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Journal of Exercise Physiologyonline

June 2019 Volume 22 Number 3

Editor-in-Chief Tommy Boone, PhD, MBA Review Board Todd Astorino, PhD Julien Baker, PhD Steve Brock, PhD Lance Dalleck, PhD Eric Goulet, PhD Robert Gotshall, PhD Alexander Hutchison, PhD M. Knight-Maloney, PhD Len Kravitz, PhD James Laskin, PhD Yit Aun Lim, PhD Lonnie Lowery, PhD Derek Marks, PhD Cristine Mermier, PhD Robert Robergs, PhD Chantal Vella, PhD Dale Wagner, PhD Frank Wyatt, PhD Ben Zhou, PhD Official Research Journal of the American Society of

Exercise Physiologists

ISSN 1097-9751

Official Research Journal of the American Society of Exercise Physiologists

ISSN 1097-9751

JEPonline

Does Indirect Stability and Mobility Training Alleviate Pain and Increase the Functionality of the Shoulders in Elderly with Shoulder Stiffness? Juthachai Saithong, Witid Mitranun Department of Sports Science, Faculty of Physical Education, Srinakharinwirot University, Ongkharak, Nakhon Nayok, Thailand

ABSTRACT Saithong J, Mitranun W. Does Indirect Stability and Mobility Training Alleviate Pain and Increase the Functionality of the Shoulders in Elderly with Shoulder Stiffness? JEPonline 2019;22 (3):95-107. This study investigated and compared the effects of indirect stability and mobility training (ISMT) on the elderly who experience shoulder stiffness. The research subjects were 24 males and females 50 to 70 yrs of age. The subjects were equally divided into an ISMT group and a control (CON) group using the stratified sampling method based on age, sex, and range of shoulder rotation. The ISMT group trained 8 to 12 times per set for 2 to 3 sets, 3 days a week for 4 wks. Received pain on the Visual Analog Scale (VAS), flexion (FX), extension (EX), internal rotation (IR), and external rotation (ER) scores before and after training were measured. It was found that for the ISMT group there was an increase in the in-group FX, IR, and ER scores (P<0.05) and an increase in the between-group FX and ER scores (P<0.05). Both in-group and between-group VAS scores decreased (P<0.05). The findings showed that VAS had negative correlations with FX (r = -0.524, P<0.01) and EX (r = -0.411, P<0.05). It can be concluded that the ISMT may help alleviate pain and increase the functionality of the shoulders. Key Words: Kinetic Chain, Mobility and Stability Training, Range of Motion, Shoulder Stiffness, Visual Analogue Scale

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INTRODUCTION Shoulder stiffness is a physical condition commonly found in middle-aged to elderly people (27). The condition results from a sudden injury or the repeated use of the body part when full recuperation has not occurred. This condition triggers pain and a limited range of shoulder motion, especially for internal rotation (IR) and external rotation (ER). This eventually makes the shoulder lose its functionality (4,19,23,25,28). Nowadays, shoulder stiffness can be treated by various methods such as ultrasound, massage, medication, thermotherapy, cryotherapy, operation, physical therapy, and exercises with resistance bands (4,7,8,14,15). Most of the therapy methods involve direct treatment of the shoulder. However, researchers believe that the direct treatment of the shoulder may result in an increase in pain due to the direct force applied and excessive movement. Also, it may discourage patients from continuing treatment. Indirect treatment that does not require much movement of the shoulder would likely trigger less pain. Thus, in the present study the researchers focus on indirect shoulder training in the hopes of encouraging more patients to seek treatment and reducing the possibility of exacerbating the injury. The indirect stability and mobility training (ISMT) method was developed by the researchers to increase the stability of immovable joints as well as the mobility of movable joints. This kinetic chain exercise aims at increasing the functionality of each body part. The human body can be seen as being like a chain with connected links. If one link is damaged, other links may soon also become damaged. Therefore, the recovery of the kinetic chain involves the recovery of each link of the body. The principle is to exercise the link farthest from the injured link before moving to the closer ones (1,31). To our knowledge, this method of therapy for shoulder stiffness has not been studied previously. Comparable studies have however been conducted on strength training or stability and mobility training of people with shoulder problems. By increasing the range of motion and developing the muscles near the shoulder and scapula, these studies found an increase in the stability and mobility of the shoulder (11,26,29,31). These previous studies have led to the present study’s research questions: (a) Is ISMT effective in curing shoulder stiffness? and (b) Based on the kinetic chain principle, which states that if one link of a chain is damaged, other links will also become damaged, by treating areas farther from the injured shoulder before treating the closer ones, will the therapy help decrease the pain and increase the range of shoulder motion?

97 METHODS Subjects The subjects were males and females recruited through Srinakharinwirot University, Nakhon Nayok, Thailand. They were divided into a control group (CON = 12) and an indirect stability and mobility training group (ISMT = 12). The subjects were patients whose age range was between 50 and 70, and whose range of external rotation at the shoulder was less than 90º. They were free from known cardiovascular diseases and had not previously experienced a severe shoulder injury that limited range of motion. Also, they were excluded from the study if they experienced any injury or accident during the training period. The study was approved by the Ethics Committee of Srinakharinwirot University, Thailand (SWUEC-01061E) and written consent was obtained from all the subjects. Training program The first day of Week 1 concerned basic training to prepare the subjects for the actual training. It started with 5 min of warm-up exercises such as walking in place, arm rotation, shoulder rotation, arm flexion, arm extension, arm swinging, and arm abduction, and adduction. After the warm-up period, the training began. It comprised 6 exercises: (1) TVA contraction; (2) pelvic imprint and release; (3) shoulder packing; (4) thoracic sagittal; (5) thoracic lateral; and (6) thoracic transverse. Each exercise was repeated 10 times per set for 1 to 2 sets. There was a break of 15 to 30 sec between the sets. After the training, there was a cool-down period involving static stretching of different muscles. From the following day until the end of the training program, training started with the same 5 min of warm-up exercises including walking in place, arm rotation, shoulder rotation, arm flexion, arm extension, arm swinging, and arm abduction and adduction. After the warm-up, the training began, which comprised 7 exercises: (1) cat and camel; (2) glute bridge; (3) thoracic sagittal; (4) thoracic lateral; (5) thoracic transverse; (6) internal and external humeral rotation; and (7) I Y W O (Figures 1 to 10). Each exercise was repeated 8 to 12 times∙set-1 for 2 to 3 sets. In each exercise, the movement of the subjects in the SMT group was held in place for 1 sec. There was a break for 15 to 30 sec between the sets. After the training, there was a cool-down period involving static stretching of different muscles. The training took place 3 d·wk-1 for 4 wks. Measurements The subjects took an after-training break for 5 min before the systolic and diastolic blood pressure measurements were performed with Omron (HEM-7130, Vietnam). The average blood pressure was calculated using the formula: blood pressure = systolic + 2(diastolic) / 3. Then subjects’ height and weight were measured with NAGATA (BW-2200, Taiwan). The measurements were used to calculate the BMI with the formula: BMI (kg·m-2) = weight (kg) / height-2 (m). After that, the range of motion of the shoulder was measured using Goniometer 360 (Mahidol University, Thailand). Four motions were measured: (1) flexion; (2) extension; (3) internal rotation; and (4) external rotation. Lastly, the subjects were asked to give a score for their current shoulder pain on a scale of 1 to 10. All measurements were performed before and after the training.

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Statistical Analyses

Average ( ) and standard deviation (SD) of all measurements were calculated, and all data were checked for normality. Independent sample t-tests were performed for between-group comparisons, and paired simple t-tests were performed for in-group comparisons. The statistical significance threshold was set at an alpha level of P≤0.05.

Figure 1. Cat and Camel

Figure 2. TVA Contraction

Figure 3. Pelvic Imprint and Release

99 Figure 4. Glute Bridge

Figure 5. Thoracic Transverse

Figure 6. Shoulder Packing Figure 7. I Y W O

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Figure 8. Internal and External Humeral Rotation Figure 9. Thoracic Sagittal Figure 10. Thoracic Lateral

101 RESULTS The baseline data of participant characteristics are shown in Table 1. Both CON and ISMT groups showed similar results based on age, height, body mass, mass index, systolic blood pressure, diastolic blood pressure, and mean arterial pressure. Table 2 demonstrated health related-physical fitness, range of motion (ROM), and visual analogue scale (VAS) scores. As for the pre-test, only the internal rotation was significant between groups. The ISMT group showed a significant increase in external rotation, internal rotation, flexion, and a decrease in VAS scores as compared to the pre-test (P<0.05). There were between-group significant changes in external rotation, flexion and VAS scores (P<0.05). There was no significant change in body mass, mass index, systolic blood pressure, diastolic blood pressure, mean arterial pressure, and extension in both groups. Correlations between range of motion and visual analogue scale are shown in Figure 11. There were correlations between VAS score and flexion (r = -0.524, P<0.01), and VAS score and extension (r = -0.411, P<0.05), but no correlations between VAS score and internal rotation, and VAS score and external rotation.

Table 1. Baseline Data of Subjects’ Characteristics.

CON

ISMT

Total Number (n)

12

12

Age (yrs) 63.8 ± 7.1 62.8 ± 6.1

Height (cm) 159.6 ± 5.2 156.3 ± 7.3

Body Mass (kg) 62.5 ± 7.7 56.6 ± 13.8

Body Mass Index (kg·m-2) 24.5 ± 2.7 23.0 ± 4.6

Systolic Blood Pressure (mmHg) 124.9 ± 9.3 126 ± 12.8

Diastolic Blood Pressure (mmHg) Mean Arterial Pressure (mmHg)

75.6 ± 10.4 92.0 ± 8.7

76.3 ± 10.3

92.9 ± 9.8

Data are Mean ± SD; CON = Control Group; ISMT = Indirect Stability and Mobility Training Group

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Table 2. Health-Related Physical Fitness, ROM, and Vas Score.

Data are mean ; CON = Control Group; ISMT = Indirect Stability and Mobility Training Group; VAS = Visual Analogue Scale; *P<0.05 vs. Pre, †P<0.05 vs. CON

CON

(n= 12)

ISMT

(n= 12)

Pre Post Pre Post

Body Mass (kg)

62.5 ± 7.7

62.4 ± 7.2

56.6 ± 13.8

56.7 ± 14.2

Body Mass Index (kg·m-2)

24.5 ± 2.7

24.5 ± 2.6

23.0 ± 4.6

23.0 ± 4.7

Systolic Blood Pressure (mmHg)

124.9 ± 9.3

125.9 ± 14.8

126.0 ± 12.8

122.9 ± 15.9

Diastolic Blood Pressure (mmHg)

75.6 ± 10.4

72.9 ± 10.5

76.3 ± 10.3

75.2 ± 10.0

Mean Arterial Pressure (mmHg) External Rotation Internal Rotation Flexion Extension Vas Score

92.0 ± 8.7

81.9 ± 7.8

64.7 ± 7.0

154.0 ± 10.6

46.3 ± 7.8

2.9 ± 3.0

90.6 ± 10.3

84.5 ± 9.7

59.4 ± 7.9

153.2 ± 10.2

49.5 ± 5.1

3.8 ± 3.5

92.9 ± 9.8

83.1 ± 4.9

47.2 ± 13.7† 155.2 ± 11.9

46.8 ± 11.1

2.6 ± 2.4

91.1 ± 11.1

96.7 ± 8.8*†

58.1 ± 17.8*

167.9 ± 6.9 †

49.7 ± 8.9

1.1 ± 1.5*†

103 Figure 11. Correlations Range of motion, Visual Analogue Scale data at post-test (after training 4 wks) VAS = Visual Analogue Scale; †FX = Flexion; *EX = Extension; ER = External Rotation; IR = Internal Rotation, *Correlation P<0.05, †Correlation P<0.01 DISCUSSION The findings showed that the ISMT group had a better range of shoulder motion for flexion, internal rotation, and external rotation. The perceived pain of the ISMT group was also significantly lower. As for correlations, flexion and extension were significantly correlated with the subjects’ perceived pain.

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ISMT focuses on the recovery of the body’s kinetic chain so that each part will function effectively. When one part of the body is injured, other parts will be affected. The principle of the therapy is to treat the area farther from the injury with exercises first before treating the areas closer to the injury (1,31). The training designed by the researchers allows the subjects to exercise within their active range of motion by themselves without assistance, using active range of motion exercises. One advantage of ISMT is that it requires only a narrow range of shoulder motion, focusing on the movements of the parts near the shoulder. The researchers believe that moving the shoulder less will result in less chance of exacerbating the injury when compared with moving the shoulder in a wider range of motion. Our hypothesis was that the movements of the parts near the shoulder would contribute to an increase in the range of shoulder motion and a decrease in the VAS scores. The exercises used in the present study did not involve direct movements of the shoulders, but instead the related links of the chain (1,31). Some of the exercises chosen were those that benefit the range of motion and lower the VAS scores of the shoulder, such as the glute bridge exercise (10). The cat exercise helps stabilize the scapula and reduces shoulder pain, which increases the functionality of the shoulder (6,13). The Y exercise and the thoracic exercise can lower VAS scores and increase the functionality of the shoulder (2,12). Internal and external rotations, the I exercise and the Y exercise also increase the functionality of the shoulder and lower the perceived shoulder pain (2). Chaconas et al. (5) found that internal and external rotation training contributes to an increased range of internal rotation, external rotation, and flexion. Hence, when training with a combination of these exercises, it can be expected to help increase the range of shoulder motion and lower the perceived pain over 4 wks. The present study found that flexion and extension were significantly correlated with the VAS scores. The exercises in the training that help increase the internal and external rotation motions also expand the range of flexion motion. Thus, it can be concluded that the major variables for perceived pain are the range of flexion and extension, respectively. Previous research found that the I exercise, the Y exercise, and the exercises that help increase the mobility of the vertebral column are associated with lower VAS scores and an increase in the functionality of the shoulder (2,13). In addition, the training in the present study also included the I and Y exercises. Thus, exercises that have flexion motion may contribute to the lower VAS scores of the shoulder. To our knowledge, no research has investigated the association between the extension motion and VAS scores. Hence, more research should be conducted in this area. As for the association between internal and external rotations and VAS scores, they do not have significant correlations. However, Bang and Deyle (2) found that internal and external rotations account for better functionality and lower pain in the shoulder. Thus, a combination of the 4 ranges of motion in the training may be associated with the decrease shoulder pain. The training in this study is based on two major principles. The first principle is in regards to the active range of motion and the kinetic chain, which means being able to perform an exercise to move the joint without providing any assistance to the muscles surrounding the joint. This contributes to an increase in the circulation of blood, synovial fluid, and lymph in the joint and related tissues. This, in turn, will help prevent related links from becoming tense, strained or locked, and will eventually result in an improved range of motion of the shoulder

105 (3,9,16,24). Lluch et al. (17) found that exercises that focus on active range of motion contribute to lower VAS scores. The second principle, the kinetic chain, is vital for shoulder recovery. The therapy should start from areas farthest from the injured shoulder. That is, it should start from the core muscles, the lower vertebral column, hips, upper vertebral column, and scapula. When the mentioned parts of the kinetic chain have recovered, the shoulder will function better. This recovery program is likely to be more effective than working only on the shoulder itself (18,21,22,30,31). Choi and Lee (6) studied exercises for scapula stability in middle-aged women and found the exercises to contribute to a better range of shoulder motion and stronger shoulder muscles. Using the kinetic chain as the main principle of the present study, it was found that the range of motion improved and perceived pain was reduced. However, the mechanism behind the improved shoulder condition needs additional clarification in future studies. CONCLUSIONS The findings indicate that ISMT may result in lower perceived pain and improved functionality of the shoulder. This is important because the training program features exercises that are not too challenging for most people before they move on to more advanced training. Also, it is important to point out that the present study found that with only 4 wks of training the condition of the shoulder resulted in improvement. It is very likely that if the training is extended to 8 wks, then even better results may be expected (20). Lastly, future studies should include a larger sample size to address the issue of homogeneity of the subjects in the pre-test before starting the exercise program. Address for correspondence: Witid Mitranun, PhD, Department of Sports Science, Faculty of Physical Education, Srinakharinwirot University, Ongkharak, Nakhon Nayok, Thailand, 26120, Email: mitranunwitid@hotmail.com REFERENCES

1. ACE. Fit Certified Personal Trainer. (5th Edition). Thailand: American Council on Exercise, 2014. 2. Bang MD, Deyle GD. Comparison of supervised exercise with and without manual

physical therapy for patients with shoulder impingement syndrome. J Orthop Sports Phys Ther. 2000;30(3):126-137.

3. Box RC, Reul-Hirche HM, Bullock-Saxton JE, et al. Shoulder movement after breast

cancer surgery: Results of a randomized controlled study of postoperative physiotherapy. Breast Cancer Res Treat. 2002;75(1):35-50.

4. Bulgen D, Binder A, Hazleman B, et al. Frozen shoulder: Prospective clinical study

with an evaluation of three treatment regimens. Ann Rheum Dis. 1984;43(3):353.

106

5. Chaconas EJ, Kolber MJ, Hanney WJ, et al. Shoulder external rotator eccentric

training versus general shoulder exercise for subacromial pain syndrome: A randomized controlled trial. Int J Sports Phys Ther. 2017;12(7):1121.

6. Choi S-H, Lee B-H. Clinical usefulness of shoulder stability exercises for middle-aged women. J Phys Ther Sci. 2013;25(10):1243-1246.

7. Clarke G, Willis L, Fish W, et al. Preliminary studies in measuring range of motion in

normal and painful stiff shoulders. Rheumatology. 1975;14(1):39-46.

8. Dacre J, Beeney N, Scott D. Injections and physiotherapy for the painful stiff shoulder. Ann Rheum Dis. 1989;48(4):322.

9. Devoogdt N, Christiaens M-R, Geraerts I, et al. Effect of manual lymph drainage in addition to guidelines and exercise therapy on arm lymphoedema related to breast cancer: Randomized controlled trial. BMJ. 2011;343:d5326.

10. Eyigor S, Uslu R, Apaydın S, et al. Can yoga have any effect on shoulder and arm

pain and quality of life in patients with breast cancer? A randomized, controlled, single-blind trial. Complement Ther Clin Pract. 2018;32:40-45.

11. Ginn K, Cohen M. Exercise therapy for shoulder pain aimed at restoring

neuromuscular control: A randomized comparative clinical trial. J Rehabil Med. 2005; (2):115-122.

12. Go S-U, Lee B-H. Effects of manual therapy on shoulder pain in office workers. Phys

Ther Sci. 2016;28(9):2422-2425.

13. Go S-U, Lee B-H. Effects of scapular stability exercise on shoulder stability and rehabilitative ultrasound images in office workers. J Phys Ther Sci. 2016;28(11):2999-3002.

14. Holloway GB, Schenk T, Williams GR, et al. Arthroscopic capsular release for the treatment of refractory postoperative or post-fracture shoulder stiffness.JBJS. 2001; 83(11):1682-1687.

15. Lee P, Lee M, Haq A, et al. Periarthritis of the shoulder. Trial of treatments investigated by multivariate analysis. Ann Rheum Dis. 1974;33(2):116.

16. Levick J. Synovial fluid and trans-synovial flow in stationary and moving normal joints. Joint Loading. Biology and Health of Articular Structures. (Editors: Helminen HJ, Kiviranta I, Säämänen AM, Tammi M, Paukkonen K Jurvelin). Butterworth & Co. Ltd. Bristol, 1987, pp. 150-152.

17. Lluch E, Arguisuelas MD, Quesada OC, et al. Immediate effects of active versus passive scapular correction on pain and pressure pain threshold in patients with chronic neck pain. J Manipulative Physiol Ther. 2014;37(9):660-666.

107

18. McMullen J, Uhl TL. A kinetic chain approach for shoulder rehabilitation. J Athl Train. 2000;35(3):329-337.

19. Murrell G, Bhargav D. Shoulder stiffness: Diagnosis. Aust Fam Physician. 2004;33 (3):143.

20. Nawoczenski DA, Ritter-Soronen JM, Wilson CM, et al. Clinical trial of exercise for

shoulder pain in chronic spinal injury. Phys Ther. 2006;86(12):1604-1618.

21. Sciascia A, Cromwell R. Kinetic chain rehabilitation: A theoretical framework. Rehabil Res Pract. 2012.

22. Sciascia A, Thigpen C, Namdari S, Baldwin K. Kinetic chain abnormalities in the

athletic shoulder. Sports Med Arthrosc Rev. 2012;20(1):16-21.

23. Shaffer B, Tibone J, Kerlan R K. Frozen shoulder. A long-term follow-up. J Bone Joint Surg Am. 1992;74(5):738-746.

24. Stubblefield MD, Keole N. Upper body pain and functional disorders in patients with breast cancer. PM&R. 2014;6(2):170-183.

25. Teasell RW. Shoulder problems in the elderly. J Back Musculoskelet Rehabil. 1994;

4(2):110-124.

26. Townsend H, Jobe FW, Pink M, Perry J. Electromyographic analysis of the glenohumeral muscles during a baseball rehabilitation program. Am J Sports Med. 1991;19(3):264-272.

27. Walton J, Murrell G, Hayes K, Paxinos A, et al. Shoulder instability: Diagnosis and

management. Aust Fam Physician. 2001;30(7):655.

28. Wassef M. Suprascapular nerve block: A new approach for the management of frozen shoulder. Anaesthesia. 1992;47(2):120-124.

29. Wilk KE, Arrigo C. Current concepts in the rehabilitation of the athletic shoulder. J

Orthop Sports Phys Ther. 1993;18(1):365-378.

30. Willson JD, Dougherty CP, Ireland ML, Davis IM. Core stability and its relationship to lower extremity function and injury. J Am Acad Orthop Surg. 2005;13(5):316-325.

31. Young JL, Herring SA, Press JM, Casazza BA. The influence of the spine on the shoulder in the throwing athlete. J Back Musculoskelet Rehabil.1996;7(1):5-17.

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