A Preliminary Study on the Effect of Low Energy Extracorporeal

Shock Wave Therapy as a Treatment for Shoulder Adhesive

Capsulitis in Hasan Sadikin Hospital Bandung, Indonesia

Megi Virgiabanon Otafirda, Tertianto Prabowo, Rachmat Zulkarnain Goesasi,

Irma Ruslina Defi and Novitri

Department of Physical Medicine and Rehabilitation, Dr. Hasan Sadikin General Hospital, University of Padjadjaran,

Bandung, Indonesia

Keywords: Adhesive Capsulitis, Frozen Shoulder, rESWT, Rehabilitation.

Abstract: Adhesive capsulitis or frozen shoulder describes the common shoulder condition characterized by painful

and limited active and passive range of motion. Extracorporeal shock wave therapy (ESWT) suggested as

alternative treatment for adhesive capsulitis. Aim of this study was to determine the effect of low energy

rESWT on adhesive capsulitis related to shoulder pain, shoulder range of motion, and function of the

shoulder joint. The study design was an interventional, experimental study. A series of single-case studies

was undertaken with patients shoulder adhesive capsulitis who came to the physical medicine and

rehabilitation department Hasan Sadikin Hospital. Each patient received four weeks applications of low

energy rESWT, 1 week apart. Outcome measure using NRS, ROM and DASH questionnaire. Result: Five

patient, 4 Female and 1 Male were included, with mean age of patient is 50,60 ± 2,97 years old, mean

length of symptoms 12 ± 6,96 month. Pain intensity, passive shoulder range of motions, and functional

outcome are improved after 4 weeks intervention rESWT(p<0,05). The low energy rESWT resulted in

significant clinical and statistical improvement pain, passive shoulder ROM and functional outcomes in

patients with shoulder adhesive capsulitis. Low energy rESWT as effective treatment alternative in

shoulder adhesive capsulitis.

1 INTRODUCTION

Adhesive capsulitis or frozen shoulder describes the

common shoulder condition characterized by painful

and limited active and passive range of motion. The

etiology of frozen shoulder remains unclear;

however, patients typically demonstrate a

characteristic history, clinical presentations, and

recovery.

Frozen shoulder is reported to affect 2% to

5% of the general population. Individuals with

primary frozen shoulder are commonly between 40

and 65 years old, and the incidence appears higher in

females than males (Kelley et al. 2009). More than

50% of frozen shoulder patients still have sequelae

of symptoms after years of undergoing therapy,

resulting in decreased quality of life of the patient

(Guiloff et al. 2015).

Extracorporeal Shock Wave Therapy (ESWT) is

defined as an acoustic wave characterized by high

pressure peaks (100 MPa), rapid pressure increase

with rise times of less than <10 nsec, shorter life

cycle less than 10 ms, and energy density range of

0.003 – 0.890 mJ/mm (Gerdesmeyer et al. 2003).

Radial ESWT is a pneumatic type shock wave,

producing low energy to medium compared with

traditional focused ESWT and lower penetration

depth than fESWT (3 cm vs 12 cm). This shock

wave will be focused at the tip of the applicator

without having to focus energy to the target point.

Systematic review studies and meta-analyses

reported rESWT has better result compared to

fESWT in patients with plantar fasciitis because the

result has a larger therapeutic area, so focusing

therapy becomes less important, does not require

local anesthesia and is more affordable (Chang et al.

2012).

Several studies have shown that ESWT is a

relatively non invasive therapeutic modality with

proven effectiveness, convenience and safety of the

therapy of musculoskeletal problems (Ioppolo et al.

Otaﬁrda, M., Prabowo, T., Goesasi, R., Deﬁ, I. and Novitri, .

A Preliminary Study on the Effect of Low Energy Extracorporeal Shock Wave Therapy as a Treatment for Shoulder Adhesive Capsulitis in Hasan Sadikin Hospital Bandung, Indonesia.

DOI: 10.5220/0009088302150219

In Proceedings of the 11th National Congress and the 18th Annual Scientiﬁc Meeting of Indonesian Physical Medicine and Rehabilitation Association (KONAS XI and PIT XVIII PERDOSRI

2019), pages 215-219

ISBN: 978-989-758-409-1

215

2014). Extracorporeal shock wave therapy has been

suggested as an alternative treatment for refractory

shoulder pain due to calcific or noncalcific tendinitis

and may be an alternative to expensive and risky

surgical interventions (Bannuru et al. 2013). Recent

studies show the use of ESWT has been suggested

for the treatment of adhesive capsulitis (Vahdatpour

et al. 2018).

The main purpose of the adhesive capsulitis

treatment is to reduce pain, increase the range of

joint motion and improve the function of the

shoulder. Therapeutic effect of ESWT is to help

revascularization, stimulation, bone reactivation and

healing of connective tissues, which will lower the

pain and improve shoulder joint function.

Shockwave modality uses sound waves of high or

low energy that impart rapid fluctuations of pressure

to tissues. The degree of energy imparted to the

tissues is measured as energy flux density (EFD).

There are many manufacturers of ESWT devices.

Shockwave therapy is usually classified as high,

medium, or low energy, according to the EFD

administered. Although there is no consensus on the

threshold values, a commonly used grouping defines

EFD 0.08 to less than 0.27 mJ/ mm

as low energy,

0.28 to less than 0.59 mJ/mm

as medium energy, and

more than 0.60 mJ/mm

as high energy (Speed 2004).

Several studies have been conducted to observe

the effects of low dose and high dose rESWT in

patients with shoulder pathology. Low dose rESWT

does not reduce pain or improve function compared

with placebo treatment in patients with chronic

tendinitis of the rotator cuff (Kolk et al. 2013).

Systematic review show that high energy fESWT is

more effective than low energy fESWT for

improving pain and shoulder function in chronic

calcific shoulder tendinitis (no similar effects were

seen in noncalcific tendinitis) and can result in the

complete resolution of calcifications (Bannuru et al.

2013). Studies that conducted in adhesive capsulitis

patients reported more effective responses with

higher energy and proper session intervals in patients

with adhesive capsulitis, hematomas as adverse

event was reported in this study (Hussein et al.

2015).

Adverse effects of ESWT were dose dependent,

patients who received high or medium energy ESWT

reported more adverse events than those who

received low energy ESWT. The most commonly

reported adverse events related to ESWT were

temporary increase acute pain and local reactions,

such as swelling, local erythema, petechiae, small

bruises and hematomas. No serious side effects have

been reported (Bannuru et al. 2013).

The aim of this study was to determine the effect

of low energy rESWT in adhesive capsulitis patient

related to shoulder pain, shoulder range of motion,

and function of the shoulder joint.

2 METHODS

The study design was an interventional, experimental

study. A series of single case studies (n=5) was

undertaken with patients shoulder adhesive capsulitis

who visited the outpatient clinic of Physical

Medicine and Rehabilitation Department Hasan

Sadikin Hospital. The participants received oral and

written information about the study and were

informed of the potential risks of treatment. Written

informed consent was obtained from all subjects

before the baseline evaluation. Ethical clearence was

given by the Health Research Ethic Committee

Hasan Sadikin General Hospital.

The inclusion criteria were patients 40 - 65 years

with shoulder pain and restriction in ROM in at least

three directions, (i.e. flexion, abduction, external

rotation, and internal rotation) for a duration of at

least 6 months. Exclusion criteria were history of

shoulder fracture, shoulder dislocation or

subluxation, previous surgery on the shoulder, pre-

rupture tendon or tendon rupture in the shoulder

cancer, glenohumeral or acromioclavicular arthritis,

presence of severe osteoporosis, inflammatory

disorders, pulmonary diseases, bleeding disorders,

pregnancy, any neuromuscular disorders, implanted

pacemaker and unwillingness to participate in the

study.

The rESWT was administered by the same

experienced trained doctor with the EMS Swiss

Dolorclast Smart20

(EMS Electro Medical Systems

Corporation, Dallas, TX, USA).

Each patient received four applications of

rESWT, 1 week apart, with 2000 impulses per

session. The air pressure of the device was set to 2.5

bars, frequency of 8 Hz, energy flux density (EFD)

0.11 mJ/mm

, and the impulses were applied with a

15 mm applicator.

The shock waves were delivered to two separate

locations per session with the coupling gel. The first

location was applied 1000 impulses in a posterior-to-

anterior direction on the posterior side of the

shoulder joint located beneath the lateral border of

the scapular spine. The second location was applied

remaining 1000 impulses of the total 2000 impulses

per session in an anterior-to-posterior direction of the

anterior shoulder joint, was about one finger breadth

lateral to the coracoid process (Hussein et al. 2015)

(Vahdatpour et al. 2018).

KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientiﬁc Meeting of Indonesian Physical

Medicine and Rehabilitation Association

216

The outcome measure consists of pain intensity

during rest and activity over the past 24 hr was

assessed on Numeric rating Scale (NRS), the

involved shoulder passive flexion abduction and

passive external internal rotation were measured by a

goniometer, function that measured by the

Disabilities of the Arm, Shoulder and Hand (DASH)

questionnaire which has been validated in

Indonesian language (Magetsari 2010). Home-based

exercise that performed by patients, incidence of

painful activity or other adverse events are

documented. All outcome measures were taken at

baseline before the treatment, after 4 weeks (at the

end of treatment) by experienced trained doctor.

The obtained data were analyses were performed

using The Statistical Package for Social Sciences

(SPSS) software ver.18.0 (SPSS Inc., Chicago, IL,

USA). A paired t-test was conducted to determine

statistical differences in the variables between the

pre and post treatment. Values are presented as mean

± standard deviation for data with a normal

distribution, and p<0.05 was considered statistically

significant.

3 RESULTS

Five patients with shoulder adhesive capsulitis who

met the selection criteria were recruited. Subject

more likely to be female, with mean age of patients

is 50,6 years old and mean length of symptoms 12

month (Table 1). All the subjects complete the

intervention phase.

Table 1: Subject demographic characteristics.

No Variable n = 5

Gender, Female ; Male

Age (years), Mean ± SD

Length of symptom (month),

Mean ±SD

4 ; 1

50,6 ± 2,97

12 ± 6,96

Shoulder pain is statistically significantly

decreased for all the subjects. Mean pain NRS was

decreased from 6 point at the baseline to 1 point after

4 weeks treatment. (Table 2)

Table 2: Numeric rating scale at initial and after 4 weeks

intervention of Reswt.

Pain

NRS initial

(Mean ± SD)

NRS 4 weeks

(Mean ± SD)

NRS 6 ± 0.71 1.20 ± 0.44 0.000

Mean passive shoulder range of motions are

statistically significantly increased in all planes after

4 weeks after radial rESWT (Table 3). Shoulder

flexion range of motion was increased from 126

degrees at baseline to 156 degrees after the

treatment. Shoulder abduction range of motion was

increased from 76 degrees at baseline to 111 degrees

after the treatment. Shoulder external rotation range

of motion was increased from 23 degress at baseline

to 48 degrees after the treatment. Shoulder internal

rotation range of motion was increased from 43

degrees at baseline to 63 degrees after the treatment.

Table 3: Shoulder range of motion at initial and after 4

weeks intervention of rESWT.

Passive

Shoulder ROM

ROM initial

(Mean ± SD)

ROM

4 weeks

(Mean ± SD)

Flexion 126 ± 21.91 156 ± 20.73 0.003

Abduction 76 ± 17.82 111 ± 27.48 0.011

Eksternal

Rotation

23 ± 14.83 48 ± 11.51 0.001

Internal

Rotation

43 ± 12.04 63 ± 13.04 0.003

Function that measured by the DASH

questionnaire improved after 4 weeks after radial

rESWT (Table 4). There was a statistically

significant decreased in mean DASH scores from

53 at baseline to 16 after the treatment.

Table 4: Functional (DASH score) at initial and after 4

weeks intervention of rESWT.

Functional

DASH Score

initial

(Mean ± SD)

DASH Score

4 weeks

(Mean ± SD)

DASH

questionnaire

53 ± 10.64 16,98 ± 11.47 0.01

Three subjects were reported discomfort or pain

when rESWT is applied at the first week of

treatment, because of that the rESWT application

was interrupted, but all of the patients were able to

completed therapy. There are no adverse events that

reported in this study.

4 DISCUSSIONS

In the present preliminary study, five patients with

adhesive capsulitis assigned to receive rESWT

treatment. This study has reported the successful

positive change use of rESWT in treating patients

A Preliminary Study on the Effect of Low Energy Extracorporeal Shock Wave Therapy as a Treatment for Shoulder Adhesive Capsulitis in

Hasan Sadikin Hospital Bandung, Indonesia

217

with shoulder adhesive capsulitis. Clinically and

statistically significant differences were shown in

pain, passive shoulder ROM and functional

outcomes that measure in rESWT treated patients.

The characteristics of the all subjects in the

present study consist of age, onset, symptoms, were

truly representative of the reported shoulder adhesive

capsulitis patient population.

The shock waves were delivered to two separate

locations at posterior-to-anterior direction and

anterior-to-posterior direction. In the present study,

we did not deliver rESWT in a third oblique

direction into the glenohumeral joint at about one

finger breadth beyond the anterior border of the

acromion tip (Chen et al. 2014) because the

arthroscopic findings showed that adhesions occur

more in the descendants fold and surrounding

synovium (Vahdatpour et al. 2018). Therefore,

stimulation from anterior and posterior directions is

more effective than of the lateral direction

(Vahdatpour et al. 2018).

The present study results in pain, passive

shoulder ROM and functional outcomes are similar

to those reported by Hussein et al., who performed a

double-blind RCT to evaluate the effectiveness of

rESWT that applied 2000 impulses each session,

with an air pressure of 3.5 bars, an EFD of 0.16

mJ/mm

and a frequency of 8 Hz and proper session

intervals. Adverse events that reported in those

studies is hematomas, which lasted from 2 to 4 days,

were that observed in 5.6% patients; no associated

discomfort or pain was reported and the rESWT

application was not interrupted (Hussein et al. 2015).

This present study using rESWT with air pressure of

2.5 bar, with the same frequency and interval as the

previous study, and EFD of 0.11 mJ/mm

that

considered to be a low energy dose (Speed 2004),

resulting significant changes in all outcome

measures; no adverse events (hematomas, etc) as

found in previous studies.

Studies that conducted rESWT in adhesive

capsulitis patients using several intervals. Previous

study that applied rESWT with an intervals 10 to 14

days show that low dose rESWT does not reduce

pain or improve function in chronic rotator cuff

tendinitis patient (Kolk et al. 2013). This present

study show more effective responses rESWT with

proper session intervals that similar with previous

study that applied rESWT in adhesive capsulitis

patient using 1 weeks intervals (Hussein et al. 2015)

(Vahdatpour et al. 2018).

Shock wave therapy stimulates soft-tissue

healing, increases blood flow to the treated site and

induces an inflammatory-mediated healing process,

and has been used in treating soft-tissue disorders

(Chen et al. 2014). Shock wave therapy using

fESWT was reported successful treating pathological

shoulder conditions, previous use of in primary

shoulder adhesive capsulitis and frozen shoulder,

(Chen et al. 2014)(Vahdatpour et al. 2018) while the

reported use of rESWT also successful treating

frozen shoulder (Hussein et al. 2015).r

The present study shows that

effect of rESWT

for hyperstimulation analgesia and

neovascularization could be attributed to the pain

relief (Yuan et al. 2018). Effect ESWT for anti-

inflammatory, antifibrotic effects, tissue healing, and

increased flexibility of the collagen fibers and

tendons, could be attributed to increase of the range

of motion (Vahdatpour et al. 2018). Consequent

functional improvement of shoulder joint would

result from the decrease in pain and the increase in

mobility.

The present study has several limitations. This

study had a small sample size and there is no control

group. The follow up time was too short to

determine the longterm effects of treatment. We

suggest to do a further investigation with larger

sample size, with short and long term evaluation for

effect of low dose rESWT on adhesive capsulitis

patient with comparison to conventional therapy.

5 CONCLUSIONS

The low energy rESWT resulted in significant

clinical and statistical improvement pain, passive

shoulder ROM and functional outcomes in patients

with shoulder adhesive capsulitis. It could be

considered low energy rESWT as an effective

optimal treatment alternative in shoulder adhesive

capsulitis, and safe without serious adverse event.

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