JOURNAL OF PUBLIC HEALTH, NURSING AND MEDICAL RESCUE 2/

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1 JOURNAL JOURNAL OF PUBLIC OF PUBLIC HEALTH, HEALTH, NURSING NURSING AND MEDICAL AND MEDICAL RESCUE RESCUE No. No.1/2015 (65-72) JOURNAL OF PUBLIC HEALTH, NURSING AND MEDICAL RESCUE 2/ Assessment of the influence of selected kinesitherapeutic methods on the function of the shoulder girdle in patients with the shoulder impingement syndrome (Ocena wpływu wybranych metod kinezyterapeutycznych na funkcję obręczy barkowej u pacjentów z zespołem bolesnego barku) I Rotter 1,A,D, H Mosiejczuk 1,C, J Żugaj 2,B, M Ptak 1,E, A Lubińska 1,F Abstract - Introduction. The shoulder impingement syndrome is a frequent musculoskeletal disease and kinesitherapy is a crucial element in the treatment of the disease. Aim of the study. A comparison of the effectiveness of the PNF method and traditional kinesitherapy in the treatment of patients with the shoulder impingement syndrome in order to reduce pain, increase the of motion in the shoulder joint and improve muscle strength. Materials and methods. The research was conducted in 2012 and 2013 in a physiotherapy clinic. The study group consisted of 60 people, both male and female, aged 54 on average, diagnosed with the shoulder impingement syndrome. The patients were divided into two groups of the first group was treated with a PNF method, and the second group was treated using standard kinesitherapy techniques. Both groups were tested before and after a series of rehabilitation. An anonymous questionnaire created by the researcher was the main research method. In order to assess pain, an 11-degree visual analogue scale (VAS) was used, the of motion was measured by a goniometer, muscle strength was assessed using the Lovett test and an assessment of the deltoid muscle mass was conducted using an arm circumference measurement or R1 short arm. The results of the trial were then statistically verified. Results. The use of kinesitherapy methods resulted in an increased of shoulder motion, enhanced muscle strength of the shoulder, pain reduction, and a smaller number of patients suffering from deltoid muscle atrophy. Conclusion. The use of kinesitherapy methods has a beneficial influence on the effectiveness of the treatment in the shoulder impingement syndrome. Key words - shoulder impingement syndrome, PNF method, standard kinesitherapy techniques. Streszczenie Wstęp. Zespół bolesnego barku jest często występującą chorobą narządu ruchu a zastosowanie kinezyterapii w jest bardzo ważnym elementem w procesie leczenia tego schorzenia. Cel pracy. Porównanie skuteczności metody PNF oraz klasycznej kinezyterapii w leczeniu osób z zespołem bolesnego barku w celu zmniejszenia dolegliwości bólowych, zwiększenia zakresu ruchu w stawie ramiennym oraz zwiększenia siły mięśniowej. Materiał i metody badań. Badania prowadzono w latach Grupa badana składała się z 60 osób z rozpoznanym zespołem bolesnego barku obojga płci, średnia wieku 54 lata. Pacjenci zostali podzieleni na dwie grupy osobowe. Pierwsza grupa została poddana rehabilitacji terapią PNF, a druga grupa była rehabilitowana za pomocą standardowych technik kinezyterapeutycznych. Obie grupy zostały poddane badaniom przed i po serii rehabilitacyjnej. Metodą badawczą był autorski anonimowy kwestionariusz ankiety. W celu oceny skali bólu posłużono się 11-stopniową skalę wizualno analogową VAS, goniometrem przeprowadzono pomiary zakresu ruchu w stawie ramiennym, testem Lovetta oceniono siłę mięśni oraz dokonano oceny masy mięśnia naramiennego wykorzystując pomiar obwodu ramienia taśmą centymetrową czyli R1 krótki ramienia. Uzyskane wyniki poddano analizie statystycznej. Wyniki. Zastosowanie metod kinezyterapeutycznych spowodowało: zwiększenie zakresu ruchomości stawu ramiennego, przyrost siły mięśni stawu ramiennego, zmniejszenie dolegliwości bólowych, zmniejszenie ilości osób u których występowały zaniki mięśnia naramiennego. Wnioski. Zastosowanie metod kinezyterapeutycznych wykazuje korzystny wpływ na skuteczność leczenia zespołu bolesnego barku. Słowa kluczowe - zespół bolesnego barku, metoda PNF, standardowe techniki kinezyterapii.

2 66 Author Affiliations: 1. Independent Laboratory of Rehabilitation Medicine 2. Students Scientific Association, Independent Laboratory of Rehabilitation Medicine Authors contributions to the article: A. The idea and the planning of the study B. Gathering and listing data C. The data analysis and interpretation D. Writing the article E. Critical review of the article F. Final approval of the article Correspondence to: Hanna Mosiejczuk, Independent Laboratory of Rehabilitation Medicine, Pomeranian Medical University in Szczecin Grudziądzka 31 Str., PL Szczecin, Accepted for publication: December 11, T I. INTRODUCTION he shoulder impingement syndrome is a collection of various ailments disturbing the proper function of the pectoral girdle. It is an ever more frequent condition of the musculoskeletal system requiring relevant treatment and rehabilitation [1,2,3,4,5,6,7]. The most frequent endogenous causes of this condition include: damage of rotator cuff tendons, shoulder synovitis, shoulder tightness, joint instability, overload and micro damage of soft tissue, fractures, local inflammation of the synovial membrane leading to the gluing and symphysis of the lower recess, calcium deposits or ossification of distal muscle tendons, capsulitis, and degenerative changes. Although the causes may be various, the most frequently indicated one is pathological changes in the supraspinatus. External factors include: damage of the brachial plexus, pressure neuropathies, changes in the intervertebral discs, and degenerative cervical spine disorders [2,8,9,10,11,12,13]. For a complete diagnosis of the condition, specialist theoretical and practical knowledge is necessary; moreover, much attention is paid to the patient s complaints [14,15,16]. The first symptom in the shoulder impingement syndrome is pain which imposes a limited mobility on the upper limb, especially in terms of abduction and rotation, but also flexion. Usually, active movement of the humeral head is lost and proprioceptive dysfunction occurs. The ailments become worse and lead to a non-physiological position of the upper limb, in which the shoulder is dropped and rotated inwards, the elbow flexed, and the limb adduced close to the chest. The pain felt by the patient often radiates toward the outer part of the shoulder or towards the neck and shoulder blade. In the course of the illness, muscle strength of the upper limb is weakened, and frequently muscle atrophy occurs in the shoulder and shoulder blade [5,17, 18,19,20,21,22]. Treatment and rehabilitation should be implemented as quickly as possible to counter the shoulder impingement syndrome. There are many surgical and non-surgical methods of treating the disease in question. Surgical methods are typically used in the event of rotator cuff tear. The various non-surgical methods must be used carefully and at an appropriate time. At the severe stage of the illness, pain is treated usually by pharmacotherapy and physical therapy. Once the pain-alleviating effect has been achieved, kinesitherapy must be incorporated into treatment as soon as possible. Physical exercise is of vast importance, especially because it helps maintain an appropriate of mobility as well as muscle strength; it positively influences local blood flow and the biological condition of affected tissue. Well-balanced kinesitherapy also alleviates pain because it prevents further pathological change and mobility restraints, and it levels muscular tension which is often increased in the painful muscles [9, 23,24,25,26,27,28,29]. From various rehabilitation methods in the shoulder impingement syndrome, the following are often used: traditional rehabilitation using basic techniques such as non-weight-bearing exercise and self-assisted exercise special kinesitherapeutic methods such as: the PNF method, manual therapy, the Cyriax method, osteopathic methods, and post-isometric relaxation. The selection of methods depends mostly on the physiotherapist [,31]. Non-weight-bearing exercise and self-assisted exercise, i.e. traditional kinesitherapy, are most frequently applied to patients who cannot make an active movement in a full. [32,33] The purpose of such exercise is to increase the of mobility, relax tense muscles, strengthen the muscles, and prevent contractures or muscular atrophy in the exercised area. Moreover, the activation of muscle groups improves tissue nutrition, flexibility and proprioceptive facilitation. These exercises are usually done in universal exercise units consisting of

3 67 suspensions, ropes and direction pulleys or using an exercise stick. The PNF method (Proprioceptive Neuromuscular Facilitation) was developed in the 1940s. The underlying assumption is that brain plasticity may be used to fully activate the receptors involved in locomotor activity. PNF therapy is aimed at enhancing the patient s functionality as much as possible with the use of techniques employing the healthy parts of the body. Objectives are met by applying movement patterns, executing these patterns in diagonal planes and accenting rotation elements in these planes. The therapist selects techniques in accordance with the therapeutic objective. PNF therapy is considered an effective method of work with patients suffering from locomotor disorders, including patients with the shoulder impingement syndrome. PNF techniques improve muscle strength, enhance the mobility, increase the durability of musculoskeletal structures, and foster coordination. They also release tension and alleviate pain [29,,34,35,36]. Due to the large number of kinesitherapeutic methods, this study evaluates the influence of selected kinesitherapeutic techniques on the function of the pectoral girdle in patients with the shoulder impingement syndrome. The authors have attempted to assess the effectiveness of these methods on alleviating pain, decreasing muscular atrophy in the pectoral girdle, increasing joint mobility and muscle strength. II. MATERIALS AND METHODS Material The study was conducted in 2012 and The study group comprised 60 patients, both male and female aged 54 on average, diagnosed with the shoulder impingement syndrome. The patients were divided into two groups, members in each. The first group (A) was subjected to rehabilitation using PNF methods; the second group (B) was rehabilitated using standard kinesitherapeutic techniques such as non-weight-bearing exercise and selfassisted exercise. Both groups were tested before and after a series of rehabilitation. In group A, women constituted 40% and 43.33% in group B. As many as 38.33% of the respondents in both groups had experienced pain for longer than 6 months, 36.67% for 3 to 6 months; pain lasting shorter than 3 months was reported by 13.33% of respondents, whereas 11.67% patients has experienced pain for about 12 months. Methods The research method was an original survey questionnaire designed to obtain information regarding the occurrence and type of pain. The respondents could select multiple painful symptoms affecting them before and after therapy. In order to assess pain, an 11-degree visual analogue scale (VAS) was used. The patients marked on a 10-centimetre scale the subjective perception of pain before and after therapy. The results were measured by the therapist using a ruler and provided in millimetres [37]. A goniometer was used to measure the active and passive mobility of the shoulder joint: elevation by flexion, elevation by abduction, extension, external and internal rotation [38,39.] The Lovett test was used to assess the strength of the muscles performing the following functions in relation to the shoulder joint: flexion, extension, abduction, rotation outside, and rotation outside. The results have been presented in points. For load reduction during the study, an axial suspension system in the universal exercise unit was used. Incomplete and complete resistance was determined consistently with the study method in relation to the healthy limb [38,39,40]. Statistical methods The results obtained were analysed statistically. Statistica 8.0 software was used for calculations. The following were used in the statistical analysis: the arithmetic mean, standard deviation, coefficient of variation as well as the minimum and maximum values in the samples. In order to verify the significance between the means, Student s t- test was applied. The significance level at which research problems were verified had been adopted to be the value of 0.05.[41,42] III. RESULTS began, patients from group A had most frequently reported the occurrence of pain at night during sleep (56.67%) and when performing abrupt movements of the upper limb (56.67%), whereas respondents in group B had most frequently complained about pain at night (53.33%), pain while performing activities related to hygiene (50%) and during abrupt movements (53.33%). Following rehabilitation, in group A there was a decrease in the number of reported activities which brought about pain of the upper limb. A complete lack of pain was indicated by 26.67% of respondents. None of the patients experienced pain in static posi-

4 68 tions. The largest number of people (46.67%) complained of pain during abrupt movements. Similarly, group B reported fewer activities triggering pain in the upper limb following rehabilitation. A complete lack of pain was indicated by 10% of patients. The number of patients complaining of pain in static positions did not decrease (10%). In the analysis of the decrease in the number of activities causing pain reported by patients, a larger improvement was observable in group A than in group B. A statistically significant difference was observed in terms of pain decrease for both groups before and after rehabilitation (A - p ; B - p ). (Fig. 1, Table 1), both groups included cases of deltoid muscle atrophy in comparison to the healthy limb. When comparing the mass of the deltoid muscle to the healthy limb in group A, 60.67% of respondents were in the normal whereas muscular atrophy affected 33.33% of them. In group B, 70% of respondents had a normal deltoid muscle and deltoid muscle atrophy was observable in % of patients. Once rehabilitation had been completed, both study groups evinced a smaller percentage of deltoid muscle atrophy cases. The group rehabilitated with the PNF method (A) showed better improvement than the group subjected to traditional methods. (Table 2) Before Before rehabilitation rehabilitation Przed rehabilitacją After After rehabilitation rehabilitation Po rehabilitacji Table 2. Results of the analysis of deltoid muscle atrophy mm 68,57 61,97 56,17 Deltoid muscle atrophy ,4 group a normal muscle mass in comparison to the healthy limb b - muscular atrophy in comparison to the healthy limb a normal muscle mass in comparison to the healthy limb b - muscular atrophy in comparison to the healthy limb 0 Group Grupa AA Group Grupa B Figure 1. Subjective evaluation of pain by patients in groups A and B before and after rehabilitation Table 1. Subjective evaluation of pain by patients in groups A and B before and after rehabilitation Evaluation of pain VAS scale in mm A B n % n % group examination n X p A In both groups, before and after rehabilitation, a statistically significant improvement has been observed in terms of active and passive mobility of the shoulder joint. (Table 3) B

5 ,07 51, ,0006 0, ,00 46, ,03 62, , , ,77 48,83 group examination JOURNAL OF OF PUBLIC HEALTH, NURSING AND AND MEDICAL RESCUE No.1/2015 2/ Table 3. Results of the analysis of movement in the shoulder joint Analysis of changes in movement of the shoulder joint Elevation by flexion Elevation by abduction Extension External rotation Internal rotation n x p x p x p x p x p x p x p x p x p x p A B

6 B A group examination JOURNAL OF OF PUBLIC HEALTH, NURSING AND AND MEDICAL RESCUE No.1/2015 2/ In both groups, a statistically significant improvement of flexion muscle strength, extension and abduction was observed; yet only in group A did external and internal rotation improve after rehabilitation, unlike in the group following the traditional methods. (Table 4) Table 4. Results of the analysis of muscle strength change Analysis of muscle strength change in the shoulder joint Flexion Extension Abduction External rotation Internal rotation n x p x p x p x p x p IV. DISCUSSION The shoulder impingement syndrome is becoming an ever more frequent disorder these days. It usually affects the elderly, but also professionally active individuals and athletes. Therefore, the disorder is an obstacle to both professional life and physical activity of people of any age, regardless of their profession. The condition is usually caused by overloading the upper limb, which leads to micro damage and degeneration of the pectoral girdle [2,3,6,7,14,15,24]. Effective treatment and rehabilitation of the shoulder impingement syndrome is the subject of study for both doctors and physiotherapists. The results presented demonstrate that the application of kinesitherapy improves the mobility and muscle strength of the shoulder joint and it contributes to the reduction of muscular atrophy and pain among the patients. The group subjected to PNF therapy has demonstrated much better results than the group rehabilitated in a standard manner. The results of the present study confirm the study conducted in 2005 at the University School of Physical Education in Wrocław by Sipko et al. The purpose of their research was to create an effective rehabilitation programme for the shoulder impingement syndrome using the PNF method. They observed improvement in the mobility and a reduction in pain among the patients as well as an overall beneficial influence of the PNF method on the rehabilitation of patients suffering from the shoulder impingement syndrome []. Kokosz et al compared Mulligan s manual therapy to the standard kinesitherapeutic methods. The purpose of their study was to compare the direct and short-term effects of movement on the extent of pain experience by patients and on the mobility of the pectoral girdle. They proved a greater improvement of the mobility and a more significant reduction of pain in patients treated using Mulligan s method in comparison to the control group.[43] Buczek et al based in Bydgoszcz undertook to study the effectiveness of post-isometric relaxation (PIR) in rehabilitation of the shoulder impingement syndrome. In the final examination, a group subjected to a series of kinesitherapy and physiotherapy and a second group additionally treated with PIR obtained similar results. The post-isometric relaxation method did not prove to be more effective in the rehabilitation of shoulder impingement patients than the standard physiotherapy methods [44]. Presumably, as the authors observe, the PIR method may have been too difficult for patients to follow. Numerous studies have evaluated the influence of kinesitherapy combined with physical therapy on the treatment of the shoulder impingement syndrome. Krukowska [45] and Piechura [46] have investigated the influence of local cryotherapy combined with standard kinesitherapy methods on the results of physical therapy of patients with the shoulder impingement syndrome. The studies have shown that kinesitherapy has a beneficial influence on the rehabilitation of the upper limb, whereas the application of cryotherapy alleviates pain. Lisiński and Grabarczyk [47] used a therapy consisting of lignocaine iontophoresis, medium-frequency current therapy and kinesitherapy, which depending on the indication involved standard exercise techniques and PNF methods. Subsequently, the respondents were divided into two groups: one was subjected to a local cryo-

7 71 therapy treatment using nitrogen steam, whereas the other group was treated using a Sollux lamp with a red filtre. As a result, the mobility and muscle strength were improved in both groups. It has not been demonstrated, however, which physical treatment was more effective. The above-mentioned research points to a positive influence of kinesitherapy on the rehabilitation of patients suffering from the shoulder impingement syndrome. Studies suggest that special methods such as the PNF and Mulligan s method are more effective than the traditional ones. This definitely results from the fact that the special methods are based on an individual, precise cooperation of the therapist with the patient. The application of physiotherapeutic methods and their combination with kinesitherapy in the treatment of the shoulder impingement syndrome is a contentious issue for various researchers. Some therapists focus on kinesitherapy, believing it to be the most important part of the rehabilitation of shoulder impingement syndrome patients. The standard procedure in the treatment of this condition is traditional kinesitherapy. It is currently being extended with special methods which often evince a higher effectiveness upon examination. In all of the studies referred to, the researchers emphasise the necessity of a more detailed diagnosis of patients suffering from the shoulder impingement syndrome. The general diagnosis of the shoulder impingement syndrome with which patients are directed to a physiotherapist should be complemented by specifying the cause of the disorder and supported by additional examinations, such as ultrasonography. Failure to specify the reason for the condition often results in problems with choosing a relevant type of physiotherapy, which prolongs the process of rehabilitation. It is advisable to extend the diagnostic methods related to this disorder to enable a precise and effective rehabilitation excluding the root of the disorder and not only the symptoms. Kinesitherapy is an indispensable element of treating the shoulder impingement syndrome. It is therefore reasonable to conduct research on the effectiveness of kinesitherapeutic methods in rehabilitating patients with the shoulder impingement syndrome so that comprehensive rehabilitation programmes are created adapted to the individual needs of patients. V. CONCLUSION 1. The application of kinesitherapeutic methods has a beneficial influence on increasing the mobility of the shoulder joint, enhancing muscle strength of the shoulder joint, alleviating pain, and decreasing the number of patients with deltoid muscle atrophy. 2. The PNF method is more effective in improving the functionality of the upper limb in shoulder impingement syndrome patients than traditional kinesitherapeutic methods.. VI. REFERENCES [1] Dziak A, Serafin- Król M, Kintzi M, Czamara A, Gawroński W. Rehabilitacja w uszkodzeniach stawu barkowego. Kraków; Wydawnictwo Med Sportiva, [2] Buckup K. Testy kliniczne w badaniu kości, stawów i mięśni. Warszawa; Wydawnictwo PZWL, [3] Łyp M, Maciak W, Cabak A, Ogonowski A. Zmiany zwyrodnieniowe stawu barkowo- obojczykowego a zespół bolesnego barku. Fizjoter Pol 2006; 1, 4: [4] Van der Windt DA, Koes B. et al. Shoulder disorders in general practice: incidence, patient s characteristic and management. Ann Rheum 1995; 10, 54: [5] Dziak A. Bolesny bark jako następstwo wad wrodzonych, urazów, eksploatacji podczas uprawiania sportu i w pracy zawodowej oraz zmian wstecznych i chorobowych zespołów tkankowych i narządowych. Med Sportiva 2003; 7(2): [6] Lauterbach G. Rehabilitacja barku sportowca. Med Sportiva 1998; vol.2, no.3: [7] Dziak A, Tayara SH. Bolesny bark. Kraków; Wydawnictwo Kasper, [8] Jens Ivar Brox, Ból barku. Med Prakt Chir 2005; 3: [9] Dutka J, Sosin P. Leczenie ortopedyczne zespołu bolesnego barku. Rehabil Med 2004; Tom 8, 2: [10] Nowotnego J. (red.) Podstawy kliniczne fizjoterapii w dysfunkcjach narządu ruchu. Warszawa; Wydawnictwo Medipage, [11] Pogorzelec P. Zastosowanie metody Kinesio Taping w terapii wybranych urazów stawu barkowego. Rehabil Prakt 2012; 5: 36. [12] Lesiak A. Ocena dysfunkcji obręczy barkowej w badaniu pacjentów z zespołem bolesnego barku. Rehabil Med 2002; 6 ( nr specjalny): [13] Kolster B. Ebelt- Paprotny G. Poradnik fizjoterapeuty. Wrocław; Wydawnictwo,,Ossolineum, [14] Jens Ivar Brox. Ból barku. Med Prakt Chir 2005;3: [15] Tayara SH. Kinezyterapia i sposoby fizykoterapii w zespole bolesnego barku. Med Sport 2001; 2 115:

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