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ARTICLE IN PRESSExercise in the treatment of rotator cuff
impingement: Asystematic review and a synthesized
evidence-basedrehabilitation protocolJohn E. Kuhn, MD, Nashville,
TNA systematic review of the literature was performed toevaluate
the role of exercise in treating rotator cuffimpingement and to
synthesize a standard evidence-based rehabilitation protocol.
Eleven randomized,controlled trials (level 1 and 2) evaluating the
effect ofexercise in the treatment of impingement were
identified.Data regarding demographics, methodology, andoutcomes of
pain, range of motion, strength, and functionwere recorded.
Individual components of eachrehabilitation program were
catalogued. Effectivenesswas determined by statistical and clinical
significance.Although many articles had methodologic concerns,
thedata demonstrate that exercise has statistically andclinically
significant effects on pain reduction andimproving function, but
not on range of motion orstrength. Manual therapy augments the
effects ofexercise, yet supervised exercise was not different
thanhome exercise programs. Information regarding
specificcomponents of the exercise programs was synthesizedinto a
gold standard rehabilitation protocol for futurestudies on the
nonoperative treatment of rotator cuffimpingement. (J Shoulder
Elbow Surg 2008;-:---.)
Systematic reviews of interventions for rotator cuff pa-thology
and shoulder pain suggest that exercise maybe an effective
treatment,1,12,15,16 whereas ultra-sound therapy is of little
benefit.16,28,37 Exercise isa broad term and includes the following
interventions:range of motion, stretching and flexibility,
andstrengthening exercises, with manual therapy and mo-dalities.
Variations on individual exercises and theseFrom the Vanderbilt
Shoulder Center.This work was funded by an unrestricted research
grant from the
Arthrex Corporation.Reprint requests: John E. Kuhn, MD,
Associate Professor and Chief
of Shoulder Surgery, Vanderbilt Sports Medicine, 4200 MCE,South
Tower, 1215 21st Ave S, Nashville, TN 37232
(E-mail:[email protected]).
Copyright 2008 by Journal of Shoulder and Elbow SurgeryBoard of
Trustees.
1058-2746/2008/$34.00doi:10.1016/j.jse.2008.06.004components
have been promoted by a number of au-thors who offer rehabilitation
protocol sugges-tions.4,6,7,10,13,20,21,22,23,26,29,30,31 These
protocolsare typically extrapolated from animal studies, ca-daver
biomechanics studies, and studies of healthysubjects by using
magnetic resonance imaging, videokinematics, electromyography, and
strength measure-ments. As such, the protocols recommended by
theseauthors are not based on high levels of evidence.
Not surprisingly, there is no consensus on an idealexercise
program to treat patients with rotator cuff dis-ease, leading
researchers who wish to conduct ran-domized trials to resort to
using expert opinion (level5 evidence) when developing protocols.3
The purposeof this systematic review is evaluate the role of
exercisein treating rotator cuff impingement and to develop
anevidence-based gold standard, physical therapy, ex-ercise program
for the treatment of rotator cuff im-pingement syndrome by
synthesizing the features ofexercise protocols from clinical
studies with the highestlevels of evidence.MATERIALS AND
METHODS
Before the search was initiated, inclusion and exclusioncriteria
for articles were defined. Articles were included ifthey were level
1 or level 2 studies (randomized controlledtrials), compared
physical therapy with other treatments orplacebo, used outcome
measures of pain, function, or dis-ability with validated
assessment tools, and were restrictedto patients with a diagnosis
of impingement syndrome, asdetermined by positive a impingement
sign by Neer32 orHawkins18 criteria, or both. Articles were
excluded if theywere concerned with other shoulder conditions
(calcific ten-dinosis, full thickness rotator cuff tears, adhesive
capsulitis,osteoarthritis, etc), addressed postoperative
management,were retrospective studies or case series, or used other
out-come measures.
A computer search was conducted using the followingdatabases:
PubMed, Ovid, the Cochrane Central Registerof Controlled Trials,
Cochrane Database of Systematic Re-views, American College of
Physicians (ACP) JournalClub, and Database of Abstracts of Reviews
of Effects.Search words included shoulder, impingement,
rotatorcuff, rehabilitation, physical therapy, physiotherapy, or
exer-cise. The combined search produced 12,428 articles. Thetitles
and abstracts were each reviewed to identify those of1
mailto:[email protected]
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2 Kuhn J Shoulder Elbow Surg-/- 2008
ARTICLE IN PRESSinterest for in-depth review. Eighty articles
were retrieved,and their bibliographies were also reviewed to
identify otherpotential articles for inclusion.
From 80 manuscripts, 11 met the inclusion
crite-ria2,8,9,11,17,24,33,34,37,38,39 and were then reviewed
usinga standard worksheet.36 The worksheet uses evidence-based
guidelines to assist in the systematic review of ortho-pedic
literature. In addition to recording practical informa-tion, such
as title, author, journal, citation, primary andsecondary
hypotheses, type of study, and results, the work-sheet also assists
in identifying and recording sources ofbias, methods of
randomization, follow-up, and other detailsimportant in assessing
the methodologic design and identify-ing the level of evidence.
Each of these 11 manuscripts wasthen reviewed in an evidence-based
medicine journal clubby 9 faculty members and fellows familiar with
evidence-based medicine concepts.
The Methods and Results sections of these 11 manuscriptswere
then reviewed. Data regarding study demographicsand methodology
were extracted and placed in tableform. Individual outcomes for
pain, range of motion,strength, and function were catalogued.
Outcomes were as-sessed for the effectiveness of each treatment
over time (intra-group evaluation) and when different treatments
werecompared (between-group comparisons). Statistical out-comes
were recorded when available. Clinical significancewas found when
statistical significance was P < .05 and theeffect size or
difference between treatments was 20% ormore. Elements of the
physical therapy programs used byeach study were collected and
divided into five major cate-gories: range of motion, flexibility
and stretching, strength-ening techniques, therapist-driven manual
therapy,modalities, and schedule, which were placed in tableform.
This information was used to develop a synthesizedphysical therapy
program.RESULTS
Demographics
Patient demographics are summarized in Table I.Patient ages
(range, 42-58 years) were typical for im-pingement syndrome.32
Workers compensation datawere frequently missing, yet because these
studiescame from a number of different countries with differ-ent
benefits and incentives for work-related injuries,these data may
not translate across studies. The diag-nosis of impingement in all
11 studies was made byphysical examination using the impingement
signs ofNeer32 or Hawkins,18 or both. Confirmation with
animpingement test, consisting of an injection of lido-caine in the
subacromial space with elimination ofthe pain with the impingement
sign,32 was used in 5studies.Methodology
These 11 randomized trials were not without meth-odologic flaws
(Table II). Randomization methodswere described in 6 of the
studies, 5 of which wereideal. Only 3 reported using blinded,
independent ex-aminers for follow-up data collection. Eleven
studiesused validated outcome measures. Brox et al8,9 useda Neer
shoulder score; however in 1993 when thestudy was done, this score
was likely the best avail-able. Follow-up was surprisingly good for
10 of thestudies, and only 1 study33 reported follow-up of lessthan
90%.
Components of the exercise programs
The components of the exercise programs hadsome variation, yet
the general principles were seenthroughout the different studies
(Table III). These com-ponents included frequency, range of motion,
stretch-ing or flexibility, strengthening, manual
therapy,modalities, and others. These data are reviewed lateras the
synthesized protocol is developed.
Exercise as a treatment for impingement
The data from this systematic review strongly sug-gest that
exercise improves symptoms in patients withimpingement syndrome
(Tables IV-VII), a finding thatagrees with other systematic
reviews.1,12,15,16 Super-vised exercise, home exercise programs,
exercise as-sociated with manual therapy, and exercise
aftersubacromial decompressions demonstrated improve-ments in pain
in all but 1 study11 (Table V). Statisticalanalysis comparing
preexercise pain with postexer-cise pain was performed in 6 of the
11 studies. In 5of 6 studies, exercise produced statistically
significantand clinically significant reductions in
pain.2,9,24,35,38
Conroy et al11 found significant improvements in painwhen
exercise was combined with manual therapy butnot for exercise
alone. Interestingly, they documentedsignificant statistical and
clinical improvements inrange of motion for both groups.11 It is
important tonote that this study followed up patients for only
3weeks, which may have been responsible for the re-duced effect of
the treatment. Two studies used con-trols, either nontherapeutic
laser treatment8,9 or notreatment.24 Both demonstrated
statistically significantimprovements in pain for exercise compared
with con-trol groups. The difference in effect size for the
Lude-wig et al24 cohort was only 15%, which did notreach our
definition of clinical significance.
Other outcome parameters
Strength was not shown to improve significantly forexercise
alone2,17,38 but did improve when exercisewas combined with manual
therapy in 1 study2 (TableVI).
Function improved with exercise in most stud-ies2,11,17,24,33
(Table VII), a finding that was statisti-cally significant in the 4
studies that analyzed theirresults. These improvements were
clinically significant
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Table I Patient demographics.
First author(year), country
Averageage, year Gender
WorkersComp
Symptomduration Diagnosis How Dx made Treatment groups
Bang (2000),USA
43 30M, 22F NR Group 1: 5.6mons;
Impingement Physical examimpingement signs
Group 1: Standard exercises
Group 2: 4.4mons
Group 2: Standard exercises +manual therapy
Brox, (1993,1999),Norway
48 66M, 59F 58% on sick leave 1-2 years Impingement Physical
examimpingement signs and+impingement test
Group 1: ArthroscopicSAD + post-op supervised exercises
Group 2: Supervised exercisesGroup 3: Placebo laser
Conroy (1998),USA
53 8M, 6F NR 26 weeks Impingement Physical examimpingement
signs
Group 1: Standard exercisesGroup 2: Standard exercises +
manual therapyHaahr (2005),
Denmark44.4 26M, 58F 73% 6 mons-3
yearsImpingement Physical exam impingement
signs and +impingement testGroup 1: Physiotherapy
treatments (19 sessions/12 weeks)Group 2: Arthroscopic SAD +
post-op HEPLudewig (2003),USA
49 67 M, 0F All M constructionworkers/claims NR
NR Impingement 6biceps tendonitis
Physical exam impingementsigns/biceps signs
Group 1: Instruction in HEPGroup 2: No intervention
Peters (1997),Germany
58 46M, 26F NR >6 mons Impingement Physical exam
impingementsigns and +impingementtest + ultrasound
Group 1: SAD (47% arthroscopic,53% open) + post-op exercise
program
Group 2: Physical therapyRahme (1998),Sweden
42 19M, 23F 76% on sick leave Almost 4years
Impingement Physical exam impingementsigns and +impingement
test
Group 1: Open SADGroup 2: Standard physiotherapy
programSenbursa(2007), Turkey
49 NR NR NR Impingement Physical exam impingementsigns
Group 1: Instruction in HEPGroup 2: HEP + manual and other
therapy
Walther (2004),Germany
51 34M, 26F NR 27.3 mons Impingement Physical
examination,impingement signs and+impingement test,radiographs,
ultrasound
Group 1: HEPGroup 2: Supervised therapyGroup 3: Functional
brace
Werner (2002),Germany
52 20M, 20F NR 27 mons Impingement Clinical findings,
radiographs,ultrasound
Group 1: HEPGroup 2: Supervised therapy
F, Female; HEP, home exercise program; M, male, NR, not
reported; SAD, subacromial decompression; USA, United States of
America.
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Table II Study methodology
First author(year) No.
Randomizationmethod
Independentexaminer
Outcomesof interest Follow-up Follow-up %
Bang (2000) 52 NR Yes Pain VAS a 60 days 96%StrengthPerception
of functionFunctional Assessment
Questionnairea
Brox (1993, 1999) 125 Random permutedblocks
Yes Neer Shoulder Score 3 and 6 mons (1993)and 2.5 years
(1999)
90% at 2.5 y
Pain Scale 1-9Emotional Distress on
Hopkins Scale a
Conroy (1998) 14 NR Yes Pain VAS a 3 weeks 93%Impingement
SignsAROMFunctional Skills
Haahr (2005) 90 Sealed envelope No Constant Scorea 12 mons
91%Pain VASa
FunctionLudewig (2003) 67 Investigator blindly
selected 1 of 2slips of paper
NR Shoulder RatingQuestionnaire
10 weeks 92%
SPADIa
Peters (1997) 72 NR No Modified Constant Scorea 1, 2, 3, and 4
years 86% for 1 y;67% for4 years
Rahme (1998) 42 Blockedrandomization
NR Pain VASa 1 year 93%
Pain with two maneuversSenbursa (2007) 30 NR NR Pain VASa 4
weeks 100%
ROMFunctional Assessment
QuestionnaireWalther (2004) 60 NR NR Constant Scorea 6 and 12
weeks NR
Pain VASa 100%?Werner (2002) 40 Drawing lots NR Constant Scorea
6 and 12 weeks NR
Pain Score 100%?Function ScoreMovement Score
AROM, active range of motion; NR, not reported; ROM, range of
motion; SPADI, Shoulder Pain and Disability Index; VAS, visual
analog scale.aOutcomes of interest that have been validated.
4 Kuhn J Shoulder Elbow Surg-/- 2008
ARTICLE IN PRESSin 2 of these studies.2,11 Interestingly, Brox
et al9 re-ported reduced functional status in a group that
under-went supervised exercise.
These results suggest that exercise therapy is highlyeffective
at reducing pain and likely effective at im-proving function. These
effects may be augmentedwith manual therapy or acromioplasty.
Home vs supervised exercise
Two studies compared the effects of supervisedphysical therapy
with a home exercise program.38,39
Although both groups improved, neither study coulddemonstrate
statistically significant differences be-tween the 2 exercise
methods. No prestudy poweranalysis was described, and as such, this
findingmay be the result of a type II statistical error.Manual
therapy
The effect of manual therapy (joint and soft tissuemobilization)
was evaluated in 3 studies.2,11,35 Ineach study, pain relief was
statistically better when pa-tients received manual therapy. In 2
of the studies, theeffect size was clinically significant2,11; in
the other,35
the difference in the effect size was 11%, which didnot reach
clinical significance.
-
Table III Components of the exercise programs in the various
studies
First author (year) Frequency Range of
motionStretching/flexibility Strengthening
Jointmobilization/
manual therapy Modalities Other
Bang (2000) 2/wk for 3 wks NR 1.Anterior shouldercorner
stretch
Elastic band: 3 sets of10 reps
Study group receivedmanual therapytechniquesspecifically
appliedto movementlimitations in theupper quarterinvolving
theshoulder and spine
NR NR
2.Posterior shouldercrossed bodyadduction stretch
1.Flexion
Each stretch hold 30secs with 10-secrest, repeat 3
2. Scaption
3. Rowing4. Horizontal
extension-externalrotation 60-sec restbetween sets
5. Seated press up6. Elbow push-up + 25
reps or to fatigueBrox (1993) Daily: supervised 2/
wk withunsupervised otherdays at home.Training continued3-6
mons.
To eliminategravitational forcesand start theexercises the
armwas suspended ina sling fixed to theroof.
Relaxedrepetitivemovements (firstrotation,
thenflexion-extension,and finallyabduction-adduction) wereperformed
for aboutan hour in dailytraining sessions.
NR Resistance wasgradually added tostrengthen the shortrotator
and thescapular stabilizingmuscles
NR NR Three lessons on theanatomy andfunction of theshoulder,
painmanagement, andergonomics
(Continued )
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Table III. Components of the exercise programs in the various
studies (Continued )
First author (year) Frequency Range of
motionStretching/flexibility Strengthening
Jointmobilization/
manual therapy Modalities Other
Conroy (1998) Supervised 3/wk for3 wks; instructionsto exercise
at home3/d.
Pendulum exerciseand posturalcorrection with painfree range
Cane-assisted flexionand externalrotation, towel-assisted
internalrotation, andnoninvolved arm-assisted
horizontaladduction
1. Chair press Study group received15 min of jointmobilization
styledafter Maitland andFoley, with inferiorglide, anteriorglide,
posteriorglide, long axistraction, oscillatorypressure
Hot packs for 15 min Soft tissuemobilization at endof treatment
for 10min; patienteducation
2. Internal andexternal rotationisometrics
3. Exercises to restoresynchronousscapulohumeralrhythm
Haahr (2005) 3/wk for 2 wks then2/wk for 3 weeksthen 1/wk for
7wks with dailyactive homeexercises then homeprogram 2-3/wk
Active trainingof periscapularmuscles (rhomboid,serratus,
trapezoid,levator scapulae,and pectoralisminor muscles)
NR Strengthening of thestabilizing musclesof the shoulder
(therotator cuff)
NR Heat, cold packs
Ludewig (2003) Home therapyinstruction. Dailyhome
stretching,strengthening 3/wk.
A muscle relaxationexercise for uppertrapezius. Patientraises
arm overhead in scapulaplane withoutshrugging.Performed infront of
mirroror by holdingupper trapeziuswith oppositehand
Corner stretchfor pectoralisminor, crossedbody adductionfor
posteriorshoulder. Hold30 secs,5/stretch/d
1.Supine protractionof the scapula withhand weight
NR NR NR
(Continued )
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Table III. Components of the exercise programs in the various
studies (Continued )
First author (year) Frequency Range of
motionStretching/flexibility Strengthening
Jointmobilization/
manual therapy Modalities Other
2. Humeral externalrotation withTheraBand, startingwith arm
close tobody andincreasingabduction angleover time. 3 10reps for wk
1, 315 reps for wk 2,3 20 reps for wk3, then increaseresistance
Peters (1997) 2 weeks intensivephysical therapyand instruction
inhome program
Normalizationof muscletension, liftingarms
withoutshrugging.Instruction inposture exercisesand
maintainingposture for activitiesof daily living
Improve mobilityof adjacentjoints. Stretchthe posteriorand
anteriorshoulder
Strengthen shortrotators in pain-freeregion, strengthenscapular
stabilizers
Manual therapy: paintraction,mobilization afterrelaxation
therapy.
Ultrasound,iontophoresis,phonophoresis,heat
Muscle relaxationtechniques,transverse
frictionmassage,hydrotherapy,subacromialinjectable steroidsup to
3
Rahme (1998) 2-3/wk. Intervalsbetween treatmentswere
successivelyincreased as thepatient becamemore familiar withthe
object of theexercises
Unloaded movementsof the shoulder.Measures tonormalize
thescapulohumeralrhythm and toincrease posturalawareness
NR Strengthening theshoulder musclesand
endurancetraining.Submaximaltraining of therotator cuff
NR NR Information onfunctional anatomyand biomechanicsof the
shoulder.Advice on how toavoid positions forwear and tear
ofsubacromialstructures
Senbursa (2007) Group 1: homeprogram 7/wk
Active ROM Stretching Strengthening of therotator cuff
muscles,rhomboids, levatorscapulae, serratusanterior with
elasticbands
Deep friction massageon supraspinatus,radial nervestretching,
scapularmobilization,glenohumeral jointmobilization
Ice Proprioceptiveneuromuscularfacilitationincluding
rhythmicstabilization andhold-relax
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Table III. Components of the exercise programs in the various
studies (Continued )
First author (year) Frequency Range of
motionStretching/flexibility Strengthening
Jointmobilization/
manual therapy Modalities Other
Group 2: Supervisedexercises andmanual therapy3/wk for 4 wkswith
home exercises
Walther (2004) Group 1: Hometherapy4 visits withtherapist
forinstruction, 5/wkfor 10-15 mins
Pendulum exercisesholding 1-kg handweight for 3-5 mins
Lateral neckstretching, posteriorshoulder stretch bypulling arm
acrossfront of body towardfloor; hold stretchfor 15 sec,
repeat3
Isometric seatedTheraBandexercises for pullingshoulder
bladesback, anddownward; hold 8-10 sec; repeat 10
NR NR Coopercare-Lastrapfunctional shoulderbrace in one
group
Group 2: Supervisedtherapy 2-3/wk
Seated TheraBandresisted humeralexternal rotation,upright rows;
repeat10
Standing TheraBandresisted shoulderextension; repeat10
Werner (2002) Group 1: Hometherapy4 visits forinstruction,
5/wkof 10-15 mins
Pendulum exercisesholding 1-kg handweight for 3-5 mins
Lateral neckstretching, posteriorshoulder stretch bypulling arm
acrossfront of body towardfloor. Hold stretchfor 15 secs,
repeat3
Isometric seatedTheraBandexercises for pullingshoulder
bladesback, anddownward; hold 8-10 secs; repeat10
NR NR NR
Group 2: Supervisedtherapy30 visitseach lasting 30 minsover 12
wks withstrengthening of therotator cuff.
Seated TheraBandresisted humeralexternal rotation,upright rows;
repeat10
Standing TheraBandresisted shoulderextension;repeat10
NR, not reported; ROM, range of motion.
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Table IV Outcomes for paina
Author(year)
Outcomescale Groups
Intragroupdifference
Statisticallysignificant
Clinicallysignificant
Between-groupdifference
Statisticallysignificant
Clinicallysignificant?
Bang (2000) 9 pain-related questions,each with 100 mmVAS total
painscore 0- 900 mm
Exercise 196.5 P < .05 Yes 204.9 (favors exercise+ manual
therapy)
P 50%reduction in RP, NP, AP
Supervisedexercises
(RP) 49% NR NA Supervised exercisevs SAD
NS No
(NP) 51% 12% favoring SAD(AP) 49%
ArthroscopicSAD withpost-opexercise
(RP) 63% Supervised exercisevs placebo 28%favoring exercise
P
-
Table IV. Outcomes for paina (Continued )
Author(year)
Outcomescale Groups
Intragroupdifference
Statisticallysignificant
Clinicallysignificant
Between-groupdifference
Statisticallysignificant
Clinicallysignificant?
(AP) 25%Conroy
(1998)Maximum pain over
past 24 hours on100 mm VAS
Exercises 2.21 P .823 No 32.07 (favorsexercise +
manualtherapy)
P .008 Yes
Exercises +manualtherapy
20.7 P .005 Yes
Haahr(2005)
VAS part of CS,0-15 mm
Exercises 3.7 NR NA 0.1 P .93 No
ArthroscopicSAD
3.6
Ludewig(2003)
VAS work-relatedpain score, 0-10
Exercise 2 P < .001 Yes 1.5 P 50% painreduction at 6 mons
Not assessed NA 24% more patients had>50% pain relieffavoring
surgerygroup.
NS NA
SAD withpost-op exercise
57% had >50%pain reductionat 6 mons
Senbursa(2007)
Pain VAS, 100 mm HEP 36 P
-
Table
IV.O
utco
mes
forp
aina
(Con
tinue
d)
Auth
or
(year)
Outc
om
esc
ale
Gro
ups
Intr
agro
up
dif
fere
nce
Sta
tist
ically
signifi
cant
Clinic
ally
signifi
cant
Betw
een-g
roup
dif
fere
nce
Sta
tist
ically
signifi
cant
Clinic
ally
signifi
cant?
Pain
atre
st,ni
ght
,lo
adre
cord
edSu
perv
ised
exer
cise
sBr
ace
Wer
ner
(2002)
Com
pone
ntof
CS,
0-3
5po
ints
HEP
App
rox
9-p
oint
impr
ovem
ent
No
stat
istic
alan
alys
isN
AM
inim
aldi
ffere
nces
betw
een
gro
ups
NRb
NA
Supe
rvis
edth
erap
yA
ppro
x8-p
oint
impr
ovem
ent
AP,
activ
itypa
in;C
S,C
onst
antS
core
,F/U
,fo
llow
-up;
HEP
,hom
eex
erci
sepr
ogra
m;N
A,n
otap
plic
able
;N
P,ni
ght
pain
;NR,
notr
epor
ted;
NS,
nots
igni
fican
t;N
SP,N
eersc
ale
forpa
in;R
P,re
stpa
in;S
AD
,sub
-ac
rom
iald
ecom
pres
sion
,VA
S,vi
sual
anal
ogsc
ale.
aA
utho
rsus
eda
variet
yof
scal
esto
mea
sure
pain
.In
tragro
updi
ffere
nces
dete
ctth
eef
fect
ofth
epa
rtic
ular
prot
ocol
over
time
and
com
pare
pret
reat
men
twith
stat
usat
follo
w-u
p.Be
twee
n-gro
updi
ffere
nces
are
repo
rted
fordi
ffere
nces
betw
een
the
diffe
rent
prot
ocol
s.C
linic
ally
signi
fican
tfind
ings
occu
rif
the
diffe
renc
esar
est
atis
tical
lysi
gni
fican
tand
the
mag
nitu
deof
the
diffe
renc
eis
20%
orm
ore.
bS
tatis
tical
lyth
edi
ffere
nces
betw
een
the
indi
vidu
alco
mpo
nent
s(o
fthe
Con
stan
tSco
re)w
ere
notd
iffer
entb
etw
een
the
two
gro
ups.
N
oP
valu
esgiv
en.
J Shoulder Elbow Surg Kuhn 11Volume -, Number -
ARTICLE IN PRESSBracing
One study38 evaluated bracing without exercise.The authors chose
a functional shoulder brace that isindicated for the treatment of
chronic tendinitis or bur-sitis. The patients randomized to the
brace group hadsignificant improvements in pain over time, with
out-comes that were statistically indistinguishable fromthe home
exercise and supervised exercise groups.Results for strength were
significantly and clinicallybetter for the brace group compared
with the 2 exer-cise groups.38Acromioplasty with exercise vs
exercise alone
Four in 5 reports compared acromioplasty with ex-ercise vs
exercise alone.8,9,17,33,34 All studies failedto show statistically
significant differences betweenthe 2 treatments. Rahme et al34
reported that after 6months, 12 of 21 patients (57%) randomized to
the ex-ercise group opted for surgery and were consideredfailures
of nonoperative treatment. Brox et al8 fol-lowed up their cohort
for 2.5 years and found 11 of50 patients (22%) randomized to the
exercise treat-ment alone ultimately came to surgery and were
con-sidered failures.DISCUSSION
This systematic review of randomized controlled tri-als
evaluates the best evidence for the role of exercisein the
treatment of rotator cuff impingement syndrome.The general findings
from this study are:
1. exercise is effective as a treatment for thereduction of
pain,
2. home exercise programs may be as effective assupervised
exercise, yet
3. the effect of exercise may be augmented withmanual
therapy,
4. acromioplasty with postoperative exercise alsoproduces
improvements in symptoms, and
5. there may be a role for bracing; however, thisinteresting
approach requires further study.
Interestingly, each study had variations in the com-ponents of
the physical therapy program, and as a re-sult, there was a
substantial amount of variation in theeffectiveness of the
individual programs. In studiesevaluating patients with rotator
cuff disease, the phys-ical therapy protocol represents a critical
confoundingvariable; which, if not controlled, may have a
substan-tial effect on outcome and then serve as a source
ofperformance bias.
This supports the development of a gold standardrehabilitation
protocol. The utility of a standardized,accepted, evidence-based
rehabilitation protocol fortreating rotator cuff impingement is
apparent. First,
-
Table V Range of motion outcomesa
Author Outcome scale GroupsIntragroupdifference
Statisticallysignificant
Clinicallysignificant
Between-group
differenceStatisticallysignificant
Clinicallysignificant
Bang (2000) NA NA NA NA NA NA NA NABrox (1993) ROM score
part of Neerscore, 0-25points
Supervisedexercises
NR NA NA NR NA NA
Arthroscopic SADwithpost-op exercise
Laser placeboBrox (1999) ROM score
part of Neerscore, 0-25points
Supervisedexercises
NR NA NA NR NA NA
Arthroscopic SADwithpost-op exercise
Laser placeboConroy (1998) ABD, EL, ER, IR
measured indegrees
Exercise Both groupssignificantlyimproved, datacombined
Each ROMmeasure
Yes Differences in allplanes
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Table V. Range of motion outcomesa (Continued )
Author Outcome scale GroupsIntragroupdifference
Statisticallysignificant
Clinicallysignificant
Between-group
differenceStatisticallysignificant
Clinicallysignificant
Senbursa (2007) ROM measuredwith goniometerin flexion, ABD,ER,
and IR
HEP Range of motionat flexion,abductionand externalrotationin
the manualtherapy groupimprovedsignificantlywhile ROM inthe
exercisegroup did not
No No data available NA NA NA
HEP withmanual therapy
P < .05
Walther (2004) Component ofCS,. 0-40 points
HEP All improvedapproximately4 points
NR NA Minimaldifferencesbetween groups
NS No
Supervisedtherapy
BraceWerner (2002) Component of CS,
0-40 pointsHEP Approx 5-point
improvementNo statistical
analysisNA Minimal
differencesbetween groups
Not differentb NA
Supervisedtherapy
Approx 2-pointimprovement
ABD, abduction; CS, Constant Score, EL, elevation, ER, external
rotation; HEP, home exercise program; IR, internal rotation; NA,
not assessed; NR, not reported; ROM, range of motion; SAD,
subacromial de-compression.aRange of motion data are lacking in
most studies. Intragroup differences detect the effect of the
particular protocol over time and compare pretreatment with status
at follow-up. Between-group differences arereported for differences
between the different protocols. Clinically significant findings
occur if the differences are statistically significant and the
magnitude of the difference is 20% or more.bStatistically the
differences between the individual components (of the Constant
Score) were not different between the two groups.No P values
given.
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Table VI Outcomes-strengtha
Author Outcome scale GroupsIntragroupdifference
Statisticallysignificant
Clinicallysignificant
Between roupdiffer ce
Statisticallysignificant
Clinicallysignificant
Bang (2000) Abduction, externalrotation, internalrotation
compositescore (Newtons, N)
Exercise 24.8 N No No A significantdifference ex
tedpretreatmenfavoring exe ise +manual thera y grouprendering po
treatmentcomparisons eaningless
NA NA
Exercise + manualtherapy
93.0 N P < .05 No
Brox (1993) NA Supervised exercises NA NA NA NA NA
NAArthroscopic SADLaser placebo
Brox (1999) NA Supervised exercises NA NA NA NA NA
NAArthroscopic SADLaser placebo
Conroy (1998) NA NA NA NA NA NA NA NAHaahr (2005) Subscore of
CS, 0-25 points Exercise 3.2 NR NA 0.1 (favors sur ry) P .96 No
Arthroscopic SAD 3.3Ludewig (2003) NA NA NA NA NA NA NA NAPeters
(1997) NA NA NA NA NA NA NA NARahme (1998) NA NA NA NA NA NA NA
NASenbursa (2007) NA NA NA NA NA NA NA NAWalther (2004) Subset of
CS HEP 0.1 NR NA 4.0
(favoring bra e vssupervised th rapy)
HEP vs supervisedexercise; NS
Yes
0-20 points Supervised therapy 1.4 Brace vs othertreatments, P
< .05
Brace 2.6Werner (2002) NA NA NA NA NA NA NA NA
CS, Constant Score; HEP, home exercise program; NA, not
assessed; NR, not reported; NS, not significant; SAD, subacromial
decompression.aStrength was measured in 1 study and the strength
subset of the Constant Score was used in two others. Walther et
al38 found that wearing a brace proved strength more than exercise,
an effect that wasstatistically and clinically significant.
Intragroup differences detect the effect of the particular protocol
over time and compare pretreatment with status a llow-up.
Between-group differences are reported for dif-ferences between the
different protocols. Clinically significant findings occur if the
differences are statistically significant and the magnitude of the
diffe nce is 20% or more.
14
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Table VII Outcomesfunctiona
AuthorOutcome
Scale GroupsIntragroupdifference
Statisticallysignificant
Clinicallysignificant
Betwee -groupdiffe ence
Statisticallysignificant
Clinicallysignificant
Bang (2000) Functional AssessmentQuestionnaire, 9questions, 5
pointseach, 45 pointstotal
Exercise 4.74 P < .05 No 4.96(favorin manualtherapy
P < .0893 No
Exercise + manualtherapy
9.89 P < .05 Yes No
Brox (1993) Subset of Neerscore, 0-30 points
Supervised exercises -6 NR NA 10.0 (Fav ing SAD) NR NA
Arthroscopic SAD +exercise
4
Laser placebo 1Brox (1999) % of patients
who could: Carry 5kg at side/andtake downsomethingfrom wall
cupboard
Supervised exercises 47% and 41% NR NA Supervise Exercisevs
SAD
Take downfrom cupboard,
P < .05
Yes
14% and %favoring AD
Arthroscopic SAD +exercise
61% and 66% Supervise exercisevs place o 29%and 16
favoringexercise
P < .01 Yes
Laser placebo 18% and 25% SAD vs pl ebo 43%and 41
favoringSAD
P < .001 Yes
Conroy (1998) Nonvalidatedquestionnairere ability to reachin 3
planes
Exercise Both groupssignificantly
improved, datacombined; 1/2
patientsreported
improvements in
P < .038 Yes No differe cesbetwee groups
No No
Exercise + manualtherapy
reaching behindhead, reaching
overhead, reachingto spinous process
Haahr (2005) Subset of CS, 0-20points
Exercise 4.5 NR NA 0.7(favorin exercisegroup)
P .46 No
(Continued )
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g)
or
d
25S
db
%
ac%
nn
g
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Table VII. Outcomesfunctiona (Continued )
AuthorOutcome
Scale GroupsIntragroupdifference
Statisticallysignificant
Clinicallysignificant
Between-groupdifference
Statisticallysignificant
Clinicallysignificant
Arthroscopic SAD +exercise
3.8
Ludewig (2003) Work RelatedDisability VAS,0-10 points
Exercise 1.6 P < .001 No 1.5(favoring exercisegroup)
P < .05 No
No intervention 0.1Peters (1997) Activity Score
from Modified CS,0-10 points
Exercise 0 at 1 year No statistical analysis NA 2 points at 1
year No statistical analysis NA
0 at 4 years 2 points at 4 yearsSAD + exercise 2 at 1 year
2 at 4 yearsRahme (1998) NA NA NA NA NA NA NA NASenbursa (2007)
Neer Functional
AssessmentQuestionnaire
HEP NR NR NA There werestatisticallysignificantdifferencesamong
the groupsin function(favoring HEP +manual therapy)
P < .05 Unknown, datanot reported
HEP + manual therapyWalther (2004) NA NA NA NA NA NA NA NAWerner
(2002) NA NA NA NA NA NA NA NA
CS, Constant Score; HEP, home exercise program; NA, not
assessed; NR, not reported; SAD, subacromial decompression; VAS,
visual analog scale.aFunction was assessed in a variety of ways.
Intragroup differences detect the effect of the particular protocol
over time and compare pretreatment to status at follow up.
Between-group differences are reported fordifferences between the
different protocols. Clinically significant findings occur if the
differences are statistically significant and the magnitude of the
difference is 20% or more.
16
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ARTICLE IN PRESSphysicians and therapists will know that their
patientsare receiving the best available rehabilitation pro-gram
that has the greatest likelihood of improvingthe patients condition
and avoiding surgery. Second,an accepted gold standard
rehabilitation protocolwould reduce confounding variables and
perfor-mance bias in research studies. This will allow com-parison
of results between studies. A gold standardprotocol would also
serve as a control allowing thestudy of modifications, such as
modalities, adding ex-ercises or other treatments, eliminating
specific com-ponents, and clarifying the effect of the
investigatedtreatment. To assist with this, we synthesized the
proto-cols described in these reviewed articles to developa
standard rehabilitation protocol.
Data from the rehabilitation protocols used in thesearticles
were compiled in table format (Table III). Infor-mation about
specific components was extracted, in-cluding frequency, range of
motion, flexibility,strengthening, manual therapy, and modalities,
andthen synthesized into a comprehensive protocol(Appendix I).
Different authors had their patients perform exer-cises at
different frequencies, ranging from twiceweekly2 to daily.8,9,24,35
Some authors used super-vised therapy with greater frequency early,
progress-ing toward home exercises later.17,34
On the basis of this information, we suggest that pa-tients have
supervised therapy 2 to 3 times each week,with the addition of
manual therapy (see subsequenttext). Patients who no longer need
manual therapyand have developed proficiency in the protocol canbe
progressed to a home exercise program. Rangeof motion exercises and
flexibility should be per-formed daily. Strengthening should be
performed 3times weekly.
Range of motion exercises were described by mostauthors.
Pendulum exercises were used in the cohortsof Conroy et al,11
Walther et al,38 and Werner et al.39
Postural exercises, such as shrugs, were used by Con-roy el
al,11 Peters et al,33 and Rahme et al.34 Activeassisted range of
motion was described witha cane,11 with the arm suspended,8,9 or
with the otherarm.24 Brox et al8,9 recommended active assisted
mo-tion with the arm suspended in a sling for rotation,
flex-ion-extension, and abduction-adduction. Ludewig etal24 had
patients stand before a mirror and work onshoulder elevation
without shrugging. If a mirror wasnot available, they had the
patient place the unin-volved hand on the contralateral trapezius
to providefeedback, making sure the upper trapezius remainedrelaxed
during elevation of the arm.24 Haahr et al17
described active training of the periscapular muscles(rhomboid,
serratus, trapezoid, levator, and pectora-lis minor).
The conclusion from this information is that all pa-tients may
begin their range of motion work with pos-tural exercise, such as
shrugs, and shoulder retraction.Glenohumeral motion should begin
with pendulum ex-ercises, progress to active assisted motion, then
to ac-tive motion as comfort dictates. Active assisted motionmay be
performed with a cane, suspended with pul-leys, or with the
uninvolved arm. Active motion maybe performed in front of a mirror
or using the oppositehand on the trapezius to prevent hiking of the
shoul-der, as described by Ludewig et al.24
Flexibility exercises generally were performed foranterior and
posterior shoulder tightness.2,11,24,38,39
In addition, Conroy et al11 had patients performcane-assisted
stretching in flexion and external rota-tion. A variety of
techniques were described for poste-rior shoulder stretching, most
commonly cross-bodyadduction.2,11,24,38,39 Interestingly, McClure
et al27
conducted a randomized trial comparing 2 differenttechniques to
stretch the posterior shoulderthesleeper stretch and the cross-body
stretchand foundthat the cross-body stretch was most effective.27
Withregard to anterior shoulder stretching, Borstad et al5
performed a randomized trial of 3 stretches designedto stretch
the pectoralis minor, consisting of unilateralself-stretch, supine
manual stretch, and sitting manualstretch. Although all patients
demonstrated gains inpectoralis minor length, they found the
unilateral self-stretch (performed in a corner or on a door jamb)
pro-duced the greatest effect.5 Most authors recommen-ded holding
each stretch for 15 or 30 seconds andrepeating 3 to 5 times, with a
10-second rest betweeneach stretch.2,24,38,39
These data indicate that stretching should be per-formed daily
and should include anterior shoulderstretching, performed by the
patient in a corner ordoor jamb, and posterior shoulder stretching,
usingthe cross-body adduction technique. Each stretchshould be held
for 30 seconds and repeated 5 times,with a 10-second rest between
each stretch. Canestretching in forward elevation and external
rotationmay also be used in a similar fashion.
Some authors did not provide much detail regard-ing their
programs for strengthening, other than re-porting that muscles of
the rotator cuff and scapulastabilizers were involved.17,34,35
Others were morespecific in describing their exercise programs. For
ex-ample, strengthening exercises include shoulder flex-ion,2
extension,38,39 scaption,2 rows,2,38,39 internalrotation of the
adducted arm,2,11,24 and external rota-tion of the adducted
arm.2,11,24,38,39
Most authors used elastic bands.2,24,35,38,39 Mostallowed joint
movement for isotonic exercise2,24,35;others relied on static
resistance with isometric musclecontraction.11,38,39
Each exercise was performed at 3 sets of 10 repe-titions with a
60-second rest between each set2 or 3sets of 10 the first week,
followed by 3 sets of 15 thesecond week, followed by 3 sets of 20
the third
-
18 Kuhn J Shoulder Elbow Surg-/- 2008
ARTICLE IN PRESSweek; then increasing TheraBand (Hygenic Corp,
Ak-ron, OH) resistance was used.24
Scapular stabilizing exercises included the seatedpress up2,11
and the elbow push-up plus2 and wereperformed on a chair or stable
bench. Each was per-formed as 1 set of 25 repetitions.2 Supine
push-upplus with a hand weight was used by Ludewig et al.24
The synthesis of these reports clearly shows thatstrengthening
exercises should focus on the rotatorcuff and scapular stabilizing
muscles. Rotator cuffstrengthening should involve the following
exerciseswith the TheraBand: internal rotation with arm ad-ducted
to side, external rotation with arm adductedto side, and scaption,
if there is no pain associatedwith the exercise. Scapular
stabilizer strengtheningshould include chair press, push-up plus
(prone usingbody weight or supine with hand weight), and
uprightrows using an elastic band. Combination strengthen-ing while
standing using elastic bands should includeforward elevation and
extension. Each exerciseshould be performed as 3 sets of 10
repetitions, withincreases in elastic resistance as strength
improves.
Manual therapy has been shown to be effective ataugmenting the
effect of exercise in relieving symp-toms of the impingement
syndrome.2,11,35 Manualtherapy includes a variety of techniques,
includingjoint mobilization, as described by Maitland25 andFoley et
al,14 and soft tissue mobilization (effleurage,friction, and
kneading techniques).11,17
Because the evidence favors the use of manual ther-apy, it
should be included in a standard evidence-based protocol. Like
exercise, the different varied as-pects of manual therapy are
worthy of further studyto identify which components are effective
in treat-ment. Manual therapy requires working with a physi-cal
therapist. During the period that patients arereceiving manual
therapy, they should be thoroughlyinstructed in the exercise
program. Patients who nolonger need manual therapy should be
progressedto a home exercise program.
Ultrasound as a therapeutic modality has beenevaluated by a
number of studies. It is beyond thescope of this review to evaluate
the effectiveness of ul-trasound; however, multiple systematic
reviews statethat ultrasound is of little value in treating
patientswith shoulder pain.16,28,37 Conroy et al11 and Haahret al17
both used heat in their protocols. Haahr et al17
and Senbursa et al35 used ice. There are no data for oragainst
the use of cold or heat as a modality; thus, theiruse must be
optional at this point. It is clear, however,that ultrasound has no
value in a rehabilitation proto-col for the impingement
syndrome.
With this information we offer a gold standard re-habilitation
protocol (Appendix I). It is important to rec-ognize that this
evidence-based protocol is not withoutlimitations. The protocol
described is a collection offeatures that have demonstrated a
reduction in symp-toms for impingement syndrome in randomized
con-trolled trials. Some components in these studies maybe
unnecessary. Other features, which may be benefi-cial, may not be
included. This may be reflective of an-other limitation of this
study; namely, the diagnosis ofimpingement syndrome is based on a
provocative testdesigned to produce pain in the subacromial
space.32
The Neer impingement sign32 and the Hawkins im-pingement sign18
may be imperfect tools to diagnoserotator cuff disease because they
both have relativelypoor specificities.19
It could be argued that impingement syndrome isnot a diagnosis
at all; but rather, is the finding of a pro-vocative physical
examination test that could be pro-duced by a variety of
subacromial pathologies,including subacromial bursitis, bursal
sided partial ro-tator cuff tears, biceps tendinitis, scapular
dyskinesis,a tight posterior capsule, and postural
abnormalities,among others. As a result, the protocol proposed
inthis article may need modifications to make it specificto a
particular patients anatomic diagnosis. For exam-ple, it may not be
applicable to an athlete with rotatorcuff pain due to excessive
laxity in the shoulder. In ad-dition, this protocol cannot be
extrapolated to the post-operative state, where the clinicians may
be interestedin protecting a healing rotator cuff.
Despite these limitations, this systematic review ofthe best
available evidence for exercise in the treat-ment of impingement
syndrome was able to generatea physical therapy protocol that has
been shown to beeffective in level 1 and level 2 studies. This
evidence-based protocol can be used by clinicians
treatingimpingement syndrome and can serve as a gold stan-dard to
reduce variables in future cohort and compar-ative studies to help
find better treatments for patientswith this disorder.
Thanks to members of the Vanderbilt Sports MedicineJournal Club
who assisted in reviewing the articles: KurtSpindler, Warren Dunn,
Buddy Hannah, Andrew Gregory,Paul Rummo, Tara Holmes, Mick Koester,
and KevinDoulens.REFERENCES
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2. Bang M, Deyle G. Comparison of supervised exercise with
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3. Bennell K, Coburn S, Wee E, et al. Efficacy and
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4. Bohmer AS, Staff PH, Brox JI. Supervised exercises in
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6. Brewster C, Schwab DR. Rehabilitation of the shoulder
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7. Browning DG, Desai MM. Rotator cuff injuries and treatment.
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Shoulder ElbowSurg 1997;8:102-11.
9. Brox J, Staff P, Ljunggren A, Brevik J. Arthroscopic surgery
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10. Cakmak A. Conservative treatment of subacromial
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11. Conroy DE, Hayes KW. The effect of mobilization as a
componentof comprehensive treatment for primary shoulder
impingement syn-drome. J Ortho Sports Phys Ther 1998;28:3-14.
12. Desmeules F, Cote CH, Fremont P. Therapeutic exercise and
ortho-paedic manual therapy for impingement syndrome. A
systematicreview. Clin J Sports Med 2003;13:176-82.
13. Ellenbecker TS, Derscheid GL. Rehabilitation of overuse
injuries ofthe shoulder. Clin Sports Med 1989 Jul;8:583-604.
14. Foley R, Janos S, Johnson R, Petersen C. Active and passive
move-ment testing of the extremities, spine, pelvis, and
temporomandib-ular joint. In: Petersen C, editor. Teaching manual
for physicaltherapy. Chicago: Northwestern University, Department
of Physi-cal Therapy and Human Movement Sciences; 1994. p.
3468.
15. Grant HJ, Arthur A, Pichora DR. Evaluation of interventions
for rota-tor cuff pathology: a systematic review. J Hand Ther
2004;17:274-99.
16. Green S, Buchbinder R, Hetrick S. Physiotherapy
interventions forshoulder pain. Cochrane Database Syst Rev
2003;2:CD004258.
17. Haahr JP, Ostergaard S, Dalsgaard J, Norup K, Frost P,
Lausen S,et al. Exercises versus arthroscopic decompression in
patients withsubacromial impingement: a randomised, controlled
study in 90cases with a one year follow up. Ann Rheum Dis
2005;64:760-4.
18. Hawkins RJ, Kennedy JC. Impingement syndrome in athletes. Am
JSports Med 1980;8:151-8.
19. Hegedus EJ, Goode A, Campbell S, et al. Physical
examinationtests of the shoulder: a systematic review with
meta-analysis of indi-vidual tests. Br J Sports Med
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20. Jobe FW, Moynes DR. Delineation of diagnostic criteria and a
re-habilitation program for rotator cuff injuries. Am J Sports
Med1982;10:226-9.
21. Kibler WB, McMullen J, Uhl T. Shoulder rehabilitation
strategies,guidelines, and practice. Orthop Clin North Am
2001;32:527-38.
22. Kibler WB. Rehabilitation of rotator cuff tendinopathy. Clin
SportsMed 2003;22:837-47.
23. Krabak BJ, Sugar R, McFarland EG. Practical nonoperative
man-agement of rotator cuff injuries. Clin J Sport Med
2003;13:102-5.
24. Ludewig PM, Borstad JD. Effects of a home exercise programme
onshoulder pain and functional status in construction workers.
OccupEnviron Med 2003;60:841-9.
25. Maitland G. Peripheral manipulation. London, UK:
Butterworth-Heinmann Ltd; 1991: 4752, 129-67.
26. Mantone JK, Burkhead WZ Jr, Noonan J Jr. Nonoperative
treat-ment of rotator cuff tears. Orthop Clin North Am
2000;31:295-311.
27. McClure P, Balaicuis J, Heiland D, Broersma ME, Thorndike
CK,Wood A. A randomized controlled comparison of stretching
pro-cedures for posterior shoulder tightness. J Orthop Sports Phys
Ther2007;37:108-14.28. Michener LA, Walsworth MK, Burnet EN.
Effectiveness of rehabil-itation for patients with subacromial
impingement syndrome: a sys-tematic review. J Hand Ther
2004;17:152-64.
29. Millett PJ, Wilcox RB III, OHolleran JD, Warner JJP.
Rehabilitationof the rotator cuff: an evaluation-based approach. J
Am AcadOrtho Surg 2006;14:599-609.
30. Morrison DS, Frogameni AD, Woodworth P. Conservative
man-agement for subacromial impingement syndrome. J Bone JointSurg
Am 1997;79:732-7.
31. Morrison DS, Greenbaum BS, Einhorn A. Shoulder
impingement.Orthop Clin North Am 2000;31:285-93.
32. Neer CS 2nd. Impingement lesions. Clin Orthop Relat
Res1983:70-7.
33. Peters G, Kohn D. Medium-tern clinical results after
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Unfallchir-urg 1997;100:623-9.
34. Rahme H, Solem-Bertoft E, Westerberg CE, Lundberg E,Sorensen
S, Hilding S. The subacromial impingement syndrome.A study of
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pain-generating mechanisms. Scand J Rehab Med1998;30:253-62.
35. Senbursa G, Baltaci G, Atay A. Comparison of
conservativetreatment with and without manual physical therapy for
patientswith shoulder impingement syndrome: a prospective,
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Arthrosc2007;15:915-21.
36. Spindler KP, Kuhn JE, Dunn W, Matthews CE, Harrell FE
Jr,Dittus RS. Reading and reviewing the orthopaedic literature: a
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37. Van Der Heijden GJ. Physiotherapy for patients with soft
tissue dis-orders: a systematic review of randomized clinical
trials. BMJ1997;315:25-30.
38. Walther M, Werner A, Stahlschmidt T, Woeffel R, Gohlke F.
Thesubacromial impingement syndrome of the shoulder treated
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39. Werner A, Walther M, Ilg A, Stahlschmidt T, Gohlke F.
Self-train-ing versus conventional physiotherapy in subacromial
impinge-ment syndrome [German]. Z Orthop Ihre Grenzgeb
2002;140:375-80.Appendix I Evidence-based medicine exercise
pro-tocol for impingement syndrome
General instructions: This physical therapy proto-col is based
on the best evidence demonstrating a ben-eficial effect for
exercise in the treatment of rotator cufftendonitis. It is largely
unknown if adding or eliminat-ing exercises will affect the
outcome. Range of motionand stretching exercises should be
performed daily.Strengthening should be performed 3 times
weekly.Modalities: Heat or cold, or both, may be used.Studies have
demonstrated that the results of ultra-sound treatment are no
better than results in control pa-tients, and it should not be
used.Manual therapy: Joint and soft tissue mobilizationtechniques
have been shown to augment the effect ofthe exercise program.
Initially, supervised exerciseswith manual therapy are recommended.
During thattime patients, should be instructed in a home
program.Patients can move entirely to a home program whenthey no
longer are in need of manual therapy.
-
Figure A1 Pendulum exercises: Let the arm dangle. Make 20
smallcounterclockwise circles. Make 20 small clockwise circles.
Makeforward and backward motions, then side to side motions.
Figure A2 Posture exercises: Put hands on the hips, lean back,
andhold.
Figure A3 Active training of the scapula muscles. (Left)
Shouldershrugs: Pull the shoulders up and back, and hold. (Right)
Pinch theback of the shoulder blades together using good
posture.
20 Kuhn J Shoulder Elbow Surg-/- 2008
ARTICLE IN PRESSRange of motion (Figures A1, A2, A3, A4, A5):
Pa-tients may begin their range of motion work with pos-tural
exercise such as shrugs and shoulder retraction.Glenohumeral motion
should begin with pendulum ex-ercises, progress to active assisted
motion, then to ac-tive motion as comfort dictates. Active assisted
motionmay be performed with a cane, suspended with pul-leys, or the
uninvolved arm. Active motion may be per-formed in front of a
mirror or using the opposite handon the trapezius to prevent hiking
of the shoulder.Flexibility (Figures A6 and A7): Stretching
shouldbe performed daily and should include anterior shoul-der
stretching, performed by the patient in a corner ordoor jamb, and
posterior shoulder stretching using thecrossed body adduction
technique. Each stretchshould be held for 30 seconds and repeated 5
times,with a 10-second rest between each stretch. Canestretching in
forward elevation and external rotationmay also be used in a
similar fashion (see Figure A4).Strengthening (Figures A8-A15):
Strengthening ex-ercises should focus on the rotator cuff and
scapula sta-bilizing muscles. Rotator cuff strengthening
shouldinvolve the following exercises with the TheraBand: in-ternal
rotation with the arm adducted to side, externalrotation with the
arm adducted to side, and scaption ifthere is no pain associated
with the exercise. Scapulastabilizer strengthening should include
chair press,push-up plus (prone using body weight or supinewith
hand weight), and upright rows using an elasticband. Combination
strengthening while standing us-ing elastic bands should include
forward elevationand extension. Each exercise should be performedas
3 sets of 10 repetitions, with increases in elastic re-sistance as
strength improves.
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Figure A5 Active range of motion. In front of a mirror, practice
rais-ing your arm in front of your body without shrugging your
shoulder.
Figure A6 Anterior shoulder stretch: Place hands at shoulder
levelon each side of a door or in a corner of a room. Lean forward
into thedoor or corner and hold.
Figure A4 Active assisted range of motion using a cane: Lying
supine, hold the cane with both hands. Elevate thearms using the
healthy arm to guide the injured arm. Increase the use of the
injured arm as directed by comfort. Thesecan be done upright when
comfortable. Images demonstrate forward elevation, external
rotation, and abduction.Can do standing if comfortable.
Figure A7 Posterior shoulder stretch: Bring the involved arm
acrossin front of the body as shown. Hold the elbow with the other
arm.Gently flex the bent arm, which will pull the other arm across
thechest until a stretch is felt in the back of the shoulder.
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Figure A10 Chair press: While seated, press up on the chair,
lift-ing the body off the chair. Try to keep the spine
straight.
Figure A8 A (Left), External rotation: Secure the elastic band
at waist level. Hold the elbow at 90, arm at the side.Pull the hand
away from the body as shown. (Right) Internal rotation: Secure the
elastic band at waist level. Hold theelbow at 90, arm at the side.
Pull the hand across the body as shown. OR B (Left), External
rotation: Lie on side,involved side up. Arm at side, elbow bent,
with or without weight. Move the hand up as shown. (Right) Internal
ro-tation: Lie on involved side, elbow bent at 90, arm at side.
With or without weight, pull hand inward across the body,as
shown.
FigureA9 Scaption: Hold the arm 30 forward, thumb up or
down,raise the arm. May add resistance. This exercise should be
doneonly if there is no pain.
Figure A11 Push-up plus: Do a push-up (either on your hands
orforearms) and then really push to bring your spine to the
ceiling.
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Figure A14 Upright row: Do one arm at a time. While
standing,lean over a table and bend at the waist. Pull the hand
weightback, pulling shoulder blade back.
Figure A15 Low trapezius: Stand upright. Grasp elastic
bands.Keep your elbows straight and pull. Try to reach behind
you.
Figure A12 Press-up: Lie on back, elbow locked straight,
weightsin hands. Move your arm up toward the ceiling as far as
possible.
Figure A13 Rows: Seated or standing, bend your elbows and
pullthe elastic cord back. Try to pinch your shoulder blades behind
you.
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Exercise in the treatment of rotator cuff impingement: A
systematic review and a synthesized evidence-based rehabilitation
protocolMaterials and
methodsResultsDemographicsMethodologyComponents of the exercise
programsExercise as a treatment for impingementOther outcome
parametersHome vs supervised exerciseManual
therapyBracingAcromioplasty with exercise vs exercise alone
DiscussionReferencesEvidence-based medicine exercise protocol
for impingement syndrome