NeuroQuantology|June 2022| Volume20|Issue6|Page 2726-2736| doi: 10.14704/nq.2022.20.6.

NQ22266
Isam Ali Hameedi et al / Comparison of Application of the Radial Vs. Focused Probes of Extracorporeal Shockwave Therapy on Pain, Range of Motion and
Function in Patients with Adhesive Capsulitis

Comparison of Application of the Radial Vs.

Focused Probes of Extracorporeal Shockwave
Therapy on Pain, Range of Motion and Function in
Patients with Adhesive Capsulitis
Isam Ali Hameedi1, Azadeh Shadmehr2*, Kazem Malmir3, Sara Fereydounnia4, Zeinab Shiravi5

Abstract
Objective: To compare the effects of application of the radial vs. focused probes of extracorporeal shockwave
therapy to treating adhesive capsulitis (AC) in order to increase range of motion (ROM), relieve pain, improve
function of the shoulder joint in fewer sessions, reduce the recovery time and reduce the patient's financial losses.
Materials and Methods: A total of 40 patients with AC were randomized into two groups: Group A (n = 20) received
rESWT with conventional therapy and Group B (n = 20) received fESWT with conventional therapy, including
Infra-red, US, supervised exercise & home exercises, two treatments every week for four weeks. All the patients
treated using ESWT one session per week as well as one session per week conventional therapy was carried out. The 1
visual analogue scale (VAS) scores during at rest and during exercise, the Disabilities of the Arm, Shoulder, and Hand
(DASH)questionnaire, scapular dyskinesia, flexion, extension, abduction, internal rotation, and external rotation
ranges of shoulder motion were evaluated before, after two weeks, and after four weeks of the intervention.
Two-way mixed analyses of variance were used to assess the impact of the type of the probe of the ESWT on the
outcomes during the assessment intervals. Results: There was a significant improvement in each outcome within the
group (P<0.001), but no significant difference was observed between groups for the outcomes at baseline, two
weeks, and four weeks after treatment (P>0.05). Conclusion: It is recommended to use the rESWT in the first weeks
of treatment for the acceleration treatment method compare to the fESWT.

Key Words: Adhesive Capsulitis, Extracorporeal Shockwave Therapy, Radial Probe, Focused Probe, DASH. 2726
DOI Number: 10.14704/nq.2022.20.6.NQ22266 NeuroQuantology 2022; 20(6):2726-2736

Introduction mobility in the absence of radiographic indications

Adhesive capsulitis (AC), also known as frozen other than osteopenia", the exact pathophysiology
shoulder, is an inflammatory disorder that causes is unknown. Inflammation begins in the joint
shoulder stiffness and pain. The American Academy capsule and synovial fluid, according to the most
of Orthopedic Surgeons (AAOS) has designated it as widely accepted theory.
"a syndrome defined by a slow development of
worldwide limiting of active and passive shoulder
Corresponding author: Azadeh Shadmehr
Address: 1MSc. Candidate, PT, Physical Therapy Department, School of Rehabilitation, Tehran University of Medical Sciences,
Tehran, Iran; 2*Ph.D., PT, Professor, Physical Therapy Department, School of Rehabilitation, Tehran University of Medical
Sciences, Tehran, Iran; 3Ph.D., PT, Associate Professor, Physical Therapy Department, School of Rehabilitation, Tehran
University of Medical Sciences, Tehran, Iran; 4Ph.D., PT, Assistant Professor, Physical Therapy Department, School of
Rehabilitation, Tehran University of Medical Sciences, Tehran, Iran; 5Ph.D., PT, Assistant Professor, Physical Therapy
Department, School of Rehabilitation, Tehran University of Medical Sciences, Tehran, Iran.
E-mail: 1isam_jettar@yahoo.com; 2*shadmehr@tums.ac.ir; 3kmalmir@tums.ac.ir; 4s-fereydounnia@sina.tums.ac.ir;
5zeinabshiravi@yahoo.com
1ORCID ID: 0000-0002-8830-1494; 2*ORCID ID: 0000-0002-1186-9997; 3ORCID ID: 0000-0002-0801-2597;
4ORCID ID: 0000-0002-9827-3108; 5ORCID ID:0000-0003-3996-861X

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NeuroQuantology|June 2022| Volume20|Issue6|Page 2726-2736| doi: 10.14704/nq.2022.20.6.NQ22266
Isam Ali Hameedi et al / Comparison of Application of the Radial Vs. Focused Probes of Extracorporeal Shockwave Therapy on Pain, Range of Motion and
Function in Patients with Adhesive Capsulitis
The initial description of this phenomenon was
provided by Codman in 1934[2]. Adhesive
capsulitis moves through three stages are quite
common. Stage 1 is called "freezing" and lasts as
long as nine months, increasing pain and stiffness.
In stage 2, the process is said to be "frozen" and
remains in a steady-state for between four and
twenty months. Going through Stage 3 is referred to
as "thawing," which can take anywhere from five to
twenty-six months [1, 2]. Frozen shoulder (FSH) is
more common in people in their 40s and 60s, and it
affects women more than men. It can also be
bilateral. Diabetes, thyroid illness, heart disease,
and shoulder injuries are all linked to the disorder,
although they do not cause it. The most typical
symptoms include vague to severe shoulder pain on
the outside of the arm, sleeping difficulties on the
affected arm, and gradual stiffness with loss of
function [3]. Different approaches to treating AC
have been studied in depth throughout the years
such as oral medicines, cortisone injection,
distension, manipulations, and surgical procedures.
The previous interventions and treatments were
not able to resolve the problems of these patients
completely. Therefore seeking other treatment
options seems to be necessary to treat this injury
[29, 30]. A shock wave is a transient pressure
disturbance that travels through three-dimensional
space and propagates rapidly. It occurs as a result
of a rapid increase in ambient pressure to its
maximum level. Cavitation due to the negative
phase of the wave is a significant tissue effect.
Shockwaves are with unique physical properties
such as nonlinearity, a high peak pressure followed
by low tensile amplitude, a short rising time, and a
short duration (10 MS), they have a single pulse
with a wide frequency range (0-20 MHz) and a
large amplitude of pressure (0-120 MPa) [4]. The
extracorporeal shockwave therapy (ESWT) has the
capacity of changing surgical procedures in lots of
orthopedic issues without the surgical risks and the
complication average is low and negligible, ESWT
induces a series of biological responses and
molecular changes, including increased new blood
vessel formation and activation of angiogenic
growth factors, thereby improving blood supply
and tissue regeneration [5]. There are two types of
probes used for shockwave, including Radial probe
(rESWT) and Focused probe (fESWT). The rESWT
is being the larger treatment area of superficial
indications, treatment depth of 3-4 cm spreads out
to treat a greater region compare with fESWT, slow
impulse, and low energy density. Make up the
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rESWT from ultrasonic pulses, audio acoustic
pulses, and relatively slow shear waves, radial
pressure waves have the highest energy at their
origin and gradually lose it as they travel. The
kinetic energy is subsequently transferred to the
tissue, where it propagates as a radial wave
spherically outward. The pressure waves lose
strength as they go deeper into the body. The
transmitter surface has the highest pressure and
energy density [4, 5, 6]. The fESWT is being a
smaller focal point for greater accuracy and greater
treatment depth. Depending on the attachments
utilized, a deep reach of up to 12cm, precise energy
delivery to a specific location, fast impulse, a high
density of energy would be possible using this type
of probe. fESWT can penetrate deeper into the
tissues and deliver all of their energy at the
specified depth. The amount of energy spread at the
actual wave production site is small. This prevents
injury to the skin and the sensitive tissues beneath
it. Each shock is directed to a specific place within
the body by the focusing device [4, 5, 7].The
biological effects of focus waves and radial waves
include an increase in cell wall permeability and an
increase in cell membrane permeability,
Microcirculation (Blood, Lymph), stimulation, pain 1
2727
regulation is aided by the release of the substance P
neurotransmitter, and it's a potent vasodilator that
causes severe hypotension. The biological effects of
only fESWT are cavitation, Nitric oxide production
(increased cell metabolism, neoangiogenesis, and
anti-inflammatory effect) and growth factor
stimulation [7, 8]. It seems that there is added value
of application of fESWT for improvement the
condition of anterior capsulitis of the shoulder. No
study has yet compared the effects of fESWT and
rESWT on the signs and symptoms of the patients
with AC. The objective of the current study,
therefore, was to compare the effects of fESWT and
rESWT on pain, ranges of shoulder flexion and
function of the patients with AC.
Materials and Methods
This study was approved by the Ethics Committee
of Tehran University of Medical Sciences the ethical
code; 1400.216 and IRCT20210214050356N3. A
total of 40 patients recruited who have been
referred to a physiotherapy clinic (Al-Zahra clinic in
Iraq) and Marjan Medical Hospital after diagnosis
by an orthopedic specialist and consultant of a
radiologist. Orthopedic surgeons have assessed
radiographic imaging results to determine a
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Isam Ali Hameedi et al / Comparison of Application of the Radial Vs. Focused Probes of Extracorporeal Shockwave Therapy on Pain, Range of Motion and
Function in Patients with Adhesive Capsulitis
radiographic severity rating of the AC, and only
patients with sub-acute and chronic have been
selected [1,2]. The inclusion criteria are as follow:
suffering history of at least 4 months, the diagnosis
was confirmed clinically by an orthopedic specialist
and consultant a radiologist and of course
physiotherapist, the presence of AC on one side, the
patient's agreement to participate in the study, the
ages above 18 years old [18]. Exclusion criteria
were: compound shoulder injuries, shoulder
fractures, previous shoulder surgery, cancer,
tumors, inflammatory diseases, bleeding disorders,
anticoagulant medication, and aspirin intake during
the last 3 days [19], presence of other pathologies
of the shoulder such as tendonitis and
impingement, bilateral AC and reluctance to
participate in the study. All the patients in group B
fESWT completed the intervention and assessment
procedures, but two patients from the group a
rESWT did not complete the last the intervention
and assessment procedures.
Figure 1. Consort flowchart of the study
Assessment of the Outcome Measures
Demographic details and initial clinical data were
recorded; to measure the pain intensity (at rest and
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Study Design
The study was a single-blinded randomized clinical
trial. As shown in Figure 1. The patients were
blinded to the treatment objective and remained
unaware of the treatment plan. The patients were
divided randomly into two groups (group A: rESWT
+ conventional treatment and group B: fESWT +
conventional treatment); the patients received the
treatment protocol under the supervision of the
first author, a total of 8 sessions, two sessions per
week, one session applying ESWT and one session
with conventional physiotherapy alone. The
assessments of the patient were done before
starting treatment sessions, after two weeks, and
after four weeks of treatment. The statistician was
also blinded to group assignment during the
analyses.
2 2728
during activity) before and after two weeks and
after four weeks of intervention. The Visual
analogue scale (VAS) was used to assess pain
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Isam Ali Hameedi et al / Comparison of Application of the Radial Vs. Focused Probes of Extracorporeal Shockwave Therapy on Pain, Range of Motion and
Function in Patients with Adhesive Capsulitis
intensity. This is performed using a 10-cm line with
endpoints marked 'no pain' and 'worst pain
imaginable. The VAS is a valid and reliable measure
of pain intensity [10, 11]. The Disabilities of the
Arm, Shoulder, and Hand (DASH) scale was used
to assess functional impairment pain, stiffness, and
function disability measures for the upper
extremity; the DASH is a self-administered
questionnaire used to assess single or multiple
upper extremity diseases, is a widely used, reliable,
valid, and responsive measure of outcome in people
with AC [12]. This questionnaire can be used to
measure disability in any area of the upper limb
compared with other specific measurements of the
upper limb joints [13]. The passive range of
motion of the shoulder joint was checked to
examine the joint range and its quality of
movement. We utilized a plastic, 41cm
comprehensive goniometer for the activity to be
dependent upon visual assessment tests. In the
supine position, the patient was asked to lie down
and axis location middle of humeral head laterally
and stationary arm parallel with the trunk and
movement arm in line with the midline of the
humerus and moving the arm by the examiner to
the passive range of shoulder flexion, abduction,
and external, internal rotation [14]. Scapular
dyskinesia was assessed using lateral scapular
slide test (LSST) which is an assessment of scapular
motion. In order for correct shoulder function to
occur, the scapula plays a number of
responsibilities. Roles such as providing scapular
rotation with humeral motion, providing a stable
base for rotator cuff activation, and operating as a
link in the kinetic chain are all associated with
these occupations [16]. Each role is essential for
optimal arm function and can only take place when
the anatomy around the shoulder is intact. Changes
occur in the scapula's role due to bone and soft
tissue injuries, muscular weakness, and
inflexibility, leading to altered scapular resting
posture and motion. Scapular dyskinesia is the
name given to this abnormal scapular posture and
movement. There should be a diagnosis made as to
whether scapular dyskinesia is present during the
clinical examination [17]. We use this test to help
determine if the pain in the shoulder is associated
with scapular dyskinesia. A patient simulates the
force couple of serratus anterior and lowers
trapezius muscles by elevating their arm while the
scapula is rotated upwards and posteriorly tilted
[15, 16]. The lateral scapular slide test (LSST)
quantitatively measures the distance between the
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thoracic spine (T7) and the inferior angle of the
scapula. The Kibler method was used in this study
due to the functional characteristic of this test. The
first has been examiner identified and marked the
prominent spinous process of C7 in cervical flexion
by palpation with the subjects in a standing
position, and then, the spinous process of other
vertebrae down to T7 was palpated. The examiner
has bilaterally measured the distance between the
inferior angle of the scapula and the spinous
process of T7 by using the caliper [31].
Intervention
The patients have been completely unaware of the
grouping of the study. The therapist made the
patient sit on a chair on which he/she asked to rest
their arms. Shockwave gel has been applied as a
2729
thin film over the shoulder joint. Shockwave probe
was placed at an angle of 90 degrees on the
shoulder joint on the anterior and posterior side.
Parameters of rESWT were as follow: number of
impulses/beats: 2000 shock, frequency: 15 Hz,
energy 4 bar [20]. Parameters of fESWT were as
follows: number of impulses/beats: 2000 shock,
frequency: 4 Hz, energy: between 0.1 and 0.3 2
mJ/mm2 [8, 9]. The patient was asked to report if
he/she feels any burning sensation or any pain
during treatment with conventional therapy (Infra-
red, US, supervised exercise & home exercises, two
treatments every week for four weeks).
Statistical analysis: All statistical analysis was
carried out by SPSS statistical software, version 24.
The descriptive statistics were reported as mean
and standard deviation of the data; Independent
samples T-test (for quantitative variables) and Chi-
square test (for qualitative variables) were utilized.
The Two-way Mixed analysis of variance (ANOVA)
model was used to examine the impact of the type
of the probe of the ESWT on the outcomes during
the assessment intervals. Alpha level was
considered at 0.05 for all of the statistical tests.
Results
A total of 40 people were studied in two groups
(rESWT group and fESWT group). In total, the mean
(standard deviation) age, weight, and height were
48.82 (7.04) years, 86.27 (10.32) kg, and 171.10
(8.47) cm, respectively. The maximum (minimum)
age, weight, and height were 63 (35) years, 108
(67) kg, and 187 (158) cm, respectively. In total,
52.5% (21 people) were women and 55% (22
people) had injuries on the right side of the body
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Isam Ali Hameedi et al / Comparison of Application of the Radial Vs. Focused Probes of Extracorporeal Shockwave Therapy on Pain, Range of Motion and
Function in Patients with Adhesive Capsulitis
(Table 1,2). The baseline characteristics were
compared between the two groups and the
homogeneity of the two groups was studied.
The homogeneity of the distribution of the
outcomes in the two groups was examined through
independent samples T-test (for quantitative
variables) and Chi-square test (for qualitative
variables). The results of the two-way Mixed
ANOVA model for examining the differences
between groups and intergroup in the VAS score at
rest and during exercise showed that the changes
within the group were significant (p<0.001), but
the differences between groups were not
significant (Table 3). According to (Table 3) the
results of the Two-way Mixed ANOVA model for
examining the intra-group and inter-group
differences in the DASH score showed that the
interaction between time and group was significant
(p<0.001). The changes of the DASH score at
different times in each group were performed
through one-way repeated measures analysis of
variance. The results showed a significant
difference between the DASH scores in different
measurements in each group (p<0.05). The results
of pairwise comparisons through the Bonferroni
test also showed that in each group the pairwise
comparison was significant. Also, the results of the
Two-way Mixed ANOVA showed the intra-group
changes in the DASH score were significant
(p<0.001), But the differences between groups
were not significant (p>0.05). Results of the
Two-way Mixed ANOVA model for examining
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intra-group and inter-group differences in scapular
dyskinesia injured side scores, flexion, extension,
abduction, internal rotation, and external rotation,
also showed that in all variables the interaction
between time and group was significant (p<0.001).
The changes of the scapular dyskinesia scores of
the injured side, flexion, extension, abduction,
internal rotation, and external rotation ranges of
motion scores at different times in each group was
performed through one-way repeated measures
ANOVA and the results showed a significant
difference between the DASH scores in different
measurements in each group (p<0.001). The results
of pairwise comparisons on three measurement
times through the Bonferroni test also showed that
in each group the pairwise comparison was
significant. The results of the two-way Mixed
ANOVA showed that the changes within the group
were significant (p<0.001) but the differences
between groups were not significant (p>0.05), 2730
according to the (Table 3). there was no significant
difference between the two groups (p>0.05).
Although there is not significant differences, you
can show the difference by use of a graph to show
the trends of their efficacy. Also in Figures 2 to 6,
Although the two groups were not significantly 3
different but were noticed to superiority use the
rESWT in the first weeks of treatment for
comparing to the fESWT in terms of scapular
dyskinesia injured side scores, flexion, extension,
internal rotation, and external rotation score in all
points (baseline, two weeks, four weeks).
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Isam Ali Hameedi et al / Comparison of Application of the Radial Vs. Focused Probes of Extracorporeal Shockwave Therapy on Pain, Range of Motion and
Function in Patients with Adhesive Capsulitis

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Isam Ali Hameedi et al / Comparison of Application of the Radial Vs. Focused Probes of Extracorporeal Shockwave Therapy on Pain, Range of Motion and
Function in Patients with Adhesive Capsulitis

1
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Isam Ali Hameedi et al / Comparison of Application of the Radial Vs. Focused Probes of Extracorporeal Shockwave Therapy on Pain, Range of Motion and
Function in Patients with Adhesive Capsulitis

2733

Discussion treat FSH. The best treatment to improve activity

The present study conducted to compare the effect
of rESWT and fESWT on shoulder joint range of
motion, scapular dyskinesia, pain and disability in
AC patients. The results showed that both rESWT
and fESWT can significantly reduce pain on VAS
score, reduce disability on DASH score and
improves scapular dyskinesia score and shoulder
ranges of motion (flexion, extension, abduction,
external rotation) after 2 weeks and after 4 weeks;
but there are no significant differences between
these two groups in all measures.
Recently ESWT was presented as a new method to
daily living and function in FSH patients is a serious
concern in novel society.
Our result is accordance with previous studies in
which ESWT can significantly decrease pain and
improve shoulder range of motion. In study of Lee
et.al ESET is an effective treatment in FSH patients
[21]. Effect of ESWT on pain in frozen shoulder
patients also confirmed by Park et al [22].
The possible mechanism of decreasing pain is
anti-inflammatory effect of ESWT and this might
explain the analgesic effect of this modality [7].
Avancini-Dobrović et al and Lee et al. concluded

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NeuroQuantology|June 2022| Volume20|Issue6|Page 2726-2736| doi: 10.14704/nq.2022.20.6.NQ22266
Isam Ali Hameedi et al / Comparison of Application of the Radial Vs. Focused Probes of Extracorporeal Shockwave Therapy on Pain, Range of Motion and
Function in Patients with Adhesive Capsulitis
extracorporeal shock waves can significantly
increase shoulder range of motion. In the present
study both groups also exhibited statistically
significant increasing in shoulder flexion, extension,
abduction and external rotation [21,23]. Decreasing
pain and antifibrotic effect of ESWT can explain the
effect of ESWT on range of motion.
Ogden et al. have found that the impact of
shockwave can cause bruising and focal cell death,
and then stimulate the formation of new tissue or
bone [23].
In an animal study, it was found that ESWT
decrease the secretion of P substance and
calcitonin generelated peptide (CGRP) in dorsal
root ganglia which can decrease inflammation in
the area [25].
The present study show scapular dyskinesia
improves in both groups. Resting position of the
scapula is very essential for normal shoulder
movement. Scapular dyskinesia is a common
Accompanying disorder in adhesive capsulitis.
Studies found patients with FSH have excessive
movements in scapula. Fayad et al. study showed
less scapula internal rotation in shoulders with
adhesive capsulitis [26]. There is no study to
compare rESWT and fESWT on FSH but this finding
is accordance with study of J M Elía Martínez which
compared rESWT and fESWT on plantar fasciitis
[27]. Mai Ahmed Abo Al-Khair et al founded
confirmed our results in patients with calcific
shoulder tendinopathy [24]. In our study, however,
the rESWT group showed a faster therapeutic
response in the short-term period than the fESWT
group, with statistical significance in all measures.
The most important point that emerges from this
study, in fact, is the faster response in terms of pain
reduction and decreasing disability and improving
scapular dyskinesia score and shoulder range of
motion in the patients treated with rESWT compare
to fESWT, significantly shortening the response
time to treatment. This finding is accordance with a
systematic review in which they found rESWT is
better than fESWT [28]. The possible mechanism of
this findings in our study is that focus probe may
cause more pain and discomfort in the area because
of more local influence of fESWT compare to
rESWT eventually rESWT may helped to improve
participation in the exercise program more than
fESWT. Radial shockwave therapy can influence on
a bigger area of capsule compare to focus
shockwave therapy which influence on a smaller
area and base of this seems rESWT can have
therapeutic effect on more area of shoulder
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capsule. More studies should be conducted to
understand the main reason of this finding.
Clinical implication
The results of this study provide that ESWT has
positive effects on the AC joint regardless of the
type of probe used rESWT or fESWT good response
in terms of pain reduction and increase shoulder
range of motion in the patients.
Limitations
The limitation of our study was the short duration
of follow- up. Future studies should be conducted
with longer follow up after treatment. The other
limitation was COVID-19 a crisis and its impact on
the patient and consent to participate in the study.
Conclusion
There was an improvement in scapular dyskinesia
and shoulder range of motion including flexion,
extension, abduction and external rotation and a
decrease in disability and pain intensity after the
use of fESWT and rESWT. There were no
differences between fESWT and rESWT in all
measures. The most important point that emerges
from this study, in fact, is the faster response in 2
terms of pain reduction and decreasing disability
and improving scapular dyskinesia score and
shoulder range of motion in the patients treated 2734
with rESWT compare to fESWT, significantly
shortening the response time to treatment.
Ethical Considerations
Compliance with Ethical Guidelines
The Ethics Committee of Tehran University of
Medical Sciences approved the protocol of the
study.
Funding
This study was supported and approved by the
Tehran University of Medical Sciences.
Authors' Contributions
Conceptualization, study design: Isam Ali Hameedi,
Dr. Azadeh Shadmehr; Data analysis: Isam Ali
Hameedi, Dr. Zeinab Shiravi; Interpretation of data:
Dr. Sara Fereydounnia, Isam Ali Hameedi; Writing
the original draft: All authors; Writing-review,
editing: All authors.
Conflict of Interest
The authors declared no conflict of interest.
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NeuroQuantology|June 2022| Volume20|Issue6|Page 2726-2736| doi: 10.14704/nq.2022.20.6.NQ22266
Isam Ali Hameedi et al / Comparison of Application of the Radial Vs. Focused Probes of Extracorporeal Shockwave Therapy on Pain, Range of Motion and
Function in Patients with Adhesive Capsulitis
Acknowledgement
We also thank the Research Deputy, Tehran
University of Medical Sciences (TUMS) for
supporting and funding this study. The present
study is the MSc. Thesis of the first author, which is
supported by Tehran University of Medical Sciences
(grant # 1401-1-103-57545).
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