CDR Damien Avery PT, DPT, OCS. * Specificity of exercise including eccentric training has value for preventing surgical intervention in patients with.

CDR Damien Avery PT, DPT, OCS

*Benefits of specificity of exercise including eccentric training for chronic subacromial impingement

*The Bottom Line

*Specificity of exercise including eccentric training has value for preventing surgical intervention in patients with a median duration of symptoms of 24 months (range 6-120 months) with a NNT of 3 (95%CI = 2 to 5).

*Citation: Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomized controlled study. Holmgren, T. et. al. BMJ. 2012;344e787 doi

*Three Part Clinical Question

*Will a 43yo male with rotator cuff tendinopathy benefit from eccentric training?

*Search Terms: Clinical Queries: Eccentric AND Rotator Cuff

*The Study

*Participant and single assessor blinded, concealed, randomized controlled trial without intention-to-treat.

*The Study Patients

*Specific Exercise Group: 14 women/37men; age:52(SD:9); Duration of pain 24 months (6-120); Heavy Load occupation: 22 (43%); Light load: 29(57%); on sick-leave: 9(18%); RC: 33(65%)intact; 15(29%) partial tear; 3(6%) full thickness.

*Non-specfic Exercise Group: 22 Women/24 men; age 52 (SD:8); Duration of pain: 12 months (6-156); Heavy Load occupation: 21 (46%); Light load 25(55%). RC: 34(74%)intact; 6(13%)partial tear; 6(13%) full thickness

*Control Group

*Non-specific exercise: (N = 46; 46 analyzed): Six unspecific movement exercises for neck and shoulder without external load (Shldr Horiz ABD; shldr elev; shldr retraction; upper-trap stretch and pec-major stretch). Completed 10 reps twice daily, and stretches 3 times/twice daily.

*Experimental Group

*(N = 51; 51 analyzed): Six different exercises (2 eccentric; 3 ecc/con; posterior shoulder stretch); 15 reps x 3 sets twice daily, and stretch 30-60 seconds 3x twice daily for eight weeks, and then once daily 8-12 weeks with resistance in pain monitoring model

*The Evidence

Outcome Time to

Outcome CER EER RRR ARR NNT

Surgery12 Weeks 0.592 0.196 67% 0.396 3

95% Confidence Intervals: 37% to 97% 0.220 to 0.572 2 to 5

MeasureControl Group Experimental Group

Difference 95% CIMean SD Mean SD

DASH 6 4 14 3 -8-12.841 to -3.159

Constant-Murley Score

9 4 24 4.5 15 8.5 to 20.6

*Are the Results Valid?

*Patients were selected thru concealed randomization

*Patients had similar prognostic factors with exception that the Specific Exercise group had a greater median duration of pain symptoms (24 months) than did the control group (12 months)

*Patients and assessing clinician were blinded to group allocation, treating clinician was not.

*Are the Results Valid?

*Study retention was good: lost total of 5 patients

*ITT analysis not completed

*Each group lost one patient 2/2 frozen shoulder

*Control group lost 3 patients at beginning of study

*NNT was able to be completed with ITT by this reviewer

*Manual treatment (stretching post. Capsule & pec minor) completed “when necessary”

*Follow-up period was only 12 weeks

*What are the Results?

*Event Defined as: opting for surgery by 12 weeks

*Non-specific Exercise Group: 29/49

*Specific Exercise Group: 10/51

*NNT: 3 (95%CI: 2-5)

*Dash: 8 (95%CI: 2.3 to 13.7) MCID: 13

*Constant-Murley Shoulder Score: 15 (95%CI: 8.5 to 20.6) MCID: assumed at 15%

*How can I apply these results to

my patient population?

*Patient’s ages ranged from 30-65

*Diagnosed with subacromial impingement

*On waiting list for subacromial decompression

*Similar to my patient population

*Treatments are low cost, low risk justify use

*Limited generalizability for sustained improvement over time

*Questions?