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?
