.2 ± 0.67. The mean difference was 5.4 and the percent of
improvement was 81.81 %. There was a significant difference between pre and post treatment in SPADI
(p = 0.0001). (Table 2)
Table 2. Pre and post treatment mean values of SPADI for Group (A) and Group (B).
SPADI
MD
% of
improvement
t
-
value
p
-
value
sig
X ±SD
Pre
GA
6.86±
0.91
6.26
91.25
25.252
0.0001
s
post
0.6±0.5
Pre
GB
6. 6±1.05
5.4
81.81
25.256
0.0001
s
post
1.2±0.67
X: Mean, SD: Standard Deviation, MD: mean difference, t value: Unpaired t value,
p value= Probability value , S= significant
SPADI between subjects for Group (A) and Group (B) post treatment
The mean value ± SD of SPADI after treatment for group A was 0.6 ± 0.5 and that for group B was 1.2 ±
0.67. The mean difference between both groups was -0.6. There was a significant difference between G A
and G B in SPADI post treatment with t- value=-2.75 (p = 0.01). (figure 2).
Figure 2. Post treatment mean values of SPADI in GA and GB ROM for Group (A)
Shimaa N et al.
Journal of medical research and practice
JMRP
Marc
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The mean and SD values of shoulder flexion, abduction, and internal rotation for GA before the application
of shock wave were 109.86 ± 23.35, 100.26 ± 7.02, and 29 ± 5.64 degrees respectively, while after
application of shock wave were 173.53 ± 6.41, 174.33 ± 5.21, and 44.4 ± 0.73 degrees respectively. The
mean difference between pre and post treatment in mean values of shoulder flexion, abduction, and
internal rotation were – 63.67, - 74.07, and -15.4 respectively. There was a significant difference between
pre and post treatment mean values of shoulder ROM (p < 0.05). (Table 3)
Table 3. Pre and post treatment mean values of ROM for Group (A)
Pre
post
MD
%of
improvement
t
-
value
p
-
value
sign
ROM
(degrees)
X±
SD
X±
SD
flexion
109.86±23.35
173.53±6.41
-
63.67
57.95
-
12.24
0.0001
S
Abduction
100.26±7.02
174.33±5.21
74.07
73.87
-
39.22
0.0001
S
Internal
rotation
29±5.64
44.4±0.73
-
15.4
53.10
-
10.69
0.0001
S
X Mean, SD: Standard Deviation, MD: mean difference, t value: Unpaired t value , p value= Probability
value , S= significant
ROM for Group (B) pre and post treatment
The mean and SD values of shoulder flexion, abduction, and internal rotation for GB before the application
of phonophoresis were 110 ± 21.38, 100.53 ± 13.51, and 28.26 ± 3.86 degrees respectively, while after
application of phonophoresis were 159.33 ± 13.47, 162.2 ±12.49, and 42.73 ± 2.12 degrees respectively.
The mean difference between pre and post treatment in mean values of shoulder flexion, abduction, and
internal rotation were - 49.33, - 61.67, and -14.47 respectively. There was a significant difference between
pre and post treatment mean values of shoulder ROM (p < 0.05). (Table 4).
Table 4. Pre and post treatment mean values of ROM for Group B
Pre
post
MD
% of
improvement
t
-
value
p
-
value
sign
ROM
(degrees)
X±
SD
X±
SD
flexion
110±21.38
159.33±13.4
-
49.33
44.84
-
14.46
0.0001
s
Abduction
100.53±13.5
162.2±12.49
-
61.67
61.34
-
27.10
0.0001
s
Internal
rotation
28.26±3.86
42.73±2.12
-
14.47
51.20
-
14.40
0.0001
s
X: Mean, SD: Standard Deviation, MD: mean difference, t value: Unpaired t value , p value= Probability
value , S= significant
Post treatment mean values of ROM for Group (A) and Group (B)
The mean value ± SD of shoulder flexion, abduction, and internal rotation post treatment for group A were
173.53 ± 6.41, 174.33 ± 5.21, and 44.4 ± 0.73 degrees respectively, and that for group B were 159.33 ±
13.47, 162.2 ±12.49, and 42.73 ± 2.12 degrees respectively. The mean difference between both groups in
mean values of shoulder flexion, abduction, and internal rotation were 14.2, 12.13, and 1.67 respectively.
With t- value= 3.68, 3.47, 3.90 respectively. There was a significant difference between group A and group
B in shoulder ROM post treatment with (p < 0.05). (Figure 3)
Shimaa N et al.
Journal of medical research and practice
JMRP
Marc
h 2013 Volume no 2 Issue 6
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Figure 3. Post treatment mean values of ROM in Group A and Group B
Discussion
Frozen shoulder syndrome is a condition of
uncertain etiology characterized by progressive
loss of both active and passive shoulder motion,
and muscle weakness from disuse
21
. It has been
estimated that a minimum of 2% of the population
are at risk of being affected by frozen shoulder per
year. Patients with frozen shoulder usually
present between the fifth and sixth decades of life,
and onset before the age of forty is very
uncommon. The peak age is 56 years, and 70% of
patients are females
22
.
To examine the analgesic effects of shock wave
therapy, comparison was done between pre and
post treatment mean values of pain using shoulder
disability index for the shoulder impingement
syndrome patients in the first experimental group.
The results showed highly significant decrease in
shoulder joint pain and increasing function at the
end of the treatment program.
This comes in agreement with Gerdesmeyer et
al.,
23
who reported that shock wave by all its
generations has a beneficial effect on shoulder
functions, as well as on self rated pain and
diminished calcification size. With the high energy
ESWT having significantly better outcomes.
This is confirmed by the work of Rompe et al.,
24
who stated that, shock waves induced analgesic
effect by over stimulating the axons thereby
increasing pain threshold. And the work of Malay
et al.,
25
who mentioned that, shock waves include
the physical alteration of small axons, so that
inhibiting pain impulse conduction, and chemical
alteration of pain receptors neurotransmitter, and
preventing pain perception.
Pan et al.,
26
stated that visual analogue scale
(VAS) improved after ESWT treatment to
tendinitis of the shoulder. Cacchio et al.,
15
showed
significant reduction in shoulder pain after 4
weeks of treatment by RSWT.
These results may be clarified by the work of
Lebrun,
27
who clarified that, Shock wave therapy
works on one level to treat pain through
overstimulation of the "pain transmission nerves"
or "hyperstimulation analgesia, and local
production of pain inhibiting substance. Higher-
level shock waves can also induce tissue changes,
by increasing metabolic activity and blood flow
through the area, and activating the body's own
repair mechanisms.
High-energy shockwaves produce an adequate
amount of energy that can produce controlled
inflammation of the designated tissue. This
inflammation has been shown to stimulate many
mediators such as transforming growth factor
beta 1 (TGF-B1) and insulin-like growth factor 1
(CGF-I) and initiates the healing process
28
. ESW
increases microcirculation in lower-leg chronic
ischaemia, improves myocardial perfusion in
patients with severe coronary artery, decreases
pain and enhances re-epithelialisation in chronic
leg ulcers and, it may improve bone vascular
disorders such as osteonecrosis and may have a
bactericidal effect against Staphylococcus
aureus
29
. This may be attributed to the effect of
ESWT that, cause reduction of substance P in the
target tissue in conjunction with reduced
synthesis of this molecule in dorsal root ganglia
cells as well as by selective destruction of
unmyelinated nerve fibers within the focal zone of
ESW
30
.
Pain severity reduction for frozen shoulder
patients after ESWT in this study could also be
attributed to positive anti-inflammatory effect,
antibacterial effect, neovascularization due to
increase the interruption of the flow of nerve
impulses.
To examine the effect of shock wave therapy on
reducing functional disability, comparison
between pre and post treatment results of
functional disability using shoulder functional
disability index for the diabetic frozen shoulder
patients was done. There was significant decrease
Shimaa N et al.
Journal of medical research and practice
JMRP
Marc
h 2013 Volume no 2 Issue 6
155
in functional disability at the end of the treatment.
These results come in agreement with Arno et al.,
(29)
who reported that (SWT) increases perfusion
in ischemic tissues, stimulate growth factors,
decreases inflammation and accelerate healing so
improve function. These results come in
agreement with HO and Hsu et al.
10
;and Cacchio
et al.,
15
. They revealed significant functional
improvement due to application of (SWT) for
patient with shoulder pain.
These results were clarified by the work of Pan et
al.,
26
who suggested that, pain relief after ESWT
for calcific tendonitis of the shoulder is achieved
through hyper stimulation analgesia. The
threshold of pain will increase and accordingly
shoulder range of motion and activity will
increase. There was a significant decrease in the
mean values of shoulder pain at the end of
treatment in the phonophoresis group.
Therapeutic ultrasound (US) is frequently used in
physiotherapy clinics to treat various
musculoskeletal disorders. Although the exact
mechanism of action is unclear, heating is the
most important effect. It encourages regional
blood flow and increases connective tissue
extensibility. Non-thermal effects are less
understood and include molecular vibration,
which increase cell membrane permeability and
thereby enhances metabolic product transport
(7)
.
Topically applied drugs can include local and
systemic effects that can be distinguished by
examining local tissue drug concentrations (under
the site of application) and blood or urine level.
For years it was thought that all topically applied
drugs entered the capillary network, became
systemic, and then returned to the local area
through the bloodstream. Research has shown
that local delivery is separate from systemic
delivery
8
.
Concerning functional disability there was
significant decrease of functional disability of the
phonophoresis group due to ultrasonic effect plus
anti inflammatory and anesthetic effect of
declophenac gel used in phonophoresis. These
include: enhanced blood flow, increased
membrane permeability and nerve conduction, as
well as stimulation of protein synthesis with
fibroblast activation. This may be attributed to the
biological changes made by the mechanical and
thermal effects of ultrasound includes an increase
in the tissues’ regenerative power, an increase in
the membrane permeability, an improvement in
tissue circulation, change of peripheral nerve
conduction velocity, and muscle relaxation,
reduction of pain
20
.
After treatment there was a significant reduction
of pain intensity of shock wave group than
phonophoresis group this may be due to the
potent analgesic effect and anti-inflammatory
effect of shock wave therapy which was stronger
than that effect of phonophresis.
Conclusion
From the finding of the current study we can
conclude that both shockwave and phonophoresis
are effective in diabetic frozen shoulder
syndrome. However, the shockwave therapy was
more effective in all measured variables (pain
severity, shoulder disability index and range of
motion) than phonphoresis in treatment of
patients with diabetic frozen shoulder.
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Conflict of interest :- Author has not declared any conflict of interest.
Source of Funding:-None
© 2013. Shimaa N et al. This is an Open Access article distributed under the terms of the Creative Commons
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