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A specific exercise strategy for patients with subacromial pain significantly reduced the need for surgery: one-year results of a randomised controlled study
Linköping University, Department of Clinical and Experimental Medicine, Orthopaedics. Linköping University, Faculty of Health Sciences. (Lars Adolfsson)
Linköping University, Department of Medical and Health Sciences, Physiotherapy. Linköping University, Faculty of Health Sciences.
Linköping University, Department of Medical and Health Sciences, Physiotherapy. Linköping University, Faculty of Health Sciences.
Linköping University, Department of Medical and Health Sciences, Physiotherapy. Linköping University, Faculty of Health Sciences.
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(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 [en]
Subacromial pain patients, exercises, eccentric, rotator cuff tear
National Category
Orthopedics Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-82118OAI: oai:DiVA.org:liu-82118DiVA: diva2:557931
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
In thesis
1. Treatment of subacromial pain and rotator cuff tears
Open this publication in new window or tab >>Treatment of subacromial pain and rotator cuff tears
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Shoulder pain is very common, affecting 14-21 % of the population at some time during their lifetime. The aims of this thesis were to improve the understanding of various aspects concerning the pathogenesis and treatment of subacromial pain and rotator cuff tears. Patients and healthy individuals were examined and compared in five studies:

Study I) Seventy patients were retrospectively examined, clinically and with ultrasound, 15 years after arthroscopic subacromial decompression. All patients had an intact rotator cuff at surgery. Ultrasound showed significantly fewer rotator cuff tears compared to the prevalence of asymptomatic tears reported in the literature for the same age group. This indicates that arthroscopic subacromial decompression might protect the rotator cuff.

Study II) Forty-two patients were retrospectively examined, clinically and with ultrasound, 39 months (mean) after an acute rotator cuff repair. All patients had pseudoparalysis after trauma, a full thickness tear and no previous history of shoulder symptoms. A delay in surgical treatment of three months and the number of tendons injured did not affect the outcome. Age affected outcome negatively.

Study III) Plasma samples from 17 patients with cuff tears and 16 plasma samples from healthy age- and gender-matched controls were collected and analysed regarding the levels of matrix metalloproteinases and their inhibitors, TIMP1-4. Elevated levels of TIMP-1 were found in the patients with cuff tears compared to controls. Higher levels of TIMP-1, TIMP-3 and MMP-9 were found in patients with full-thickness tears compared to patients with partial-thickness tears.

Study IV) Ninety-seven patients with longstanding subacromial pain, on the waiting-list for arthroscopic subacromial decompression, were prospectively randomised to specific shoulder exercises or control exercises for three months. Thereafter they were clinically examined and asked if they still wanted surgery. The specific shoulder exercises focusing on eccentric exercise for the rotator cuff and scapula stabilisers were found to be effective in reducing subacromial pain and improving shoulder function, thereby reducing the need for surgery.

Study V) All patients including those operated, in Study IV were re-examined after one year using clinical assessment scores. The option of surgery was continuously available up to the one-year follow-up. Ultrasound and radiological examinations performed at inclusion were analysed in relation to the choice of surgery. The positive effects of the specific exercise programme were maintained after one year and significantly fewer patients in this group chose surgery. Surgery was significantly more often chosen by patients who had a low baseline shoulder score, and/or a full thickness rotator cuff tear.  All patients showed significant improvement in the clinical scores one year after inclusion or one year after surgery.

These results support the concept that subacromial pain has a multifactorial aetiology and that the first line of treatment should be specific shoulder exercises. When conservative treatment fails, an acceptable result can be achieved with arthroscopic subacromial decompression. The rotator cuff status is important to consider when treating and studying these patients.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2012. 90 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1312
Keyword
Shoulder, rotator cuff tear, ultrasound, surgery, exercises
National Category
Clinical Medicine
Identifiers
urn:nbn:se:liu:diva-82094 (URN)978-91-7519-862-0 (ISBN)
Public defence
2012-10-26, Berzeliussalen, Campus US, Linköpings universitet, Linköping, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2012-10-02 Created: 2012-09-28 Last updated: 2013-03-15Bibliographically approved
2. Exercise treatment of patients with long-standing subacromial pain
Open this publication in new window or tab >>Exercise treatment of patients with long-standing subacromial pain
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:nbn:se:liu:diva-90021 (URN)978-91-7519-695-4 (ISBN)
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

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Björnsson Hallgren, HannaHolmgren, TheresaÖberg, BirgittaJohansson, KajsaAdolfsson, Lars

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