Clinical Journal of Sport Medicine, 13:176182 2003 Lippincott Williams & Wilkins, Inc.

, Philadelphia

Critical Review

Therapeutic Exercise and Orthopedic Manual Therapy for Impingement Syndrome: A Systematic Review
Franois Desmeules, BSc, PT, Claude H. Ct, PhD, and Pierre Frmont, MD, PhD
Laval University Hospital Research Center, Laval University, Quebec, Canada

Objective: To review randomized controlled trials evaluating the effectiveness of therapeutic exercise and orthopedic manual therapy for the treatment of impingement syndrome. Data Source: Reports up to October 2002 were located from MEDLINE, the Cochrane Database of Systematic Reviews, the Physiotherapy Evidence Database (PEDro), the TRIP database, and the Cumulative Index to Nursing & Allied Health Literature (CINAHL) using shoulder and clinical trial/randomized controlled trial as search terms. Study Selection: Studies were included if (1) they were a randomized controlled trial; (2) they were related to impingement syndrome, rotator cuff tendinitis, or bursitis; (3) one of the treatments included therapeutic exercise or manual therapy. Data Extraction: Two independent observers reviewed the methodological quality of the studies using an assessment tool

developed by the Cochrane Musculoskeletal Injuries Group. Differences were resolved by consensus. Data Synthesis: Seven trials met our inclusion criteria. After consensus, the mean methodological score for all studies was 13.9 2.4 (of 24). Four studies of 7, including the 3 trials with the best methodological score (67%), suggested some benefit of therapeutic exercise or manual therapy compared with other treatments such as acromioplasty, placebo, or no intervention. Conclusions: There is limited evidence to support the efficacy of therapeutic exercise and manual therapy to treat impingement syndrome. More methodologically sound studies are needed to further evaluate these interventions. Key Words: exerciseimpingement syndromemanual therapyphysical therapyshouldersystematic review Clin J Sport Med 2003;13:176182.

INTRODUCTION What should a health professional think of an article stating that physiotherapy is ineffective in treating shoulder pain? He or she should wonder: what kind of treatment was used and for what pathology? Interestingly, in the last 5 years, 4 reviews have been published on the efficacy of interventions for nonspecific shoulder pain or nonspecific soft tissue disorder of the shoulder (Table 1). In these 4 reviews, only 6 different trials were related to therapeutic exercise (TE) and orthopedic manual therapy (MT), whereas marginal methods considered to be part of the field of physiotherapy, such as electromagnetic field therapy and low-level laser therapy, were the principal intervention in many of the studies. On average, only 18% of the studies evaluating physiotherapy interventions were related to TE or MT. In sharp contrast, a survey of the treatment used for shoulder impingement
Received for publication June 2002; accepted November 2002. F. Desmeules was supported by the Fond de Recherche en Sant du Qubec, the Ordre Professionnel des Physiothrapeutes du Qubec, Canada, and Re seau Provincial de Recherche en adaptation readaptation. Reprints: Pierre Frmont, MD, Unit de mdecine familiale du CHUL, 2705 Boul Laurier Ste-Foy, Qubec, G1V 4G2, Canada. E-mail: pierre.fremont@crchul.ulaval.ca

syndrome (SIS) by 10 physiotherapists from 6 different clinics in the Quebec City area with at least 5 years of experience clearly showed that the marginal methods described previously are minimally used, and that the combination of TE and MT is consistently used (F.D., C.H.C., P.F., unpublished data, August 2001). Therefore, we strongly believe that reviews on the effectiveness of physiotherapy should focus on specific treatment methods for properly defined clinical syndromes. Accordingly, the objective of the present review was to systematically analyze the methodological quality and findings of randomized controlled trials (RCTs) on the efficacy of TE and MT on a clinically defined shoulder problem, SIS. To address this objective, two questions had to be considered. One question was how we can define the impingement as a clinical syndrome. Although shoulder pain is the most common musculoskeletal complaint encountered in clinical practice after low back pain, the clinical definition of the different problems characterized by shoulder pain is still very controversial.1 One of the most commonly used concepts to describe a category of shoulder problems is SIS,1 in which the different structures found in the subacromial space are in an inflamed or degenerative state, leading to pain and dysfunction. Although some clinical criteria for SIS have been proposed,24 none has received the level of acceptance re176

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TABLE 1. Treatment Modalities in the Studies Analyzed by 4 Recent Reviews of Treatments for Painful Shoulder Problems
Nonsurgical Medical Treatment* 30 11 8 0 Studies Listed as Physiotherapy 5 17 21 10 TE and/or MT 1 5 3 1 TE and/or MT/Physiotherapy Ratio, % 20 29 14 10

177

Study Green et al29 (2002) van der Heijden13 (1999) van der Heijden28 (1997) Philadelphia Panel27 (2001)

* Nonsteroidal antiinflammatory drugs; glucocorticosteroids, oral or injection; manipulation during anesthesia; hydrodilatation. All modalities of the field of physiotherapy: therapeutic exercise (TE), manual therapy (MT), ultrasound, and all electrotherapy, including transcutaneous electrical neural stimulation, magnetotherapy, laser, and iontophoresis. Some studies were mentioned by more than one review so that a total of only 6 different studies on TE or MT were cited.

quired to make it useful as a study selection criterion for the present review. We therefore concluded that it was appropriate to retain studies dealing with any of the impingement-related diagnoses (eg, tendinitis or bursitis) and to analyze the inclusion and exclusion criteria used as an outcome of the present review. The second question we had to consider was how we define TE and MT. TE can be defined as the use of active or assisted exercises aimed at improving range of motion, strength, or dynamic neuromuscular control of joint motion, whereas MT can be defined as the use of manually and/or mechanically applied movement techniques to improve joint motion.5 Both TE and MT are commonly used as part of physical therapy programs aimed at improving shoulder kinematics. As long as a statement indicated that TE or MT was one of the independent variables of a given trial, it could be included in the review. The quality of the description of these interventions was one of the criteria used to assess the methodological quality of the included studies. Therefore, the clinical definition of SIS and the interventions used in the studies are, to some extent, as much the premises as they are some of the outcomes of the present review. METHODS Data Source Reports of RCTs were located from MEDLINE, the Cochrane Database of Systematic Reviews, the Physiotherapy Evidence Database (PEDro), the TRIP database, and the Cumulative Index to Nursing & Allied Health Literature (CINAHL) using the search strategy described in Table 2. No limits were included concerning the year of publication, and this research was conducted up to October 2002. References of all included trials were searched for relevant studies. Study Selection All titles and abstracts retrieved were read to assess their relevance. Studies were included if their inclusion criteria were related to SIS, rotator cuff tendinitis, tendinosis, or bursitis. Studies with shoulder pain as the only inclusion criterion that stated a significant number

of subjects had SIS were included. At least 1 of the treatments had to be TE or MT supervised or given by a physiotherapist. Other interventions typical of the field of physiotherapy (thermotherapy, cryotherapy, electrotherapy, massage, transverse friction) could be used, but TE and/or MT had to be identified as the main treatment. Data Extraction Although there seems to be a certain consensus on basic principles regarding the evaluation of the methodological quality of RCTs, there is no gold standard presently available in the literature. After reviewing various tools, we found the one developed by the Cochrane Musculoskeletal Injuries Group6 to be the most adequate for our purpose, as it provides specific criteria on how to score each methodological item. Even though this tool has yet to be formally validated, it was developed using the basic principles elaborated by the Cochrane collaboration groups7 for reviewing the quality of RCTs (Table 3). Two researchers independently reviewed all included studies. An overall methodological score (of 24) was calculated for each study by each independent evaluator. The researchers were not blinded to the title, authors, or journal title of the trials. To evaluate the degree of agreement between the two evaluators (interobserver reliability), a Spearman correlation coefficient was calculated. Both reviewers met afterwards, and any differences between scores were resolved by consensus. The data presented are the resulting consensus score.

TABLE 2. Literature Search Strategy Using a Combination of MEDLINE Subject Headings, Text Words, and Publication Type
Step 1 2 3 Search Shoulder (MeSH) or (TW) and clinical trial (PT) Shoulder (MeSH) or (TW) and randomized controlled trial (PT) Searches performed in steps 1 and 2 Results 905 457 457

MeSH indicates MEDLINE subject headings; PT, publication type; TW, text words.

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DESMEULES ET AL the lowest methodological score (Table 3). The definition of interventions score of each study is also presented in Table 4. Because of a lack of homogeneity among studies, pooling of data was not possible. Four studies, including the 3 studies with the best methodological score (66%),24,9,10 suggest a favorable treatment effect for the physiotherapy interventions considered in this review. In Table 4, the 2 studies comparing TE with placebo3,4 or with no treatment10 suggest a favorable treatment effect of TE. The 3 studies comparing MT with exercise alone2,9,12 suggest a favorable treatment effect of MT. Overall, 5 studies showed a significant treatment effect of TE or MT when pretreatment/posttreatment analyses were made within groups.24,9,10,12 In 3 of the 4 studies with lower methodological scores (37 to 58%), the investigators found that other types of conservative treatment were better interventions to treat SIS than TE or MT. Two of these studies showed better outcome when corticosteroid injections or open anterior acromioplasty were used compared with TE or MT.11,12 The last of the 3 studies showed no added benefit of a physiotherapistsupervised TE program compared with a home selftraining exercise program.8 Table 4 also shows the outcome measures for all included studies, as well as the follow-up period. As outlined by van der Heijden13 in his review of shoulder disorders, there is no gold standard that provides a valid and reliable estimate for clinically relevant changes in patients with shoulder disorders. Based on his review, our analysis of the main outcome measures focused on the following elements: pain, range of motion, strength, and functional outcomes. Pain was assessed by all studies and was the only outcome measure in 3 of the trials.1012 The length of follow-up varied greatly and ranged from 3 weeks to 30 months. Three of the 4 studies with a follow-up period shorter than 3 months showed a favorable treatment effect for the physiotherapy interventions considered in this review.2,9,10 For studies with a follow-up period of more than 3 months, 1 concluded in favor of TE over placebo,3,4 1 showed no added benefit of a physiotherapist-supervised exercise program compared with a home self-training exercise program,8 and 1 concluded a significant reduction of pain for open anterior acromioplasty over TE at 12 months but not at 6 months.11 Table 5 shows that inclusion criteria varied greatly and were sometimes scarce or poorly defined. Age and duration of symptoms are also shown because they can greatly affect the outcome of treatment. The criteria listed in Table 5 have been selected based on a review of the existing literature, in which many authors have outlined the important clinical features of SIS1422: (1) active and passive range of motion are often normal, with the exception of movements that stretch the posterior glenohumeral capsule, which is sometimes limited; (2) results of strength testing (isometric or isokinetic) or the Jobe23 test and the Speed test24 are positive when pain and/or weakness are present; (3) a painful arc is often found in active elevation of the arm (abduction

TABLE 3. Mean Methodological Score for all Included Randomized Controlled Trials Detailed by Methodological Items Addressed in the Cochrane Musculoskeletal Injuries Group Assessment Tool*
Methodological Items Treatment allocation process Intention-to-treat analysis Blinded assessment of the outcomes Consideration for possible initial group differences Blinding of subjects Blinding of treatment providers Consideration for cointerventions Definition of inclusion/exclusion criteria Definition of interventions Definition of the outcomes Clinical relevance of the outcome measures Quality/duration of follow-up Mean (SD) out of 2 1.3 (0.5) 1.3 (0.7) 1.1 (0.6) 1.6 (0.7) 0.1 (0.4) 0 1.1 (0.8) 1.9 (0.4) 0.9 (0.8) 1.9 (0.4) 1.3 (0.5) 1.4 (0.5)

* All items are scored (0, 1, or 2) according to detailed standardized scoring criteria elaborated for each question by the Cochrane Musculoskeletal Injuries Group. The criteria applicable to each methodological item can be accessed at http://healthsci.otago.ac.nz/dsm/cmsig/. Last accessed October 2002.

RESULTS Study Selection A total of 457 studies (title and abstract) were retrieved from MEDLINE (Table 2). No other studies were identified through the other electronic databases. A total of 8 studies met our inclusion criteria.24,812 Even though 1 of those studies10 included patients with adhesive capsulitis, it was selected because 60% of the patients had a diagnosis related to SIS, rotator cuff tendinitis, or bursitis. Another study that also included patients with disorders of the cervical spine and pain irradiation at the shoulder12 was included for similar reasons. Brox et al3,4 published 2 articles, both related to the same trial and population but with a different follow-up period and blinding of assessors. Therefore, the 2 studies were included and analyzed as 1 trial in our review. Another study8 met our basic inclusion criteria, and even though it looked at rehabilitation after arthroscopic subacromial decompression for treating SIS, it was included in our study (Table 2). Data Extraction The overall agreement between the 2 observers was good, with an average Spearman correlation coefficient of 0.79 0.20 for the 12 criteria applied to the 7 studies. This suggests that the methodological assessment tool used has good to very good interobserver reliability. When differences occurred between evaluators, the majority resulted from objective information missed by 1 evaluator rather than subjective disagreements. Consensus was therefore easily achieved. The mean methodological score for the 7 studies was 13.6 1.8 and 14.0 2.1 (of 24) for observer 1 and observer 2, respectively. After consensus, the mean score for all included studies was 13.9 2.4 or 58% (Table 4). Besides blinding of subjects and blinding of treatment providers, which are inherent problems of research in physical therapy, definition of interventions was the single criterion with
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TABLE 4. Included Randomized Controlled Trial for Impingement Syndrome

Study Bang and Deyle2 (2000) Interventions 1. Supervised exercise with manual physical therapy vs. 2. Supervised exercise Brox et al3,4 (1999, 1993) Definition of Intervention* 1 n Outcome Measures Treatment Effect Group 1 is significantly better than group 2 for strength, pain, and function (P 0.0155, P 0.0017, P 0.0049). Groups 1 and 2 had significantly less pain and increased function (P < 0.0001). Success rate (at 6 and 30 mo) for groups 1 and 2 better than for placebo group 3 (P < 0.01) Follow-up Period 2 mo Score After Consensus 16

28 Pain (during tasks) Strength

Functional questionnaire 24

1. Arthroscopic surgery

45 Pain (at rest, at night, during tasks) Self-perceived change in symptoms 30 ROM Strength/endurance 50 Functional questionnaire Functional tests 7 Pain (last 24 h, during tasks) ROM Functional tests

6 mo and 30 mo

16

vs. 2. Supervised exercises vs. 3. Placebo (detuned laser) Conroy and Hayes9 (1998) 1. Comprehensive treatment alone (exercises, hot packs, soft tissue mobilization, education) vs. 2

No difference between group 1 and 2 (P 0.80)

Group 2 had significantly less pain than group 1 (P < 0.008 and P < 0.032). No difference in ROM and function tests Both groups improved on function, ROM, and functional tests (P < 0.05).

3 to 4 wk

16

Andersen et al8 (1999)

Winters et al12 (1997)

2. Comprehensive treatment and joint mobilizations Arthroscopic subacromial decompression, both groups 1. Self-training exercises vs. 2. Physiotherapistsupervised exercises 1. Classic physiotherapy (exercise, massage, physical applications) vs. 2. Manipulation (mobilization, manipulation) vs. 3. Corticosteroid injections 1. Therapeutic exercise

Pain (rest, ADL, night) ROM 22 Strength Functional questionnaire 21 Functional test

No difference between groups

12 mo

14

64 Pain

Duration of complaints less with group 2 than group 1 (P < 0.001) Duration of complaints significantly less with group 3 than group 1 or group 2 (P < 0.001) All groups had significantly less pain (P < 0.001).

11 wk

14

61

47 1 Pain (during tests) Group 1 significantly improved in pain-free abduction, flexion ROM, function, and self perception compared with the no treatment group 2 (P < 0.05). 1 mo 12

Ginn et al (1997)

10

vs. 2. No treatment Rahme et al11 (1998)

1. Open anterior acromioplasty vs. 2. Exercise and education

66 Self-perceived change in symptoms ROM Strength Functional questionnaire 21 Pain (at rest, during functional test)

No differences in HBB ROM, strength, and pain during reaching task test Significant reduction of pain for group 1 compared with group 2 at 1 year (P < 0.0005) No difference at 6 months

12 mo

18 Mean (SD) 13.86 2.42 out of 24

* Treatment description as scored with the Cochrane Musculoskeletal Injuries Group assessment tool: 2 clearly defined interventions applied with a standardized protocol; 1 clearly defined interventions are applied, but the application protocol is not standardized; 0 intervention and/or application protocol are defined poorly or not defined. Prepost treatment analysis. Brox et al. published two studies on the same population but with a different follow-up (6 months and 30 months). Some of these items were evaluated using the Neer Shoulder Score. Emotional distress was evaluated also with Hopkins Symptom check list; pain medication and absence from work were also monitoroed. All of these items were evaluated using the Constant Score. Evaluated using the Shoulder Pain Score. ADL indicates activities of daily living; HBB, hand behind back; ROM, range of motion.

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TABLE 5. Inclusion Criteria of Selected Studies According to Relevant Clinical Features of Impingement Syndrome
Subjective and Objective Signs Strength Testing/ Symptoms Resisted Painful Duration Range of Motion Test Arch 112 mo * *

Study

Age

Impingement Signs Passive overpressure at full shoulder flexion with scapula stabilized or Passive internal rotation at 90 flexion Neer sign

Impingement Test (Lidocaine/Neer Test)

Other

1865 y Bang and Deyle2 (2000)

Brox et al3,4 (1999, 1993) Conroy and Hayes9 (1998) Andersen et al8 (1999) Winters et al12 (1997)

1866 y

>3 mo

Full

Active range of motion deficits

Passive abduction 90 and horizontal adductionabduction

>8 mo

Working age

>12 mo

Ginn et al10 (1997) Rahme et al11 (1998)

18 y

Forced elevation and internal rotation

Resistant to physiotherapy Resistant to NSAIDs and steroids Pain at the shoulder Primary impingement syndrome Limited functional movement patterns Impingement pain No or disappointing results of >6 months of conservative treatments Shoulder complaints of any source Shoulder pain reproduced by active shoulder movements Author states that 60% of subjects had tendinopathy or impingement Pain at rest for more than 1 year Isolated shoulder disease

* Mentioned in the study as exclusion criteria. NSAIDs indicates nonsteroidal antiinflammatory drugs.

and flexion); (4) the Neer25 or KennedyHawkins26 impingement signs, although not specific, are often positive; and (5) the Neer25 lidocaine injection impingement test is positive when the impingement signs are significantly less painful following local anesthesia of the subacromial space. Only 4 studies24,9,11 used more than 2 inclusion criteria specific to SIS, including the 3 with the best methodological scores. Impingement signs were the most frequently used signs in 4 of 7 studies.24,9,11 The study by Brox et al.3,4 was the only trial that specifically looked at all of the inclusion criteria outlined in our review of the literature. In the same manner, the 8 exclusion criteria listed in Table 6 were identified from a review of the literature1422 as possible conditions or pathology that would interfere with a successful outcome of SIS treatment. Any other exclusion criteria specific to a given study are also shown in Table 6. Cervical pathology (5 of 7) and rotator cuff tears/rupture (5 of 7) followed by instability (3 of 7) were the most frequently used exclusion criteria. The 3 studies24,9 that identified at least 50% of the exclusion criteria also had the best overall methodological score. DISCUSSION The recent reviews published on the efficacy of treatment of painful shoulder problems suggest that there is not enough evidence to support or refute the efficacy of
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common physiotherapy interventions for shoulder pain.13,2729 However, the analysis of the studies considered by these reviews revealed that, on average, TE and MT were the interventions studied in less than 20% of the trials. We therefore suspected that the collective analysis of the therapeutic methods used in the field of physical therapy might have inaccurately estimated treatment effect for specific treatments. Accordingly, this review focused on a specific group of physical therapy methods applied to 1 of the clinically defined painful shoulder problems, SIS. This review confirmed the lack of uniformity in defining, evaluating, and treating impingement syndrome. The methodological quality of the studies reviewed was low to very low, with an average methodological score of 58%. However, this is better than the average methodological score of 42% reported by Green et al29 for studies of common physiotherapy interventions for shoulder pain. The other reviews mentioned in Table 1 did not provide a methodological score. In the review by Green et al,29 only 1 study was related to TE and MT. van der Heijden13 concluded that knowledge of the effect of all methods in the field of physiotherapy on long-term outcome or recurrence of shoulder disorder is lacking. Based on 3 of the studies listed in the present review, van der Heijden13 also concluded that very limited evidence supports the effectiveness of TE or MT. An earlier review by van der Heijden et al,28 pub-

THERAPY FOR IMPINGEMENT SYNDROME

TABLE 6. Exclusion Criteria for all Included Studies
Rotator Cuff Tears/ Adhesive Acromioclavicular Cervical Neurologic Joint Pathology Pathology Pathology Instability Rupture Capsulitis * * * * * Radiologic/ Imaging Finding

181

Trials Band and Deyle2 (2000) Brox et al3,4 (1999, 1993) Conroy and Hayes9 (1998) Andersen et al8 (1999) Winters et al12 (1997) Ginn et al10 (1997) Rahme et al (1998)
11

Systemic Disease

Other Other form of treatment during study or before treatment, except medication Bilateral upper extremity pain Inability to relax shoulder, neck, and temporomandibular joint Calcific tendonitis Degenerative diseases Fractures of upper extremity Treatment for shoulder complaints in the last 6 months Bilateral pain Severe traums Psychiatric disorder Inflammatory condition Trauma within 4 weeks Psychogenic pain syndrome

Herniated disc *

Rheumatic disorder

* Mentioned in the study as exclusion criteria.

lished when only 1 of the trials considered in the present review was available, reached similar conclusions. In the last review,27 the investigators were unable to make any conclusions regarding the effectiveness of TE for shoulder pain because poorly defined inclusion criteria and nonvalidated outcomes were used. Only 1 study related to TE was included and reviewed. In light of this analysis, we conclude that the quantity and quality of clinical trials related to TE and MT for SIS have sufficiently evolved over the last 5 years to justify the present reevaluation. The present review shows that the studies with the best methodological design constitute limited evidence supporting the efficacy of TE and MT to treat the SIS. More methodologically sound studies are needed to further evaluate these interventions. Future trials need to better define SIS and to exclude the main clinical shoulder conditions that can be distinguished from it, such as the frozen shoulder or neurologic conditions. Also, further validation of outcome measures applied to patients suffering from SIS is necessary. Even though there is no gold standard for evaluating shoulder disorders such as SIS, the use of validated functional outcomes is necessary to fully evaluate the patients condition and evolution. The use of pain, range of motion, and strength as secondary outcome measures seems to be acceptable, and their basic construct validity for the evaluation of a musculoskeletal disorder is acceptable. However, there is a need to fully validate the metrologic qualities of these outcome measures. CONCLUSION Evaluating the entire field of physiotherapy as a single therapeutic entity for treating musculoskeletal conditions can be misleading. The emphasis of future randomized controlled trials should be on specific therapeutic meth-

ods, such as well-defined TE programs or a MT regimen, for better-defined pathology, such as SIS. At present, there is limited evidence to support the use of TE programs and MT for treating SIS. However, more methodologically sound studies are needed to draw more definitive conclusions. REFERENCES
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