As MSK elves we already know shoulder pain is one of the most common presenting musculoskeletal conditions accounting for between 7 -26% of general practitioner consultations in the UK.
There are a variety of causes of shoulder pain and some of our previous blogs have discussed challenges to developing an acurate diagnosis. Once we have our appropriately reasoned diagnosis the next step is to choose what treatment modality to use. What evidence is there for our choice of treatment, especially exercises? There are several factors to consider when prescribing exercises; target tissue, frequency, loaded or unloaded, number of repetitions and progression of exercises. A recent systematic review focuses on physiotherapy exercises for subacromial impingement syndrome (SAIS) let’s look at it in more detail and examine the evidence.
Here’s what they did
They searched elctronic databases for studies that used any mode of exercise for the management of stage I or stage II SAIS or rotator cuff disease/tendinopathy. They excluded studies that contained participants with alternative diagnoses for example rotator cuff rupture or post surgical patients or if exercise made up only a small portion of the treatment modalities used. Sixteen studies were included in the systematic review with 6 included in the meta-analysis.
Here’s what they found
From the qualitative synthesis of the data in the 16 selected studies the authors made the following three informed observations.
- Overall there was evidence to show that exercise was effective in reducing pain and improving function in the 6 -12 week time period.
- There was strong evidence that improvement in function was maintained at long term follow-up.
- There was moderate evidence to show that exercise can improve mental health and strength in the short term.
Data from six studies were used for the meta-analysis.
- Exercise had a small positive effect on strength of the rotator cuff in the short term (SMD −0.46 (−0.76, 0.16); P = 0.003)
- Exercise had a small positive effect on long-term function (SMD −0.31 (−0.57, 0.04); P = 0.02).
The authors concluded
Physiotherapy exercises are effective in the management of SAIS.
The Musculoskeletal Elf’s view
It would be great if there was a set prescription of exercises for patients with shoulder impingement syndrome but as Lewis (2009) points out the use of subacromial impingement as a term is not accurate or specific enough as pain related to subacromial impingement can originate from a number of coexisting pathologies.
The authors of this systematic review stated that heterogeneity of the exercise interventions, coupled with poor reporting of exercise protocols, prevented conclusions being drawn about which specific components of the exercise protocols (ie, type, intensity, frequency and duration) are associated with best outcomes.
The authors also excluded studies from the meta-anaylsis because of high risk of bias/scoring less than 6/12 on the van Tulder Scale. The MSK Elf assesses risk of bias using the Cochrane Collaboration’s ‘Risk of bias’ tool (Higgins 2011). We typically look at the following six key domains: sequence generation; allocation concealment; blinding; incomplete outcome data; selective outcome reporting; and “other bias” (comparability of treatment and control group at entry, and appropriateness of duration of surveillance).
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- Hanratty CE, McVeigh JG, Kerr DP, Basford JR, Finch MB, Pendleton A, Sim J. The Effectiveness of Physiotherapy Exercises in Subacromial Impingement Syndrome: A Systematic Review and Meta-Analysis. Semin Arthritis Rheum. 2012 May 17. [Epub ahead of print]
- Lewis. J.S. 2009. “Rotator cuff tendinopathy/subacromial impingement syndrome: is it time for a new method of assessment?” Br J Sports Med. Vol.43, pp. 259–264. doi:10.1136/bjsm.2008.052183 259
- Verhagen AP, de Vet HC, de Bie RA, et al. 2001 “The art of quality assessment of RCTs included in systematic reviews”. J Clinical Epidemiology. Vol. 54. pp. 651-654
Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from http://www.cochrane-handbook.org.
Hi Tracey – I had chronic shoulder pain for months, tried lots of things but the best advise I got was from a co-worker of mine who’s partner was a physio and simply advised me to stretch, stretch, stretch. Nothing too demanding, but regular and deliberate. And I’m pleased to say it worked for me. Hope this helps anyone with similar pain, good luck to you all.
Thank you for reviewing our paper- I was thrilled to see it and will definitely be signing up to feeds from the Elf- its great! Just to clarify though- we also used the Cochrane Risk of Bias Tool as well as the van Tulder Scale to rate bias.
Threats to bias identified using the Cochrane Risk of Bias Tool were: inadequate randomization, inadequately concealed treatment allocation, non-blinding of assessors, no intention-to-treat analysis, and no measurement of compliance with the exercise intervention. Studies were deemed to be of high quality if they scored at least 6/12 on the van Tulder Scale and evidenced four of the five criteria above; which must include concealed allocation. Medium-quality studies were classified as achieving at least 6/12 on the van Tulder Scale and satisfying at least any three of the five prerequisite criteria listed above. Studies were deemed to be of low quality if they scored less than 6/12 on the van Tulder scale and/or satisfied two or fewer of the five listed risks to bias. Using these criteria we then rated studies to be of high, medium or low-quality so that we could summarise the strength of evidence. We hoped this combination would be a thorough method of assessing study quality/bias.
Thank you again- its great to get word out there that exercises for shoulder impingement can have benefits for our patients and we’re currently looking at an evidence based exercise protocol in more detail.
Thanks for sharing such a helpful updated information and your valuable view also. I read your post and shoulder pain is very difficult to go through and handle.
i suffer from sub acromial impingement syndrome and to be honest,the notion that physiotherapy is a universal panacea forany given health condition is preposterous, evidance has shownt to be without scientific merit and anecdotal.try asking a patient!! physiotherapy and steroid injections are inadequate, hopelessly so. torn tendons with r without physio will eventually heal.quackery of the highest order
added to my earlier comments, at my second physio session i damaged my biceps tendon, after a few weeks i returned to physio and again damaged my bicep tendon, after further x-rays and mri scan, it was discovered i had torn my rotator cuff due to impingement caused by acromian, physiotherapy was an exacerbating cause of the tear. this compulsion to conservatively treat all shoulder disorders is blinkered and damaging to patients well being