Pain Relief Due to Physiotherapy Doesn’t Change 2

8/7/2019 Pain Relief Due to Physiotherapy Doesnt Change 2

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Raja M. Al Nasrallah


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Researchers:Falk Morl, PhD, Andreas Matkey,

PT, Susanne Bretschneider, Annette Bernsdorf,MD, Ingo Bradl, PhD

Published in Journal of Bodywork & MovementTherapies

Received 20 January 2010; received in revisedform 17 May 2010; accepted 25 June 2010

Design: Randomized trial.

Setting: Ambulatory care in University HospitalJena in Germany


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The coordinative capabilities of the shoulder areimportant to ensure the precise movement of thehumerus.

Spatial coordination does not just affect single bones articulating with each other.

Without the compensatory motions of adjacent joints, incorrect motions of the shoulder as theroot in a segmented body part like the arm will be propagated to the forearms and the hands.


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Lack of coordination of the shoulder may affectevery day-life activities like picking up a pencilor moving a cup to the mouth.

Shoulder pain is often linked to: Poor motor function

Miss-coordination Biomechanical stress


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Studies of exercise therapy for the shoulder-neck region claim all kinds of correlations betweentraining, pain relief and a significant

enhancement in physical parameters likestrength and range of motion .

Studies justify their achievement in therapy only

in terms of pain relief .


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Functional parameters have been reasoned only partly, using questionnaire methods (disability indexetc.).

At the moment there is no clear evidence for a mainphysical measure in correlation to pain relief.

only one study so far has investigated the effect of

physical training on proprioception and kinesthesiaof the shoulder (Swanik et al., 2002)

lack of information about changes in coordinativeabilities from therapeutic intervention.


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Is physiotherapy able to changeproprioceptive abilities such as thecapability to reproduce a specific angle

of the glenohumeral joint?

Is there a connection between painreduction and change of ability to

reproduce an angle?


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to evaluate the effect of different trainingmethods in physiotherapy on pain relief and

change in proprioception and kinesthesia of theshoulder.Further, the connections between pain relief andchange in motor function of the shoulder will beinvestigated.


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Shoulder

Training

Motor

Function

Pain Relief


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Shoulder patients were recruited with the co-operation of the State Ministry of theEnvironment.

All patients were examined medically andorthopedically by an orthopedist in order toexclude subjects who did not fulfill the inclusioncriteria.


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Inclusion Criteria

Unspecific pain of atleast one shoulder incombination withorthopedically-assessedfunctional deficits.

Exclusion Criteria

Common contraindicationslike;

Diseases of thecardiovascular system

High blood pressure

Post-surgical conditions; Acute prolapse of anintervertebral disc (4months)

Neurological symptoms

Rotator cuff tear.


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n=30

Unspecific Shoulder Pain

Group 1

n=12

Flexible Foil

Group 2

n=10

Flexible Bands

non-symptomaticsubjects

Group 3

n=8


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The training course was subdivided into 24 workouts and extended over at least 12 weeks, with 2 workouts per week.

When there was loss of a workout because of holiday or illness the workout was carried out inthe following week.

Every workout was individual (there were nogroup-workouts) and coached by aphysiotherapist or a sports therapist.


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Shoulder pain patients usually have higher tonicity in upper trapezius , which may reduce the benefit of the training (e.g. the patient would not be able toexercise as instructed by the therapist).

To reduce muscle tone, the region of the uppertrapezius was treated randomly through

physiotherapy techniques such as myofascial release or a hot rolled towel (5-10 min) at the beginning of every workout.


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The flexible foil aims mainly at stabilizing theshoulder. At this time, there is no evidence for its

efficiency.Resemble Body blade All exercises were done

in standing positionSuitable to patients' ability


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Training using flexible bands mainly affects theforce production of muscles surrounding theshoulder.

Evidence is rareBands in different colors were used for differentforce exertion according

to gender, the weight andthe strength of the patient.


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Female patients usually trained with yellow orred bands whereas male patients trained withred or green bands.

An exception was made for patients sufferingfrom severe pain or restrictions. These patientsused white bands.4 exercises3 sets5-10 repetitions


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Both training groups showed comparable data inage, height and weight. An exception is gender: theflexible-foil group having more female patients.

To obtain values of a non-restricted capability toreproduce angles of the shoulder for comparison tothe patients data, a group of young subjects withouta history of shoulder pain or injury was recruitedand measured using the angle-replication-test .


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Outcome

Measure

Pain

Constant-Murley Score

Proprioceptive& Kinesthetic ability

Active-active Angle-Replication Test


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The CMS is a 100-point functional shoulder-assessment tool in which higher scores reflectincreased function . It combines four separate

subscales:1. Subjective pain (15 points)2. Function (20 points)

3. Objective clinicianassessment of ROM(40 points)1. Strength (25 points)


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Because the test did not discriminate the forcelevels depending on the subjects gender, they

also showed data without strength information.

The pain of the shoulder during testing was

gathered using a visual analogue scale.


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Procedure:To get a specific measure of proprioceptionThe patients had to move their arms to the testposition themselves during the test.The angular location of the shoulder was visualized on a display located in front of the

subject.In this way, the subject was able to correct theangular location up to the specific angular value based on the test-protocol.


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the subjects had to closetheir eyes and keep thearm in the pre-defined

position for about 10 s.

The therapist leading thetest advised the subjectsto sense the position of the shoulder arm-complex without visual

feedback .


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With eyes closed, the subject had to change the armposition to a neutral position e.g. hanging relaxed atthe side of the body. Then, (eyes still closed) thetherapist advised the subject to change the positionof the arm to the instructed position.

A difference between the pre-adjusted position (with

visual control) and the newly adjusted position(without visual control) was measurable in thecoordinative ability of the subjectBoth shoulders were tested separately.


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The angle-repetition-test was performed for threedifferent motions in different angles.

The motions were:1. Anteversion (sagittal plane)2. Abduction (frontal plane)3. inward and outward rotation (transversal plane).4. Inward and outward rotation of the humerus were

measurable in the neutral position of the upperarm with the elbow flexed at 90

Every test was repeated 3 times


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Using the CMS-HS 3D motionmeasuring systemapplied on landmark C7 & T12.

On the shoulder arm- complex,markers were applied onacromion, epicondylus lateralisat the elbow and caput ulna of the ulna.It was thereby possible tomeasure the angle betweentrunk and humerus as ameasure for all ROM.


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Before Training

-Constant-Murley Score-Active-active Angle-ReplicationTest

Halfway

Constant-Murley Score

After Training-Constant-Murley Score-Active-active Angle-ReplicationTest

Training period was 12 weeks


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The difference between pre-adjusted and self adjusted angle without visual control wascalculated using Matlabroutines (The

MathWorks, Inc., NatickMA, USA).

Significance level for all tests was p = .05.

A linear correlation analysis was calculated toget a measure of the coherence of pain relief andthe change in motor function.


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Improvement in Functional Pain Assessment:Pain was reduced in both intervention groups.

VAS p


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Changes in Motor Function by Physiotherapy:

After intervention, the patients, in comparison with

the non-symptomatic group, still showedsignificantly lower abilities to reproduce the testangles in abduction and anteversion at 60 (p < .01),and significantly lower ability to reproduce angles in

anteversion at 90

(p < .05).


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Coherence of Pain Relief and Change in MotorFunction:

There is no statistical coherence of pain relief and change in motor function (p > .05).This means that the improvement in pain of theshoulder is not associated with good or poorcapability in proprioception.


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Intervention using physiotherapy-driven trainingreduces the pain of the shoulder.

This result was expected and is comparable to otherstudies in efficiency of physical interventions.

A clear deficit in the ability to reproduce angles of the shoulder as a special part of proprioception was

detected before and after 12 weeks of interventionfor the patients. a very imprecise reproduction of aspecific angle.


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Pain relief and change in motor function of theaffected shoulder joints were not in coherence. Thisresult is a first sign that shoulder pain is not closely associated with poor motor functionPoor motor function of the shoulder may lead toshoulder pain sooner or later, but this is not themain reason for pains of the shoulder

Other parameters like muscle-strength, flexibility,intra-and intermuscular coordination, or propertiesof passive joint structures may also play a role in thiscontext. of the shoulder.


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In this study, the data of a passive control group,consisting of young subjects without shoulder pain, was used to evaluate the data of the patients.

For future studies, the data of a placebo traininggroup of patients should be compared to the data of the active patient group.


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In conclusion, data shows pain relief by physiotherapy but gives no information about why pain is relieved.

Because both devices clearly affect musclessurrounding the glenohumeral joint and the rotatorcuff, the pain relief may correlate with change inmuscle function.

Systematic exercises and training affect themetabolism of passive structures like articularcartilage and ligaments.The intervention may have an effect on painful

processes of such structures.


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Pain Relief Due to Physiotherapy Doesn’t Change 2

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