Comparison of the Proprioceptive Neuromuscular Facilitation and Mobilization In Subacromial Impingement Syndrome

Study Overview
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Brief Summary
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Aim of the study was to compare the effectiveness of Proprioceptive Neuromuscular Facilitation (PNF) exercises and Shoulder Mobilization (SM) on pain, range of motion (ROM), functionality, and muscle strength in patients with Subacromial Impingement Syndrome (SIS). Patients received 20 sessions (for 4 weeks) under the supervision of a physiotherapist. Patients were evaluated at baseline, at week two, at week four, and at week sixteen.

Detailed Description
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Aim of the study was to compare the effectiveness of Proprioceptive Neuromuscular Facilitation (PNF) exercises and Shoulder Mobilization (SM) on pain, range of motion (ROM), functionality, and muscle strength in patients with Subacromial Impingement Syndrome (SIS). Forty-four patients were divided into three groups as Group I: Conventional physiotherapy receiving group (control group; n=14), Group II: Conventional physiotherapy + PNF exercises receiving group (PNF group; n=15), and Group III: conventional physiotherapy + SM receiving group (SM group; n=15). Pain, ROM, muscle strength, and functionality were evaluated by using visual analog scale (VAS), goniometer, push-pull dynamometer, Constant-Murley score and The Disabilities of the Arm, Shoulder and Hand (DASH) Score respectively. Patients received 20 sessions in total under supervision of a physiotherapist. Patients were evaluated at baseline, at week two, at week four, and at week sixteen.

Official Title
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Comparison of the Effectiveness of Proprioceptive Neuromuscular Facilitation Exercises and Shoulder Mobilization Patients With Subacromial Impingement Syndrome: A Randomised Clinical Trial

Conditions
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Subacromial Impingement, Subacromial Impingement Syndrome

Intervention / Treatment
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* Other: Conventional Physiotherapy
* Other: Shoulder Mobilization
* Other: Proprioceptive Neuromuscular Facilitation


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Aged between 25-65 years old, Having the diagnosis of Subacromial Impingement Syndrome (SIS), Having shoulder pain at least for four weeks Exclusion Criteria: Having a neuromuscular disease, Pregnancy, History of cancer, Unstable angina, Having pulmonary and/or vascular problems, History of surgery at neck, shoulder, elbow or/and hand, Having communication problems Having systemic anti-inflammatory joint diseases Being contraindicated for electrical stimulation and/or exercise Having cervical disc herniation or radiculopathy History of physiotherapy on the same shoulder due to SIS, A history of corticosteroid injection in the last three months, Any orthopedic, rheumatologic, or congenital condition that effects the targeted shoulder

Ages Eligible for Study
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Minimum Age: 25 Years
Maximum Age: 65 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Factorial Assignment
Interventional Model Description: There were three study groups: 1. The control group: Participants in this group received only conventional physiotherapy treatment. 2. The shoulder mobilization group: Participants in this group received conventional physiotherapy and shoulder joint mobilization techniques as treatment. The Proprioceptive Neuromuscular Facilitation (PNF) group. Participants in this group received conventional physiotherapy and PNF exercises as treatment.
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Group I<br>The control group. Participants in this group received only conventional physiotherapy. Number of the participants were 14. | Other: Conventional Physiotherapy<br>* The conventional physiotherapy program consisted of electrotherapy and exercise approaches. The electrotherapy program consisted of infrared (for 15 minutes, from 70 cm distance), conventional Transcutaneous Electrical Nerve Stimulation (TENS) in an encircled region (for 20 minutes; with 4 electrodes, 100 Hz, 100 msec), and therapeutic Ultrasound (for 3 minutes; 1 megahertz (MHz), power: 1,5 W/cm²). A physiotherapist supervised exercise program was performed following the electrotherapy program. Elastic resistive exercises were added at the week three. While, the first set of wand exercises and elastic resistive exercises was performed under supervision, two sets of the showed exercises were given as the home exercise program.<br>|
| Experimental: Group II<br>The shoulder mobilization group. Participants in this group received conventional physiotherapy and shoulder joint mobilization techniques. Number of the participants were 15. | Other: Conventional Physiotherapy<br>* The conventional physiotherapy program consisted of electrotherapy and exercise approaches. The electrotherapy program consisted of infrared (for 15 minutes, from 70 cm distance), conventional Transcutaneous Electrical Nerve Stimulation (TENS) in an encircled region (for 20 minutes; with 4 electrodes, 100 Hz, 100 msec), and therapeutic Ultrasound (for 3 minutes; 1 megahertz (MHz), power: 1,5 W/cm²). A physiotherapist supervised exercise program was performed following the electrotherapy program. Elastic resistive exercises were added at the week three. While, the first set of wand exercises and elastic resistive exercises was performed under supervision, two sets of the showed exercises were given as the home exercise program.<br>Other: Shoulder Mobilization<br>* In shoulder mobilization technique while the shoulder joint was placed in the traction, anterior, posterior, and inferior gliding and circumduction were applied to the humerus for 2-3 minutes. All mobilization applications were performed in painless range of motion (ROM) limits. The degree of traction and gliding were increased as the relaxing obtained in the tissues.<br>|
| Experimental: Group III<br>The Proprioceptive Neuromuscular Facilitation (PNF) group. Participants in this group received conventional physiotherapy and PNF exercises. Number of the participants were 15. | Other: Conventional Physiotherapy<br>* The conventional physiotherapy program consisted of electrotherapy and exercise approaches. The electrotherapy program consisted of infrared (for 15 minutes, from 70 cm distance), conventional Transcutaneous Electrical Nerve Stimulation (TENS) in an encircled region (for 20 minutes; with 4 electrodes, 100 Hz, 100 msec), and therapeutic Ultrasound (for 3 minutes; 1 megahertz (MHz), power: 1,5 W/cm²). A physiotherapist supervised exercise program was performed following the electrotherapy program. Elastic resistive exercises were added at the week three. While, the first set of wand exercises and elastic resistive exercises was performed under supervision, two sets of the showed exercises were given as the home exercise program.<br>Other: Proprioceptive Neuromuscular Facilitation<br>* In the Proprioceptive Neuromuscular Facilitation (PNF) program participants received PNF exercises with contract-relax technique, in the patterns of flexion-abduction-external rotation, extension-adduction-internal rotation, flexion-adduction-external rotation and extension-abduction-internal rotation along with the verbal and manual facilitation of the physiotherapist.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Shoulder pain: VAS | Pain was defined with Visual Analog Scale (VAS). A 10-cm long horizontal visual analog scale (VAS) with marks 0 point (no pain) and 10 point (unbearable pain) was used for evaluating the pain severity. The patients were asked to mark the representing point of their pain levels. The values were recorded in cm. The pain severity was asked in three occasions as: at resting (VASr), during activity (VASa) and during night (VASn). | Change from baseline pain scale of shoulder at week 2, 4 and 16. | 
| Disability of the shoulder | The Disabilities of the Arm, Shoulder and Hand (DASH) Score was used to evaluate the upper extremity physical function. DASH includes two modules as disability / symptom section and work section. The scores are ranged between 0-100. Higher scores indicate lower functionality. | Change from baseline Disabilities of the Arm, Shoulder and Hand (DASH) Score at week 2, 4 and 16. | 
| Function of the shoulder | In addition to DASH, the Constant-Murley score was used to evaluate the functionality of the shoulder. Constant-Murley score is a 100-point scoring system and consisted of four sub-scores as pain (15 points), daily living activities (20 points), active range of motion (40 points), and muscle strength (25 points). | Change from baseline Constant-Murley score at week 2, 4 and 16. | 
| Range of motion | The active range of motion was assessed by using a universal goniometer. | Change from baseline active range of motion at week 2, 4 and 16. | 
| Muscle Strength | The muscle strength of shoulder flexion, shoulder abduction, shoulder adduction, shoulder external rotation, and shoulder internal rotation were determined by using Baseline Push-Pull (New York, USA) dynamometer. The dynamometer was placed in a 90 degrees angle on the location and the patient was asked to contract in maximum for two seconds and then maintain this position for five seconds. Two assessments were performed, and average values were recorded. Pain was avoided during the measurements. | Change from baseline muscle strength of shoulder flexion, shoulder abduction, shoulder adduction, shoulder external rotation, and shoulder internal rotation at week 2, 4 and 16. | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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proprioceptive neuromuscular facilitation, functionality, mobilization, pnf