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Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE October 2021 Subacromial Impingement RCT: Are We Being Fooled by the Literature…. Conservative Care Prescribing for SA Impingement Re-examined by Mike Napierala, PT, SCS, CSCS, FAFS Clinical Scenario...What would you do? A 50 yr old male c/o gradual onset R dominant side shoulder pain possibly related to a new fitness routine started 3 months ago with increasingly heavier loads and new exercises along with a weekend of trimming trees and other yardwork. He has (+) impingement test findings, tender at SS and LHB tendons, limited/painful elevation and Horiz Add AROM, and weakness/pain with resisted Abd, Jobe, and Abd’d rotations isometric screening. Plain radiographs show mild Type II acromion, no frank osteophytic or DJD changes. Patient has used NSAIDs, seen massage therapist several times, and tried 4 weeks of BIW Physical Therapy without significant improvement. My clinical thinking is: PT/ treatment failed: Do a dexamethasone subacromial injection and FU in 2-4 weeks to consider Physical Therapy again. PT /treatment failed: Order an MRI to better ascertain involved structures and ensure no labral pathology or cuff tearing that might explain lack of improvement, then determine best care. Keep things simple: Provide the patient your customized shoulder/RC HEP sheet and encourage specific adherence to that progression, place on prescription level NSAIDs and FU in 4-6 weeks. Prior care may be inadequate/limited: Briefly review what was done in PT. If excellent/thorough then consider A, B, or C, otherwise refer to more expert PT/group for more thorough assessment and individualized program involving manual therapy, customized exercise, and modalities if necessary then FU in 4-6 weeks. PT / treatment failed: Schedule MRI and prepare patient for likelihood of Arthroscopy to get a better look at the joint/tissues and address findings since prior care has failed. CURRENT EVIDENCE Clausen MK et al, Effectiveness of Adding a Large Dose of Shoulder Strengthening to Current Nonoperative Care for Subacromial Impingement. Am J Sports Med, 49:11, 2021, 3040 - 3049. https://journals.sagepub.com/doi/full/10.1177/03635465211016008 (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) SUMMARY: Shoulder impingement is a highly prevalent shoulder condition that is seen frequently in office by both primary care and orthopedic specialist physicians. Discerning best practices for prescribing conservative care is key, especially as more recent studies have recommended against subacromial decompression surgery ( BMJ 2019), at least as an early treatment option. But clinicians must be wary of quick scanning the literature to avoid misguided thinking based on inappropriate conclusions offered by study authors. As is said…”The devil is in the details” holds true! Clausen et al examined the addition of (an intended) 12 hrs of rotator cuff strengthening exercises over 16 weeks to increase the time under tension stimulus in an Intervention Group(IG) along with “usual care” compared to the control group receiving only “usual care” that reportedly could include modalities, education, exercise, and manual therapy (but were not standardized). There were no between group differences in SPADI score improvements noted from baseline to 4 months. The Intention to Treat analysis also showed no differences for change in Abd or ER strength, Abd AROM scores nor for Patient Acceptable Scale Score(PASS) or global rating of change. Also, only 48% control and 54% intervention groups reached the PASS. The authors concluded that larger strength doses during Subacromial impingement care do not result in superior results. The initial reaction to their conclusion for some may be that four months of therapy was only effective at a mediocre level and some might even characterize as “chance” since only approximately 50% reached the PASS. Others risk deeming this RCT a bit of a “nail in the coffin” of more extensive or lengthy therapy exercise routines, particularly strengthening. One might even be led to ponder “Maybe simple HEP sheets are adequate vs doing formal PT.” It risks serving as evidence that conservative care is inadequate and possibly become reason to entertain surgical intervention earlier. The authors’ conclusion seems premature and inappropriate once you “look under the hood” of this study though. This study’s failure to show superior results with “more strengthening” exercises alone is not disappointing but rather somewhat predictable, especially considering the design allowed in the “usual care” portion. Their findings would, if true, nevertheless, support our position that each patient’s care must be customized to determine not only which exercises are appropriate and when, but also the loading parameters and progressions, as well as pain or inflammation reducing modality/procedure use (ie Class IV laser, iontophoresis, etc) and manual therapy needs for hastening recovery of kinetic chain function. The patient case study demonstrates a comprehensive functional biomechanics and manual therapy based program using customized exercise progressions to achieve recovery in a patient with impingement/RC pain syndrome that is commonly seen in the clinic. Background: With recent recommendations against subacromial decompression non-operative care options become primary treatment, but some studies suggest current care approaches may lack adequate strengthening effect. Purpose: To determine effectiveness of adding a large dose of “time under tension” inducing strength exercises to “usual care” conservative care alone. Methods: RCT design double blind study allocating 200 consecutive patients diagnosed with subacromial impingement syndrome (SIS) aged 18-65 yrs into a Control Group of “usual care” ranging from BIW to 1/mo Physical Therapy over 16 weeks or an Intervention Group (IG) that had four sessions for added training and follow up with a time under tension optimizing strength exercise HEP added that involved eventually three exercises and progressed from 3x20 QD for the first and eventually became QOD for 2x10 for all three during Phase III portion. Measures included SPADI and secondary strength, ROM, quality of life rating, and Patient Acceptable Symptom State (PASS) score. Findings: Both per-protocol and intention-to-treat analysis showed no between group significant differences for any of the outcome measures. SPADI improved for both groups. At 4 months only 54% of IG and 48% of CG patients reached PASS. Author's Conclusion: The addition of larger doses of strengthening exercises to usual nonoperative care for shoulder impingement treatment did not result in superior outcomes. Only half of patients having conservative care achieved PASS by four months, leaving many with unacceptable symptoms. THE PEAK PERFORMANCE PERSPECTIVE It is subtly clear in the background presentation by these authors that the 2019 BMJ recommendation against subacromial decompression surgery was less than appreciated. They state “Such drastic changes to care pathways may leave patients without further treatment options if nonoperative care fails.” Their conclusion added “...leaving many of these patients with unacceptable symptoms. This study showed that adding more exercise is not a viable solution to this problem.” As orthopedic specialists and primary care physicians seeing patients diagnosed with subacromial impingement syndrome making correct decisions about conservative care options is a daily requirement, if not at least weekly. The search for evidence to base those decisions upon could easily land one on articles such as this month’s by Clausen et al in AJSM, considered a highly regarded resource for clinical judgement and introspection. While the data has increasingly supported non-operative measures as a first line of defense for shoulder impingement we do not believe that surgery is unnecessary, unwarranted, or inappropriate depending on the case. Again, the challenge may more so be in how studies are done and data presented. We go back to the concept that each patient is an individual and the patient’s history plus findings along with the professional scientific data can both inform that decision process. Both are necessary. This study does demonstrate, however, that “The devil is in the details” still holds true with scientific studies. In school we’ve all been warned to not simply read the abstract and move on, assuming an author’s conclusions are sincere and thoughtful and reasonable. The risks in Clausen et al’s conclusions here are several fold. One might be led to conclude that conservative care (ie, physical therapy) is generally inadequate and ineffective and thus that surgery may be a necessity earlier in the process of treatment, especially when apparent “failure of care” seems evident. Also, some may believe this data demonstrates that more extensive exercise regimens are unnecessary and ineffective compared to “keeping things simple” with a basic series of HEP from a prepared sheet that could be given out in the office or expected to be the level of “simple care” offered at a PT clinic. Their premise for adding strength exercises is based on evidence of inadequate strength gains from “standard” physical therapy, however, a careful look reveals this came from a design where patients only did strengthening during in-clinic visits and did not have any Home Exercise Program (HEP) responsibilities. That is hardly evidence the “usual” physical therapy is, as a proven standard outcome, falling short in restoring strength. Nevertheless, their contention that therapists oftentimes do underdose strengthening exercises is likely a very valid criticism/concern. Still, before simply throwing more volume of strengthening exercises at patients we must remember that other factors contribute significantly to exercise tolerance and design. ● How inflamed and pain sensitive (and reactive) are the tissues involved? ● Are we seeing true “weakness” having developed or is this potentially pain-induced inhibition that does not necessarily require substantial strengthening dosages/stimuli? ● Are there comorbidities to consider that impact common exercises choices? ● How will pain/discomfort during or after exercises be handled? ○ Attempting generally symptom free strengthening? ○ Allowing limited symptoms during and/or after that must resolve within 2-24 hrs (depending on rationale/philosophy)? ○ Encouraging intensity adequate to produce mild (or greater) symptoms lasting only 2-24 hrs? They also make the mistake of overgeneralizing the concept of “larger doses of strengthening” in the title and article. It more accurately should read “time under tension (including isometric phase) optimized HEP RC strengthening” instead. Clausen et al ignore external validity rules when stating that more “strengthening” exercises are no more effective than usual care. Actually, what is no more effective is utilizing a limited amount of isometric based time-under-tension emphasized home exercise reliance with limited 1/mo average provider training and feedback. A major factor also is the lack of clarity on what sort of strengthening the “usual care” group had already performed. Clausen et al utilized a thoughtful progression regarding QD exercise moving toward QOD, however, it was odd that they added one exercise per month with an eventual program of 2x15- - - > 2x10 QOD for each of the three added strengthening drills, two of which were for ER’s. It was a bit unusual that during the QD phase patients performed 3x20 as their “to failure” target. Normally in strength and conditioning if an athlete were performing a progressive resistive exercise for three sets to fatigue they’d very likely be taking 48 hr recovery between sessions. They utilize very specific slow contractions + isometric “time under tension” model program of only three additional Abd and ER exercises. This hardly qualifies as what many might deem “larger doses” of exercise and, in fact, the eventual compliance finding was that instead of 12 hrs of additional total exercise achieved that the IG only did 2.9 hrs of added exercise (per time under tension) over the course of the study. Despite being a “gold standard” RCT design, the findings here should be taken with caution in leading a clinician to forsake significant strengthening stimuli for impingement cases. It does also call to question the common concept of “protocol” type approaches to care. While the study individualized the loading used based on performance and symptom resolution within 24 hours, it nevertheless used very specific, limited exercises and did not allow for customizing angles, planes, exercise choices and sequencing/progressions or altering exercise parameters. It is not clear that cervicothoracic or scapular issues were adequately addressed as key contributing factors to the condition’s onset or recovery capacity. Decades of experience have shown us that individualized functional biomechanics screening and exercise progressions are very often necessary, instead of more simplistic protocol driven simple progressions. Customizing exercise selection, order, sequencing, and making unique adjustments (such as path of motion plane tweaks to avoid symptoms, hand placement to effect more RC stimulus, the use of or cueing away from allowing kinetic chain synergy among others. Manual therapy to address pec minor restrictions that are facilitating functional impingement along with ensuring thoracic extension and ipsilateral rotation especially ( due to more common same-side reaching with ADL) is crucial. With more advanced demands during goal activity then Type I and II thoracic motion can be considered. Finally, modalities such as the Class IV laser can be very helpful in reducing pain and inflammation to allow earlier intensive exercise. The case below illustrates a comprehensive approach that worked successfully, rather than a mere “extra-volume” of simple RC strengthening drills. A kinetic chain approach helps ensure that the key or at least some of the likely underlying contributing factors for having developed an overuse problem are addressed. THE PEAK PERFORMANCE EXPERIENCE Michael said: “I feel better than I have in years! Now I can lift weights again and golf without pain!" HX: 57 yr old male reports h/o five years with (B) shoulder pain that developed gradually with increasing fitness exercise and weight lifting as well as ADL use. His CC are frequent L and infrequent but more intense dominant side R shoulder pain with fitness/exercise, ADL lifting and reaching, sleep, and recreation (golf, shooting basketball with son). Subjective: Pt reports 80% function and pain L 2/10 and R 4/10. Quick Dash 11% and Sport module 19%. Objective: (Pt had inconsistent attendance due to job demands. Seen 14x over 4 months) (*=pain) Initial Eval DC Re-Eval Flexion AROM 1500/1500 1630/1520 IR AROM T9 * / T11 T6 / T9-10 Abd IR AROM 250/250 550/470 Pec Minor Tightness Mod/Mod Min+/Mod Isometric Flexion 6.6 kg* / 12.8kg 12.8kg / 14.5kg Abd 8.8kg * / 13.7kg 13.4kg / 13.4kg Overhead Press 1st sx L 3# / R> 45# 25# elliptical 16x/19x Abd ER NT 15# 27x / 30x Push ups ½ depth painful 10” box > 10x no sx Key Findings: Thoracic extension and rotation limited, pec minor very tight (B), posterior RC/capsule limited with Hor Add and Abd IR ROM. Elevation strength and Abd Rot’s all weak and painful. Impingement tests (+) in (B) shoulders. Treatment: Manual therapy targeting thoracic spine and pec minor along with GH joint capsule mobilizations for restoring especially inferior capsule length to allow elevation end ranges along with Horiz Add and Abd IR. Self stretching/mobilization/ROM program for same structures-tissues done. Painfree strengthening progression initiated for promoting better scapular retraction and also improving upward rotation ease (based on pec minor induced chronic protraction with reaching/lifting especially) and also 300 abd’d rotations. Strengthening progressed on to sx-free plane elevation with reduced depth starting motion on incline press to reduce gravity demand at 90 and end ranges of lift. Long lever strengthening began lying with tubing to again reduce demands at key impingement ROM zones will still proprioceptively stimulating independent function into full available elevation without pain. Early on parameters were BID 10- - ->30x and then later once a base established PRE were gradually progressed to 2x15 QD and then finally 3x 10-12 TIW for more intensive loading. Outcome: Pt had difficulty attending regularly due to demands of job. He was only infrequently seen BIW and more often 1/wk and still then bouts of 2-3 weeks without visits. Nevertheless he reached self reported > 90% function on each shoulder and had resumed canoeing, kayaking, shooting baskets with his son, playing golf and sleeping comfortably. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com

The team at Peak Performance PT helped me work through a variety of exercises to reduce my shoulder pain/impingement. Andrew, Rachele, and the entire staff really care about your recovery (and work you hard They design a plan to get you well, and if you do your part, you will get well! ~ Eugene Rogalski

As the colder temperatures set in, we often see a rise in the number of patients who come to physical therapy for shoulder pain. Despite living in Rochester, the cold weather is not likely to blame for these problems! Overhead sports, all sorts of yard work and things like shoveling can really take a toll on your joints until they start to nag you so much that you change how you move. Eventually you’re forced to change the way you are functioning and...all too often...to STOP enjoying your favorite activities. Many different structures in the shoulder can cause pain. The rotator cuff ("rotor cup" as some would say), part of the biceps muscle, the labrum (shoulder socket cartilage ring), AC joint (small bump on top of shoulder), and multiple bursae (fluid sac friction reducers) can all be culprits that cause pain and limit function. But sometimes people are too quick to assume the cause is where the pain is and are "fooled" into blaming the shoulder when other nearby parts could really be at fault. Did you know that your shoulder pain can come from its nearby neighbors, the neck (cervical) or mid-back (thoracic spine)? Radiating pain from joints and nerves in both the neck and trunk can send symptoms to the shoulder blade and sometimes down the arm...which can be tricky as they pass right through the shoulder area. Pain doesn't have to be the only "feeling" that can raise a flag or concern; weakness or numbness/tingling can also be a sign that something is wrong. For those of you reading this thinking, "I know, stretching and strengthening exercises are the answer"…you might be right. Or you might not be. And do you know which ones are the right ones to do? You see, the real challenge is first doing an evaluation to determine the source of the pain, figuring out which tissue is making that shoulder hurt but then ALSO digging deeper to find any underlying causes for why it happened in the first place! Seeing a skilled, knowledgeable health care professional is that first step. A good history and a thorough physical exam are the key first steps to discovering why your shoulder hurts. Yes, there are times when "films” might be necessary. But be careful of ‘hanging your hat’ on X-ray or MRI findings. Studies remind us that plenty of people with no pain often have similar findings on imaging studies...so they’re sometimes part of discovering what’s going on, but they have to be interpreted alongside an excellent clinical exam. Too many of today’s common treatments focus on simply masking your symptoms. Temporary “feel good” options do work to block your pain or inflammation, but have they really helped handle the actual problem? Can you be confident this isn’t going to come right back again? Keep an eye out in your inbox for our next email and we’ll share a little more about understanding those different causes of shoulder pain better. Hope this helps!Allison Pulvino, PT, MSPT, CMP, CAFS and Andrew Neumeister, PT, DPT, FAFS

My shoulder impingement pain affected all aspects of my life, including my sleep and ability to work out or even be on my bike. I had already been to PT, but the pain and weakness returned. I was referred to Mike through PowerTrain and from the first day, I realized I had found someone who could lead me to getting back to things I love. Working with Mike has shown me how to not only complete exercises correctly for my shoulder, but the correct way to engage the muscles in any exercise. I am happy to report that I am pain free and enjoying working out again and making strength progress weekly. Thank you, Mike! Lisa M. June 14, 2018

I came to Peak Performance with pain in my shoulder and upper arm due to joint impingement and numerous areas of tendonopathy. I was unable to play tennis or golf –each making the pain worse. Now I am back playing tennis and can even serve with the full upward arm motion. Such a joy! I’m also looking forward to getting back on the golf course. Karen’s program for me led to shoulder muscular development and strengthening, which brought overall relief to the shoulder. She also emphasized strengthening of the hips and legs, which reduced the dependency on the shoulder. Robert P.