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The effectiveness of exercise on function for adults with shoulder impingement

syndrome (sis): a structured literature review.
Mussa El Mughrabi1, Adel El Alwani2, Naser Amein2 and Adel Almangoush3*
1
Glasgow Caledonian University & Higher Institute of Medical Professions – Benghaz, Glasgow, United Kingdom
2
Higher Institute of Medical Professions – Benghaz, United Kingdom
3
Salford University, Salford, United Kingdom

Abstract
Objective: To examine the effects of exercise on the function of adults with shoulder impingement
syndrome (SIS).
Design: A structured literature review of randomized controlled trials (RCTs).
Methods: Studies were identified from databases searched from 2007 to April 2016 MEDLINE,
EMBASE, PEDro, Sports Discus, AMED and Cochrane Library, only one reviewer selected
studies meeting inclusion criteria. The methodological quality of the included studies was
independently assessed by the same reviewer using the PEDro quality assessment tool.
Results: Eight studies were included in the review and appraised for content. Five studies
achieved a score of 6 or above indicating good quality, tree trials were rated as moderate quality.
No study achieved lower <4 to indicate poor quality.
Conclusion: Due to the lack of a detailed description of the exercise protocols used, the current
evidence is difficult to interpret in relation to use in clinical practice. Therefore, future RCTs
studying exercise therapy should also concentrate on the effect of different exercise protocols,
including the intensity, duration, frequency and load of the exercises.

Accepted on November 14, 2016

Background towards the proper treatment mechanisms that can strengthen

and deter the advancement specifically of Stage I of SIS [6].
Description of the condition
The pain caused by the SIS can significantly diminish the quality
Shoulder impingement syndrome (SIS) is a common disorder of life that patients endure [7,8]. It occurs in three stages based
that results in the disability and functional loss for patients overall on severity and duration of the condition: Stage I is characterized
[1,2]. Around 1% of adults seek medical attention for shoulder by localized inflammation, swelling and is seen in patients under
pain each year. It is the third most common musculoskeletal
the age of 25 years old. This may be due to overusing the muscle
reason for general practitioner consultations and estimates of
or pain from acute trauma. Shoulder impingement at this stage
its prevalence in the UK range from 7% to 26% [3]. Also, an
is reversible [9]. Stage II is associated with a progression and
epidemiological survey of this phenomenon based on job title
tear in the rotator cuff. This condition is not reversible yet can
and cumulative exposure found at the 95% confidence interval
be affected through rest and conservative precautions. Patients
for slaughterhouse workers, indicating the prevalence of this
with stage II impingement may require surgical intervention [1].
condition amongst shoulder intensive positions [4,5]. There
Stage III SIS is demonstrated amongst those over the age of
are a variety of interrelated pathologies that are present within
forty as a destruction of soft tissue and rupture of the rotator
Subacromial Impingement Syndrome; these include partial
thickness of rotator cuff, tendinosis, subacromial bursitis and cuff. Physical and other surgical interventions are necessary
calcific tendinitis. Each of these can be categorized as SIS frequently in this stage.
and can present in relatively similar manners through initial When shoulder symptoms are present for more than three months
clinical investigation. Mostly, these pathologies would lead to during the past year, it is possible to diagnose impingement.
rotator cuff injuries, which affect the supraspinatus superiorly, Magnetic Resonance Imaging (MRI) techniques allow
subscapularis anteriorly, the infraspinatus and tears minor differentiation to guide further physiological management [10].
posteriorly [5].
Description of the intervention
These lead to impingement syndrome in the shoulder and are
common amongst those who raise their upper arm a shoulder There are numerous management techniques through
level for extended periods of time and this is prevalent amongst physiotherapy that aim to assist symptoms of SIS. Exercise
those who play various sports. It is a lifelong process that and manual mobilization are some common forms that have
culminates through three stages. In order for proper diagnosis, it been proved efficacious [11,12]. Treatment is subjective to the
is imperative that proper detection and quantification of rotator dependence of training and requires careful evaluation. The
cuff tears must be provided to gauge the severity and create common theme is an element of exercise that can benefit any
valuable prognosis for the patient and this would be contingent physiotherapy program for SIS. Therefore, exercise is a valuable

13 J Pain Manage Ther. 2016 Volume 1 Issue 1

Citation: El Mughrabi M, El Alwani A, Amein N, et al. (2016) The effectiveness of exercise on function for adults with shoulder impingement
syndrome (sis): a structured literature review. J Pain Manage Ther. 1(1):13-23.

intervention that can potentially provide benefits to patients Since it has been demonstrated that certain elements of patient
suffering from shoulder pain of this variety. Should exercise discomfort can be managed through the use of exercise, exploring
can promote strengthening, relief of pain and healing that can this review will provide a clear and useful explanation of the
reverse conditions of abnormal muscle imbalance. These can specific function that exercise can provide for SIS. Studying
restore a pain-free sate of motion [13]. Since Stage I of SIS can this area of treatment can help cultivate an understanding of
be reversed according to the proper management and exercise, it the efficacy that certain exercise has for patients with clinical
is possible that loaded exercise can demonstrate benefits towards signs of SIS. While there are documented examples of the value
the management of the disorder [14]. This disorder does not that physiotherapist initiated and led programs have towards
have to self-limiting as shoulder impingement can frequently managing pain, there are significant areas of comparison
be seen as refractory and patients can benefit from nonsurgical that will illustrate the benefit of exercise in comparison to
intervention. Therapeutic exercise programs can add value to other non-surgical and surgical interventions alike [1]. Such
patients with initial stages of impingement (McClure et al, an understanding can assist in creating physiotherapy plans
2004). This is due to the ability for physical exercise to restore that involve useful aspects for the diversified type of pain or
mobility and stability through enhancement of glenohumeral condition that a patient experience. In such a way the modality
and scapulothoracic muscular function. It has been demonstrated of healing and improvement will be contingent on education and
further that the incorporation of active exercise in combination practice that a physiotherapist can involve within their practice
with joint mobilization and other modalities of therapy can be for maximum efficacy and value towards patient healing.
beneficial towards healing shoulder impingement and limiting Previous reviews had a similar aim as the current review were
the pain that patients experience while assisting in reversal of constrained by the limited number of good-quality studies and
the condition [14]. available methodological quality was generally poor, with no
sample size calculations, lack of detail on interventions and lack
How the intervention might work?
of blinding of outcome assessment [16,17].The uncertainty for
Shoulder pain can decrease as a result of strength through the effects of exercises on function, pain, muscle strength and
exercise. These changes are relevant to the improvement quality of life needs a recent review with up to date studies.
of functional activities such as simple forward reaching or
overhead extension [6]. Exercise, especially in therapeutic The objectives
forms can determine long-term benefits that result in optimal To examine the effects of exercise on the function of adults with
conditions for strengthening functions. In his way, exercise shoulder impingement syndrome. In this review the intervention
could contribute to increased pain-free range of motion as well will be compared with standard physiotherapy intervention.
as significant reduction in overall shoulder pain [14].
Methods
Since SIS has been managed with exercise, the results
of particular mechanisms would be based on the unique This review was conducted following the Preferred Reporting
protocol established by the particular exercise regime [15]. Items for Systematic reviews and Meta-Analyses (PRISMA)
In demonstrating the three dimensional scapular kinematics, guidelines [18].
functional limitations and physical impairments that could be Criteria for considering studies for this review
changed through exercise, it can be demonstrated that passive
ranges of motion could increase for both internal and external The criteria of inclusion have been adopted because the study
rotation [14]. Exercise can potentially diminish pain, increase aims to be carried out with the minimum bias, and as many
shoulder functions and related physical functions. Combined grounded conclusions as possible. According to Rochon et al.,
with proper education and effective strategies, simple exercise “one powerful strategy to minimize selection bias is to restrict
routines can contribute to patient expansion and understanding inclusion in the study to those with a defined diagnosis or
of the underlying improvement techniques and mechanisms. specific characteristics” [19].
Since it is unclear how the specific nature of this modality works Types of studies include
because of the highly diversified nature of clinical presentations
and exercise regimes, further research and incorporation of Only randomised controlled trails (RCTs) which test the effects
specific assessments on the range of motion and other qualitative of exercise interventions on people with shoulder impingement
perceptions the patient may face is necessary to elucidate how syndrome (SIS) were included in this review. The participants
the intervention will work [15]. of the included trails were randomized to the following:
• Intervention group: who will experience a single exercise
Why It Is Important To Do This Review?
intervention or a multiple exercise intervention, versus
It is important to study the effect of exercise on shoulder
• Control group: who will experience usual activities,
impingement in order to review the validity of the intervention
usual health care, electrotherapy, or activities (such
as well as comparisons regarding usual care amongst
as attending recreational or educational activities or
physiotherapy. By utilizing only randomized controlled trials
groups) that received the same attention (number of
(RCTs) it is possible to trials to assess the intervention group
attendances at classes or contact with the research team)
with regards the therapeutic exercise and combination exercises.
as the exercise group.
In evaluating the effectiveness of exercise the purpose of this
investigation will be identify functional improvement to the Trials that compare two or more exercise interventions and a
shoulder amongst adults. control group were also included.

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 El Mughrabi/El Alwani/Amein/et al.

Types of participants the researcher to do the following subgroup analysis that was
planned a priori: Gender, athletic or not, duration and intensity
Participant characteristics of interest included adult patients
of exercises sitting of the delivered interventions and types of
diagnosed with signs and symptoms of SIS Stage 1 or 2. Studies
supervisions.
which included participants with SIS stage three, or painful/
stiff shoulder is associated with other diagnoses, e.g. frozen Search Strategy
shoulder, or postsurgical patients were excluded.
To achieve the goal of maximising the relevance of as many types
Type of interventions of physiotherapy exercises interventions as possible because of
Exercise interventions designed to improve SIS were defined the possibility, because there is a possibility that papers might
as those in which participants exercise their muscles (and have been missing through the searches of database, and also to
neuromuscular responses) against an external force as an identify different materials and documents. So, a hand search took
outcome of voluntary movement. This was also defined as loaded place for all the relevant articles and reviews. Papers published
(against gravity or resistance) exercise or active free exercises 2008-2016 were exclusively included. The reason why only these
(unloaded exercises) as a component of the intervention. papers were included is that the research studies before those
Examples of exercise interventions include: functional static times were assessed in previous reviews Table 1 [20].
and strengthening exercises. Key words used to extract the relevant articles for
There are different places where the exercise interventions Terms were used to conduct the search “Shoulder Impingement
can take place: home, institutions, local community, or at Syndrome” OR “subacromial impingement” AND
the clinic. They can also be self-monitored by using exercise “physiotherapy exercise intervention” OR "stage I" Or "stage
sheets and video, or they can be monitored by individuals or II", musculoskeletal injuries of the shoulder, tendon injuries,
groups. Different persons can play the role of supervisor: the preventing sports injuries, stretching, injury (strain, sprain and
patients themselves, the patines’ peers, or physiotherapist or tendonitis) adult, upper limb, upper extremity, overuse and
any healthcare. shoulder injury, to ensure a detailed and comprehensive search
A comparison was made with control groups who performed the strategy Table 2.
usual activities, the usual health supervision, attending different Study selection process
types of activities which are group-related or educational. These
activities gain the same attention as the exercise group in terms It is desired that more than one reviewer applies the selection
of the number of attendances or being connected with research criteria in order to minimise bias in the study selection process
team. The studies which include combined interventions were [21]. Due to the circumstances of the current study (being a
carried out. Master degree dissertation with limited time and size), only
one investigator took part in the application of the previously
Type of outcome measures determined selection criteria, because it was not possible or
The result measures are very significant in any study. The use of easy to have more than one reviewer for the literature review.
the outcome data and investigation will guarantee the strength The minimization of bias
and validity of the study and it will support it. It will also
ascertain that the data has reliability and authority. There can be found bias during the production of a literature
review. While the review was being conducted every effort
Primary outcomes of interest included: Measures of function, was made to eliminate the following: publication bias, bias in
such the disability of the arm, shoulder and hand (DASH), location of studies and biased inclusion criteria [22].
patient- reported function (PRF) and quality of life.
A large number of databases were used in an attempt to guarantee
Secondary outcomes were: pain and upper limb muscle strength. a comprehensive search of articles regardless of type, so as to
Subgroup analysis and investigation of heterogeneity avoid publication bias. As far as possible, studies conducted
in different contexts and environments were sought to avoid
The data mentioned in the included studies did not enable bias in the location of studies. Finally, to achieve the goal of

Table 1. Details of search strategy.

No. Criteria Details
MEDLINE, Cochrane Library (systematic reviews and controlled trials registers), EMBASE, CINAHL, Science Direct,
1 Database utilized EBSCO, Physiotherapy
Evidence Database (PEDro) & LILACS.
#1 -(" Shoulder Impingement Syndrome"[Mesh]) (which includes rotator cuff syndrome, bursitis, and tendonitis)
2 Search used
#2 -(" Physical Therapy Modalities"[Mesh]) (limited to any type of exercise therapy)
3 Boolean Operators AND, OR
("Shoulder Impingement Syndrome"[Mesh]) AND ("Physiotherapy OR Physical Therapy Exercise Modality" [Mesh] OR
4 Search String with Booleans
"Physical Therapy Specialty"[Mesh]) OR "Exercise"[Mesh])
5 Limits
a  Published date From April 2008 to April 2016
 b Humans/Animals Humans only
 c Type of Studies Randomised controlled trials (RCTs)
 d Language English

15 J Pain Manage Ther. 2016 Volume 1 Issue 1

Citation: El Mughrabi M, El Alwani A, Amein N, et al. (2016) The effectiveness of exercise on function for adults with shoulder impingement
syndrome (sis): a structured literature review. J Pain Manage Ther. 1(1):13-23.

Table 2. An example of the search strategy that was performed on MEDLINE search strategy. This strategy was modified for use on the other
electronic databases with support from a librarian.
Search term Limited to
Shoulder pain or shoulder impingement or shoulder tend or shoulder burs or rotator cuff or subacromial impingement or
1 Title & abstract
subacromial burs or supraspinatus or impingement or contractile dysfunction or painful arc
2 Rotator cuff/shoulder pain/shoulder impingement syndrome MeSH
3 1 or 2
Exercise or eccentric or concentric or loaded or resistance or muscle or physiotherapy or physical therapy or rehabilitation or
4 Title & abstract
conservative management
Exercise/resistance training/physiotherapy/physiotherapy or physical therapy specialty/rehabilitation/muscle strength/exercise
5 MeSH
therapy
6 4 or 5
7 Randomized controlled or randomised controlled or controlled trial or randomized or placebo or randomly or quasi controlled trial
8 Humans NOT Animals
9 3 and 6 and 7 not 8

eradicating bias in the inclusion criteria, all possible ways were on evidence. The evaluation supports empowering the research
adopted not to select studies on this basis. Articles were instead understanding and it will also show the interrelatedness between
chosen according to their relatedness to the main question of theory and practice that will lead to a more improved healthcare
the review. Each included study was scored independently by quality [24].
the same reviewer, using the criteria made by PEDro critical
The PEDro critical appraisal tool was used for the assessment
appraisal tool [23].
of the quality of every single study’s methodology). This is
Data Extraction an easy to administer 11-item tool giving information about
the internal validity and reporting the statistical outcomes
It is advisable to have at least two analysts for extracting and of a RCT (PEDro, 1999). Truthfulness and credibility of the
investigating the information in order to prevent extracting PEDro-scale has been tested by a large numbers of studies and
information and the inclination to dissect. Anyhow, it was not it is commonly accepted as a compatible tool for categorizing
possible in this review as specified previously. The aim of this RCTs in systematic reviews [23,25]. Data recorded by this
procedure was to extract the findings in a consistent manner outcome measure are descriptions of: eligibility criteria,
from each qualified study. The data extraction form underlined random allocation, concealed allocation, comparability of
the major elements of each study, which is related to the review groups at baseline, blinding of subjects, blinding of therapists,
aim. The data extracted from selected studies were: the authors blinding of assessors, measurement of key outcome in at
details, purpose of trial, participant characteristics (mean age, least 85% of initially allocated participants, intention to treat
duration of symptoms), type of exercise intervention, outcome analysis, statistical comparison between groups and point and/
measurements and findings. or variability measure. The only case where discretionary
Methodological quality of articles points are granted in the trial is when the information required
is evaluated as it is described in the information about additional
The aim of the scholar was to answer the questions of the rating that is provided. Scores for RCTs as rated on the PEDro-
PEDro chick listed questions. Each one of the papers was scale (PEDro, 1999): Excellent quality 9-11; Good quality 6-8;
read with care and scrutinised twice. In the first time, papers Moderate quality 4-5; any scores below 4 were low quality. This
were read quickly using simple approach that is time saving assessment was taken by the same investigator as mentioned
in order to obtain the relevant data. This was done by dividing above.
the checklist which contained 11 items into 4 sections which
were highlighted: The relevant information regarding PEDro criterion was
collected by usig all the articles and assessed in accordance to
• study population study sample the scoring criteria established by the PEDro database (PEDro,
• intervention, 1999). In order to achieve a lucid comparison of ratings were
gathered together on a single spread sheet. The ratings were
• measurement of effect measuring the outcome performed by the author because this study is a requirement of
• statistical validity statistical credibility the MSc dissertation; however, this method was confirmed as a
possible reason for bias. In order to achieve a lucid comparison
So, the authors completed answering the questions in a sensible, of ratings were gathered together on a single spread sheet.
organised way. Recording related answer in the same colour
was found to be time saving, and it also allowed answers to be Best evidence synthesis
ready for analysis. Best-evidence synthesis criteria were adopted in summarizing
Methodological quality assessment the clinical interrelatedness of the qualitative results. Synthesis
criteria as presented by [26], which were modified to reflect items
There is a need that the evidence resulted by the study should be that were relevant for trials involving exercise. Consequently,
systematically evaluated in order to create strength, reliability threats to bias were inadequate randomization, inadequately
and relevance for the research. This should take place before concealed treatment allocation, non-blinding of assessors, no
findings are used to make a decision regarding practice and it intention-to-treat analysis, and no measurement of compliance
should be a crucial component in a clinical practice that is based with the exercise intervention. In order to summarise the veracity

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 El Mughrabi/El Alwani/Amein/et al.

of evidence for each outcome, the PEDro quality classifications texts were maintained and analysed in accordance with the
were added to the criteria in Figure 1. criteria of inclusion and exclusion.
Data analysis and synthesis Included Articles
A meta-analysis is a statistical methodological tool which The selection criteria of inclusion that have been adopted
provides a straightforward estimate of the overall effectiveness allowed only 8 RCTs to be selected. This is a small
of exercise on SIS and increases the power of the analysis [21]. number but that is what the inclusion criteria permitted the
Because outcome measurements and intervention of included researcher. However, these 8 papers are relevant and valuable
studies were heterogeneous, it was not possible to include meta- because they include relevant) information concerning
analysis. the effectiveness of exercises on function for adults with
Therefore, a narrative way which uses depiction was adopted shoulder impingement syndrome. The RCTs included in this
for analysis and comparison of findings yielded by the included review were conducted in different places across the world:
trials. Recording of problematic effects and dropout rates was Norway [27,28], Sweden [29], Brazil [30], UK [31], USA
done. [32], Canada [33] and Belgium [2].

Dealing with missing data Assessment of Risk of Bias

In the case when some missing data were found during data PEDro scale was used to assess the methodological quality
extraction, it was attempted to contact the original investigators of the included studies. These studies were assessed for bias.
of the study to request the missing information. The PEDro scale is a rating system which consists of 11items.
This system is used for the evaluation of internal validity of
Selection of Studies RCTs (PEDro 1999). It is a developed and advanced copy of
146 papers that may be relevant were the result of primary the Delphi list originated by Verhagen et al (1998) and based
search of the websites as well as hand searches of the list of on ‘the consensus of expert (PEDro, 1999). PEDro scales are
references. 87 studies were excluded because they did not meet considered to be the only one way to evaluate the methodological
the criteria of inclusion and exclusion. The remaining articles quality of papers: it is, however, a very common one used to
were downloaded with the full texts that were screened as evaluate RCTs included in systematic reviews that looked
well. However, even the remaining 59 articles were subject to at physiotherapy intervention. Its use thereby increases the
recording and removal of duplicates. In this case, only 8 full comparability of findings with those of other articles.

Figure 1. Results of PRISMA flow diagram search strategy.

17 J Pain Manage Ther. 2016 Volume 1 Issue 1

Citation: El Mughrabi M, El Alwani A, Amein N, et al. (2016) The effectiveness of exercise on function for adults with shoulder impingement
syndrome (sis): a structured literature review. J Pain Manage Ther. 1(1):13-23.

The information on eligibility criteria for subjects included and [28]. Finally, a positive result on Jobes test and positive result
randomization process was provided clearly by 5 of included on Patte’s manoeuvre were applied by Holmgren et al. [29] and
studies [27- 29, 31]. Only two trials [31,32] comparing between Maenhout et al. [2].
experimental and control group did not take place and the two
Study size
groups were not specified. The studies included were all too
high to measure the effects for 85% of the patients who were Sample sizes ranged from a total of 33 participants [32] to 112
allocated at an initial stage. The intension-to-treat analysis was in [31]. Østerås et al. and Maenhout et al. studied a sample of 61
used in 5 of the included studies. All the studies clearly included participants. Lombardi et al. included 60 participants. Szczurko
between-group comparisons of findings as well as measures of et al. included 85 patients, Engebretsen et al. studied 104 and
variability Table 3. Holmgren et al. included 97 participants. With the exception of
that conducted by Maenhout et al. a power calculation was not
Quality of Evidence employed in any of the studies to determine the sample size.
Based on the previously determined PEDro scale, five studies All articles did not mention the patient’s professions or their
were considered to be of good quality [27-29,31]. No study physical activities except the study done by Szczurko et al. [33]
achieved lower <4. The remaining tree trials were rated as stated that they involved a member of postal employees. All
moderate quality trials. the studies were ethically approved apart from Szczurko et al.
[33] and Engebretsen et al. [28], the status of their study, in this
Study characteristics regard, not being stated.
In order to mitigate the effect resulted from the fact that the Age, weight and body mass index were reported to be
similarities and differences between the included studies were determinants of baseline characteristics. The authors stated
not uniform, it was suggested that a narrative summation of that the baseline measurement was significant when assessing
the results to be used as the most workable way for presenting a point of departure to which the later measurements can be
extracted data Table 4. compared [31,32].
Study Population In all the studies under consideration, the age of the patients
Diagnostic varied with the youngest being 18 years in the studies and the
oldest being 88 years in the study by Cloke et al. [31].The
A positive (painful) Neer test for the diagnosis of shoulder mean age with standard deviation (SD) were not stated in any
impingement syndrome and a positive painful Hawkins- included studies. All studies included males and females, with
Kennedy impingement test were used. The clinical sign of no comparison between them as shown in Table 5(a).
painful arc was considered positive if there was pain originating
from the subacromial region of the shoulder during arm active Dropouts
abduction against gravity without resistance and was used only Dropout rates ranged from 5% half of them 2.5% from exercise
by [31]. Limitation with the functional movement patterns of group Engebretsen et al. [28] to 20% (7 active & 10 control) did
hand-behind-back or hand-behind-head used by Kachingwe et not complete the study Szczurko et al. [33]. As shown in Table
al. [32]. Also, Speeds, Apprehension, and Subscapularis Lift 5(b). Of the reasons included, one can mention, failure to do it
tests were used by Szczurko et al. [33]. Humerus abducted 90 again because of injury, being ill or having to do something else.
degrees in the maximal passive inward rotation should give
you bacromial pain applied by Østerås et al. [27]. Dysfunction Blinding
or pain on abduction normal passive glenohumeral range of Participants
motion, pain on two of three isometric tests (abduction at 0°or
30° external or internal rotation) used by Engebretsen et al. It is not easy to be certain that participants are blinded during

Table 3. Overview of all PEDro rating performed by the author (Y=yes; N=No; U=Unsure).
Lombardi et al., Cloke et al., Kachingwe et Szczurko et al., Østerås et al., Engebretsenet al., Holmgren, et Maenhut et
PEDro criteria
2008 2008 al., 2008 2009 2009 2009 al., 2012 al., 2013
1. Eligibility criteria U Y N N Y Y Y Y
2. Random allocation Y U N Y U Y Y Y
3. Concealed allocation Y Y U Y N Y U Y
4. Comparable baseline Y U N Y Y Y Y Y
5. Subjects blinded N N N N U N N N
6. Therapists blinded N N N N N N N N
7. Assessors blinded Y U Y Y N Y Y N
8. Outcomes for 85% of
Y Y Y Y Y Y Y Y
initial participants
9. Intention-to- treat
Y N U U Y Y Y Y
analysis
10. Between group stat
Y Y Y Y Y Y Y N
comparison
11. Point & variability
Y U Y U U U N N
measures
Total score 8 5 4 6 5 8 7 6

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 El Mughrabi/El Alwani/Amein/et al.

Table 4. Study Characteristics.

The study Interventions Outcome Measure Findings
Function: DASH 3and
DASH 2
Pain: VAS 10 cm. Exercise group displayed significant
Intervention group: Progressive exercise resistance training
QoL: SF-36. reduction during movement (P=0.001),
for twice a wk/ 2 mo: Resisted extension/flex/MR/LR, exercise
Lombardi et al. 2008 Strength: Isokinetic and in pain at rest (P=0.001) and patient
achieved by Multi-pulley muscle building equipment
evaluation reported function and strength and
Control group: No treatment
improved QoL,
Timing tests: 0 & 2 mo
Function: OSS.
Exercise parameters up to 6 sessions for 18 wk QoL: SF-36 No statistically significant between-groups
Cloke et al. 2008
No additional information given Timing tests: 0 & 18 wk difference at base line or 1-year follow-up.
and 1 yr
Exercise group (1): Posterior capsular exercise & stretching.
Exercise group (2): as group 1 plus Mobilizations (GH joint).
Function: SPADI The pain intensity was reduced significantly
Exercise group (3): as group 1 plus (Mulligan
Kachingwe et al. 2008 Pain: 10 point VAS. in all groups.
mobilizations).
Timing tests: 0 & 6 wk Exercise groups changed clearly on SPADI.
Control group (4): advice only.
Frequency: From 1to 3 groups 1/wk for 6 wk.
Exercise group: exercise (AROM & passive) & Placebo tablets. QoL: SF-36
once weekly/ 30 minutes/12 wk. Pain & disability: Significantly improvements in QoL &
VAS & SPADI shoulder pain indices for two groups.
Szczurko et al. 2008
Naturopathic group: anti-inflammatory diet & Acupuncture. Naturopatihc group improved significantly
Timing tests: 0, 4, 8, & in SPADI & disability scores.
(no further detail given) 12 wk
Frequency: 3 PT sessions/wk12 wk Function: SRQ
Progressive resistance, Resisted shoulder & elbow (flexion & Strength: strength Improvement in function, less pain and
Osteras et al. 2009 extension). (Isometric). significantly greater isometric strength were
Group (1) a high-graded exercise therapy (HD), Group (2) a low- Pain: VAS. showed in HD group.
graded exercise therapy (LD) Timing tests: 0 & 3 mo
Function: 7-point rating
scale.
Exercise group: 1 PT sessions a week for 12 wk. Pain and disability:
SPADI scores was significantly different at
Engebretsen et al. 2009 Sling suspension exercises. SPADI.
6, 12, and 18 wk. in exercise group only.
Shockwave therapy group. Pain: 9-point rating scale.
Timing tests: 0, 6, 12 &
18 wk
Function: DASH
Questionnaire The exercise group showed significantly
Weights and resistance bands 3 sets x 15 reps 2x day for 8 weeks
EQ 5D and EQ VAS higher DASH & improved significantly in
then 1x day for 4 weeks 12 weeks pain monitoring Mode
Holmgren et al. 2012 VAS. constant Murley Score & VAS. EQ 5D
Group (1) specific exercise
Constant Murley Score significantly higher at 3 months in the
Group (2) control exercise
exercise group.
Timing tests: 0 & 3 mo
SPADI questionnaire Treatment and eccentric training group
Isometric strength showed a 15 higher gain In abduction
Abductors Standing, full can, thumb up, abduction in scapular
measured using a handheld strength at 90° than the treatment group.
plain.
dynamometer Both groups showed a significant
Dumbbells (Heavy load) 3 sets x 15 Reps 2x day, 7 days/week 12
Maenhout, et al. 2013 Subjective perception of improvement in SPADI scores over time;
weeks Pain monitoring mode.
improvement of shoulder No significant differences in patient
Group (1) Traditional training rotator cuff
pain (5-point scale SPADI self-rated perception of shoulder pain
Group (2) Eccentric training
questionnaire. Improvement between treatment and
Timing tests: 0, 6 & 12 wk exercise groups

Table 5(a). Participants.

No Study No of participants Age (years) Range Mean (SD)
Experimental group (mean age 56.3 yr). Control
1 Lombardi et al. 2008 60 patients; 46 women & 14 men.
group (mean age 54.8yr).
2 Cloke et al. 2008 112 patients; 64 Women & 48 men. Age 22 to 88 yr old.
3 Kachingwe et al. 2008 33 patients; 17 men, 16women. Aged 18-74 yr.
4 Szczurko et al. 2008 85 patients; 50 Women & 35 men. Aged 18-65 yr.
5 Osteras et al. 2009 61 patients, 51 women & 10 men. Aged 18-60 yr.
6 Engebretsen et al. 2009 104 patients: 52 Women & 52 men. Age 18-70 yr.
7 Holmgren et al. 2012 97 participants: 36 female & 61 male Age 30-65 years
Group 1 means=age 40.2 years.
8 Maenhout, et al. 2013 61participants: 16 Female &15 males.
Group 2 means: Age 39.4 years.

the studies of exercise intervention. All trials are through and Assessors
assumed to have a high risk of bias for this item. One study is A total of 5 studies reported that the person who assessed the
an exception: it is the study that was rated as not to have clear outcomes was blinded when it came to deal with the allocation
bias [27]. Another study also attempted to reduce bias by using of groups [28-30,32,33]. However, 2 studies reported that the
only the advice of the physician as far as the control group was assessor was not blinded and there was one study where it was
concerned [32]. unclear from the translation [27,31].

19 J Pain Manage Ther. 2016 Volume 1 Issue 1

Citation: El Mughrabi M, El Alwani A, Amein N, et al. (2016) The effectiveness of exercise on function for adults with shoulder impingement
syndrome (sis): a structured literature review. J Pain Manage Ther. 1(1):13-23.

Table 5(b). Dropout rates, ethical approvals and power calculation.

Power Calculation Ethically Approve Outline baseline characteristics Dropouts
Lombardi et al. 2008 Not reported yes yes 13%
Cloke et al. 2008 Not reported Yes Not reported 20%
Kachingwe et al. 2008 Not reported Yes Not reported Not reported
Szczurko et al. 2009 Not reported Not reported Yes 20%
Osteras et al. 2009 Not reported Yes Yes 8%
Engebretsen et al. 2009 Not reported Not reported Yes 5%
Holmgren et al. 2012 Not reported Yes Yes 8%
Maenhout, et al. 2013 Yes Yes Yes 18%

Interventions VAS Constant Murley Score [29] and a handheld dynamometer

subjective perception of improvement of shoulder pain (5-point
The progressive resistance training (resisted flex/extension)
scale SPADI questionnaire) [2]. For Quality of life 'QoL': SF-
was applied to an exercise groups in two studies [27,30].
36 used by. Finally, strength: Isokinetic evaluation. Isometric
While, Cloke et al. applied exercise parameters, Szczurko et
strength [2,30-33].
al. applied passive and active range of movement (AROM)
exercises. Engebretsen et al. used sling suspension exercises Results of studies (effects of treatments)
with education sessions on anatomy of the shoulder. Holmgren
A reduction in pain at rest with statistical significance (P=0.001)
et al. used weights and resistance bands, Maenhout et al. used
and during movement (P=0.001) was demonstrated in study
abductors standing, full can, thumb up, abduction in scapular
carried out by Lombardi et al. All groups in Kachingwe et
plain. Finally, Kachingwe et al. had three intervention groups:
al. Decreases in pain level before and after the treatment had
group one: supervised exercise: exercises and stretching
statistical significance. Also, in Szczurko et al. the two groups
(posterior capsular), group two: supervised exercises as group
participated in the study displayed reduction in shoulder pain
1 plus (Mulligan mobilizations) and group three: supervised
and QoL idices. NC group improved significantly over the PE
exercise as group 1 plus joint mobilizations [28,29,31-33].
group in SPADI total, pain, and disability subcategory scores
Exercise delivery NC group demonstrated more improvement than the PE group
The period of time for the exercise programmes was 6 weeks in SPADI total pain and disability scores. 12 wk: PE group VAS
Kachingwe et al. to a maximum of 18 weeks Cloke et al. with scores prepost test: 4.85 (1.48) to 4.05 (1.69) (P=0.0431). Both
the most frequent being three m12 weeks Szczurko et al.; groups showed a significant improvement in SPADI scores over
Østerås et al. Engebretsen et al., Holmgren et al.; Maenhout et time [2]. There was a significant difference between groups
al. The individual sessions took place as often as 1-3 sessions (P0.05) in Osteras et al. study. HD group underwent less pain and
a week (Kachingwe et al., Szczurko et al., Holmgren et al. to made improvement and better isometric ABD and ER strength.
three sessions a week Østerås et al., in two of the studies, there There was a significant statistical difference of exercise group
were two sessions every week Lombardi et al., Maenhout et al. for SPADI scores at 6, 12, and 18 week which was reported in
One of the studies reduced the frequency of sessions from twice Engebretsen et al. [28].
a week to once a week two months after the intervention had In study patients in the extension only group were reported
started. Only one study reported the duration of each session; it to make more improvement of QoL than those in the control
was a 30-minute session Szczurko et al. [30-33]. group. Three intervention groups were reported to have a
Comparison Interventions significant change on SPADI [30]. Group 1 and 2 experienced
higher changes on all the measures of pain in comparison with
Only four trails included a programme of exercise only [27,28,30- the group of exercise alone [32]. Mean score of significant
33], six other trials included exercise as combined with another change in the DASH was higher in the specific exercise group.
type of treatment such as education sessions on anatomy of A greater improvement was reported by the specific exercise
shoulder [28]. Comparison was made between the exercise group according to Murley Score. Mean score changed in VAS
interventions and control group. There was no treatment in the
at night in a significant way in the specific exercise group. After
control group, injection treatment, anti-inflammatory diet and
3 months, 5D was significantly higher in specific exercise group
acupuncture, control exercise, a Shockwave therapy group and
[29]. Treatment and eccentric training group demonstrated a
traditional training rotator cuff. A low-graded exercise therapy
gain which is 15 higher in abduction strength at 90° than the
group was compared with low-graded exercise therapy group in
treatment.
Østerås et al. It was not clear that the control group participated
in the study conducted by Kachingwe et al. [2,30-33]. In Cloke et al. there were not significant between- groups
differences at the end of intervention or 1 year later. However,
Outcome Measures Used according to the outcome of power calculation, 110 patients will
These studies used a multi-outcome measures for function need an arm each. Likewise, Kachingwe et al. [32] reported no
DASH Questionnaire [29], DASH 2 and DASH 3[30] , a self- significant between group differences. No significant differences
administered questionnaire of 12 item 'OSS' [31] shoulder pain were reported of VAS activity and rest EQ Holmgren et al.
and disability index 'SPADI' [2,31,32], SRQ [27] and 7-point [29]. No significant differences in patient self-rated perception
rating scale [28]. For pain: 10-point VAS [32], 10 cm VAS [30], of shoulder pain Improvement between treatment and exercise
100 mm VAS [27], VAS 0-7 cm [33], 9-point rating scale [28], groups. At the level of patient self-reported perception of

J Pain Manage Ther. 2016 Volume 1 Issue 1 20

 El Mughrabi/El Alwani/Amein/et al.

shoulder pain Improvement, also there were no significant also no guidance to follow to inform clinicians whether the
differences stated. exercise needs to be specific or general in nature. Additionally,
it is unclear why the exercise may be having a beneficial effect.
Discussion Uncertainty exists regarding the advice a clinician should offer
The present review provided data on the evidence for the patients concerning the benefit of exercise therapy.
effectiveness of exercise therapy and several usual care Appropriately designed randomised clinical investigations that
interventions for SIS. Following evaluation of the studies it address the areas identified as deficiencies in our knowledge
can only be suggested that exercise is effective in relieving base as a result of this review would help to address this lack
pain and improving function in SIS. The quality of information of understanding and provide clinicians with better and more
relating to the type of exercise, duration, intensity, repetitions appropriate information to present to patients to help inform
and progression varied substantially in the included studies. On discussions and decisions regarding management and care
the basis of the information provided, it would be possible to pathways. For these studies to provide meaningful information,
repeat the exercise programme from only five of the included it is imperative that appropriate and validated impairment and
investigations. disability outcome measures are incorporated into the design.
We were able to come to a number of conclusions on the basis To be able to pool the results from future randomised controlled
of the 8 studies we analyzed. All, however, are accompanied trials, these studies should endeavour to use the same validated
by caveats. First, the over-all results of the qualitative synthesis outcome measures.
suggest that exercise is effective at reducing pain and improving
function for the 6 to 12-week period following treatment, with
Implications for Research
this assessment being accepted with caution because it is sup- Most of the existing studies in this area were found to be
ported by only 6 and 4 medium/high-quality RCTs, respectively poorly reported and lacking sufficient and useable data for the
purposes of secondary analyses and summary. Future work
Second, there is strong evidence that the improvements in
in this field needs to conform to the standards laid out in the
function are maintained at long-term follow-up. Again this
revised CONSORT statement. Future studies need to consider
conclusion is accepted cautiously because it is supported by
their choice of outcome measurement so as to ensure clinical
only 2 high-qualities RCTs. Third, there is moderate evidence
that exercise is effective in terms of improving short-term relevance. Furthermore, particular consideration should be
strength. Despite descriptions of the exercise protocols, given to the use of valid and reliable methods for collecting
prevented definitive conclusions about which types of exercises adverse event data. Finally, studies of longer duration are
and exercise parameters are associated with better outcomes. required to establish the necessary length of treatment and
However, common types of exercise used in high- and longer term outcomes, and studies involving a diverse range of
medium-quality articles, and associated with decreased pain ethnic and cultural groups would ensure greater generalizability
and increased function, were scapular stability exercises and of findings.
rotator cuff strengthening exercises using pulley equipment or The benefits of exercise interventions on SIS may be
elastic band resistance and progressing through range to 90° relatively small, so the sample sizes reported need to have
abductions. These were conducted in supervised sessions 1 to 2 adequate power to answer the research question, allowing the
times per week and in daily home exercise programs. detection of clinically significant differences between groups.
Moderate evidence was found in favour of patients who received Reporting should include the method of randomisation and
exercise therapy when compared with patients who had placebo treatment allocation concealment and an intention-to-treat
or other physiotherapy modalities. Unfortunately, because of analysis performed. The history and reasons for drop-outs
the lack of detailed description of baseline characteristics and and exclusions (including appropriate adverse event data)
exercise protocols used (e.g., intensity, duration, frequency and throughout the trial should be ascertained and reported, so that
load), the current evidence is not fully validated and difficult to factors affecting exercise adherence can be further explored.
interpret in relation to use in clinical practice. Ideally, rather than focusing on immediately post intervention,
studies should include long-term follow-up participants (e.g.
Appropriately designed and analysed randomised placebo for at least one year). To enable comparison and pooling of the
controlled trials are considered to be the most rigorous study results of randomised controlled trials, we suggest that future
design to assess the effectiveness of a clinical investigation. studies report means with standard deviations for continuous
Due to the diversity of study inclusion criteria, interventions, measures or number of events and total numbers analysed for
types of exercise, outcome measurements, follow-up times, dichotomous measures.
and home versus clinic-based programmes, it was considered
inappropriate to attempt to pool the results. Comparison with Previous Literature
It is arguable that, on the basis of the findings, the effect at This review assessed the effectiveness of exercise systematically
present should only be considered as modest. It is also not qualitatively in the treatment of SIS. One previous qualitative
possible to determine if it is exercise alone or exercise in review had a similar aim as the current review; using best
combination with other interventions that offers the greatest evidence synthesis, it concluded that there was limited or
benefit. In addition, guidance as to the most appropriate exercise unclear evidence for the effectiveness of exercise in the
therapy, including duration, intensity and number of repetitions, management of SAIS [17]. The authors examined 8 RCTs that
remains speculative. There is also uncertainty as to when to published between 1993 to 2007 the review was constrained by
start and how to progress the exercise programme. There is the limited number of good-quality studies available. Although

21 J Pain Manage Ther. 2016 Volume 1 Issue 1

Citation: El Mughrabi M, El Alwani A, Amein N, et al. (2016) The effectiveness of exercise on function for adults with shoulder impingement
syndrome (sis): a structured literature review. J Pain Manage Ther. 1(1):13-23.

only RCTs were included, methodological quality was cross-sectional comparison of five questionnaires. J Bone Joint
generally poor, with no sample size calculations, lack of detail Surg Am. 1996;78:882-90.
on interventions and lack of blinding of outcome assessment. 8. Gartsman GM. Arthroscopic treatment of rotator cuff disease. J
As a result of these limitations no firm conclusions can be made. Shoulder Elbow Surg. 1995;4:228-41.
Another review conducted by Michener et al. included studies
9. Maenhout AG, Mahieu NN, De Muynck M, et al. Does adding
published between 1980 to 2003 [16]. This review stated lots of
heavy load eccentric training to rehabilitation of patients with
limitations and recommended that further studies are needed to unilateral subacromial impingement result in better outcome? A
investigate these rehabilitation interventions, the superiority of randomized, clinical trial. Knee Surg Sports Traumatol Arthrosc.
one intervention over another, and the long-term outcomes of 2013;21:1158-67.
rehabilitation. Moreover, it is imperative that clinical guidelines
10. Koester MC, George MS, Kuhn JE. Shoulder impingement
are developed to indicate those patients who are likely to
syndrome. Am J Med. 2005;118:452-55.
respond to rehabilitation.
11. Desmeules F, Côté CH, Frémont P. Therapeutic exercise and
Conclusion orthopaedic manual therapy for impingement syndrome: A sys-
The findings of this review suggest that the inclusion of exercise tematic review. Clin J Sports Med. 2003;13:176-82.
therapy, either in isolation or as part of a non-operative package 12. Linsell L, Dawson J, Zondervan K, et al. Prevalence and incidence
of care has limited evidence for its effectiveness. However, of adults consulting for shoulder conditions in UK primary care;
because of the lack of a detailed description of the exercise patterns of diagnosis and referral. Rheumatol. 2006;45:215-21.
protocols used, the current evidence is difficult to interpret 13. Green S, Buchbinder R, Hetrick S. Physiotherapy interventions for
in relation to use in clinical practice. Therefore, future RCTs shoulder pain. Cochrane Database of Systematic Reviews. 2003;2.
studying exercise therapy should also concentrate on the effect
14. Bang MD, Deyle GD. Comparison of supervised exercise with
of different exercise protocols, including the intensity, duration,
and without manual physical therapy for patients with shoulder
frequency and load of the exercises. However, there is no impingement syndrome. J Orthop Sports Phys Ther. 2000;30:126-37.
definitive guidance as to when to start the programme, what
to include in the programme and when to refer for a surgical 15. Desmeules F, Côté CH, Frémont P, et al. Acromio-humeral
opinion. This review draws attention to the fact that many distance variation measured by ultrasonography and its association
diverse exercise approaches with different levels of supervision with the outcome of rehabilitation for shoulder impingement
syndrome. Clin J Sports Med. 2004;14:197-205.
have been investigated, but that no definitive clinical guidance
is possible. As such, it is essential that appropriately designed 16. Michener LA, Walsworth MK, Burnet EN. Effectiveness
randomised clinical investigations, using appropriate validated of rehabilitation for patients with subacromial impingement
outcome measurements, are conducted to begin to address the syndrome: a systematic review. J Hand Ther. 2004;17:152-64.
considerable deficiencies in our knowledge base regarding best 17. Kelly SM, Brittle N, Allen GM. The value of physical tests
management practice for this common and disabling condition. for subacromial impingement syndrome: a study of diagnostic
accuracy. Clin rehabil. 2010;24:149-58.
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*Correspondence to:
Adel Almangoush
Salford University
United Kingdom
Tel: 00447979771883
E-mail: [email protected]

23 J Pain Manage Ther. 2016 Volume 1 Issue 1