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Bulletin of Faculty of Physical Therapy
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Effectiveness of hydrotherapy on pain and functional status of shoulder joint among individuals undergone intra-articular injections

Bulletin of Faculty of Physical Therapy volume 29, Article number: 68 (2024) Cite this article

Abstract

Background

The shoulder complex with its varied pathology responds differently from patient to patient and so, the best option for progression is a choice of rehabilitation. In the present post-COVID scenario, many patients are referred to acute and sub-acute shoulder pain and dysfunction. It is very difficult to predict the outcome of therapy. Some patients recover even without any modalities. Recurrent or adverse symptoms are also possible. Gender, other demographic features, physiological response, and progressive outcome need to be considered in rehabilitation. This study is intended to evaluate the short-term effects of hydrotherapy post-intra-articular injections of shoulder dysfunctions.

Aims and objectives

To evaluate the effectiveness of hydrotherapy during early rehabilitation of individuals who have undergone intra-articular injections of shoulder joint on pain and function.

Materials and methods

In this prospective study, we have studied a total of 59 cases within the age group of 40–70 years with idiopathic frozen shoulder, acromio-clavicular joint dysfunction, and grade-1 untreated rotator cuff injuries. Group A patients were treated with conventional shoulder exercises and group B patients were treated in a hydrotherapy pool. The chief aim was to obtain earlier pain relief with controlled movement patterns and earlier relief from functional disability. The Constant-Murley score (CMS–100 points scale) composing pain and functional parameters was the outcome measure.

Results

After confounding all the demographic factors, it was found that the experimental group B treated by hydrotherapy revealed a statistically extremely significant difference (p value < 0.0001) at the end of the first week as compared to the conventional group. The treatment protocol was continued for 5 weeks. More than 90% of patients in the hydrotherapy group felt it easier and exercise participation progression was best. Better progression and improvement of shoulder function were achieved in the hydrotherapy group compared to the conventional group.

Conclusion

From this study, we conclude that hydrotherapy during early management of shoulder dysfunctions post-intra-articular injections is safer and provides excellent relief from pain as early as the first week. Functional progression is better and avoids complications related to mobilization.

Introduction

The shoulder complex with its complex physiology and biomechanics tends to be the most apprehensive joint in terms of kinesiophobia.

Kinesiophobia and its relation in post-intra-articular injectionon chronic shoulder pain

The aim of rehabilitation in shoulder rehabilitation among post-intra-articular injections is to overcome kinesiophobia and improve motor function, autonomy, and quality of life. Hydrotherapy promotes individuals to participate more actively in the rehabilitation process, ultimately promoting functional recovery and improved quality of life [1, 2].

It is essential to move your shoulder after any invasive procedures very safely. The acute rehabilitation of the shoulder has become the most critical and depicts the progression in the future. The immediate common side effect is a transient increase in pain or flare, which can occur during the early phase post-procedure and be perceived in different forms. Compulsory physiotherapy should have been indicated in that phase and the priority of hydrotherapy differs among any therapist to date. Still, updates of evidence are lacking on it. Intra-articular infusions are of different types and they work on different levels as per the subjects.

The incremental advantage of hydrotherapy is in recognizing the primary cause of the delay in the recovery process. Water gives the arm buoyancy, making it easier to complete active tasks. It may also contribute to improved proprioceptive feedback, which could further support the rehabilitation process. [3]

Consequence of intra-articular injection of the shoulder joint

It is used to decrease inflammatory reactions associated with the joint, most prominently indicated for the use of conservative management of an impingement. An intra-articular injection for the shoulder is known as a subacromial injection as it is injected into subacromial space in the shoulder. This form of treatment is a common remedy for painful conditions of the shoulder joint such as rotator cuff disease aiming to provide a maximum of 6 weeks of relief from shoulder pain. During this period, light pain-free activities are advocated.

The degree of hydro-dilatation varies from individual to individual and the metabolic factors vary. Depending on the associated inflammation and joint function the treatment protocol needs variations. Any local tenderness or exacerbations due to any physiological changes will have an effect on the progression of the condition.

Precautions taken after intra-articular injection

They are to rest the joint, ice the joint, monitor for any allergic reaction, avoid exposure in water for about 24 h minimum post-injection, and limit the physical activities. Patients misunderstand the pain and perceive it differently or get into kinesiophobia.

A study indicates that patients can typically resume light activities, including hydrotherapy, after 4 days of post-corticosteroid injection. This helps to ensure the injection site has properly healed and the medication has started to take effect.[3]

Indications to acromio-clavicular joint/sub-acromial joint injections

Therapeutic joint injection is indicated for pain relief and functional improvement in symptomatic subacromial impingement syndrome, rotator cuff disorders, adhesive capsulitis, and arthritic inflammatory conditions.

Contraindications to acromio clavicular joint/sub-acromial joint injections

It includes infection in or around the joint (septic arthritis), hypersensitivity or known allergy to the injected solution, skin breakdown at the injection site, and a fracture at the proposed injection site.

Risks of an acromio-clavicular joint/sub-acromial joint injections

Possible complications from this procedure could include infection, skin discoloration, or tendon injury. For diabetic patients, steroid injections can cause elevated blood sugars for a few days.

Hydrotherapy is an easier form of treatment enabling the patient to move the arm more freely, reducing pain and joint stiffness, as the buoyancy will support the weight of your arm. Hydrotherapy has been an excellent tool to restore natural movement patterns after an injury or after any form of procedure till date. The hypothesis is that hydrotherapy may or may not provide faster recovery than standard rehabilitation. The available literature is limited and often prone to bias. A rapid, non-surgical, and cost-effective treatment that reduces pain and restores function is an attractive option. Soft tissue therapeutic massage, simple spa-type hydrotherapy units, etc., are used in the treatment of these ailments by various health care providers. Additional therapeutic exercises and suspension therapy are used progressively towards active rehabilitation of the shoulder as per the structures involved [4].

Need of the study

  1. 1.

    Intra-articular injections are said to be the standard treatment for reducing the pain and inflammation in the shoulder joint. But patient response differs and full recovery is very difficult. So continuous research is needed.

  2. 2.

    Hydrotherapy and Land exercises are done in different situations and patients have confusion at different stages. The orthopedicians too can’t justify in case of recurrent inflammation and pain. So, research in different stages of shoulder rehabilitation is essential.

  3. 3.

    There is still a lack of literature regarding hydrotherapy and its impact on shoulder joint pain and functional status following injuries. So it is necessary to study the effectiveness of hydrotherapy on pain and functional status of shoulder joints among individuals undergone intra-articular injections.

  4. 4.

    It’s very difficult to predict the outcome of therapy. Some patients recover even without any modalities. Recurrent or adverse symptoms are also possible. Apprehensive behavior is more sensitive and ignored in the case of adults with co-morbidities. The immediate common side effect is a transient increase in pain or flare, which can occur during the early phase post-procedure.

Methodology

This experimental study was conducted during the post-COVID period, well after variants were established, and when patients had a fear of public access. Fifty-nine subjects of both genders with ages of 40 to 70 years were allocated using simple random sampling into groups A and B.

Sample size calculation and evidence

The sample size of this study is calculated by using formula (i.e., n = 4pq/L( 2)). Samples were randomly distributed with even numbers of patients selected for group 2 and an odd number of patients were selected for group 1. With a 95% confidence interval and 95% power, considering the 10% attrition rate of subjects during the period of study, the study was started with 59 subjects [5].

Reference

A study done by De Ruvo F., and Zanazzo M. on “Efficacy of hydrotherapy on patients who underwent a rotator cuff surgical repair” stated that 20 non-randomized patients after surgical repair of the rotator cuff (no long head of the biceps tenodesis) were included divided in two groups. In group A, 10 patients (2 men, 8 women, mean age 66) refused for personal reasons to utilize the swimming pool; group B was formed by 7 men and 3 women, mean age 60 years [5].

Division of subjects in the study

The subjects were divided into two groups 31 patients (group A) and 28 patients (group B). Seven patients left the trial due to unavoidable reasons and were unable to continue the study.

Group A denotes conventional exercises conducted in the outpatient department. Group B denotes the experimental group conducted in the hydrotherapy pool.

Blinding procedure followed in the study

In the experimental group, the subjects were treated in the hydrotherapy pool of the orthopedic department by a junior physiotherapist with 3 years of experience. In the control group, the subjects were treated by a different junior physiotherapist with 3 years of experience in the Kinesiotherapy Lab. None of them were aware of the procedure followed and everything was maintained confidential.

The water was maintained at a normal temperature (i.e., below 30°). The study was conducted during the day hours. The study has been completed with 52 subjects out of 26 subjects in each group.

Safety measures and preventive measures

  • All subjects in both groups were assessed completely with relation to vital parameters, Completion of breakfast 2 h prior to the treatment procedure, and if any difficulty interfering with the procedure.

  • The subjects were never left alone in the pool.

  • A life vest was provided in spite of the pool safety and other safety gadgets for ear plugs, eyeglasses, etc.

  • The temperature was well maintained at the tolerance level below 37 °C.

  • Complete protection was taken care of against water-borne pollution and water-related problems ensuring complete safety for all subjects.

  • All subjects were assessed for incontinence too before including them in the study. People with cancer, HIV, and other immunodeficiency.

  • Complete safety measures are built up against potential hazards for both patients and Physiotherapy staff. Hazards include drowning, heat exhaustion, falls, slipping, infection, pool entry and egress, skin irritation, droplet infections, and electric shock.

Safety measures and preventive measures during data collection

In common the subjects were assessed mainly during post-evaluation on the next day on completion of their protocol. This avoids the sustainability of the progress and any complaints post-therapy sessions.

Statistical method was used to compare within and between groups

The statistical method was a non-parametric Mann–Whitney test used in this study to compare within and between groups and analyze the results of this study.

Inclusion criteria

  1. 1.

    Age group 40 to 70 years

  2. 2.

    Individuals diagnosed with shoulder dysfunction received intra-articular injections within the past 1–3 months.

  3. 3.

    Participants with moderate to severe pain

Exclusion criteria

  1. 1.

    Recent shoulder surgery

  2. 2.

    The presence of any severe comorbidities that contraindicate hydrotherapy

  3. 3.

    Hydrophobia to the participant

Outcome measure

The Constant-Murley score (CMS-100-point scale) [5]. The units are in points. Higher denotes the best response and lower denotes the poor response.

Reliability of outcome measure

It has shown that the CMS score is a reliable (ICC = 0.80–0.87) and responsible (effect size = 0.59) instrument in the assessment of the impact of shoulder interventions. The Constant-Murley score (CMS-100-point scale) [5]. The units are in points. Higher denotes the best response and lower denotes poor response.

The formula for the total score is pain (0 − 15) + ADL (4 × (0 − 5) = 0 − 20) + Mobility (4 × (0 − 10) = 0 − 40) + Strength (0 − 25) = 100 points in total.

Exercise protocol

Exercise rules in common for both groups

Exercise rehabilitation as per the research groups starts after 4 days post-intra-articular injections of the shoulder joint. The protocol is for 5 weeks, which is the early rehab. Perform each exercise for 1 min, with the goal to progress to 90 s progressively. Remember to go bilaterally and unilaterally. Total duration of exercises: 20 min/session for 5 days/week for 3 weeks duration. Contrast baths were common to both groups before and after exercises.

Protocol timing

It was mentioned according to the Guidelines and Standards for Aquatic India—an Initiative by ATNI (Aquatic Therapy Network of India). Fifty percent of the time limit was taken into consideration due to the safer side considering the patient’s pain status and also the focus was on the patient’s ability to progress towards exercise on land easily.

Specific attire during hydrotherapy

All subjects undergoing hydrotherapy were advised to wear swimwear on arrival to their session with clothes that can be easily removed, i.e., a dressing gown. Males with simple T-shirts and Females with undergarments and gowns were allowed. They were provided with safe provisions to change dress and pack up. Without proper hydrotherapy appointments, subjects were not allowed to enter the pool due to infection control risks.

Hydrotherapy pool setup and its accessibility

The hydrotherapy pool is a customized pool built up with all facilities on the ground floor attached as an extension to the musculoskeletal physiotherapy department. The whole rehabilitation is unique, separate with all accessibilities for disabled and wheelchair mobility starting from the entrance of the hospital. It extends throughout the departments and lift facilities are available.

Pool dimensions

The hydrotherapy setup was rectangular in shape. Its length is about 20 feet long, its depth is about 1.5 m to 2.5 m, and the width of the pool is 12 feet.

Group A protocol

Conventional exercise protocol pertaining to shoulders:

Progression of exercises during the first week:

  1. 1)

    All physiological movements from a safe initial range progress to full range bilaterally.

  2. 2)

    Wand exercises on land.

  3. 3)

    Wall ladder exercises and pendulum exercises.

Progression of exercises during the second and third weeks:

  1. 1)

    Theraband exercises with low resistance.

  2. 2)

    Lateral raise with dumbbells progressively increases by 100 g sequentially every 3 days, up to 500 g.

  3. 3)

    Diagonal arm raise

  4. 4)

    Swinging arms

  5. 5)

    Circular motions and repetitive full-range movements.

Progression of exercises during the fourth and fifth weeks:

Repeated exercises with limited breaks and full range with precision twice a day.

Group B protocol

Hydrotherapy exercise protocol pertaining to shoulders:

Progression of exercises during the first week:

  1. 1)

    All physiological movements from a safe initial range progress to full range bilaterally.

  2. 2)

    Wand exercises.

  3. 3)

    Strokes and ball exercises in the pool.

Progression of exercises during the second and third weeks:

  1. 1)

    Pass behind the back with a ball

  2. 2)

    External rotation with resistance band: stand tall with your core and gluteus engaged. The chest is up and the shoulder blades are squeezing together.

  3. 3)

    Lateral rise with dumbbells progressively increases by 100 g sequentially every 3 days, up to 500 g.

  4. 4)

    Diagonal arm raise

  5. 5)

    Walking breaststroke

Progression of exercises during the fourth and fifth weeks:

Repeated exercises with limited breaks and full range with precision twice a day.

Pictures showing hydrotherapy rehabilitation

Pictures were taken with the consent of the therapist and patient. For clarity of pictures, it is shown from one end of the pool.

Sample pictures of the study in a customized hydrotherapy pool are attached for reference (Figs. 1 and 2).

Fig. 1
figure 1

A Wand exercise for mobility with bilateral upper limb. B Progression of wand exercise

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Fig. 2
figure 2

A Ball exercise for mobility with bilateral upper limbs. B Progression of ball exercises (throw)

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Compliance with protocol

The research was completed with 52 participants out of 59 participants who received a single dose of Intra-articular injection with equal distribution among both groups. Four participants received a second dose of Intra-articular injection due to pain severity and higher disability for which they were excluded from the study. Three participants did not receive any treatment because of non-attendance. All patients received manual assistance during the first week. Participants in both groups were to continue their physiotherapy sessions for 5 weeks, as per the groups. The pre-test measures were taken as per Constant-Murley score on the starting day of prior sessions and post-test measures were taken as per Constant-Murley score after a 5-week protocol. The physiotherapy sessions and further progress were continued as per the post-test measures and investigations [6].

Data analysis and interpretation

The results with p value are mentioned in the tabular column for both groups related to the individual components of the Constant-Murley score (pain, activities of daily living, range of motion, and power). The total Constant Murley score between both groups with p value is also mentioned.

Normality distribution and effect size

The age of the subjects, period of pain, and disability were limited to the mean value overall. The pre- and post-outcome scores of the subjects were symmetric towards the mean between mid-range of 30%, following a normal distribution. Effect size falls under medium (i.e., 0.5) related to outcome scores of data considering the two groups of the subjects. Paired t test statistical method was used to compare within and between groups.

Interpretation

The pre-test and post-test measures of group A and group B are found significant for pain, range of motion (ROM), and power (muscle strength). An activity of daily living (ADL) is found not significant. The total score of the Constant-Murley Score is found significant (Figs. 3 and 4).

Fig. 3
figure 3

Post-intervention for both groups

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Fig. 4
figure 4

Pre- and post-intervention

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Interpretation

Improvement was significantly greater as the total score of Constant-Murley score in group B (hydrotherapy) in the 5th-week post-test measures comparison with group A (conventional) (p < 0.001) on the non-parametric Mann–Whitney test.

Results

The results concluded with 52 participants (26 subjects underwent injection plus conventional exercise, 26 subjects in a hydrotherapy pool). The mean age was 54 (range 40–70), 36 were women and 16 were men, and all had a median of 15 weeks of shoulder pain. In week 5, the differences between the groups related to pain, activities in daily living, range of motion, and strength. After a week, the assessment was done and post-intervention, both the groups showed significant improvement but the group with injection plus hydrotherapy showed significantly more improvement as compared to the conventional group in pain, range of motion, and power (p < 0.0001) activities of daily living showed no significant improvement by the injection plus hydrotherapy group by post-values comparison.

Discussion

In this study, the common subjects with 12 weeks of unilateral shoulder dysfunction who had all undergone intra-articular injections were assessed for shoulder function and pain post-5 weeks of physiotherapy. The dysfunction for 60% of people who had undergone the procedure and a 4-day period of rest was allowed in common to all subjects post-intra-articular injection. As per the inclusion criteria, the subjects were randomly allocated into 2 groups. Shoulder function tends to precipitate or worsen with many internal and external factors affecting the cartilage [7,8,9,10].

Significantly earlier and progressive improvements in pain were better at the end of the first week in the hydrotherapy group (group B). The components of pain, range of movement, and power progressed in an ascending manner with exercises in a hydrotherapy pool during the end of the second to fifth weekend. Activities of daily living were found not significant due to various factors like fear, confidence in consecutive activities, and pain-perceiving behaviors during activities [11,12,13,14]. At the end of 5 weeks, power and function were statistically significant in the hydrotherapy group (group B) with sustenance compared with the conventional free exercise group done on land [15,16,17,18,19]. The subjects in hydrotherapy had comfort and confidence about the quality performance of exercises. This was beneficial for them to progress better with each and every component of recovery and subjects preferred their own style of self-reliant management [20,21,22,23].

The Constant-Murley score records individual parameters and provides a general clinical functional assessment. Therefore, it is applicable irrespective of details of the diagnostic or radiological abnormalities. Scores and strength of the Constant-Murley test are age-related, both will decrease as the patient is older.

A recent study on “Bone channeling in arthroscopic rotator cuff repair: a systematic review and meta-analysis of level I studies” is good evidence [30]. The short duration of 7 min maximum is required to complete the test and it is much easier for both patients and clinicians to understand.

Potential bias in the study

The potential bias during the study was more time-consuming for each patient, as they needed individual attention and fear of any disturbance by any others other than themselves in the pool. So, to avoid non-performance, individual attention was provided. In case, the subjects weren’t allowed individually in the pool, their performance would get impaired which was a challenge in shoulder rehabilitation subjects with kinesiophobia.

The generalizability of the trial finding between the sample size was that the patients had similar characteristics of pain during activity. The target population had a median of 15 weeks of shoulder pain. The minimum duration of 12 weeks was more considered.

Due to the safety concerns with manipulation under anesthesia, iatrogenic complications, etc. were not included in the inclusion criteria. Related to physiotherapy, only active and active assisted exercises in different ranges were included in the groups, promoting natural healing and motivating self-reliant strategies for subjects [24,25,26,27,28,29].

The movements were progressing with uniform speed and alteration of arm movements improved repetitions in hydrotherapy. Range of motion significantly improved restoring normal function and no pain has been perceived by the subjects pertaining to hydrotherapy treatment. Further, it was found there were no compensatory movements with a normal painless physiological range of movement, indicating the readiness for further rehabilitation training. The subjects treated in hydrotherapy were able to move the shoulder easily with moderate force compared to the conventional group.

Conclusion

The study concludes that the subjects need personal freedom to find out while initiation of shoulder movements as per their patho-mechanics and biomechanical impairments.

With reference to this, hydrotherapy rehabilitation during the early phase supports tendon healing better which is evident from the performance progression found among the experimental group.

Hydrotherapy is an effective therapeutic intervention for improving pain and functional status in individuals with shoulder joint issues post-intra-articular injections. The study’s outcome supports the measures on pain and functional status among the patients receiving hydrotherapy for shoulder joint post-intra-articular injection.

Limitations of the study

Further studies with a greater sample size will be needed to analyze the differences in terms of endurance, strength, or other healing factors of tendons and to record the satisfaction index of the patient.

Strength of the study

The strength of the study is the subjects were taken from senior surgeons of more than 5 years of duration and the subjects belong to the same geographical area of semi-urban background with similar socio-economic living status.( Table 1)

Table 1 Pre- and post-intervention
Full size table

Availability of data and materials

The authors confirm that the data supporting the findings of this study are available within the article [and/or its supplementary materials]..

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Funding

The author(s) declare hereby that we have not received financial support for the research, authorship of this article in any form.

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Author notes

  1. S. Senthil Kumar

    Present address: School of Physiotherapy, Dhanalakshmi Srinivasan University, Samayapuram, Trichirappalli, Tamil Nadu, 621112, India

Authors and Affiliations

  1. Physiotherapy in Community Health Sciences, Krishna College of Physiotherapy, Krishna Vishwa Vidyapeeth “Deemed To Be University”, Karad, Maharashtra, 415539, India

    Anandh Srinivasan

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The author confirms sole responsibility for the following: study conception and design, data collection, analysis and interpretation of results, and manuscript preparation

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Correspondence to Anandh Srinivasan.

Ethics declarations

Ethics approval and consent to participate

This study was approved by Institutional Review Board of the conducting institutions (Yongin Severance Hospital; 9–2021-0085, Myongji Hospital; 2021–07-035). Informed consent to participate was obtained from all the participants. All methods were carried out in accordance with declaration of Helsinki.

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Not applicable.

Competing interests

The authors declare no competing interests.

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Srinivasan, A., Kumar, S.S. Effectiveness of hydrotherapy on pain and functional status of shoulder joint among individuals undergone intra-articular injections. Bull Fac Phys Ther 29, 68 (2024). https://doi.org/10.1186/s43161-024-00232-4

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