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The effectiveness of routine physiotherapy with and without neuromobilization on pain and functional disability in patients with shoulder impingement syndrome; a randomized control clinical trial

The effectiveness of routine physiotherapy with and without neuromobilization on pain and... Background: The objective of the study was to compare the effects of neuromobilization (NM) techniques and routine physiotherapy on pain and functional disability in patients having shoulder impingement syndrome (SIS). Present study was aimed to discover evidence based conservative and cost effective remedy on pain and functional disability. Study design: Single blinded randomized control clinical trial. Methods: A total of 80 patients with SIS were randomly assigned into care and experimental groups (40 in each group). After the baseline assessment routine physiotherapy was executed on both groups, while NM was applied additionally to experimental group. Pain and functional disability score were evaluated by Visual Analogue Scale and University of California at Los Angeles rating score at baseline, 5th and 11th week. Differences in outcome between groups were evaluated with clinical improvement. Results: The experimental group compared with care group at 11th week had lower mean pain score 2.15(1.66– 2.64) vs 4.90(4.41–5.40); between group difference, 1.82; 95% (CI), − 2.38 to − 1.25; P < 0.001 and Partial ƞ = 0.33, similarly functional disability score 28.58(27.32–29.83) vs 20.10(18.84–21.36); between group difference,5.62; 95%CI, (4.32–6.92); P< 0.001 and Partial ƞ = 0.49 respectively. In experimental group NM was a more effective technique to reduce the pain severity and disability in SIS patients as compare to care group. Conclusion: Neuromobilization techniques in addition to routine physiotherapy were significantly effective for the treatment of SIS. Trial registration: IRCT20190121042445N1, Registered 19 February 2019. Keywords: Shoulder impingement, Neuromobilization, Functional disability * Correspondence: a.hunjra@gmail.com University of Lahore, Lahore, Pakistan © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Akhtar et al. BMC Musculoskeletal Disorders (2020) 21:770 Page 2 of 9 Background mechanical stimulation used at low frequency, low in- The shoulder impingement syndrome (SIS) consists of tensity ultrasound is indicated to arouse neurons in the rotator cuff tendonitis and bursitis of the shoulder mouse brain by activating voltage gated sodium and cal- [1]. It shows the inflammation of the supraspinatus ten- cium channels. The slow elongation can cause structural don inside the anteroinferior junction of the acromion changes in myelin sheath, axon regeneration, deposition and the greater tuberosity of the humerus. Patients with of endoneurial collagen. The nodes of ranvier can open SIS report severe acute pain which increases during over- further as it causes the Schmidt- Lanterman clefts which head activities as well as sleeping on affected side [2]. affects the levels of local cytoplasm [8]. SIS comprises of three stages, the 1st stage is defined The neural component is over looked due to poor by edema and hemorrhage of the subacromial bursa and outcomes among patients with tendinopathy. Matocha rotator cuff muscle; it has been detected in patients where MA et al. highlighted neural involvement in patients age group is less than 25 years. The next stage indicates ir- with tendon pain and discussed the role of NM for reversible changes, which are fibrosis combine with tendi- tendon pain [9]. The utilization of neurodynamics may nopathy of the rotator cuff muscle. It is highly prevalent be important for the treatment purposes in patients among 25 to 40 years old population. At 3rd stage im- who suffer with tendonopathies which has neural pingement is evident by more severe changes, like partial component [6, 10]. or complete tears of the rotator cuff, mostly observed among patients who are above 40 years age [3, 4]. Objective The execution of specific components of body move- The objective of the study was to compare the effects of ments to generate particular mechanical incident in the NM techniques and routine physiotherapy on pain and neural system is called NM. Mechanical management functional disability in patients having SIS. Present study may therefore be used to augment physiology in the ner- was aimed to discover evidence based conservative and vous system [5]. cost effective remedy on pain and functional disability. It has already been observed that there are three theor- ies projected for the local etiological origin of tendon pain: 1-mechanical, 2-vascular and 3- neural [6, 7]. Methods Mechanical and vascular theories are regularly used Trial design for the treatment of tendon pain. The mechanical theory The model of study was single blinded randomized con- is based on the idea of mechanical overload of the ten- trolled clinical trial. This controlled trial used a parallel don resulting in damage to the collagen. Tendons that design where patients were allotted by 1:1 ratio in two receive high strain loads such as the Achilles are often groups’ experimental group as well as care group. These loaded during movement and have been suggested to patients had gone through a complete systemic physical sustain physiological strain up to 6–8%. examination that included the whole neurologic and The vascular theory is based on the concept that ten- musculoskeletal assessments. Patients with history of don may experience vascular compromise and neurovas- shoulder surgery, shoulder injury, trauma, shoulder joint cularization. Due to lack of vascularity, the tendon is not dislocation, cervical radioculopathy and having other capable of healing because of repetitive high strain load. systemic diseases were excluded from the study. The pa- A study conducted by Rees JD et al. observed mechan- tients with positive upper limb tension test [11], Neer ical, vascular and neural theories which have proposed test [3, 4], Hawkins Kennedy [12] Empty Can [12], pain- for tendinopathy and point out the potential appropriate ful arc and cross body adduction test [13] were included use of NM. The use of NM has the potential to lessen for study. the perception of pain. The movement of the nervous system during NM may restore axoplasm flow, restoring Randomization nutrients to the nerves. The restoration of nerve func- A sample of 80 participants was selected and allocated tion may then lessen sensitivity (i.e ion channels) to the in to two groups experimental and care group by using area and restore normal blood flow to the tendon [7]. computer generator method in simple random sampling Physiologically we may explain that a nerve which technique. closely passes to a joint is mostly kept in a tunnel or it is attached with collagen fibres or fascia to the nearby musculoskeletal components. Nerves move side by side Blinding within the upper limb hence the neuromobilization An independent assessor, who specialized in musculo- given during management cause break of the cross link- skeletal injuries with more than 5 year experience of ages. The possible effect of stretch on axons is the im- dealing patients with shoulder injury, had performed al- proved ion flux in stretch sensitive ion channels. The location of patients. Akhtar et al. BMC Musculoskeletal Disorders (2020) 21:770 Page 3 of 9 Participants Routine physical therapy Diagnosed patients with SIS was participated in this re- The routine Physiotherapy consisted of pulsed Short search. The study purpose was described to all patients Wave Diathermy (SWD) with frequency 27.12 MHZ and informed consent was taken from them. After ap- [16], Ultrasonic Therapy (US) with frequency 1.0 MHZ proval from Institutional Review Board “The University of and intensity 1.45w/cm [17] and Transcutaneous Elec- Lahore” and present study was completed at physiother- trical Nerve Stimulator (TENS) 2–200 HZ with output apy department of Social Security Hospital Gujranwala. current < 20 Ma width 200 μ seconds along with continu- ous mode. Exercises were comprised of shoulder streng- Procedures thing and stretching exercises that were performed for 5 After initial assessment, the investigator used to take s with 10 repetitions for both experimental and care demographic details of the participants along with visual groups as shown in Table 1 [18]. analogue scale (VAS) and functional disability rating score. Neuromobilization All the patient related information was kept confiden- NM was applied by using Butler’s recommendations tial and they were free to quit the study at anytime. [19]. Initially, the patient performed neural sliders and VAS was used to evaluate the severity of pain and it gradually progressed to neural tensioners. Neural sliders was considered as primary outcome of the current study. consisted of cervical lateral flexion movement, toward A constant scale had been employed to inquire the pa- the involved side, simultaneously with elbow flexion and tients about the shoulder pain during the activity and to extension movements. While moving the head in to cer- classify it by indicating on a 10-mm line; it was con- vical lateral flexion the elbow was extended. When the nected “no pain” and the “worst pain you have ever felt”. elbow began to flex, the cervical spine was returned to This is common method of evaluating severity of shoul- neutral position as shown in Figs. 1 and 2. Neural ten- der pain. The findings of the study indicate the VAS is a sioners were performed to create tension in the nerve to high reliable as well as valid method to assess the sever- get the desired results. The tension position was not ity of pain [14]. The UCLA score was used to assess held for a length of time, but is released by extending functional disability and it has total 35 points, with the elbow and returning the cervical spine to neutral. higher values indicating better shoulder condition. The Once the patient had pushed slight pain or discomfort at UCLA score has 5 domains; pain 10 points, function 10 any point as shown in Figs. 3 and 4 [20]. NM technique points, active forward flexion 5 points, strength of for- was performed for 5 s with 10 repetitions to control the ward flexion 5 points and satisfaction of the patient 5 pain and improve the functional disability score to relive points [15]. The score was assessed at base line, 5th and the pain shown in Table 1. 11th week. The internal consistency or reliability of UCLA was 0.78 to 0.89 and 0.51 to 0.59 for post surgical Outcome measures and non surgical respectively. As an outcome measure for pain severity (0 = no pain and 10 = severe pain) VAS was used with reliability 0.94 Interventions at baseline, 5th and 11th week [14]. Pain was considered Routine physiotherapy was performed on both groups as primary outcome. while NM was done on experimental group. Patients UCLA score was assessed at baseline, 5th and 11th week. were treated thrice a week on alternative days. The UCLA score was used to assess functional disability Table 1 List of exercises performed under experimental and routine physiotherapy group Experimental group (stretching and strengthing exercises Routine physiotherapy group (stretching and strengthing + neuromobilization) exercises) 1) STRETCHING EXERCISES 1) STRETCHING EXERCISES a) Shoulder external rotation stretch a) Shoulder external rotation stretch b) Cross body posterior stretch b) Cross body posterior stretch c) Stretch for anterior aspect of shoulder c) Stretch for anterior aspect of shoulder d) Shoulder flexion stretch d) Shoulder flexion stretch 2) STRENGTHING EXERCISES 2) STRENGTHING EXERCISES a) Chair press a) Chair press b) Restricted scapular retraction b) Restricted scapular retraction c) Restricted scapular protraction c) Restricted scapular protraction o o o o d) Shoulder abduction “Scaption” (0 -90 ) with theraband d) Shoulder abduction “Scaption” (0 -90 ) with theraband e) Shoulder scapular extension with theraband e) Shoulder scapular extension with theraband 3) NEUROMOBILIZATION EXERCISES a) Neural slider technique b) Neural tensioner technique Akhtar et al. BMC Musculoskeletal Disorders (2020) 21:770 Page 4 of 9 Fig. 3 Neural tensioner starting position cervical lateral flexion and elbow flexion Fig. 1 Neural slider starting position with elbow flexion 2SD Z þ Z a=2 Sample size ¼ and it has total 35 points, with higher values indicating bet- ter shoulder condition. The UCLA score has 5 domains; pain 10 points, function 10 points, active forward flexion 5 Where SD = Standard deviation = 14.08, Z is type 1 − a/2 points, strength of forward flexion 5 points and satisfaction 1 error = 1.96, Z = 0.84, d = μ − μ = 10.7 β 2 1 . of the patient 5 points [15]. The score was assessed at base Based on this a total sample size of around 80(experi- line 5th and 11th week. The internal consistency or reliabil- mental = 40, care = 40) was calculated to be an adequate ity of UCLA was 0.78 to 0.89 and 0.51 to 0.59 for post sur- mean to reach the conclusion. Considering a loss of 20% gical and non surgical respectively. The UCLA score was follow-up, at least 80% patients followed the treatments considered as secondary outcome. [23]. An experimental group and a care group were re- cruited which were based on the inclusion criteria for this study (Fig. 5). Both groups were selected by regu- Sample size larly visiting the physiotherapy department at Social Se- Sample size calculation was derived from Yamany AA curity Hospital Gujranwala. et al. study [21]. According to clinical trials, the sample size estimation formula was implemented [22]. Data analysis Statistical analysis Data were analyzed by using (SPSS Version 22.0) software. Qualitative data were presented in frequencies and percent- ages while mean and S. D were calculated for Quantitative Fig. 2 Neural slider final position with cervical flexion along with Fig. 4 Neural tensioner final position extending the elbow and elbow extension returning the cervical spine in neutral Akhtar et al. BMC Musculoskeletal Disorders (2020) 21:770 Page 5 of 9 Fig. 5 Experimental sheet/flow sheet data. Line chart was drawn at various times in weeks during Participant flow the treatment vs pain score and UCLA score. One hundred and twenty participants had been observed Repeated measure ANOVA was applied to compare aver- for eligibility process at the time of September 2016 till age pain score as primary outcome while average UCLA February 2018, among 30 participants had not been found score as a secondary outcome at different time points (base- eligible. The ineligible participants were excluded from line, 5th week, 11th week). The confidence level of 95% was the current study and was given the routine physiotherapy used as well as p value ≤0.05 was considered as significant. treatment. The reasons for ineligibility of the patients are presented in Fig. 5, out of 90 eligible participants, 10 had further excluded as they denied being part of study. The Results above mentioned 10 participants were also given the rou- Recruitment tine physiotherapy treatment. The rest of 80 participants The current study was started on September 2016 and divided in an experimental group and a care group. On last follow up was occurred on March 2018 and then 11th week follow-up, 12 participants left the study and 68 trial ended. It was considered regarding the number of patients had completed the whole evaluation. The cause the participants in each group laid within the range esti- of withdrawal is provided in Fig. 5. The participants who mated (40 each group). Data was collected at Social Se- did not complete treatment on 11th week measurements curity Hospital Gujranwala. had been included for further analysis. The missing values Akhtar et al. BMC Musculoskeletal Disorders (2020) 21:770 Page 6 of 9 Table 2 Comparison of Scio-demographic data of the patients Variable Experimental group (N = 40) Control group (N = 40) P-value Age Years 36.38 ± 8.93 34.40 ± 9.32 0.336 Gender Male 8 (20%) 14 (32.4) 0.133 Female 32 (80%) 26 (65%) Neer test Type 1: Pain at 90° 34 (85.0%) 38 (95.0%) 0.136 Type 2: Pain at 60°-70° 6 (15.0%) 2 (5.0%) Affected side Right 23 (57.5%) 23 (57.5%) 0.889 Left 15 (37.5%) 14 (35.0%) Both 2 (5.0%) 3 (7.5%) of dropped out patients were included in the current ana- compared to care group at different time points (base lysis by using last observation carried forward (LOCF). line, 5th and 11th week). The experimental sheet/ flow sheet is presented through Fig. 5. Secondary outcome The results of secondary outcome were reported in The baseline demographic profile Table 4. For the care group, average UCLA score were The baseline characteristics are presented in Table 2. 14.50 ± 2.37, 19.07 ± 4.43 and 20.10 ± 4.08 at base line, Demographic profile shows that most of the patients 5th and 11th week respectively. Similarly, average UCLA suffering from SIS were female, who were 32 in experi- score for experimental group were 14.05 ± 2.59, 27.90 ± mental group and 26 in care group. It was also observed 4.13 and 28.58 ± 3.89 at base line, 5th and 11th week re- that mostly patients falling in type-1 Neer classification. spectively. The UCLA score of experimental group was Neer type-1 impingement was categorized by oedema as more improved as compared to care group at different well as subacromial bursitis and supraspinatus muscle stages. involvement. It was mostly diagnosed among those par- ticipants who were younger than 25 years of age and Outcomes and estimation shown in Table 2 [3]. For between group comparison Comparison of VAS Primary outcome between experimental and care group was assessed at The results of primary outcome were reported in 11th week. Statistically significant difference was Table 3. For the care group, mean scores of VAS for found with P value < 0.001 and partial ƞ = 0.33. For shoulder pain were 6.78 ± 1.14, 5.0250 ± 1.79 and the main effect of time and interaction (time*group) 2 2 4.90 ± 1.58 at base line, 5th and 11th week respect- were ƞ =0.79 and ƞ 0.43 respectively that was ively. For experimental group, average score of VAS shown in Table 3.Similarly,UCLAscoresfor func- was 6.95 ± 1.28, 2.15 ± 1.87 and 2.15 ± 1.55 at base tional disability in shoulder were compared between line, 5th and 11th week respectively. These results in- experimental and care group at 11th week that was dicate significant difference in score of VAS. Shoulder found statistically significance difference with P value pain of experimental group was average improved as <0.001 and Partial ƞ = 0.49. For the main effect of Table 3 Comparison of mean difference (95% CI) of between and within group comparison and partial ƞ with P value Outcome measures Mean (95% CI) Within group comparison Mean difference Partial P-value (95% Cl) of ƞ Experimental group Control group between group comparison by ANOVA (Experimental vs Control) Pain assessment Baseline 6.95 (6.60–7.30) 6.78 (6.42–7.13) 1.82(−2.38 to-1.25) 0.34 < 0.001 5th week 2.15 (1.60–2.71) 5.03 (4.46–5.59) 11th week 2.15 (1.66–2.64) 4.90 (4.41–5.40) Partial ƞ for time 0.79 –– – Partial ƞ for interaction (time*group) 0.43 –– – P-value for within group < 0.001 < 0.001 –– – Akhtar et al. BMC Musculoskeletal Disorders (2020) 21:770 Page 7 of 9 Table 4 Comparison of mean difference (95% CI) of between and within group comparison and partial ƞ with P value Outcome measures Mean (95% CI) Within group comparison Mean difference Partial P-value (95% Cl) of between ƞ Experimental group Control group group comparison by ANOVA (Experimental vs Control) UCLA score Baseline 14.05 (13.27–14.83) 14.50 (13.72–15.28) 5.62 (4.32–6.92) 0.49 < 0.001 5th week 27.90 (26.55–29.25) 19.08 (17.73–20.42) 11th week 28.58 (27.32–29.83) 20.10 (18.84–21.36) Partial ƞ for time 0.81 –– – Partial ƞ for interaction (time*group) 0.49 –– – P-value for within group < 0.001 < 0.001 –– – time and interaction (time*group) were ƞ =0.81 and clinicians in making education decision for implement- ƞ 0.49 respectively that was shown in Table 4.Over ing these techniques in to clinical practice [20]. all pain severity and shoulder disability were de- In a systemic review efficacy of neuromobilization was creased in experimental group as compare to care examined, this study concluded the positive therapeutic group at 11th week. effects of the neuromobilization [27]. Harms The effects of routine physiotherapy with and without Total six participants were dropped out on 11th week in NM on UCLA score experimental group, two patients were dropped out be- The results of the current study have shown improve- cause they were not satisfied with the treatment, one pa- ment in UCLA scores of experimental group as compare tient dropped out due to worsening of the symptoms to care group at 5th and 11th week. Findings of this and three patients due to lack of time. Similarly in con- study indicated NM has positive effects to improve trol group four patients dropped out due to dissatisfac- UCLA score. tion of the treatment given to them and two participants The given findings of our study confirm this NM is ef- due to lack of time. fective in improving UCLA score on 5th week and 11th week. The similar results were also noted in the study of Discussion Richard F. Ellis et al. who found that shoulder pain and The results of routine physiotherapy with and without disability scores were significantly improved in the ex- NM during the pain perimental group [27]. The results of the current study demonstrated the im- Neurophysiological result of spinal mobilization was provement of pain among the two groups with SIS at earlier shown that mobilization of nervous tissue en- 5th and 11th week. So, it was greater betterment in the hances peripheral blood flow, using a physiological shift experimental group as compared to the care group. The toward parasympathetic domination [28, 29]. results of a study by Pritam Deka revealed that NM has Different neuromuscular responses (like hypoalgesia, fruitful effects in mitigating the pain by restoring neuro- the motor neuron pool activity, afferent discharge and dynamics properties in upper limb [24]. Robert J Nee changes in the mobility of muscle) associated with neu- et al. study has found immediate relief of pain in arm romobilization indirectly indicates the spinal cord medi- with no evidence of harmful effects and future ated effect of the NM. Neuromobilization had an quick researches are recommended to check long term effects hypoalgesic effect on C-fibre mediated pain perception, of NM on pain [25]. It was observed that the use of neu- as not on A-delta fibre mediated pain perception [30]. romobilization has shown beneficial effect for short Another reason of more improvement of function in period over pain [26]. the experimental group may be shown the restoration of The results of current study were also similar with Pri- mobility due to the biomechanical effects which are tam Deka, who explored that neuromobilization was ef- inter-linked with NM [30]. fective treatment for pain. When neurombilization combined with TENS were used, more effective results Limitations were found on cervical radiculopathy [24]. The current There are several limitations of current study that war- study determined the results to be similar to those of rant the further discussion. However, benefits of a Matocha MA et al. who found that pain intensity de- smaller sample size were the ability to supervise the ex- creased weekly basis as decreased in present study on ercises program and more closely interaction with pa- 5th and 11th week but further research is needed to help tients on a daily basis during the exercise sessions for Akhtar et al. BMC Musculoskeletal Disorders (2020) 21:770 Page 8 of 9 better results. In particular, the adherence to the pre- interpretation of data. AG: Revision of the manuscript and critical appraisal for final approval to be published. AA: Drafting and data interpretation. AR: scribed exercise intensity and program was excellent for Statistical analysis and interpretation. All authors have read and approved the both exercise treatment groups. Second, the present manuscript. study (11 weeks) was also relatively reasonable in dur- Funding ation compared to previous training investigations [31]. There is no funding source for this article publication. Improvements in pain and functional disability score was found in the present study which indicated that 11 Availability of data and materials The data sets used and/or analyzed during the current study are available weeks exercise training period was a sufficient time from the corresponding author on reasonable request. frame to demonstrate significant training effects. Ethics approval and consent to participate Ethical approval was taken from University of Lahore, Ethical review Generalizability committee Professor Dr. Syed Amir Gilani Dean Faculty of Allied Health Sciences is Chairman of committee with reference No. IRB-UOL-FAHS/ Clinical considerations for effective neuromobilization 00238-II. The written informed consent was obtained from all participants with the following consent statement. in clinical treatment After recognizing the close rela- “I have read this consent form and agreed to participate in this study. I give tionship between physical capacities and life style, it is my consent to enroll myself in this study”. likely to be declared that implementation of NM recom- Participant’s signature-------------------------------- Date. mended standard part of the treatment for SIS patients Consent for publication will decrease shoulder pain and improve function. This Not applicable. study shows that NM is not only feasible as a part of the treatment, but it also has a large effect size and efficient Competing interests The authors declared that Professor Dr. Amir Gilani is Chairperson of ethical for all the times. review committee and also coauthor of our study. Patients of SIS who suffer from many challenges, so it is important to recognize that shoulder pain and func- Received: 9 March 2020 Accepted: 11 November 2020 tional disability score constitute an important part of overall health and daily tasks. Since shoulder impinge- References ment syndrome are known to be important key factor 1. Gebremariam L, Hay EM, van der Sande R, Rinkel WD, Koes BW, Huisstede BM. Subacromial impingement syndrome—effectiveness of physiotherapy for daily life activities in term of pain and function. Im- and manual therapy. Br J Sports Med. 2014;48(16):1202–8. portantly, this study, as well as neuromobilization re- 2. Koh E-K, Jung D-Y. 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The effectiveness of routine physiotherapy with and without neuromobilization on pain and functional disability in patients with shoulder impingement syndrome; a randomized control clinical trial

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Springer Journals
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Copyright © The Author(s) 2020
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1471-2474
DOI
10.1186/s12891-020-03787-0
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Abstract

Background: The objective of the study was to compare the effects of neuromobilization (NM) techniques and routine physiotherapy on pain and functional disability in patients having shoulder impingement syndrome (SIS). Present study was aimed to discover evidence based conservative and cost effective remedy on pain and functional disability. Study design: Single blinded randomized control clinical trial. Methods: A total of 80 patients with SIS were randomly assigned into care and experimental groups (40 in each group). After the baseline assessment routine physiotherapy was executed on both groups, while NM was applied additionally to experimental group. Pain and functional disability score were evaluated by Visual Analogue Scale and University of California at Los Angeles rating score at baseline, 5th and 11th week. Differences in outcome between groups were evaluated with clinical improvement. Results: The experimental group compared with care group at 11th week had lower mean pain score 2.15(1.66– 2.64) vs 4.90(4.41–5.40); between group difference, 1.82; 95% (CI), − 2.38 to − 1.25; P < 0.001 and Partial ƞ = 0.33, similarly functional disability score 28.58(27.32–29.83) vs 20.10(18.84–21.36); between group difference,5.62; 95%CI, (4.32–6.92); P< 0.001 and Partial ƞ = 0.49 respectively. In experimental group NM was a more effective technique to reduce the pain severity and disability in SIS patients as compare to care group. Conclusion: Neuromobilization techniques in addition to routine physiotherapy were significantly effective for the treatment of SIS. Trial registration: IRCT20190121042445N1, Registered 19 February 2019. Keywords: Shoulder impingement, Neuromobilization, Functional disability * Correspondence: a.hunjra@gmail.com University of Lahore, Lahore, Pakistan © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Akhtar et al. BMC Musculoskeletal Disorders (2020) 21:770 Page 2 of 9 Background mechanical stimulation used at low frequency, low in- The shoulder impingement syndrome (SIS) consists of tensity ultrasound is indicated to arouse neurons in the rotator cuff tendonitis and bursitis of the shoulder mouse brain by activating voltage gated sodium and cal- [1]. It shows the inflammation of the supraspinatus ten- cium channels. The slow elongation can cause structural don inside the anteroinferior junction of the acromion changes in myelin sheath, axon regeneration, deposition and the greater tuberosity of the humerus. Patients with of endoneurial collagen. The nodes of ranvier can open SIS report severe acute pain which increases during over- further as it causes the Schmidt- Lanterman clefts which head activities as well as sleeping on affected side [2]. affects the levels of local cytoplasm [8]. SIS comprises of three stages, the 1st stage is defined The neural component is over looked due to poor by edema and hemorrhage of the subacromial bursa and outcomes among patients with tendinopathy. Matocha rotator cuff muscle; it has been detected in patients where MA et al. highlighted neural involvement in patients age group is less than 25 years. The next stage indicates ir- with tendon pain and discussed the role of NM for reversible changes, which are fibrosis combine with tendi- tendon pain [9]. The utilization of neurodynamics may nopathy of the rotator cuff muscle. It is highly prevalent be important for the treatment purposes in patients among 25 to 40 years old population. At 3rd stage im- who suffer with tendonopathies which has neural pingement is evident by more severe changes, like partial component [6, 10]. or complete tears of the rotator cuff, mostly observed among patients who are above 40 years age [3, 4]. Objective The execution of specific components of body move- The objective of the study was to compare the effects of ments to generate particular mechanical incident in the NM techniques and routine physiotherapy on pain and neural system is called NM. Mechanical management functional disability in patients having SIS. Present study may therefore be used to augment physiology in the ner- was aimed to discover evidence based conservative and vous system [5]. cost effective remedy on pain and functional disability. It has already been observed that there are three theor- ies projected for the local etiological origin of tendon pain: 1-mechanical, 2-vascular and 3- neural [6, 7]. Methods Mechanical and vascular theories are regularly used Trial design for the treatment of tendon pain. The mechanical theory The model of study was single blinded randomized con- is based on the idea of mechanical overload of the ten- trolled clinical trial. This controlled trial used a parallel don resulting in damage to the collagen. Tendons that design where patients were allotted by 1:1 ratio in two receive high strain loads such as the Achilles are often groups’ experimental group as well as care group. These loaded during movement and have been suggested to patients had gone through a complete systemic physical sustain physiological strain up to 6–8%. examination that included the whole neurologic and The vascular theory is based on the concept that ten- musculoskeletal assessments. Patients with history of don may experience vascular compromise and neurovas- shoulder surgery, shoulder injury, trauma, shoulder joint cularization. Due to lack of vascularity, the tendon is not dislocation, cervical radioculopathy and having other capable of healing because of repetitive high strain load. systemic diseases were excluded from the study. The pa- A study conducted by Rees JD et al. observed mechan- tients with positive upper limb tension test [11], Neer ical, vascular and neural theories which have proposed test [3, 4], Hawkins Kennedy [12] Empty Can [12], pain- for tendinopathy and point out the potential appropriate ful arc and cross body adduction test [13] were included use of NM. The use of NM has the potential to lessen for study. the perception of pain. The movement of the nervous system during NM may restore axoplasm flow, restoring Randomization nutrients to the nerves. The restoration of nerve func- A sample of 80 participants was selected and allocated tion may then lessen sensitivity (i.e ion channels) to the in to two groups experimental and care group by using area and restore normal blood flow to the tendon [7]. computer generator method in simple random sampling Physiologically we may explain that a nerve which technique. closely passes to a joint is mostly kept in a tunnel or it is attached with collagen fibres or fascia to the nearby musculoskeletal components. Nerves move side by side Blinding within the upper limb hence the neuromobilization An independent assessor, who specialized in musculo- given during management cause break of the cross link- skeletal injuries with more than 5 year experience of ages. The possible effect of stretch on axons is the im- dealing patients with shoulder injury, had performed al- proved ion flux in stretch sensitive ion channels. The location of patients. Akhtar et al. BMC Musculoskeletal Disorders (2020) 21:770 Page 3 of 9 Participants Routine physical therapy Diagnosed patients with SIS was participated in this re- The routine Physiotherapy consisted of pulsed Short search. The study purpose was described to all patients Wave Diathermy (SWD) with frequency 27.12 MHZ and informed consent was taken from them. After ap- [16], Ultrasonic Therapy (US) with frequency 1.0 MHZ proval from Institutional Review Board “The University of and intensity 1.45w/cm [17] and Transcutaneous Elec- Lahore” and present study was completed at physiother- trical Nerve Stimulator (TENS) 2–200 HZ with output apy department of Social Security Hospital Gujranwala. current < 20 Ma width 200 μ seconds along with continu- ous mode. Exercises were comprised of shoulder streng- Procedures thing and stretching exercises that were performed for 5 After initial assessment, the investigator used to take s with 10 repetitions for both experimental and care demographic details of the participants along with visual groups as shown in Table 1 [18]. analogue scale (VAS) and functional disability rating score. Neuromobilization All the patient related information was kept confiden- NM was applied by using Butler’s recommendations tial and they were free to quit the study at anytime. [19]. Initially, the patient performed neural sliders and VAS was used to evaluate the severity of pain and it gradually progressed to neural tensioners. Neural sliders was considered as primary outcome of the current study. consisted of cervical lateral flexion movement, toward A constant scale had been employed to inquire the pa- the involved side, simultaneously with elbow flexion and tients about the shoulder pain during the activity and to extension movements. While moving the head in to cer- classify it by indicating on a 10-mm line; it was con- vical lateral flexion the elbow was extended. When the nected “no pain” and the “worst pain you have ever felt”. elbow began to flex, the cervical spine was returned to This is common method of evaluating severity of shoul- neutral position as shown in Figs. 1 and 2. Neural ten- der pain. The findings of the study indicate the VAS is a sioners were performed to create tension in the nerve to high reliable as well as valid method to assess the sever- get the desired results. The tension position was not ity of pain [14]. The UCLA score was used to assess held for a length of time, but is released by extending functional disability and it has total 35 points, with the elbow and returning the cervical spine to neutral. higher values indicating better shoulder condition. The Once the patient had pushed slight pain or discomfort at UCLA score has 5 domains; pain 10 points, function 10 any point as shown in Figs. 3 and 4 [20]. NM technique points, active forward flexion 5 points, strength of for- was performed for 5 s with 10 repetitions to control the ward flexion 5 points and satisfaction of the patient 5 pain and improve the functional disability score to relive points [15]. The score was assessed at base line, 5th and the pain shown in Table 1. 11th week. The internal consistency or reliability of UCLA was 0.78 to 0.89 and 0.51 to 0.59 for post surgical Outcome measures and non surgical respectively. As an outcome measure for pain severity (0 = no pain and 10 = severe pain) VAS was used with reliability 0.94 Interventions at baseline, 5th and 11th week [14]. Pain was considered Routine physiotherapy was performed on both groups as primary outcome. while NM was done on experimental group. Patients UCLA score was assessed at baseline, 5th and 11th week. were treated thrice a week on alternative days. The UCLA score was used to assess functional disability Table 1 List of exercises performed under experimental and routine physiotherapy group Experimental group (stretching and strengthing exercises Routine physiotherapy group (stretching and strengthing + neuromobilization) exercises) 1) STRETCHING EXERCISES 1) STRETCHING EXERCISES a) Shoulder external rotation stretch a) Shoulder external rotation stretch b) Cross body posterior stretch b) Cross body posterior stretch c) Stretch for anterior aspect of shoulder c) Stretch for anterior aspect of shoulder d) Shoulder flexion stretch d) Shoulder flexion stretch 2) STRENGTHING EXERCISES 2) STRENGTHING EXERCISES a) Chair press a) Chair press b) Restricted scapular retraction b) Restricted scapular retraction c) Restricted scapular protraction c) Restricted scapular protraction o o o o d) Shoulder abduction “Scaption” (0 -90 ) with theraband d) Shoulder abduction “Scaption” (0 -90 ) with theraband e) Shoulder scapular extension with theraband e) Shoulder scapular extension with theraband 3) NEUROMOBILIZATION EXERCISES a) Neural slider technique b) Neural tensioner technique Akhtar et al. BMC Musculoskeletal Disorders (2020) 21:770 Page 4 of 9 Fig. 3 Neural tensioner starting position cervical lateral flexion and elbow flexion Fig. 1 Neural slider starting position with elbow flexion 2SD Z þ Z a=2 Sample size ¼ and it has total 35 points, with higher values indicating bet- ter shoulder condition. The UCLA score has 5 domains; pain 10 points, function 10 points, active forward flexion 5 Where SD = Standard deviation = 14.08, Z is type 1 − a/2 points, strength of forward flexion 5 points and satisfaction 1 error = 1.96, Z = 0.84, d = μ − μ = 10.7 β 2 1 . of the patient 5 points [15]. The score was assessed at base Based on this a total sample size of around 80(experi- line 5th and 11th week. The internal consistency or reliabil- mental = 40, care = 40) was calculated to be an adequate ity of UCLA was 0.78 to 0.89 and 0.51 to 0.59 for post sur- mean to reach the conclusion. Considering a loss of 20% gical and non surgical respectively. The UCLA score was follow-up, at least 80% patients followed the treatments considered as secondary outcome. [23]. An experimental group and a care group were re- cruited which were based on the inclusion criteria for this study (Fig. 5). Both groups were selected by regu- Sample size larly visiting the physiotherapy department at Social Se- Sample size calculation was derived from Yamany AA curity Hospital Gujranwala. et al. study [21]. According to clinical trials, the sample size estimation formula was implemented [22]. Data analysis Statistical analysis Data were analyzed by using (SPSS Version 22.0) software. Qualitative data were presented in frequencies and percent- ages while mean and S. D were calculated for Quantitative Fig. 2 Neural slider final position with cervical flexion along with Fig. 4 Neural tensioner final position extending the elbow and elbow extension returning the cervical spine in neutral Akhtar et al. BMC Musculoskeletal Disorders (2020) 21:770 Page 5 of 9 Fig. 5 Experimental sheet/flow sheet data. Line chart was drawn at various times in weeks during Participant flow the treatment vs pain score and UCLA score. One hundred and twenty participants had been observed Repeated measure ANOVA was applied to compare aver- for eligibility process at the time of September 2016 till age pain score as primary outcome while average UCLA February 2018, among 30 participants had not been found score as a secondary outcome at different time points (base- eligible. The ineligible participants were excluded from line, 5th week, 11th week). The confidence level of 95% was the current study and was given the routine physiotherapy used as well as p value ≤0.05 was considered as significant. treatment. The reasons for ineligibility of the patients are presented in Fig. 5, out of 90 eligible participants, 10 had further excluded as they denied being part of study. The Results above mentioned 10 participants were also given the rou- Recruitment tine physiotherapy treatment. The rest of 80 participants The current study was started on September 2016 and divided in an experimental group and a care group. On last follow up was occurred on March 2018 and then 11th week follow-up, 12 participants left the study and 68 trial ended. It was considered regarding the number of patients had completed the whole evaluation. The cause the participants in each group laid within the range esti- of withdrawal is provided in Fig. 5. The participants who mated (40 each group). Data was collected at Social Se- did not complete treatment on 11th week measurements curity Hospital Gujranwala. had been included for further analysis. The missing values Akhtar et al. BMC Musculoskeletal Disorders (2020) 21:770 Page 6 of 9 Table 2 Comparison of Scio-demographic data of the patients Variable Experimental group (N = 40) Control group (N = 40) P-value Age Years 36.38 ± 8.93 34.40 ± 9.32 0.336 Gender Male 8 (20%) 14 (32.4) 0.133 Female 32 (80%) 26 (65%) Neer test Type 1: Pain at 90° 34 (85.0%) 38 (95.0%) 0.136 Type 2: Pain at 60°-70° 6 (15.0%) 2 (5.0%) Affected side Right 23 (57.5%) 23 (57.5%) 0.889 Left 15 (37.5%) 14 (35.0%) Both 2 (5.0%) 3 (7.5%) of dropped out patients were included in the current ana- compared to care group at different time points (base lysis by using last observation carried forward (LOCF). line, 5th and 11th week). The experimental sheet/ flow sheet is presented through Fig. 5. Secondary outcome The results of secondary outcome were reported in The baseline demographic profile Table 4. For the care group, average UCLA score were The baseline characteristics are presented in Table 2. 14.50 ± 2.37, 19.07 ± 4.43 and 20.10 ± 4.08 at base line, Demographic profile shows that most of the patients 5th and 11th week respectively. Similarly, average UCLA suffering from SIS were female, who were 32 in experi- score for experimental group were 14.05 ± 2.59, 27.90 ± mental group and 26 in care group. It was also observed 4.13 and 28.58 ± 3.89 at base line, 5th and 11th week re- that mostly patients falling in type-1 Neer classification. spectively. The UCLA score of experimental group was Neer type-1 impingement was categorized by oedema as more improved as compared to care group at different well as subacromial bursitis and supraspinatus muscle stages. involvement. It was mostly diagnosed among those par- ticipants who were younger than 25 years of age and Outcomes and estimation shown in Table 2 [3]. For between group comparison Comparison of VAS Primary outcome between experimental and care group was assessed at The results of primary outcome were reported in 11th week. Statistically significant difference was Table 3. For the care group, mean scores of VAS for found with P value < 0.001 and partial ƞ = 0.33. For shoulder pain were 6.78 ± 1.14, 5.0250 ± 1.79 and the main effect of time and interaction (time*group) 2 2 4.90 ± 1.58 at base line, 5th and 11th week respect- were ƞ =0.79 and ƞ 0.43 respectively that was ively. For experimental group, average score of VAS shown in Table 3.Similarly,UCLAscoresfor func- was 6.95 ± 1.28, 2.15 ± 1.87 and 2.15 ± 1.55 at base tional disability in shoulder were compared between line, 5th and 11th week respectively. These results in- experimental and care group at 11th week that was dicate significant difference in score of VAS. Shoulder found statistically significance difference with P value pain of experimental group was average improved as <0.001 and Partial ƞ = 0.49. For the main effect of Table 3 Comparison of mean difference (95% CI) of between and within group comparison and partial ƞ with P value Outcome measures Mean (95% CI) Within group comparison Mean difference Partial P-value (95% Cl) of ƞ Experimental group Control group between group comparison by ANOVA (Experimental vs Control) Pain assessment Baseline 6.95 (6.60–7.30) 6.78 (6.42–7.13) 1.82(−2.38 to-1.25) 0.34 < 0.001 5th week 2.15 (1.60–2.71) 5.03 (4.46–5.59) 11th week 2.15 (1.66–2.64) 4.90 (4.41–5.40) Partial ƞ for time 0.79 –– – Partial ƞ for interaction (time*group) 0.43 –– – P-value for within group < 0.001 < 0.001 –– – Akhtar et al. BMC Musculoskeletal Disorders (2020) 21:770 Page 7 of 9 Table 4 Comparison of mean difference (95% CI) of between and within group comparison and partial ƞ with P value Outcome measures Mean (95% CI) Within group comparison Mean difference Partial P-value (95% Cl) of between ƞ Experimental group Control group group comparison by ANOVA (Experimental vs Control) UCLA score Baseline 14.05 (13.27–14.83) 14.50 (13.72–15.28) 5.62 (4.32–6.92) 0.49 < 0.001 5th week 27.90 (26.55–29.25) 19.08 (17.73–20.42) 11th week 28.58 (27.32–29.83) 20.10 (18.84–21.36) Partial ƞ for time 0.81 –– – Partial ƞ for interaction (time*group) 0.49 –– – P-value for within group < 0.001 < 0.001 –– – time and interaction (time*group) were ƞ =0.81 and clinicians in making education decision for implement- ƞ 0.49 respectively that was shown in Table 4.Over ing these techniques in to clinical practice [20]. all pain severity and shoulder disability were de- In a systemic review efficacy of neuromobilization was creased in experimental group as compare to care examined, this study concluded the positive therapeutic group at 11th week. effects of the neuromobilization [27]. Harms The effects of routine physiotherapy with and without Total six participants were dropped out on 11th week in NM on UCLA score experimental group, two patients were dropped out be- The results of the current study have shown improve- cause they were not satisfied with the treatment, one pa- ment in UCLA scores of experimental group as compare tient dropped out due to worsening of the symptoms to care group at 5th and 11th week. Findings of this and three patients due to lack of time. Similarly in con- study indicated NM has positive effects to improve trol group four patients dropped out due to dissatisfac- UCLA score. tion of the treatment given to them and two participants The given findings of our study confirm this NM is ef- due to lack of time. fective in improving UCLA score on 5th week and 11th week. The similar results were also noted in the study of Discussion Richard F. Ellis et al. who found that shoulder pain and The results of routine physiotherapy with and without disability scores were significantly improved in the ex- NM during the pain perimental group [27]. The results of the current study demonstrated the im- Neurophysiological result of spinal mobilization was provement of pain among the two groups with SIS at earlier shown that mobilization of nervous tissue en- 5th and 11th week. So, it was greater betterment in the hances peripheral blood flow, using a physiological shift experimental group as compared to the care group. The toward parasympathetic domination [28, 29]. results of a study by Pritam Deka revealed that NM has Different neuromuscular responses (like hypoalgesia, fruitful effects in mitigating the pain by restoring neuro- the motor neuron pool activity, afferent discharge and dynamics properties in upper limb [24]. Robert J Nee changes in the mobility of muscle) associated with neu- et al. study has found immediate relief of pain in arm romobilization indirectly indicates the spinal cord medi- with no evidence of harmful effects and future ated effect of the NM. Neuromobilization had an quick researches are recommended to check long term effects hypoalgesic effect on C-fibre mediated pain perception, of NM on pain [25]. It was observed that the use of neu- as not on A-delta fibre mediated pain perception [30]. romobilization has shown beneficial effect for short Another reason of more improvement of function in period over pain [26]. the experimental group may be shown the restoration of The results of current study were also similar with Pri- mobility due to the biomechanical effects which are tam Deka, who explored that neuromobilization was ef- inter-linked with NM [30]. fective treatment for pain. When neurombilization combined with TENS were used, more effective results Limitations were found on cervical radiculopathy [24]. The current There are several limitations of current study that war- study determined the results to be similar to those of rant the further discussion. However, benefits of a Matocha MA et al. who found that pain intensity de- smaller sample size were the ability to supervise the ex- creased weekly basis as decreased in present study on ercises program and more closely interaction with pa- 5th and 11th week but further research is needed to help tients on a daily basis during the exercise sessions for Akhtar et al. BMC Musculoskeletal Disorders (2020) 21:770 Page 8 of 9 better results. In particular, the adherence to the pre- interpretation of data. AG: Revision of the manuscript and critical appraisal for final approval to be published. AA: Drafting and data interpretation. AR: scribed exercise intensity and program was excellent for Statistical analysis and interpretation. All authors have read and approved the both exercise treatment groups. Second, the present manuscript. study (11 weeks) was also relatively reasonable in dur- Funding ation compared to previous training investigations [31]. There is no funding source for this article publication. Improvements in pain and functional disability score was found in the present study which indicated that 11 Availability of data and materials The data sets used and/or analyzed during the current study are available weeks exercise training period was a sufficient time from the corresponding author on reasonable request. frame to demonstrate significant training effects. Ethics approval and consent to participate Ethical approval was taken from University of Lahore, Ethical review Generalizability committee Professor Dr. Syed Amir Gilani Dean Faculty of Allied Health Sciences is Chairman of committee with reference No. IRB-UOL-FAHS/ Clinical considerations for effective neuromobilization 00238-II. The written informed consent was obtained from all participants with the following consent statement. in clinical treatment After recognizing the close rela- “I have read this consent form and agreed to participate in this study. I give tionship between physical capacities and life style, it is my consent to enroll myself in this study”. likely to be declared that implementation of NM recom- Participant’s signature-------------------------------- Date. mended standard part of the treatment for SIS patients Consent for publication will decrease shoulder pain and improve function. This Not applicable. study shows that NM is not only feasible as a part of the treatment, but it also has a large effect size and efficient Competing interests The authors declared that Professor Dr. Amir Gilani is Chairperson of ethical for all the times. review committee and also coauthor of our study. Patients of SIS who suffer from many challenges, so it is important to recognize that shoulder pain and func- Received: 9 March 2020 Accepted: 11 November 2020 tional disability score constitute an important part of overall health and daily tasks. Since shoulder impinge- References ment syndrome are known to be important key factor 1. Gebremariam L, Hay EM, van der Sande R, Rinkel WD, Koes BW, Huisstede BM. Subacromial impingement syndrome—effectiveness of physiotherapy for daily life activities in term of pain and function. Im- and manual therapy. Br J Sports Med. 2014;48(16):1202–8. portantly, this study, as well as neuromobilization re- 2. Koh E-K, Jung D-Y. 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