Exercise in Patients With Subacromial Impingement Syndrome
Exercise in Patients With Subacromial Impingement Syndrome
Objective To evaluate if a specific exercise strategy, targeting the rotator cuff and scapula stabilisers, improves shoulder function and pain more than unspecific exercises in patients with subacromial impingement syndrome, thereby decreasing the need for arthroscopic subacromial decompression.
Design Randomised, participant and single assessor blinded, controlled study.
Setting Department of orthopaedics in a Swedish university hospital.
Participants 102 patients with long standing (over six months) persistent subacromial impingement syndrome in whom earlier conservative treatment had failed, recruited through orthopaedic specialists.
Interventions The specific exercise strategy consisted of strengthening eccentric exercises for the rotator cuff and concentric/eccentric exercises for the scapula stabilisers in combination with manual mobilisation. The control exercise programme consisted of unspecific movement exercises for the neck and shoulder. Patients in both groups received five to six individual guided treatment sessions during 12 weeks. In between these supervised sessions the participants performed home exercises once or twice a day for 12 weeks.
Main outcome measures The primary outcome was the Constant-Murley shoulder assessment score evaluating shoulder function and pain. Secondary outcomes were patients’ global impression of change because of treatment and decision regarding surgery.
Results Most (97, 95%) participants completed the 12 week study. There was a significantly greater improvement in the Constant-Murley score in the specific exercise group than in the control exercise group (24 points (95% confidence interval 19 to 28.0) v 9 points (5 to 13); mean difference between group: 15 points (8.5 to 20.6)). Significantly more patients in the specific exercise group reported successful outcome (defined as large improvement or recovered) in the patients’ global assessment of change because of treatment: 69% (35/51) v 24% (11/46); odds ratio 7.6, 3.1 to 18.9; P<0.001. A significantly lower proportion of patients in the specific exercise group subsequently chose to undergo surgery: 20% (10/51) v 63% (29/46); odds ratio 7.7, 3.1 to 19.4; P<0.001).
Conclusion A specific exercise strategy, focusing on strengthening eccentric exercises for the rotator cuff and concentric/eccentric exercises for the scapula stabilisers, is effective in reducing pain and improving shoulder function in patients with persistent subacromial impingement syndrome. By extension, this exercise strategy reduces the need for arthroscopic subacromial decompression within the three month timeframe used in the study.
Subacromial impingement syndrome is said to have multiple causes. Several structures, such as the subacromial bursa, the tendons of the rotator cuff, the acromion, the coraco-acromial ligament, and the caput longum tendon of the biceps brachii muscle, are involved in the pathogenesis of subacromial impingement syndrome (Figure 1). Multiple factors have been proposed as contributing to the development of subacromial impingement syndrome, including altered shoulder kinematics associated with dysfunction of the rotator cuff and scapular muscles, capsular tightness, poor posture, and overuse secondary to sustained intensive work.
(Enlarge Image)
Figure 1.
Anatomy of the shoulder
Conservative treatment is the first choice, often with corticosteroid injection or different physiotherapy interventions, or both. Some studies have reported specific exercise treatment to be effective, but the summarised evidence for its effectiveness is uncertain because of the limited number of studies and several with methodological concerns. Therefore more well designed and powered clinical trials evaluating specific exercise interventions are needed. When conservative treatment fails, arthroscopic subacromial decompression is recommended. Surgery is performed in about 30% of all patients because conservative treatment fails. The number of patients who undergo arthroscopic subacromial decompression in Sweden has increased substantially in recent years, from 2287 in 2005 to 7959 in 2008 (Swedish Board of Health and Welfare, 2009). Studies have compared different exercise programmes with surgery and concluded that the two strategies have equivalent effects. A 65-80% success rate, improved shoulder function, and decreased pain have been reported after one year. These results challenge the need for surgery. Some patients still do not respond to conservative and surgical intervention, indicating that the selection of patient for the different treatments is not optimal, and further research is required to identify those who really need surgery.
Despite limited evidence, several systematic reviews have suggested exercise treatment as the first line management for patients with subacromial impingement syndrome. There is currently no consensus of the most appropriate exercise strategy. Further research is needed to develop evidence based exercise programmes that can be recommended and implemented for these patients. We evaluated whether a specific exercise strategy targeting the rotator cuff and scapula stabilisers improves shoulder function and pain more than unspecific exercises in patients with subacromial impingement syndrome, thereby decreasing the need for arthroscopic subacromial decompression.
Abstract and Introduction
Abstract
Objective To evaluate if a specific exercise strategy, targeting the rotator cuff and scapula stabilisers, improves shoulder function and pain more than unspecific exercises in patients with subacromial impingement syndrome, thereby decreasing the need for arthroscopic subacromial decompression.
Design Randomised, participant and single assessor blinded, controlled study.
Setting Department of orthopaedics in a Swedish university hospital.
Participants 102 patients with long standing (over six months) persistent subacromial impingement syndrome in whom earlier conservative treatment had failed, recruited through orthopaedic specialists.
Interventions The specific exercise strategy consisted of strengthening eccentric exercises for the rotator cuff and concentric/eccentric exercises for the scapula stabilisers in combination with manual mobilisation. The control exercise programme consisted of unspecific movement exercises for the neck and shoulder. Patients in both groups received five to six individual guided treatment sessions during 12 weeks. In between these supervised sessions the participants performed home exercises once or twice a day for 12 weeks.
Main outcome measures The primary outcome was the Constant-Murley shoulder assessment score evaluating shoulder function and pain. Secondary outcomes were patients’ global impression of change because of treatment and decision regarding surgery.
Results Most (97, 95%) participants completed the 12 week study. There was a significantly greater improvement in the Constant-Murley score in the specific exercise group than in the control exercise group (24 points (95% confidence interval 19 to 28.0) v 9 points (5 to 13); mean difference between group: 15 points (8.5 to 20.6)). Significantly more patients in the specific exercise group reported successful outcome (defined as large improvement or recovered) in the patients’ global assessment of change because of treatment: 69% (35/51) v 24% (11/46); odds ratio 7.6, 3.1 to 18.9; P<0.001. A significantly lower proportion of patients in the specific exercise group subsequently chose to undergo surgery: 20% (10/51) v 63% (29/46); odds ratio 7.7, 3.1 to 19.4; P<0.001).
Conclusion A specific exercise strategy, focusing on strengthening eccentric exercises for the rotator cuff and concentric/eccentric exercises for the scapula stabilisers, is effective in reducing pain and improving shoulder function in patients with persistent subacromial impingement syndrome. By extension, this exercise strategy reduces the need for arthroscopic subacromial decompression within the three month timeframe used in the study.
Introduction
Subacromial impingement syndrome is said to have multiple causes. Several structures, such as the subacromial bursa, the tendons of the rotator cuff, the acromion, the coraco-acromial ligament, and the caput longum tendon of the biceps brachii muscle, are involved in the pathogenesis of subacromial impingement syndrome (Figure 1). Multiple factors have been proposed as contributing to the development of subacromial impingement syndrome, including altered shoulder kinematics associated with dysfunction of the rotator cuff and scapular muscles, capsular tightness, poor posture, and overuse secondary to sustained intensive work.
(Enlarge Image)
Figure 1.
Anatomy of the shoulder
Conservative treatment is the first choice, often with corticosteroid injection or different physiotherapy interventions, or both. Some studies have reported specific exercise treatment to be effective, but the summarised evidence for its effectiveness is uncertain because of the limited number of studies and several with methodological concerns. Therefore more well designed and powered clinical trials evaluating specific exercise interventions are needed. When conservative treatment fails, arthroscopic subacromial decompression is recommended. Surgery is performed in about 30% of all patients because conservative treatment fails. The number of patients who undergo arthroscopic subacromial decompression in Sweden has increased substantially in recent years, from 2287 in 2005 to 7959 in 2008 (Swedish Board of Health and Welfare, 2009). Studies have compared different exercise programmes with surgery and concluded that the two strategies have equivalent effects. A 65-80% success rate, improved shoulder function, and decreased pain have been reported after one year. These results challenge the need for surgery. Some patients still do not respond to conservative and surgical intervention, indicating that the selection of patient for the different treatments is not optimal, and further research is required to identify those who really need surgery.
Despite limited evidence, several systematic reviews have suggested exercise treatment as the first line management for patients with subacromial impingement syndrome. There is currently no consensus of the most appropriate exercise strategy. Further research is needed to develop evidence based exercise programmes that can be recommended and implemented for these patients. We evaluated whether a specific exercise strategy targeting the rotator cuff and scapula stabilisers improves shoulder function and pain more than unspecific exercises in patients with subacromial impingement syndrome, thereby decreasing the need for arthroscopic subacromial decompression.
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