Effects of shock wave therapy on inflammatory markers in diabetic and non-diabetic frozen shoulder - jpr solutions
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Research Article
Effects of shock wave therapy on inflammatory markers in
diabetic and non-diabetic frozen shoulder
Magdy Mostafa Ahmed1*, Shahesta Ahmed Osama2, Mohammed Naeem Mohamed3,
Samar HassabAllah Kassem4, Ahmed Tamer Farag Ahmed5
ABSTRACT
Aim: The aim of the study was to investigate the effect of shock wave therapy on inflammatory markers in diabetic and
non-diabetic frozen shoulder. Materials and Methods: This study was conducted on 50 subjects with frozen shoulder. They
were classified according to the fasting blood sugar (FBS) level into two groups. The diabetic group had FBS level of more
than or equal to 126 mg/dl, while the non-diabetics group had FBS level of 0.05). However, there was a greater percentage of improvement in non-diabetic group than in the diabetic group.
Conclusion: Shock wave is effective in reducing pain, disability, and inflammatory markers, as well as improving shoulder
ROM in both diabetic and non-diabetic patients with frozen shoulder, with a greater improvement in non-diabetics.
KEY WORDS: Diabetes, Frozen shoulder, Inflammatory markers, Non-diabetes, Shock wave
INTRODUCTION inflammatory cells, including T and B cells,
macrophages, and mast cells, as well as elevated
Frozen shoulder is a clinical debilitating painful levels of inflammatory markers (interleukins and
condition characterized by inflammatory adhesions cytokines) in shoulder capsule biopsies from frozen
and stiffness of the glenohumeral capsule, as well shoulder patients.[6] The occurrence of a high
as the painful restriction in both active and passive level of chronic inflammatory cytokines cells is
movements of the shoulder, especially external related to angiogenesis, neurogenesis, and capsular
rotation.[1] Pain and functional impairment could limit inflammation and may lead to increased frozen
activities of daily living and disturb sleep at night on shoulder pain.[7]
the affected side.[2] The prevalence of frozen shoulder
among diabetics and non-diabetics is about 11–30% Physiotherapy is widely adopted as an initial and first
and 2–10%, respectively.[3,4] The higher prevalence in line of treatment in a frozen shoulder and can improve
diabetic patients may be attributed to microvascular outcome scores. There are many methods of physical
abnormalities that delay collagen repair and cause therapy treatment for idiopathic or secondary frozen
degenerative alterations.[5] shoulder as passive exercises and gentle pendulum
exercises.[8]
The pathogenesis of frozen shoulder is not fully
understood in spite of its high prevalence. Recent Extracorporeal shock wave therapy is a new
research has identified increased expression of conservative therapeutic modality that deals with
musculoskeletal pain caused by different conditions.[9]
Access this article online It helps regeneration of new blood capillary in the
Website: jprsolutions.info ISSN: 0975-7619
affected lesion, accelerates the healing process of
connective tissue, decreases pain, and finally facilitates
1
Department of Physical Therapy for Internal Diseases, Faculty of Physical Therapy, October 6 University, Giza, Egypt,
2
Department of Physical Therapy for Orthopedics, Faculty of Physical Therapy, October 6 University, Giza, Egypt,
3
Department of Physical Therapy for Basic Sciences, Faculty of Physical Therapy, Beni Suef University, Beni Suef, Egypt,
4
Department of Biochemistry, Faculty of Medical Applied Science, October 6 University, Giza, Egypt, 5Department of
Orthopedic Medicine, Faculty of Medicine, October 6 University, Giza, Egypt
*Corresponding author: Magdy Mostafa Ahmed, Department of Physical Therapy for Internal Diseases, Faculty of Physical
Therapy, October 6 University, Giza, Egypt. E-mail: dr.mgdy.mostafa91@gmail.com
Received on: 21-09-2019; Revised on: 16-10-2019; Accepted on: 27-11-2019
296 Drug Invention Today | Vol 14 • Issue 2 • 2020Magdy Mostafa Ahmed, et al.
the function of the shoulder joint.[10] In addition, it Shock wave therapy
activates the rate of fibroblasts proliferation, synthesis All patients in both groups received shock wave
of collagen, and gene expression for cytokines and/or therapy once per week, for 4 weeks. The treatment
growth factors. Both effects of extracorporeal shock position was sitting with the full support of the back;
wave therapy on enhancing blood flow and activating the affected shoulder was exposed, and a coupling
fibroblasts collaborate to accelerate the repairing gel was applied on it to limit the loss of energy at the
process.[11] interface between skin and applicator head. Then,
the shock wave was applied close to the insertion
To the best of our knowledge, there was no study of rotator cuff muscle on the most trigger point. The
compared the efficacy of shock wave therapy on shock wave applied 2000 impulses in one session. The
systemic inflammation in diabetic versus non-diabetic density of energy was 0.22 mJ/mm², the pulse rate was
frozen shoulder. Therefore, this study aimed to assess 10/s, and the frequency was 1–15 Hz.[13]
the effect of shock wave intervention on major
inflammatory cytokines (C-reactive protein [CRP] Therapeutic exercise program
and interleukin-6 [IL-6]) in diabetic and non-diabetic
Each patient in both groups received a therapeutic
frozen shoulder.
exercise program in the form of passive stretching
exercise, strengthening exercise, and mobilization
MATERIALS AND METHODS for the shoulder joint, 3 times per week, for 4 weeks.
Design The passive stretching exercise was applied for
the shoulder capsule and its musculature and was
The work was designed as a prospective comparative
repeated for 3 times, with 30 s of hold and 10 s of a
study, a pre- and post-test. It was conducted between
rest period in between.[14] The strengthening exercises
March 2018 and April 2019 and followed the
were performed for the stabilization of shoulder
guidelines of Declaration of Helsinki on the conduct
muscles. First, the repetition maximum was identified,
of human research.
depending on the pattern of movement of patient and
Participants patient’s reactions; pain and fatigue were considered.
The strength training exercise was performed in the
A sample of 50 patients (27 females and 23 males) was
form of three sets, every one duplicated 10 times, with
recruited from the out-patient clinic of physical therapy
brief rest between each one.[15] The mobilization of the
at October 6 University Hospitals, Giza, Egypt. To be
shoulder was used to decrease pain and increase ROM
included in the study, the participants were chosen
of the shoulder joint. Sustained traction mobilization
adult patients suffering from frozen shoulder for 2 to
technique with grades (I, II, III, and IV) and Maitland
9 months (stage 1; the painful phase). They should
oscillatory technique in the form of anterior, inferior,
have three hallmarks for the diagnosis of frozen
and posterior glide were applied.[16]
shoulder, including severe limitation of joint motion,
exaggerated pain (particularly in evening time), and Outcome Measures
significant loss of external rotation range of motion
(ROM) during passive and active movement.[12] The Visual analog scale (VAS)
patients’ ages ranged from 40 to 60 years old. The It was used to assess the severity of pain before and
diabetic patients were diagnosed as type 2 diabetes after treatment for both groups. It consists of a 10 cm
for at least 5 years (fasting blood sugar [FBS] ≥ line with varying degrees of pain intensity from 0 (no
126 mg/dl), while the non-diabetics patients had FBS pain) to 10 (killing pain). Patients were instructed
ofMagdy Mostafa Ahmed, et al.
was calculated by averaging the scores of pain and statistically non-significant difference (P > 0.05).
disability subscales.[18] However, there was a greater percentage of
improvement with regard to VAS in non-diabetic group
Shoulder ROM (75%) than in the diabetic group (64.55%) [Table 2].
The shoulder ROM was evaluated, by electro
goniometer device, for all patients in both groups The SPADI showed a statistically significant reduction
pre- and post-treatment. The assessment was done (P < 0.05) within both groups. The post-treatment
for shoulder flexion, abduction, and internal rotation comparison of both groups revealed a statistically
for every patient. Three continuous measures were non-significant difference (P > 0.05). However, there
recorded in each direction and the average of them was a greater percentage of improvement with regard
was taken.[19] to SPADI in the non-diabetic group (78.3%) than in
the diabetic group (74.3%) [Table 2].
Inflammatory markers levels
The shoulder ROM in all directions (flexion,
Blood samples were collected from each patient in abduction, and internal rotation) showed a statistically
both groups pre- and post-treatment to measure the significant increase (P < 0.05) within both groups.
levels of inflammatory markers, including CRP and The post-treatment comparison of both groups
IL-6. The serum CRP was controlled by utilizing revealed a statistically non-significant difference
the CRP latex agglutination test. The occurrence (P > 0.05). However, there were greater percentages of
of agglutination demonstrated a level of CRP in improvement with regard to shoulder ROM in flexion,
the sample >8 mg/L. The absence of agglutination abduction, and internal rotation in the non-diabetic
demonstrated a CRP level of ≤ 8 mg/L. The level group (50.01%, 56.3%, and 72.07%) than in diabetic
of plasma IL-6 was determined, using ELISA unit, group (46.86%, 49.32%, and 63.3%) [Table 2].
according to the technique of Feldmann et al.[20]
The inflammatory markers (CRP and IL-6) showed a
Statistical Analysis statistically significant reduction (P < 0.05) within both
The mean and standard deviation (SD) were used for the groups. The post-treatment comparison of both groups
expression of results for data analysis. Unpaired t-test revealed a statistically non-significant difference
was used to compare various variables between groups. (P > 0.05). However, there were greater percentages
Paired t-test was performed within the same group for of improvement with regard to CRP and IL-6 in the
various variables as compare pre- and post-assessment non-diabetic group (67.28.6% and 43.4%) than in the
in normal data. The analysis of data was done using diabetic group (57.89% and 34.6%) [Table 2].
Statistical Package for the Social Sciences computer
program (version 23 windows). The significance of DISCUSSION
research was determined at P ≤ 0.05.
To the best of our knowledge, no previous work
has studied the effects of shock wave therapy on
RESULTS inflammatory markers in the diabetic and non-diabetic
Both groups were similar at baseline (P > 0.05) patients with frozen shoulder. Therefore, this research
regarding age, duration of illness, weight, BMI, and is considered the first study on this point. Accordingly,
all outcome measures [Tables 1 and 2]. However, the results cannot be compared or discussed directly
there was a significant difference between both groups with other research outcomes.
regarding FBS (P < 0.05) [Table 1].
The mean age of frozen shoulder patients in this
The VAS showed a statistically significant investigation was 52.7 ± 7.5 years. This is consistent
reduction (P < 0.05) within both groups. The post- with Harris et al.[21] who found that frozen shoulder
treatment comparison of both groups revealed a was very rarely noticed early below the age of 40 years.
A clinical study by Ulusoy et al.[22] in Turkey showed
Table 1: Basic characteristics of patients in both groups that the average age of frozen shoulder is somewhere
in the range of 40–60 years. One study conducted
Characteristics Diabetic Non-diabetic P value by Watson[23] suggested that the higher prevalence
group (n=25) group (n=25)
of frozen shoulder in older individuals may be due
Age (years) 52.7±7.8 52.4±7.1 0.62NS
to aging as there are inflammatory reactions in the
Duration of 6.3±2.58 6.1±2.32 0.84NS
shoulder joint and its ligament.
illness (month)
Weight (kg) 76.4±6.2 78.1±9.1 0.42NS
The results of the current study showed a significant
BMI (kg/m²) 27.8±2.8 28.3±2.97 0.1NS
FBS (mg/dl) 178.34±11.6 86.75±7.2 0.001S reduction in VAS, SPADI, and levels of inflammatory
P>0.05, SPMagdy Mostafa Ahmed, et al. Table 2: The VAS, SPADI, shoulder ROM, and inflammatory markers for both groups Items Diabetic group (n=25) Non-diabetic group (n=25) P value* VAS Pre-treatment 7.9±1.2 7.6±1.34 0.22NS Post-treatment 2.8±0.92 1.9±0.73 0.08NS % of improvement 64.55 75.0 P value** 0.000S 0.000S SPADI Pre-treatment 7.4±1.2 6.92±1.3 0.36NS Post-treatment 1.9±0.85 1.5±0.68 0.1NS % of improvement 74.3 78.3 P value** 0.001S 0.001S Shoulder flexion Pre-treatment 94.35±6.38 96.79±6.87 0.47NS Post-treatment 138.52±12.3 145.2±11.15 0.16NS % of improvement 46.86 50.01 P value** 0.001S 0.001S Shoulder abduction Pre-treatment 103.53±7.98 102.1±7.63 0.1NS Post-treatment 154.66±20.32 159.5±10.97 0.54NS % of improvement 49.32 56.3 P value** 0.001S 0.001S Shoulder internal rotation Pre-treatment 23.33±4.57 24.6±4.26 0.28NS Post-treatment 38.2±6.21 42.33±2.44 0.35NS % of improvement 63.3 72.07 P value** 0.001S 0.001S CRP (mg/L) Pre-treatment 12.54±1.3 10.24±1.24 0.2NS Post-treatment 5.28±1.15 3.35±0.48 0.21NS % of improvement 57.89 67.28 P value** 0.001S 0.001S IL-6 (ng/ml) Pre-treatment 13.3±3.8 11.33±1.6 0.52NS Post-treatment 8.7±2.56 6.41±0.95 0.08NS % of improvement 34.6 43.4 P value** 0.001S 0.001S *Intergroup comparison; **intragroup comparison of the results pre- and post-treatment. NSP>0.05, SP
Magdy Mostafa Ahmed, et al.
The favorable effect of passive stretching exercises markers, as well as increasing shoulder ROM in both
on frozen shoulder patients could be related to the diabetic and non-diabetic frozen shoulder, with a
tensile stresses on the non-contractile connective greater improvement in non-diabetics.
tissue in and around the muscle. Furthermore, it
produces inhibition of the muscular contractile ACKNOWLEDGMENTS
elements by the Golgi tendon organ that causes reflex
relaxation of the muscle thus enabling the muscle to The authors would like to thank all individuals who
elongate against less muscle tension.[33] Application contributed to the completion of this work.
of passive stretching at low intensity and velocity for
long period induces breakdown of the collagen fibers AUTHORS’ CONTRIBUTIONS
bonds, resulting in flexibility improvement, ROM
MM, SA, and MN, conceived of the study, designed
increase, and functional recovery.[34] The positive
the study protocol, and drafted the manuscript.
effect of mobilization on the frozen shoulder could be
MM, SA, and MN wrote the manuscript. MM is the
attributed to its influence on breaking down adhesions,
corresponding author and supervisor of the research.
realigning collagen, increasing fiber gliding through
SH helped us in drafting the revised manuscript and
particular movements stressing the capsular tissues,
substantively helped us to revise the manuscript.
inducing rheological alterations in synovial fluid,
All authors have reviewed the final version of the
increasing fluid exchange between synovial tissue and
manuscript and approve it for publication.
the cartilage matrix, and enhancing the turnover of
synovial fluid.[35]
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Source of support: Nil; Conflicts of interest: None Declared
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