November article review/discussion

[ABengtsson]

Savoie A, Mercier C, Desmeules F, Frémont P, Roy JS. Effects of a movement training oriented rehabilitation program on symptoms, functional limitations and acromiohumeral distance in individuals with subacromial pain syndrome. Man Ther. 2015;20(5):703-8.

DOI: http://dx.doi.org/10.1016/j.math.2015.04.004

The two objectives of this study were assessing the effectiveness of a movement based rehab program in subjects with subacromial pain syndrome (SPS), and differences in acromiohumeral distance (ADH) between subjects and the control group, as well as changes in ADH after treatment.

Participants: n(symptomatic)=29; 25 completed study; n(control)=20; age=18-65y/o
Inclusion criteria: one (+) finding in each category
1) painful arc of movement during flexion or abduction
2) positive Neer or Kennedy-Hawkins impingement signs
3) pain on resisted lateral rotation, abduction or empty can test
Combination of these tests, sensitivity and specificity ≥0.74
Exclusion criteria: one of the following
1) previous shoulder sx
2) shoulder pain reproduced by neck movement
3) clinical signs of full-thickness RC tears
4) shoulder capsulitis
Study design: 3 evaluations, 10 PT sessions over 6 weeks, no long-term follow-up; control: evaluation at beginning, end of 6 weeks; DASH (MDC=11, MCID=10); WORC (MDC=12, MCID=13); Ultrasonographic measurements of AHD at rest, 45° and 60° of active ABD
Subgroups:
AHDbelow and AHDwithin 95% confidence interval of control group AHD measured at 45° ABD.

Intervention consisted of 30 minutes of movement training, manual therapy, strengthening and stretching exercises, as well as patient education. Approximately 75% of each session consisted of movement training (2.4-2.4.4 in study).

Results
– significant improvements in both DASH and WORC
– significant increase in AHD at 45° and 60° in for SPS group
o larger increase in AHDbelow subgroup
o no significant differences in DASH and WORB between subgroups
– no significant changes in AHD for control group
– no significant differences in AHD between groups at any time (Fig. 2)

Discussion:
The results of this study suggest that a movement training centered treatment approach is effective in reducing symptoms and increasing function in pts with SPS. Furthermore, the results indicate that the intervention led to an increase in AHD, especially with a smaller initial AHD.
I liked the increased specificity of the inclusion criteria, trying to use a combination of tests to select subjects in the study. It would have been helpful to have further specifics regarding the subjects, as well as stage and type of impingement, or source of subacromial pain (structure at fault). One limitation that the authors did not mention in their discussion is the lack of specificity with the first inclusion criterion – painful arc of motion. Since the AHD measurements were very specific (neutral, 45°, 60°), it would have been helpful to know during which ranges subjects experienced pain and how that relates to the outcome measures. The authors did not mention specifically why they used these angles, however, a study they cited used the same measures (Desmeules et al., 2004 – see references). In that study it is stated that “Measurements of the AHD were taken with the patient sitting with the arm at 0°, at 45° and 60° of active abduction, with the elbow at 90° of flexion. Because of the constraint of the imaging technique, measurements over 60° of abduction were not possible” (Desmeules). There were no other measurements of symptoms and function above 60°. The authors cite two studies by Grainchen et al., investigating AHD and scapulothoracic-GH motion patterns, in which measurements were performed at 30°, 90° and 120° of ABD, both with and without resistance. The 1999 study by Grainchen et al. found significant decreases in AHD at aforementioned angles with muscle activation in subjects with SPS.
Furthermore, the authors mention that some patients received manual intervention (stretching, STM, mobilizations), however, do not specify the number of subjects, dosage (as needed), or difference in outcomes between subjects with/without manual intervention.
Other measurements that would have been interesting and that were not performed was comparing AHD of the involved side to the uninvolved side in SPS subjects and re-testing Neer’s and Hawkins-Kennedy (and resisted ROM) at the end. It would have been interesting to see whether these tests would be negative after the intervention to clear more objective asterisks and to check for a possible change at higher ranges of elevation.

Questions:
1) Do the angles at which AHD was measured reflect painful AROM of the patients with SPS, or shoulder impingement that you have seen/treated so far and how applicable are the results to those patients?
2) What are other factors/tests/measures that you would include in this patient population?
3) How specific are you in classification of shoulder pain/impingement/SPS etc. and what inclusion/exclusion criteria would you have added, or changed in this particular study?
4) Do you have any specific exercises/cues you use to improve reaching/overhead movement patterns with these patients (either from VOMPTI, or otherwise)?

Looking forward to hearing your thoughts!

[Nick Law]

Thanks for posting Alex! I enjoyed the article the AHD measurement was one I had not yet encountered.

1. “Subgroups were divided according to initial AHD at 45 degrees, since a previous study showed that the most important narrowing is observed at this position (Desmeueles et al, 2004).” At the least, that is the reason why they observed at 45 degrees. I have certainly seen people who have onset of arc type symptoms this low, though it is certainly more common in my experience (and in my reading of the literature) for this to occur higher than 60. In Eric’s shoulder presentation, 70-110 is the range given for the painful arc sign. I have not read the study they reference, however I too am a little puzzled that they did not at least comment further on why they only measured at what seem to be relatively lower elevation angles. 45 and 90 or 60 and 105 would have seemed more appropriate to me.

2. For me, the painful arc itself is a great objective asterisk sign that can be immediately re-assessed following any number of interventions. With the large emphasis on movement training in this study, I sure would expect this outcome measure to be markedly improved. Cuff irritability and strength (resisted ER, scaption) is also a measure that can be quickly re-assessed and compared contralaterally.

3.I hope the answer to the third question is “growing,” although I still am nowhere near where I want to be with regards to at least a more concentrated effort at being specific with my diagnosis, though of course the recent Cook article suggests that we are not all too good at achieving a tissue specific diagnosis in shoulder pain. I need to continue to review the Ann Cools algorithm presented at the 2nd course series weekend. Although I wish that more objective exam info was reported on/reexamined at DC, I think that for a study like this the inclusion criteria is appropriate. This is the same cluster presented at the course series for impingement and is reported to have a (+) LR of 10.56 and (-) of 0.17, which is pretty good.

4. Not too many secrets here beyond what is commonly employed, however here is one recent variation of a typical serratus wall slide that I came across recently. It is shown by Eric Cressey (who has some good material) with good coaching of the movement. Certainly improving serratus activation/upward rotation is a goal in a number (though not all) of patients with SPS.

http://www.ericcressey.com/serratus-anterior-activation-reach-round-and-rotate

[ABengtsson]

Thanks for your response Nick!

1. The only reason that the authors cited for using these angles and not going above 60 was “constraint of the imaging technique”, which is a valid point, but I don’t think that means that they should disregard syx above 60, especially considering that their 1st incl criterion was Neer’s and H-K. Definitely on the same page as you with pt experience in regards to onset of syx at higher ranges. I think another aspect that the authors could’ve considered more closely is the literature that is available on AHD, especially since they already quoted 2 studies by Graichen et al. talking about AHD and motion patterns at larger angles (both of those studies are definitely worth reading, especially because the authors make some interesting points about function and relation to symptoms; I emailed Heiko Graichen with a few follow-up questions and if he gets back to me I’ll write a separate post)

2. and 3. great points!

4. thanks for sharing that video. I like the way he breaks down the cueing. I haven’t tried anything like that specific technique, but I’ve gotten some good results with the AAROM exercises Eric went over (prone with arm on the stool/ball).

[Nick Law]

Thanks for the help on point #1 Alex – I missed over that on your first post

With regards to those other studies that examined AHD at larger angles, did they utilize US or MRI?

[Laura Thornton]

I like this article because it provides a well-detailed, comprehensive approach encompassing multi-modal interventions. The exercise/manual therapy and the motor control protocols were well thought out and very detailed. The article shows that normalizing movement patterns to optimize loading environment can provide successful outcomes in pain and function with subacromial syndromes (a sentence that I grabbed from the most recent issue of JOSPT on tendinopathy that I thought was very applicable).

I liked the strengthening progression that they used and that there was no time limit on how long that each patient stayed within each phase. However, I’m not sure if it’s feasible for all the patients to able to complete Phase 3 in 6 weeks. We don’t know where each patient stood at the end of the study, unless this was given and I missed it.

1. I agree, there is some misconnect between the commonly seen painful arc of motion in a higher range than where they measured ACH distance. In the Michener article they referenced for the sensitivity and specificity of the cluster, they state the painful arc is between 60 and 120 degrees going along with the Graichen articles and VOMPTI presentation.

Can anyone get access to the Desmeules et al. 2004 article on why they found that the most important narrowing is observed at 45 degrees?

Thanks for posting that video, good stuff!

[ABengtsson]

Nick – the Graichen articles utilized MRI, sorry I forgot to mention that initially. I haven’t found any US articles looking at larger angles. Desmeules et al. state in the 2004 article that measurements >60 were not possible.

Laura – the 45 deg was just were they found the most significant narrowing as compared to 0 deg. They did not find a statistically significant narrowing from 45 to 60 deg (see attached article). Unless I missed it in that article, I don’t think they related the narrowing at 45, or 60 deg to reproduction of symptoms. If that is the case the question is whether or not that narrowing is significant functionally, or pathophysiologically. I’ll have to read through the article again to double check if there was a difference in that narrowing between symptomatic and asymptomatic subjects and whether that could be significant.
I think that’s where the Graichen articles make for and interesting addition, because of the ranges they measure and how those findings are related to what we consider more painful ranges.

Hope this helps!

[omikutin]

Great article Alex!
The inclusion criteria are for participants 18-65. In my 60 yo patients have a decreased ADH which may contribute to a painful arch at earlier ranges. That’s an interesting finding where 45 degrees was the most significant narrowing as compared to 0 and there is no significant narrowing from 45 to 60 deg, I would think greater elevation would increase narrowing.

I still find it difficult to classify impingement versus SPS. Either way treatment would be similar and that’s to decrease the irritation causing the increased narrowing. Now if there’s a hard end feel and a potential osteophyte then treatment will be different.

I found this interesting from reading Roy et al (article quoted by Savoie) “increased activity of the upper trapezius and decreased activity of the lower trapezius during arm elevation in the frontal plane for young athletes performing overhead sports and decreased activity of the serratus anterior. Increased activity of the lower trapezius during arm elevation in the scapular plane for construction workers routinely exposed to overhead work.” It’s interesting how motor strategies are dependent on what activity you do. I find that a majority of my SPS patient have a downwardly tilted/ anteriorly tilted scapula (which makes sense why they have SPS). I’m still trying to find the best protocols without progressing to far and further increasing inflammation.

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