GUIDED EXERCISES WITH OR WITHOUT JOINT MOBILIZATION OR NO TREATMENT IN PATIENTS WITH SUBACROMIAL PAIN SYNDROME: A CLINICAL TRIAL

BackgroundGraded resistance training is the recommended treatment for patients with subacromial pain syndrome. It is debated whether adding joint mobilization will improve the outcome. The aim of this study was to evaluate the clinical outcome of guided exercises with or without joint mobilization, compared with controls who did not receive any treatment.MethodsA 3-armed controlled trial in a primary care setting. A total of 120 patients, with clinically diagnosed subacromial pain syndrome, were randomized into guided exercise groups with and without additional joint mobilization, and a control group that did not receive any treatment. Data were analysed at baseline, 6 weeks, 12 weeks and 6 months. Primary outcome was the Constant-Murley score, and secondary outcomes were pain and active range of motion.ResultsShoulder function improved in all groups, as measured with the Constant-Murley score. At 12 weeks and 6 months the exercise groups improved significantly compared with the control group (p ≤ 0.05). Add-on joint mobilization resulted in decreased pain in active range of motion at 6 and 12 weeks compared with guided exercise or no treatment (p ≤ 0.05). Range of motion increased over time in all 3 groups.ConclusionIn patients with subacromial pain syndrome guided exercises improved shoulder function compared with no treatment. Add-on joint mobilization decreased pain in the short-term compared with exercise alone or no treatment.LAY ABSTRACTTo determine treatment efficacy in patients with shoulder pain treated with a combination of joint mobilization and guided training or guided training alone, and compare this with a control group who received no treatment. The study was a randomized controlled trial in Swedish primary care. A total of 120 patients aged between 20 and 59 years were recruited from general practice in Stockholm. Guided exercises, with or without joint mobilization, improved shoulder function compared with no treatment. In the short term, add-on joint mobilization decreased pain, and may thus serve as a substitute for non-steroidal anti-inflammatory drugs (NSAIDs) or other painkillers at the start of a treatment period.Key words: Constant-Murley score, manual therapy, resistance training, shoulder pain

Subacromial pain syndrome (SAPS) is a clinical diagnosis and one of the most common reasons for seeking physical therapy in primary care (1). The aetiology is known to be multi-factorial and includes several rotator cuff pathologies, such as increased tendon thickness (e.g. tendinopathies), bursitis, and tears affecting the rotator cuff or the long head of the bicepstendon (2). No single examination test has the specificity and sensitivity to alone set the diagnosis. A combination of different tests has been suggested (3). There is little knowledge about the natural history and treatment of patients with SAPS. This syndrome is believed to consist of inflammatory cells, and therefore patients with SAPS are often treated with non-steroidal anti-inflammatory drugs (NSAIDs) or corticosteroid injection (4). Even if current evidence suggests that the inflammatory response is a key component, the presence of inflammation has not been confirmed in those with tendinopathy (5).A consensus on physical therapy treatment for patients with SAPS was reached in 2015 (6). This was after the start of the current clinical trial. However, the current trial followed the guiding principles for implementing exercise therapy for shoulder pain recommended by the consensus. Namely, a limited number of exercises, performed with appropriate scapulo-humeral coordination and humeral head alignment, in a gradually progressed manner.A common reason for using joint mobilization is to reduce hypomobility and improve shoulder function, but it has also been used to decrease pain (7, 8). The main mechanism for joint mobilization discussed is neurophysiological, and includes stimulating mechanoreceptors, releasing endorphins, and reducing the cytokine concentration (9). Whether joint mobilization evokes pain relief, which then provides suitable conditions for resisted exercises, is inconclusive (10, 11). However, the joint mobilization according to Kaltenborn used in the current study is a theory, and was used in order to decrease pain and increase relaxation (8).The aim of the current study was to evaluate the clinical outcome, in terms of shoulder function and pain, of guided exercises with or without the addition of joint mobilization compared with no treatment, in patients diagnosed with SAPS. The hypothesis was that the addition of joint mobilization of the gleno-humeral joint would be superior to guided exercises alone or no treatment in patients with SAPS.