Exercise Should Be Primary Approach to Shoulder Impingement

By Scott Baltic

July 18, 2017

NEW YORK (Reuters Health) - Shoulder-specific exercises should be prescribed for all patients with shoulder impingement syndrome, according to a new systematic review and meta-analysis of 200 trials comparing conservative strategies to treat shoulder impingement.

The review, released online June 19 in the British Journal of Sports Medicine, found that supplementing exercise with manual therapy, tape, extracorporeal shockwave therapy (ECSWT), and laser therapy might add a small benefit.

Evidence for or against numerous other non-exercise physical therapy modalities was inadequate, leading the researchers to recommend that they be used only in addition to exercise.

Shoulder impingement syndrome was defined as injury of structures in the subacromial space, such as rotator cuff tendinitis, partial-thickness tears of the rotator cuff, and bursitis.

The authors, who are based in Switzerland and Belgium, acknowledged that the underlying studies generally produced evidence of very low quality, for reasons including non-blinding of outcome assessors and incomplete outcome data. In addition, diagnostic criteria and length of follow-up varied widely.

“Although the quality of the evidence is overall very low, we are confident that exercise is effective in improving pain, function and active range of motion in patients with shoulder impingement. Therefore, clinicians should use exercise as the first treatment,” corresponding author Roger Hilfiker, of the School of Health Sciences, University of Applied Sciences and Arts Western Switzerland Valais, Leukerbad, told Reuters Health in an email.

Hilfiker added that other modalities, such as NSAIDs, corticosteroid injections (with an advantage for ultrasound-guided injections), manual therapy, tape in combination with exercise, ECSWT and laser therapy, could be added to exercise.

A meta-analysis “is only as strong as the weakest article,” cautioned Dr. Mark Hutchinson of the University of Illinois College of Medicine in a phone interview with Reuters Health. He added that it would have been better if the lower-quality studies had been excluded from the meta-analysis.

As the study stands, Dr. Hutchinson continued, “It’s a valuable review, but it does have inherent bias . . . . The results are interesting, but not necessarily practice-changing.”

Overall, the researchers found very low quality evidence that:

1. For pain and function, corticosteroid injections were superior to doing nothing, ultrasound-guided corticosteroid injection was superior to blind injection, exercise was superior to doing nothing, specific exercise was superior to non-specific exercise, and nerve block was superior to control.

2. For pain, manual therapy was superior to doing nothing or sham, manual therapy plus exercise was superior to exercise alone (but only at shorter follow-ups), manual therapy had immediate effects, laser therapy was superior to sham.

3. For active range of motion, exercise was superior to non-exercise physical therapy modalities.

Further, they wrote, “NSAIDs and corticosteroids are superior to placebo, but it is unclear how these treatments compare to exercise . . . . Corticosteroid injections seem to be a valid alternative only when exercise or other modalities are not possible while NSAIDs can be helpful, if necessary, in addition to exercise.”

There was insufficient evidence for or against the use of therapy involving hyaluronate, pulsed electromagnetic fields, transcutaneous electrical nerve stimulation, acupuncture, diacutaneous fibrolysis, myofascial trigger points, microwave, comprehensive physiotherapy, platelet-rich plasma, interferential light therapy, massage, microcurrent electrical stimulation or ultrasound-guided percutaneous electrolysis.

SOURCE: http://bit.ly/2rL6U2Y

Br J Sports Med 2017.


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