A specific exercise program for patients with subacromial impingement syndrome can improve function and reduce the need for surgery

Holmgren A et al (2012) Effect of specific exercise strategy on need for surgery on patients with subacromial impingement syndrome: randomised controlled study. BMJ 344: e787. [Prepared by Nicholas Taylor, CAP Editor.] Question: Does a specific exercise program improve shoulder function more than non-specific exercises in patients with subacromial impingement? Design: Randomised, controlled trial with concealed allocation and blinded outcome assessment. Setting: University hospital in Sweden. Participants: Patients aged 30 to 65 years with subacromial impingement syndrome of at least 6 months duration, and on the waiting listing for surgery were included. Key exclusion criteria included previous shoulder fractures, and frozen shoulder. Randomisation of 102 participants allocated 52 to the intervention exercise group and 50 to a control exercise group. Interventions: Both groups received a subacromial corticosteroid injection at inclusion and commenced exercises 2 weeks later. Both groups visited a physiotherapist 7 times over 10 weeks and were prescribed home exercises for 12 weeks. The intervention exercise group were prescribed 6 exercises: 2 eccentric exercises for the rotator cuff, 3 concentric/eccentric exercises for the scapula stabilisers, and a posterior shoulder stretch. Each strengthening exercise was repeated 15 times in 3 sets twice daily for 8 weeks and then once daily for 4 weeks. The stretch was completed for 30 to 60 seconds and repeated 3 times twice daily. Training load was progressed using weights or elasticised bands. The control group exercise program consisted of 6 non-specific movement exercises for the neck and shoulder (e.g. neck retraction, shoulder abduction). The control group exercises were not loaded or progressed and were completed 10 times 3 times daily. Outcome measures: The primary outcome was the Constant shoulder score at 3 months. The Constant score is scored from 0 to 100 with a higher score indicating better function. Secondary outcome measures included the disability of the arm, shoulder and hand questionnaire (DASH), a visual analogue score for pain, the EuroQol quality of life instrument, and whether the participant thought they still needed surgery. Results: 97 participants completed the study. At 3 months, the change in Constant score was significantly more in the specific exercise group than the control group by 15 (95% CI 8.5 to 20.6) points. The DASH improved significantly more in the intervention than the control group by 8 (95% CI 2.3 to 13.7) points. The intervention group also improved significantly more than the control group in ratings of night pain, and quality of life. A lower proportion of the specific exercise group subsequently chose surgery (20% v 63%, Number Needed to Treat 3, 95% CI 1.6 to 3.9). Conclusion: A specific, progressive exercise program focusing on training the rotator cuff and scapular stabilisers was effective in improving function, reducing pain and reducing the need of surgery for patients with chronic subacromial impingement syndrome.