#030 – Exercise therapy for Shoulder Impingement

ByAl-Jallad

Estimated reading time: 3 minutes, 3 seconds.*

Arthroscopic Subacromial Decompression is Not Superior to Exercise Therapy for Shoulder Impingement

A 5-year follow-up of a randomised, placebo surgery controlled clinical trial

The primary goal of this study is not entirely physiotherapy focused, but it is very relevant.

?Why?

  • Up to 70% of patients suffering from shoulder pain without a preceding traumatic event receive a diagnosis of shoulder impingement or subacromial pain syndrome. (Reference)
  • Therefor, the most common shoulder surgery is Arthroscopic Subacromial Decompression (ASD)
  • Recent systematic reviews and meta-analyses concluded with high certainty that in people with painful shoulder impingement, subacromial decompression surgery does not improve pain, function or health-related quality of life compared with placebo surgery or other options that included various forms of physiotherapy, in the short term. (Cool)
  • According to the Cochrane review, the fate of this enormously popular surgical procedure now hangs on the thread of this study as it is the only ongoing low risk of bias trial assessing the long-term efficacy of subacromial decompression surgery. (No pressure, ha)
  • So, the aim of this study is to assess the long-term (5 years) efficacy of ASD in patients with symptoms consistent with shoulder impingement syndrome.
    • Also, compared ASD and exercise therapy.

??‍?How?

Inclusion criteria:

  1. Adult men or women ages 35–65 years.
  2. Subacromial pain for greater than 3 months with no relief from non-operative means (physiotherapy, non-steroidal anti-inflammatory medication, corticosteroid injections and rest).
  3. Pain provoked by abduction and positive painful arc sign.
  4. Positive impingement test (temporary relief of pain by subacromial injection of lidocaine).
  5. Pain in at least two out of three of isometric tests (abduction 0° and 30° or external rotation)

Exercise therapy

Individually designed exercise therapy by a physiotherapist was started within 2 weeks of randomization.

  • Phase 1 (Weeks 0-3):
    • Goals: Decrease pain, restore A/PROM, relieve pain and inflammation, re-establish muscular balance, and improve posture; Inform the patient.
    • Passive Exercises:
      1. PROM.
      2. Joint mobilization/posterior capsule stretching.
      3. Soft tissue mobilization.
    • Active Exercise:
      1. AAROM.
      2. Submaximal isometric rotator cuff exercises.
      3. Thoracic spine mobilization.
      4. Scapular retraction/protraction.
  • Phase 2 (Weeks 4&5):
    • Goals: Re-establish full and pain free AROM, restore rotator cuff strength, restore normal scapulothoracic motion.
    • Passive exercises:
      1. Joint mobilization/posterior capsule stretching.
      2. Soft tissue mobilization.
    • Active exercises:
      1. AROM.
      2. Maximal isometric rotator cuff exercises.
      3. Thoracic spine mobilization.
      4. Scapulothoracic motion.

Phase 3 (Weeks 6-8):

  • Goals: Restore muscle strength and endurance, re-establish full and pain free AROM. Restore normal scapulothoracic motion.
  • Passive exercises:
    1. Joint mobilization
  • Active exercises:
    1. Dynamic rotator cuff exercises.
    2. Scapulothoracic motion.

Phase 4 (Weeks 9-12):

  • Goals: Enhance muscle strength and endurance, re-educate neuromuscular control of rotator cuff muscles
  • Passive exercises:
    1. Continued stretching program.
  • Active exercises:
    1. Continued dynamic rotator cuff program.

Surgical Interventions

  1. Diagnostic arthroscopy
  2. Arthroscopic subacromial decompression
    • Both Groups were given Home exercise by a physiotherapist.

?Results

Participants included in the analysis at 5 years

  • Exercise Therapy (ET) group: 62 Participants.
  • Diagnostic arthroscopy (DA) group: 55 Participants.
  • Arthroscopic subacromial decompression (ASD) group: 53 Participants.

ASD versus exercise therapy

  • Primary outcome measures: Pain at rest and pain on arm activity using Visual Analogue Scale (VAS) ranging from 0 (no pain) to 100 (extreme pain). Considered 15 points as the minimal important difference (MID) Results:
    1. There was marked improvement from baseline to 5 years for both primary outcomes in the ASD and exercise therapy group.
    2. No significant between-group differences in VAS pain at rest or VAS on arm activity.
  • Secondary and other outcomes:
    1. No significant between group differences in any of the secondary outcomes
    Secondary outcome measures were:
    • Shoulder function using the Constant-Murley score (CM) and the simple shoulder test (SST).
    • Health-related quality of life: the SF-36 Health Survey and the 15D.

Complications and Adverse Events:

  • Two participants in the exercise therapy group developed a frozen shoulder.
  • One participant reported aggravation of low back pain over the course of exercise therapy regimen.
  • No other AEs directly related to the exercise therapy were registered.

⏩Conclusion

  • ASD and diagnostic arthroscopy (placebo surgery) as well as exercise therapy resulted in significant improvements in pain and functional outcomes with no difference in the incidence of adverse events.
  • Patients assigned to ASD had no superior improvement over those assigned to diagnostic arthroscopy or exercise therapy at the 5 years follow-up.

As the current evidence indicates that the impingement theory has become antiquated, we would also recommend to abandon the term shoulder impingement as it refers to this mechanical theory. The more generic term ‘subacromial pain’ should be preferred.

Final Note

  • That was a good read.
  • I think now, physiotherapists should step-up and improve our management of subacromial pain, since we’re an optimal solution for patients with subacromial pain.

?️Recommended Read

?Reference

*Calculation is based on the average reading speed that around 200 words per minute (wpm).

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