Vol. 5, No. 9, September 2024

E-ISSN:2723 – 6692

P-ISSN:2723– 6595

http://jiss.publikasiindonesia.id/

Journal of Indonesian Social Sciences, Vol. 5, No. 9, September 2024 2351

Physiotherapy Management of Frozen Shoulder Dextra with

InfraRed (IR), Transcutaneous Electrical Nerve Stimulation

(TENS) and Active Exercise Modalities

Ardianus Jefri Kriatiawan, Didik Purnomo

Universitas Widya Husada Semarang, Indonesia

Email : ardyjeff31@gmail.com, purnomodidik833@gmail.com

Correspondence: ardyjeff31@gmail.com

KEYWORDS

ABSTRACT

Frozen Shoulder; InfraRed;

Transcutaneous Electrical

Nerve Stimulation; Active

Exercise

Frozen shoulder, commonly called adhesive capsulitis, is a painful

condition in the shoulder and results in a limited range of motion of

the joint (LGS). Frozen shoulder is a condition where shoulder

movement becomes limited. Frozen shoulder has varying degrees of

severity, ranging from mild to severe pain, and the degree of

limitation to movement of the glenohumeral joint. To reduce pain

and limited joint movement, which will later increase the ability for

functional activities, the role and modalities of physiotherapy can be

used in the form of InfraRed, Transcutaneous Electrical Nerve

Stimulation, and Active Exercise. This scientific paper is a case study

that raises patient cases and collects data through physiotherapy.

InfraRed, Transcutaneous Electrical Nerve Stimulation, and Active

Exercise are the modalities provided. After receiving physiotherapy

treatment 3 times, the results of the shoulder already appear

symmetrical; there is an increase in the Joint Scope of Motion (LGS)

of the shoulder dextra, a decrease in pain in the shoulder dextra, the

loss of spasm of the anterior and medial deltoid muscles, and the

ability of the patient's functional activities using the Shoulder Pain

and Disability Index (SPADI). Conclusion: Physiotherapy treatment

of Frozen Shoulder Dextra using InfraRed, Transcutaneous

Electrical Nerve Stimulation, and Active Exercise modalities has

been proven to eliminate spasms, increase joint range of motion

(LGS), reduce pain, increase muscle strength and increase functional

activity capabilities using Shoulder Pain and Disability Index

(SPADI).

Attribution-ShareAlike 4.0 International (CC BY-SA 4.0)

Introduction

Frozen shoulder, referred to as adhesive capsulitis, is a condition of pain in the shoulder and

results in a limited scope of joint motion (Akhadiany, 2022; Pandey & Madi, 2021). Frozen shoulder is

a condition where shoulder movement is limited. Frozen shoulder has varying degrees of severity,

ranging from mild to severe pain, and how much limitation there is on glenohumeral joint movement

(Mertens et al., 2022; Suharti et al., 2018). The prevalence of frozen shoulder is 2% of the general

population and 1029% in diabetics in the world. In Indonesia, frozen shoulder occurs in 2-3% of the

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general population and often occurs at the age of more than 40 years. In women aged 50 years, as

many as 15% experienced bilateral frozen shoulder (Suharti et al., 2018).

In the shoulder joint, it is generally preceded by a trauma or immobilization which can cause

stiffness of the joint. This complaint can occur in people with hemiplegia or superior monoplegia,

diabetes mellitus, which is also referred to as a triggering factor for frozen shoulder. The physiological

problem in frozen shoulder is hypomobility or capsular pattern problems of the glenohumeral joint.

Hypomobility is due to decreased synovial fluid volume in the joint, which results in increased

pressure inside the joint during movement. Furthermore, the joint surface distance narrows due to

the depletion of joint lubricant and an increase in the number of collagen fibers that are crossed and

arranged irregularly. Tangled collagen fibers will reduce the flexibility of the connective tissue and

limit joint movement (Suharyadi & Ismanda, 2021).

The symptoms caused by Mrs. H.Z's Frozen Shoulder which was examined on February 5, 2024

found pain in the shoulder area, spasm in the shoulder area, and limited LGS make a person's

functional activity impaired, therefore as a medical physiotherapist has a role to help reduce pain,

increase muscle strength, restore functional activity to reduce problems caused by Frozen Shoulder.

As explained above.

The purpose of this study is to determine the process of physiotherapy management of Frozen

Shoulder Dextra with the modality of “InfraRed, Transcuntaneous Electrical Nerve Stimulation and

Active Exercise”.

Given the importance of physiotherapy can develop and restore patients with cases of Frozen

Shoulder Mrs. H.Z by providing InfraRed, Transcuntaneous Electrical Nerve Stimulation, and Active

Exercise. Based on the description above, the authors are interested in making KTI with the title

“Physiotherapy Management of Frozen Shoulder Dextra with InfraRed Modalities, Transcuntaneous

Electrical Nerve Stimulation and Active Exercise”.

Materials and Methods

Case report

A general history was taken, and the patient's identity data obtained was Mrs H.Z, aged 50 years,

Muslim, used to work as a domestic assistant abroad but is now a housewife and lives in Kendal. The

patient came to RSI Muhammadiyah Kendal complaining of pain in her right shoulder. Approximately

5 months ago, the patient began to feel pain in the shoulder during activities. Then, on January 23,

2024, the patient felt uncomfortable and immediately came to RSI Muhammadiyah Kendal to do an

examination with a neurologist; then, the patient was referred to medical rehabilitation for

physiotherapy action. The patient had previously experienced frozen shoulder on her left shoulder

but had recovered. The patient is a housewife.

The initial physical examination was carried out on February 6, 2024, and the following results

were obtained: Normal vital signs were obtained, but the patient appeared in pain when the arm was

moved. The right shoulder showed tenderness, decreased muscle strength, and muscle spasms.

There are three types of basic motion examination: active motion examination, passive motion

examination, and active motion examination against resistance. Active Motion: Limited with pain in

flexion, extension, abduction, adduction, exorotation, and endorotation. Passive Motion: Full range of

motion but with pain and firm endfeel. Active Motion Against Resistance: Pain is felt against

resistance, especially in abduction and adduction.

Other Examinations:

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• Intra-personal: Patients are cooperative and eager to recover.

• Basic Functional: Difficulty lifting heavy objects and putting items on high shelves.

• Functional Activity: Using SPADI, the patient experienced moderate pain with a total score of 22

and a SPADI result of 16.9%.

Activity Environment: The home environment supports recovery; the patient does not do heavy work

and is active in pendulum exercises.

Specific Inspection and Measurement

• Specific Test: Painful arm test shows positive results.

• Measurement with VAS: Used to assess motion, pressure, and stillness pain.

• LGS examination: A goniometer was used to show the the right shoulder's motion limitation.

Muscle Strength Test: The MMT test shows the difference in muscle strength between the right

and left arms, with the right shoulder muscle weaker. Patients receive recommendations to continue

physiotherapy to improve shoulder function and reduce pain.

Physiotherapy Diagnosis

Physiotherapy diagnosis aims to assess patients' physical capacity and functional abilities

based on the interpretation of the data collected. From the results of the examination, there are

several physiotherapy problems were identified:

• Body Structure: The patient experiences pain in the right shoulder area. There are muscle spasms

in M. Deltoid Anterior, M. Deltoid Medial, M. Infraspinatus, M. Teres Minor, and M. Trapezius

Upper. A decrease in muscle strength is detected. The joint range of motion (LGS) in the right

shoulder is limited, especially in flexion, extension, abduction, adduction, extroversion, and end

rotation movements.

• Activities: Patients can still perform daily cooking and sweeping.

• Participation: Patients can socialize well in the community.

This diagnosis provides a comprehensive picture of the patient's condition and serves as the

basis for planning appropriate physiotherapy interventions.

Physiotherapy programs

Physiotherapy programs are designed with specific goals in mind, both in the short and long

term. Short-term goals include reducing pain, especially in shoulder muscles such as M. Deltoid

Anterior and M. Deltoid Medial, increasing the scope of motion of the right shoulder joint in the

directions of flexion, extension, abduction, adduction, exhortation, and end rotation, increasing

muscle strength, and reducing muscle spasm in M. Deltoid Anterior, M. Deltoid Medial, M.

Infraspinatus, M. Teres Minor, and M. Trapezius Upper. The long-term goal is to improve the patient's

functional activities to carry out their daily activities without obstacles. To achieve this goal, the

physiotherapy actions provided include using modalities such as InfraRed and Transcutaneous

Electrical Nerve Stimulation and exercise therapy in the form of active exercise. In addition,

promotive and preventive measures were also given at home to support the success of therapy.

Patients are asked to do independent exercises as the therapist teaches, avoid actions that cause

shoulder pain, and reduce activities that aggravate pain, such as lifting heavy objects.

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Physiotherapy Treatment

In the case of N.y H Z, physiotherapy was performed thrice on February 9, 13, and 16, 2024.

This implementation should follow the planned guidelines while communicating with relevant

parties and documenting the program's results and methodology. The evaluation was conducted

before, during, and after the physiotherapy sessions to monitor the patient's response. In this case,

the management involved the use of InfraRed (IR), Transcutaneous Electrical Nerve Stimulation

(TENS), and exercise therapy in the form of active exercise.

For InfraRed, preparation of the device includes checking the cables and switches, ensuring the

device is well connected, and warming up the device for 5 minutes before therapy. The patient is

positioned as comfortably as possible and informed about the heat sensation that will be felt. The

therapist is next to the patient, setting the dose by positioning the IR lamp on the right shoulder at a

distance of 35-45 cm for 16 minutes while monitoring the patient every 5 minutes.

Figure 1. Intervention InfraRed

Source: (Personal Documentation,2024)

In Transcutaneous Electrical Nerve Stimulation, the device is checked to ensure the wires and

electrodes are in good condition. The patient was positioned comfortably and the shoulder area was

freed from clothing. Electrodes were placed on the right shoulder, and the dose was set according to

the patient's pain threshold for 16 minutes, with monitoring every 5 minutes.

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Figure 2. Intervention TENS

Source: (Personal Documentation,2024)

Exercise therapy includes Towel Stretch, Pandulum Exercise, and Active Exercise. In Towel

Stretch, the patient stands or sits with their hands behind their back, pulling the towel for 8 seconds

with 5 repetitions. Pandulum Exercise is performed with the patient standing at the edge of the bed,

moving the hand in various directions and rotations according to the pain limit, with 8 movements

per session. Active Exercise involves flexion, extension, abduction, adduction, exorotation, and

endorotation movements, with 8 movements per session. All exercises are performed in a clean and

comfortable environment, with the therapist giving instructions from the patient's side.

Figure 3. a) Intervention Towel Strech, b) Intervention Pendulum Exercise,

c) Active Exercise Movement

Source: (Personal Documentation,2024)

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Evaluation

After undergoing therapy three times, the patient experienced a slight decrease in tenderness

and motion pain. Evaluation of pain using the VAS scale showed that silent pain remained at 0, but

tenderness decreased from 4 to 2, and motion pain decreased from 3 to 2. Evaluation of active joint

motion scope (LGS) with a goniometer showed improvement, especially in extension-flexion

movements, which increased from 30 ° - 0 ° - 150 ° to 40 ° - 0 ° - 160 °, as well as an increase in vertical

and horizontal abduction-adduction, and exorotation-endorotation. Passive LGS evaluation also

showed improvement, especially in horizontal abduction-adduction and exorotation-endorotation.

Functional activity evaluation using SPADI showed a decrease in pain and difficulty scores, with the

total SPADI score reducing from 16.9% (moderate) at T1 and T2 to 12.3% (mild) at T3. This indicates

an improvement in the patient's pain and functional ability after therapy.

Final Theraphy Result

After undergoing three therapy sessions, patient Mrs. H.Z, diagnosed with a frozen shoulder on

the right shoulder, showed positive results through the use of TENS modality, InfraRed (IR), and

exercise therapy with Active Exercise. There is a decrease in tenderness in the right shoulder and an

increase in the scope of joint motion, especially in flexion, abduction, and endorotation movements.

In addition, the strength of the M. Deltoid anterior and M. Deltoid middle muscles increased, and there

was a decrease in spasm in the M. Supraspinatus, M. Infraspinatus, and M. Deltoid anterior muscles.

Overall, the patient's functional activity also improved, showing significant progress in the recovery

of the patient's shoulder condition.

Results and Discussions

After getting treatment 3 times against the patient, the results: Decreased pain, increased LGS

and muscle strength, and increased functional activity ability. The long-term goal in therapy this time

is to continue the short-term and improve functional activity abilities such as lifting heavy objects,

and activities without pain barriers.

Pain reduction using VAS

Graph 1. Results of pain reduction evaluation

Source: (Personal Documentation,2024)

T1 T2 T3

VAS Measurement

Nyeri Gerak Nyeri Tekan Nyeri Diam

0-4 ringan

4-7 sedang

7-10 berat

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The results of 3 times of physiotherapy evaluation with pain measurement using VAS obtained

results of movement pain and tenderness. Based on the graph above, it can be seen that there is a

decrease in pain in the third therapy. Decrease in the intensity of motion pain from 3 to 2, decrease

in the intensity of pressure pain from 4 to 2. This decrease in intensity resulted from the

administration of InfraRed, Transcutaneous Electrical Nerve Stimulation. After being administered, the

nociceptive TENS modality will spur algogenic chemical pain, which plays a role in continuing the

nociceptive stimulus by stimulating enkephalin receptors. Stimulation of enkepline receptors is a

prodromic stimulus that will be followed by the release of endorphins to reduce pain. On the other

hand, the activation of the algogenic chemical pain will spur the P substance, which causes the

vasodilation of capillary blood vessels. It is a way of using electrical energy to stimulate the nervous

system or other body tissues through the surface of the skin (Astuti, 2018) and infrared which aims to

stimulate heat receptors and nociceptors to feel warmth, thereby increasing blood flow in the muscles

and improving stiffness and muscle pain. When infrared radiation is applied to the patient's body, it

will increase local blood flow and tissue metabolism (Febrianto et al., 2024; Tsai & Hamblin, 2017).

The infrared light, given in the case of a frozen shoulder, can reduce pain. This is because

infrared radiation can increase the temperature of tissues. According to Hoff's Varit Law, chemical

changes can be accelerated by the presence of heat. Thus, tissue heating will accelerate chemical

changes, namely metabolic processes. The supply of O2 and food juices will increase so that the tissue

needs for O2 and food juices will be quickly met. This will happen because heating will activate the

glandulagudoifera (sweat glands) of the tissue area that is given irradiation or heating so that it will

increase the elimination of the remnants of the metabolic system through automatic sweating, pain

can be reduced (Hardini & Putri, 2021; Saputro Bintang, 2022).

Decrease in muscle spasm

Table 1 Evaluation results of decreased muscle spasm

Otot

M.Deltiod anterior.

There’s spasm

No spasm

M. Infraspinatus

There’sspasm

There’s spasm

No spasm

M. supraspinatus

There’sspasm

There’s spasm

No spasm

Source: (Personal document,2024).

The table above shows a decrease in a spasm of the anterior M. deltoid muscle and M.

Infraspinatus, M. deltoid, middle Dextra from T1 there is a spasm to T3 reduced spasm. This is due to

the effect of infrared irradiation, which allows relaxation to be easily achieved if the tissue is warm.

Infrared radiation can increase the temperature of tissues to eliminate spasms and relaxation in the

muscles and increase the muscles' ability to contract. According to Agustiningsih (2023), active exercise

reduces pain and spasms in the shoulder muscles, especially Active Exercise, which aims to maintain

physiological elasticity and muscle contractility.

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Improvement of MMT evaluation results

Graph 2. MMT shoulder dextra evaluation results

Source: (Personal document, 2024).

The graph above shows that at T1, there is a value of 3, but at the second and third meetings,

there is an increase in muscle strength from a value of 3 to 4.

Decreased muscle strength is common in frozen shoulder sufferers, especially in the shoulder-

driving muscles. This is due to immobilization in the shoulder area for a long time. Patients will avoid

movements that make the shoulder painful so that spasm in the shoulder area occurs. From this,

infrared intervention and towel stretch can reduce muscle pain and spasms in the shoulder area,

especially in towel stretch, which has to maintain physiological elasticity and muscle contractility.

Towel exercise is a soft tissue stretching technique with certain techniques to reduce muscle tension

physiologically so that the muscles become relaxed and can increase the range of motion of the joints

and increase muscle strength (Tri Nurhayati et al., 2023). Towel exercise is a soft tissue stretching

technique with certain techniques to reduce muscle tension physiologically so that the muscles

become relaxed and can increase the range of motion of the joints (Tri Nurhayati et al., 2023).

0 1 2 3 4 5

Manual Muscle Testing

Endorotasi Eksorotasi Adduksi Abduksi Ekstensi Fleksi

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Increase in the Range of Motion of Dextra active Joint Motion

Graph 3. Results of LGS evaluation on dextra

Source: (Personal Documents, 2024)

Based on the graph above, it can be seen that there is an increase in the range of motion of the

active shoulder joint, in flexion motion – extension T1 shows (S) 30° – 0° – 150° after T3 increases to

(S) 40° – 0° – 160°, vertical abduction – T1 shows (F) 100° – 0° – 50° after T3 increases to (F) 110° –

0° – 55°, abduction – horizontal adduction T1 shows (T) 20° – 0° – 100° after T3 increases to (T) 25°

– 0° – 115°, Exorotation – Endorotation T1 shows (R) 70° – 0° – 50° after T3 increases to (R) 80° – 0°

– 65°. Mobilization in patients was obtained as a result of the examination, namely an increase in LGS

in stiff joints, heat combined with joint mobilization and an increase in the elongation of collagen and

an increase in physiological movement. The intervention given to the patient is in the form of

pendulum exercises to prevent active adhesion to the shoulder joint and is given weights and self-

mobilization techniques that utilize the influence of gravity to produce the effect of pulling the humeri

os from the glenoidalis fossa (Tri Nurhayati et al., 2023).

Implementation of LGS improvement in accordance with research (Ii & Bahu, 2023), that

pandulum exercise and active exercise interventions can reduce shoulder pain in frozen shoulder

conditions. With a frequency of 2 times a week for 3 weeks, interventions are carried out. Pendulum

exercises are able to expand the structure of soft tissues such as muscles and tendons so that the

flexibility of these tissues can be maintained so that there is an increase in the scope of motion of the

shoulder joint and reduce pain.

30 30

150 150

160

100 100

110

50 50

20 20 25

100 100

115

70 70

50 50

100

120

140

160

180

T1 T2 T3

Lingkup Gerak Sendi

Ekstensi Fleksi Abduksi Vertikal Adduksi Vertikal

Abduksi Horizontal Adduksi Horizontal Eksorotasi Endorotasi

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Functional Enhancement with SPADI

Graph 4 SPADI evaluation results

Source: (Personal Document, 2024).

From the graph above, it shows that the results of measuring functional activity using SPADI

dimna got a decrease in first therapeutic pain from a score of 15 to 11. Then for the first therapy

disability score from a score of 7 to 5. For the total number of SPADI T1 scores of 22 to 16, so that the

total SPADI score from 16.9% moderate pain to 12.3% mild pain.

The results of the SPADI measurement in the form of a percentage, the greater the value, the

lower the functional ability of the shoulder joint. SPADI has been proven to be reliable and valid as a

measure of shoulder functional ability in various populations (Suharyadi & Ismanda, 2021). Increased

functional activity resulted in a decrease in pain, spasms, and an increase in LGS as well as an increase

in the strength of the Dextra shoulder muscles. Reduced pain will improve the patient's functional

activities such as raising the hand up, placing objects on a high shelf, buttoning clothes. The evaluation

results of improving functional activities are also supported by activities and exercises carried out by

patients at home. For this reason, physiotherapy provides education, namely doing active exercises,

pandulum exercises and towel strech. From various exercises carried out in hospitals and homes, they

affect the speed of recovery from the patient's illness so that patients can return to normal activities

(khoerul ummah, 2022).

This study has demonstrated the significant impact of physiotherapy modalities such as

InfraRed, TENS, and Active Exercise on improving the condition of patients with Frozen Shoulder,

particularly in reducing pain, increasing muscle strength, and improving joint range of motion.

However, it is important to acknowledge the limitations of this research. First, the study is based on

a single case study, which limits the generalizability of the findings. While the results are promising

for this patient, the treatment outcomes may vary for other patients with different severity levels of

Frozen Shoulder or other underlying conditions. Future studies involving a larger sample size are

necessary to verify the efficacy of these physiotherapy treatments in a broader population. Second,

the short duration of the therapy (three sessions) may not provide a comprehensive view of the

T1 T2 T3

15 15

7 7

22 22

SPADI

Pain Score Disability Score SPADI Score

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long-term effects of the treatment. A more extended follow-up period could better understand how

sustained treatment affects recovery and whether these improvements are maintained over time.

Lastly, no control group was included in the study, which makes it difficult to compare the

effectiveness of these specific modalities against other potential treatments for Frozen Shoulder, such

as manual therapy or different types of physical rehabilitation techniques. Future research could

address this by including randomized controlled trials to compare the efficacy of these interventions.

While, the study provides valuable insights into the benefits of InfraRed, TENS, and Active Exercise

modalities, future research with a larger sample, longer therapy duration, and control groups would

help to strengthen the validity and applicability of these findings to the broader population of Frozen

Shoulder patients.

Conclusion

Frozen shoulder is a condition in which shoulder movement is limited. The severity varies from

mild pain to severe pain or how much the limited range of motion of the Frozen shoulder joint causes

the capsule that wraps around the shoulder joint to wrinkle, and scar tissue is formed so that it causes

pain and stiffness in the shoulder joint so that it will affect shoulder movement and is difficult to move.

The physiotherapist's treatment with TENS, IR and exercise therapy in the case of Frozen shoulder

experienced by Mrs. H.Z obtained the following results: 1) There are benefits of giving TENS, and IR

where it reduces pain. 2) There are benefits of exercise therapy, namely the administration of

pendulum exercises and active exercises, there is a slight increase in LGS. 3) There are benefits of

exercise therapy, namely towel stretches, there is a slight increase in muscle strength. 4) There is a

measurement using SPADI and the results are a slight change in activity and an increase in functional

activity ability.

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