Effectiveness of transcutaneous electrical nerve stimulation - Punjab ...

Original ArticleEffectiveness of transcutaneous electrical nerve stimulation andinterferential electrotherapy in adhesive capsulitisAarti Dewan*, Rohit Sharma*** Assistant ProfessorDepartment of Orthopedics,** Department of PhysiotherapySri Guru Ram Das Institute of Medical Sciences & Research,Amritsar, Punjab, INDIA.ABSTRACTA total of 50 subjects were randomly allocated to receive (i) trancutaneous electrical nerve stimulation(n=25) (ii) inter­ferential electrotherapy (n=25) . Subjects in groups (i) and (ii) received 10 sessions of therespective treatment. Each subject's score on Range of Moition ,Constant Murley Assessment and visualanalogue scale were recorded at baseline, post­treatment session and subse­quent follow­up sessions. Inboth the trancutaneous electrical nerve stimulation and interferential electrotherapy groups, the Range ofMoition , Constant Murley Assessment score increased and the visual analogue scale score de­creasedsignifcantly (both p < 0.0001), and sig­nifcant difference was found between the 2 intervention groups(all p < 0.05). The observed improvement was well maintained in both intervention groups at least until the6­month follow­up session. Both trancutaneous electrical nerve stimulation or interferential electrotherapyare effective in treating frozen shoulder patients. Interferential therapy is more effective in reducing painintensity and restoring shoulder function for people with adhesive capsulitis.Keywords: adhesive capsulitis, interferential therapy, transcutaneous electrical nerve stimulationINTRODUCTIONAdhesive capsulitis, also known as frozen shoulder, is one ofthe most frequent pathologies in the middle-aged population.The aetiology of frozen shoulder is unclear, possibly involvinga non-specifc chronic infammatory reaction of subsynovialtissue and resulting in capsular and synovial thickening, butthe problem affects the function of the glenohumeral joint 1-3 Itusually results in pain, decreased range of motion, and muscleweakness 4 . Persistent shoulder pain and compromised mobilitymay cause diffculty in performing activities of daily living oreven lead to disability 5 .Transcutaneous electrical nerve stimulation (TENS) is anon-invasive technique in which a low-voltage electrical currentis delivered through wires from a small power unit to electrodesCorresponding Author :Dr. Aarti Dewan*, MS (Orthopaeric Surgery)# 470, Basant Avenue, Amritsar, 143001, Punjab, INDIA.Fax: +91-0183-2587621Email: aartidew@gmail.comlocated on the skin 6 . TENS is often used to treat pain in varietyof acute and chronic musculoskeletal conditions. 7-9 Recentreports, however, suggest that the absorption of calcific depositsin the shoulder muscle tendons is accelerated by low frequencyTENS therapy and may be related to increased microcirculationin the region of the stimulation 9-12 . Although no con-trolledstudies were identified to document those hypotheses, themost consistent and extensive pain relief appears to occur withstimulation of the acupuncture points thought to be associatedwith shoulder pain 13 .Interferential electrotherapy (IFE) is a commonphysiothera-peutic treatment modality used in Westerncountries. Its high carrier frequency (around 4000 Hz) produceslower impedance to the skin and allows deeper penetrationinto tissue 14 . IFE predominately excites large-diameter nervefbres and reduces the transmission of nociceptive signalsthrough small-diameter nerve fbres to the spinal dorsal hornby presynaptic inhibition 15-16 , thus achieving pain modulationin the higher centre. Some studies have shown that IFE isPb Journal of Orthopaedics Vol-XII, No.1, 201164PDF created with pdfFactory Pro trial version www.pdffactory.com

Transcutaneous electrical nerve stimulation and interferentialelectrotherapy in adhesive capsulitiseffective in the manage-ment of various pain conditions 17-19 ,but not much work has been done on shoulder conditions.Theaim of the study is to find out whether TENS or IFT is effectivein per arthritis shoulder.MATERIAL AND METHODSStudy Design:The study is comparative in nature in which the effectivenessof TENS vs. Interferential therapy is seen in Periarthritisshoulder.Research SettingThe study was performed in the Department of Physiotherapyand Rehabilitation (Shri Guru Ram Das Institute of MedicalScience and Research), Vallah, Amritsar.ParticipantsMale & females subjects of Shri Guru Ram Das Institute ofMedical Sciences and Research, Vallah, Amritsar formulatedthe population for this study. Representative sample of 70 males& females with unilateral shoulder affection who volunteeredto participate were taken, out of whom 50 samples who met theinclusion criteria were taken as experimental group. 25 patientsare in group I which are given interferential therapy and 25patients are in group II which are given transcutaneous electricalnerve stimulation. Inclusive criteria were patients of Age Group40-60 yrs.who reported localized pain over one shoulder,experienced night pain and had restricted active and passiveshoulder motions. Exclusive criteria included Age GroupBelow 40 and above 60 ,a history of trauma, fractures, previousshoulder surgery, cervical or thoracic pain syndrome,complex regional pain syndrome, malignancies, on anticoagulanttherapy, Psychic patient, Hyper mobile joint or hadreceived acupuncture treatment to the painful shoulder in thepast 6 months. Written consent was obtained from allsubjects. The study was approved by the local ethicscommittee. The subjects were randomly allocated into: (i) theIFE group (n = 25); (ii) TENS group (n = 25)InterventionsINTERFERENTIAL THERAPY (IFT) GROUPThe subjects in this group received IFE treatment for 10sessions over 4 weeks. The patient is positioned comfortablyand the skin is prepared, washed and any skin lesion insulatedwith petroleum jelly. An IFE machine delivered current sweptfrom 80 to 120 Hz, and 4 suction-type electrodes were placedaround the shoulder region used in two pairs, (quadripolartechnique is applied) each pair being indicated by the coloringsof the wire from the machine. The electrodes of each pair areplaced diagonally opposite one another in such a way that theinterference effect is produced in the tissues where it is required,which is very deep. The patient is warned that he will feel atingling sensation which should not be too uncomfortable orburning.The intensity of the stimulation was adjusted to just belowthe pain threshold and the stimulation lasted for 20 minutes.TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION(TENS) GROUPAll the subjects in this group received TENS treatment for10 sessions over a 4-week period (2-3 times a week)The skinin the treatment area was frst sterilized with an isopropylalcohol skin wipe. Conductive rubber electrodes covered witha conductive gel in order to gain good skin contact re placedon the patient's skin. The electrodes can be bandaged onto thepatient or fixed with adhesive tape. Four electrodes are placedfor the treatment of periarthritis, we used high frequency TENSin our study. The intensity of the stimulation was adjusted to atolerance level of just below the pain threshold. Large mainunits are available to produce the current, but often small unitmade to be placed in the patient's pocket and utilizing batteriesare preferred.Pulses of around 0.2 ms at about 100Hz are given atintensities that provoke gentle contraction. The patient shouldfeel a tingling pins and needle sensation. This stimulates thehigh threshold 'A' delta and 'C' fibres leads to release ofendogenous opiods afferents which reduces pain. It is appliedto acupuncture points but is sometime applied to motor pointsof muscles. The intensity of the stimulation was adjusted to atolerance level of just below the pain threshold. The needlewas retained for 20 min, and was manually lifted and thrustedevery 10 min.OUTCOME MEASURESRange of motionGoniometry is measurement of angles created at human jointby the bones of the body. The instrument used for thisMeasurement is known as Goniometer. The patient joint isplaced in a starting position of Zero degree then permit thepatients to move the joint through available range of motionand measure the angle. Goniometeric measurementsare recorded in numerical table and range of motionmeasured.Pb Journal of Orthopaedics Vol-XII, No.1, 201165PDF created with pdfFactory Pro trial version www.pdffactory.com

Transcutaneous electrical nerve stimulation and interferentialelectrotherapy in adhesive capsulitisIn patients treated with IFT, pre-treatment VAS scorewas 7.50 and after the treatment the score was reduced at 2.15,showing highly significant differences (p 0.0001) between thepre and post score (t=29.44). In patients treated with TENS,pre-treatment VAS score was 7.70 and after the treatment thescore was reduced to 5.10, showing highly significantdifferences (p 0.0001) between the pre and post score(t=13.17).Pain Scale Readting9876543210Graph of Mean of Pain Score between IFT andTENS7.5 7.7IFT2.15Pre Treatment ScoreFig. 1: Mean pain score with IFT and TENSTable 2 shows the mean differences of pain scores measuredby Visual Analog Scale in patients treated with IFT andTENS. The patients treated with IFT shows higher meandifferences (5.35) than patients treated with TENS (2.60)showing highly significant differences (p 0.0001) between them(t=10.25).Table 25.1TENSRange of Motion200180160140120100806040200Graph of Mean of Range of Motion for Flexion148.572 71.5IFTPre Treatment ROMPost Treatment ROMTENSFig. 2: Mean range of motion of flexionTable 3 shows the distribution of scores of range of Motion(ROM) of flexion in patients treated with IFT and TENS(Figure 2). In patients treated with IFT, pre treatment ROMscore was 72.00 and the post treatment score was increased by148.50 showing highly significant differences (p 0.0001)between the pre and post score (t=22.09). In patient treatedwith TENS, pre treatment ROM score was 71.50 and posttreatment score was increased to 99.00 showing highlysignificant differences (p 0.0001) between the pre and postscore (t=15.64).Table 399Scores of Range of motion of flexion patients intreated with IFT and TENSMean differences of scores of Visual Analog Scales inpatients treated with IFT and TENSScores Differences t-value p-valueMean S.D. S.E.IFT 5.35 ±0.81 0.18 10.25 p 0.0001TENS 2.60 0.80 0.20RANGE OF MOTIONFlexionTable 4 shows the mean differences of scores of rangeof motion of flexion in patients treated with IFT and TENS.The patients treated with IFT shows higher mean difference(76.50) than in patients treated with TENS. (27.50) showinghighly significant differences (p≤0.0001) between them(t=12.62).Pb Journal of Orthopaedics Vol-XII, No.1, 201167PDF created with pdfFactory Pro trial version www.pdffactory.com

Dewan and SharmaTable 4Mean differences of scores of range of motion of flexion inpatients treated with between IFT and TENSScores Differences t-value p-valueMean S.D. S.E.IFT 76.50 15.48 3.46 12.62 p 0.0001TENS 27.50 7.86 1.76Table 5Scores of Range of motion for abduction in patients intreated with IFT and TENSPre Treatment Reading Post Treatment Reading tvalueMean S.D. S.E. Mean S.D. S.E.pvalueIFT 74.45 22.56 5.05 154.0 14.29 3.20 20.17 p≤0.0001TENS 78.00 20.35 4.55 104.00 16.35 3.66 14.17 p≤0.0001ABDUCTIONTable 5 shows the distribution of scores of Range of motion(ROM) of abduction in patients treated with IFT and TENS(Figure 3). In patients treated with IFT, pre-treatment ROMscore was 74.75 and the post treatment score was increased to154.0 showing highly significant differences (p 0.0001) betweenthe pre and post treatment score (t=20.17). In patients treatedwith TENS pre-treatment ROM score was 78.00 and posttreatment score was increased to 104.00 showing highlysignificant differences (p 0.0001) between the pre and postscore (t=14.17).Range of Motion180160140120100806040200Graph of Mean of Range of Motion for Abduction15474.75 78IFTPre Treatment ROMTENS104Post Treatment ROMFig. 3: Mean range of motion of abductionTable 6 shows the mean difference of scores of range ofmotion of abduction in patients treated with IFT and TENS.The patients treated with IFT shows higher mean difference(78.75) than patients treated with TENS (26.00) showinghighly significant differences (p 0.0001) between them(t=11.78).Table 6Mean differences of scores of range of motion ofabduction in persons treated with IFT and TENSScores Differences t-value p-valueMean S.D. S.E.IFT 78.75 18.27 4.09 11.78 p 0.0001TENS 26.00 8.21 1.84EXTERNAL ROTATIONTable 7 shows the distribution of scores of Range of motion(ROM) of external rotation in patients treated with IFT andTENS (Figure 4). In patients treated with IFT, pretreatment range of motion (ROM) score was (21.75) andpost treatment score was increased to (65.50) showinghighly significantly differences (p 0.0001) between thepre and post score (t=22.45). In patient treated withTENS, pre treatment ROM score was (23.00) and posttreatmentscore was increased to 34.00 showing highlysignificant differences (p 0.0001) between the pre and postscore (t=10.34).Pb Journal of Orthopaedics Vol-XII, No.1, 201168PDF created with pdfFactory Pro trial version www.pdffactory.com

Transcutaneous electrical nerve stimulation and interferentialelectrotherapy in adhesive capsulitis26. Basbaum AI, Fields HL. Endogenous pain control systems:brainstem spinal pathways and endorphin circuitry. Annu RevNeurosci 1984; 7: 309–338.27. Johnson MI, Ashton C.H Thomson J.W. (2006). An in depth studyof long term uses of transcutaneous electrical nerse stimulation(TENS). Implications for clinical use of TENS, Pain 44, 221-9.28. Somers and Somers (2007). Relevance of transcutaneous electricalnerve stimulation parameters to neurophysio-logical effects.Proceedings, 12 th International congress of world confederationsfor Physical Therapy, p.576.29. Van der Heijden GJ, Leffers P, Wolters PJMC, Verheijden JJD, vanMameren H, Houben JP, et al. No effect of bipolar interferentialelectrotherapy and pulsed ultrasound for soft tissue shoulder disorders:a randomized controlled trial. Ann Rheum Dis 1999; 58:530–540.30. Cheing GLY, Hui-Chan CWY. Analgesic effects of transcutaneouselectrical nerve stimulation and interferential currents on heat painin healthy subjects. J Rehabil Med 2003; 35: 15–19.31. Low J, Reed A, editors. Electrotherapy explained. Principle andpractice. 2nd edn. Oxford: Butterworth Heinemann; 1998.Pb Journal of Orthopaedics Vol-XII, No.1, 201171PDF created with pdfFactory Pro trial version www.pdffactory.com