Documente Academic
Documente Profesional
Documente Cultură
Background. Little is known about the effectiveness of exercise programs after decom
pression surgery for subacromial impingement syndrome. For patients with difficulty returning
to usual activities, special efforts may be needed to improve shoulder function.
Objective. The purpose of this study was to evaluate the effectiveness at 3 and 12 months
of a standardized physical therapy exercise intervention compared with usual care in patients
with difficulty returning to usual activities after subacromial decompression surgery.
Design. A multicenter randomized controlled trial was conducted.
Setting. The study was conducted in 6 public departments of orthopedic surgery, 2
departments of occupational medicine, and 2 physical therapy training centers in Central
Denmark Region.
Patients. One hundred twenty-six patients reporting difficulty returning to usual activities
at the postoperative clinical follow-up 8 to 12 weeks after subacromial decompression surgery
participated.
D.H.
Christiansen,
PT,
PhD,
D epartm ent
of
O ccupational
Medicine, Danish Ramazzini Cen
tre,
Regional
Hospital West
Jutland-University Research Clinic,
Cl Landevej 61, 7400 Herning,
Denmark. Address all correspon
dence to Dr Christiansen at:
David.Christiansen@ vest.rm.dk.
P. Frost, M D, PhD, D epartm ent of
O ccupational Medicine, Danish
Ramazzini Centre, Aarhus Hospi
tal, Aarhus University Hospital,
Aarhus, Denmark.
D. Falla, PT, PhD, School o f Sport,
Exercise and Rehabilitation Sci
ences, College of Life and Environ
mental Sciences, University of
Birm ingham , Birm ingham , United
Kingdom , and Pain Clinic, Center
fo r Anesthesiology, Emergency
and Intensive Care Medicine, Uni
versity Hospital G ottingen, G o ttin
gen, Germany.
J.P. Haahr, M D, MPH, Departm ent
o f O ccupational Medicine, Danish
Ramazzini
Centre,
Regional
Hospital West Jutland-University
Research Clinic.
Outcome Measures. The primary outcome measure was the Oxford Shoulder Score.
Secondary outcome measures were the Constant Score and the Fear-Avoidance Beliefs
Questionnaire.
Results. At 3 and 12 months, follow-up data were obtained for 92% and 83% of the patients,
respectively. Intention-to-treat analyses suggested a between-group difference on the Oxford
Shoulder Score favoring the exercise group at 3 months, with an adjusted mean difference of
2.0 (95% confidence interval = 0.5, 4.6), and at 12 months, with an adjusted mean difference
of 5.8 (95% confidence interval=2.8, 8.9). Significantly larger improvements for the exercise
group were observed for most secondary and supplementary outcome measures.
Limitations. The nature of the exercise intervention did not allow blinding of patients and
S.W.
Svendsen,
M D,
PhD,
D epartm ent
of
O ccupational
Medicine, Danish Ramazzini Cen
tre, Regional Hospital West Jut
land-U niversity Research Clinic.
care providers.
P o s t a R a p id R e s p o n s e t o
t h is a r t ic le a t:
ptjournal.apta.org
June 2 0 1 6
V o lu m e 9 6
N um ber 6
Physical T h e ra p y
787
o f s ta n d a rd iz e d
p h y s ic a l
th e ra p y
Ther.
ra n d o m iz e d
c o n tro lle d
tria l.
Phys
2 0 1 6 ;9 6 : 7 8 7 - 7 9 6 . ]
788
P h ysica l T h e ra p y
V o lu m e 9 6
ubacromial impingement syn sion surgery for SIS.15 The trial had 4
drome (SIS) is the most common randomization arms: (1) physical therapy
upper extremity musculoskeletal exercises, (2) occupational medical assis
disorder in the working population.1
tance, (3) physical therapy exercises and
Initial treatment of SIS is nonsurgical and occupational medical assistance, and (4)
includes
rest,
nonsteroidal
anti usual care. Patients were randomized to
inflammatory drugs, corticosteroid injec 1 of the 4 arms if they were employed in
tions, and different modalities of physical paid work for at least 25 hours per week.
therapy. Surgical intervention, in the Patients who did not meet the 25 hours
form of arthroscopic subacromial employment criterion were randomly
decompression, is usually reserved for assigned to only 1 of the 2 arms without
patients who do not respond sufficiently occupational medical assistance (ie,
to initial nonsurgical treatment.2 Data physical therapy exercises or usual care).
suggest 2- to 8-fold increases in surgery Accordingly, we planned to use a parallel
rates since the late 1990s,3-6 with prob group design to evaluate the effective
abilities of success varying between 60% ness of the physical therapy interven
and 84%.7-9
tion, treating occupational medical assis
tance as a cointervention; all patients
Physical therapist-supervised exercises (with and without paid work) could be
and instructions in self-training are often included in these analyses. For patients
used to restore shoulder function after who were employed in paid work, the
surgery for SIS.10 There is no consensus effectiveness of the occupational inter
about the most appropriate postopera vention will be evaluated in a separate
tive exercise strategy, and little is known publication, with primary' outcomes
about the effectiveness of different exer being sickness absence percentage at 3
cise programs following subacromial months and transfer income percentage
decompression.11-14 It is unknown at 12 months.15
whether physical therapist-supervised
exercises should be offered to all Setting and Participants
patients or reserved for those with more Patients were recruited from the 6 public
persistent symptoms. Special efforts may departments of orthopedic surgery in
be needed to facilitate return to normal Central Denmark Region over a 3-year
function for patients who have failed to period until December 31, 2013. At the
return to usual activities 8 to 12 weeks postoperative clinical follow-up 8 to 12
after surgery. The aim of this study was weeks after surgery, patients aged >18
to compare the effectiveness of a stan to <63 years and living in the region
dardized physical therapy exercise inter were assessed for eligibility if they had
vention with usual care in patients with undergone arthroscopic subacromial
difficulty returning to usual activities decompression surgery' (surgical code
after subacromial decompression sur KNBH51, KNBH91, KNBG09, K.NBL39,
gery for SIS. We hypothesized that stan or KNBM79 according to the Danish ver
dardized physical therapy exercises sion of the Nordic Medico-Statistical
would yield superior results with respect Committee Classification of Surgical
to improvement in shoulder pain and Procedures16) under a main diagnosis of
function compared with usual care.
SIS or acromioclavicular osteoarthritis
(International Classification o f Dis
eases, 10th revision17: M75.1-M75.8 or
Method
Ml 9). Exclusion criteria were full
Design Overview
The study was conducted within the thickness rotator cuff tear, traumatic
framework of the Shoulder Intervention lesion, rheumatoid arthritis, frozen
Project, which included a pragmatic shoulder, severe fibromyalgia, glenohu
multicenter randomized controlled trial meral osteoarthritis, and insufficient
to evaluate the effectiveness of physical Danish language skills. Until April 2012,
therapy exercises and occupational med patients also were excluded if they had
ical assistance in reducing shoulder pain previous shoulder surgery or diabetes, if
and improving function and in reducing they were not employed in paid work for
postoperative work disability after at least 25 hours per week, and if they
arthroscopic subacromial decompres were not full-time sick-listed; these
Num ber 6
June 2 0 1 6
th e r a p y
e x ercise
in te r
June 2 0 1 6
V o lu m e 9 6
Num ber 6
Physical T h e ra p y
789
S ta n d a r d iz e d P h ysical T h e r a p y Exercises a n d S u b a c ro m ia l Im p in g e m e n t S y n d r o m e
790
Physical T h e ra p y
V o lu m e 9 6
Num ber 6
Results
P a rtic ip a n ts
June 2 0 1 6
C h a ra c te ris tic
Fem ale
U sual C are
P hysical T h e ra p y
C ro u p ( n = 6 6 )
Exercise C ro u p ( n = 6 0 )
4 2 (6 3 .6 )
4 0 (6 6 .7 )
A g e (y), X (SD )
4 9 .0 (7 .1 )
48.1 (7 .9 )
2 9 .8 (7 .5 )
2 8 .2 (5 .0 )
B ila te ra l s h o u ld e r p a in b
30 (4 6 .2 )
2 2 (3 6 .7 )
D o m in a n t s h o u ld e r a ffe c te d
4 5 (6 8 .2 )
37 (6 1 .7 )
3 7 (5 6 .1 )
34 (5 6 .3 )
3 (4 .6 )
3 (5 .0 )
1 6 (2 4 .2 )
15 (2 5 .0 )
8 (1 2 .1 )
7 (1 1 .7 )
E m p lo y m e n t status
E m p lo y e d in p a id w o r k 3 :2 5 h /w k
S e lf-e m p lo y e d
U n e m p lo y e d
Early re tire m e n t/fle x ib le jo b /d is a b ility p e n s io n
S tu d e n t/o n leave
2 (3 .0 )
1 (1 -7 )
4 2 (6 3 .6 )
38 (6 3 .3 )
P a ra c e ta m o l/N S A ID s
5 2 (7 8 .8 )
4 3 (7 1 .7 )
O p io id s
1 9 (2 8 .8 )
9 ( 1 5 .0 )
N o in s tr u c tio n o r h a n d o u ts
1 0 (1 5 .2 )
1 0 (1 6 .7 )
2 6 (3 9 .4 )
1 8 (3 0 .0 )
30 (4 5 .5 )
32 (5 3 .3 )
1 (1 -9 )
3 (1 -7 )
51 (7 7 .3 )
4 6 (7 6 .7 )
6 (9 .1 )
4 (6 .7 )
5 (7 .6 )
8 (1 3 .3 )
M a s s a g e /a c u p u n c tu re
4 ( 6 .1 )
2 (3 .3 )
2 0 (3 0 .3 )
2 2 (3 6 .7 )
Treatment Effect
N u m b e r o f sessions w it h a ph y s ic a l th e ra p is t,
m e d ia n (IQ R )
A d d itio n a l tre a tm e n t
None
S te ro id in je c tio n
1 7 (2 5 .8 )
12 (2 0 .0 )
Irre le v a n t
2 9 (4 3 .9 )
2 6 (4 3 .3 )
June 2016
Volum e 96
N um ber 6
Physical Therapy
791
Physical T h e ra p y
In t e n t io n - to - T r e a t
G ro u p
Exercise G ro u p
T r e a t m e n t E ffe c t6
V a ria b le s
C o n tin u o u s o u tc o m e s , n, X, (SD )
M e a n d iffe r e n c e ( 9 5 % C l)
66
29.1 (8.0)
60
31.0 (6.4)
3 mo
61
35.0 (9.5)
55
37.7 (7.9)
12 mo
S3
34.2 (11.3)
51
41.2 (7.1)
Constant Scored
Baseline
66
52.7(13.5)
60
54.1 (15.0)
3 mo
59
63.9 (19.1)
54
70.4(17.5)
11.3(6.4)
65
12.6 (6.0)
60
3 mo
61
10.1 (7.0)
55
7.8 (6.5)
- 1 .8 (- 3 .8 , 0.3)
12 mo
53
10.2 (7.4)
51
6.0 (5.9)
- 3 .3 (- 5 .6 , -0 .9 )
Baseline
66
0.67 (0.16)
60
0.72 (0.11)
3 mo
60
0.72 (0.21)
55
0.77 (0.14)
12 mo
53
0.71 (0.24)
51
0.83 (0.14)
61
26.3 (8.3)
59
29.3 (8.3)
3 mo
55
27.1 (7.6)
51
32.3 (9.6)
B in a ry o u tco m e s , n, X, ( % )
66
53 (80.3)
60
38 (63.3)
3 mo
55
36 (61.0)
54
23 (42.6)
Baseline
59
18 (30.5)
56
16 (28.6)
3 mo
52
13 (25.0)
50
4 (8.0)
Scapular dyskinesish
C a te g o ric a l o u tc o m e , n ( % )
7(11.5)
3 (5.5)
No change
21 (34.4)
Better
20 (32.8)
9 (16.4)
Much better
13(21.3)
24 (43.6)
19(34.6)
12 mo
Worse
10(19.9)
3 (5.9)
No change
17(32.1)
15 (29.4)
Better
12(22.6)
10 (19.6)
Much better
14 (26.4)
23(45.1)
792
Physical Therapy
Volume 96
Number 6
June 2016
Excluded (n=276)
Inclusion criteria not met (n=92)*
Frozen shoulder (n=38)
Planned reoperation (n=14)
Declined to participate (n=132)
Excluded (n=202)
Could not be contacted/late referral
(n=41)
Inclusion criteria not met (n=72)
Reported no problems (n=62)
Other inclusion criteria not met (n=10)
Declined to participate (n=89)
Distance\work\personal reasons (n=49)
Satisfied w ith current treatm ent (n=19)
Planned surgery on other shoulder (n=2)
Other reason/reason not stated (n=19)
Excluded (n=9)
Frozen shoulder (n=6)
New trauma (n=1)
Inability to participate due to other health
problems (n=2)
Randomized (n=126)
Department of occupational medicine:
east center (n=76), west center (n=50)
a
>
June 2 0 1 6
<
'
Lost to follo w -u p at 12 m onths (n=8)
Did not respond to questionnaire (n=8)
F ig u re.
Flowchart of participants in the study, fin April 2012, when 9 patients were included in the
trial, the following exclusion criteria were abandoned due to slow recruitment: previous
shoulder surgery or diabetes, not employed in paid work for at least 25 hours per week, and
not full-time sick-listed.
V o lu m e 96
Num ber 6
Physical T h e ra p y
793
S ta n d a r d iz e d P h ysical T h e r a p y Exercises a n d S u b a c ro m ia l Im p in g e m e n t S y n d r o m e
794
Physical T h e ra p y
V o lu m e 9 6
Num ber 6
June 2 0 1 6
S ta n d a r d iz e d Physical T h e r a p y Exercises a n d S u b a c ro m ia l Im p in g e m e n t S y n d r o m e
M o lle r,
PT, an d
Klaus
R egion
Research
C o m m itte e s
Ethics
M -2 0 1 0 0 1 3 1 )
P ro te c tio n
on
an d
A g e n cy
by
th e
B iom edical
n u m b e r:
D anish
(jo u rn a l
Data
n u m b e r:
2 0 1 0 -4 1 -4 3 1 6 ).
This w as a rese a rch e r-in itia te d study, p rim a r
ily fu n d e d b y th e Danish A g e n cy f o r Science,
T e c h n o lo g y and In n o v a tio n (g ra n t n u m b e r
0 9 -0 6 6 9 8 5 ) w ith c o -fu n d in g fro m th e D a n
ish Ram azzini C entre.
T rial re g is tra tio n : C u rre n t C o n tro lle d Trials
(ISRCTN55 7 6 8 7 4 9 ).
D O I: 1 0 .2 5 2 2 /p tj.2 0 1 5 0 6 5 2
References
June 2 0 1 6
V o lu m e 9 6
N um ber 6
Physical T h e ra p y
795
796
Physical T h e ra p y
V o lu m e 9 6
Num ber 6
June 2 0 1 6
Copyright of Physical Therapy is the property of American Physical Therapy Association and
its content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder's express written permission. However, users may print, download, or email
articles for individual use.