Exercise as a conservative treatment modality for shoulder impingement syndrome : a systematic review

Abstract

Shoulder impingement syndrome (SIS) is a clinical presentation likely in people who participate in physical activities, sports and occupations involving repeated overhead arm movements. It is one of the most common causes of shoulder pain. Shoulder impingement syndrome can be treated surgically or conservatively, and it is generally asserted that to ensure effective rehabilitation, exercise interventions should be evidence-based with due regard to type, duration, frequency, intensity and supervision of exercise. In this dissertation, the first aim was to determine whether there is conclusive evidence for homebased or supervised exercise as conservative treatment modality for SIS. Secondly, the study aimed to determine consistencies in the type, duration, frequency and intensity of rehabilitation exercises that can serve as guidelines for rehabilitation of SIS. A systematic review and metaanalysis using data from randomized, controlled intervention studies were conducted to meet these aims. Only English publications meeting the inclusion criteria were included, resulting in six RCTs (n=475; intervention duration, 3 to 12 weeks) meeting the inclusion criteria. Outcomes of interest were pain at rest, pain during movement, as well as shoulder ROM, patient satisfaction and function. Data were summarised and mean differences (MD), standard mean differences (SMD) and an overall effect size of 95% confidence intervals (CI) were extracted using Review Manager 5.3. Pain at rest was reported by four studies and one study showed statistically significant improvement for exercise (MD -1.90; 95% CI -3.36 to -0.44; p=0.01). All six studies reported pain during movement. Only two studies reported significant improvement in pain during movement favouring exercise (compared to no intervention) (SMD -0.81; 95% CI -1.18 to -0.44; p<0.0001) while the remaining studies reported no significant improvements between groups. Three studies assessed shoulder range of motion (ROM) and one ROM measurement (medial rotation) from one study reported statistically significant improvement in the exercise group (MD 9.70; 95% CI 2.34 to 17.06; p=0.010). Two studies demonstrated no significant improvement in shoulder ROM among groups and were inconclusive. Function was reported by all six studies and two studies demonstrated statistically significant improvements for the exercise groups (SMD -0.66; 95% CI -1.02 to -0.29; p=0.0004). Two studies showed improvement in favour of the exercise group, but were not significant. One study favoured radial extracorporeal shockwave therapy (rESWT) but the results were also not significant and the results for this study were inconclusive. Patient satisfaction was reported by one study and showed statistically significant results in favour of the exercise group. Some patients in the exercise treatment groups improved significantly on key outcome measurements, but in other studies the improvements did not reach significant or clinically important levels. These results demonstrate a lack of moderate evidence for conservative exercise rehabilitation in the treatment of SIS with regards to frequency, intensity, duration and modality of treatment. Based on the limited evidence, guidelines were compiled for the treatment of SIS with exercise rehabilitation. However, more research is needed to obtain strong evidence for SIS rehabilitation and in order to update the proposed guidelines presented in this dissertation