PT Critically Appraised Topics
 

Document Type

Critically Appraised Topic

Publication Date

2015

Clinical Scenario

The patient who led me to pursue this question is a 35 y/o female with a diagnosis of Subacromial Impingement Syndrome. Medical treatment to date has included: (1) physical therapy involving joint mobilizations, range of motion treatment (passive range of motion, active range of motion, and active-assisted range of motion), rhythmic stabilization exercises, rotator cuff strengthening exercises, neuromuscular coordination and periscapular exercises; (2) use of oral prednisone over a 9 day period as prescribed by a primary care physician and (3) local injection of corticosteroids. Problems identified (or physical therapy [PT] diagnosis) include range of motion impairments in all planes, deficits in neuromuscular coordination of periscapular musculature and deficits in rotator cuff strength, leading to an inability to tolerate any overhead activity.

Clinical Question

Is the utilization of eccentric therapeutic exercise in the treatment of subacromial impingement syndrome more effective than the use of traditional therapeutic exercise at decreasing symptoms and increasing overall function?

Clinical Bottom Line

Analysis of the findings in these four articles suggests that utilizing an eccentric-based exercise program may provide some additional benefits when compared to more traditional exercise programs. These benefits include improvements in patient function (as measured by the SPADI, DASH, and Constant-Murley Shoulder Assessment), improvement in pain at night, and slight increases in strength at certain positions of shoulder abduction. There appears to be some disagreement as to whether using an eccentric-based exercise program can serve as a viable alternative to surgery. However, the studies with the stronger methods and subject population (Holmgren et al and Maenhout et al) seem to agree that an eccentric program can indeed serve as an alternative to surgical intervention. It is difficult to determine if eccentric-based programs are any more effective as an alternative to surgery than traditional therapeutic exercise programs as only two of the studies compared an eccentric-based program directly to a more traditional program.. Also noteworthy is the fact that all of the exercise programs varied between the studies for both the traditional and eccentric-based groups and this must be taken into consideration when comparing the findings. Neither Jonsson et al nor Camargo et al had particularly strong internal validity making their results even more difficult to apply to the original clinical question. Overall, given that the use of an eccentric-based therapeutic exercise program delivers similar efficacy in most outcome measures but shows some additional improvements in shoulder strength, nighttime pain, and function it is worth considering adding into treatment plans of subacromial impingement syndrome, and may serve as a viable alternative to surgery. This is especially true considering the feasibility and cost of introducing such a program would not be any greater than traditional programs already being utilized. Further considerations and merits are discussed in the synthesis and discussion section.

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