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CDR Damien Avery PT, DPT, OCS

Benefits of specificity of exercise including eccentric training for chronic subacromial impingement . CDR Damien Avery PT, DPT, OCS.

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CDR Damien Avery PT, DPT, OCS

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  1. Benefits of specificity of exercise including eccentric training for chronic subacromial impingement CDR Damien Avery PT, DPT, OCS

  2. Specificity of exercise including eccentric training has value for preventing surgical intervention in patients with a median duration of symptoms of 24 months (range 6-120 months) with a NNT of 3 (95%CI = 2 to 5). • Citation: Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomized controlled study. Holmgren, T. et. al. BMJ. 2012;344e787 doi The Bottom Line

  3. Will a 43yo male with rotator cuff tendinopathy benefit from eccentric training? • Search Terms: Clinical Queries: Eccentric AND Rotator Cuff Three Part Clinical Question

  4. Participant and single assessor blinded, concealed, randomized controlled trial without intention-to-treat. The Study

  5. Specific Exercise Group: 14 women/37men; age:52(SD:9); Duration of pain 24 months (6-120); Heavy Load occupation: 22 (43%); Light load: 29(57%); on sick-leave: 9(18%); RC: 33(65%)intact; 15(29%) partial tear; 3(6%) full thickness. • Non-specficExercise Group: 22 Women/24 men; age 52 (SD:8); Duration of pain: 12 months (6-156); Heavy Load occupation: 21 (46%); Light load 25(55%). RC: 34(74%)intact; 6(13%)partial tear; 6(13%) full thickness The Study Patients

  6. Non-specific exercise: (N = 46; 46 analyzed): Six unspecific movement exercises for neck and shoulder without external load (Shldr Horiz ABD; shldr elev; shldr retraction; upper-trap stretch and pec-major stretch). Completed 10 reps twice daily, and stretches 3 times/twice daily. Control Group

  7. (N = 51; 51 analyzed): Six different exercises (2 eccentric; 3 ecc/con; posterior shoulder stretch); 15 reps x 3 sets twice daily, and stretch 30-60 seconds 3x twice daily for eight weeks, and then once daily 8-12 weeks with resistance in pain monitoring model Experimental Group

  8. The Evidence

  9. Patients were selected thru concealed randomization • Patients had similar prognostic factors with exception that the Specific Exercise group had a greater median duration of pain symptoms (24 months) than did the control group (12 months) • Patients and assessing clinician were blinded to group allocation, treating clinician was not. Are the Results Valid?

  10. Study retention was good: lost total of 5 patients • ITT analysis not completed • Each group lost one patient 2/2 frozen shoulder • Control group lost 3 patients at beginning of study • NNT was able to be completed with ITT by this reviewer • Manual treatment (stretching post. Capsule & pec minor) completed “when necessary” • Follow-up period was only 12 weeks Are the Results Valid?

  11. Event Defined as: opting for surgery by 12 weeks • Non-specific Exercise Group: 29/49 • Specific Exercise Group: 10/51 • NNT: 3 (95%CI: 2-5) • Dash: 8 (95%CI: 2.3 to 13.7) MCID: 13 • Constant-Murley Shoulder Score: 15 (95%CI: 8.5 to 20.6) MCID: assumed at 15% What are the Results?

  12. Patient’s ages ranged from 30-65 • Diagnosed with subacromial impingement • On waiting list for subacromial decompression • Similar to my patient population • Treatments are low cost, low risk justify use • Limited generalizability for sustained improvement over time How can I apply these results to my patient population?

  13. Questions?

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