Role of physiotherapy in the treatment of subacromial   impingement syndrome: a     prospective study
 Dickens VA, Williams JL, Bhamra MS
   
Target Condition:
726.10 - Disorders of bursae and tendons in shoulder region, unspecified
Element of Patient/Client Management Model: Intervention

Practice Pattern(s):
Musculoskeletal - Pattern D: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Connective Tissue Dysfunction
Design Type: Clinical Trial, Random

Study Population: Adults (18-64 years), Older persons (65 years or older)

Population Location: Outpatient / ambulatory care

Inclusion Criteria: Patients with a diagnosis of subacromial impingement were identified at a specialist shoulder clinic. The diagnosis of subacromial impingement was made using the clinical history, clinical examination and radiographic findings, together with diagnostic local anesthetic injections into the subacromial space and acromioclavicular joint. These patients underwent three steroid injections into the subacromial space, given at 6-weekly intervals as part of an existing protocol. All injections were performed without imaging guidance. Subsequent to this, patients were reviewed and their outcome assessed. If the patients had no improvement in their symptoms, they still complained of pain, loss of function and objectively presented with positive impingement tests, subacromial decompression surgery was recommended. Patients who were placed on the waiting list for surgery were asked to participate in the current study. An independent surgeon (JLW) reviewed all patients and confirmed the diagnosis.


Exclusion Criteria: Evidence of cervical radiculopathy, adhesive capsulitis or a clinically obvious rotator cuff tear. This was assessed using the clinical history and examination findings, with appropriate plain radiographs if indicated. Complex imaging (ultrasound or magnetic resonance imaging) was not used. Patients were also excluded if they had previously received a course of physiotherapy or had a grade III subacromial spur on their shoulder supraspinatus outlet radiograph.

How were subjects selected: Not Described
How many subjects were contacted initially: Not Reported
How many subjects were eligible to participate: 85
How many subjects agreed to participate: 85

Non-clinical characteristics of study participants: 26 men and 19 women in the Physiotherapy group, and 22 men and 18 women in the Control group. Mean age: Physiotherapy group 55 years, range 27–68; Control group 54 years, range 26–73.

Clinical characteristics of study participants: Patients with a diagnosis of subacromial impingement were identified at a specialist shoulder clinic. The diagnosis of subacromial impingement was made using the clinical history, clinical examination and radiographic findings, together with diagnostic local anesthetic injections into the subacromial space and acromioclavicular joint.
Blinded Clinicians: No
Blinded Subjects: No
Same person providing treatment and testing measures: No
Blinded assessor: Yes
Intention to treat analysis: Yes

Treatment Group 1 : This group was comprised of 45 patients randomly assigned. All subjects received an individualized rehabilitation program based on the findings from the initial assessment that was completed by a physical therapist. The individualized rehabilitation program consisted of a combination of supervised therapy at the hospital and a home exercise program. All patients received some or all of the following treatment modalities: acromioclavicular joint, thoracic, cervical spine and glenohumeral joint mobilization, exercise therapy including attention to muscle imbalance, postural advice, strapping and, very occasionally, electrotherapy. The patients were seen once or twice a week at the hospital until it was felt that they were capable of maintaining their therapy program without supervision. The need for joint mobilizations was decided upon at the physiotherapy assessment. The physiotherapist assessed the range of accessory movement available in each patient’s glenohumeral and thoracic spine joints with passive accessory movements. Any joints that were found to have restricted movement were addressed with mobilizations into the direction of resistance and pain to help restore full pain-free range of movement. Exercises were taught to all subjects in functional positions wherever possible, allowing patients to easily replicate them throughout their normal daily routine. Great emphasis was placed on teaching subjects a ‘good posture’ and ‘neutral’ starting positions for all exercises. The exercise program was progressed to involve strengthening of infraspinatus, subscapularis and teres minor relative to the supraspinatus and deltoid, aiming to restore the necessary depressor effect of the rotator cuff on the humeral head during arm elevation, resulting in less impingement. The rotator cuff exercises were done with the use of resistance bands for home use. These exercises started in neutral positions with isometric contractions and were progressed to inner range, through range, outer range and into functional positions. The resistance and speed of these exercises were altered and progressed. Each patient’s exercise program was re-assessed regularly and all patients were asked to complete the exercises at least twice a day. However, all patients were advised to concentrate on their posture and getting into the ‘neutral’ position regularly throughout the day (hourly).

Control/Referent Group R : This group was comprised of 40 patients. The control group did not receive any further intervention once enrolled in the study. They were advised to maintain their normal activities of daily living while waiting for surgery. All patients were advised that their surgery would not be prejudiced by involvement in the study. All patients were advised to continue taking analgesics as appropriate throughout the course of the study.

Authors Stated Purpose: To investigate the effectiveness of a physiotherapy program in patients with subacromial impingement syndrome.
Interventions:

Patient / Client Related Instruction

Therapeutic Exercise
         * Body mechanics / postural stabilization
         * Flexibility
         * Muscle strength, power, and endurance training

Manual Therapy Techniques
         * mobilization / manipulation

Electrotherapeutic Modalities
         * Electrical stimulation

Study Outcomes:

Impairments
         * Musculoskeletal
                 * pain
                 * range of motion

Functional Limitations
         * Mobility / Movement

Societal resources
         * utilization of services

Results By Outcome:
Outcome 1 - continuous
	Constant Shoulder Score - This measure was developed to evaluate functional recovery of the shoulder after injury or surgery. II. Treatment 1 Number of Subjects: 42 End Mean: 72 End Standard Deviation: Baseline Mean: 52 Baseline Standard Deviation: Treatment R Number of Subjects: 31 End Mean: 56.65 End Standard Deviation: Baseline Mean: 56 Baseline Standard Deviation:
Outcome 2 - dichotomous
	Participants who avoided surgery I. Treatment 1 and Control/Referent Group Odds Ratio: 27.00 95% Confidence Interval: 1.53 to 475.09 Risk Ratio: 20.50 95% Confidence Interval: 1.25 to 337.12 NNT: 4.21
	Participants who avoided surgery II. Treatment 1 Subject with Outcome: 11 Subjects without Outcome: 34 Treatment R Subject with Outcome: 0 Subjects without Outcome: 40