Change search
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf
Exercise treatment of patients with long-standing subacromial pain
Linköping University, Department of Medical and Health Sciences, Physiotherapy. Linköping University, Faculty of Health Sciences.
2013 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Subacromial pain is the most common problem among patients with shoulder complaints seeking primary care. The recommended treatment for these patients is primarily non-surgical with a focus on exercise treatment. If this treatment fails arthroscopic subacromial decompression (ASD) followed by exercise treatment is recommended. Surgical treatment with ASD has increased substantially in Sweden in recent years even though studies comparing exercise treatment with surgery report equally positive results. Still, there is a need of evidence based preand postoperative exercise treatments, standardised and described in detail, to guide treatment of these patients in clinical practice.

The overall aim of this thesis was to evaluate the efficacy of pre- and postoperative exercise strategies on shoulder function and how the preoperative strategy affects the need for surgery in patients with long-standing subacromial pain.

This thesis comprises four papers which are based on two randomised controlled trials. In study A, patients were randomised after ASD surgery to either physical therapist (PT) supervised strength-endurance exercises for the rotator cuff and scapula stabilisers or to home-based movement exercises for a period of three months. Shoulder function and pain, health related quality of life and return to work was evaluated for 6 months (paper I). In study B, patients on the waiting list for surgery were randomised to either specific exercise strategy with strengthendurance exercises for the rotator cuff and the scapula stabilisers or to control exercises with movement exercises for the neck and shoulders for a period of three months. After completing the exercise program and also after 12 months, shoulder function and pain, need for surgery and health related quality of life was evaluated. Baseline shoulder function, rotator cuff status and radiological findings were analysed in relation to the choice of surgery (paper II, III). The minimal important clinical change (MIC) of the Constant-Murley (CM) score, used as primary outcome in this thesis, was determined by using a visual anchor-based MIC distribution method (paper IV).

Six months after ASD surgery, patients who performed PT-supervised strength-endurance exercises improved significantly more in shoulder function and pain compared to patients who had performed home-based movement exercises (paper I). Patients on the waiting list for surgery who performed specific strength-endurance exercises had significantly greater improvements in shoulder function and pain compared to patients performing movement exercises (paper II). A significantly lower proportion of those performing specific strength-endurance exercises chose surgery at the three- and 12 months follow-ups (paper II, paper III). Low baseline values in shoulder function and pain measured with the CM score and/or having a full thickness rotator cuff rupture were associated with an increased risk of choosing surgery (paper III). Regarding the CM score, a change between 17-24 points seems to be clinically important for patients with long-standing subacromial pain (paper IV).

Supervised strength-endurance exercises seem to be more effective than home-based movement exercises after ASD surgery. For patients on the waiting list for surgery, the specific strategy of strength-endurance exercises was effective in improving shoulder function and pain and the need for surgery was reduced at 12 months. Low baseline values for shoulder function and pain measured with the CM score and/or having a full thickness rotator cuff tear seem to be predictors for choosing surgery. The CM score is able to detect the MIC in individual patients with long-standing subacromial pain when the rotator cuff is intact. In all patients with longstanding subacromial pain, the MIC value was dependent on the subgroup as well as the choice of statistical analysis.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2013. , 95 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1352
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-90021ISBN: 978-91-7519-695-4 (print)OAI: oai:DiVA.org:liu-90021DiVA: diva2:611238
Public defence
2013-04-12, Berzeliussalen, Campus US, Linköpings universitet, Linköping, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2013-03-15 Created: 2013-03-15 Last updated: 2013-03-15Bibliographically approved
List of papers
1. Supervised strengthening exercises versus home-based movement exercises after arthroscopic acromioplasty: A randomized clinical trial
Open this publication in new window or tab >>Supervised strengthening exercises versus home-based movement exercises after arthroscopic acromioplasty: A randomized clinical trial
2012 (English)In: Journal of rehabilitation medicine : official journal of the UEMS European Board of Physical and Rehabilitation Medicine, ISSN 1651-2081, Vol. 44, no 1, 12-18 p.Article in journal (Refereed) Published
Abstract [en]

Objective: To evaluate and compare the efficacy of 2 rehabilitation strategies after arthroscopic acromioplasty: supervised physical therapy focusing on strengthening exercises of the rotator cuff and scapula stabilizers (PT-group) vs home-based movement exercises (H-group). Design: A randomized, single-blinded, clinically controlled study. Patients: Thirty-six patients entered the study. Thirteen in the PT-group and 16 in the H-group fulfilled all the assessments. Methods: For 12 weeks following surgery, patients performed either supervised physical therapy or home exercises. Follow-ups were conducted periodically for 6 months after surgery to evaluate shoulder function, pain (Constant-Murley (CM) and Disabilities of the Arm, Shoulder, and Hand (DASH) scores), and health-related quality of life. Results: The PT-group exhibited significantly greater improvements in CM (p  =0.02) and DASH (p = 0.05) scores. After treatment, the between-group mean difference in CM scores was 14.2 p (95% confidence interval 2-26). At the 6-month follow-up, the between-group mean difference in DASH scores was 13.4 p (95% confidence interval 0.1-23). Conclusion: PT-supervised rehabilitation with strengthening exercises of the rotator cuff and scapula stabilizers seems to be superior to home exercises focusing on mobility for improving shoulder function after arthroscopic acromioplasty.

Keyword
arthroscopic acromioplasty; exercise; rehabilitation; rotator cuff; subacromial impingement; physical therapy.
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-72791 (URN)10.2340/16501977-0889 (DOI)000300263900003 ()22124602 (PubMedID)
Available from: 2011-12-07 Created: 2011-12-07 Last updated: 2013-03-15
2. Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomised controlled study
Open this publication in new window or tab >>Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomised controlled study
Show others...
2012 (English)In: BMJ. British Medical Journal (International Ed.), ISSN 0959-8146, E-ISSN 0959-535X, Vol. 344, e787- p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: To evaluate if a specific exercise strategy, targeting the rotator cuff and scapula stabilisers, improves shoulder function and pain more than unspecific exercises in patients with subacromial impingement syndrome, thereby decreasing the need for arthroscopic subacromial decompression.

DESIGN: Randomised, participant and single assessor blinded, controlled study.

SETTING: Department of orthopaedics in a Swedish university hospital.

PARTICIPANTS: 102 patients with long standing (over six months) persistent subacromial impingement syndrome in whom earlier conservative treatment had failed, recruited through orthopaedic specialists.

INTERVENTIONS: The specific exercise strategy consisted of strengthening eccentric exercises for the rotator cuff and concentric/eccentric exercises for the scapula stabilisers in combination with manual mobilisation. The control exercise programme consisted of unspecific movement exercises for the neck and shoulder. Patients in both groups received five to six individual guided treatment sessions during 12 weeks. In between these supervised sessions the participants performed home exercises once or twice a day for 12 weeks.

MAIN OUTCOME MEASURES: The primary outcome was the Constant-Murley shoulder assessment score evaluating shoulder function and pain. Secondary outcomes were patients' global impression of change because of treatment and decision regarding surgery.

RESULTS: Most (97, 95%) participants completed the 12 week study. There was a significantly greater improvement in the Constant-Murley score in the specific exercise group than in the control exercise group (24 points (95% confidence interval 19 to 28.0) v 9 points (5 to 13); mean difference between group: 15 points (8.5 to 20.6)). Significantly more patients in the specific exercise group reported successful outcome (defined as large improvement or recovered) in the patients' global assessment of change because of treatment: 69% (35/51) v 24% (11/46); odds ratio 7.6, 3.1 to 18.9; P<0.001. A significantly lower proportion of patients in the specific exercise group subsequently chose to undergo surgery: 20% (10/51) v 63% (29/46); odds ratio 7.7, 3.1 to 19.4; P<0.001).

CONCLUSION: A specific exercise strategy, focusing on strengthening eccentric exercises for the rotator cuff and concentric/eccentric exercises for the scapula stabilisers, is effective in reducing pain and improving shoulder function in patients with persistent subacromial impingement syndrome. By extension, this exercise strategy reduces the need for arthroscopic subacromial decompression within the three month timeframe used in the study.

TRIAL REGISTRATION: Clinical trials NCT01037673.

Place, publisher, year, edition, pages
BMJ Publishing Group, 2012
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-75436 (URN)10.1136/bmj.e787 (DOI)000300881600009 ()22349588 (PubMedID)
Note

funding agencies|physiotherapy orthopaedic department of the University Hospital in Linkoping, Sweden||research council in the south east of Sweden (FORSS)||

Available from: 2012-03-01 Created: 2012-03-01 Last updated: 2017-12-07
3. A specific exercise strategy for patients with subacromial pain significantly reduced the need for surgery: one-year results of a randomised controlled study
Open this publication in new window or tab >>A specific exercise strategy for patients with subacromial pain significantly reduced the need for surgery: one-year results of a randomised controlled study
Show others...
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background: A specific exercise strategy focusing on eccentric exercises, for treating sbacromial pain has in a previous study been found effective at three-month followup.

The aim of the present study was to investigate if the positive short-term results were maintained after one year. A further aim was to examine if baseline clinical score, rotator cuff status and radiological findings influenced the choice of surgery.

Methods: 97 patients on the waiting-list for arthroscopic subacromial decompression were in the first study randomized to a three-month specific exercise strategy or unspecific exercises (controls). Patients were examined with radiology, ultrasound and assessed with clinical scores: primary Constant-Murley score. After three months of exercises the patients were asked if they still wanted surgery and this option was available until the one-year follow-up. All patients were re-assessed with clinical scores one year after inclusion or one year after surgical intervention and the number of patients that had chosen surgery in each group was compared. The baseline Constant-Murley score and the status of subacromial structures were analyzed in relation to patient's choice of surgery.

Results: The positive short-term effect (improved shoulder function and pain) of the specific exercises was maintained after one-year. Compared to the three-month followup all patients had improved significantly (p < 0.0001) in Constant-Murley score. The number of patients that had chosen surgery in the control exercise group (63%) was significantly larger (p < 0.0001) than in the specific exercise group (24%). Patients that had chosen surgery had a significantly lower baseline Constant-Murley score and significantly more often a full-thickness tear. Patients with partial-thickness tears did not differ from those with intact cuff tendons.

Conclusions: The positive short-term outcomes after specific exercises were maintained after one year and reduced the need of surgery significantly more than the unspecific control exercises. Patients with low baseline clinical score and/or a full-thickness tear significantly more often chose surgery.

Level of evidence: I, Randomized controlled trail according to Consort statement.

Keyword
Subacromial pain patients, exercises, eccentric, rotator cuff tear
National Category
Orthopedics Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-82118 (URN)
Note

The original title of this article was: A specific exercise strategy reduces the need of surgery in subacromial pain patients: one-year results after a randomised controlled study. The title was changed before submitted to the journal.

On the day of the defence day the status of this article was Manuscript                        

Available from: 2012-10-01 Created: 2012-10-01 Last updated: 2014-06-24Bibliographically approved
4. Minimal important changes in the Constant Murley score in patients with subacromial pain
Open this publication in new window or tab >>Minimal important changes in the Constant Murley score in patients with subacromial pain
2014 (English)In: Journal of shoulder and elbow surgery, ISSN 1058-2746, E-ISSN 1532-6500, Vol. 23, no 8, 1083-1090 p.Article in journal (Refereed) Published
Abstract [en]

Objective: The purpose of this study was to determine the minimal important change (MIC) of improvement in the Constant‐Murley score (CM score) in patients with longstanding subacromial pain and in subgroups of patients with subacromial pain with and without rotator cuff ruptures.

Method: The MIC was estimated by using the visual anchor‐based MIC distribution method, which integrates an anchor‐ and distribution‐based approach: the optimal cut‐off point of the receiver operator characteristic curve (MIC ROC) and the 95% limit cut‐ off point (MIC 95%limit). The study population consisted of 93 patients included in a randomized clinical trial evaluating the effect of a specific exercise strategy in patients with longstanding subacromial pain.

Results: The MIC ROC was found at a mean change of 17 points in the CM score. The MIC 95% limit was found at a mean change of 24 points. In the subgroup analysis the MIC ROC was found at a mean change of 19 points and the MIC 95% limit at 18 points in patients with an intact rotator cuff. In patients with rotator cuff ruptures the MIC ROC was found at a mean change of 15 points and the MIC 95% limit at 30 points.

Conclusion: The CM score is able to detect the minimal important change in individual patients with long‐standing subacromial pain when the rotator cuff is intact. In all patients with longstanding subacromial pain, the MIC value was dependent on the subgroup as well as the choice of statistical analysis. The estimated MIC values could be used as an indication for relevant changes in the CM score in clinical practice and guide the clinician in how to interpret the results of specific treatments for patients with longstanding subacromial pain.

Place, publisher, year, edition, pages
Mosby-Elsevier, 2014
National Category
Health Sciences Clinical Medicine
Identifiers
urn:nbn:se:liu:diva-90020 (URN)10.1016/j.jse.2014.01.014 (DOI)000341135000006 ()
Available from: 2013-03-15 Created: 2013-03-15 Last updated: 2017-12-06

Open Access in DiVA

Exercise treatment of patients with long-standing subacromial pain(4293 kB)9103 downloads
File information
File name FULLTEXT01.pdfFile size 4293 kBChecksum SHA-512
d981c6e1357c80f88233d29df7d3f313541966794176c0155e893b4f0fa3534113aba1f8f90628de442170733507e5c96ae86d6adef0176ec1752f6f16444c52
Type fulltextMimetype application/pdf
omslag(3211 kB)75 downloads
File information
File name COVER01.pdfFile size 3211 kBChecksum SHA-512
d8190bfc3aca693f4995df864c1fb2b92bca72d7a9cbeff27b450b23dc9ebe060c33ba6ebe1da1bb4077fefbd49c17bb58572dde163479e4c113a7113926d577
Type coverMimetype application/pdf

Search in DiVA

By author/editor
Holmgren, Theresa
By organisation
PhysiotherapyFaculty of Health Sciences
Medical and Health Sciences

Search outside of DiVA

GoogleGoogle Scholar
Total: 9103 downloads
The number of downloads is the sum of all downloads of full texts. It may include eg previous versions that are now no longer available

isbn
urn-nbn

Altmetric score

isbn
urn-nbn
Total: 1935 hits
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf