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Effects of deep and superficial heating in the management of frozen shoulder

Authors:

Abstract

To determine whether the addition of deep or superficial heating to stretching produces better clinical outcomes than stretching alone in the management of frozen shoulder. A single-blinded, randomized controlled study. Thirty subjects suffering from the stiffness phase of frozen shoulder. Subjects were randomly allocated to receive: (i) deep heating plus stretching; (ii) superficial heating plus stretching; or (iii) stretching alone. Both heating groups received the respective treatments 3 times per week for 4 weeks. All groups received a standard set of shoulder stretching exercises. The American Shoulder and Elbow Surgeons assessment form was recorded at the baseline, sessions 6 and 12, and at the 4-week follow-up session. A significant improvement was seen in all groups in all outcome measures except for that of shoulder flexion range. The improvement in the shoulder score index and in the range of motion was significantly better in the deep heating group than in the superficial heating group. The addition of deep heating to stretching exercises produced a greater improvement in pain relief, and resulted in better performance in the activities of daily living and in range of motion than did superficial heating.
ORIGINAL REPORT
J Rehabil Med 2008; 40: 145–150
J Rehabil Med 40
© 2007 The Authors. doi: 10.2340/16501977-0146
Journal Compilation © 2007 Foundation of Rehabilitation Information. ISSN 1650-1977
Objectives: To determine whether the addition of deep or
supercial heating to stretching produces better clinical out-
comes than stretching alone in the management of frozen
shoulder.
Design: A single-blinded, randomized controlled study.
Subjects: Thirty subjects suffering from the stiffness phase
of frozen shoulder.
Methods: Subjects were randomly allocated to receive: (i)
deep heating plus stretching; (ii) supercial heating plus
stretching; or (iii) stretching alone. Both heating groups
received the respective treatments 3 times per week for 4
weeks. All groups received a standard set of shoulder stretch-
ing exercises. The American Shoulder and Elbow Surgeons
assessment form was recorded at the baseline, sessions 6 and
12, and at the 4-week follow-up session.
Results: A signicant improvement was seen in all groups
in all outcome measures except for that of shoulder exion
range. The improvement in the shoulder score index and in
the range of motion was signicantly better in the deep heat-
ing group than in the supercial heating group.
Conclusion: The addition of deep heating to stretching ex-
ercises produced a greater improvement in pain relief, and
resulted in better performance in the activities of daily living
and in range of motion than did supercial heating.
Key words: shortwave, hot pack, stretching, frozen shoulder,
range of motion.
J Rehabil Med 2008; 40: 145–150
Correspondence address: Gladys Cheing, Department of Re-
habilitation Sciences, The Hong Kong Polytechnic University,
Hung Hom, Kowloon, Hong Kong. E-mail: gladys.cheing@
inet.polyu.edu.hk
Submitted April 27, 2007; accepted October 4, 2007
INTRODUCTION
Frozen shoulder or adhesive capsulitis is a common insidious
condition that is associated with pain and with a restricted range
of motion (ROM) around the shoulder joint. Its prevalence in
the general population has been estimated at between 3% and
5%. It can arise from idiopathic or post-traumatic causes. Fro-
zen shoulder usually involves 3 phases: (i) the painful phase,
which usually lasts for 2–9 months and leads to progressive
stiffness; (ii) the stiffness phase, which usually lasts for 3–9
months, during which the pain gradually subsides but marked
stiffness develops in all planes of the shoulder joint; (iii) the
thawing phase, which usually persists for 12–42 months, dur-
ing which there is a slow gain in motion and comfort (1, 2).
Stretching exercises are a key component of exercise therapy
for musculoskeletal disorders. In addition, heat modalities are
frequently used as an adjuvant treatment to exercise therapy
in order to help the patient regain ROM and restore function
to the affected shoulder.
The rationale for achieving therapeutic goals through heat-
ing is to alter the viscoelastic properties of connective tissues

occurs with a rise in the temperature of soft tissues to between
40°C and 45°C, compared with that recorded at room tempera-


agents are ultrasound (9) or shortwave diathermy (SWD) (10).
SWD can heat up a larger treatment area and volume of tissue
than is possible with ultrasound, while ultrasound can produce
some mechanical effects in addition to the heating effect. Hot
pack (HP) is the most traditional method of providing super-

could produce a greater increase in tissue extensibility than


gain in tissue extensibility than did HP. Peres et al. (11) showed
that the combination of pulsed SWD and stretching exercises
     
with what could be achieved by stretching alone.
      
previous study found that deep heat applied before stretching

of hamstring muscles (12). However, the study involved only
a 5-day treatment period, which may have been too short to

Gursel et al. (13) found that true ultrasound brought no further

physical therapy interventions in the management of soft tis-
sue disorders of the shoulder. However, they did not control
the other physical therapy interventions that were delivered
to their patients.

and shoulder stretching exercises in normal subjects concluded

prolonged stretching produced more long-lasting changes in


May S. F. Leung, MSc
1,2
and Gladys L. Y. Cheing, PhD
2
From the
1
Physiotherapy Department, Our Lady of Maryknoll Hospital and
2
Department of Rehabilitation Sciences,
The Hong Kong Polytechnic University, Hong Kong
146
M. S. F. Leung and G. L. Y. Cheing
the extensibility of soft tissue than did stretching alone (14).

to muscle relaxation, thus reducing the resistance to stretches
within and around the muscle, and consequently increasing the
ROM of the shoulder (14). However, some studies found that
stretching exercises alone could increase the extensibility of
rats tails (15) and the ROM of human shoulders (1, 16).

the effects of heat treatment in increasing the extensibility
of soft tissues. There is a lack of evidence to support the use
of SWD or HP in combination with stretching in managing
patients with frozen shoulder. Therefore, the aim of this study
was to determine whether the addition of deep heating (using

would produce better clinical outcomes than stretching alone
in the management of frozen shoulder.

Subjects
Thirty subjects (9 men and 21 women, age range 37–79 years, mean
59.87, standard deviation (SD) 12.45) with idiopathic frozen shoul-
der in the stiffness phase participated in this study. The diagnosis of
frozen shoulder was made by an orthopaedic surgeon. Subjects were
included if they had experienced shoulder pain and limited shoulder
movement for at least 8 weeks. Subjects were excluded if they had a
 
the shoulder, intrinsic shoulder pathology, were taking analgesic or
   
hot and cold, were pregnant, or had a cardiac pacemaker. Demographic
data for the subjects are shown in Table I.
Treatment procedures
A single-blinded, randomized controlled study was conducted. The rater
was blinded to the group allocation. The study was approved by a local
ethics committee. After informed consent had been obtained, the subjects
were randomly allocated into one of the following 3 groups: (i) SWD
plus stretching (n = 10); (ii) HP plus stretching (n = 10); or (iii) stretching
exercises alone (n = 10). Randomization was performed using an on-line
randomization plane (http://www.randomization.com). The subjects in
the SWD and HP groups received the respective treatments 3 times per

groups received a standard set of shoulder stretching exercises.

Netherlands) with an operating frequency of 27.12 MHz was used
to deliver the deep heating treatment. The subjects were positioned
comfortably sitting on a wooden chair with their back and affected
arm supported. A pair of disc electrodes was placed on the anterior-
posterior aspects of the affected glenohumeral joint, separated by
a hands-breadth from the surface of the body. The intensity of the
current was adjusted according to the subject’s subjective feeling of
comfortable warmth. If the level of perceived heating changed dur-
ing the application, the machines output was adjusted to maintain
the sensation of comfortable warmth throughout the treatment. For
the HP group, an electrical hot pack sized 35.5 × 68.5 cm was used

subjects were informed that the only purpose of the heating was to
produce a feeling of comfortable warmth. If they felt that the heat
was excessive, the temperature of the electrical HP was adjusted
immediately to ensure that the heat remained at a comfortably warm
level only throughout the treatment.
Immediately after the heat treatment, subjects were asked to perform


the-back and cross-body adduction. They were asked to repeat the

rest between each stretch. The subjects were asked to perform the
stretching exercises at home every day. Assessments were made prior
to treatment at the baseline, at sessions 6 and 12, and at the 4-week
follow-up session (Fig. 1). A therapist checked for compliance with
the exercise regime.
Outcome measures

was used to measure the treatment outcomes in the present study.


consists of 2 parts: a patient self-evaluation section and a physician
assessment section.
The patient self-evaluation section is designed to measure pain
and functional limitation of the shoulder. The pain score is calculated
from the patient’s response to a single question about pain, using a
10-cm horizontal visual analogue scale (VAS) line. The function score
is calculated from the sum of the 10 questions addressing the activi-
 

Table I. Demographic data for the subjects in the 3 groups
SWD + stretching
(n = 10)
HP + stretching
(n = 10)
Stretching alone
(n = 10)
Age (years);
mean (SD)
59.80 (12.87) 62.50 (12.13) 57.30 (13.10)
Sex F/M 5/5 8/2 8/2

p < 0.05)
SD: standard deviation; F: female; M: male; SWD: shortwave
diathermy; HP: hot pack.
Fig. 1. Study design. ROM: range of motion; SWD: shortwave diathermy;
HP: hot pack.
SWD group
SWD + daily stretching
exercises (n = 10)
HP group
HP + daily stretching
exercises (n = 10)
Stretching group
Daily stretching
exercises (n = 10)
12 treatment sessions
Re-assessment in session 6 and session 12 before intervention
Pain level
Activities of daily living
Shoulder ROM
Re-assessment in the 4-week follow-up
session
Pain level
Activities of daily living
Shoulder ROM
Baseline evaluation (pre-treatment)
Pain level
Activities of daily living
Shoulder ROM
30 subjects
J Rehabil Med 40
147
Shortwave diathermy for frozen shoulder

Both the pain score and function score are weighted equally (50 points
each) and combined for a total score of 100 points, with a higher score

using the following formula (18):
(10 – VAS pain score) × 5 + (5/3 ×
The physician assessment part involved measuring the joint’s ROM.
The shoulder forward elevation, external rotation with the arm by the
side, external rotation with the arm in 9abduction was measured
using a standard goniometer. The hand-behind-back position, the dis-
tance between 2 thumb tips (with both shoulders performing the hand-
behind-the-back), was measured by using a tape measure. Cross-body
adduction was measured as the distance between the antecubital fossa
and the opposite shoulder (2). The subjects were positioned standing
for all of the ROM tests. All of the assessments were performed by the
same physiotherapist, who was blinded to each subject and interven-
tion order throughout.
Data analysis
Statistical analyses were performed using the software package SPSS
for Windows, version 10. A repeated measures analysis of variance was
performed to examine the change in each outcome measure among the
treatment groups and across treatment sessions. The analysis of vari-
ance was followed by Tukey’s post hoc multiple comparisons. If the


(alpha) was set at 0.05 and the Bonferroni Correction was used to adjust


None of the participants in any of the treatment groups dropped
out throughout the study period. The exercise compliance of
-
ence (p > 0.05) was found among all of the outcome measures
at the baseline. The changes in the shoulder score index and
shoulder ROM in different directions over time are presented
in Tables II, III and IV.
Shoulder score index
By session 12, the shoulder score index in the SWD group had
increased by 63.4%, compared with 45.2% in the HP group and
38.4% in the stretching alone group (Table II). The improve-
ment was well maintained or a further improvement was noted
at the 4-week follow-up session. The overall within-group dif-

(p < 0.001). A post hoc test showed that the differences came
from the comparisons between the data obtained in session 6
or session 12 to the baseline. The between-group difference
p = 0.046). The post hoc test showed that the
SWD group improved more than the stretching alone group
did (p
the HP group and stretching alone group (p > 0.05).
Flexion range

analyses were conducted separately for the groups” and the

range had increased by 13.9% in the SWD group and 3.5% in
the HP group (Table III). By contrast, the range in the stretch-
ing alone group decreased by 4.2%. By the 4-week follow-up
session, the effect was maintained or a slight improvement was
seen in the SWD and HP groups. The within-group difference

Table III. Average group mean (SD) of the shoulder exion range of motion (ROM) and shoulder cross-body adduction across the study period
SWD + stretching
(n = 10)
HP + stretching
(n = 10)
Stretching alone
(n = 10) p-value (between-group)
Shoulder exion range (degree)
Baseline 129.0 (18.4) 117.9 (20.3) 137.9 (16.1) 0.068
Session 6 146.9 (13.5) 120.2 (21.0) 134.7 (16.6) 0.007
Session 12 146.9 (14.2) 122.0 (20.9) 132.1 (25.7) 0.049
4-week follow-up 148.2 (14.4) 124.7 (20.3) 137.6 (20.8) 0.031
p-value (within-group)
0.002 0.538 0.247
Shoulder cross-body adduction (cm)
Baseline 29.8 (3.4) 30.3 (3.9) 29.3 (3.7) 0.830
Session 6 25.9 (2.9) 29.0 (3.7) 29.4 (3.7) 0.079
Session 12 25.0 (2.2) 29.0 (3.3) 29.1 (4.4) 0.079
4-week follow-up 24.2 (2.0) 29.1 (3.5) 27.8 (5.1) 0.079
p-value (within-group)
0.000 0.000 0.000

groups. Type I errors are corrected by the Bonferroni method.
SWD: shortwave diathermy; HP: hot pack; SD: standard deviation.
Table II. Average group mean (SD) of the shoulder score index
SWD +
stretching
(n = 10)
HP +
stretching
(n = 10)
Stretching
alone
(n = 10)
p-value
(between-
group)
Shoulder Score Index
Baseline 41.5 (12.1) 38.9 (11.8) 33.3 (12.51)
Session 6 56.3 (15.0) 54.2 (15.4) 45.3 (11.2) 0.046
Session 12 67.8 (15.1) 56.5 (14.1) 46.1 (12.7)
4-week follow-up 71.3 (19.3) 57.8 (16.3) 53.8 (16.5)
p-value
(within-group)
< 0.001

Repeated measures ANOVA showed an overall between-group
difference as 0.046, and within-group difference as < 0.001.
SWD: shortwave diathermy; HP: hot pack; SD: standard deviation.
J Rehabil Med 40
148
M. S. F. Leung and G. L. Y. Cheing
(p = 0.002) and a post hoc test showed that the range achieved

by the HP group (p = 0.025). A between-group difference was
found in session 6 (p = 0.007), session 12 (p = 0.049), and in
the follow-up session (p = 0.031). However, after an adjustment
was made using the Bonferroni Correction (adjusted p-value

in session 6.
Shoulder cross-body adduction
By session 12, the cross-body adduction range of the SWD
group demonstrated a 16.1% cumulative improvement (Table

the HP group, and 0.7% for the stretching alone group. The
treatment effects were more or less maintained in the SWD and
HP groups in the 4-week follow-up session. The within-group
p < 0.001). A post
hoc test showed that the difference came from the data obtained
in session 6, session 12, and the 4-week follow-up session com-

difference was found among the 3 treatment groups.
External rotation with arm by side
By session 12, the SWD group demonstrated a 14.5% gain
in shoulder external rotation, compared with 21.1% in the
HP group and 22.6% in the stretching groups (Table IV). The
overall within-group difference across the study period was
p = 0.008). A post hoc test showed that the differ-
ence came from the comparison made between the 4-week
      
group difference in the external rotation range (p = 0.009). The
post hoc test showed that the SWD group achieved a greater
external rotation range than did the HP group (p = 0.007)
External rotation with arm in 90° abduction
In all 3 treatment groups, the external rotation range of the
shoulder tended to increase during the study period (within-
group p = 0.011) (Table IV). By the 4-week follow-up session,
the SWD group demonstrated a 17.4% cumulative increase,
compared with 14.2% for the HP group, and 15.3% for the
stretching alone group. A post hoc test showed that the differ-
ence came from comparisons made between session 12 and
the baseline, and from the 4-week follow-up session and the
baseline. The between-group difference was statistically sig-
p = 0.021). The post hoc

greater than in the HP group (p = 0.016).
Hand-behind-back
The hand-behind-back distance decreased progressively over
time (Table IV). By the 4-week follow-up session, there was a
cumulative decrease in the group mean of 51.2% in the SWD
group, 26.5% in the HP group, and 18.8% in the stretching
group. The within-group difference across the study period
  p < 0.001). A post hoc test showed that the
difference came from the comparison made between session
6, session 12 and the 4-week follow-up to that of the baseline.

behind-back range (p = 0.004). The post hoc test showed that
the gain in the hand-behind-back range achieved by the SWD

group (p = 0.003).
Table IV. Average group mean (SD) of the shoulder external rotation (arm by the side and arm in 90° abduction) and hand-behind-back range of
motion (ROM) across the study period
SWD + stretching
(n = 10)
HP + stretching
(n = 10)
Stretching alone
(n = 10)
p-value (between-
group)
Shoulder external rotation range (arm by side) (degree)
Baseline 50.4 (14.1) 28.2 (23.4) 39.5 (21.7)
Session 6 59.3 (19.8) 27.6 (18.7) 39.5 (20.6) 0.009
Session 12 60.9 (14.5) 32.6 (21.1) 43.3 (22.6)
4-week follow-up 62.1 (11.5) 32.6 (21.7) 41.1 (23.2)
p-value (within-group)
0.008
Shoulder external rotation range (arm in 90˚ abduction) (degree)
Baseline 51.6 (18.2) 26.7 (26.0) 42.5 (18.7)
Session 6 57.8 (22.7) 27.0 (26.5) 43.4 (20.8) 0.021
Session 12 59.6 (19.3) 30.1 (26.8) 45.7 (23.3)
4-week follow-up 60.6 (11.0) 30.5 (24.4) 49.0 (27.2)
p-value (within-group)
0.011
Hand-behind-back (cm)
Baseline 12.3 (4.8) 24.9 (11.5) 16.0 (9.6)
Session 6 7.2 (6.1) 22.2 (11.5) 14.7 (8.1) 0.004
Session 12 7.6 (5.7) 18.5 (8.9) 14.7 (8.0)
4-week follow-up 6.0 (7.3) 18.3 (7.5) 13.0 (6.7)
p-value (within-group)
< 0.001

difference for each outcome.
SWD: shortwave diathermy; HP: hot pack; SD: standard deviation.
J Rehabil Med 40
149
Shortwave diathermy for frozen shoulder
DISCUSSION
The popularity of the deep heating agent SWD has declined
in recent years. This may be partly due to a shortage of qual-
ity controlled studies (19–21), or because the SWD machine
may cause radio-interference with other medical devices. The



       -
cantly greater increase in the shoulder score index than did

gain in the ROM of most shoulder movements than did HP.

heat is just as effective as deep heat therapy in the management
of joint disorders such as frozen shoulder.
Pain relief

The improvement in the shoulder score index observed in the
present study could have resulted from a reduction in pain,


to patients with wrist pain stemming from various causes (22).
Previous studies have demonstrated that both deep and super-
   


within the group across the study period. Interestingly, our

the shoulder score index than the HP group. The deep heating
effect produced by SWD increases the temperature of localized
tissue, with the result that vascular dilation is promoted and
the pain threshold elevated. Such vascular improvement also

and oxygen supply, and by removing metabolites and waste
products. This leads to a decrease in pain and swelling.
Extensibility of soft tissues
When temperature is increased, the stress-relaxation property


-
ies have reported that 15 minutes of SWD treatment increased
the temperature of soft tissue (3 cm deep) by 4.58
± 0.87°C
(28, 29). By contrast, an HP treatment elevated muscle
temperature by only C (30). This implies that SWD could
produce deeper penetration than did HP, thus increasing the
extensibility of tissue. Studies have found that a deep heating
agent (shortwave and ultrasound) in combination with stretch-
 
(9, 11). Robertson et al. (10) found that SWD could increase


gain in shoulder range than did HP.
        -
ence was found in cross-body adduction among the groups.
The postero-inferior part of the shoulder joint is covered by
     
penetrate deep into the tight structures of the muscle, as the
layer of muscle is thick. As a result, the rise in temperature may
not be enough to produce therapeutic effects. Therefore, in our

between-group differences.
According to previous studies, the gain in therapeutic tem-
perature after SWD can be maintained for around 7 min (28,
29). The subjects in our study spent at least 8 min completing

adduction was done, it may not have been possible to maintain
-
perature level. This could have been another reason why the

between the groups.
Previous researchers studied the effect of heat on tissue
extensibility with different treatment frequencies. The treat-
ment frequencies that were tried varied from one treatment per
day to 2 treatments per week (9–14, 22, 32). Further studies

frequency of shortwaves on increasing the extensibility of
tissue.
In the present study, all subject groups received training of a
standard set of shoulder stretching exercise by an experienced
   
-
pist checked for compliance with the exercise regime for all
subjects. As we aimed to determine whether the application of
various heat treatments enhanced the effectiveness of stretching
exercise, the group receiving SWD or HP had more contact
with the therapist compared with the exercise-alone group,
which may affect the treatment outcome. This is a limitation

to take this factor into consideration.

heating (using SWD) to stretching exercises is more effective

-
proving shoulder pain and function. Also, the addition of deep


side, external rotation with the arm in abduction and in the


heating to stretching will not produce a further enhancement
of the shoulder score index or a gain in shoulder ROM for
patients with frozen shoulder.

1. Goldberg BA, Scarlat MM, Harryman DT. Management of the stiff
shoulder. J Orthop Sci 1999; 4: 462–471.

In: Rockwood CA, Matsen FA III, editors. The shoulder. 2nd edn.
Philadelphia: WB Saunders Co.; 2004, p. 1121–1167.


      
J Rehabil Med 40
150
M. S. F. Leung and G. L. Y. Cheing

212–314.
       
        
Thermal agent in rehabilitation. 3rd edn. Philadelphia: FA Davis
Co.; 1996, p. 107–135.
6. Hardy M, Woodall W. Therapeutic effects of heat, cold, and stretch
on connective tissue. J Hand Ther 1998; 11: 148–156.
       
therapeutic temperatures on tendon extensibility. Arch Phys Med
Rehab 1970; 51: 481–487.
8. Mason P, Riby BJ. Thermal transitions in collagen. Biochim Bio
-
phys Acta 1963; 66: 448–450.

-
-

10. Robertson VJ, Ward AR, Jung P. The effect of heat on tissue

Phys Med Rehab 2005; 86: 819–825.

diathermy and prolonged long-duration stretching increase dorsi-
        
diathermy. J Athl Train 2002; 37: 43–51.
      

bility. J Athl Train 2002; 37: 37–43.

-
ing ultrasound in the management of soft tissue disorders of the
shoulder: a randomized placebo-controlled trial. Phys Ther 2004;
84: 336–344.

-

stretch. J Orthop Sports Phys Ther 1992; 16: 200–207.
15. Taylar BF, Waring CA, Brashear TA. The effect of therapeutic
application of heat or cold followed by static stretch on hamstring
muscle length. J Orthop Sports Phys Ther 1995; 21: 283–286.


capsulitis of the shoulder joint: a multiple-subject case report. Phys
Ther 2000; 80: 1204–1213.


self-report section: reliability, validity, and responsiveness. J


Gristina AG, et al. A standardized method for the assessment of

19. Green S, Buchbinder R, Glazier R, Forbes. Systemic review of
randomized controlled trials of interventions for painful shoulder:

316: 354–361.
20. Green S, Buchbinder R, Hetrick S. Physiotherapy interventions

21. Van der Heijden GJMG, Van der Windt DAWM, De Winter AF.
Physiotherapy for patients with soft tissue shoulder disorders: a
systemic review of randomized clinical trials. BMJ 1997; 315:
25–31.

therapy in effective for treating wrist pain. Arch Phys Med Rehab
2004; 85: 1409–1416.
         
        
1–12.

-

3rd edn. Philadelphia: F. A. Davis Co.; 1996, p. 213–250.


Belfus, Inc.; 2002, p. 7–18.
      



of rat tail tendon. J Gen Physiol 1959; 43: 265–283.

in human muscle during and after pulsed short-wave diathermy. J
Orthop Sports Phys Ther 1999; 29: 13–22.

leg from pulsed short-wave diathermy and ultrasound treatments.
J Athl Train 2000; 35: 50–56.
30. Minton J. A comparison of thermotherapy and cryotherapy in

3: 233–237.
31. Snell RS. Clinical anatomy for medical students. 6th edn. Phila
-

32. Draper DO, Anderson C, Schulthies SS, Richard MD. Immediate
-
sound heat and stretch routine. J Athl Train 1998; 33: 141–144.
J Rehabil Med 40
... One of the physiotherapy treatments used to relieve inflammation and promote healing is the application of heat treatment either in the form of hot packs or deep heat diathermy. [1][2][3] Deep heat diathermy can be achieved using therapeutic ultrasound, shockwaves, or microwaves. 4,5 Some studies have indicated ultrasound diathermy to be effective 4,6 while others show no demonstrable benefit. ...
... 7,8 Ultrasound diathermy can result in thermal injury to the skin, subcutaneous tissue and muscles. [1][2][3] An uncommon complication of diathermy is injury to the cortical bone, causing osteonecrosis. 9 During the past 3 years, we encountered 10 patients who had received diathermy treatment and had bone lesions visible on subsequent magnetic resonance imaging (MRI) examinations performed for pain. ...
... Corticosteroid injections, patient education, therapeutic ultrasound, heat, electroacupuncture, stretching, and joint mobilization have been described for the treatment of AC [7][8][9][10][11][12][13][14] . Interventions used to manage AC are usually tailored to the phase of the condition. ...
... In terms of physical therapy research on AC, treatment targets remain unclear, and very few studies have clearly identified treatment targets 9,10,13,43) . In this study, the finding that the cause of resting and night pain in the freezing phase of AC may be related to the abnormal condition of the SST and BT diagnosed by ultrasonography appears to be important. ...
Article
[Purpose] This study aimed to clarify the changes in the tissue thickness of the abnormal supraspinatus and biceps long-head tendons among elderly patients to select the treatment targets and evaluate the treatment effects in the freezing phase of adhesive capsulitis. [Participants and Methods] Thirty-two elderly patients with unilateral shoulder pain underwent ultrasound of the supraspinatus and biceps long-head tendons, pain evaluation, and orthopedic testing. Both the supraspinatus and biceps long-head tendons were classified as normal, abnormal, and other groups. Participants with negative orthopedic test results were assigned the "normal group". Participants with positive orthopedic test results and resting and night pain were assigned the "abnormal group". Differences in tissue thickness were calculated from the differences between the symptomatic and non-symptomatic sides. [Results] The thickness of the supraspinatus and biceps long-head tendons was significantly higher in the abnormal than in the normal group. [Conclusion] This study clarified the changes in tissue thickness of the abnormal supraspinatus and biceps long-head tendons among elderly patients to select the treatment targets and assess the treatment effects in the freezing phase of adhesive capsulitis. The study results suggest the usefulness of ultrasound for selecting the treatment targets for analgesia and assessing the treatment efficacy in cases of adhesive-capsulitis freezing phase.
... The benefit of heating on soft tissues has been reported; indeed it could alter their viscoelastic properties and drop their tensile stress [22] [23] [24]. In case of AC of the shoulder heating may improve pain relief and shoulder ROM and function [25] [26] [27]. Its use is common especially during the stiffness predominant stage with twenty minutes application [26] [28] [29]. ...
Article
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Adhesive capsulitis (AC) of the shoulder is a painful condition in which ac-tive and passive range of motion (ROM) of the shoulder becomes restricted.Severe pain and ROM restriction may last approximately 1 to 3 years withincomplete resolution leading to an impairment of daily living and profes-sional activities and quality of life with a consequent social and economicburden. Since health care services have been shifted to the fight against thedeadly coronavirus disease 2019 (COVID-19), a minimum of necessary careshould be allocated to manage painful and impairing musculoskeletal condi-tions such as AC of the shoulder. Home exercises (HEs) are accepted as a keyelement in the conservative treatment of AC of the shoulder. The aim of thispoint of view is to propose a concise and clinically relevant HE recommenda-tion for patients with AC of the shoulder during the time of covid-19 restric-tions. During the pain predominant stage of AC, pendulum exercises andpassive and active-assisted ROM mobilizations are mainly proposed. Heatapplication and shoulder muscle strengthening should be added during thestiffness predominant stage. Optimally, three daily sessions with 30 min du-ration each are proposed for three to six months. HEs remain a practical so-lution to help AC patients relieve pain and gain shoulder ROM during pan-demics restrictions.
... These are all the more important as the frequency is high [33]. In addition, as some studies have shown, diathermy uses specific forms of energy, such as microwave diathermy, to raise the temperature of the deepest soft tissues [34][35][36]. ...
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Ultrasound (US) therapy in sports and medical pathologies is widely used by many physiotherapists and sports medicine clinicians; however, data regarding their potential side effects remain rare. We report a case of a 21-year-old woman with iliotibial band (ITB) syndrome treated with a physiotherapy session combined with US therapy. She had twenty 7 min US sessions on the knee, for 3 months (US at 1 Mhz with an intensity between 1 and 2 W/cm2). Due to persistence of the ITB syndrome’s symptomatology after the 3 months of physiotherapy sessions, an MRI (magnetic resonance imaging) was carried out and revealed osteonecrosis-like bone abnormalities on the external femoral condyle, the external tibial plateau, and the proximal fibula. In view of these lesions, the ultrasonic therapy was stopped, and a repeat MRI demonstrated the progressive disappearance of these imaging abnormalities one year after the last US (ultrasound) treatment. In light of this case, we propose here a short review of reported osseous “osteonecrosis” abnormalities associated with US therapies.
... Dogru et al. showed that stretching with US is more effective than stretching alone for limited ROM [1]. In this regard, Leung et al. maintained that the combination of deep heating and stretching exercises significantly improves shoulder ROM [10]. These findings also support that the increase in ROM observed in our study was derived from the use of US in combination with exercise therapy. ...
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Introduction: Ultrasound (US) has been used to improve range of motion; however, there is no consensus on its therapeutic effects. This study aimed to explore the therapeutic effects of US in combination with exercise and mobilization on range of motion based on a single-case design. Methods: The patient was a 40-year-old man who had a fracture of the greater tuberosity of the right humerus and presented with limited shoulder range of motion in flexion postoperatively. In addition to standard treatment (exercise and mobilization), US was performed as an additional intervention. The therapeutic effect of US was examined using Tau-U. Results: The range of motion of the shoulder flexion significantly increased in the period when standard treatment and US were combined compared to that in the period when only standard treatment was administered (p < 0.001). The effect size was high (tau-U = 0.758). Conclusion: The use of US improved shoulder range of motion during flexion. The Tau-U analysis can be useful to indicate the effect of intervention in a single-case design.
... The control group's reason for pain reduction could be the infrared's superficial heating effect, which assisted in vascular dilation and pain threshold alteration through a local tissue heating effect. This dilation of blood vessels helped supply oxygen and nutrients, removed waste products, and metabolites and promoted the inflammatory process (Leung & Cheing, 2008). Exercise within the pain-free ROM aids in the movement of synovial fluid within the joints, and mechanoreceptor stimulation that aids in muscle relation reflex and inflammatory and pain reduction (Leon Chaitow, 2013). ...
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Background: The latest osteopathic manual therapy method widely used is the Spencer Muscle Energy Technique (SMET) adopted in western clinical practices to treat various shoulder ailments. Objective: The study compares conventional treatment procedures' effects and the SEMT for a frozen shoulder. Methodology: A randomized, single-blind observational experiment was carried out from February to May 2019. The study included idiopathic frozen shoulder patients of either sex aged 30 to 70 years, phases 1 and 2, or a stiff joint of an agonizing shoulder for a minimum of 3 months. Among the 60 patients examined, 40 were involved: 20 (50 %) in both groups. The mean age in the control and experimental groups was 49.75±8.52 and 49.10±9.01, respectively, the dissimilarities of the groups in terms of disability and pain were not substantial (P > 0.05) at standard, but there was a considerable variance in the assessments of halfway and post-intercession (p < 0.05), and similarly was the issue of shoulder Range of Motion (ROM). They comprised 30 (65 %) females and 10 (35 %) males randomly divided into two groups. The first group received SMET, and the second group received the conventional treatment procedure. Numeric Pain Rating Scale (NPRS) was utilized to evaluate Shoulder pain, comprising 11 objects of no pain with a value of 0 and objects of most pain with a value of 10. Standard physical goniometer used to record Shoulder ROM as a consistent device for the analysis of degrees' movement. Results: NPRS score values were t = 26.1, p-value of 0.000. The Wilcoxon Sign Rank test was adopted in the control group to discover the significance of the pain intensity treatment. The NPRS score values were W =-4.06, p-value of 0.000. A double-sample t-test was adopted to discover the treatment significance with the experimental and control group. The values for the Disability Index (SPADI) score in the experimental group were t=17.31p-value of 0.000. The values for the SPADI score in the control group were t=18.55 p-value 0.000. Conclusions: SMET was more effective in shoulder pain reduction, in which conventional treatment showed more effectiveness in enhancing the shoulder ROM. It can be concluded that SMET can be used or incorporated as an alternative treatment method or combined with other treatment procedures for pain reduction.
... PT plays vital role in pain management and restoration of shoulder movement to normal. 16 Electrotherapeutic agents such as hot packs, 17 transcutaneous electrical nerve stimulation (TENS), 18 cryotherapy, 19 and ultrasound 20 can be engaged for pain management regimen. Physical therapy comprises of manual therapies such as gentle stretching and soft tissue mobilization, therapeutic exercises such as mobilization and proprioceptive neuromuscular facilitation (PNF) techniques. ...
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Background: Adhesive capsulitis is a painful condition comprises of reduced glenohumeral joint movement and the scapular neuromuscular facilitation techniques is considered effective, non-invasive approach for treating this condition. Objective: To compare the effects of neuromuscular facilitation techniques on clinical outcomes in patients with adhesive capsulitis. Methods: This trial was registered in ClinicaTrials.gov (ref: NCT05151783) and approval was taken (IRB No. 818-II). This single-blinded randomized controlled trial was conducted on patients (n=96) having adhesive capsulitis in six months. Non-probability purposive sampling technique was used for randomization via sealed envelope method. Conventional group received routine physiotherapy including ultrasound, hot packs, shoulder range of motion, stretching exercises, and joint mobilization five times per week for four weeks with 40 minutes’ duration of each session. Glenohumeral joint distraction, caudal, dorsal, and ventral glides were given at a rate of 2-3/second oscillations for 1-2 minutes to patients. Visual analogue scale, functional activity was calculated at baseline, 2nd and 4th week. The descriptive statistics (continuous variables) values for each variable in form of means and standard deviations were calculated and their p-values were also calculated using an independent sample t-test. For the qualitative data (categorical variables), frequency and percentage were estimated. Frequencies and percentages of different variables like gender had also been calculated. Repeated measure analysis of variance (ANOVA) was calculated to calculate within-group differences in the mean of each variable between the assessment points. Results: Test of within subject effects showed significant difference for all variables at follow-up and difference between groups also showed significant difference at different follow-ups (p-value≤0.001). Both groups showed statistically significant results (p≤0.001), but scores were higher in experimental group. Conclusion: Scapular proprioceptive neuromuscular facilitation technique along with routine physical therapy are more effective as compared to routine physical therapy alone in patients with adhesive capsulitis.
... (21) The Leung et al. propounded that a superficial heating can lead to muscle relaxation, thus easing the restriction to stretches within and around the muscle, and consequently enhancing the ROM of the glenohumeral joint. (22) In a study published by Ansari et al. evaluated the effects of ultrasound therapy combined with end range mobilization to cryotherapy and stretching for 6 days a week for 4 weeks on pain in 40 individuals with primary adhesive capsulitis. And thereforth the ultrasound when combined with end range mobilization was more effective than cryotherapy and stretching (23) whereas pande p et al. stated furthmore that PNF and mobilization combined with ultrasound is a better treatment for frozen shoulder patients, which is consistent with our findings. ...
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Introduction: Physiotherapy intervention plays a crucial role in management of adhesive capsulitis at primary care level in clinical practice. Present study aimed to evaluate the effect of Scapular mobilization versus proprioceptive neuromuscular facilitation technique on pain, range of motion and disability of shoulder among subjects with adhesive capsulitis. Materials and Methods: The 20 subjects were then randomly allocated into two groups A and B. Group A were treated with Scapular mobilization and Group B with Proprioceptive neuromuscular facilitation technique were conventional therapy been common in both the groups. The Pain, Range of motion (ROM) and functional disability was measured using a Visual Analogue Scale (VAS), universal goniometer and shoulder Pain disability index for both the group and the two groups received intervention for 3 days in a week for 4 weeks. Pre and post treatment evaluation were compared and statistically analyzed. Results: Both the Group A and Group B demonstrated statistically significant difference in reducing pain, improving ROM and functional disability, Although Group A was superior in improving in VAS (p=0.001), shoulder abduction (p=0.001), and shoulder pain disability index (p=0.001) when compared to group B. Conclusion: Both the group seemed to be significantly efficacious in diminishing pain, ameliorating ROM and lowering the functional disability among patients with adhesive capsulitis. However, the group who received scapular mobilization showed higher improvement. So herewith the physician should be acquainted about these outputs and the importance of physiotherapy management on adhesive capsulitis which executes at primary care level.
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This study was funded in part by a Minigrant award from California State University, Fresno. The use of thermal modalities to enhance stretching procedures is not well documented clinically. This study documented the effectiveness of applying superficial heat and cold in conjunction with a low-load prolonged stretch (LLPS) for increasing shoulder flexibility. Ninety-two healthy males were randomly assigned to one of five groups: 1) an LLPS alone, 2) heat applied in the initial phase of an LLPS, 3) cold applied in the final phase of stretch, 4) a combination of heat initially followed by cold, and 5) no intervention. Subjects received three, 40-minute treatments across a 5-day period. A follow-up measurement was taken 3 days later. Results demonstrated that an LLPS associated with the use of heat, ice, or a combination of both facilitated greater long-term improvements in flexibility compared with controls. However, only subjects receiving heat in the initial phase of an LLPS showed significant gains when compared with those who received stretching alone (p </= 0.05). We concluded that applying heat in conjunction with an LLPS to a nonpathologic shoulder is a clinically superior method of improving flexibility compared with an LLPS alone. J Orthop Sports Phys Ther 1992;16(5):200-207.
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The American Shoulder and Elbow Surgeons have adopted a standardized form for assessment of the shoulder. The form has a patient self-evaluation section and a physician assessment section. The patient self-evaluation section of the form contains visual analog scales for pain and instability and an activities of daily living questionnaire. The activities of daily living questionnaire is marked on a four-point ordinal scale that can be converted to a cumulative activities of daily living index. The patient can complete the self-evaluation portion of the questionnaire in the absence of a physician. The physician assessment section includes an area to collect demographic information and assesses range of motion, specific physical signs, strength, and stability. A shoulder score can be derived from the visual analogue scale score for pain (50%) and the cumulative activities of daily living score (50%). It is hoped that adoption of this instrument to measure shoulder function will facilitate communication between investigators, stimulate multicenter studies, and encourage validity testing of this and other available instruments to measure shoulder function and outcome.
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