EFFECT OF STRENGTHENING EXERCISE ON MANAGING SHOULDER PAIN IN THE

DIABETIC POPULATION: AN OVERVIEW STUDY

Adil, Nazrene Sky; Aguanta, Cyrra Lynne; Alcoseba, John Paolo; Arcilla, Deborah; Astillo, Neil;
Balagot, John Mark; Banaybanay, Kyla; Balascopo, Tefhanie; Fuentes, Lourdes Mikaela; Garcia, Angel
Kaye; Garcia, Johannah Kriscel; Gascon, Jeianne; Laran, Jaimuel; Vitualla, John Erick; Yana, Dane
Alexis

Abstract

Patients with diabetes frequently complain of shoulder pain, which limits their range of motion
and renders them functionally disabled. The most typical incapacitating shoulder condition is adhesive
capsulitis (AC). There is no ideal non-surgical management of AC in diabetics. The optimal method for
managing frozen shoulders in diabetics is unknown. Diabetes and the recovery process following
shoulder replacement surgery are unknown variables. Furthermore, we are unsure of the elements that
can influence function following shoulder replacement surgery. Shoulder pain is related to shoulder
rotator cuff weakness.

Introduction

Patients with diabetes suffer from frozen shoulders five times more frequently than the general
population. Relatively, as mentioned in the study conducted by Alasmari et al. (2020), it was found that
patients with diabetes had a higher prevalence of shoulder disorders (27.5%) than patients with other
medical conditions (5%). Pain and disability resulted from a frozen shoulder. The typical treatments
lessen shoulder discomfort and disability, but for people with diabetes, these treatments are frequently
unsuccessful. At this time, it is unclear which management strategy is most effective for patients with
diabetes who have frozen shoulders. The impact of diabetes on the healing process following shoulder
replacement surgery and the variables that might influence function following shoulder replacement
surgery is still unknown. Patients with diabetes are known to experience frozen shoulders more
frequently. When non-surgical treatment fails to treat a diabetic frozen shoulder, Arthroscopic Capsular
release is an option. Although the precise cause of primary adhesive capsulitis is not yet known, diabetes
mellitus (DM) and the condition have a strong correlation. Adhesive capsulitis of the shoulder can be
treated with Arthroscopic Capsular release. This study sought to examine the clinical outcomes of
arthroscopic capsular release in patients with primary, secondary, and idiopathic adhesive capsulitis. To
ascertain whether arthroscopic capsular release (ACR) reduces the duration of the frozen shoulder (FS)
illness in comparison to the depicted natural course of 30.1 months and to identify risk factors for
persistent complaints.

Diabetes is a metabolic disorder characterized by chronic hyperglycemia brought on by

insufficient insulin, impaired insulin action, or both. It is one of the most difficult health issues of the
twenty-first century. The two main types of diabetes can be distinguished by their etiologies: type 1
diabetes, which is brought on by the cell-mediated autoimmune destruction of the pancreatic islet beta
cells, which results in the loss of insulin production; and type 2 diabetes, which is brought on by insulin
resistance and/or insulin deficiency. There are other types of diabetes, including type 3 diabetes (brain
insulin resistance) and gestational diabetes, which occur during pregnancy. Diabetes has widely
recognized side effects that include neuropathy, cardiovascular disease, retinopathy, stroke, peripheral
vascular disease (amputation), and renal failure, which shorten life spans, cause disability, and raise
medical expenses. The musculoskeletal system's complications are often less documented. One of the
most typical complaints of those suffering from diabetes is shoulder pain, which impairs motion, renders
them functionally disabled, and lowers their quality of life. Patients with diabetes have a higher
prevalence of shoulder disorders, with AC and RC tendinopathy being the most prevalent disabling
shoulder disorders. Bridgman (1972) discovered that 10.8% of patients with diabetes and 2.3% of patients
without diabetes had AC, establishing the first known link between the two conditions. This association
has been supported by subsequent research, which found that type 1 and type 2 diabetes patients were
more likely to have AC (compared to the general population, which had a prevalence of 0–10%). In both
types of diabetes, as well as type 1, adhesive capsulitis has been shown to be related to age and duration.
Diabetes patients are at a higher risk of developing RC tendinopathy than people without the disease,
whether or not they use insulin. Additionally, chronic RC tendinopathy and shoulder pain have been
linked to diabetes. Moreover, it has been documented that patients with diabetes also have AC and RC
tendinopathy, which can cause shoulder pain and contracture. Diabetes has also been linked to
postoperative stiffness following rotator cuff repair. There is a lack of knowledge regarding
pathophysiology that makes diabetic patients more likely to develop AC or RC disease. The two
conditions might, however, have a similar diabetes-related mechanism in common.
Objectives of the Study

The objective of the study is to describe and evaluate a physiotherapy program targeted to reduce
pain intensity and improve the daily functioning of diabetics with shoulder problems.

Specially, seeks to:

1. To determine if arthroscopic capsular release (ACR) shortens the period of illness in frozen
shoulder (FS) in comparison to the depicted natural course of 30.1 months, and

2. To identify risk factors for persisting complaints.

Definition of Terms

To aid the readers, the following list contains the definition of the terms being used throughout
this study. The terms are listed in alphabetical order, and not necessarily the order in which they are found
in this paper.

Adhesive Capsulitis

A painful reduction in active passive shoulder mobility that leads to fibrosis and rigidity of the
joint capsule. Adhesive capsulitis may be distinguished from other disorders that produce stiffness or
shoulder pain using information from the history and physical examination (Andrew & Neviaser, 2011).

Arthroscopic Capsular Release

A capsule release that results in an immediate reduction in pain, functional outcomes, and range
of motion. Patients who underwent surgery all experienced notable pain reduction, increases in range of
motion, and upgrades in overall shoulder function. (Barnes et. al., 2015).

Diabetes

Cole and Florez (2020) estimate that by 2045, 693 million individuals would be affected by this
disease, which is one of the diseases with the quickest global growth rates. Early studies also tried to
establish that familial linkage analysis is the genetic cause of diabetes. Additionally, this could result in
kidney failure, blindness, and a general decline in the quality of life for diabetics.

Scapulothoracic Strengthening Exercise

The addition of scapulothoracic strengthening physical activity (serratus anterior) effects In

individuals with adhesive capsulitis, the anterior, middle, and lower trapezius, latissimus dorsi, are added
to a physical treatment plan. They came to the conclusion that including scapulothoracic exercises in
addition to a glenohumeral range of motion exercises helped patients with frozen shoulders experience
less pain. Because the scapulohumeral rhythm was reestablished, the researchers speculated that the group
receiving scapula strengthening therapy got better. (Celik, 2010).

Strengthening Exercises

An activity that needs considerably greater physical effort than regular. As a result, it improves
muscle endurance, strength, and size. uses resistance or weights as well.

Related Literature
The management of shoulder pain in diabetic populations is a complex and multifaceted issue
that requires a broad knowledge base and interdisciplinary approach to address effectively. Strengthening
exercises are one modality that has shown promise in the management of shoulder pain; however, their
effectiveness in diabetic populations requires careful consideration.

Diabetes is a chronic disease that affects millions of people worldwide and can result in a range
of complications, including shoulder pain. Shoulder pain is a common complication of diabetes and can
significantly affect the quality of life of affected individuals. The management of shoulder pain in
diabetic populations requires a comprehensive assessment of the patient's medical history, physical
examination, and imaging studies, including magnetic resonance imaging (MRI) and ultrasound.

Strengthening exercises are a form of physical therapy that aims to increase muscle strength,
flexibility, and range of motion. Strengthening exercises may be an effective treatment option for
shoulder pain, as they can improve muscle function and reduce pain. In addition, strengthening exercises
can improve glucose control in diabetic patients, which can reduce the risk of complications.

Research indicates that strengthening exercises can be an effective treatment option for shoulder
pain in diabetic populations. A randomized controlled trial by Yoosefinejad et al. (2016) compared the
effectiveness of therapeutic exercise and ultrasound therapy in the management of shoulder pain in
diabetic patients. The study found that therapeutic exercise was more effective than ultrasound therapy in
reducing pain and improving function.

Another study by Umer et al. (2016) examined the effectiveness of physical therapy in the
management of shoulder pain in diabetic patients. The study found that physical therapy, including
strengthening exercises, was effective in reducing pain and improving function in diabetic patients with
shoulder pain.

Strengthening exercises may also be effective in reducing the risk of future shoulder pain in
diabetic populations. Research indicates that strengthening exercises can improve muscle function, which
can reduce the risk of injury and subsequent shoulder pain. In addition, strengthening exercises can
improve cardiovascular health, which can reduce the risk of diabetes-related complications

Massoud et al. (2002) conducted a study to evaluate the outcome of shoulder surgery in patients.
A satisfactory outcome was defined as the patient feeling better or significantly better, while an
unsatisfactory outcome was when the patient felt the same or worse. The study found that in 78.8% of the
cases, the outcome was good, with 51.1% of the shoulders feeling far better and 27.7% feeling better. In
21.2% of the cases, the outcome was poor, with 19.1% of the shoulders feeling the same and 2.1% feeling
worse. There was also an improvement in the mean (standard deviation) Constant score.

Park et al. (2014) studied the effect of stiffness treatment on range of motion tests, functional
ratings, and muscle strength ratios in patients who underwent shoulder surgery. They found that
irrespective of the treatment approach, all patients showed considerable improvement postoperatively.
Patients with diabetes mellitus showed greater improvement in forward flexion after 3 months and 1 year,
as well as in external rotation at the side for all time points. The study also found that there was no
significant difference in outcome measures between patients who underwent capsular release and those
who did not, regardless of the severity of stiffness. However, retears occurred more frequently in patients
who underwent capsular release and manipulation than in those who received manipulation alone.

Butchart et al. (2009) examined chronic pain in patients with heart failure and diabetes mellitus.
The study found that more than 60% of people in each group experienced chronic pain, with the majority
suffering from back, hip, or knee discomfort. Patients with chronic pain were more likely to report fair or
poor health in all categories, and a larger percentage of patients with pain were not working due to health
reasons in the HF and diabetic groups. The study also found that more than 70% of people with pain in
each group took pain medications, and less than 50% used exercise to treat their pain.

Abd Elhamed et al. (2018) examined scapular changes in patients with frozen shoulders and
focused on pain alleviation and range of motion improvement in the treatment program. The study found
that patients with adhesive capsulitis exhibit higher upper trapezius activity and an imbalance of upper
trapezius/lower trapezius activity. In the treatment of frozen shoulder, the insufficiency of increased lower
trapezius muscle activation should be taken into account. Therefore, the study aimed to look at the
additional effect of lower trapezius muscle strengthening activities on scapular tilting in patients with
Diabetic Frozen Shoulder (DFS).

Düzgün et al. (2012) investigated the effectiveness of manual treatment in the rehabilitation of
patients with frozen shoulders, both diabetic and non-diabetic. The study found that manual treatment was
an effective physiotherapy strategy for rehabilitation in both groups, with no negative effects on the
process of rehabilitation in diabetes patients. Before therapy, diabetic and non-diabetic individuals had no
difference in range of motion, functional activity level, discomfort, or muscular strength. The study
suggested that this could be because the patients' diabetes levels were under control with medication
prescribed by their primary care physician.

Conclusion and Recommendations

People with diabetes are more likely to experience shoulder pain, reduced joint motion, and
adhesive capsulitis. As part of managing glycemic control and overall health, physical activity and
exercise should be advised to and prescribed for all individuals who have diabetes. Various suggestions
and precautions will be given based on the type of diabetes, age, activity level, and the presence of
diabetes-related health concerns. Recommendations should be tailored to each individual's specific need.
This review discovered that moderate-quality evidence supported an early improvement in shoulder ROM
and function that slows over time and leads to long-term limitations, calling into question the commonly
held belief that AC is a self limiting condition. Strengthening of exercises management of shoulder pain
for patients without diabetes receiving specific physiotherapy treatment improved more frequently and
rapidly than patients with diabetic without specific physiotherapeutic interventions. The researchers found
that low quality evidence suggested large effects of joint mobilization plus exercises on AC in people
with diabetes. These observations have implications for the recommendation of exercise for type 2
diabetics and people with musculoskeletal pain who are not active. Preliminary research suggests that
only 8 weeks of low-volume, high-intensity combined aerobic and resistance exercise training might
possess a marginally positive effect on musculoskeletal pain. However, the research implies that exercise
may not be a cure for neuropathic pain. Exercise experts may need to offer close supervision and
instruction to address. Active exercise is recommended as the main course of treatment. and that regular
re-evaluation is carried out to guarantee that all clinical aspects causing the presenting shoulder
discomfort are dealt with.
References

Abd Elhamed, H. B., Koura, G. M., Hamada, H. A., Mohamed, Y. E., & Abbas, R. (2018). Effect of
strengthening lower trapezius muscle on scapular tipping in patients with diabetic frozen
shoulder: A randomized controlled study.

Aljethaily, A., Alshuwayrikh, A., Alkhonezan, S., Alasmari, A., Almakdob, M., Albogami, A., Aloriney,
A., Ahmed, I., & Alzahrani, B. (2020). The Prevalence of Shoulder Pain and Its Functional
Limitations Among Patients With Uncontrolled Diabetes. Cureus, 12(11), e11487.
https://doi.org/10.7759/cureus.11487

Arkkila, P. E. T., & Gautier, J.-F. (2003). Musculoskeletal disorders in diabetes mellitus: an update. Best
Practice & Research Clinical Rheumatology, 17(6), 945–970.

Barnes, C.P., Lam, P.H., Murrell, G.A.C., DPhil. 2016. Short-term outcomes after arthroscopic capsular

release for adhesive capsulitis. https://doi.org/10.1016/j.jse.2015.12.025

Bridgman, J. F. (1972). Periarthritis of the shoulder and diabetes mellitus. Annals of Rheumatic Diseases,
31(1), 69.

Butchart, A., Kerr, E. A., Heisler, M., Piette, J. D., & Krein, S. L. (2009). Experience and management of
chronic pain among patients with other complex chronic conditions. The Clinical Journal of Pain,
25(4), 293-298.

Cole, J.B., Florez, J.C. Genetics of diabetes mellitus and diabetes complications. Nat Rev Nephrol 16,

377–390 (2020). https://doi.org/10.1038/s41581-020-0278-5

Dhanvijay, R. P., & Pohekar, S. (2021). Efficacy of relaxation therapy on the breathing pattern among
bronchial asthma patients. Journal of Pharmaceutical Research International, 33(42B), 55–60.
https://doi.org/10.9734/jpri/2021/v33i42B32424

Dhanvijay, R., & Pohekar, S. (2021). Assessment of auto-rickshaw drivers knowledge regarding the
effects of air pollution on health and its prevention. Journal of Pharmaceutical Research
International, 33(41B), 20–26. https://doi.org/10.9734/jpri/2021/v33i41B32340

Dhanvijay, R., & Pohekar, S. (2021). Case report on rheumatoid arthritis. Journal of Pharmaceutical
Research International, 33(39A), 212–216. https://doi.org/10.9734/jpri/2021/v33i39A32162
Dhanvijay, R., & Pohekar, S. (2021). Review on air pollution on health and its prevention. Journal of
Pharmaceutical Research International, 33(45B), 17–23.
https://doi.org/10.9734/jpri/2021/v33i45B32773

Dhanvijay, R., Taksande, A., Fating, M. S., Jadhav, K., Bhandekar, A., & Pradhan, M. (2021). Assess the
knowledge regarding prevention of accidents of schoolers among primary school teachers in
selected schools. Journal of Pharmaceutical Research International, 33(44B), 220–228.
https://doi.org/10.9734/jpri/2021/v33i44B32670

Dhengare, A., & Pohekar, S. (2021). To assess the effectiveness of selected breathing exercises among
chronic obstructive pulmonary disease patients. Journal of Pharmaceutical Research International,
33(54B), 354–361. https://doi.org/10.9734/jpri/2021/v33i54B33798

Dhengare, A., Pohekar, S., Sakharwade, P., Sakharkar, S., Gujhar, S., Tembare, V., & Ankar, R. (2021).
Case report of typhoid fever (Salmonella Typhi). Journal of Pharmaceutical Research
International, 33(58A), 55–59. https://doi.org/10.9734/jpri/2021/v33i58A34089

Dhengare, A., Sharma, R., Waware, S., & Wagh, P. (2021). A case report of Steven Johnson Syndrome.
Journal of Pharmaceutical Research International, 33(58A), 132-139.
https://doi.org/10.9734/jpri/2021/v33i58A34098

Dhobe, S. B., & Gujar, S. S. (2021). Prevalence of associated factors of depressive symptoms among
school going children. Journal of Evolution of Medical and Dental Sciences, 10(15), 1060-1063.
https://doi.org/10.14260/jemds/2021/226

Dhobe, S. N., & Mahakarkar, M. (2021). To assess the prevalence of bacterial vaginosis among women in
selected rural areas. Journal of Pharmaceutical Research International, 33(47A), 410-414.
https://doi.org/10.9734/jpri/2021/v33i47A33027

Dhobe, S., & Singh, S. (2021). Prevalence of nutritional anemia and its causes among adolescent girls.
Journal of Pharmaceutical Research International, 33(46B), 485-490.
https://doi.org/10.9734/jpri/2021/v33i46B32965

Dhobe, S., Ankar, R., Dhanvijay, R., Dighikar, V., & Thakre, P. (2021). Airway management in COVID-
19 patients. Journal of Pharmaceutical Research International, 33(46B), 562-566.
https://doi.org/10.9734/jpri/2021/v33i46B32977
Dhobe, S., Singh, S., Sharma, R., & Ankar, R. (2021). A case report of complete heart block. Journal of
Pharmaceutical Research International, 33(46B), 546-550.
https://doi.org/10.9734/jpri/2021/v33i46B32974

Dhole, P. (2021). Surgical outcome of Hirschsprung’s disease in male child: A rare case report. Journal of
Pharmaceutical Research International, 33(37B), 54-58.
https://doi.org/10.9734/jpri/2021/v33i37B32020

Dhote, S., Bawiskar, D., & Phansopkar, P. (2021). A case report: Post-operative physiotherapy
rehabilitation program for a patient with tibial osteosarcoma. Journal of Pharmaceutical Research
International, 33(58A), 497-504. https://doi.org/10.9734/jpri/2021/v33i58A34143

Dhulse, P. S., & Mourya, A. (2021). Serum vitamin D status is associated with health problems in
children with PEM. Journal of Pharmaceutical Research International, 33(49A), 215-218.

Düzgün, İ., Baltacı, G., & Atay, Ö. A. (2012). Manual therapy is an effective treatment for frozen
shoulder in diabetics: An observational study. Joint Diseases and Related Surgery, 23(2), 94-99.

Dyck, R., Osgood, N., Lin, T. H., Gao, A., & Stang, M. R. (2010). Epidemiology of diabetes mellitus
among first nations and non-first nations adults. Cmaj, 182(3), 249–256.

Greenberg, D. L. (2014). Evaluation and treatment of shoulder pain. Medical Clinics of North America,
98(3), 487-504.

Massoud, S. N., Pearse, E. O., Levy, O., & Copeland, S. A. (2002). Operative management of the frozen
shoulder in patients with diabetes. Journal of Shoulder and Elbow Surgery, 11(6), 609-613.

Neviaser, Andrew S. MD; Neviaser, Robert J. MD. Adhesive Capsulitis of the Shoulder. American
Academy of Orthopaedic Surgeon 19(9):p 536-542, September 2011.

Neviaser, Andrew S. MD; Neviaser, Robert J. MD. Adhesive Capsulitis of the Shoulder. American
Academy of Orthopaedic Surgeon 19(9):p 536-542, September 2011.

NHS. 2022 November 18. How to improve your strength anf flexibility.
https://www.nhs.uk/live-well/exercise/strength-and-flexibility-exercises/how-to-improve-strength-
flexibility/

Park, J. Y., Chung, S. W., Hassan, Z., Bang, J. Y., & Oh, K. S. (2014). Effect of capsular release in the
treatment of shoulder stiffness concomitant with rotator cuff repair: Diabetes as a predisposing
 factor associated with treatment outcome. The American Journal of Sports Medicine, 42(4), 840-
850.

Walke, R., & Telang, A. A. (2022). Strengthening exercises in management of shoulder pain in diabetic
population. Journal of Pharmaceutical Negative Results, 13(1), 2860-2864.