Effect of scapular stabilization exercise program in patients with subacromial impingement syndrome: a systematic review

Strength and activity of the protractor and retractor muscles of the asymptomatic dyskinetic scapula

The role of scapular dyskinesis as a risk factor of shoulder injury has been largely discussed. However, most studies have focused on symptomatic patients and less is known on the asymptomatic dyskinetic scapula. Removing the confounding effects of the pathologies could contribute to better characterize the scapula dyskinesis. As muscle properties (strength, fatigue, nerve injury …) have been identified as causative factors of scapular dyskinesis, this study focuses specifically on characterizing the protractor and retractor muscles of the dyskinetic scapula. Thirteen asymptomatic dyskinetic volunteers were compared to eleven asymptomatic non-dyskinetic control volunteers. Muscle characteristics were evaluated in terms of maximal strength, fatigue resistance and electromyographic activity during a functional closed-chained task. The results did not identify kinematic or muscle activity significant differences between the dyskinetic and the control group even in fatigue conditions. However, the results demonstrated that protractors vs. retractors fatigue resistance ratios were imbalanced (<0.8) in the dyskinetic group and significantly lower than in the non-dyskinetic one. Our study suggests that that strength imbalances are not necessarily related to the presence of pain at the shoulder joint. These results demonstrated the importance to complete the clinical assessments of the scapula with strength evaluations even for asymptomatic sport practitioners.

Effectiveness of specific scapular therapeutic exercises in patients with shoulder pain: a systematic review with meta-analysis

Background

Therapeutic exercise has been considered a useful tool to rehabilitate shoulder pain, namely through its influence on scapular dynamics. Accordingly, the effectiveness of scapular therapeutic exercise needs to be explored. The present study aims to evaluate the effectiveness of scapular therapeutic exercises in shoulder pain and to identify the most effective exercise type (focal or multijoint) and ways of delivering them (as dose and progression).

Methods

Search was conducted at EMBASE, Cochrane Library, MEDLINE via PubMed, Web of Science, PEDro (Physiotherapy Evidence Database), and trial registration databases. The meta-analysis considered randomized controlled/crossover trials that compared the effect of scapular exercises against other types of intervention in the shoulder pain, shoulder function, scapular motion, and/or muscular activity. The risk of bias was assessed through the PEDro scale.

Results

From the 8318 records identified, 8 (high to low risk of bias- scoring from 4 to 8 on the PEDro scale) were included. The overall data, before sensitivity analysis, indicated that the scapular therapeutic exercises are: a) more effective than comparators in improving shoulder function (standardized mean difference [SMD] = 0.52 [95% Cl: 0.05, 0.99], P = .03, I2 = 76%); and b) as effective as comparators in reducing shoulder pain (SMD = 0.32 [95% Cl: -0.09, 0.73], P = .13, I2 = 70%). Subgroup analysis revealed that scapular exercises are more effective in improving shoulder function when the program duration is equal to or higher than 6 weeks (SMD = 0.43 [95% Cl: 0.09, 0.76] P = .01, I2 = 21%) and/or when the maximum number of exercise repetitions per session is lower than 30 (SMD = 0.79 [95% Cl: 0.15, 1.42], P = .01, I2 = 77%). Only 1 study considered scapular motion as an outcome measure, revealing therapeutic exercise effectiveness to improve scapular range of motion.

Conclusions

Intervention programs involving scapular therapeutic exercises are effective in improving shoulder function, presenting benefits when performed for 6 or more weeks and/or when used up to a maximum of 30 repetitions per exercise, per session.

Effects of manual therapy in addition to stretching and strengthening exercises to improve scapular range of motion, functional capacity and pain in patients with shoulder impingement syndrome: a randomized controlled trial

BACKGROUND

The current study aimed to measure the effectiveness of manual therapy in addition to stretching and strengthening exercises in patients with shoulder impingement syndrome to improve functional capacity, pain, and scapular range of motion.

METHODS

This is a single-blinded randomized controlled trial. Thirty-two participants with chronic shoulder impingement syndrome were randomly allocated into two groups. Both groups received stretching and strengthening exercises while the treatment group was given manual therapy additionally. Treatment was started after the patients signed an informed consent form. The data were collected from the University of Lahore Teaching Hospital between March 2022 and December 2022. The study aimed to measure pain using a numeric pain rating scale, functional capacity was assessed by the disability of the arm and shoulder, and goniometry was used for scapular ranges, i.e., scapular protraction and upward rotation. Each treatment session lasted 45 min for the treatment group and 30 min for the control group. The treatment comprised five days a week for four weeks, after which post-intervention measurements were taken.

RESULTS

Thirty-two participants were enrolled in the study, and 16 were divided into each group. The mean age of the participants in the treatment group was 38.19 ± 7.31 while the comparison group was 35.69 ± 7.98. An independent sample t-test was run on the data with a 95% confidence interval, statistically significant results were obtained, i.e., p-value < 0.05, post-intervention in the treatment group. Both groups have significantly improved functional capacity and scapular protraction (p < 0.005), however, pain and scapular upward rotation were not found statistically significant in the control group (p > 0.05).

CONCLUSION

The addition of manual therapy along with exercise therapy showed clinical and statistical significant results for pain, functional capacity, and scapular range of motion. It demonstrated superior effects than exercise therapy alone for the chronic condition of SIS.

TRIAL REGISTRATION

The trial was registered in the Iranian Registry of Clinical Trials ( https://www.irct.ir/ ) with the registration number: IRCT20230526058291N1, (Date: 12/08/2023).

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.

Integrating Physio-Yogic Exercises for Rotator Cuff Tendinopathy in Indian Overhead Athletes: A Comprehensive Approach

Background

Athletes affected by rotator cuff tendinopathy experience discomfort, stiffness, reduced range of motion, diminished athletic performance, and decreased quality of life. This study aimed to determine the efficacy of physio-yogic exercises in reducing pain and disability, increasing range of motion, and improving quality of life in Indian overhead athletes with rotator cuff tendinopathy.

Methods

Sample from 45 athletes was divided into three groups scapular recruitment exercises, physio-yogic exercises, and yoga asanas. Pre-intervention readings of the Shoulder Pain and Disability Index (SPADI), Athlete Quality of Life Scale (ALQS), and Shoulder Active Range of Motion (AROM) were taken at day 1 and post-intervention readings were taken at the end of week 8. The paired Student's t-test was used to compare the values of the outcome measures for the preintervention and postintervention within the groups. Analysis of variance was used to compare the mean values of change in the outcome measures from preintervention to postintervention between the groups. Post hoc test was conducted to compare the postintervention values of the outcome measures between the groups.

Results

Total scores of SPADI (p < 0.0001), ALQS (p < 0.0001), and Shoulder AROM (p < 0.0001) demonstrated statistically significant improvements in the physio-yogic exercise group.

Conclusion

The physio-yogic exercise protocol for rotator cuff tendinopathy is a unique regimen that combines the positive effects of yoga asanas and the advantages of scapular recruitment exercises. Thus, the physio-yogic exercise protocol can further promote the rehabilitation program for rotator cuff tendinopathy.

Scapular stabilization exercise training improves treatment effectiveness on shoulder pain, scapular dyskinesis, muscle strength, and function in patients with subacromial pain syndrome: A randomized controlled trial

INTRODUCTION

Subacromial pain syndrome (SPS) is a common cause of shoulder pain, and is associated with functional limitation, workdays lost, disability, and poor quality of life.

PURPOSE

Our purpose was to investigate the effects of scapular stabilization exercises in patients with SPS.

METHOD

Sixty-four patients with SPS who also exhibit observable scapular dyskinesis defined by the scapular dyskinesis test were recruited and randomized to scapular stabilization exercise training group or to control group. All participants received the same rehabilitation protocol including glenohumeral and scapular mobilization, pendulum exercises, shoulder stretching, range of motion exercises, strengthening, and proprioceptive exercises. Patients in the scapular stabilization exercise training group performed additional scapular stabilization exercises. The presence of scapular dyskinesis, shoulder pain severity, motion, muscle strength, scapular upward rotation, and shoulder disability were assessed before and after the four-week rehabilitation program.

RESULTS

The scapular stabilization exercise training group had better improvement in scapular dyskinesis, pain, muscle strength, and shoulder disability compared to the control group (p < 0.05). However, there was no statistically significant time-group interaction regarding shoulder motion and scapular upward rotation (p > 0.05).

CONCLUSIONS

Scapular stabilization exercises added to the shoulder mobilization, stretching, and strengthening are effective in improving scapular dyskinesis, reducing pain, increasing muscle strength and shoulder function in patients with SPS accompanied by scapular dyskinesis.

Utilizing Scapula Retraction Exercises With or Without Glenohumeral Rotational Exercises With a Gradual Progression for Subacromial Pain Syndrome

BACKGROUND

Although exercise interventions are recommended in the management of subacromial pain syndrome (SPS), there is a lack of data regarding the exercises focusing on the principal biomechanical deficiencies that cause symptoms.

HYPOTHESIS

Utilizing progressive scapula retraction exercises (SRE) and glenohumeral rotation exercises (GRE) in the scapula stabilization program may lead to more reduction in symptoms and greater acromiohumeral distance (AHD) values.

STUDY DESIGN

A double-blind, randomized controlled trial.

LEVEL OF EVIDENCE

Level 2.

METHODS

A total of 33 patients were assigned randomly to either SRE or SRE+GRE. Both groups received a 12-week supervised rehabilitation program, including manual therapy and exercises (stretching and progressive scapula stabilization exercises). In addition, the SRE+GRE group performed GRE exercises at gradual elevation angles. From 12 to 24 weeks, patients performed exercise programs less frequently (3 times per week). Disability (shoulder pain and disability index [SPADI]), AHD (at 5 active abduction angles), pain intensity (visual analogue scale [VAS]), and patient satisfaction were recorded at baseline, 12 weeks, and 24 weeks. A total of 16 healthy individuals were recruited as a control group to compare AHD values. Data were analyzed using mixed model analyses of variance.

RESULTS

A statistically significant group-by-time interaction was found for AHD values (F4,92 = 6.38; P = 0.001), a significant group-by-time interaction for SPADI-disability (F1,33 = 5.148; P = 0.01), SPADI-total (F1,32 = 4.172; P = 0.03), and for pain during activity (F2,62 = 3.204; P = 0.05). However, no significant group-by-time interaction for SPADI-pain (F1,33 = 0.533; P = 0.48), for pain at rest (F1,31 < 0.001; P = 0.99), and at night (F1,32 = 2.166; P = 0.15). Yet, a significant time effect was observed.

CONCLUSION

Progressive SRE and GRE in the scapula stabilization program lessens symptoms and improves AHD values in patients with SPS. Moreover, this program could preserve outcomes and further increase AHD when applied less frequently.

CLINICAL RELEVANCE

Utilizing SRE and GRE in the scapula stabilization program at gradual shoulder abduction angles provides better rehabilitation outcomes.

Comparing the effect of physiotherapy and physiotherapy plus corticosteroid injection on pain intensity, disability, quality of life, and treatment effectiveness in patients with Subacromial Pain Syndrome: a randomized controlled trial

PURPOSE

To compare the short and medium-term effects of physiotherapy plus corticosteroid injection (combined) with physiotherapy alone on pain intensity, disability, Quality of Life (QoL), and treatment effectiveness in patients with Subacromial Pain Syndrome (SAPS).

METHODS

In this double-blind, parallel Randomized Controlled Trial (RCT), 50 patients with SAPS were randomly assigned into combined (N = 25, a single injection 3-6 days before physiotherapy) and physiotherapy alone group (N = 25). Pain, disability, QoL, and treatment-effectiveness were measured at pre-intervention, post-intervention, and 3 and 6-month follow-up with Visual Analog Scale (VAS), Shortened Disability of the Arm, Shoulder, and Hand (Quick-DASH), Shoulder Pain and Disability Index (SPADI) (primary outcome measure), Western Ontario Rotator Cuff (WORC), and Global Rating of Change (GRC) respectively. A 2 × 4 (group × time) mixed model analysis of variance (ANOVA) was applied for analysis.

RESULTS

The ANOVA revealed statistically significant group-in-time interaction for all outcome measures (p-value < 0.05). The independent t-test showed more effectiveness in the combined group at medium-term, as the mean scores of almost all outcome measures were substantially lesser (p < 0.01). Moreover, in short-time, despite a greater number of patients stating "completely recovered" in the combined group, there was no statistically significant difference between groups.

CONCLUSIONS

Effects of physiotherapy plus corticosteroid injection could be more long-lasting than physiotherapy alone in improving pain intensity, disability, QoL, and treatment effectiveness in patients with SAPS.

TRIAL REGISTRATION NUMBER

IRCT20201010048980N1.IMPLICATIONS FOR REHABILITATIONShoulder pain is common, persistent, and predominantly results from subacromial pain syndrome (SAPS).Physiotherapy and corticosteroid injections are effective interventions for this condition.Comprehensive physiotherapy alone can be as effective as corticosteroid injection combined with physiotherapy in the short term.A combined approach versus physiotherapy alone may have more medium-term effects on SAPS patients' pain, disability, quality of life, and treatment effectiveness.

Comparison of the physiotherapy with and without focus on the scapulothoracic joint on pain, range of motion, functional disability, quality of life, and treatment effectiveness of patients after arthroscopic shoulder rotator cuff tendon repair: A randomized controlled trial with short-term follow-up

BACKGROUND

Rotator cuff tears are prevalent shoulder injuries, significantly affecting shoulder stabilization and patient quality of life. Despite rehabilitation efforts post-arthroscopic surgery, the efficacy of scapular-focused exercises remains uncertain with limited supportive evidence.

PURPOSE

This study aimed to compare the immediate and short-term effects of emphasizing scapulothoracic joint rehabilitation in addition to conventional physiotherapy on pain, range of motion (ROM), function, quality of life, and treatment effectiveness in patients after shoulder arthroscopic rotator cuff tendon repair (ARCR).

STUDY DESIGN

Two arms, parallel-group, randomized controlled trial, with concealed allocation METHODS: This parallel-group randomized controlled trial, with concealed allocation, was conducted in a clinic setting on 28 participants aged 30-75 years, exhibiting progressive degenerative full-thickness tears of rotator cuff muscles and undergoing ARCR, provided the tear size was small or medium. Participants were randomly allocated to receive 21 sessions of conventional rehabilitation (n = 14) or comprehensive rehabilitation (with a focus on scapula training; n = 14) in 12 weeks (reporting of intervention complied with Consensus on Exercise Reporting Template (CERT) and Template for Intervention Description and Replication (TIDieR) Guideline). Pain (as primary outcome), ROM, functional disability, quality of life, and treatment effectiveness were assessed both pre- and post-intervention, along with a 3-month follow-up. Participants, assessors, and statistician were blinded to group assignment. For the reporting of the RCT, the Consolidated Standards of Reporting Trials (CONSORT) has been used.

RESULTS

Trial was completed with 28 participants and no dropouts. The analysis of variance revealed statistically significant group-by-time interaction (p < 0.05) for all outcome measures except for active ROMs (p > 0.05). Multiple comparison analysis showed statistically significant between-group differences (p < 0.05) at 3-month follow-up with large effect size (>0.8 Hedges' g) for all outcomes (mean differences: visual analog scale: 1.3, American Shoulder and Elbow Surgeons: -17.3, Shoulder Pain and Disability Index: 17.6, Western Ontario Rotator Cuff: -19.5, QuickDASH: 17.8), except for extension ROM (passive ROM: confidence interval = -25.4 to 0.56; active ROM: confidence interval = -20.0 to 6.0). The differences in American Shoulder and Elbow Surgeons and Western Ontario Rotator Cuff were also clinically significant based on their minimally clinical important difference cutoff points. For the Global Rating of Change scale, more participants stated "much improved" in the comprehensive group than in the conventional. No adverse effects were reported.

CONCLUSIONS

Comprehensive rehabilitation, compared to conventional physiotherapy, has shown a statistically and clinically significant difference in improving pain, ROM, functional disability, quality of life, and treatment effectiveness in patients after ARCR.

Efficacy of Interferential Current Therapy in Patients Diagnosed with Subacromial Impingement Syndrome

OBJECTIVE

The objective of the study was to evaluate the effectiveness of interferential current treatment on a range of motion of joint and shoulder pain, functional status, and quality of life in patients with subacromial impingement syndrome and to compare interferential current with transcutaneous electrical nerve stimulation and sham interferential current.

MATERIALS AND METHODS

Patients complaining of shoulder discomfort participated in the present study. Diagnosis of subacromial impingement syndrome is based on anamnesis, clinical examinations, and shoulder magnetic resonance imaging. A total of 52 patients divided into 3 groups: Group 1 (17 patients, mean age 51.8 years) received interferential current, group 2 (18 patients, mean age 51.8 years) received transcutaneous electrical nerve stimulation, and group 3 (17 patients, mean age 49.1 years) received sham interferential current. Hot pack and exercise treatments were added to all groups. All groups were treated for 3 weeks, 5 times a week, for 15 sessions and 20 minutes for each session. Evaluations were made before treatment (T0), in the middle of treatment (T1; end of 8th session), and at the end of treatment (T2; end of 15th session) using active range of motion and visual analog scale for pain, the Arm, Shoulder, and Hand Problems Questionnaire for functional status, and Short Form-36 for quality of life.

RESULTS

There were significant improvement effects on all of the range of motion, visual analog scale, and the Arm, Shoulder, and Hand Problems Questionnaire scores at T2 and on the scores in some subparameters of Short Form-36 in all groups (P < .05). However, there was no statistically significant difference at T2 between the groups (P > .05).

CONCLUSION

Interferential current and transcutaneous electrical nerve stimulation exhibited equivalent results regarding range of motion, pain, function, and quality of life of patients with subacromial impingement syndrome, with no significant difference between interferential current and transcutaneous electrical nerve stimulation. Adding interferential current or transcutaneous electrical nerve stimulation treatments to hot pack +exercise therapy did not result in any extra benefits to the patients.

Effects of the combination of traditional Thai massage, scapular stabilization exercise, and chest mobilization in subjects with forward head posture: a single-blinded randomized clinical trial

BACKGROUND

Forward head posture (FHP) is  a common condition where the head appears to be positioned in front of the vertical midline of the body. FHP is associated with shortening of the neck extensors and pectoral muscles, and the deep neck flexors and shoulder retractors are weakened. FHP is also found to cause decreases in respiratory function. Few clinical trials have investigated the effects of combination treatments to alleviate these problems. The aim of this study was to examine the effects of combination of traditional Thai massage, scapular stabilization exercise, and chest mobilization on forward head angle (FHA), forced vital capacity (FVC), and cervical flexion in subjects with FHP.

METHODS

Forty-eight subjects with FHP were randomly allocated to a treatment group receiving a Combination of Traditional Thai massage, Scapular stabilization exercise, and Chest mobilization (CTSC group) (n = 24) and a control group (relaxed by lying supine) (n = 24). FHA, FVC, and cervical flexion were measured before and after the four-week intervention (Week 4) and one month after the intervention period (Week 8).

RESULTS

The CTSC group showed statistically significantly greater improvement in FHA and cervical flexion than the control group at Week 4 (FHA, mean difference - 6.05; 95% CI - 8.03, - 4.07; cervical flexion, mean difference 6.84; 95% CI 3.14, 10.55) and Week 8 (FHA, mean difference - 4.64; 95% CI ( - 6.71, - 2.58); cervical flexion, mean difference 5.21; 95% CI 0.84, 9.58). There were no significant between-group differences in FVC at week 4 (mean difference 0.09; 95% CI - 0.06, 0.23) and week 8 (mean difference 0.04; 95% CI - 0.11, 0.19).

CONCLUSION

This study showed that CTSC had a positive effect on FHA and cervical flexion in subjects with FHP.

TRIAL REGISTRATION

Thai Clinical Trials Registry (TCTR) (Identification number: TCTR20211119001), registered 19 November 2021; https://www.thaiclinicaltrials.org/show/TCTR20211119001 .

Effectiveness of Scapular Strengthening Exercises on Shoulder Dysfunction for Pain and Functional Disability after Modified Radical Mastectomy: A Controlled Clinical Trial

BACKGROUND

Breast cancer is the most prevalent from of cancer among women worldwide and leading cause of death. Breast cancer can be treated surgically, systemically (with hormonal therapy, chemotherapy) or with radiotherapy. Through the years, breast cancers management evolved towards conservation surgery. A surgical remove of partial or complete breast tissue, surrounding tissues, and nearby lymph nodes is called mastectomy. In Modified Radical Mastectomy, there is removal of entire breast tissue and lymph nodes. Treatment of modified radical mastectomy may lead to side effects such as shoulder pain, restricted shoulder mobility and anatomical and biomechanical changes of the shoulder, and also reduce functional disability.

METHOD

Eighty six participants were included in this study. Two groups, each of 43 were made, Group A (control group) was given conventional exercises and Group B (study group) was given scapular strengthening exercises with conventional exercises. Outcome measures - Shoulder Pain And Functional Disability, Shoulder range of motion were assessed both pre and post-test.

RESULT

Group B had lower pain intensity (77.116 ± 5.798vs 82.837 ± 3.860) and functional disability (70.326 ± 5.281 vs 77.791± 5.102) and higher shoulder flexion (167.98 ± 8.230 vs 107.05 ±8.018), abduction (156.91 ± 8.230 vs 107.63 ±8.230) and external rotation (62.372 ± 7.007 vs 41.907 ±6.771) range of motion than Group A.

CONCLUSION

The current study concluded that, scapular strengthening exercises along with conventional treatment proved beneficial and effective rather than only conventional treatment on shoulder dysfunction for pain and functional disability after modified radical mastectomy.

The effect of EMG biofeedback training on muscle activation in an impingement population

Subacromial impingement syndrome (SAIS) is one of the most diagnosed causes of pain in the upper extremity. The purpose of this study was to investigate muscle activity between asymptomatic and SAIS shoulders on the same subject while understanding the effectiveness of EMG biofeedback training (EBFB) on bilateral overhead movements. Ten participants (7 male), that tested positive for 2/3 SAIS clinical tests, volunteered for the study. Bilateral muscle activity was measured via electrodes on the upper trapezius (UT), lower trapezius (LT), serratus anterior (SA), and lumbar paraspinals (LP). Participants performed bilateral scapular plane overhead movements before and after EBFB. EBFB consisted of 10 bilateral repetitions of I, W, T, and Y exercises focused on reducing UT and increasing LT and SA activity. Prior to EBFB, no significant difference in muscle activity was present between sides. A significant main effect of time indicated that after EBFB both sides exhibited reduced UT activity at 60° (p = 0.003) and 90° (p = 0.036), LT activity was increased at all measured humeral angles (p < 0.0005), and SA muscle activity was increased at 110° (p = 0.001). EBFB in conjunction with scapular based exercise effectively alters muscle activity of asymptomatic and symptomatic scapular musculature.

Integrating molecular biomarkers in breast cancer rehabilitation. What is the current evidence? A systematic review of randomized controlled trials

Background: Quality of life issues is a crucial burden in breast cancer (BC) survivors with relevant implications in terms of survivorship and health-care costs. The increasing long-term survival of these patients provides new challenges, with translational research now focusing on innovative and tailored approaches to improve their complex management. In this scenario, several emerging biomarkers have the potential to improve the clinical rehabilitative management of patients with BC. However, to date, guidelines supporting biomarker implementation in this area are still lacking. Therefore, the aim of this systematic review was to summarize the currently available biomarkers that might be potentially integrated into rehabilitation practice to promote a precision medicine approach to BC survivorship issues.

Methods: On 9th March 2022, PubMed, Scopus, Web of Science, Cochrane, and PEDro were systematically searched for randomized controlled trials (RCTs) assessing rehabilitation interventions in BC patients. Molecular biomarker modifications induced by physical exercise have been assessed through the review of the study protocols and published results. The Jadad scale was used to assess the quality of the studies included.

Results: Out of 2,224 records, 22 studies were included in the present systematic review. Exercise therapy showed significant results in 15 RCTs, in terms of metabolic biomarkers, including glycemic and insulin profile, and lipid profile (p ≤ 0.05). Similarly, 12 studies underlined significant effects in inflammation and immune response biomarkers, including TNF-α, IL-6, IL-10, C-reactive protein, leptin, and adiponectin (p ≤ 0.05). On the other hand, cardiac biomarkers were assessed in three studies without reporting significant differences after exercise therapy (p = NS). The quality assessment identified 19 RCTs as high-quality studies and three RCTs of low quality.

Conclusion: Our findings reveal significant biochemical perturbations in key molecules induced by physical exercise in patients with BC, suggesting room for the implementation of actionable biomarkers. Future research might clarify the role of biomarkers on treatment effectiveness monitoring, to optimize rehabilitative strategies tailored to patient’s needs.

Resident Case Series: Blood Flow Restriction as an Adjunct to Strengthening Exercises in Two Patients with Subacromial Impingement and High Irritability

Introduction

Evidence informed management of individuals presenting with subacromial impingement syndrome (SAIS) includes strengthening exercises directed at the shoulder musculature. Patients with subacromial impingement syndrome (SAIS) can present with pain during and after completion of heavy resistance training limiting the applicability of this recommended treatment approach. Blood flow restriction (BFR) training is indicated for patients who have pain while completing heavy resistance training and may represent an important treatment modification for patients with SAIS unable to fully participate in a strengthening exercise program. The purpose of this case series is to describe the inclusion of BFR in the treatment of two patients with SAIS.

Case descriptions

Two middle aged, non-operative patients with signs and symptoms consistent with SAIS and high levels of irritability were included. Treatment over one month consisted of three commonly used exercises in the treatment of SAIS in conjunction with a standard BFR protocol: 75 reps broken up into sets of 30,15,15,15 with the BFR cuff placed over proximal humerus.

Outcomes

Immediate within session improvements beyond measurement error were observed in resting pain and pain pressure thresholds at three sites. At the end of the course of treatment, clinically meaningful improvements were observed in patient reported outcomes including the PENN Score, ASES score, and the patient-specific functional scale. Clinically meaningful improvements and change beyond measurement error were also observed in range of motion and strength which (assessed via a handheld dynamometer).

Discussion

The incorporation of low load resistance training with BFR may be a useful adjunct for treating patients with SAIS to promote exercise-induced hypoalgesia, decrease pain, and increase function in the upper extremity.

Level of Evidence

5.

Causal mechanisms of a scapular stabilization intervention for patients with subacromial pain syndrome: a secondary analysis of a randomized controlled trial

Background

Causal mediation analysis is one way to bridge this gap by exploring the causal pathways of a given intervention. The aim of this study was to assess whether scapular motion, position, and periscapular muscle strength are mediators for pain and shoulder disability outcomes following a scapular stabilization intervention for patients with subacromial pain syndrome.

Methods

Sixty patients were randomized into two groups: scapular stabilization or periscapular strengthening exercises. The intervention consisted of three sessions per week for 8 weeks. The primary outcome measures were pain and disability and the following outcome measures were considered as potential mediators: scapular motion, scapular position, periscapular muscle strength, age, duration of symptoms, and side of the complaint. A model-based inference approach with bootstrap simulations was used to estimate the average causal mediation effect, average direct effect, and the average total effect from the data of a randomized clinical trial that evaluated the effect of adding scapular stabilization exercises to a scapulothoracic strengthening program in people with subacromial pain syndrome.

Results

The results demonstrated that none of the putative mediators were influenced by the intervention. However, muscle strength of serratus anterior, upper, middle, and lower trapezius muscles was associated with shoulder disability.

Conclusion

Scapular kinematic and periscapular muscle strength did not mediate the effect of scapular stabilization exercises on shoulder pain or disability scores in subjects with subacromial pain syndrome. Muscle strength of serratus anterior, upper, middle and lower trapezius were associated with shoulder disability scores at 8-weeks follow-up.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40945-022-00138-1.

Co-creation of an exercise inventory to improve scapular stabilization and control among individuals with rotator cuff-related shoulder pain: a survey-based study amongst physiotherapists

Background

Scapular stabilization exercises (SSE) are often included in the treatment of individuals with rotator cuff-related shoulder pain (RCRSP) to decrease pain and improve function. These SSE typically aim to strengthen the scapular muscles and optimize dynamic neuromuscular control of the scapula, which may improve overall shoulder stability and movement quality. No consensus of the recommended SSE for the management of RCRSP is available. Hence, this study aimed to consult physiotherapists to co-create an inventory of recommended SSE based on the exercise’s relevance and frequency of prescriptions for the rehabilitation of individuals with RCRSP.

Methods

A group of 16 physiotherapists with experience in treating shoulder pain participated in a sequential consultation incorporating two distinct rounds of consultation focusing on SSE (modified Delphi design). In round 1, physiotherapists identified and demonstrated up to 10 SSE that they commonly recommend or use among individuals with RCRSP. The description and performance of all SSE were audio and video recorded. All SSE suggested by more than one participant in round 1 advanced to round 2. In round 2, physiotherapists rated these SSE on a 4-point Likert scale according to their perceived relevance and frequency of prescription for this population.

Results

In round 1, out of the 25 SSE recommended by participants, 19 SSE (76.0%) were recommended by more than one physiotherapist and advanced to round 2. In round 2, 13 SSE were consensually classified (agreement ≥75%) as being relevant for the rehabilitation of individuals with RCRSP. SSE targeting the recruitment of the serratus anterior and lower trapezius muscles were considered the most relevant for the management of RCRSP, whereas SSE targeting neuromuscular scapular control were the most prescribed SSE for the management of RCRSP.

Conclusions

An inventory composed of 13 SSE was co-created by physiotherapists based on their relevance and frequency of prescription for the rehabilitation of individuals with RCRSP. When designing an exercise program, physiotherapists can use this SSE inventory to inform their exercise selection, in combination with their current knowledge on shoulder rehabilitation, as well as patients’ preferences.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40945-022-00132-7.

Scapular Dynamic Muscular Stiffness Assessed through Myotonometry: A Narrative Review

Several tools have been used to assess muscular stiffness. Myotonometry stands out as an accessible, handheld, and easy to use tool. The purpose of this review was to summarize the psychometric properties and methodological considerations of myotonometry and its applicability in assessing scapular muscles. Myotonometry seems to be a reliable method to assess several muscles stiffness, as trapezius. This method has been demonstrated fair to moderate correlation with passive stiffness measured by shear wave elastography for several muscles, as well as with level of muscle contraction, pinch and muscle strength, Action Research Arm Test score and muscle or subcutaneous thickness. Myotonometry can detect scapular muscles stiffness differences between pre- and post-intervention in painful conditions and, sometimes, between symptomatic and asymptomatic subjects.

In vivo effects of two shoulder girdle motor control exercises on acromiohumeral and coracohumeral distances in healthy men

INTRODUCTION

Altered motor control and proprioceptive deficits are associated with kinematics dysfunctions and may cause alterations in subacromial space (SAS) that could lead to shoulder pathologies. Dimensions of the subacromial space, as well as interventions aimed at its normal restitution, can be explored by ultrasound (US).

OBJECTIVE

To describe the effect of two shoulder girdle motor control exercises with cognitive training strategies on SAS dimensions, measured with US.

METHODS

Cognitive movement control strategies, with visual and haptic feedback were applied on 21 healthy participants. SAS dimensions were measured through in vivo variations of acromiohumeral (AHD) and coracohumeral distances (CHD) using US.

RESULTS

Our results show that as exercise repetitions are performed, an increasing trend in both measures can be observed, being wider for AHD (i.e. humeral head descent exercise) than CHD (i.e. scapular retraction exercise).

CONCLUSION

Specific cognitive and motor control exercises improve congruence joint and centering of the humeral head.

A Targeted Approach to Post-Mastectomy Pain and Persistent Pain following Breast Cancer Treatment

Persistent pain following treatment for breast cancer is common and often imprecisely labeled as post-mastectomy pain syndrome (PMPS). PMPS is a disorder with multiple potential underlying causes including intercostobrachial nerve injury, intercostal neuromas, phantom breast pain, and pectoralis minor syndrome. Adding further complexity to the issue are various musculoskeletal pain syndromes including cervical radiculopathy, shoulder impingement syndrome, frozen shoulder, and myofascial pain that may occur concurrently and at times overlap with PMPS. These overlapping pain syndromes may be difficult to separate from one another, but precise diagnosis is essential, as treatment for each pain generator may be distinct. The purpose of this review is to clearly outline different pain sources based on anatomic location that commonly occur following treatment for breast cancer, and to provide tailored and evidence-based recommendations for the evaluation and treatment of each disorder.

Stepwise increase of upper limb muscle activity induced by progressive 4 positions of a handstand training

BACKGROUND: Handstand is the most important fundamental skill in gymnastics. A gradual and well-balanced increase in muscle loading in a manner is preferred for young beginners and/or recovering gymnasts to safely achieve the muscle strength required to perform a stable handstand. OBJECTIVE: To examine upper limb muscle activity during different levels of handstand training positions. METHODS: This study utilized four different positions for progressive handstand training; namely, the 90, 135, elbow stand, and handstand positions. The activities of eight upper limb muscles (upper, middle, and lower trapezius; serratus anterior; anterior and middle deltoid; infraspinatus; and latissimus dorsi were measured by surface electromyography (EMG) for each position. The percentages of EMG in each muscle compared to the values during maximum voluntary contraction were calculated and compared between the positions. RESULTS: Muscle activity around the shoulder increased gradually throughout the progression of the four handstand training positions. Furthermore, the muscles required for scapular stabilization, such as the upper and middle trapezius and serratus anterior muscles, were activated at levels similar to those for a handstand without performing this movement. CONCLUSIONS: A progressive handstand training program of four different positions resulted in gradual and well-balanced increases in muscle activity.

Exploring pain interference with motor skill learning in humans: a protocol for a systematic review

INTRODUCTION

Motor skill learning is intrinsic to living. Pain demands attention and may disrupt non-pain-related goals such as learning new motor skills. Although rehabilitation approaches have used motor skill learning for individuals in pain, there is uncertainty on the impact of pain on learning motor skills.

METHODS AND ANALYSIS

The protocol of this systematic review has been designed and is reported in accordance with criteria set out by the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. Web of Science, Scopus, MEDLINE, Embase and CINAHL databases; key journals; and grey literature will be searched up until March 2021, using subject-specific searches. Two independent assessors will oversee searching, screening and extracting of data and assessment of risk of bias. Both behavioural and activity-dependent plasticity outcome measures of motor learning will be synthesised and presented. The quality of evidence will be assessed using the Grading of Recommendations Assessment, Development and Evaluation approach.

ETHICS AND DISSEMINATION

No patient data will be collected, and therefore, ethical approval was not required for this review. The results of this review will provide further understanding into the complex effects of pain and may guide clinicians in their use of motor learning strategies for the rehabilitation of individuals in pain. The results of this review will be published in a peer-reviewed journal and presented at scientific conferences.

PROSPERO REGISTRATION NUMBER

CRD42020213240.

Current concepts in the rehabilitation of rotator cuff related disorders

Rotator cuff related disorders (RCRD) are common. Exercise-based rehabilitation can improve outcomes, yet uncertainty exists regarding the characteristics of these exercises. This scoping review paper summarises the key characteristics of the exercise-based rehabilitation of rotator cuff related disorders (RCRD). An iterative search process was used to capture the breadth of current evidence and a narrative summary of the data was produced. 57 papers were included. Disagreement around terminology, diagnostic standards, and outcome measures limits the comparison of the data. Rehabilitation should utilise a biopsychosocial approach, be person-centred and foster self-efficacy. Biomedically framed beliefs can create barriers to rehabilitation. Pain drivers in RCRSD are unclear, as is the influence of pain during exercise on outcomes. Expectations and preferences around pain levels should be discussed to allow the co-creation of a programme that is tolerated and therefore engaged with. The optimal parameters of exercise-based rehabilitation remain unclear; however, programmes should be individualised and progressive, with a minimum duration of 12 weeks. Supervised or home-based exercises are equally effective. Following rotator cuff repair, rehabilitation should be milestone-driven and individualised; communication across the MDT is essential. For individuals with massive rotator cuff tears, the anterior deltoid programme is a useful starting point and should be supplemented by functional rehabilitation, exercises to optimise any remaining cuff and the rest of the kinetic chain. In conclusion, exercise-based rehabilitation improves outcomes for individuals with a range of RCRD. The optimal parameters of these exercises remain unclear. Variation exists across current physiotherapy practice and post-operative rehabilitation protocols, reflecting the wide-ranging spectrum of individuals presenting with RCRD. Clinicians should use their communication and rehabilitation expertise to plan an exercise-based program in conjunction with the individual with RCRSD, which is regularly reviewed and adjusted.