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Supervised Training Compared With No Training or Self-training in Patients With Subacromial Pain Syndrome: A Systematic Review and Meta-analysis

Open AccessPublished:April 27, 2021DOI:https://doi.org/10.1016/j.apmr.2021.03.027

      Abstract

      Objective

      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.

      Keywords

      List of abbreviations:

      CI (confidence interval), GRADE (Grades of Recommendation Assessment, Development, and Evaluation), MD (mean difference), MID (minimal important difference), RCT (randomized controlled trial), RR (risk ratio), SAPS (subacromial pain syndrome), SMD (standardized mean difference)
      Shoulder pain has a prevalence of 7%-26% in the general population and is often associated with poor improvement in symptoms.
      • Picavet HS
      • Schouten JS.
      Musculoskeletal pain in the Netherlands: prevalences, consequences and risk groups, the DMC(3)-study.
      ,
      • Hill CL
      • Gill TK
      • Shanahan EM
      • et al.
      Prevalence and correlates of shoulder pain and stiffness in a population-based study: the North West Adelaide Health Study.
      Subacromial pain syndrome (SAPS)
      • Beard DJ
      • Rees JL
      • Cook JA
      • et al.
      Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial.
      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,
      • Littlewood C
      • May S
      • Walters S.
      A review of systematic reviews of the effectiveness of conservative interventions for rotator cuff tendinopathy.
      and rotator cuff–related shoulder pain,
      • Lewis J.
      Rotator cuff related shoulder pain: assessment, management and uncertainties.
      have been used to describe these symptoms.
      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.
      • Holmgren T
      • Hallgren HB
      • Oberg B
      • et al.
      Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomised controlled study.
      Contributing factors have been suggested related to muscle dysfunction,
      • Cools AM
      • Witvrouw EE
      • Mahieu NN
      • et al.
      Isokinetic scapular muscle performance in overhead athletes with and without impingement symptoms.
      • Kibler WB.
      Scapular involvement in impingement: signs and symptoms.
      • Ludewig PM
      • Cook TM.
      Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement.
      altered shoulder kinematics,
      • Tyler TF
      • Nicholas SJ
      • Roy T
      • et al.
      Quantification of posterior capsule tightness and motion loss in patients with shoulder impingement.
      overuse due to sustained intensive work,
      • Christiansen DH
      • Frost P
      • Frich LH
      • et al.
      The use of physiotherapy among patients with subacromial impingement syndrome: impact of sex, socio-demographic and clinical factors.
      • Frost P
      • Bonde JP
      • Mikkelsen S
      • et al.
      Risk of shoulder tendinitis in relation to shoulder loads in monotonous repetitive work.
      • Miranda H
      • Viikari-Juntura E
      • Martikainen R
      • et al.
      A prospective study of work related factors and physical exercise as predictors of shoulder pain.
      and slouched posture.
      • Bullock MP
      • Foster NE
      • Wright CC.
      Shoulder impingement: the effect of sitting posture on shoulder pain and range of motion.
      ,
      • Lewis JS
      • Green A
      • Wright C.
      Subacromial impingement syndrome: the role of posture and muscle imbalance.
      Consequently, this has resulted in various treatments being investigated.
      • McCreesh K
      • Lewis J.
      Continuum model of tendon pathology - where are we now?.
      Current guidelines provide inconsistent recommendations for subacromial surgery but generally advice against surgery for the treatment of SAPS as first line of treatment.
      • Vandvik PO
      • Lahdeoja T
      • Ardern C
      • et al.
      Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline.
      ,
      • Hohmann E
      • Shea K
      • Scheiderer B
      • et al.
      Indications for arthroscopic subacromial decompression. A level V evidence clinical guideline.
      Whereas a positive effect of training has been implicit for many years, most recently a high-impact review
      • Pieters L
      • Lewis J
      • Kuppens K
      • et al.
      An update of systematic reviews examining the effectiveness of conservative physical therapy interventions for subacromial shoulder pain.
      concluded a strong recommendation for exercise-based treatment in this patient group. Besides being as effective as surgery, training is safe and cost-effective.
      • Littlewood C
      • May S
      • Walters S.
      A review of systematic reviews of the effectiveness of conservative interventions for rotator cuff tendinopathy.
      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
      • Higgins JPT
      • Thomas J
      • Chandler J
      • et al.
      Cochrane handbook for systematic reviews of interventions version 6.0.
      for systematic reviews of interventions. The study reporting adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations.
      • Moher D
      • Shamseer L
      • Clarke M
      • et al.
      Preferred Reporting Items for Systematic Review and Meta-Analysis protocols (PRISMA-P) 2015 statement.
      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,
      • Page MJ
      • Green S
      • McBain B
      • et al.
      Manual therapy and exercise for rotator cuff disease.
      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
      • Erdem EU
      • Ünver B.
      Effects of supervised home-based exercise therapy on disability and function in patients with shoulder pain.
      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.
      • Thabane L
      • Thomas T
      • Ye C
      • et al.
      Posing the research question: not so simple.

      Population

      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.
      • Guyatt GH
      • Oxman AD
      • Schunemann HJ
      • et al.
      GRADE guidelines: a new series of articles in the Journal of Clinical Epidemiology.
      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.
      • Vandvik PO
      • Lahdeoja T
      • Ardern C
      • et al.
      Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline.
      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),
      • Vandvik PO
      • Lahdeoja T
      • Ardern C
      • et al.
      Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline.
      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)
      • Vandvik PO
      • Lahdeoja T
      • Ardern C
      • et al.
      Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline.
      ; the Shoulder Pain and Disability Index with a 100-point scale similar to Disability of the Arm, Shoulder, and Hand (MID 8-13)
      • Angst F
      • Goldhahn J
      • Drerup S
      • et al.
      Responsiveness of six outcome assessment instruments in total shoulder arthroplasty.
      ,
      • Paul A
      • Lewis M
      • Shadforth MF
      • et al.
      A comparison of four shoulder-specific questionnaires in primary care.
      ; the Shoulder Rating Questionnaire, ranging from 17 (worse) to 100 (better) (MID, 12-13)
      • Dabija DI
      • Jain NB.
      Minimal clinically important difference of shoulder outcome measures and diagnoses: a systematic review.
      ; 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.
      • Shea BJ
      • Grimshaw JM
      • Wells GA
      • et al.
      Development of AMSTAR: a measurement tool to assess the methodological quality of 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.
      • Higgins JP
      • Altman DG
      • Gotzsche PC
      • et al.
      The Cochrane Collaboration's tool for assessing risk of bias in randomised trials.
      Authors were not blinded to study identification (authors and journal).
      • Morissette K
      • Tricco AC
      • Horsley T
      • et al.
      Blinded versus unblinded assessments of risk of bias in studies included in a systematic review.
      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)
      • Guyatt GH
      • Oxman AD
      • Schunemann HJ
      • et al.
      GRADE guidelines: a new series of articles in the Journal of Clinical Epidemiology.
      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
      • Page MJ
      • Green S
      • McBain B
      • et al.
      Manual therapy and exercise for rotator cuff disease.
      ,
      • Gutierrez-Espinoza H
      • Araya-Quintanilla F
      • Cereceda-Muriel C
      • et al.
      Effect of supervised physiotherapy versus home exercise program in patients with subacromial impingement syndrome: a systematic review and meta-analysis.
      ,
      • Steuri R
      • Sattelmayer M
      • Elsig S
      • 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.
      were identified including 9 RCTs (published in 10 articles) of interest. The Cochrane review by Page et al
      • Page MJ
      • Green S
      • McBain B
      • et al.
      Manual therapy and exercise for rotator cuff disease.
      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
      • Erdem EU
      • Ünver B.
      Effects of supervised home-based exercise therapy on disability and function in patients with shoulder pain.
      ,
      • 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.
      • Brox JI
      • Staff PH
      • Ljunggren AE
      • et al.
      Arthroscopic surgery compared with supervised exercises in patients with rotator cuff disease (stage II impingement syndrome).
      • 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.
      • 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.
      • Dickens VA
      • Williams JL
      • Bhamra MS.
      Role of physiotherapy in the treatment of subacromial impingement syndrome: a prospective study.
      • Granviken F
      • Vasseljen O.
      Home exercises and supervised exercises are similarly effective for people with subacromial impingement: a randomised trial.
      • Lombardi Jr, I
      • Magri AG
      • Fleury AM
      • et al.
      Progressive resistance training in patients with shoulder impingement syndrome: a randomized controlled trial.
      • Ludewig PM
      • Borstad JD.
      Effects of a home exercise programme on shoulder pain and functional status in construction workers.
      • 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.
      • Wiener M
      • Mayer F.
      Effects of physiotherapy on peak torque and pain in patients with tendinitis of the supraspinatus muscle.
      (11 articles) were included (fig 1), of which 1 was in German
      • Wiener M
      • Mayer F.
      Effects of physiotherapy on peak torque and pain in patients with tendinitis of the supraspinatus muscle.
      and the others in English.
      Fig 1
      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.

      Study characteristics

      The 10 eligible RCTs included 597 patients (43.4% female) of interest (table 1). The mean age at baseline was 21.9 years in 1 study
      • 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.
      and ranged from 43-60.8 years in the rest. Nine studies included patients with a clinical diagnosis of SAPS
      • Erdem EU
      • Ünver B.
      Effects of supervised home-based exercise therapy on disability and function in patients with shoulder pain.
      ,
      • 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.
      • Brox JI
      • Staff PH
      • Ljunggren AE
      • et al.
      Arthroscopic surgery compared with supervised exercises in patients with rotator cuff disease (stage II impingement syndrome).
      • 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.
      • 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.
      • Dickens VA
      • Williams JL
      • Bhamra MS.
      Role of physiotherapy in the treatment of subacromial impingement syndrome: a prospective study.
      • Granviken F
      • Vasseljen O.
      Home exercises and supervised exercises are similarly effective for people with subacromial impingement: a randomised trial.
      • Lombardi Jr, I
      • Magri AG
      • Fleury AM
      • et al.
      Progressive resistance training in patients with shoulder impingement syndrome: a randomized controlled trial.
      • Ludewig PM
      • Borstad JD.
      Effects of a home exercise programme on shoulder pain and functional status in construction workers.
      • 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.
      and 1 study
      • Wiener M
      • Mayer F.
      Effects of physiotherapy on peak torque and pain in patients with tendinitis of the supraspinatus muscle.
      with supraspinatus tendinosis. Nine studies
      • Erdem EU
      • Ünver B.
      Effects of supervised home-based exercise therapy on disability and function in patients with shoulder pain.
      ,
      • 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.
      • Brox JI
      • Staff PH
      • Ljunggren AE
      • et al.
      Arthroscopic surgery compared with supervised exercises in patients with rotator cuff disease (stage II impingement syndrome).
      • 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.
      ,
      • Dickens VA
      • Williams JL
      • Bhamra MS.
      Role of physiotherapy in the treatment of subacromial impingement syndrome: a prospective study.
      • Granviken F
      • Vasseljen O.
      Home exercises and supervised exercises are similarly effective for people with subacromial impingement: a randomised trial.
      • Lombardi Jr, I
      • Magri AG
      • Fleury AM
      • et al.
      Progressive resistance training in patients with shoulder impingement syndrome: a randomized controlled trial.
      • Ludewig PM
      • Borstad JD.
      Effects of a home exercise programme on shoulder pain and functional status in construction workers.
      • 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.
      • Wiener M
      • Mayer F.
      Effects of physiotherapy on peak torque and pain in patients with tendinitis of the supraspinatus muscle.
      included adults from the general population, and 1 study
      • 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.
      included young male baseball players only.
      Table 1Study, participant, inclusion criteria, and characteristics of the intervention and outcome of the included studies
      Author, CountryParticipants (n); Age (y), Mean ± SD, Female, n (%)Inclusion CriteriaInterventionComparisonOutcomes
      Bennell et al
      • 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.


      Australia
      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
      Brox et al
      • Brox JI
      • Staff PH
      • Ljunggren AE
      • et al.
      Arthroscopic surgery compared with supervised exercises in patients with rotator cuff disease (stage II impingement syndrome).
      • 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.


      Norway
      n=80 (125
      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
      Cha et al
      • 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.


      Korea
      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 trainingPain at rest (NRS)

      Pain strenuous activity (NRS)

      Pain normal daily activity (NRS)

      Endpoint: 12 wk
      Dickens et al
      • Dickens VA
      • Williams JL
      • Bhamra MS.
      Role of physiotherapy in the treatment of subacromial impingement syndrome: a prospective study.


      United Kingdom
      n=85,

      Intervention

      55 (range, 27-68)

      Control

      54 (range, 26-73),

      37 (44)
      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.Nonstructured trainingFunction (CS)

      Dropout

      Endpoint: 6 mo
      Erdem et al
      • Erdem EU
      • Ünver B.
      Effects of supervised home-based exercise therapy on disability and function in patients with shoulder pain.


      Turkey
      n=32 (41
      No. of randomized participants but only 32 participants included in analysis.
      ),

      Intervention

      47 (range, 27-63)

      Control

      43 (range, 19-65),

      13 (41)
      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
      Granviken et al
      • Granviken F
      • Vasseljen O.
      Home exercises and supervised exercises are similarly effective for people with subacromial impingement: a randomised trial.


      Norway
      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
      Lombardi et al
      • Lombardi Jr, I
      • Magri AG
      • Fleury AM
      • et al.
      Progressive resistance training in patients with shoulder impingement syndrome: a randomized controlled trial.


      Brazil
      n = 60,

      Intervention

      56.3±11.6 Control

      54.8±9.4,

      46 (77)
      A positive Neer test and Hawkin test and pain between 3 and 8 on the NRS in the arc of movement that produces the greatest shoulder pain.Progressive resistance training program for the shoulder muscles, which was carried out twice a wk for 2 moWaiting listPain at rest (VAS, 0-10cm)

      Pain during movement (VAS, 0-10cm)

      Function (DASH)

      Quality of life (SF-36)

      Endpoint: 2 mo
      Ludewig and Borstad
      • Ludewig PM
      • Borstad JD.
      Effects of a home exercise programme on shoulder pain and functional status in construction workers.


      United States
      n=67 (92
      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 trainingPain during work (NRS)

      Function (SRQ score)

      Patient-perceived effect (Satisfaction score 0-10)

      Endpoint: 8-12 wk
      Melegati et al
      • 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.


      Italy
      n=60 (90
      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 groupFunction (CS)

      Endpoint

      Intervention group: 8 mo after 15-wk training.

      Control: 8 mo after initial examination
      Wiener et al
      • Wiener M
      • Mayer F.
      Effects of physiotherapy on peak torque and pain in patients with tendinitis of the supraspinatus muscle.


      Germany
      n=17

      Intervention

      NA

      Control

      NA

      0 (0)
      Diagnosis of supraspinatus tendinosisPhysiotherapy 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 trainingPain (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.
      low asterisk 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.
      Two studies
      • Erdem EU
      • Ünver B.
      Effects of supervised home-based exercise therapy on disability and function in patients with shoulder pain.
      ,
      • Granviken F
      • Vasseljen O.
      Home exercises and supervised exercises are similarly effective for people with subacromial impingement: a randomised trial.
      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,
      • 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.
      ,
      • Dickens VA
      • Williams JL
      • Bhamra MS.
      Role of physiotherapy in the treatment of subacromial impingement syndrome: a prospective study.
      ,
      • Ludewig PM
      • Borstad JD.
      Effects of a home exercise programme on shoulder pain and functional status in construction workers.
      ,
      • Wiener M
      • Mayer F.
      Effects of physiotherapy on peak torque and pain in patients with tendinitis of the supraspinatus muscle.
      1 study kept the control group on a waiting list,
      • Lombardi Jr, I
      • Magri AG
      • Fleury AM
      • et al.
      Progressive resistance training in patients with shoulder impingement syndrome: a randomized controlled trial.
      1 study gave advice about joint protection,
      • 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.
      and 2 studies compared with sham treatment (detuned soft laser treatment
      • Brox JI
      • Staff PH
      • Ljunggren AE
      • et al.
      Arthroscopic surgery compared with supervised exercises in patients with rotator cuff disease (stage II impingement syndrome).
      • 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.
      and inactive ultrasonography
      • 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.
      ). 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
      • Ludewig PM
      • Borstad JD.
      Effects of a home exercise programme on shoulder pain and functional status in construction workers.
      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
      • 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.
      ,
      • Wiener M
      • Mayer F.
      Effects of physiotherapy on peak torque and pain in patients with tendinitis of the supraspinatus muscle.
      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 2
      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 3
      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
      • 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.
      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
      • 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.
      as low risk) could not explain heterogeneity.

      Important outcomes

      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).

      Risk of bias assessment of individual studies

      Regarding selection bias, 3 studies
      • 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.
      ,
      • Granviken F
      • Vasseljen O.
      Home exercises and supervised exercises are similarly effective for people with subacromial impingement: a randomised trial.
      ,
      • Lombardi Jr, I
      • Magri AG
      • Fleury AM
      • et al.
      Progressive resistance training in patients with shoulder impingement syndrome: a randomized controlled trial.
      were rated as having low risk of bias, 6 studies
      • Erdem EU
      • Ünver B.
      Effects of supervised home-based exercise therapy on disability and function in patients with shoulder pain.
      ,
      • Brox JI
      • Staff PH
      • Ljunggren AE
      • et al.
      Arthroscopic surgery compared with supervised exercises in patients with rotator cuff disease (stage II impingement syndrome).
      • 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.
      • 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.
      • Dickens VA
      • Williams JL
      • Bhamra MS.
      Role of physiotherapy in the treatment of subacromial impingement syndrome: a prospective study.
      ,
      • 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.
      ,
      • Wiener M
      • Mayer F.
      Effects of physiotherapy on peak torque and pain in patients with tendinitis of the supraspinatus muscle.
      had some concerns (unclear descriptions of the random sequence generation and/or allocation concealment), and 1 study
      • Ludewig PM
      • Borstad JD.
      Effects of a home exercise programme on shoulder pain and functional status in construction workers.
      was rated as having high risk of selection bias. We rated 9 studies
      • Erdem EU
      • Ünver B.
      Effects of supervised home-based exercise therapy on disability and function in patients with shoulder pain.
      ,
      • Brox JI
      • Staff PH
      • Ljunggren AE
      • et al.
      Arthroscopic surgery compared with supervised exercises in patients with rotator cuff disease (stage II impingement syndrome).
      • 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.
      • 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.
      • Dickens VA
      • Williams JL
      • Bhamra MS.
      Role of physiotherapy in the treatment of subacromial impingement syndrome: a prospective study.
      • Granviken F
      • Vasseljen O.
      Home exercises and supervised exercises are similarly effective for people with subacromial impingement: a randomised trial.
      • Lombardi Jr, I
      • Magri AG
      • Fleury AM
      • et al.
      Progressive resistance training in patients with shoulder impingement syndrome: a randomized controlled trial.
      • Ludewig PM
      • Borstad JD.
      Effects of a home exercise programme on shoulder pain and functional status in construction workers.
      • 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.
      • Wiener M
      • Mayer F.
      Effects of physiotherapy on peak torque and pain in patients with tendinitis of the supraspinatus muscle.
      as having high risk of performance bias because patients could not be blinded when answering the self-reported outcomes, and 1 study
      • 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.
      was rated as having low risk of bias. Five studies
      • 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.
      ,
      • Brox JI
      • Staff PH
      • Ljunggren AE
      • et al.
      Arthroscopic surgery compared with supervised exercises in patients with rotator cuff disease (stage II impingement syndrome).
      ,
      • 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.
      ,
      • Dickens VA
      • Williams JL
      • Bhamra MS.
      Role of physiotherapy in the treatment of subacromial impingement syndrome: a prospective study.
      • Granviken F
      • Vasseljen O.
      Home exercises and supervised exercises are similarly effective for people with subacromial impingement: a randomised trial.
      • Lombardi Jr, I
      • Magri AG
      • Fleury AM
      • et al.
      Progressive resistance training in patients with shoulder impingement syndrome: a randomized controlled trial.
      ensured adequate blinding of outcome assessments and were rated as having low risk of detection bias, 7 studies
      • 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.
      ,
      • Brox JI
      • Staff PH
      • Ljunggren AE
      • et al.
      Arthroscopic surgery compared with supervised exercises in patients with rotator cuff disease (stage II impingement syndrome).
      • 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.
      • 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.
      ,
      • Granviken F
      • Vasseljen O.
      Home exercises and supervised exercises are similarly effective for people with subacromial impingement: a randomised trial.
      • Lombardi Jr, I
      • Magri AG
      • Fleury AM
      • et al.
      Progressive resistance training in patients with shoulder impingement syndrome: a randomized controlled trial.
      • Ludewig PM
      • Borstad JD.
      Effects of a home exercise programme on shoulder pain and functional status in construction workers.
      ,
      • Wiener M
      • Mayer F.
      Effects of physiotherapy on peak torque and pain in patients with tendinitis of the supraspinatus muscle.
      had complete outcome data and were rated as having low risk of attrition bias, 3 studies
      • Lombardi Jr, I
      • Magri AG
      • Fleury AM
      • et al.
      Progressive resistance training in patients with shoulder impingement syndrome: a randomized controlled trial.
      ,
      • Ludewig PM
      • Borstad JD.
      Effects of a home exercise programme on shoulder pain and functional status in construction workers.
      ,
      • Wiener M
      • Mayer F.
      Effects of physiotherapy on peak torque and pain in patients with tendinitis of the supraspinatus muscle.
      did not have selective reporting of data and were rated as having low risk of reporting bias, and 5 studies
      • 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.
      ,
      • 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.
      ,
      • Granviken F
      • Vasseljen O.
      Home exercises and supervised exercises are similarly effective for people with subacromial impingement: a randomised trial.
      ,
      • Lombardi Jr, I
      • Magri AG
      • Fleury AM
      • et al.
      Progressive resistance training in patients with shoulder impingement syndrome: a randomized controlled trial.
      ,
      • Wiener M
      • Mayer F.
      Effects of physiotherapy on peak torque and pain in patients with tendinitis of the supraspinatus muscle.
      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
      Anticipated Absolute Effects
      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).
      (95% CI)
      Relative Effect (95% CI)No. of Participants (Studies)Certainty of the Evidence (GRADE)Comments
      OutcomesRisk With No TrainingRisk With Supervised Training
      Pain at restMean pain at rest was 4MD 1.68 lower

      (3.06 lower to 0.31 lower)
      -286

      (4 RCTs)
      ⨁⨁◯◯

      Low
      Lack of blinding and self-reported outcome.
      ,
      Wide confidence intervals.
      Supervised training may reduce pain at rest compared with no training.
      Pain on movementMean pain on movement was 6MD 1.84 lower

      (2.76 lower to 0.91 lower)
      -353

      (5 RCTs)
      ⨁⨁◯◯

      Low
      Lack of blinding and self-reported outcome.
      ,
      Wide confidence intervals.
      Supervised training may reduce pain on movement compared with no training.
      Function-SMD 0.3 lower

      (0.07 lower to 0.52 lower)
      -396

      (5 RCTs)
      ⨁⨁◯◯

      Low
      Wide confidence intervals.
      ,
      Lack of blinding.
      Supervised training may result in little to no difference in function compared with no training.
      Quality of lifeMean quality of life was 58.45MD 6.75 higher

      (0.81 lower to 14.3 higher)
      -176

      (2 RCTs)
      ⨁⨁◯◯

      Low
      Wide confidence intervals.
      ,
      Lack of blinding.
      Supervised training may result in little to no difference in quality of life compared with no training.
      Patient-perceived effect (overall successful outcome)295/1000422/1000

      (257-690)
      RR 1.43

      (0.87-2.34)
      118

      (1 RCT)
      ⨁⨁◯◯

      Low
      Wide confidence intervals.
      ,
      Only 1 study.
      Supervised training may increase patient-perceived effect (overall successful outcome) compared with no training.
      Return to work (no. at work)429/1000570/1000

      (343-934)
      RR 1.33

      (0.80-2.18)
      72

      (1 RCT)
      ⨁⨁⨁◯

      Moderate
      Wide confidence intervals.
      ,
      Only 1 study.
      Supervised training probably increases return to work (no. at work) compared with no training.
      Dropout all causes99/100045/1000

      (8-270)
      RR 0.45

      (0.08-2.72)
      265

      (3 RCTs)
      ⨁⨁⨁◯

      Moderate
      Wide confidence intervals.
      Supervised training probably reduces dropout all causes compared with no training.
      Adherence934/1000916/1000

      (822-1000)
      RR 0.98

      (0.88-1.08)
      118

      (1 RCT)
      ⨁⨁⨁◯

      Moderate
      Wide confidence intervals.
      ,
      Only 1 study.
      There is probably a high level of adherence to supervised training.
      Adverse events82/1000309/1000

      (122-782)
      RR 3.77

      (1.49-9.54)
      116

      (1 RCT)
      ⨁⨁⨁◯

      Moderate
      Wide confidence intervals.
      ,
      Only 1 study.
      Supervised training probably increases adverse events compared with no training.
      Serious adverse events0/10000/1000

      (0-0)
      Not estimable116

      (1 RCT)
      ⨁⨁⨁◯

      Moderate
      Only 1 study.
      ,
      No events.
      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.
      low asterisk 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).
      Lack of blinding and self-reported outcome.
      Wide confidence intervals.
      § Lack of blinding.
      Only 1 study.
      No events.
      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
      Anticipated Absolute Effects
      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).
      (95% CI)
      Relative Effect (95% CI)No. of Participants (Studies)Certainty of the Evidence (GRADE)Comments
      OutcomesRisk With Self-trainingRisk With Supervised Training
      PainMean pain was 4.3MD 0.2 lower

      (1.47 lower to 1.07 higher)
      -44 (1 RCT)⨁⨁◯◯

      Low
      Lack of blinding and self-reported outcome.
      ,
      Wide confidence intervals.
      Supervised training may result in little to no difference in pain compared with self-training.
      FunctionMean function was 32MD 1 higher

      (8.8 lower to 10.79 higher)
      -76 (2 RCTs)⨁⨁◯◯

      Low
      Lack of blinding.
      ,
      Only 1 study.
      Supervised training may result in little to no difference in function compared with self-training.
      Return to work (no. at work)667/1,000567/1,000 (353-907)RR 0.85

      (0.53-1.36)
      44 (1 RCT)⨁⨁◯◯

      Low
      Wide confidence intervals.
      ,
      No events.
      Supervised training may reduce return to work (no. at work) slightly compared with self-training.
      Dropout all causes209/1,00054/1,000 (15-197)RR 0.26

      (0.07-0.94)
      87 (2 RCTs)⨁⨁⨁◯

      Moderate
      Wide confidence intervals.
      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.
      low asterisk 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).
      Lack of blinding and self-reported outcome.
      Wide confidence intervals.
      § Lack of blinding.
      Only 1 study.
      No events.
      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.
      • Vandvik PO
      • Lahdeoja T
      • Ardern C
      • et al.
      Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline.
      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
      • Penning LI
      • de Bie RA
      • Walenkamp GH.
      The effectiveness of injections of hyaluronic acid or corticosteroid in patients with subacromial impingement: a three-arm randomised controlled trial.
      and was lower than the predefined MID of 8.3 for this outcome measure.
      • Vandvik PO
      • Lahdeoja T
      • Ardern C
      • et al.
      Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline.
      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).
      • Hao Q
      • Devji T
      • Zeraatkar D
      • et al.
      Minimal important differences for improvement in shoulder condition patient-reported outcomes: a systematic review to inform a <em>BMJ</em>Rapid Recommendation.
      Our findings on the critical outcomes pain and function are in line with previous reviews,
      • Page MJ
      • Green S
      • McBain B
      • et al.
      Manual therapy and exercise for rotator cuff disease.
      ,
      • Steuri R
      • Sattelmayer M
      • Elsig S
      • 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.
      ,
      • Haik MN
      • Alburquerque-Sendín F
      • Moreira RF
      • et al.
      Effectiveness of physical therapy treatment of clearly defined subacromial pain: a systematic review of randomised controlled trials.
      ,
      • Abdulla SY
      • Southerst D
      • Côté P
      • et al.
      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.
      although those reviews reported different evidence levels from very low
      • Steuri R
      • Sattelmayer M
      • Elsig S
      • 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.
      to high.
      • Haik MN
      • Alburquerque-Sendín F
      • Moreira RF
      • et al.
      Effectiveness of physical therapy treatment of clearly defined subacromial pain: a systematic review of randomised controlled trials.
      ,
      • Abdulla SY
      • Southerst D
      • Côté P
      • et al.
      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.
      The reasons for these discrepancies are likely based on methodological choices. Steuri et al
      • Steuri R
      • Sattelmayer M
      • Elsig S
      • 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.
      included most of the studies
      • 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.
      ,
      • Lombardi Jr, I
      • Magri AG
      • Fleury AM
      • et al.
      Progressive resistance training in patients with shoulder impingement syndrome: a randomized controlled trial.
      ,
      • Ludewig PM
      • Borstad JD.
      Effects of a home exercise programme on shoulder pain and functional status in construction workers.
      ,
      • Wiener M
      • Mayer F.
      Effects of physiotherapy on peak torque and pain in patients with tendinitis of the supraspinatus muscle.
      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
      • Page MJ
      • Green S
      • McBain B
      • et al.
      Manual therapy and exercise for rotator cuff disease.
      ), 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,
      • Steuri R
      • Sattelmayer M
      • Elsig S
      • 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.
      which seems to be based on our inclusion of 2 additional studies
      • 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.
      • Brox JI
      • Staff PH
      • Ljunggren AE
      • et al.
      Arthroscopic surgery compared with supervised exercises in patients with rotator cuff disease (stage II impingement syndrome).
      • 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.
      reporting the lowest improvements in favor of training. Abdulla et al
      • Abdulla SY
      • Southerst D
      • Côté P
      • et al.
      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,
      • Haik MN
      • Alburquerque-Sendín F
      • Moreira RF
      • et al.
      Effectiveness of physical therapy treatment of clearly defined subacromial pain: a systematic review of randomised controlled trials.
      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
      • Desmeules F
      • Boudreault J
      • Dionne CE
      • et al.
      Efficacy of exercise therapy in workers with rotator cuff tendinopathy: a systematic 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.
      • Dong W
      • Goost H
      • Lin XB
      • et al.
      Treatments for shoulder impingement syndrome: a PRISMA systematic review and network meta-analysis.
      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.
      • Vandvik PO
      • Lahdeoja T
      • Ardern C
      • et al.
      Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline.
      More transparent protocols with detailed information about the interventions are needed to ensure higher treatment fidelity.
      The lack of difference between supervised training and self-training on pain and function is in line with a recent meta-analysis.
      • Gutierrez-Espinoza H
      • Araya-Quintanilla F
      • Cereceda-Muriel C
      • et al.
      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),
      • Granviken F
      • Vasseljen O.
      Home exercises and supervised exercises are similarly effective for people with subacromial impingement: a randomised trial.
      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,
      • Klintberg IH
      • Cools AM
      • Holmgren TM
      • et al.
      Consensus for physiotherapy for shoulder pain.
      but evidence does not support additional benefits of combining manual therapy and training. One of the included studies
      • 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.
      (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.
      • Dickens VA
      • Williams JL
      • Bhamra MS.
      Role of physiotherapy in the treatment of subacromial impingement syndrome: a prospective study.
      ,
      • Desmeules F
      • Boudreault J
      • Dionne CE
      • et al.
      Efficacy of exercise therapy in workers with rotator cuff tendinopathy: a systematic review.
      ,
      • Kachingwe AF
      • Phillips B
      • Sletten E
      • et al.
      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.
      • Pieters L
      • Lewis J
      • Kuppens K
      • et al.
      An update of systematic reviews examining the effectiveness of conservative physical therapy interventions for subacromial shoulder pain.
      ,
      • Dong W
      • Goost H
      • Lin XB
      • et al.
      Treatments for shoulder impingement syndrome: a PRISMA systematic review and network meta-analysis.
      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.
      • Tegner H
      • Frederiksen P
      • Esbensen BA
      • et al.
      Neurophysiological pain education for patients with chronic low back pain: a systematic review and meta-analysis.
      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.
      • Lin I
      • Wiles L
      • Waller R
      • et al.
      What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review.

      Implications for clinicians and research

      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.
      • Aitken D
      • Buchbinder R
      • Jones G
      • et al.
      Interventions to improve adherence to exercise for chronic musculoskeletal pain in adults.
      There is a paucity of knowledge about the ideal dosage and type of exercise,
      • Littlewood C
      • May S
      • Walters S.
      A review of systematic reviews of the effectiveness of conservative interventions for rotator cuff tendinopathy.
      ,
      • Pieters L
      • Lewis J
      • Kuppens K
      • et al.
      An update of systematic reviews examining the effectiveness of conservative physical therapy interventions for subacromial shoulder pain.
      ,
      • Littlewood C
      • Ashton J
      • Chance-Larsen K
      • et al.
      Exercise for rotator cuff tendinopathy: a systematic review.
      but high training dosage
      • Naunton J
      • Street G
      • Littlewood C
      • et al.
      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.
      and scapular focused interventions
      • Bury J
      • West M
      • Chamorro-Moriana G
      • et al.
      Effectiveness of scapula-focused approaches in patients with rotator cuff related shoulder pain: a systematic review and meta-analysis.
      may be preferable. Mild transient pain during therapeutic training is considered a normal response to training
      • Niemeijer A
      • Lund H
      • Stafne SN
      • et al.
      Adverse events of exercise therapy in randomised controlled trials: a systematic review and meta-analysis.
      and need not be a barrier to successful outcomes
      • Smith BE
      • Hendrick P
      • Smith TO
      • et al.
      Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis.
      ; 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
      • 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.
      ,
      • 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.
      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
      Tabled 1
      #SearchesResults
      1Shoulder Impingement Syndrome/ or subacromial pain syndrome*.mp.1776
      2SAPS.mp.3062
      3Shoulder Joint/ or shoulder joint*.mp.20976
      4Shoulder Pain/ or shoulder pain*.mp.8810
      5shoulder impingement*.mp.2009
      6Rotator Cuff/ or rotator cuff*.mp.12683
      7rotator cuff disease*.mp.500
      8Rotator Cuff Injuries/ or rotator cuff tear*.mp.7397
      9non traumatic shoulder pain*.mp.11
      10Supraspinatus* or supra-spinatus*.mp.3518
      11physiotherap*.mp.25344
      12exp Physical Therapy Modalities/ or Physical Therapy Modalitie*.mp.148937
      13physical therap*.mp.53514
      14Physical Therapy Modality.mp.20
      15Physical Therapy speciality.mp.9
      16Physical 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
      18rehabilitation*.mp. or Rehabilitation/310645
      19exp Exercise Therapy/48734
      20exercise*.mp. or *Exercise/ or Exercise Therapy/ or exp Exercise Test/368482
      21exp Resistance Training/ or resistance training*.mp.12433
      22strength training*.mp.5003
      23stability training*.mp.109
      24aquatic 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.221172
      29Cochrane.jw.14884
      3026 or 27 or 28 or 29871030
      31or/1-1038865
      32or/11-25736846
      3330 and 31 and 32623
      34limit 33 to yr="2009 - 2020"518
      Embase (130120)
      Database(s): Embase 1996 to 2020 Week 02
      Tabled 1
      #SearchesResults
      1Shoulder Impingement Syndrome/ or subacromial pain syndrome*.mp.2793
      2SAPS.mp.5550
      3Shoulder Joint/ or shoulder joint*.mp.26868
      4Shoulder Pain/ or shoulder pain*.mp.16651
      5shoulder impingement*.mp.2875
      6Rotator Cuff/ or rotator cuff*.mp.14934
      7rotator cuff disease*.mp.550
      8Rotator Cuff Injuries/ or rotator cuff tear*.mp.6723
      9non traumatic shoulder pain*.mp.11
      10Supraspinatus* or supra-spinatus*.mp.4205
      11physiotherap*.mp.94475
      12exp Physical Therapy Modalities/ or Physical Therapy Modalitie*.mp.73468
      13physical therap*.mp.30687
      14Physical Therapy Modality.mp.38
      15Physical Therapy speciality.mp.24
      16Physical 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
      18rehabilitation*.mp. or Rehabilitation/280771
      19exp Exercise Therapy/65751
      20exercise*.mp. or *Exercise/ or Exercise Therapy/ or exp Exercise Test/425659
      21exp Resistance Training/ or resistance training*.mp.19688
      22strength training*.mp.6268
      23stability training*.mp.166
      24aquatic 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.270387
      29Cochrane.jx.21254
      3026 or 27 or 28 or 291131992
      31or/1-1057447
      32or/11-25729520
      3330 and 31 and 321081
      34limit 33 to yr="2009 - 2020"920
      PEDro (130120)
      Searched for
      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.
      Tabled 1
      #QueryResults
      S20S6 AND S14 AND S18
      Limiters - Published Date: 20090101-20201231325
      S19S6 AND S14 AND S18408
      S18S15 OR S16 OR S17322,418
      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
      S15PT (Systematic Review or Meta Analysis)86,800
      S14S7 OR S8 OR S9 OR S10 OR S11 OR S12 OR S13283,376
      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
      S9physical therap*60,713
      S8(MH "Physical Therapy+") OR "physiotherapy"136,096
      S7(MH "Exercise+") OR "exercise"180,076
      S6S1 OR S2 OR S3 OR S4 OR S514,677
      S5(MH "Rotator Cuff Injuries") OR (MH "Rotator Cuff+") OR "rotator cuff"5,916
      S4(MH "Shoulder Impingement Syndrome") OR "schoulder impingement"1,235
      S3shoulder impingement*1,323
      S2(MH "Shoulder Pain") OR "shoulder pain" OR (MH "Shoulder Injuries+")11,646
      S1shoulder pain*5,123

      Search matrix for full-text articles

      Medline (090320)
      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
      Tabled 1
      #SearchesResults
      1Shoulder Impingement Syndrome/ or subacromial pain syndrome*.mp.1790
      2SAPS.mp.3093
      3Shoulder Joint/ or shoulder joint*.mp.21169
      4Shoulder Pain/ or shoulder pain*.mp.8915
      5shoulder impingement*.mp.2029
      6Rotator Cuff/ or rotator cuff*.mp.12872
      7rotator cuff disease*.mp.506
      8Rotator Cuff Injuries/ or rotator cuff tear*.mp.7529
      9non traumatic shoulder pain*.mp.11
      10supra-spinatus*.mp.21
      11physiotherap*.mp.25698
      12exp Physical Therapy Modalities/ or Physical Therapy Modalitie*.mp.150099
      13physical therap*.mp.54005
      14Physical Therapy Modality.mp.21
      15Physical Therapy speciality.mp.9
      16Physical 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
      18rehabilitation*.mp. or Rehabilitation/313167
      19exp Exercise Therapy/49266
      20exercise*.mp. or *Exercise/ or Exercise Therapy/ or exp Exercise Test/372201
      21exp Resistance Training/ or resistance training*.mp.126414
      22strength training*.mp.5069
      23stability training*.mp.111
      24aquatic 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
      26or/1-1038619
      27or/11-25743393
      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.170856
      3128 or 29 or 30747233
      3226 and 27 and31 1148
      33limit 32 to yr="2015 - 2020"510
      Embase (090320)
      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
      Tabled 1
      #SearchesResults
      1Shoulder Impingement Syndrome/ or subacromial pain syndrome*.mp.1790
      2SAPS.mp.3093
      3Shoulder Joint/ or shoulder joint*.mp.21169
      4Shoulder Pain/ or shoulder pain*.mp.8915
      5shoulder impingement*.mp.2029
      6Rotator Cuff/ or rotator cuff*.mp.12872
      7rotator cuff disease*.mp.506
      8Rotator Cuff Injuries/ or rotator cuff tear*.mp.7529
      9non traumatic shoulder pain*.mp.115
      10supra-spinatus*.mp.21
      11physiotherap*.mp.25698
      12exp Physical Therapy Modalities/ or Physical Therapy Modalitie*.mp.150099
      13physical therap*.mp.54005
      14Physical Therapy Modality.mp.21
      15Physical Therapy speciality.mp.9
      16Physical 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
      18rehabilitation*.mp. or Rehabilitation/313167
      19exp Exercise Therapy/49266
      20exercise*.mp. or *Exercise/ or Exercise Therapy/ or exp Exercise Test/372201
      21exp Resistance Training/ or resistance training*.mp.12641
      22strength training*.mp.5069
      23stability training*.mp.111
      24aquatic 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
      26or/1-1038619
      27or/11-25743393
      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
      3128 or 29 or 30745414
      3226 and 27 and 311145
      33(books or chapter or conference abstract or "conference review" or editorial or letter).pt.1584358
      3432 not 331137
      35limit 34 to yr="2015 - 2020"502
      PEDro (060320)
      Searched for:
      Subacromial impingement and pain and exercise, and clinical trial from 2015 and onwards. and
      Shoulder and pain and exercise and clinical trial from 2015 and onwards.
      In total 23 references
      Tabled 1
      S17S13 AND S14 AND S15, Limiters - Published Date: 20150101-20201231366
      S16S13 AND S14 AND S15829
      S15S11 OR S12463,430
      S14S6 OR S7 OR S8 OR S9 OR S10276,505
      S13S1 OR S2 OR S4 OR S514,875
      S12(placebo* or single-blind* or double-blind* or triple-blind* or ((single or double or triple) N1 (blind* or mask*))100,563
      S11(((random* or cluster-random* or control#ed or crossover or cross-over or blind* or mask*) N3 (trial* or study or studies or analy*)) or rct)453,872
      S10stability training*99
      S9(MH "Therapeutic Exercise+") OR "exercise therap*" OR (MH "Aquatic Exercises")49,608
      S8(MH "Muscle Strengthening+") OR "strength training*" OR (MH "Resistance Training")20,257
      S7"physiotherap*" OR (MH "Physical Therapy+")140,423
      S6(MH "Exercise+") OR (MH "Resistance Training") OR "exercise*"192,126
      S5(MH "Rotator Cuff+") OR (MH "Rotator Cuff Injuries") OR "rotator cuff*"6,012
      S4(MH "Shoulder Impingement Syndrome") OR (MH "Shoulder Injuries+")8,362
      S3(MH "Shoulder Pain")3,652
      S2shoulder impingement*1,332
      S1shoulder pain*5,1797

      Supplementary appendix 2.A

      Tabled 1
      Study, year1. Was an 'a priori' design provided?2. Was there duplicate study selection and data extraction?3. Was a comprehensive literature search performed?4. Was the status of publication (i.e. grey literature) used as an inclusion criterion?5. Was a list of studies (included and excluded) provided?6. Were the characteristics of the included studies provided?7. Was the scientific quality of the included studies assessed and documented?8. Was the scientific quality of the included studies used appropriately in formulating conclusions?9. Were the methods used to combine the findings of studies appropriate?10. Was the likelihood of publication bias assessed?11. Was the conflict of interest included?Total
      Page, 20161YesYesYesYesYesYesYesYesYesYesYes11/11
      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.
      Unlabelled image
      Supervised training compared with no training, outcome: patient-perceived effect (patient satisfaction).
      Unlabelled image
      Supervised training compared with no training, outcome: return to work (number at work).
      Unlabelled image
      Supervised training compared with no training, outcome: dropout all causes.
      Unlabelled image
      Supervised training compared with no training, outcome: adherence.
      Unlabelled image
      Supervised training compared with no training, outcome: adverse events.
      Unlabelled image
      Supervised training compared with no training, outcome: serious adverse events.
      Unlabelled image
      Supervised training compared with self-training, outcome: return to work (number at work).
      Unlabelled image
      Supervised training compared with self-training, outcome: dropout all causes.
      Unlabelled image

      Supplementary appendix 2.C

      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.
      Unlabelled image

      References

      • 1.
        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-+.

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