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Department of Sports Science and Clinical Biomechanics, Research Unit for Musculoskeletal Function and Physiotherapy, University of Southern Denmark, Odense
Department of Sports Science and Clinical Biomechanics, Research Unit for Musculoskeletal Function and Physiotherapy, University of Southern Denmark, Odense
To study the effects of supervised training in adults with subacromial pain syndrome.
Data Sources
Embase, MEDLINE, Cochrane Library, Cumulative Index to Nursing and Allied Health, and Physiotherapy Evidence Database were searched from inception to March 2020.
Study Selection
Independent reviewers selected randomized controlled trials comparing supervised training with (1) no training or (2) self-training in adults with subacromial pain syndrome lasting for at least 1 month. Critical outcomes were shoulder pain, function, and patient-perceived effect. Important outcomes included other potential benefits and adverse events at 3-month follow-up.
Data Extraction
Two independent reviewers extracted data for the meta-analysis. Risk of bias was assessed using the Cochrane Risk of Bias tool 1, and certainty of evidence was evaluated using the Grades of Recommendation Assessment, Development, and Evaluation (GRADE).
Data Synthesis
Ten studies (n=597, 43% female) were included. Supervised training resulted in larger improvements than no training on pain (at rest: n=286; mean difference [MD], 1.68; 95% confidence interval [CI], 0.31-3.06 on 0-10 scale; during movement: n=353; MD, 1.84; 95% CI,0.91-2.76), function (n=396; standardized MD, 0.30; 95% CI, 0.07-0.52), and patient-perceived effect (n=118; risk ratio, 1.43; 95% CI, 0.87-2.34). Supervised training had potential benefits regarding quality of life, return to work, dropout, and training adherence, albeit more patients reported mild, transient pain after training. Supervised training and self-training showed equal improvements on pain (n=44) and function (n=76), with no data describing patient-perceived effect. Certainty of evidence was low for critical outcomes and low-moderate for other outcomes.
Conclusions
Supervised training might be superior to no training and equally effective as self-training on critical and important outcomes. Based on low-moderate certainty of evidence, these findings support a weak recommendation for supervised training in adults with subacromial pain syndrome.
describes the clinical entity of a painful and functionally impaired shoulder, usually experienced when combining shoulder elevation and rotation. Different terms, including subacromial impingement syndrome, rotator cuff tendinopathy,
The pathogenesis of SAPS is unknown but has traditionally been linked to pathology in a variety of shoulder structures, that is, the rotator cuff muscles and tendons, the acromion, the coracoacromial ligament, and capsular or intra-articular tissue.
Current guidelines provide inconsistent recommendations for subacromial surgery but generally advice against surgery for the treatment of SAPS as first line of treatment.
concluded a strong recommendation for exercise-based treatment in this patient group. Besides being as effective as surgery, training is safe and cost-effective.
However, delivering methods vary from patients being offered a leaflet or a link to a video that introduces self-training to a training program with intensive weekly supervised sessions. Unfortunately, the delivery method is often not addressed in the conclusion about the effect of training in current recommendations. Therefore, it remains unknown whether the effect of supervised training exceeds the effect of no training and/or self-training, and the evidence behind the strong recommendations for training should be further evaluated and specified.
To our knowledge, no previous studies have reviewed training for SAPS using strict definitions of training interventions as being either supervised or self-training. Therefore, the objective of this systematic review and meta-analysis was to study the effect of supervised training in adult patients with SAPS for more than 1 month compared with (1) no training or (2) self-training on pain, function, and patient-perceived effect at 3-month follow-up.
Methods
This systematic review and meta-analysis was based on the guidelines of the Cochrane Collaboration
for systematic reviews of interventions. The study reporting adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations.
The systematic review was conducted as part of the preparation of a national clinical guideline on treatment of nontraumatic shoulder pain published by the Danish Health Authority in 2020. The protocol was preregistered with PROSPERO (trial registration no. CRD42020164218).
Data sources and search strategy
The search consisted of 2 steps. First, a search for systematic reviews published from 2009-2020 was performed on January 13, 2020, to identify systematic reviews with relevant primary studies to be included in the synthesis. Second, a systematic search was performed on March 9, 2020, to identify individual randomized controlled trials (RCTs) based on the latest search date from the included systematic review by Page et al,
which had the most comprehensive literature search. Searches were performed in Embase, MEDLINE, Cochrane Library, Cumulative Index to Nursing and Allied Health, and Physiotherapy Evidence Database. The search strategy included subject heading and text words related to the eligibility criteria, and no restrictions concerning publication status or language were applied (supplemental appendix S1, available online only at http://www.archives-pmr.org/).
Study selection
Duplicates were removed in RefWorks, and the remaining records were imported to Covidence (Covidence systematic review softwarea). Records were screened by 2 independent reviewers for title and abstract (M.H., S.B.), and full-text articles were assessed independently for eligibility by 2 reviewers (B.L., S.B.). Any discrepancies between the 2 authors were resolved through discussion until consensus was reached. If necessary, the decision was adjudicated by a third author (A.U.). Authors were not blinded to study identification (authors and journal). Reference lists of the included studies were hand-screened for potentially further relevant studies. One additional study
was identified via communication with a shoulder expert.
We searched for RCTs in all languages if there was an English abstract, and no studies were excluded because of language. Nonrandomized studies, unpublished studies (eg, conference abstracts, trial protocols), and animal studies were excluded. Prespecified eligibility criteria were based on the population, intervention, comparison, and outcome framework.
Adult patients with nontraumatic shoulder pain and clinical symptoms of SAPS lasting for at least 1 month were included because many patients are assumed to seek professional advice if symptoms are not resolved within this time frame. Related terms for SAPS such as subacromial impingement syndrome, rotator cuff tendinopathy, and rotator cuff–related shoulder pain were included. Instead of setting strict diagnostic criteria, we accepted the studies’ own criteria for SAPS. Exclusion criteria were posttraumatic pain, traumatic rotator cuff rupture, traumatic shoulder instability, frozen shoulder, symptomatic osteoarthritis of the shoulder or acromioclavicular joints, acute tendinitis calcarea, arthralgia and arthritis in connective tissue and joint diseases, neck disorders, pain triggered by other organ systems, pathology in and around the biceps tendon, neoplasms and metastases, neuropathic pain, and generalized pain in the body (eg, fibromyalgia).
Intervention
Supervised training was defined as training that was instructed, supervised, and monitored by a health care professional including 2 or more supervised sessions.
Comparator
For aim (1) we included studies with no training (defined as no treatment, wait-and-see, active following, and sham), whereas for aim (2) it was self-training (eg, self-training provided by a leaflet and/or 1-time instruction).
Outcome
Pain, shoulder function, and patient-perceived effect were classified as critical outcomes.
Pain could be measured by using a visual analog scale or Numeric Pain Rating Scale, with 0 indicating “no pain” and 10 indicating “extreme pain.” The minimal important difference (MID) was set at 1.5.
Function could include different measurement tools, for example, the Constant score, a 100-point scale combining subjective (pain, activities of daily living) and objective (strength, range of motion) measurements (MID, 8.3),
with higher scores indicating higher function; the Disability of the Arm, Shoulder, and Hand, with a score ranging from 0 (no disability) to 100 (most severe disability) (MID, 10.2)
; and the Neer shoulder scale, a 0-100 scale combining subjective (pain) and objective (muscle strength, reaching ability, stability, active range of motion, and an anatomic or radiological evaluation), with higher scores indicating higher function (MID unknown). Patient-perceived effect included Global Perceived Effect (1-7), Patient Global Impression of Improvement, or Clinical Global Impression. MIDs were defined as a score of 1 or 2 on Patient Global Impression of Improvement or Clinical Global Impression and a score of +3 or +2 on Global Perceived Effect. Pain, function, and patient-perceived effect were considered the critical outcomes to evaluate the effect of training in shoulder related problems. Patient-perceived effect is a broad effect measure of both satisfaction and experience of treatment effect that are not captured with the narrower effect measures, such as pain and function. Patient-perceived effect was considered a critical outcome because perceived effect is of great importance for the patient's motivation and adherence to exercise.
Important (not critical) outcomes included quality of life, for example, European Quality of life scale, dropouts for all reasons, serious adverse events (eg, events requiring hospitalization), adverse events (eg, symptom flare up), return to work, and adherence or compliance to the training protocol.
The primary endpoint of interest for all outcomes was 3 months after starting the training intervention. However, this was extended to periods between 6 weeks and 6 months after looking through the retained studies.
Data extraction
Two authors (A.U., S.B.) independently extracted the data using a predefined extraction template: study design, study population, baseline characteristics, and outcome measures. Any discrepancies between the 2 authors were resolved through discussion until consensus was reached. If necessary, a third independent author (B.L.) was consulted. Where possible, missing values (eg, SD) were calculated from the available data (P value, t value, confidence interval [CI], or Standard error). Study authors were contacted for missing data.
Risk of bias
We assessed the internal validity of the systematic reviews using a Measurement Tool to Assess Systematic Reviews.
All included RCTs were assessed in Covidence for risk of bias using the Cochrane Risk of Bias tool 1 by 2 independent reviewers (S.B., A.U.), with disagreements resolved by discussion and a third author (B.L.) being consulted if consensus could not be reached.
Each item was graded (unclear, low, or high risk of bias) based on randomization sequence generation, treatment allocation concealment, blinding of patients and personnel, blinding of outcome assessors, completeness of outcome data, selective outcome reporting, and other sources of bias.
Certainty of evidence
The Grades of Recommendation Assessment, Development, and Evaluation (GRADE)
approach was used to assess the overall certainty of evidence for each outcome deemed critical or important, using the GRADEpro Guideline Development Tool (https://gradepro.org/). According to GRADE, RCTs begin as “high certainty” evidence and can be downgraded to “moderate,” “low,” or “very low certainty” based on limitations in study design, indirectness, imprecision, inconsistency, and publication bias. The overall certainty of evidence was determined by the lowest certainty level for the critical outcomes. No funnel plots were generated to judge publication bias because no more than 10 studies were included in each analysis.
Data analysis
Review Manager 5.3 softwareb was used for data analysis, data synthesis, and creation of forest plots. Continuous outcomes were reported as mean difference (MD) with 95% CIs. For the function outcome in supervised compared with no training, the standardized mean difference (SMD) with 95% CI was reported because different scales were used in the included studies. Dichotomous outcomes (ie, patient-perceived effect in supervised compared with no training) were reported as risk ratios (RRs) with 95% CIs. Heterogeneity was assessed by visual inspection of the forest plot, by using the chi-square test, and the I2 statistic. Because we anticipated variation between studies, meta-analysis was carried out using the random-effects model when 2 or more studies were included in the analyses; otherwise the fixed-effects model was used. The Inverse Variance method was used for continuous outcomes and the Mantel-Haenszel method for dichotomous outcomes.
Data were extracted for the duration and intensity of the intervention as well as the duration of pain at inclusion/baseline to describe the included studies and to report on the interpretation of duration and intensity of training interventions. A sensitivity analysis was conducted excluding studies with extreme results to explain potential heterogeneity.
Results
Study selection
After the initial search for systematic reviews and after duplicate removal, 1800 records were screened by title and abstract, 86 full-text articles were considered for inclusion, and 3 systematic reviews
Effect of supervised physiotherapy versus home exercise program in patients with subacromial impingement syndrome: a systematic review and meta-analysis.
Effectiveness of conservative interventions including exercise, manual therapy and medical management in adults with shoulder impingement: a systematic review and meta-analysis of RCTs.
reported adequate description of all the necessary domains assessed by a Measurement Tool to Assess Systematic Reviews (score 11/11) (supplemental appendix S2A, available online only at http://www.archives-pmr.org/). Based on this review, a search for primary studies from 2015 and onward was conducted, where 1401 additional records were identified plus 1 record identified through other sources, 29 full-text articles were considered, and 1 additional RCT was included. In total, 10 RCTs
Arthroscopic surgery versus supervised exercises in patients with rotator cuff disease (stage II impingement syndrome): a prospective, randomized, controlled study in 125 patients with a 2 1/2-year follow-up.
A 12-week rehabilitation program improves body composition, pain sensation, and internal/external torques of baseball pitchers with shoulder impingement symptom.
Effectiveness of extracorporeal shock wave therapy associated with kinesitherapy in the treatment of subacromial impingement: a randomised, controlled study.
Fig 1Flowchart showing the process of selecting (A) systematic reviews and (B) primary studies. The number of included studies and reasons for exclusion are provided.
A 12-week rehabilitation program improves body composition, pain sensation, and internal/external torques of baseball pitchers with shoulder impingement symptom.
Arthroscopic surgery versus supervised exercises in patients with rotator cuff disease (stage II impingement syndrome): a prospective, randomized, controlled study in 125 patients with a 2 1/2-year follow-up.
A 12-week rehabilitation program improves body composition, pain sensation, and internal/external torques of baseball pitchers with shoulder impingement symptom.
Effectiveness of extracorporeal shock wave therapy associated with kinesitherapy in the treatment of subacromial impingement: a randomised, controlled study.
Arthroscopic surgery versus supervised exercises in patients with rotator cuff disease (stage II impingement syndrome): a prospective, randomized, controlled study in 125 patients with a 2 1/2-year follow-up.
Effectiveness of extracorporeal shock wave therapy associated with kinesitherapy in the treatment of subacromial impingement: a randomised, controlled study.
A 12-week rehabilitation program improves body composition, pain sensation, and internal/external torques of baseball pitchers with shoulder impingement symptom.
n=20, Intervention 59.3±10.1 Control 60.8±12.4, 56 (47)
Age >18 y, shoulder pain >3 mo, pain on movement >3/10 (0-10 NRS), pain on active abduction or external rotation, and a positive quick test for shoulder impingement.
A manual therapy and home exercise program; 10 individual supervised sessions, 30-45 min each over 10 wk. For the following 12 wk, the group continued the home exercise program. Exercises: dynamic scapular control, strengthening scapular stabilizer and rotator cuff muscles, shoulder and thoracic posture, and range of motion of thoracic extension.
Inactive ultrasound therapy and application of an inert gel; 10 visits, 10 min each; 10 sessions of individual, standardized treatment over 10 wk.
Pain during movement (NRS) Pain at rest (NRS) Function (SPADI) Quality of life (SF-36) Patient-perceived effect (participants’ perceived global rating of change) Adverse events Dropout adherence Endpoint: 10 wk
Arthroscopic surgery versus supervised exercises in patients with rotator cuff disease (stage II impingement syndrome): a prospective, randomized, controlled study in 125 patients with a 2 1/2-year follow-up.
Total no. of participants in the 3-arm study design, but we only extracted data from the intervention and comparator of interest.
), Intervention 47±NA Control 48±NA Arthroscopic surgery 48±NA, 43 (54)
Aged 18-66 y; shoulder pain >3 mo, no effect of previous physiotherapy and anti-inflammatory drugs; dysfunction or pain on abduction; a normal passive glenohumeral range of movement; pain during 2 of the 3 isometric-eccentric tests (abduction at 0 and 30 ° and external rotation); and positive impingement tests.
Exercise regimen over 3-6 mo, supervised 2/wk (supervision was gradually reduced). On the other days they followed the same exercise program at home. Resistance was added gradually to strengthen the short shoulder rotator and the scapular stabilizing muscles.
12 sessions of detuned soft laser treatment over 6 wk.
Pain during movement (NRS, 1-9) Pain at rest (NRS, 1-9) Function (Neer shoulder score) Return to work Endpoint: 3 mo
A 12-week rehabilitation program improves body composition, pain sensation, and internal/external torques of baseball pitchers with shoulder impingement symptom.
n=30, Intervention 21.31±1.74 Control 22.57±1.79, 0 (0)
Baseball players with impingement symptoms: posterosuperior shoulder pain during throwing; pain during the apprehension test and pain relief during the relocation test; or a positive response in 1 of the abovementioned tests associated with another of the following diagnostic indicators: Neer, Hawkins, or Jobe for reproducible pain.
Physical therapy, warm-up, workout, and cooldown. Ultrasonic wave (5min) and laser therapy (10min). Warm-up with stationary cycling (15min) and standing stretching (5min). A supervised progressive rehabilitation program 3/wk. Exercises: targeting the shoulder and upper extremity.
Nonstructured training
Pain at rest (NRS) Pain strenuous activity (NRS) Pain normal daily activity (NRS) Endpoint: 12 wk
Patients on waiting list for subacromial decompression. Subacromial impingement: clinical history, clinical examination, and radiographic findings, together with diagnostic local anesthetic injections into the subacromial space and acromioclavicular joint.
Combination of supervised therapy at the hospital and a home exercise program, assessed regularly. 3 steroid injections into the subacromial space, given at 6 weekly intervals as part of an existing protocol. Optional joint mobilization. The exercise program was progressed to involve strengthening and lasted 6 mo, twice a day. Exercises: posture and recruitment and strength of scapulothoracic muscles. Progressed to involve strengthening of infraspinatus, subscapularis, and teres minor relative to the supraspinatus and deltoid with the use of resistance.
Shoulder pain, positive painful arc test, and “extreme sensation” to palpation of biceps or rotator cuff tendons, pain aggravation due to resisted range of shoulder movements.
6 wk of training, 3 times a day. Supervised group was appointed 2/wk. Exercises: pendulum exercises, wand exercises, and isometric exercises.
Same as intervention without supervision.
Function (SPADI) Function (DASH) Dropout Endpoint: 6 wk
n=46, Intervention 47.6±10.0 Control 48.2±9.8, 22 (48)
Aged 18-65 y, unilateral shoulder pain >12 wk. The following 3 tests positive: painful arc test, positive infraspinatus test (pain and/or weakness), and the Kennedy Hawkins test. Normal passive glenohumeral physiological range of motion.
10 treatments of supervised exercise therapy, in addition to home exercises. Exercises were individually adapted. A thin rubber band was used for many of the exercises to reduce the arm load, control movement, or provide resistance. The exercises were performed with as little pain as possible. 3 sets of 30 repetitions for most exercises. 4-6 exercises twice a day every day. Optional stretching exercises. Exercises: reestablish normal shoulder movement patterns through awareness, correct scapula placement, scapular stabilizing exercises, rotator cuff exercises, and pain-free range of motion exercises.
Same as intervention without supervision. The home exercise group had 1 supervised treatment session with a physiotherapist to set up a tailored home exercise program. They were instructed in the progression opportunities for the appropriate exercises.
Pain average previous wk (NRS) Function (SPADI) Return to work Dropout Endpoint: 6 wk
Total no. of participants in the 3-arm study design, but we only extracted data from the intervention and comparator of interest.
), Intervention 48±1.8 Control 49.2±1.8 Asymptomatic control 49.4±2.5, 0 (0)
At least 2 positive shoulder impingement tests (Neer, Hawkins/Kennedy, Yocum, Jobe, and/or Speeds tests) and pain reproduction during 2 of 3 of (1) painful arc; (2) tenderness to palpation of the biceps or rotator cuff tendons; and (3) pain with 1 or more resisted glenohumeral joint motions (flexion, abduction, internal rotation, external rotation).
A standardized 8-wk home exercise program including progressive resistance strengthening exercises 3 d/wk for 2 muscle groups. Supervision after 1 wk. Phone contact at 4 wk to monitor compliance, discuss any problems, and ensure proper progression of the exercises. 4-wk recheck optional. Exercises: stretching, upper trapezius relaxation exercise, serratus anterior strengthening; external rotation strengthening.
Nonstructured training
Pain during work (NRS) Function (SRQ score) Patient-perceived effect (Satisfaction score 0-10) Endpoint: 8-12 wk
Effectiveness of extracorporeal shock wave therapy associated with kinesitherapy in the treatment of subacromial impingement: a randomised, controlled study.
Total no. of participants in the 3-arm study design, but we only extracted data from the intervention and comparator of interest.
), Intervention 53.66±7.35 Control 55.76±13.08 Shock wave 53.66±8.98, 42 (70)
Neer stage I and II subacromial impingement.
Exercises were performed under the supervision of a rehabilitation therapist; after the last session the participants were asked to continue the exercises at home on alternate days. Advice: (1) during desk work, rest the elbow on a support abducting the shoulder 30-40 °; (2) avoid long hanging of the upper limb; (3) avoid sleeping on the affected shoulder and apply a small pillow under the armpit on the affected side; (4) when handling loads keep the weight near the trunk to shorten the lever arm. Exercises: (1) Codman; (2) capsular stretching; (3) isometric for the rotators and deltoid; (4) elastic resistance for the rotators, deltoid, and trapezius.
Same advice as in the intervention group
Function (CS) Endpoint Intervention group: 8 mo after 15-wk training. Control: 8 mo after initial examination
Physiotherapy treatment consisting of 10 appointments, each lasting 30 min, and ice treatment and electrotherapy or ultrasonography. Exercises: stretching the chest muscles; strengthening the shoulder muscles near the spine, the rotator cuff, the humeral head depressors, and the deltoid muscle, supplemented by neurophysiological techniques with activation of entire muscle loops and transverse friction.
Nonstructured training
Pain (McGill Pain Questionnaire and Pain Disability Index) Endpoint: 35 d
Abbreviations: CS, Constant score; DASH, Disabilities of the Arm Shoulder and Hand; NA, not applicable; NRS, Numeric Rating Scale; SF-36, 36-Item Short Form Survey; SPADI, Shoulder Pain and Disability Index; SRQ, Shoulder Rating Questionnaire; VAS, visual analog scale.
Total no. of participants in the 3-arm study design, but we only extracted data from the intervention and comparator of interest.
† No. of randomized participants but only 32 participants included in analysis.
compared supervised training with self-training consisting of a maximum of 1 supervised session. Eight studies compared supervised training with no training: 4 studies compared with no training,
A 12-week rehabilitation program improves body composition, pain sensation, and internal/external torques of baseball pitchers with shoulder impingement symptom.
Effectiveness of extracorporeal shock wave therapy associated with kinesitherapy in the treatment of subacromial impingement: a randomised, controlled study.
Arthroscopic surgery versus supervised exercises in patients with rotator cuff disease (stage II impingement syndrome): a prospective, randomized, controlled study in 125 patients with a 2 1/2-year follow-up.
). The included studies used various exercises and dosages, but all of them included components of strengthening the rotator cuff and scapular muscles. The extent of supervision also varied between the individual studies but included weekly appointments for most of them.
Critical outcomes
Supervised training resulted in larger improvements than no training on pain at rest (4 studies; n=286; MD, 1.68; 95% CI, 0.31-3.06 on 0-10 scale), pain during movement (5 studies; n=353; MD, 1.84; 95% CI, 0.91-2.76), and function (5 studies; n=396; SMD, 0.30; 95% CI, 0.07-0.52) (fig 2A-C). Supervised training resulted in higher patient-perceived effect (1 study; n=118; RR, 1.43; 95% CI, 0.87-2.34, mean absolute difference=127 of 1000 more patients get much better improvement) (fig 2D). In 1 study
patient-perceived effect was reported on a scale from 0-10, and these data could therefore not be included in the analysis. A separate analysis of these data also favored supervised training (n=67; MD, 1.2; 95% CI, 0.24-2.16). Two studies
Effectiveness of extracorporeal shock wave therapy associated with kinesitherapy in the treatment of subacromial impingement: a randomised, controlled study.
were not included in the meta-analysis, of which 1 had a primary endpoint at 8 months, and 1 used McGill Pain Questionnaire and Pain Disability Index, which in this study was considered not relevant for the current predefined outcomes of interest. Both studies reported that supervised training was superior to no training.
Fig 2Forest plots of the comparison between supervised training and no training on (A) pain at rest, (B) pain during movement, (C) function, and (D) patient-perceived effect (overall successful outcome). Risk of bias: green (+) indicates low risk of bias, yellow (?) indicates unclear risk of bias, and red (−) indicates high risk of bias.
Supervised training and self-training showed equal effect on pain (1 study; n=44; MD, 0.20; 95% CI, −1.07 to 1.47 on 0-10 scale) and function (2 studies; n=76; MD, 1.00; 95% CI, −8.80 to 10.79 on 0-100 scale) (fig 3A,B), whereas there were no available data about patient-perceived effect.
Fig 3Forest plots of the comparison between supervised training and self-training on (A) pain and (B) function. Risk of bias: green (+) indicates low risk of bias, yellow (?) indicates unclear risk of bias, and red (−) indicates high risk of bias.
Two sensitivity analyses were performed to explain heterogeneity for supervised training compared with no training. For pain at rest, removing the study by Cha et al
A 12-week rehabilitation program improves body composition, pain sensation, and internal/external torques of baseball pitchers with shoulder impingement symptom.
because of the extreme results substantially reduced heterogeneity (MD, 0.96; 95% CI, 0.32-1.60; I2=20%). Risk of bias (rating the study by Bennell et al
Supervised training resulted in improvements in quality of life, return to work, adherence, and lower dropout compared with no training (see supplemental appendix S2B). Adverse events were relatively more frequent with training compared with no training (transient pain after training), but no serious adverse events were reported in the included studies (see supplemental appendix S2B).
Supervised training may reduce return to work (number of patients that have returned to work after the intervention) slightly compared with self-training (RR, 0.85; 95% CI, 0.53-1.36) and further reduces dropout compared with self-training (RR, 0.26; 95% CI, 0.07-0.94) (see supplemental appendix S2B).
Arthroscopic surgery versus supervised exercises in patients with rotator cuff disease (stage II impingement syndrome): a prospective, randomized, controlled study in 125 patients with a 2 1/2-year follow-up.
A 12-week rehabilitation program improves body composition, pain sensation, and internal/external torques of baseball pitchers with shoulder impingement symptom.
Effectiveness of extracorporeal shock wave therapy associated with kinesitherapy in the treatment of subacromial impingement: a randomised, controlled study.
Arthroscopic surgery versus supervised exercises in patients with rotator cuff disease (stage II impingement syndrome): a prospective, randomized, controlled study in 125 patients with a 2 1/2-year follow-up.
A 12-week rehabilitation program improves body composition, pain sensation, and internal/external torques of baseball pitchers with shoulder impingement symptom.
Effectiveness of extracorporeal shock wave therapy associated with kinesitherapy in the treatment of subacromial impingement: a randomised, controlled study.
Arthroscopic surgery versus supervised exercises in patients with rotator cuff disease (stage II impingement syndrome): a prospective, randomized, controlled study in 125 patients with a 2 1/2-year follow-up.
Arthroscopic surgery versus supervised exercises in patients with rotator cuff disease (stage II impingement syndrome): a prospective, randomized, controlled study in 125 patients with a 2 1/2-year follow-up.
A 12-week rehabilitation program improves body composition, pain sensation, and internal/external torques of baseball pitchers with shoulder impingement symptom.
A 12-week rehabilitation program improves body composition, pain sensation, and internal/external torques of baseball pitchers with shoulder impingement symptom.
as low risk of other bias (see supplemental appendix S2C).
Certainty of evidence (GRADE)
The certainty of evidence started as high because we only included RCTs. Regarding supervised training compared with no training, we downgraded 1 level for lack of blinding of patients in self-reported outcomes and 1 level for wide CIs for pain at rest and during movement, and for function we downgraded 1 level because of wide CIs and 1 level because of lack of blinding. For patient-perceived effect, we downgraded 1 level for lack of blinding and 1 level because only 1 study reported the relevant data. The overall certainty of evidence for supervised training compared with no training for the critical outcomes was therefore low (table 2).
Table 2Summary of findings for supervised training compared with no training
Risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
Supervised training probably results in little to no difference in serious adverse events compared with no training. There are probably no serious adverse events of supervised training.
NOTE. GRADE Working Group grades of evidence:
High certainty: We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: We are moderately confident in the effect estimate. The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low certainty: Our confidence in the effect estimate is limited. The true effect may be substantially different from the estimate of the effect.
Very low certainty: We have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of effect.
Risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
Regarding supervised training compared with self-training, we downgraded 1 level for lack of blinding of patients in pain and 1 level because only 1 study reported the relevant data for pain, and for function we downgraded 1 level for lack of blinding and 1 level for wide CIs. Therefore, also here the certainty of evidence for supervised training compared with self-training for the critical outcomes was low (table 3).
Table 3Summary of findings for supervised training compared with self-training
Risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
Supervised training probably reduces dropout all causes slightly compared with self-training.
NOTE. GRADE Working Group grades of evidence:
High certainty: We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: We are moderately confident in the effect estimate. The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low certainty: Our confidence in the effect estimate is limited. The true effect may be substantially different from the estimate of the effect.
Very low certainty: We have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of effect.
Risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
For important outcomes, certainty of evidence was graded as low to moderate for both study aims (see tables 2 and 3).
Discussion
Supervised training was superior to no training on the following primary outcomes: pain during rest and movement, shoulder function, and patient-perceived effect, albeit the effect on shoulder function was small. There were potential benefits related to quality of life, return to work, dropout, and training adherence. Supervised training and self-training were equally effective on pain and shoulder function. More people undergoing a training intervention experienced mild transient pain after training, which can be considered a minor adverse event to this intervention.
The difference in pain reduction between supervised training and no training was statistically significant and clinically relevant. However, when looking at the 95% CI, the reduction in pain for some patients with SAPS was not above the predefined MID.
The small increase in function (SMD, 0.31) corresponded to an MD of 4.86 (95% CI, 1.41-8.15) on the Constant Score, calculated using the SD from the final mean value in the control group from a previous study
The effectiveness of injections of hyaluronic acid or corticosteroid in patients with subacromial impingement: a three-arm randomised controlled trial.
However, an important caveat is that these MIDs are estimated from studies with differences related to participants’ disease/conditions, sample size, anchors and analytical methods, and the range of reported MID is wide for some of the outcome measures (eg, visual analog scale MIDs of 0.5-3.0 and the Constant score MIDs of 8-36).
Minimal important differences for improvement in shoulder condition patient-reported outcomes: a systematic review to inform a <em>BMJ</em>Rapid Recommendation.
Effectiveness of conservative interventions including exercise, manual therapy and medical management in adults with shoulder impingement: a systematic review and meta-analysis of RCTs.
Is exercise effective for the management of subacromial impingement syndrome and other soft tissue injuries of the shoulder? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.
Effectiveness of conservative interventions including exercise, manual therapy and medical management in adults with shoulder impingement: a systematic review and meta-analysis of RCTs.
Is exercise effective for the management of subacromial impingement syndrome and other soft tissue injuries of the shoulder? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.
Effectiveness of conservative interventions including exercise, manual therapy and medical management in adults with shoulder impingement: a systematic review and meta-analysis of RCTs.
A 12-week rehabilitation program improves body composition, pain sensation, and internal/external torques of baseball pitchers with shoulder impingement symptom.
from our review and concluded very low certainty evidence for the benefits of training using GRADE. In contrast, we could only find consensus on downgrading the evidence to “low” (similar to Page et al
), which we based on insufficient or no “blinding” and/or wide CIs on the critical outcomes. Our effect estimates are slightly lower than reported by Steuri et al,
Effectiveness of conservative interventions including exercise, manual therapy and medical management in adults with shoulder impingement: a systematic review and meta-analysis of RCTs.
Arthroscopic surgery versus supervised exercises in patients with rotator cuff disease (stage II impingement syndrome): a prospective, randomized, controlled study in 125 patients with a 2 1/2-year follow-up.
Is exercise effective for the management of subacromial impingement syndrome and other soft tissue injuries of the shoulder? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.
found high-certainty evidence using a different appraisal tool (Scottish Intercollegiate Guidelines Network criteria) as well as selected studies with adequate internal validity (ie, low risk of bias), including RCTs, cohort studies, or case-control studies, and excluded training in combination with other interventions in their qualitative evidence synthesis. Haik et al,
who included RCTs and quasi-RCTs in English, Spanish, and Portuguese, reported high evidence because of what they perceived as large effect estimates, using 3 of the studies included in this article together with an additional pilot study excluded here because of the study design. A more recent review
did not evaluate the overall certainty of evidence, which may result in overlooking important sources of bias and may neglect their effect on study results.
These findings indicate that although the evidence levels are different across reviews with different grading methods and outcomes selected, the main message is the same: exercise is a relevant and important treatment option for this population.
However, we conclude that the current evidence supports a weak recommendation for training because of the absence of high-certainty evidence and improvements below the predefined MIDs.
Effect of supervised physiotherapy versus home exercise program in patients with subacromial impingement syndrome: a systematic review and meta-analysis.
However, the previous review used less strict criteria for study inclusion compared with the current study, and it reflected results from studies that were designed to compare different training interventions rather than just therapist guidance and attention (ie, supervision). The current review adds to the existing body of evidence with a more focused conclusion about the role of supervision. Our results suggest that structured self-training is a relevant alternative to supervised training. However, it has been suggested that supervised training may be more useful for patients with large baseline symptoms (eg, above 49/100 on the Shoulder Pain and Disability Index),
and it may allow the clinician to consistently guide into relevant exercises, motivate and encourage the patient to adhere to the training intervention, and support the patient during potential symptom flares. Finally, our review did not discourage the use of supervised training; it suggests that supervision is a relevant variation of exercise therapy, which may be beneficial to some but not all patients with shoulder pain. These factors should be considered when planning the amount of supervision before initiating a training intervention.
In a clinical setting, training will usually be combined with other interventions. Training combined with manual therapy is the most clinically used intervention,
(low risk of bias) indicated no clinically important differences between manual therapy plus training compared with placebo with respect to pain, function, and other health-related outcomes. These findings are in line with other studies.
Comparison of manual therapy techniques with therapeutic exercise in the treatment of shoulder impingement: a randomized controlled pilot clinical trial.
However, short-term pain relief from manual therapy can create a window to initiate more active training interventions, and as such manual therapy may provide a clinical pathway to initiate the training.
Patient education is a well-documented intervention, which seems to be more effective when used in combination with training, physical activity, and/or manual therapy.
Evidence for the benefits of pain education has mostly been documented on low back pain, but the benefits of adding an educational intervention to treat musculoskeletal pain is considered best practice.
What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review.
One of the first decisions most primary practitioners face is whether the patient presenting clinical symptoms of SAPS should be recommended formally structured training over no training and whether providing supervision should be prescribed. On a group level, supervised training and self-training are likely to benefit the majority of patients with SAPS, with several additional benefits of the supervised training (eg, guiding in relevant exercises, motivation and encouragement, support in symptom flares). As in other studies, individuals could also benefit from no treatment or need a referral to secondary care (eg, orthopedic surgeons) because the pathogenesis and natural course of SAPS are still unclear. Clinicians should always try to embrace the expectations and needs of the patients when designing the intervention, considering baseline symptoms, patient preferences, training experience, and whether the patient can adhere to the intervention with or without supervision. Based on limited data, self-training may be considered for those patients who prefer that (eg, because of time constraints or financial barriers) because the beneficial effects on pain and function may be the same as for supervised training, provided satisfactory adherence to the prescribed training. However, patients seem more likely to follow the training program if they are supervised rather than completing a self-administered program.
Effectiveness of progressive and resisted and non-progressive or non-resisted exercise in rotator cuff related shoulder pain: a systematic review and meta-analysis of randomized controlled trials.
; however, it is important to inform the patient about the risk of mild transient pain before initiating the training intervention. Future studies should compare supervised training with self-training using transparent and well-described training protocols. These should aim at understanding the optimal parameters of training as well as combining training-based interventions with patient education to better defining the optimal treatment of SAPS.
Study limitations
Important limitations are highlighted here. First, for supervised training, we included 2 studies that combined training with manual therapy, making it difficult to determine whether a potential effect was caused by training or manual therapy. However, none of the included studies that used the combined treatment
A 12-week rehabilitation program improves body composition, pain sensation, and internal/external torques of baseball pitchers with shoulder impingement symptom.
showed significantly larger effect sizes than training alone. Next, using our strict inclusion criteria, only 2 small studies comparing supervised training with self-training were available. Other limitations related to our inclusion of studies are that we accepted the studies’ own definition of SAPS, accepted differences in follow-up time periods without data about long-term (eg, 12 months) effects, and included a broad definition of no training. Finally, the conclusions are drawn based on low certainty of evidence for the critical outcomes pain, function, and patient-perceived effect and low-moderate certainty of evidence for the important outcomes. Therefore, it is possible that future studies can change the current effect estimates.
Conclusions
Supervised training might be superior to no training and equally effective as self-training on critical and important outcomes after 3 months in patients with SAPS lasting for more than 1 month. However, only improvements in pain were above the predefined MID. Supervised training showed potential benefits regarding quality of life, return to work, dropout, and training adherence compared with no training, albeit more patients reported mild transient pain and muscle soreness after training. Based on low-moderate certainty of evidence, these findings support a weak recommendation for the use of supervised training in patients with SAPS.
Suppliers
a.
Covidence systematic review software; Veritas Health Innovation.
b.
Review Manager 5.3 software; The Nordic Cochrane Centre, The Cochrane Collaboration.
Search matrix for systematic reviews
Last updated 29 January 2020.
Medline (130120)
Database(s): Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions(R) 1946 to January 10, 2020
Search Strategy:
Tabled
1
#
Searches
Results
1
Shoulder Impingement Syndrome/ or subacromial pain syndrome*.mp.
1776
2
SAPS.mp.
3062
3
Shoulder Joint/ or shoulder joint*.mp.
20976
4
Shoulder Pain/ or shoulder pain*.mp.
8810
5
shoulder impingement*.mp.
2009
6
Rotator Cuff/ or rotator cuff*.mp.
12683
7
rotator cuff disease*.mp.
500
8
Rotator Cuff Injuries/ or rotator cuff tear*.mp.
7397
9
non traumatic shoulder pain*.mp.
11
10
Supraspinatus* or supra-spinatus*.mp.
3518
11
physiotherap*.mp.
25344
12
exp Physical Therapy Modalities/ or Physical Therapy Modalitie*.mp.
148937
13
physical therap*.mp.
53514
14
Physical Therapy Modality.mp.
20
15
Physical Therapy speciality.mp.
9
16
Physical Therapy Specialty/
2780
17
(physiotherapy or physiotherapies).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms]
18816
18
rehabilitation*.mp. or Rehabilitation/
310645
19
exp Exercise Therapy/
48734
20
exercise*.mp. or *Exercise/ or Exercise Therapy/ or exp Exercise Test/
368482
21
exp Resistance Training/ or resistance training*.mp.
12433
22
strength training*.mp.
5003
23
stability training*.mp.
109
24
aquatic exercise*.mp.
348
25
(aqua therapy or aqua therapies).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms]
10
26
(((systematic or method* or rapid or integrative or umbrella) adj3 (review* or overview* or study or studies or search* or approach*)) or meta analy* or meta-analy* or metaanaly*).ti,ab,kw,kf.
787914
27
(pooled adj1 (data or analys*)).ti,ab.
17429
28
(pubmed or medline or embase or cochrane or "web of science" or psycinfo or psychinfo or scopus).ti,ab.
Shoulder Impingement Syndrome/ or subacromial pain syndrome*.mp.
2793
2
SAPS.mp.
5550
3
Shoulder Joint/ or shoulder joint*.mp.
26868
4
Shoulder Pain/ or shoulder pain*.mp.
16651
5
shoulder impingement*.mp.
2875
6
Rotator Cuff/ or rotator cuff*.mp.
14934
7
rotator cuff disease*.mp.
550
8
Rotator Cuff Injuries/ or rotator cuff tear*.mp.
6723
9
non traumatic shoulder pain*.mp.
11
10
Supraspinatus* or supra-spinatus*.mp.
4205
11
physiotherap*.mp.
94475
12
exp Physical Therapy Modalities/ or Physical Therapy Modalitie*.mp.
73468
13
physical therap*.mp.
30687
14
Physical Therapy Modality.mp.
38
15
Physical Therapy speciality.mp.
24
16
Physical Therapy Specialty/
71532
17
(physiotherapy or physiotherapies).mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword, floating subheading word, candidate term word]
80463
18
rehabilitation*.mp. or Rehabilitation/
280771
19
exp Exercise Therapy/
65751
20
exercise*.mp. or *Exercise/ or Exercise Therapy/ or exp Exercise Test/
425659
21
exp Resistance Training/ or resistance training*.mp.
19688
22
strength training*.mp.
6268
23
stability training*.mp.
166
24
aquatic exercise*.mp.
676
25
(aqua therapy or aqua therapies).mp. [mp=title, abstract, heading word, drug trade name, original title, device manufacturer, drug manufacturer, device trade name, keyword, floating subheading word, candidate term word]
19
26
(((systematic or method* or rapid or integrative or umbrella) adj3 (review* or overview* or study or studies or search* or approach*)) or meta analy* or meta-analy* or metaanaly*).ti,ab,kw.
1023785
27
(pooled adj1 (data or analys*)).ti,ab.
26340
28
(pubmed or medline or embase or cochrane or "web of science" or psycinfo or psychinfo or scopus).ti,ab.
Subacromial impingement and pain and exercise, and systematic review from 2009 and onwards and
Shoulder and pain and exercise and systematic review from 2009 and onwards.
In total 37 references.
Cinahl (140120)
Tabled
1
#
Query
Results
S20
S6 AND S14 AND S18
Limiters - Published Date: 20090101-20201231
325
S19
S6 AND S14 AND S18
408
S18
S15 OR S16 OR S17
322,418
S17
(pooled N1 (data or analys*))
8,161
S16
(((systematic or method* or rapid or integrative) N3 (review* or overview* or study or studies or search* or approach*)) or meta analy* or meta-analy* or metaanaly*)
311,799
S15
PT (Systematic Review or Meta Analysis)
86,800
S14
S7 OR S8 OR S9 OR S10 OR S11 OR S12 OR S13
283,376
S13
"stability training*"
97
S12
"exercise therap*" OR (MH "Therapeutic Exercise+") OR (MH "Aquatic Exercises")
48,989
S11
(MH "Resistance Training") OR "resistance training*"
6,773
S10
(MH "Muscle Strengthening+") OR "strength training*"
19,996
S9
physical therap*
60,713
S8
(MH "Physical Therapy+") OR "physiotherapy"
136,096
S7
(MH "Exercise+") OR "exercise"
180,076
S6
S1 OR S2 OR S3 OR S4 OR S5
14,677
S5
(MH "Rotator Cuff Injuries") OR (MH "Rotator Cuff+") OR "rotator cuff"
5,916
S4
(MH "Shoulder Impingement Syndrome") OR "schoulder impingement"
1,235
S3
shoulder impingement*
1,323
S2
(MH "Shoulder Pain") OR "shoulder pain" OR (MH "Shoulder Injuries+")
Database(s): Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and
Versions(R) 1946 to March 06, 2020
Search Strategy:
Tabled
1
#
Searches
Results
1
Shoulder Impingement Syndrome/ or subacromial pain syndrome*.mp.
1790
2
SAPS.mp.
3093
3
Shoulder Joint/ or shoulder joint*.mp.
21169
4
Shoulder Pain/ or shoulder pain*.mp.
8915
5
shoulder impingement*.mp.
2029
6
Rotator Cuff/ or rotator cuff*.mp.
12872
7
rotator cuff disease*.mp.
506
8
Rotator Cuff Injuries/ or rotator cuff tear*.mp.
7529
9
non traumatic shoulder pain*.mp.
11
10
supra-spinatus*.mp.
21
11
physiotherap*.mp.
25698
12
exp Physical Therapy Modalities/ or Physical Therapy Modalitie*.mp.
150099
13
physical therap*.mp.
54005
14
Physical Therapy Modality.mp.
21
15
Physical Therapy speciality.mp.
9
16
Physical Therapy Specialty/
2795
17
(physiotherapy or physiotherapies).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms]
19077
18
rehabilitation*.mp. or Rehabilitation/
313167
19
exp Exercise Therapy/
49266
20
exercise*.mp. or *Exercise/ or Exercise Therapy/ or exp Exercise Test/
372201
21
exp Resistance Training/ or resistance training*.mp.
126414
22
strength training*.mp.
5069
23
stability training*.mp.
111
24
aquatic exercise*.mp.
357
25
(aqua therapy or aqua therapies).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms]
10
26
or/1-10
38619
27
or/11-25
743393
28
(((random* or cluster-random* or control?ed or crossover or cross-over or blind* or mask*) adj3 (trial*1 or study or studies or analy*)) or rct).ti,ab,kw,kf.
653422
29
(placebo* or single-blind* or double-blind* or triple-blind*).ti,ab,kw.
278930
30
((single or double or triple) adj2 (blind* or mask*)).ti,ab,kw.
Database(s): Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and
Versions(R) 1946 to March 06, 2020
Search Strategy:
Tabled
1
#
Searches
Results
1
Shoulder Impingement Syndrome/ or subacromial pain syndrome*.mp.
1790
2
SAPS.mp.
3093
3
Shoulder Joint/ or shoulder joint*.mp.
21169
4
Shoulder Pain/ or shoulder pain*.mp.
8915
5
shoulder impingement*.mp.
2029
6
Rotator Cuff/ or rotator cuff*.mp.
12872
7
rotator cuff disease*.mp.
506
8
Rotator Cuff Injuries/ or rotator cuff tear*.mp.
7529
9
non traumatic shoulder pain*.mp.
115
10
supra-spinatus*.mp.
21
11
physiotherap*.mp.
25698
12
exp Physical Therapy Modalities/ or Physical Therapy Modalitie*.mp.
150099
13
physical therap*.mp.
54005
14
Physical Therapy Modality.mp.
21
15
Physical Therapy speciality.mp.
9
16
Physical Therapy Specialty/
2795
17
(physiotherapy or physiotherapies).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms]
19077
18
rehabilitation*.mp. or Rehabilitation/
313167
19
exp Exercise Therapy/
49266
20
exercise*.mp. or *Exercise/ or Exercise Therapy/ or exp Exercise Test/
372201
21
exp Resistance Training/ or resistance training*.mp.
12641
22
strength training*.mp.
5069
23
stability training*.mp.
111
24
aquatic exercise*.mp.
357
25
(aqua therapy or aqua therapies).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms]
10
26
or/1-10
38619
27
or/11-25
743393
28
(((random* or cluster-random* or control?ed or crossover or cross-over or blind* or mask*) adj3 (trial*1 or study or studies or analy*)) or rct).ti,ab,kw.
651340
29
(placebo* or single-blind* or double-blind* or triple-blind*).ti,ab,kw.
278930
30
((single or double or triple) adj2 (blind* or mask*)).ti,ab,kw.
170856
31
28 or 29 or 30
745414
32
26 and 27 and 31
1145
33
(books or chapter or conference abstract or "conference review" or editorial or letter).pt.
Results of the AMSTAR (A MeaSurement Tool to Assess systematic Reviews) Quality Appraisal
Supplementary appendix 2.B
Forest plots for important outcomes from the 10 included studies2-12. Risk of bias: green (+) indicates low risk of bias, yellow (?) indicates unclear risk of bias, and red (-) indicates high risk of bias.
Supervised training compared with no training, outcome: quality of life.
Risk of bias as assessed by the Cochrane risk of bias tool. A plus (+) indicates low risk of bias; a question mark (?) indicates unclear risk of bias, and a minus (-) indicates high risk of bias. The specific type of bias is presented in the right row, and the individual studies in the top column.
Page MJ, Green S, McBain B, et al. Manual therapy and exercise for rotator cuff disease. Cochrane Database Syst Rev 2016(6):Cd012224. doi: 10.1002/14651858.Cd012224 [published Online First: 2016/06/11]
2.
Bennell K, Wee E, Coburn S, et al. Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ (Clinical research ed) 2010;340(Journal Article):c2756. doi: 10.1136/bmj.c2756 [doi]
3.
Brox JI, Staff PH, Ljunggren AE, et al. Arthroscopic surgery compared with supervised exercises in patients with rotator cuff disease (stage II impingement syndrome). BMJ (Clinical research ed) 1993;307(6909):899-903. doi: 10.1136/bmj.307.6909.899 [doi]
4.
Brox JI, Gjengedal E, Uppheim G, et al. Arthroscopic surgery versus supervised exercises in patients with rotator cuff disease (stage II impingement syndrome): a prospective, randomized, controlled study in 125 patients with a 2 1/2-year follow-up. J Shoulder Elbow Surg 1999;8(2):102-11. doi: S1058-2746(99)90001-0 [pii]
5.
Cha JY, Kim JH, Hong J, et al. A 12-week rehabilitation program improves body composition, pain sensation, and internal/external torques of baseball pitchers with shoulder impingement symptom. Journal of exercise rehabilitation 2014;10(1):35-44. doi: 10.12965/jer.140087 [doi]
6.
Lombardi I, Jr., Magri AG, Fleury AM, et al. Progressive resistance training in patients with shoulder impingement syndrome: a randomized controlled trial. Arthritis Rheum 2008;59(5):615-22. doi: 10.1002/art.23576 [doi]
7.
Ludewig PM, Borstad JD. Effects of a home exercise programme on shoulder pain and functional status in construction workers. Occup Environ Med 2003;60(11):841-49. doi: 10.1136/oem.60.11.841 [doi]
8.
Dickens VA, Williams JL, Bhamra MS. Role of physiotherapy in the treatment of subacromial impingement syndrome: a prospective study. Physiotherapy 2005;91(3):159-64. doi: 10.1016/j.physio.2004.10.008
9.
Erdem EU, Ünver B. Effects of supervised home-based exercise therapy on disability and function in patients with shoulder pain. 2018:143-49.
10.
Granviken F, Vasseljen O. Home exercises and supervised exercises are similarly effective for people with subacromial impingement: a randomised trial. J Physiother 2015;61(3):135-41. doi: 10.1016/j.jphys.2015.05.014 [doi]
11.
Melegati G, Tornese D, Bandi M. Effectiveness of extracorporeal shock wave therapy associated with kinesitherapy in the treatment of subacromial impingement: A randomised, controlled study. 2000;22((2)):58-64.
12.
Wiener M, Mayer F. Effects of physiotherapy on peak torque and pain in patients with tendinitis of the supraspinatus muscle. DEUTSCHE ZEITSCHRIFT FUR SPORTMEDIZIN 2005;56(11):383-+.
References
Picavet HS
Schouten JS.
Musculoskeletal pain in the Netherlands: prevalences, consequences and risk groups, the DMC(3)-study.
Effect of supervised physiotherapy versus home exercise program in patients with subacromial impingement syndrome: a systematic review and meta-analysis.
Effectiveness of conservative interventions including exercise, manual therapy and medical management in adults with shoulder impingement: a systematic review and meta-analysis of RCTs.
Arthroscopic surgery versus supervised exercises in patients with rotator cuff disease (stage II impingement syndrome): a prospective, randomized, controlled study in 125 patients with a 2 1/2-year follow-up.
A 12-week rehabilitation program improves body composition, pain sensation, and internal/external torques of baseball pitchers with shoulder impingement symptom.
Effectiveness of extracorporeal shock wave therapy associated with kinesitherapy in the treatment of subacromial impingement: a randomised, controlled study.
The effectiveness of injections of hyaluronic acid or corticosteroid in patients with subacromial impingement: a three-arm randomised controlled trial.
Minimal important differences for improvement in shoulder condition patient-reported outcomes: a systematic review to inform a <em>BMJ</em>Rapid Recommendation.
Is exercise effective for the management of subacromial impingement syndrome and other soft tissue injuries of the shoulder? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.
Comparison of manual therapy techniques with therapeutic exercise in the treatment of shoulder impingement: a randomized controlled pilot clinical trial.
What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review.
Effectiveness of progressive and resisted and non-progressive or non-resisted exercise in rotator cuff related shoulder pain: a systematic review and meta-analysis of randomized controlled trials.
Supported by the Danish Health Authority. The Parker Institute, Bispebjerg and Frederiksberg Hospital, is supported by a core grant from the Oak Foundation (OCAY-18-774_OFIL).
Total no. of participants in the 3-arm study design, but we only extracted data from the intervention and comparator of interest.
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