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Effects of moderate physical activity on diabetic adhesive capsulitis: a randomized clinical trial

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Abstract

Background Moderate physical activity (MPA) has proven advantages for glycemic control, cardiovascular health, and functional independence. However, physical activity is not part of routine conventional physical therapy (CPT) in managing diabetic adhesive capsulitis patients. Objective To determine the effects of moderate MPA on diabetic adhesive capsulitis (AC). Methodology A randomized control trial was conducted at the Combined Military Hospital (CMH), Muzaffarabad, Pakistan from March 2022 to October 2022. A total of n = 44 patients with diabetic AC, aged 40 to 65 years, HbA1c > 6.5% were enrolled. Group A received MPA and CPT, while Group B only received CPT for six weeks. The upper extremity function, pain, and range of motion were assessed at baseline, third week, and sixth week through the disability of arm, shoulder, and hand (DASH) questionnaire, numeric pain rating scale (NPRSS), and goniometer respectively. Results The NPRS score and ROMs showed significant improvement ( p < 0.05) in group A compared to group B with a large effect size. When comparing the mean difference of the DASH score (73 + 7.21 vs . 57.9 + 12.64, p < 0.001, Cohen’s d = 1.46) was significantly improved with large effect size in group A as compared to group B. Conclusion MPA along with CPT has positive effects on patient pain, range of motion, and disability in patients with diabetic adhesive capsulitis.
Effects of moderate physical activity on
diabetic adhesive capsulitis: a randomized
clinical trial
Raheela Kanwal Sheikh
1
,
*, Amna Toseef
2,3
, Aadil Omer
4,5
,
Anam Aftab
6
, Muhammad Manan Haider Khan
7
, Saeed Bin Ayaz
2
,
Omar Althomli
1
, Aisha Razzaq
3
, Samra Khokhar
8
, Nazia Jabbar
9
and
Waqar Ahmed Awan
3
,
*
1Department of Physiotherapy, College of Applied Medical Sciences, University of Hail, Hail,
Saudi Arabia
2Physical Medicine & Rehabilitation, Sheikh Khalifa Bin Zayed Al Nahyan Hospital CMH,
Muzaffarabad, Azad Kashmir, Pakistan
3Faculty of Rehaibilitation & Allied Health Sciences, Riphah International University, Islamabad,
islamabad, Pakistan
4School of Rehabilitation, Tehran University of Medical Sciences, Tehran, Iran
5Islamabad College of Physical Therapy, Margalla Institute of Health Sciences, Islamabad,
Pakistan
6M. Islam Institute of Rehabilitation Sciences, Gujranwala, Pakistan
7Department of Rehabilitation Sciences, Shifa Tamer e Millat University, Islamabad, Pakistan
8Nawabshah Institute of Medical and Health Sciences, College of Physical Therapy and
Rehabilitation Sciences (NIMHS), Shaheed Benazirabad, Pakistan
9Royal Institute of Physiotherapy and Rehabilitation Sciences, Hidayat Campus, Sukkur, Pakistan
*These authors contributed equally to this work.
ABSTRACT
Background: Moderate physical activity (MPA) has proven advantages for glycemic
control, cardiovascular health, and functional independence. However, physical
activity is not part of routine conventional physical therapy (CPT) in managing
diabetic adhesive capsulitis patients.
Objective: To determine the effects of moderate MPA on diabetic adhesive capsulitis
(AC).
Methodology: A randomized control trial was conducted at the Combined Military
Hospital (CMH), Muzaffarabad, Pakistan from March 2022 to October 2022. A total
of n= 44 patients with diabetic AC, aged 40 to 65 years, HbA1c > 6.5% were enrolled.
Group A received MPA and CPT, while Group B only received CPT for six weeks.
The upper extremity function, pain, and range of motion were assessed at baseline,
third week, and sixth week through the disability of arm, shoulder, and hand (DASH)
questionnaire, numeric pain rating scale (NPRSS), and goniometer respectively.
Results: The NPRS score and ROMs showed signicant improvement (p< 0.05) in
group A compared to group B with a large effect size. When comparing the mean
difference of the DASH score (73 + 7.21 vs. 57.9 + 12.64, p< 0.001, Cohens d = 1.46)
was signicantly improved with large effect size in group A as compared to group B.
Conclusion: MPA along with CPT has positive effects on patient pain, range of
motion, and disability in patients with diabetic adhesive capsulitis.
How to cite this article Sheikh RK, Toseef A, Omer A, Aftab A, Haider Khan MM, Ayaz SB, Althomli O, Razzaq A, Khokhar S, Jabbar N,
Awan WA. 2024. Effects of moderate physical activity on diabetic adhesive capsulitis: a randomized clinical trial. PeerJ 12:e18030
DOI 10.7717/peerj.18030
Submitted 23 April 2024
Accepted 12 August 2024
Published 18 September 2024
Corresponding authors
Raheela Kanwal Sheikh,
r.sheikh@uoh.edu.sa
Waqar Ahmed Awan,
waqar.ahmed@riphah.edu.pk
Academic editor
Manuel Jimenez
Additional Information and
Declarations can be found on
page 11
DOI 10.7717/peerj.18030
Copyright
2024 Sheikh et al.
Distributed under
Creative Commons CC-BY 4.0
Subjects Clinical Trials, Diabetes and Endocrinology, Rheumatology, Rehabilitation, Sports
Medicine
Keywords Adhesive capsulitis, Frozen shoulder, HBA1c, Physical therapy, Physical activity, ROMs,
Shoulder function
INTRODUCTION
Adhesive capsulitis (AC) results in pain, stiffness, and a progressive reduction in range of
motion in the shoulder joint, which ultimately contributes to a signicant decrease in
functional active and passive movements (Le et al., 2017). A total of 25% of the worlds
population is affected by AC, and women between the ages of 50 and 70 are more likely to
get it. The chance of getting AC is increased by several conditions, including thyroid
disorders and diabetes mellitus (DM) (Alhashimi, 2018;Eom, Wilson & Bernet, 2022;Kim
et al., 2023;Le et al., 2017). Patients with DM have a 13.4% prevalence rate for AC and are
20 times more likely to develop it (Zreik, Malik & Charalambous, 2016).
Evidence suggested that the individuals with adhesive capsulitis should also be screened
for diabetes (Rai et al., 2019). Incidence of AC is 2.7% more likely with prolonged poor
glycemic control and HbA1c (Chen et al., 2018). As inammatory markers are raised in
DM, cause increased growth factor expression and lead to joint synovitis and capsular
brosis. Raised glucose level enhances glycosylation and the endothelial growth factors
slow down the natural inammatory response of body and makes the disease stay for
longer time with worse symptoms (Sözen et al., 2018;Zreik, Malik & Charalambous, 2016).
Physical therapy techniques including manual therapy exercise therapy and
electrotherapy are also strongly recommended for pain relief, improvement of ROM, and
functional status (Chan, Pua & How, 2017). Physical activity, especially endurance
training, is still essential for managing diabetes, as evidenced by improvements in HBA1c,
which are linked to inammation in AC (Asfaw & Dagne, 2022;Struyf, Mertens &
Navarro-Ledesma, 2022;Zhu et al., 2021). Aerobics are also found to improve HbA1c,
muscle strength, related disease and complication progression (Williams et al., 2006).
Treadmill use, bicycling or walking 100 min per week at variable speeds are found to have
signicant effects on diabetics and are preferable (Qiu et al., 2014;Wang et al., 2020).
Elevated blood glucose levels have the potential to aggravate inammation and impair
the ability to regulate the inammatory process (Zreik, Malik & Charalambous, 2016). The
cornerstone of managing diabetes is moderate physical activity, which has proven
advantages for glycemic control, cardiovascular health, and general wellbeing (Asfaw &
Dagne, 2022;Struyf, Mertens & Navarro-Ledesma, 2022;Zhu et al., 2021). Since the
patients with diabetes mellitus are more prone to slow recovery, moderate physical activity
lowers the risk of type 2 diabetes and the complications associated with it. At the time of
this study, physical activity is not studied or even in practice while managing the adhesive
capsulitis in diabetics with physical therapy. Thus, in addition to conventional physical
therapy, MPA may help to reduce hyperglycemia and insulin sensitivity which can lead to
reduced inammation and improve adhesive capsulitis. Therefore, the study objective was
to determine the effects of added moderate physical activity on diabetic AC. It was
Sheikh et al. (2024), PeerJ, DOI 10.7717/peerj.18030 2/14
hypothesized that moderate physical activity with conventional physical therapy
signicantly improves the symptoms of diabetic adhesive capsulitis.
MATERIALS AND METHODS
Study design
A randomized clinical trial (NCT04925128) was conducted at the Rehabilitation
Department of Sheikh Khalifa Bin Zayed al Nahyan (SKBZ) Combined Military Hospital
(CMH), Muzaffarabad, Pakistan from March 2022 to October 2022. The study was
approved from the Research Ethical Committee (RIPHAH/RCRS/REC/Letter-01240) of
Faculty of Rehabilitation & Allied Health Sciences, Riphah International University. It was
carried out after obtaining approval from Ethics Review Committee of SKBZ CMH (Ref.
No. Ethical Committee/DME-826). Prior to the study, written informed consent was taken
from all participants.
Participants
A convenient sampling technique was used for sample selection. 100 patients with
Adhesive Capsulitis (AC) who visited CMH during the recruitment period were assessed
for eligibility. Out of n= 100, n= 51 patients did not full the criteria and n=05
participants declined to participate due to accessibility issues. So, the n= 56 participants
were excluded during sampling process. Participants with uncontrolled Type 2 diabetes
(HBA1c 6.5 consistently for more than 6 months) who were on medication for more
than 3 years and were physically active both male and female in their daily routine
activities but not regularly participating in intense exercises were included. The
participants with stage 1 or stage 2 adhesive capsulitis, who ranged in age from 40 to 65,
had reduced active and passive range of motion in a capsular pattern, and also had
complain of pain (Pandey & Madi, 2021) were included in the study. However, the patients
with history of shoulder dislocation, lower limb injury, diabetic foot ulcer, diabetic
neuropathy, acute or chronic heart disease, rheumatologic disorder, mobility disorder and
post-surgical or trauma related patients were excluded during the screening.
Sample size
A total of n= 44 sample size was calculated through G-power, keeping effect size small
(0.25) as the physical activity was not studied previously for managing adhesive capsulitis,
aerror margin at 0.05. To avoid βerror probability, the power (1β) was set at 0.95%. A
total of n= 100 patients with AC were assessed for eligibility who visited CMH during the
recruitment period. The n= 44 patients were then randomly divided into group A (n= 22)
which received moderate physical activity (MPA) on treadmill in addition to conventional
physical therapy (CPT) and group B (n= 22) received conventional physical therapy
(CPT). There were no dropouts during the study (Fig. 1).
Randomization & blinding
The randomization was done by the individual who was not related to the study. The
sealed envelope method was used to allocate the patient randomly. The random numbers
Sheikh et al. (2024), PeerJ, DOI 10.7717/peerj.18030 3/14
were generated through the Random Number Generator software. The random numbers
were then written on index cards and placed in thick and opaque sealed envelopes before
the study. After written informed consent, physical therapist opened the envelope and
randomly allocated the patients into respective group. The study was single blinded as the
participants were unaware of allocation in the groups (Malick et al., 2022).
Interventions
All patients received a total of 30 sessions, ve sessions per week for 6 weeks (Page &
Labbe, 2010). The duration of session in group A, conventional physical therapy (CPT)
and moderate physical activity (MPA), was 60 min, while group B only received CPT had
30 min duration intervention. Before intervention, a brief introduction of interventions
was given to both groups. All participants were asked to stop any physical activity during
the study period to avoid any confounding effects on the outcomes.
Group A was instructed to perform physical activity in addition to CPT on treadmill,
walking speed and overall handling of the machine. The physical therapist supervised the
physical activity on the treadmill to maintain safety and monitor any complication.
Initially, walking was started with patient comfortable speed and then increased to the
desired level. The participants performed moderate physical activity on treadmill for 5
Figure 1 CONSORT diagram. Full-size
DOI: 10.7717/peerj.18030/g-1
Sheikh et al. (2024), PeerJ, DOI 10.7717/peerj.18030 4/14
days in a week for 30 min at 4 mph speed (36 METs) with 0% inclination. The warm up
and cold down for a 5 min at the beginning and then at the end with speed of 2 mph
without inclination (Umpierre et al., 2011). The protocol was performed for 6 weeks while
maintaining the maximum heart rate between 5070% of every individual.
Group B received only received CPT including hot pack and transcutaneous electrical
nerve stimulation (TENS) for ten minutes. The shoulder was passively mobilized for 10
repetitions in each of the anterior, posterior, and inferior directions while in a pain-free
range. The patient actively participated in a variety of stretches, making sure to stay within
their pain thresholds. These included shoulder rolls, pendulum stretches, cross-body arm
stretches, and towel stretches (10 repetitions in a single session) (Järvinen et al., 2005).
Outcome measures
The average blood glucose level over the previous 6 weeks was measured with
haemoglobinA1c (HbA1c) test. The hemoglobin A1c level should fall between 4% and
5.6% in the normal range. Pre-diabetes is identied by a range of 5.7% to 6.4%. When 6.5%
or higher, diabetes is present. Validity and reliability have r values of 0.96 and 0.99,
respectively (Carter et al., 1996).
Shoulder pain was assessed using numeric pain rating scale (NPRS), a reliable
(Cronbachsa= 0.94) and valid tool (CI [0.960.98]) for assessing pain (Modarresi et al.,
2022).
Shoulder range of motions (ROMs) including abduction, external rotation and internal
rotation were measured through the goniometer, has documented reliability of
(ICC = 0.92) and validity (r = 0.97, ICC = 0.98) (Kolber & Hanney, 2012).
Shoulder functions were evaluated with the Disability of Arm, Shoulder, and Hand
(DASH) questionnaire, a reliable and valid tool for upper limb function. Validity and
reliability of this scale is (ICC = 0.95) and (ICC = 0.92) respectively (Kitis et al., 2009). The
data was collected at the baseline, 3
rd
week and 6
th
week.
Statistical analysis
For interaction effects between interventions and assessment level mixed ANOVA was
used, while for main effects repeated measure ANOVA was applied with pairwise
comparison on NPRS, shoulder range of motion (ROMs) and DASH score. As HBA1c was
assessed at baseline and after 6th week, the paired sample t-test was used for within group
changes. When comparing the groups on outcome measures, an independent t-test was
applied on means of NPRS, ROMs. HBA1c and DASH score were not comparable at the
baseline so independent t-test was applied to compare the mean of the mean differences.
The partial eta squared, and Cohens d were used to determine the effect sizes. The p< 0.05
was considered as statistically signicant value and analyzed by using SPSS version 21.
RESULTS
Out of n= 44 patients the mean age was 52.61 ± 5.81 years. Patients having diabetes for
5.61 ± 3.1 years and mean BMI was 27.2 ± 1.9, n= 43 (97.7%) were overweight and n=1
(2.3%) obese. A total of n= 38 (86.4%) were females and n= 6 (13.6%) were males
Sheikh et al. (2024), PeerJ, DOI 10.7717/peerj.18030 5/14
participated in the study. The frequency of insulin dependent patients was n= 4 (9.1%),
hypoglycemic medication was taken by n= 36 (81.8%) and n= 4 (9.1%) was on both
insulin and hypoglycemic medication. For groupwise distribution please see Table 1.
The results of mixed ANOVA showed signicant interaction effect between
interventions and assessment level regarding the pain intensity {F = 23.68 (1.75, 73.87),
p< 0.001, ηp
2
0.36}, ROMs including abduction ROM {F = 5.94 (1.38, 58.3), p< 0.001, ηp
2
0.12}, External Rotation {F = 8.8 (1.33, 56.1), p< 0.001, ηp2 0.17} and DASH score
{F = 22.2 (1.22, 51.3), p< 0.001, ηp
2
0.34}. But non-signicant interaction effect regarding
internal rotation {F = 1.76 (1.30, 54.8), p< 0.189, ηp
2
0.04} and HbA1c (Fig. 2).
The within-group main effect with RM-ANOVA showed that all variables in group A
(MPA+CPT) and B (CPT) were signicantly improved from baseline to (p< 0.001)
six-week and each level of assessment except shoulder internal rotation. HBA1c only
improved signicantly with a large effect size (p< 0.001, Cohens d = 0.26) in group A,
while no signicant change (p0.05) was observed in group B (Table 2).
To compare the NPRS Score and ROMs between group A and group B, an independent
T-test was used which showed that after, 3
rd
week and 6
th
week in pain and all ROMs
signicant improvement (p< 0.05) observed in group A as compared to group B with
medium to large effect size. No signicant (p= 0.41) difference was seen in abduction after
3
rd
week of intervention (Table 3).
Table 1 Group wise demographic information.
Groups Mean/n Std. Deviation/% p-value
Age Experimental 51.14 5.642 0.208
Control 53.18 4.953
Gender
Male Experimental 4 9.09% 0.31
Control 2 4.55%
Female Experimental 18 40.91%
Control 20 45.45%
Duration of diabetes mellitus (years) Experimental 4.500 2.4251 0.019*
Control 6.727 3.5076
Body mass index Experimental 26.595 1.2038 0.017*
Control 27.941 2.2466
Management
Insulin Experimental –– 0.008**
Control 4 9.09%
Medication Experimental 22 50%
Control 14 31.82%
Both Experimental ––
Control 4 9.09%
Note:
Level: p< 0.05*,p< 0.01**,p< 0.001***.
Sheikh et al. (2024), PeerJ, DOI 10.7717/peerj.18030 6/14
As HBA1c was not normally distributed and DASH score were not comparable at the
baseline, so compared the mean of the mean difference (MD) of HBA1c (0.21 + 0.26 vs.
0.04 + 0.14, p= 0.01, Cohens d = 0.21) and DASH score (73 + 7.21 vs. 57.9 + 12.64,
p< 0.001, Cohens d = 1.46), which showed signicant improvement with large effect size
in group A as compared to group B (Fig. 3).
Figure 2 Interaction effect between variables. Full-size
DOI: 10.7717/peerj.18030/g-2
Sheikh et al. (2024), PeerJ, DOI 10.7717/peerj.18030 7/14
DISCUSSION
The objective of study was to determine effects of moderate physical activity (MPA) on
diabetic adhesive capsulitis in addition to conventional physical therapy (CPT). The results
suggest that participants in both groups showed signicant improvement in shoulder pain,
range of motions, DASH score. However, signicant HbA1c changes were noted only in
group A (MPA+CPT). While comparing both groups after 6 weeks, group A showed
signicant improvement than group B (CPT) in pain, ROMs, overall functionality
according DASH score and HBA1c. These participants were almost back to their routines
and were able to perform their ADLs and IADLs without any pain and restriction as
compared to conventional physical therapy group.
The current studysndings showed that conventional physical therapy (CPT)
considerably reduced pain, shoulder range of motions, and upper limb function.
According to the literature, conventional physical therapy for adhesive capsulitis attempts
to reduce discomfort, expand the range of motion, enhance joint nutrition and lubrication,
prevent muscle atrophy, and trigger neurological changes (Jain & Sharma, 2014;
Nakandala et al., 2021). The underlying mechanism of these results include breaking
adhesions, stretching constrictive tissues, encouraging joint uid circulation, enhancing
Table 2 With-in group changes.
Group A (MPA+CPT) Group B (CPT)
Variable Assessment Mean SD MD/F(df) p-value ηp
2
/
cohensd
Mean SD MD/F(df) p-value ηp
2
/
cohensd
NPRS Baseline 7.18 0.958 2.18 0.00***
a
0.98 7.41 0.503 1.59 0.00***
a
0.91
3
rd
Week 5.0 1.069 2.77 0.00***
b
5.82 0.733 2.0 0.00***
b
6
th
Week 2.13 0.752 1,062 (1.60, 33.5) 0.00***
c
3.82 0.733 232 (1.59, 33.57) 0.00***
c
ROM shoulder
abduction
Baseline 92.95 19.18 27.9 0.00***
a
0.87 97.95 9.62 20.09 0.00***
a
0.92
3
rd
Week 120.8 13.57 20.5 0.00***
b
118.05 8.59 17.31 0.00***
b
6
th
Week 141.4 4.55 142.3 (1.36, 28.6) 0.00***
c
135.36 6.66 270.1 (1.47, 30.8) 0.00***
c
ROM shoulder external
rotation
Baseline 29.5 8.90 17.1 0.00***
a
0.97 26.91 6.83 14.7 0.00***
a
0.87
3
rd
Week 46.6 8.92 23.3 0.00***
b
41.64 7.24 17.3 0.00***
b
6
th
Week 70.5 6.47 963.2 (1.71, 36.0) 0.00***
c
58.95 9.36 149 (1.24, 26.1) 0.00***
c
ROM shoulder internal
rotation
Baseline 50.82 6.85 15.4 0.00***
a
0.95 47.50 7.20 14.3 0.00***
a
0.87
3
rd
Week 66.36 5.61 15.8 0.00***
b
61.86 4.77 13.4 0.00***
b
6
th
Week 82.18 5.33 422 (1.49, 31.4) 0.00***
c
75.27 6.32 147 (1.10, 23.3) 0.00***
c
DASH Baseline 79.46 6.26 31.9 0.00***
a
0.988 85.68 4.95 27.3 0.00***
a
0.95
3
rd
Week 47.52 5.12 28.6 0.00***
b
58.36 6.40 20.6 0.00***
b
6
th
Week 18.82 3.05 1,687 (1.36, 28.9) 0.00***
c
37.74 9.07 441 (1.15, 24.2) 0.00***
c
HBA1c Baseline 10.24 2.37 0.22 0.00*** 0.26 10.72 2.47 0.04 0.18 0.14
6
th
Week 10.02 2.32 10.68 2.47
Notes:
a
Baseline week vs. week 3
rd
,
b
week 3
rd
vs.6
th
week,
c
baseline week vs.6
th
week.
NPRS, numeric pain rating scale; Visual Analogue Scale; ROM, range of motion; DASH, disabilities of the arm, shoulder and hand; HBA1c, glycated haemoglobin; CPT,
conventional physical therapy; MPA, moderate physical activity.
Differences within groups were analyzed by independent sample t-test.
Signicance level-*p< 0.05, **p< 0.01,***p< 0.001.
Sheikh et al. (2024), PeerJ, DOI 10.7717/peerj.18030 8/14
Table 3 Between group analysis.
Variable Time Period Group A (MPA+CPT) Group B (CPT) MD p-value Cohensd
Mean SD Mean SD
NPRS Baseline 7.18 0.958 7.41 0.503 0.227 0.330
3
rd
Week 5 1.069 5.82 0.733 0.818 0.005** 0.916
6
th
Week 2.13 0.752 3.82 0.733 1.591 0.00*** 0.742
ROM shoulder abduction Baseline 92.95 19.18 97.95 9.62 5.0 0.281
3
rd
Week 120.8 13.57 118.05 8.59 2.8 0.415 11.36
6
th
Week 141.4 4.55 135.36 6.66 6.0 0.00*** 5.7
ROM shoulder external rotation Baseline 29.5 8.90 26.91 6.83 2.59 0.285
3
rd
Week 46.6 8.92 41.64 7.24 5.04 0.046*8.12
6
th
Week 70.5 6.47 58.95 9.36 11.09 0.00*** 8.04
ROM shoulder internal rotation Baseline 50.82 6.85 47.50 7.20 3.31 0.125
3
rd
Week 66.36 5.61 61.86 4.77 4.50 0.006** 5.20
6
th
Week 82.18 5.33 75.27 6.32 6.90 0.00*** 5.81
DASH Baseline 79.46 6.26 85.68 4.95 6.21 0.00***
3
rd
Week 47.52 5.12 58.36 6.40 10.84 0.00***
6
th
Week 18.82 3.05 37.74 9.07 18.91 0.00***
HBA1c Baseline 10.24 2.37 10.72 2.47 0.22 0.51
6
th
Week 10.02 2.32 10.68 2.47 0.04 0.37
Notes:
NPRS, numeric pain rating scale; Visual Analogue Scale; ROM, range of motion; DASH, disabilities of the arm, shoulder and hand; HBA1c, glycated haemoglobin; CPT,
conventional physical therapy; MPA, moderate physical activity.
Differences between groups were analyzed by independent sample t-test.
Signicance Level-*p< 0.05, **p< 0.01,***p< 0.001.
Figure 3 Comparison of mean difference between groups (HBA1c & DASH).
Full-size
DOI: 10.7717/peerj.18030/g-3
Sheikh et al. (2024), PeerJ, DOI 10.7717/peerj.18030 9/14
muscle strength, and offering the nervous system sensory input (Page et al., 2014a,2014b;
Shabbir et al., 2021). The conventional physical therapy for adhesive capsulitis does not
have any role in glycemic control because it only focuses on local management of AC. So,
in current study the results also depicted the same.
In the current study, the addition of the moderate physical activity along with
conventional PT also signicantly improved HBA1c as well as the adhesive capsulitis
symptoms including pain, ROMs and functional disability. Diabetes may affect the bodys
ability to regulate blood sugar levels, contributing to the severity of adhesive capsulitis
(Struyf, Mertens & Navarro-Ledesma, 2022). The accumulation of advanced glycation
end-products (AGEs) in the joint tissues due to hyperglycemia may reduce the collagen
elasticity as well as microcirculation (Chen et al., 2018). Systematic and meta-analysis
supported the current study in which effect of moderate physical activity was seen on
glycemic control in diabetic patients (Asfaw & Dagne, 2022;Zhu et al., 2021).
Brisk walking, aerobic training and resistance training had a signicant impact on level
of HbA1c when conducted for 3 months (Najapour et al., 2017). A systematic review and
meta-analysis reviewed the impact on HbA1c in diabetics and it was found that signicant
differences were seen after at least 12 weeks of intervention (Bekele et al., 2021). In the
current study HbA1c was compared at the beginning and after 6 weeks, which also showed
statistically signicant improvement in HBA1c level.
The current study also suggested that in comparison to conventional physical therapy,
addition of moderate physical activity showed signicantly better results in patients with
diabetic adhesive capsulitis patients. MPA may facilitate the improvement in the
symptoms by controlling the effects of hyperglycemia and overall metabolic health
(Kanaley et al., 2022). Better metabolic control can indirectly contribute to improved
healing and reduced pain. Physical activity also stimulates the release of endorphins, which
are natural pain-relieving chemicals produced by the body and can help reduce pain
perception and promote a sense of well-being (Chen et al., 2022;Geneen et al., 2017).
HbA1c gives an overview of the typical blood sugar levels during the previous three
months (Sherwani et al., 2016). However, the HbA1c measurement was only performed
once after 6 weeks in the study under consideration. Therefore, the shorter research period
may make it more difcult to reliably record substantial increases in HbA1c levels. In the
current study, patients with diabetic adhesive capsulitis had their shoulder joints capsular
pattern evaluated. The study did not, however, provide any data on the patients
nutritional intake. The management of diabetes and general health can be signicantly
inuenced by dietary considerations (Rajput, Ashraff & Siddiqui, 2022). A thorough
understanding of the relationship between dietary components and the desired outcomes
may be constrained if food intake is not considered in the study.
Limitations: although the results are signicant but in current study stage 1 and 2 both
were included. Which may affect timeline of improvement in the symptoms at varied rate.
Moreover, the history of change in the medication was not observed, which may affect the
result signicantly.
Sheikh et al. (2024), PeerJ, DOI 10.7717/peerj.18030 10/14
CONCLUSIONS
Moderate physical activity (MPA) for the management of diabetic adhesive capsulitis was
found to be effective in improving pain and stiffness, range of motion and overall
functionality along with reducing HBA1c level. To enhance effectiveness of physical
therapy management of diabetic AC, it is recommended that incorporation of moderate
physical activity, may improve the clinical effectiveness of physical therapy for such
population. Adding dietary recommendations or controlling diet and change in the
medication in place together with considering severity level of adhesive capsulitis may
provide more valid result on AC symptoms associated with HbA1c levels.
ACKNOWLEDGEMENTS
Thanks to the participants of this study for sharing their personal experiences with pain.
ADDITIONAL INFORMATION AND DECLARATIONS
Funding
The authors received no funding for this work.
Competing Interests
The authors declare that they have no competing interests.
Author Contributions
.Raheela Kanwal Sheikh conceived and designed the experiments, analyzed the data,
prepared gures and/or tables, and approved the nal draft.
.Amna Toseef conceived and designed the experiments, performed the experiments,
authored or reviewed drafts of the article, and approved the nal draft.
.Aadil Omer conceived and designed the experiments, prepared gures and/or tables, and
approved the nal draft.
.Anam Aftab analyzed the data, authored or reviewed drafts of the article, and approved
the nal draft.
.Muhammad Manan Haider Khan analyzed the data, prepared gures and/or tables, and
approved the nal draft.
.Saeed Bin Ayaz performed the experiments, authored or reviewed drafts of the article,
and approved the nal draft.
.Omar Althomli conceived and designed the experiments, authored or reviewed drafts of
the article, and approved the nal draft.
.Aisha Razzaq analyzed the data, authored or reviewed drafts of the article, and approved
the nal draft.
.Samra Khokhar performed the experiments, authored or reviewed drafts of the article,
and approved the nal draft.
.Nazia Jabbar performed the experiments, authored or reviewed drafts of the article, and
approved the nal draft.
Sheikh et al. (2024), PeerJ, DOI 10.7717/peerj.18030 11/14
.Waqar Ahmed Awan conceived and designed the experiments, performed the
experiments, analyzed the data, prepared gures and/or tables, authored or reviewed
drafts of the article, and approved the nal draft.
Human Ethics
The following information was supplied relating to ethical approvals (i.e., approving body
and any reference numbers):
The study was approved by the Research Ethical Committee of the Faculty of
Rehabilitation & Allied Health Sciences, Riphah International University (RIPHAH/
RCRS/REC/Letter-01240).
It was carried out after obtaining approval from the Ethics Review Committee of Sheikh
Khalifa Bin Zayed al Nahyan (SKBZ) Combined Military Hospital (CMH), Muzaffarabad,
Pakistan (Ref. No. Ethical Committee/DME-826).
Data Availability
The following information was supplied regarding data availability:
The raw data is available in the Supplemental File.
Clinical Trial Registration
The following information was supplied regarding Clinical Trial registration:
NCT04925128.
Supplemental Information
Supplemental information for this article can be found online at http://dx.doi.org/10.7717/
peerj.18030#supplemental-information.
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