Effectiveness of rehabilitation for patients with subacromial impingement syndrome.

Michener LA, Walsworth MK, Burnet EN. Effectiveness of rehabilitation for patients with subacromial impingement syndrome: a systematic review. 2004;17: 152–164. Which physical rehabilitation techniques are effective in reducing pain and functional loss for patients with subacromial impingement syndrome (SAIS)? Investigations were identified by MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Cochrane Central Register of Controlled Trials Register searches from 1966 through October 2003 and by hand searching the references of all retrieved articles and relevant conference proceedings. The search terms were and combined with and and limited to clinical trial, random assignment, or placebo. Inclusion criteria involved randomized controlled trials or clinical trials comparing nonsurgical, nonpharmacologic physical interventions for patients with SAIS with another intervention, no treatment, or a placebo treatment. Included studies required clinically relevant and well-described outcome measures of pain, disability, or functional loss. The study was limited to adult patients who met specific inclusion criteria for the signs and symptoms of SAIS and exclusion criteria for systemic impairment, cervical involvement, degenerative joint changes, clinical findings of other shoulder injury, previous history of surgery or physical therapy treatment, and workers' compensation claim/litigation. A 23-item checklist, with each item assigned 0, 1, or 2 quality points for a total of 46 possible points, was used independently by 2 examiners to assess each study. In their original report, Michener et al stated that the 23-item checklist was worth a possible 69 points. However, in a conversation with L. A. Michener, she stated that this was an inadvertent publication error and confirmed that the possible point value for this checklist was indeed 46. This checklist encompasses 7 major areas, including the rationale for the research question, study design, subjects, intervention, outcome, analysis, and recommendations. If a discrepancy of more than 1 quality point was present for any item, the 2 investigators discussed it to reach a consensus. The total quality points were summed for each independent evaluator, and the average of the 2 final scores was used to determine the total quality score for an individual study. The specific search criteria identified a total of 635 papers for review, of which only 12 met the inclusion and exclusion criteria for study. The average total quality score of these 12 studies was 37.6 (range, 33.5–41) of 46 possible points. Analysis of the inclusion criteria for SAIS revealed that shoulder pain was present in all 12 trials, painful or weak resisted abduction was present in 7 trials, positive Neer test was present in 6 trials, painful arc was present in 5 trials, positive Hawkins-Kennedy test was present in 4 trials, painful or weak resisted shoulder internal and external rotation in 4 trials, and positive impingement injection test was present in 2 trials. Physical interventions, performed in isolation or in combination, for patients with SAIS were divided into 5 types: exercise, joint mobilization, ultrasound, acupuncture, and laser. Authors employed a variety of outcomes measures, with all studies using a numeric rating or visual analog scale for pain, a direct measure of functional loss or disability (in 10 of 12 studies), or an indirect measure of a global rating of change or a measure of strength in a functional position (in 2 of 12 studies). Therapeutic exercise was the most widely studied form of physical intervention and demonstrated short-term and long-term effectiveness for decreasing pain and reducing functional loss. Upper quarter joint mobilizations in combination with therapeutic exercise were more effective than exercise alone. Laser therapy is an effective single intervention when compared with placebo treatments, but adding laser treatment to therapeutic exercise did not improve treatment efficacy. The limited data available do not support the use of ultrasound as an effective treatment for reducing pain or functional loss. Two studies evaluating the effectiveness of acupuncture produced equivocal results. These data indicate that exercise, joint mobilization, and laser therapy are effective physical interventions for decreasing pain and functional loss or disability for patients with SAIS. The current evidence does not support the use of ultrasound, and studies evaluating the effectiveness of acupuncture were equivocal. The number of trials evaluating the effectiveness of physical rehabilitation interventions for patients with SAIS is limited, and those available are of moderate quality. Clinicians should interpret the conclusions with these limitations in mind.