Role of physiotherapy in the treatment of subacromial impingement syndrome: a prospective study
Introduction
Subacromial impingement is a common cause of shoulder pain and many patients with this condition recover with conservative management [1], [2], [3], [4], [5], [6]. The most commonly used modalities of non-operative treatment include activity modification, anti-inflammatory medication [7], [8], subacromial injection of steroid [9], [10], [11], [12], ultrasound [9], [13] and physical therapy programmes [14], [15], [16], [17].
The goals of non-operative treatment of subacromial impingement are to decrease subacromial inflammation, to allow healing and strengthening of a dysfunctional rotator cuff and to restore pain-free shoulder function [17], [18].
Subacromial impingement syndrome occurs as a result of pathology of one or more of the structures located within the subacromial space [2]. Located within the subacromial space are the tendons of the rotator cuff and the long head of biceps, the subacromial/subdeltoid bursa and the superior capsule of the glenohumeral joint. The diagnosis of subacromial impingement is specific. It is not the only cause of pain in the anterolateral aspect of the shoulder. Other conditions can cause similar symptoms in the shoulder, calcific tendinitis, glenohumeral instability, cervical radiculitis, adhesive capsulitis, degenerative joint disease, isolated acromioclavicular arthritis and local nerve compression [6]. The diagnosis of impingement is usually made on the basis of a thorough history and examination, together with plain radiographs [19]. Neer's test [1] is frequently used as a diagnostic adjunct. Although additional imaging modalities are helpful in excluding other pathology, they are not generally useful in diagnosing subacromial impingement [6], [20]. In this study, the diagnosis of impingement was made using the above criteria. Ultrasound and magnetic resonance imaging were not performed routinely.
Evidence suggests that subacromial impingement syndrome has a multi-factorial aetiology [2]. Factors implicated include rotator cuff over-use and degeneration, glenohumeral hypermobility and instability, restrictive processes of the shoulder, abnormalities and changes of the acromion, functional scapular instability and poor posture [2].
Few studies have been performed to investigate the efficacy of physical therapy programmes for subacromial impingement [21], [22], [23]. The majority of these are either retrospective or fail to isolate a single treatment modality. A recent Cochrane report [23] has reviewed the evidence for physiotherapy intervention in shoulder pain and concluded that there is little evidence to either support or refute the efficacy of many of the modalities used. It also comments that the interpretation of the results of the studies was difficult because the shoulder disorders are often poorly defined. In the most recent review, only three trials comparing supervised exercises (two studies) and mobilisation (one study) with no treatment were eligible for inclusion [23].
In a study not included in the Cochrane review, Morrison et al. [3] assessed the result of non-operative treatment in 616 patients over a mean 27-month period. Of these, 67% had a satisfactory result, not requiring surgery.
This study assessed the value of physiotherapy in patients with subacromial impingement syndrome.
Section snippets
Materials and methods
Patients with a diagnosis of subacromial impingement were identified at a specialist shoulder clinic. The diagnosis of subacromial impingement was made using the clinical history, clinical examination and radiographic findings, together with diagnostic local anaesthetic injections into the subacromial space and acromioclavicular joint. These patients underwent three steroid injections into the subacromial space, given at 6-weekly intervals as part of an existing protocol. All injections were
Results
The two groups were well matched for age, sex and initial Constant score (Table 1).
Three patients in the physiotherapy group were unable to complete the physiotherapy programme for social reasons and were therefore excluded, leaving 42 patients. All patients in this group had improved Constant scores over the 6-month period. The mean Constant score at initial assessment was 52 (range 23–84). The mean improvement in the Constant score was 20 (range 4–45) (Fig. 1). Eleven patients felt that they
Discussion
In this study, we investigated the isolated effect of a physiotherapy programme on patients with a specific diagnosis of subacromial impingement. The patients included in this trial were recruited following failed conservative treatment consisting of three subacromial injections of steroid at 6-weekly intervals. At this stage, they were placed on the waiting list for surgery (acromioplasty) when it was felt that operative intervention was indicated, according to an existing protocol. This has
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