Shoulder impingement revisited: evolution of diagnostic understanding in orthopedic surgery and physical therapy

Effect of scapular stabilization exercises on subacromial pain (impingement) syndrome: a systematic review and meta-analysis of randomized controlled trials

Objective

To evaluate the effectiveness of scapular stabilization exercises (SSE) in the treatment of subacromial pain syndrome (SAPS).

Methods

Clinical randomized controlled trials (RCTs) on SSE in the treatment of SAPS were searched electronically in PubMed, Science Direct, Cochrane Central Register of Controlled Trials (CENTRAL), EBSCOhost, Physiotherapy Evidence Database (PEDro), Web of Science, and other databases from 2000 to 2022, supplemented by manual search. Final RCTs were selected based on inclusion and exclusion criteria, and the Physiotherapy Evidence Database scale was used to evaluate the methodological quality of the study. A meta-analysis was conducted on data using the RevMan5.4 software.

Results

Eight RCTs involving 387 participants were included. The meta-analysis showed that the experimental group (SSE) had greater improvements in the Visual Analog Scale score [Weighted Mean Difference (WMD) = -0.94, 95% CI (-1.23, -0.65), p < 0.001] and the Shoulder Pain and Disability Index score [WMD = -10.10, 95% CI (-18.87, -1.33), p = 0.02] than the control group (conventional physical therapy). However, range of motion (ROM) was not found to be greater in the experimental group than in the control group.

Conclusion

Existing evidence moderately supports the efficacy of SSE for reducing pain and improving function in SAPS, without significant improvement in ROM. Future research should focus on larger, high-quality, standardized protocols to better understand SSE's effects across diverse SAPS populations, treatment, and outcome measures.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=307437, CRD42022307437.

Pressure pain sensitivity, thermographic changes, function, life and sleep quality in patients with unilateral rotator cuff injury: A case-control study

INTRODUCTION-AIM

This study aimed to assess pressure pain sensitivity, thermographic changes, functional status, quality of life, and sleep in individuals with unilateral shoulder pain due to rotator cuff tear and compare these parameters with the unaffected side and asymptomatic individuals.

MATERIAL-METHOD

Thirty-two patients with unilateral rotator cuff injury and 32 volunteers without shoulder problems were included. Pain was evaluated using a visual analogue scale, pressure pain sensitivity with a digital algometer, thermographic changes with a thermal camera, upper extremity function through the Disabilities of the Arm, Shoulder, and Hand Disability Questionnaire, sleep quality using the Pittsburgh Sleep Quality Index, and quality of life using SF-36.

RESULTS

Pressure pain sensitivity of the deltoideus, supraspinatus, and subscapularis muscles in the affected limb was lower than in the unaffected limb (p = 0.027, p = 0.005, p < 0.001). Conversely, pressure sensitivity of the deltoideus, biceps brachii, and subscapularis muscles was higher in the patient group (p = 0.008, p = 0.042, p < 0.001). Furthermore, a decrease in temperature was observed in all patients, except for the trapezius muscles of the affected side (p < 0.05).

CONCLUSION

This study sheds light on altered pressure pain sensitivity and thermographic changes in individuals with unilateral shoulder pain due to rotator cuff tear. Additionally, the study highlights impairments in functional status, quality of life, and sleep in these individuals, emphasizing the broader impact of such injuries. Targeted interventions based on these findings have the potential to enhance overall well-being and functional outcomes for affected individuals.

LEVEL OF EVIDENCE

Level III, Case-control study, prognosis study.

Between Two Rocks and in a Hard Place: Reflecting on the Biomechanical Basis of Shoulder Occupational Musculoskeletal Disorders

OBJECTIVE

The aim was to review the biomechanical origins of occupational shoulder damage, while considering the complexity of shoulder mechanics and musculoskeletal consequences of diverse task demands.

BACKGROUND

Accessible measures of physical exposures are the primary focus of occupational shoulder assessments and analyses. This approach has led to guidelines and intervention strategies that are often inadequate for mitigating shoulder disorders amongst the complexity of modern workplace demands. Integration of complex shoulder mechanics into occupational assessments, analyses, and interventions is critical for reducing occupational shoulder injury risk.

METHOD

This narrative review describes shoulder biomechanics in the context of common injury mechanisms and consequent injuries, with a particular focus on subacromial impingement syndrome. Several modulators of shoulder injury risk are reviewed, including fatigue, overhead work, office ergonomics considerations, and pushing and pulling task configurations.

RESULTS

Relationships between work requirements, muscular demands, fatigue, and biomechanical tissue loads exist. This review highlights that consideration of specific workplace factors should be integrated with our knowledge of the intricate arrangement and interpersonal variability of the shoulder complex to proactively evaluate occupational shoulder demands and exposures.

CONCLUSION

A standard method for evaluating shoulder muscle exposures during workplace tasks does not exist. An integrated approach is critical for improved work design and prevention of shoulder tissue damage and accompanying disability.

APPLICATION

This review is particularly relevant for researchers and practitioners, providing guidance for work design and evaluation for shoulder injury prevention by understanding the importance of the unique and complex mechanics of the shoulder.

Exercise for rotator cuff tendinopathy: Proposed mechanisms of recovery

Rotator cuff (RC) tendinopathy is a common recurrent cause of shoulder pain, and resistance exercise is the first-line recommended intervention. Proposed causal mechanisms of resistance exercise for patients with RC tendinopathy consist of four domains: tendon structure, neuromuscular factors, pain and sensorimotor processing, and psychosocial factors. Tendon structure plays a role in RC tendinopathy, with decreased stiffness, increased thickness, and collagen disorganization. Neuromuscular performance deficits of altered kinematics, muscle activation, and force are present in RC tendinopathy, but advanced methods of assessing muscle performance are needed to fully assess these factors. Psychological factors of depression, anxiety, pain catastrophizing, treatment expectations, and self-efficacy are present and predict patient-reported outcomes. Central nervous system dysfunctions also exist, specifically altered pain and sensorimotor processing. Resisted exercise may normalize these factors, but limited evidence exists to explain the relationship of the four proposed domains to trajectory of recovery and defining persistent deficits limiting outcomes. Clinicians and researchers can use this model to understand how exercise mediates change in patient outcomes, develop subgroups to deliver patient-specific approach for treatment and define metrics to track recovery over time. Supporting evidence is limited, indicating the need for future studies characterizing mechanisms of recovery with exercise for RC tendinopathy.

Terminology and diagnostic criteria used in studies investigating patients with subacromial pain syndrome from 1972 to 2019: a scoping review

INTRODUCTION

There is no recognised terminology, nor diagnostic criteria, for patients with subacromial pain syndrome (SAPS). This is likely to cause heterogeneity across patient populations. This could be a driver of misconceptions and misinterpretations of scientific results. We aimed to map the literature regarding terminology and diagnostic criteria used in studies investigating SAPS.

MATERIALS AND METHODS

Electronic databases were searched from inception to June 2020. Original peer-reviewed studies investigating SAPS (also known as subacromial impingement or rotator cuff tendinopathy/impingement/syndrome) were eligible for inclusion. Studies containing secondary analyses, reviews, pilot studies and studies with less than 10 participants were excluded.

RESULTS

11 056 records were identified. 902 were retrieved for full-text screening. 535 were included. 27 unique terms were identified. Mechanistic terms containing 'impingement' are used less than before, while SAPS is used increasingly. For diagnoses, combinations of Hawkin's, Neer's, Jobe's, painful arc, injection test and isometric shoulder strength tests were the most often used, though this varied considerably across studies. 146 different test combinations were identified. 9% of the studies included patients with full-thickness supraspinatus tears and 46% did not.

CONCLUSION

The terminology varied considerably across studies and time. The diagnostic criteria were often based on a cluster of physical examination tests. Imaging was primarily used to exclude other pathologies but was not used consistently. Patients with full-thickness supraspinatus tears were most often excluded. In summary, studies investigating SAPS are heterogeneous to an extent that makes it difficult, and often impossible, to compare studies.

Investigation on the Efficiency of the Closed Kinetic Chain and Video-Based Game Exercise Programs in the Rotator Cuff Rupture: A Randomized Trial

Objective: To examine the effectiveness of video-based game exercises and structured closed kinetic chain exercises in individuals with rotator cuff rupture. Materials and Methods: Forty-five individuals with rotator cuff rupture were included in this study. Individuals were randomly divided into three groups: a conventional exercise group (CEG), a structured closed kinetic chain exercise group (CKCEG), and a video-based game exercise group (VGEG). Interventions were performed twice a week for 6 weeks. Pain severity; pain threshold; disabilities of the arm, shoulder, and hand questionnaire (DASH); rotator cuff quality of life index (RCQOL); range of motion (ROM); and joint position sense and approximation force of all individuals were evaluated pre- and post-treatment. Results: There was a statistically significant difference in all values of the pre- and post-treatment of the groups (P < 0.05). When the differences between the groups were compared, CKCEG and VGEG values were more significant than CEG in all parameters (P < 0.017). Improvements in pain threshold, ROM in shoulder flexion and abduction, DASH score, and all parameters of the RCQOL questionnaire in VGEG were statistically more significant than CKCEG (P < 0.017). Conclusion: Individuals with rotator cuff rupture obtained more improvements in primary and secondary outcomes after closed kinetic chain exercise and video-based game exercise, rather than conventional methods. It was considered that video-based game exercise programs would be used in rotator cuff problems.

International physical therapists consensus on clinical descriptors for diagnosing rotator cuff related shoulder pain: A Delphi study

BACKGROUND

There is a lack of standardized criteria for diagnosing rotator cuff related shoulder pain (RCRSP).

OBJECTIVE

To identify the most relevant clinical descriptors for diagnosing RCRSP.

METHODS

A Delphi study was conducted through use of an international physical therapists expert panel. A 3-round Delphi survey involving an international panel of physical therapists experts with extensive clinical, teaching, and research experience was conducted. A search query was performed in Web of Science, along with a manual search, to find the experts. The first round was composed of items obtained from a previous pilot Delphi study along with new items proposed by the experts. Participants were asked to rate items across six clinical domains using a five-point Likert scale. An Aiken's Validity Index ≥ 0.7 was considered indicative of group consensus.

RESULTS

Fifteen experts participated in the Delphi survey. After the three rounds, consensus was reached on 18 clinical descriptors: 10 items were included in the "subjective examination" domain, 1 item was included in the "patient-reported outcome measures" domain, 3 items in the "diagnostic examination" domain, 2 items in the "physical examination" domain", and 2 items in the "functional tests" domain. No items reached consensus within the "special tests" domain. The reproduction of symptoms in relation to the application of load, the performance of overhead activities, and the need of active and resisted movement assessment were some of the results with greatest consensus.

CONCLUSION

In this Delphi study, a total of 18 clinical descriptors across six clinical domains were agreed upon for diagnosing RCRSP.

Impingement on the internet: evaluating the quality and readability of online subacromial impingement information

Patients increasingly access the internet to learn about their orthopaedic conditions. Despite this, online information may be unregulated, of questionable quality and difficulty to read.

OBJECTIVES

Therefore, this study aimed to evaluate the readability and quality of the online information concerning subacromial impingement syndrome.

METHODS

A search using Australia's three most popular online search engines was undertaken using the search terms 'subacromial impingement syndrome' and 'shoulder impingement'. The first 15 websites for each term were evaluated. Duplicates, advertisements and sponsored links were removed.The quality and readability of each website were calculated using the DISCERN and Flesch-Kincaid Reading Ease (FKRE) tools, respectively. The differences in quality and readability between each website type (healthcare/academic, commercial, news outlet, charitable/not-for-profit, layperson, government) was assessed using analysis of variance. The correlation between quality and readability was assessed using the Pearson correlation coefficient.

RESULTS

The majority of 35 unique websites analysed were of 'poor'/'fair' quality (determined via the DISCERN instrument) and 'difficult' readability (per the FKRE tool), with no correlation established between the scores. There was no statistically significant difference in quality across website types, however layperson, news outlet and government websites were found to be significantly more readable than alternate website categories (p<0.05).

CONCLUSIONS

We determined that much of the online information concerning subacromial impingement syndrome may be difficult to read and/or of poor quality. By recognising the shortcomings of information accessed by patients online, it is hoped clinicians may be prompted to better educate their patients.

Which biopsychosocial factors are associated with the development of chronic musculoskeletal pain? Protocol for an umbrella review of systematic reviews

INTRODUCTION

Recent systematic reviews have identified many biopsychosocial factors associated with the development of chronic musculoskeletal pain (CMP). Despite often being specific to a particular musculoskeletal condition, findings are similar across systematic reviews. Research is needed to aggregate these findings to identify consistent factors across musculoskeletal disorders that are associated with the development of CMP. The objective of this study is to provide a meta-level synthesis of all biopsychosocial factors associated with the development of CMP.

METHODS AND ANALYSIS

An umbrella review and meta-level narrative synthesis±meta-analysis has been designed informed by Joanna Briggs Institute and Cochrane guidance. This protocol is reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis-P. Sources will include Ovid Medline, Embase, Web of Science Core Collection, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, PsycINFO, CINAHL, PEDro, PROSPERO, Google Scholar and grey literature.

INCLUSION CRITERIA

any systematic review which investigates biopsychosocial factors which may be associated with the development of CMP through prospective longitudinal methods. The outcome is musculoskeletal pain lasting beyond 3 months. Two independent reviewers will be involved in all stages; screening, selection, data extraction and risk of bias evaluation using the Assessing the Methodological Quality of Systematic Reviews-2 guidelines. A meta-level narrative synthesis will be conducted based on (a) factors associated with development of CMP, (b) the range of musculoskeletal disorders for which the same/similar findings have been established and (c) the quality of studies informing these findings. Where possible, meta-analysis will be performed. The Grading of Recommendations, Assessment, Development and Evaluation guidelines will be followed to determine the level of evidence for each biopsychosocial factor.

ETHICS AND DISSEMINATION

This umbrella review does not require ethical approval. Findings will be presented at conferences and published in a peer reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42020193081.

A prospective, comparative study of subacromial corticosteroid injection and subacromial corticosteroid injection plus suprascapular nerve block in patients with shoulder impingement syndrome

INTRODUCTION

Efforts are recently focused on the management of shoulder impingement syndrome (SIS) with a conservative and targeted approach because of its psychosocial impact, reduction in the quality of life, the cost to the economy and its negative effect on daily activities. Therefore, many studies have been designed to evaluate and compare the effectiveness of different treatments. The main purpose of this study was to identify the effect of combination of subacromial corticosteroid injection (SCI) and suprascapular nerve block (SSNB) on shoulder impingement syndrome (SIS).

MATERIALS AND METHODS

66 patients with SIS were randomly divided into two groups (33 patients per group): Group 1: SCI; Group 2: SCI plus SSNB. The estimation of the severity of pain by the visual analogue scale (VAS) and shoulder disability using quick DASH (Disabilities of the Arm, Shoulder and Hand) were assessed at baseline and 1, 3 months post-injection.

RESULTS

The mean age of patients was 55.55 ± 10.42 years in Group 1 and 57.24 ± 12.75 years in Group 2. In steroid group, pre- and post-treatment (at 1 and 3 months) VAS/quickDASH scores were 8.64 ± 0.99/78.03 ± 9.24, 2.09 ± 0.84/15.58 ± 7.23 and 3.06 ± 1.12/25.06 ± 8.74, respectively. In steroid plus SSNB group, pre- and post-treatment (at 1 and 3 months) VAS/quickDASH scores were 8.45 ± 0.90/75.15 ± 9.86, 1.24 ± 0.43/10.88 ± 2.14 and 1.51 ± 0.56/15.51 ± 5.04, respectively. Both treatment groups showed a significant relief of pain at 1 and 3 months post-injection (p < 0.05). However, the VAS and quickDASH scores at 1 and 3 months were significantly lower in Group 2 versus Group 1 (p < 0.05).

CONCLUSION

The combination of SCI and SSNB seems to produce the long-term effect in pain relief and functional improvement.

Humeral elevation workspace during daily life of adults with spinal cord injury who use a manual wheelchair compared to age and sex matched able-bodied controls

Shoulder pain and pathology are extremely common for individuals with spinal cord injuries (SCI) who use manual wheelchairs (MWC). Although risky humeral kinematics have been measured during wheelchair-based activities performed in the lab, little is known about arm kinematics in the free-living environment. The purpose of this study was to measure the humeral elevation workspace throughout a typical day for individuals with SCI who use a MWC and matched able-bodied controls. Thirty-four individuals with SCI who use a MWC (42.7±12.7 years of age, 28 males/6 females, C6-L1) and 34 age-and sex-matched controls were enrolled. Participants wore three inertial measurement units (IMU) on their upper arms and torso for one to two days. Humeral elevation angles were estimated and the percentage of time individuals spent in five elevation bins (0–30°, 30–60°, 60–90°, 90–120°, and 120–180°) were calculated. For both arms, the SCI cohort spent a significantly lower percentage of the day in 0–30° of humeral elevation (Dominant: SCI = 15.7±12.6%, Control = 32.1±15.6%, p<0.0001; Non-Dominant: SCI = 21.9±17.8%, Control = 34.3±15.5%, p = 0.001) and a significantly higher percentage of time in elevations associated with tendon compression (30–60° of humeral elevation, Dominant: SCI = 62.8±14.4%, Control = 49.9.1±13.0%, p<0.0001; Non-Dominant: SCI = 58.8±14.9%, Control = 48.3±13.6%, p = 0.003) than controls. The increased percentage of time individuals with SCI spent in elevations associated with tendon compression may contribute to increased shoulder pathology. Characterizing the humeral elevation workspace utilized throughout a typical day may help in understanding the increased prevalence of shoulder pain and pathology in individuals with SCI who use MWCs.

Reliability and Concurrent Validity of Shoulder Tissue Irritability Classification

OBJECTIVE

Rating tissue irritability has been recommended to aid decision making in several recent clinical practice guidelines. An explicit method for rating tissue irritability was proposed as part of the Staged Algorithm for Rehabilitation Classification: Shoulder Disorders (STAR-Shoulder), but the reliability and validity of this classification are unknown. The purpose of this study was to examine the reliability and concurrent validity of shoulder tissue irritability ratings as part of a system designed to guide appropriate treatment strategy and intensity.

METHODS

A clinical measurement, prospective repeated-measures cross-sectional design was used. The 101 consecutive participants with primary complaints of shoulder pain were assessed by pairs of blinded raters (24 raters in total) and rated for tissue irritability. Patients completed 3 patient-reported outcome (PRO) measures reflecting both pain and disability, and these scores were compared with ratings of tissue irritability. Paired ratings of irritability were analyzed for reliability with prevalence-adjusted, bias-adjusted Kappa for ordinal scales. Analysis of variance was used to compare PRO measures across different levels of irritability. Receiver operating characteristic curve analysis was utilized to derive cut-off scores for 3 PRO instruments.

RESULTS

Interrater reliability was 0.69 (95% CI = 0.59-0.78), with 67% agreement. All PRO measures were significantly different among 3 levels of tissue irritability.

CONCLUSION

There appears to be acceptable reliability and a strong relationship between PRO measures and therapist-rated tissue irritability, supporting the use of the STAR-Shoulder irritability rating system.

IMPACT

Several clinical practice guidelines have recommended that clinicians rate tissue irritability as part of their examination. This study provides important new information supporting the reliability and validity of the STAR-Shoulder tissue irritability rating system.

High-Intensity Shoulder Abduction Exercise in Subacromial Pain Syndrome

Subacromial pain syndrome (SAPS) defined as pain of nontraumatic origin localized around the acromion, is a debilitating, common, and often chronic condition. Among many proposed underlying causes of SAPS, hypoperfusion and hypoxic conditions in and around the tendons may be an intrinsic cause of SAPS.

PURPOSE

This study aimed to determine if adding high-intensity aerobic interval training (HIIT) of the rotator cuff to usual care was feasible in SAPS and improved shoulder endurance more than usual care alone, as well as to examine the influence on shoulder pain and disability and the response of tendinous microcirculation after HIIT.

METHODS

Twenty-one subjects with chronic SAPS were randomized to two groups: experimental group (EG; n = 13) receiving HIIT in addition to treatment as usual and control group (CG; n = 8) receiving treatment as usual. Before and after 8 wk of exercise therapy, endurance performance was assessed by an incremental abduction exercise of the arm to exhaustion (TTE). Pain and disability was assessed by the shoulder pain and disability index (SPADI). Contrast-enhanced ultrasound of the musculus supraspinatus and tendon was utilized to indicate tendon blood flow.

RESULTS

Endurance in the TTE test improved by an estimated 233 s more on average in EG than in CG (P = 0.001; 95% confidence interval, 102 to 363). The SPADI score was reduced 22 points more on average in EG (P = 0.017; 95% confidence interval, -40 to -5). The change from pretest to posttest was significant in EG for both TTE test and SPADI improvement (P < 0.001). EG also experienced less pain during exercise after the intervention compared with CG (P < 0.001). Contrast-enhanced ultrasound indicated an increase in tendinous blood flow in EG (P = 0.019).

CONCLUSIONS

HIIT rotator cuff exercise seems to be a feasible intervention in SAPS, increasing endurance performance more than usual care alone.

Subacromial impingement syndrome: a survey of Italian physiotherapists and orthopaedics on diagnostic strategies and management modalities

BACKGROUND AND AIM

The subacromial impingement syndrome (SIS) represents a common cause of disability in approximately 74% of patients with Shoulder Pain (SP). Even if contemporary research suggests that this mechanism is not (always) the dominant driver in SP, SIS is still a source of debate among scholars and clinicians. From a clinical point of view, evidence has suggested that clinicians can use both medical and physiotherapy approaches as effective methods to treat SIS.This survey aims to investigate models of management of patients with SIS in a sample of Italian physiotherapist specialists (Orthopaedic Manipulative Physical Therapists, -OMPTs-) and orthopaedic surgeons.

MATERIALS AND METHODS

An online survey with 29-item questionnaire was administered to assess the knowledge of OMPTs and orthopaedic surgeons about: a) strategies of clinical examination; b) the role of imaging in the diagnostic process; c) the physiotherapy management; and d) the pharmacological and surgical management in patients with SIS.

RESULTS

Six-hundred and twenty-nine respondents completed the survey (511 OMPTs (79.97%) and 128 orthopaedic surgeons (20.03%)). Ninety-two percent (n = 470) of the OMPTs and 80.5% (n = 103) of orthopaedic surgeons stated that in patients with SIS, a combination of diagnostic tests produced better accuracy (p = < 0.001). Twenty point seven % of OMPTs (n = 106) and 4.7% of orthopaedic surgeon (n = 6) stated that the Lift off was the most specific test (p = < 0.001). Four-hundred-and-twenty-four OMPTs (83%) and 40 orthopaedic surgeons (31.3%) answered that the gold standard for diagnosis of a patient with SIS are history and clinical examination (p < 0.001).

CONCLUSION

OMPTs and orthopaedic surgeons approach patients with SIS differently during both the assessment and the treatment. OMPTs appear to be appropriate in planning and managing clinical examination and therapeutic strategies to use with patients with SIS.

The Effectiveness of Ischemic Compression Technique on Pain and Function in Individuals With Shoulder Pain: A Systematic Review

OBJECTIVE

To systematically review current literature to determine the effectiveness of the ischemic compression (IC) technique on pain and function in individuals with shoulder pain.

METHODS

This review was conducted according to recommendations of Preferred Reporting Items for Systematic Reviews and Meta-Analyses and the Cochrane Collaboration for Systematic Reviews; a search was performed in the electronic databases PubMed, Cumulative Index to Nursing and Allied Health Literature, SPORTDiscus, Physiotherapy Evidence Database, and Web of Science. Randomized clinical trials and quasi-randomized clinical trials were included, and the methodological quality was evaluated through the Physiotherapy Evidence Database scale.

RESULTS

The search found 572 studies; of these, 71 were selected by title and, subsequently, 29 were selected through abstract analyses. After critical analyses, 5 studies were included. The methodological quality ranged from 4 (reasonable) to 9 (excellent) points. Pain was assessed by all studies using the visual analog scale, Global Perceived Effect scale, Numerical Rating Scale, pressure pain threshold, or Perceived Amelioration Numerical Scale. Function was evaluated by 3 studies through the Shoulder Pain and Disability Index; Neck Disability Index; American Shoulder and Elbow Surgeons Standardized Shoulder Assessment; and Disabilities of the Arm, Shoulder, and Hand questionnaires. The studies showed that the IC technique produces immediate and short-term positive effects for pain, and positive short-term effects for shoulder function in individuals with shoulder pain.

CONCLUSION

The IC technique seems to be beneficial for pain and shoulder function. However, caution is needed when considering this evidence owing to the limited quality of some studies, the few articles found, and the lack of standardization of the application parameters of the technique to facilitate its reproducibility.

Seven Key Themes in Physical Therapy Advice for Patients Living With Subacromial Shoulder Pain: A Scoping Review

OBJECTIVE

To systematically scope the reported advice and education in physical therapy management of patients with subacromial shoulder pain, and to define key themes of the advice and education.

DESIGN

Scoping review.

LITERATURE SEARCH

We searched MEDLINE, Scopus, Web of Science, and CINAHL, with publication dates from 2007 to September 2019.

STUDY SELECTION CRITERIA

We included quantitative and qualitative research that reported on physical therapy interventions for subacromial shoulder pain.

DATA SYNTHESIS

We performed a qualitative synthesis that identified items included in patient advice and education.

RESULTS

Of 89 original studies included, there were 61 randomized controlled trials; 5 prospective studies; 16 nonrandomized observational intervention studies or case series; and 7 surveys, audits of physical therapy patient records, and focus groups with physical therapists. We identified 7 key themes for advice and education: exercise intensity and pain response, activity modification advice, posture advice, pain self-management advice, pathoanatomical and diagnosis information, behavioral approaches, and pain biology advice.

CONCLUSION

While advice focused predominantly on the local tissue pathology model, 10% of studies included information about pain neuroscience education, psychosocial factors, motor imagery, or behavior change. J Orthop Sports Phys Ther 2020;50(6):285-293. doi:10.2519/jospt.2020.9152.

Altered Scapular Time Series in Individuals With Subacromial Pain Syndrome

Altered scapular movement in subacromial pain syndrome has been demonstrated using discrete data reduction approach. However, this approach does not consider the data collinearity and variability, and scapular translations are poorly investigated in symptomatic individuals. The purpose of this study was to investigate the scapular rotation and translation of asymptomatic individuals and those with subacromial pain syndrome during arm motions using principal component analysis. Scapulothoracic kinematics were evaluated in 47 participants with subacromial pain syndrome and 50 asymptomatic individuals. The symptomatic group had increased range of scapular anterior/posterior tilt during arm elevation (P = .01, effect size = .59) and arm lowering (P < .01, effect size = .61), and increased range of scapular forward/backward translation during arm lowering (P < .01, effect size = .60) compared with the asymptomatic group. In addition, the symptomatic group had a reduced difference in anterior tilt angular velocities between the early-arm and mid-arm lowering phases and between the mid- and late-arm lowering phases compared with the asymptomatic group (P = .03, effect size = .44). This study demonstrated that scapular anterior/posterior tilt motion and angular velocity and scapular forward/backward translation of symptomatic individuals were different from asymptomatic individuals when considering the entire arm movement.

Effect of supervised physiotherapy versus home exercise program in patients with subacromial impingement syndrome: A systematic review and meta-analysis

OBJECTIVE

To determine whether supervised physiotherapy is more effective for functional improvement and pain relief than a home exercise program in subjects with subacromial impingement syndrome.

DESIGN

Systematic review and meta-analysis of randomized clinical trials.

METHODS

An electronic search was performed in Medline, Central, Embase, PEDro, Lilacs, Cinahl, SPORTDiscus, and Web of Science databases. The eligibility criteria for selecting studies included randomized clinical trials that compared supervised physiotherapy versus home exercise program, in the shoulder function, pain, and range of motion in subjects older than 18 years of age with a medical diagnosis of subacromial impingement syndrome treated conservatively.

RESULTS

Seven clinical trials met the eligibility criteria, and for the quantitative synthesis, four studies were included. The standardized mean difference for shoulder function was -0.14 points (95% CI: -1.04 to 0.76; p = 0.760), mean difference 0.21 cm (95% CI: -1.36 to 1.78; p = 0.790) for pain, and mean difference 0.62° (95% CI: -7.15 to 8.38; p = 0.880) for range of motion of flexion.

CONCLUSION

Supervised physical therapy and home-based progressive shoulder strengthening and stretching exercises for the rotator cuff and scapular muscles are equally effective in patients with subacromial impingement syndrome treated conservatively.

TRIAL REGISTRATION NUMBER

CRD42018086348.

Kinesiology taping with exercise does not provide additional improvement in round shoulder subjects with impingement syndrome: A single-blinded randomized controlled trial

OBJECTIVE

Round shoulder posture (RSP) may exaggerate symptoms of subacromial impingement. The effects of kinesiology taping with exercise on posture, pain, and functional performance were investigated in subjects with impingement and RSP.

DESIGN

This study was a single-blinded randomized controlled trial.

SETTING

An outpatient rehabilitation clinic in a university hospital.

PARTICIPANTS

Thirty-four subjects with subacromial impingement and RSP.

INTERVENTIONS

Kinesiology taping with and without tension was applied 2 times per week for 4 weeks. Both groups also performed strengthening and stretching exercises 3 times per week for 4 weeks.

MAIN OUTCOME MEASUREMENTS

The pain level, shoulder angle and self-reported score were evaluated at pre-intervention, 2-week post-intervention and 4-week post-intervention time points.

RESULTS

Functional performance improved after intervention in both groups (p = 0.027). A greater decrease in pain level was related to better functional performance of the shoulder in both groups (r = -0.760 and -0.674; p < 0.010). Moderate correlations were found for posture and functional performance of the shoulder in the intervention group (0.48).

CONCLUSION

Four weeks of strengthening and stretching exercises with or without kinesiology taping improved functional performance in subjects with impingement and RSP. Improvement in clinical symptoms was related to better performance of posture.

Bilateral magnetic resonance imaging findings in individuals with unilateral shoulder pain

BACKGROUND

Magnetic resonance imaging (MRI) is commonly used to diagnose structural abnormalities in the shoulder. However, subsequent findings may not be the source of symptoms. The aim of this study was to determine comparative MRI findings across both shoulders of individuals with unilateral shoulder symptoms.

MATERIALS AND METHODS

We prospectively evaluated 123 individuals from the community who had self-reported unilateral shoulder pain with no signs of adhesive capsulitis, no substantial range-of-motion deficit, no history of upper-limb fractures, no repeated shoulder dislocations, and no neck-related pain. Images in the coronal, sagittal, and axial planes with T1, T2, and proton density sequences were generated and independently and randomly interpreted by 2 examiners: a board-certified, fellowship-trained orthopedic shoulder surgeon and a musculoskeletal radiologist. Absolute and relative frequencies for each MRI finding were calculated and compared between symptomatic and asymptomatic shoulders. Agreement between the shoulder surgeon and the radiologist was also determined.

RESULTS

Abnormal MRI findings were highly prevalent in both shoulders. Only the frequencies of full-thickness tears in the supraspinatus tendon and glenohumeral osteoarthritis were higher (approximately 10%) in the symptomatic shoulder according to the surgeon's findings. Agreement between the musculoskeletal radiologist and shoulder surgeon ranged from slight to moderate (0.00-0.51).

CONCLUSION

Most abnormal MRI findings were not different in frequency between symptomatic and asymptomatic shoulders. Clinicians should be aware of the common anatomic findings on MRI when considering diagnostic and treatment planning.

The Influence of Glenohumeral Joint Posterior Capsule Tightness and Impingement Symptoms on Shoulder Impairments and Kinematics

BACKGROUND

Posterior capsule tightness (PCT) and shoulder impingement syndrome (SIS) symptoms are both associated with altered shoulder biomechanics and impairments. However, their combined effect on kinematics, pain, range of motion (ROM), strength, and function remain unknown.

OBJECTIVE

The purpose of this study was to determine if the combination of PCT and SIS affects scapular and humeral kinematics, glenohumeral joint ROM, glenohumeral joint external rotation strength, pain, and function differently than does either factor (PCT or SIS) alone.

DESIGN

The design was a cross-sectional group comparison.

METHODS

Participants were placed into 1 of 4 groups based on the presence or absence of SIS and PCT: control group (n = 28), PCT group (n = 27), SIS group (n = 25), and SIS + PCT group (n = 25). Scapular kinematics and humeral translations were quantified with an electromagnetic motion capture system. Shoulder internal rotation and external rotation ROM, external rotation strength, and pain and Shoulder Pain and Disabilities Index scores were compared between groups with ANOVA.

RESULTS

The SIS group had greater scapular internal rotation (mean difference = 5.13°; 95% confidence interval [CI] = 1.53°-8.9°) and less humeral anterior translation (1.71 mm; 95% CI = 0.53-2.9 mm) than the other groups. Groups without PCT had greater internal rotation ROM (16.05°; 95% CI = 5.09°-28.28°). The SIS + PCT group had lower pain thresholds at the levator scapulae muscle (108.02 kPa; 95% CI = 30.15-185.88 kPa) and the highest Shoulder Pain and Disabilities Index score (∼ 44.52; 95% CI = 33.41-55.63).

LIMITATIONS

These results may be limited to individuals with impingement symptoms and cannot be generalized to other shoulder conditions.

CONCLUSIONS

Decreased ROM and lower pain thresholds were found in individuals with both impingement symptoms and PCT. However, the combination of factors did not influence scapular and humeral kinematics.

Immediate Effects of Spinal Manipulation on Shoulder Motion Range and Pain in Individuals With Shoulder Pain: A Randomized Trial

Objective

The purpose of this study was to investigate the influence of thoracic spinal manipulation (SM) on shoulder pain and ranges of motion in individuals with shoulder pain.

Methods

The sample was composed of 60 individuals, randomly allocated into the manipulation group (n = 30), who received the SM, and the placebo group (n = 30) who received a placebo manipulation. Pain evaluation was performed using the visual analog scale, and evaluation of shoulder flexion and abduction ranges of motion was assessed using a goniometer pre- and post-intervention. The intervention was performed by either upper thoracic SM or a placebo manipulation.

Results

The manipulation group demonstrated increased flexion and abduction of the painful shoulder (P < .01) and increased abduction of the nonpainful shoulder (P = .03), but only the abduction of the painful shoulder reached the minimal detectable change. The placebo group showed a post-intervention increase in the flexion (P = .03) and abduction (P < .01) movement of the painful shoulder. Both groups presented a statistically significant reduction in post-intervention pain (P < .01), but not clinically significant.

Conclusion

Although the SM demonstrated a statistically significant difference for shoulder pain, this was not over the clinically meaningful change. Only the abduction of the painful shoulder reached the minimal detectable change.

The Impact of Decreased Scapulothoracic Upward Rotation on Subacromial Proximities

BACKGROUND

Decreased scapulothoracic upward rotation has been theorized to increase an individual's risk for rotator cuff compression by reducing the clearance for the tendons in the subacromial space (ie, subacromial proximities). However, the impact of decreased scapulothoracic upward rotation on subacromial proximities has not been tested during dynamic in vivo shoulder motion.

OBJECTIVE

To determine the impact of decreased scapulothoracic upward rotation on subacromial proximities.

METHODS

Shoulder kinematics were quantified in 40 participants, classified as having high or low scapulothoracic upward rotation, during scapular plane abduction using single-plane fluoroscopy and 2-D/3-D shape-matching. Subacromial proximities were calculated as (1) the normalized minimum distance between the coracoacromial arch and humeral rotator cuff insertion, and (2) the surface area of the humeral rotator cuff insertion in immediate proximity to the coracoacromial arch. The effect of decreased scapulothoracic upward rotation on subacromial proximities was assessed using 2-factor mixed-model analyses of variance. The prevalence of contact between the coracoacromial arch and rotator cuff was also quantified.

RESULTS

Subacromial distances were generally smallest below 70° of humerothoracic elevation. With the arm at the side, the normalized minimum distance for participants in the low scapulothoracic upward rotation group was 34.8% smaller compared to those in the high upward rotation group (P = .049). Contact between the coracoacromial arch and rotator cuff tendon occurred in 45% of participants.

CONCLUSION

Decreased scapulothoracic upward rotation shifts the range of risk for subacromial rotator cuff compression to lower angles. However, the low prevalence of contact suggests that subacromial rotator cuff compression may be less common than traditionally presumed. J Orthop Sports Phys Ther 2019;49(3):180-191. Epub 18 Jan 2019. doi:10.2519/jospt.2019.8590.

Can clinical assessment differentiate partial thickness rotator cuff tears from full thickness rotator cuff tears? A secondary analysis

Purpose: Shoulder pain causes significant disability, with rotator cuff disease as a common diagnosis. Differentially diagnosing partial tears of the rotator cuff tendons is difficult despite use of imaging and clinical examination. Our objective was to determine if a clinical assessment framework could discriminate between patients with partial and full thickness tears.Materials and Methods: Pre-operative baseline data from two randomized controlled trials of 452 adult patients awaiting rotator cuff repair were analyzed in this secondary analysis. Nineteen items from a pre-defined clinical assessment framework were investigated for association with the outcome of surgically confirmed partial or full thickness tear. Logistic regression tested independent associations and multivariable models were developed to create the most parsimonious model.Results: Thirty-two participants (7%) had partial thickness tears. Constant Power Score was the sole item associated with partial thickness tears (OR 1.07, 95% CI 1.02-1.12). Traumatic mechanism of injury trended toward significance (OR 2.17, 95% CI 1.06-4.48).Conclusions: Greater abduction strength (i.e., Constant Power Score) was associated with partial thickness tears. Other clinical assessment items did not differentiate between partial and full tears. Our results add to the growing body of research showing most clinical findings are not associated with a diagnosis in rotator cuff disease.Implications for RehabilitationGreater shoulder abduction strength (as measured with the Constant Power Score) was associated with partial thickness rotator cuff tears.Most findings within our clinical assessment framework did not distinguish between partial thickness and full thickness rotator cuff tears and thus, did not contribute to a differential pathoanatomical diagnosis.Since structural integrity of the rotator cuff and patient presentation show poor association, and rehabilitation intervention is often impairment-based, pathoanatomical diagnosis may not adequately direct non-surgical treatment. Including movement-based diagnoses or treatment classification systems in evaluation of rotator cuff disease may improve selection of appropriate conservative treatment.

Kinesiologic considerations for targeting activation of scapulothoracic muscles - part 1: serratus anterior

BACKGROUND

The serratus anterior (SA) is capable of a wide range of actions across the scapulothoracic joint. Furthermore, the lack of control, strength, or activation of this important muscle is believed to be associated with several painful conditions involving the shoulder complex. Studies and clinical intuition have therefore identified several exercises that selectively target the activation of the SA.

METHODS

This paper reviews the anatomy, innervation, testing, and complex actions of the SA. In addition, this paper describes the classic signs and symptoms of weakness or reduced activation of the SA. Several exercises are described and illustrated that purportedly target the activation of the SA, with the intention of optimizing muscular control and encouraging pain free shoulder motion.

CONCLUSIONS

This review provides the theoretical background and literature-based evidence that can help explain the SA's complex pathokinesiology, as well as guide the clinician to further develop exercises that likely challenge the muscle. This paper is written along with a companion paper entitled: Kinesiologic considerations for targeting activation of scapulothoracic muscles: part 2: trapezius. Both papers prepare the reader to expand their pallet of exercises that target and challenge these two dominant muscles, with a goal of improving function of the shoulder for several painful conditions caused by their reduced or altered activation pattern.

Shoulder tendon characteristics in disabled swimmers in high functional classes - Preliminary report

OBJECTIVE

To characterize disabled swimmers in comparison to an able-bodied swimmers for (1) supraspinatus tendon thickness, (2) subacromial space and (3) occupation ratio.

DESIGN

Cross-Sectional Study.

SETTING

Research laboratory.

PARTICIPANTS

Disabled swimmers with upper (DSw-Upper) (n = 8) and lower (DSw-Lower) (n = 7) extremity disorders. The DSw-Upper were classified in sports class S7-S8, while DSw-Lower in S9-S10. The control group had 15 able-bodied swimmers.

MAIN OUTCOME MEASURES

Ultrasound images of (1) supraspinatus tendon in short axis and long axis, (2) subacromial space, and (3) occupation ratio.

RESULTS

A thicker supraspinatus tendon in short axis was observed in DSw-Upper versus C-Sw (p = 0.012) and DSw-Upper versus DSw-Lower (p = 0.018); and in long axis for DSw-Upper versus CSw (p = 0.0001), and DSw-Upper versus DSw-Lower (p = 0.002). There was a greater occupation ratio in DSw-Upper versus DSw-Lower in short axis (p = 0.013) and long axis (p = 0.035).

CONCLUSIONS

The present study showed a thicker supraspinatus tendon and greater occupation ratio with the tendon occupying more of the subacromial space that may predispose upper extremity disabled swimmers to tendon disorders such as subacromial impingement syndrome. Ultrasound examination can be used to assess shoulder tendon characteristics and the relationship to the subacromial space, to determine potential for injury and training load monitoring.

Factors influencing final outcomes in patients with shoulder pain: A retrospective review

STUDY DESIGN

Retrospective cohort.

INTRODUCTION

Rehabilitation interventions are commonly prescribed for patients with shoulder pain, but it is unclear what factors may help clinicians' prognosis for final outcomes.

PURPOSE OF THE STUDY

The purpose of this study is to determine what factors are the best predictors of improved patient-reported outcomes at discharge in patients with shoulder pain.

METHODS

Retrospective chart review of 128 patients presenting with shoulder pain to an outpatient physical therapy clinic. Chart review captured data regarding patient demographics, treatment interventions, patient history, and patient-reported outcome scores. The primary dependent variable was the overall change score of the QuickDASH (initial to discharge). Thirty-eight predictor variables were entered into a forward stepwise multivariate linear regression model to determine which variables and to what degree contributed to the dependent variable.

RESULTS

The linear regression model identified 5 predictor variables that yielded an R = 0.74 and adjusted R² = 0.538 (P < .001). The 5 predictor variables identified in order of explained variance are QuickDASH change at the fifth visit, a total number of visits, initial QuickDASH score, scapular retraction exercise, and age.

DISCUSSION

Early change scores, equal to minimal detectable change scores on patient-reported outcomes appear to be strong indicators that patients with shoulder pain are on a positive trajectory to benefit from rehabilitation.

CONCLUSION

Using patient-reported outcomes throughout care, not just at the start and end of care, will provide therapist feedback regarding patient's progress and indicate treatment effectiveness.

LEVELS OF EVIDENCE

4.

Validation of imaging-based quantification of glenohumeral joint kinematics using an unmodified clinical biplane fluoroscopy system

Model-based tracking, using CT and biplane fluoroscopy, allows highly accurate quantification of glenohumeral motion and changes in the subacromial space. Previous investigators have used custom-built biplane fluoroscopes designed specifically for kinematic applications, which are available at few institutions and require FDA approval prior to clinical use. The aim of this study was to demonstrate the utility of an off-the-shelf clinical biplane fluoroscope for kinematic applications by validating model-based tracking for measurement of glenohumeral motion using an unmodified clinical system. Biplane images of each shoulder of a cadaver torso were acquired at various joint positions and during simulated movements along anatomical planes of motion. The pose of each humerus and scapula was determined using model-based tracking and compared to a bead-based gold standard. Error due to a temporal-offset between corresponding biplane images, characteristic of clinical biplane systems, was determined by comparison of measured and known relative position of 2 bead clusters of a phantom that was imaged while moved throughout the fluoroscopy image volume. Model-based tracking had global kinematic mean absolute errors of 0.27 mm and 0.29° (static), and 0.22-0.32 mm and 0.12-0.45° (dynamic). Glenohumeral mean absolute errors were 0.39 mm and 0.45° (static), and 0.36-0.42 mm and 0.41-0.48° (dynamic). The temporal-offset was predicted to add errors of 0.06-0.85 mm and 0.05-0.28° for cadaveric trials for the speeds examined. For defined speeds, sub-millimeter and sub-degree kinematic accuracy and precision were achieved using an unmodified clinical biplane fluoroscope for quantification of glenohumeral motion.

Three-dimensional kinematics of shoulder laxity examination and the relationship to clinical interpretation

Understanding clinical test kinematics improves utility of exam techniques. The purposes of this study were as follows: (1) determine inter-examiner repeatability of translation magnitude for the Anterior/Posterior Drawer and Sulcus shoulder laxity tests; (2) describe the relationships between glenohumeral joint translations and subjective grades for each laxity test; and (3) describe the relationship of overall glenohumeral joint laxity to a composite subjective score from the three laxity tests. Eleven subjects with shoulder symptomology were examined with three laxity tests. Motion was tracked with electromagnetic sensors affixed to the humerus and scapula via transcortical pins. ICCs were calculated to determine repeatability of translation magnitudes between two examiners for each test. Descriptive statistics and regression analyses were performed for comparisons of single laxity test grades with translation magnitudes and for composite subjective laxity scores and overall translation across all three tests. Inter-examiner ICCs regarding kinematic repeatability were 0.87 for Anterior Drawer, 0.84 for the Sulcus test, and not calculable for the Posterior Drawer. No linear relationships between subjective grades of individual tests and translation magnitudes were found. The relationship of overall translation with the composite subjective score from all laxity tests was r² = 0.75 (r = 0.86). Clinicians from different disciplines are capable of imparting similar translations during laxity tests. Single-test subjective laxity grades demonstrate large ranges of translation between subjects for the same grade. By combining results of three laxity tests, clinicians are capable of identifying the level of overall shoulder joint laxity in patients.

Diagnostic Injections About the Shoulder

Injections about the shoulder serve diagnostic as well as therapeutic purposes. Diagnosis of shoulder conditions, such as rotator cuff tears, acromioclavicular joint pathology, subacromial impingement or anterolateral pain syndrome, glenohumeral joint pathology, suprascapular nerve entrapment, and biceps tendon pathologies, is often complicated by concomitant conditions with overlapping symptoms and by inconclusive physical examination and imaging results. Injections of anesthetic agents can often help clinicians locate the source of pain. However, technique and accuracy of needle placement can vary by route. Accuracy is often improved with the use of ultrasonography guidance, although studies differ on the benefits of guided versus unguided injection.

Effect of glenohumeral elevation on subacromial supraspinatus compression risk during simulated reaching

Mechanical subacromial rotator cuff compression is one theoretical mechanism in the pathogenesis of rotator cuff disease. However, the relationship between shoulder kinematics and mechanical subacromial rotator cuff compression across the range of humeral elevation motion is not well understood. The purpose of this study was to investigate the effect of humeral elevation on subacromial compression risk of the supraspinatus during a simulated functional reaching task. Three-dimensional anatomical models were reconstructed from shoulder magnetic resonance images acquired from 20 subjects (10 asymptomatic, 10 symptomatic). Standardized glenohumeral kinematics from a simulated reaching task were imposed on the anatomic models and analyzed at 0, 30, 60, and 90° humerothoracic elevation. Five magnitudes of humeral retroversion were also imposed on the models at each angle of humerothoracic elevation to investigate the impact of retroversion on subacromial proximities. The minimum distance between the coracoacromial arch and supraspinatus tendon and footprint were quantified. When contact occurred, the magnitude of the intersecting volume between the supraspinatus tendon and coracoacromial arch was also quantified. The smallest minimum distance from the coracoacromial arch to the supraspinatus footprint occurred between 30 and 90°, while the smallest minimum distance to the supraspinatus tendon occurred between 0 and 60°. The magnitude of humeral retroversion did not significantly affect minimum distance to the supraspinatus tendon except at 60 or 90° humerothoracic elevation. The results of this study provide support for mechanical rotator cuff compression as a potential mechanism for the development of rotator cuff disease. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2329-2337, 2017.

Eccentric versus conventional exercise therapy in patients with rotator cuff tendinopathy: a randomized, single blinded, clinical trial

PURPOSE

To investigate the effectiveness of isolated eccentric versus conventional exercise therapy in patients with rotator cuff tendinopathy.

METHODS

Thirty-six patients with rotator cuff tendinopathy, diagnosed by an orthopaedic surgeon, were included and randomly allocated to an isolated eccentric exercise (EE) group (n = 20, mean age = 50.2 ± 10.8 years) or a conventional exercise (CG) group (n = 16, mean age = 48.6 ± 12.3 years). Both groups fulfilled a 12-week daily home-based exercise programme and received a total amount of nine treatment sessions. The Constant Murley score was used to evaluate both objective (e.g. range of motion and strength) and subjective measures (e.g. pain and activities of daily living). A visual analogue scale (VAS) was used to evaluate pain during daily activities. As secondary outcomes, shoulder range of motion and isometric abduction strength in 45° in the scapular plane were evaluated. All measurements were taken at baseline, at 6, 12 and 26 weeks.

RESULTS

After 26 weeks, both groups showed a significant increase in the Constant Murley score and a significant decrease in VAS scores. No difference was found between the groups, for any of the evaluated outcome measures.

CONCLUSION

A 12-week-isolated eccentric training programme of the rotator cuff is beneficial for shoulder function and pain after 26 weeks in patients with rotator cuff tendinopathy. However, it is no more beneficial than a conventional exercise programme for the rotator cuff and scapular muscles. Based on the results, clinicians should take into account that performing two eccentric exercises twice a day is as effective as performing six concentric/eccentric exercises once a day in patients with rotator cuff tendinopathy.

Effectiveness of conservative interventions including exercise, manual therapy and medical management in adults with shoulder impingement: a systematic review and meta-analysis of RCTs

OBJECTIVE

To investigate the effectiveness of conservative interventions for pain, function and range of motion in adults with shoulder impingement.

DESIGN

Systematic review and meta-analysis of randomised trials.

DATA SOURCES

Medline, CENTRAL, CINAHL, Embase and PEDro were searched from inception to January 2017.

STUDY SELECTION CRITERIA

Randomised controlled trials including participants with shoulder impingement and evaluating at least one conservative intervention against sham or other treatments.

RESULTS

For pain, exercise was superior to non-exercise control interventions (standardised mean difference (SMD) -0.94, 95% CI -1.69 to -0.19). Specific exercises were superior to generic exercises (SMD -0.65, 95% CI -0.99 to -0.32). Corticosteroid injections were superior to no treatment (SMD -0.65, 95% CI -1.04 to -0.26), and ultrasound guided injections were superior to non-guided injections (SMD -0.51, 95% CI -0.89 to -0.13). Nonsteroidal anti-inflammatory drugs (NSAIDS) had a small to moderate SMD of -0.29 (95% CI -0.53 to -0.05) compared with placebo. Manual therapy was superior to placebo (SMD -0.35, 95% CI -0.69 to -0.01). When combined with exercise, manual therapy was superior to exercise alone, but only at the shortest follow-up (SMD -0.32, 95% CI -0.62 to -0.01). Laser was superior to sham laser (SMD -0.88, 95% CI -1.48 to -0.27). Extracorporeal shockwave therapy (ECSWT) was superior to sham (-0.39, 95% CI -0.78 to -0.01) and tape was superior to sham (-0.64, 95% CI -1.16 to -0.12), with small to moderate SMDs.

CONCLUSION

Although there was only very low quality evidence, exercise should be considered for patients with shoulder impingement symptoms and tape, ECSWT, laser or manual therapy might be added. NSAIDS and corticosteroids are superior to placebo, but it is unclear how these treatments compare to exercise.

Characterization of humeral head displacements during dynamic glenohumeral neuromuscular control exercises using quantitative ultrasound imaging: A feasibility study

The objectives of the present study were to test the feasibility of measuring humeral head displacements using quantitative ultrasound imaging during the performance of two different dynamic glenohumeral neuromuscular control exercises and to investigate the influence of these exercises on the acromiohumeral distance (AHD) and anterior-posterior distance (APD). Ten individuals who have no history of shoulder injury at the non-dominant shoulder completed three repetitions of an active humeral head lowering exercise and three repetitions of a posteriorisation exercise in a random order in a seated position. The AHD and the APD of the humeral head relative to the glenoid cavity were measured continuously using an ultrasound imaging system during each exercise. Variations in AHD and APD, defined as the difference between the distance obtained before the exercise and the maximal distance reached during the exercise, were compared for each exercises. The active humeral head lowering exercise significantly increased the AHD by 0.94 ± 0.28 mm (relative: + 11.4%), but had no significant effect on the APD. The active humeral head posteriorisation exercise significantly increased the AHD by 0.65 ± 0.41 mm (relative: + 6.3%) and the APD by 1.51 ± 0.51 mm (relative: + 13.8%). The use of quantitative ultrasound imaging allows physiotherapists to quantify inferior and posterior humeral head displacements during dynamic glenohumeral neuromuscular control exercises. These measures, confirming favourable inferior and posterior humeral head displacements at the shoulder, may become useful when studying the effectiveness of rehabilitation programs incorporating dynamic glenohumeral neuromuscular control exercises.

Specific or general exercise strategy for subacromial impingement syndrome-does it matter? A systematic literature review and meta analysis

Background

Exercise is frequently suggested as a treatment option for patients presenting with symptoms of subacromial impingement syndrome. Some would argue implementing a specific exercise strategy with special focus on correction of kinematic deficits would be superior to general exercise strategy. There is however a lack of evidence comparing such exercise strategies to determine which is the most effective in the treatment of subacromial impingement syndrome. The aim of this review is to evaluate whether implementing specific exercise strategies involving resistive exercises are more effective than a general exercise strategy for the treatment of patients with subacromial impingement syndrome.

Methods

Randomized controlled trials were identified through an electronic search on PubMed/MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science and PEDro. In addition, article reference lists and Clinicaltrials.gov were searched. Studies were considered eligible if they included interventions with resistive specific exercises as compared to general resistance exercise. Four reviewers assessed risk of bias and methodological quality guided by Cochrane recommendations. Results were synthesised qualitatively or quantitatively, where appropriate.

Results

Six randomized controlled trials were included with 231 participants who experienced symptoms of subacromial impingement syndrome. Four studies evaluated the effectiveness of specific scapular exercise strategy and two studies evaluated the effectiveness of specific proprioceptive strategy. Five studies were of moderate quality and one study was of low quality. No consistent statistical significant differences in outcomes between treatment groups were reported in the studies. Standardized mean difference (SMD) for pain was SMD −0.19 (95% CI −0.61, 0.22) and SMD 0.30 (95% CI −0.16, 0.76) for function.

Conclusions

There is insufficient evidence to support or refute the effectiveness of specific resistive exercise strategies in the rehabilitation of subacromial impingement syndrome. More high quality research is needed to accurately assess this. This review provides suggestions on how to improve the methodological design of future studies in this area.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-017-1518-0) contains supplementary material, which is available to authorized users.

A systematic review of thrust manipulation for non-surgical shoulder conditions

Purpose

Although many conservative management options are available for patients with non-surgical shoulder conditions, there is little evidence of their effectiveness. This review investigated one manual therapy approach, thrust manipulation, as a treatment option.

Methods

A systematic search was conducted of the electronic databases from inception to March 2016: PubMed, PEDro, ICL, CINAHL, and AMED. Two independent reviewers conducted the screening process to determine article eligibility. Inclusion criteria were manuscripts published in peer-reviewed journals with human participants of any age. The intervention included was thrust, or high-velocity low-amplitude, manipulative therapy directed to the shoulder and/or the regions of the cervical or thoracic spine. Studies investigating secondary shoulder pain or lacking diagnostic confirmation procedures were excluded. Methodological quality was assessed using the PEDro scale and the Cochrane risk-of-bias tool.

Results

The initial search rendered 5041 articles. After screening titles and abstracts, 36 articles remained for full-text review. Six articles studying subacromial impingement syndrome met inclusion criteria. Four studies were randomized controlled trials (RCTs) and 2 were uncontrolled clinical studies. Five studies included 1 application of a thoracic spine thrust manipulation and 1 applied 8 treatments incorporating a shoulder joint thrust manipulation. Statistically significant improvements in pain scores were reported in all studies. Three of 4 RCTs compared a thrust manipulation to a sham, and statistical significance in pain reduction was found within the groups but not between them. Clinically meaningful changes in pain were inconsistent; 3 studies reported that scores met minimum clinically important difference, 1 reported scores did not, and 2 were unclear. Four studies found statistically significant improvements in disability; however, 2 were RCTs and did not find statistical significance between the active and sham groups.

Conclusions

No clinical trials of thrust manipulation for non-surgical shoulder conditions other than subacromial impingement syndrome were found. There is limited evidence to support or refute thrust manipulation as a solitary treatment for this condition. Studies consistently reported pain reduction, but active treatments were comparable to shams. High-quality studies of thrust manipulation with safety data, longer treatment periods and follow-up outcomes are needed.

Electronic supplementary material

The online version of this article (doi:10.1186/s12998-016-0133-8) contains supplementary material, which is available to authorized users.

Shoulder impingement syndrome: a systematic review of clinical trial participant selection criteria

BACKGROUND

Shoulder impingement syndrome (SIS) is a common diagnosis for patients with pain and dysfunction of the shoulder. Variations in the signs and symptoms might lead to uncertainty regarding the definition of SIS. The aim of this review is to explore the participant selection criteria used in the literature when investigating SIS and to assess differences in criteria among treating professions.

METHODS

This is a PRISMA systematic review of publications from 2009 to 2014 from MEDLINE, PubMed, The Cochrane Library, Embase, Scopus and CINAHL.

RESULTS

Ninety-seven articles met inclusion criteria for this review. Twenty-five different surgical and nonsurgical treatments were investigated. Impingement-specific index tests were used in all studies. Exclusion index tests were used in 62% of studies. Twenty index tests were identified. Radiological investigations were reported in 53% of all studies, of which a further 53% reported using two or more radiological investigations.

CONCLUSIONS

This systematic review has illustrated that studies investigating SIS test for various signs and symptoms, which is in keeping with describing the condition as a 'syndrome'. However, there are inconsistencies in participant selection criteria between health disciplines, highlighting a need for harmonization of the selection criteria in the form of an international editorial consensus.

The Use of Physiotherapy among Patients with Subacromial Impingement Syndrome: Impact of Sex, Socio-Demographic and Clinical Factors

Background

Physiotherapy with exercises is generally recommended in the treatment of patients with subacromial impingement syndrome (SIS).

Objective

We aimed to investigate the use of physiotherapy in patients with SIS in Danish hospital settings as part of initial non-surgical treatment and after SIS-related surgery and to evaluate to which extent sex, socio-demographic and clinical factors predict the use of physiotherapy.

Methods

Using national health registers, we identified 57,311 patients who had a first hospital contact with a diagnosis of ICD-10, groups M75.1–75.9, 1 July 2007 to 30 June 2011. Records of physiotherapy were extracted within 52 weeks after first contact (or until surgery), and for surgically treated patients within 26 weeks after surgery. Predictors of the use of physiotherapy after first contact and after surgery were analysed as time-to-event.

Results

Within 52 weeks after first contact, 43% of the patients had physiotherapy and 30% underwent surgery. Within 26 weeks after surgery, 80% had a record of physiotherapy. After first contact and after surgery, exercise was part of physiotherapy in 65% and 84% of the patients, respectively. A public hospital contact, physiotherapy before hospital contact, administrative region, female sex, a diagnosis of other or unspecified disorders (M75.8-M75.9), and surgical procedure predicted higher use of physiotherapy. Low education level predicted slightly lower use of physiotherapy after first contact, but not after surgery.

Conclusion

In patients with SIS in Danish hospital settings, physiotherapy was more often used after surgery than as part of initial non-surgical treatment. The use of physiotherapy was less common among men than women, whereas unequal use of physiotherapy in relation to education level was not noticeable. The use of physiotherapy with exercises in initial non-surgical treatment was relatively limited.

Effects of overhead work configuration on muscle activity during a simulated drilling task

Overhead work is a known catalyst for occupational shoulder injury. Industrial workers must often adopt awkward overhead postures and loading profiles to complete required tasks, potentially elevating injury risk. This research examined the combined influence of multiple overhead working parameters on upper extremity muscular demands for an industrial drilling application. Twenty-two right-handed males completed 24 unilateral and bilateral overhead work exertions stratified by direction (upward, forward), point of force application (15, 30 and 45 cm in front of the body), and whole-body posture (seated, standing). The dependency of electromyographic (EMG) activity on several factors was established. Significant two-way interactions existed between point of force application and direction (p < 0.0001) and direction and whole body posture (p < 0.0001). An average increase in muscular activity of 6.5% maximal voluntary contraction (MVC) occurred for the contralateral limb when the bilateral task was completed, compared to unilateral tasks, with less than a 1% MVC increase for the active limb. These findings assist evidence-based approaches to overhead tasks, specifically in the construction industry. A bilateral task configuration is recommended to reduce glenohumeral stability demands. As well, particularly for tasks with a far reach distance, design tasks to promote a forward directed exertion. The considerable inter-subject variability suggests that fixed heights are not ideal, and should be avoided, and where this is not possible reaches should be reduced.