Shoulder impingement: exercise versus exercise and manual therapy
What is the best course of action for shoulder pain caused by subacromial impingement? This article compares exercise alone versus exercise and manual therapy on addressing this particular issue.
Shoulder impingement syndrome (SIS) is a common problem derived from repetitive use of the arm at or above shoulder level. While there is proven success on the management of SIS through conservative treatment, researchers and physical therapists still debate the best course of action to most efficiently address this problem.
The study:
Camargo et al performed a randomized controlled trial in 2015, comparing two approaches in managing patients with SIS:
Group 1 was given exercise alone.
Group 2 was given the same exercise program as Group 1, plus a manual therapy regime.
Outcome measures included pain, mechanical sensitivity, and changes in scapular kinematics. Post-intervention measures were taken after the 4-week intervention.
The results:
No significant changes in scapular kinematics were found with both groups pre- and post-intervention.
Both groups experienced significant decreases in pain at rest and during movement when comparing pre- and post-intervention, but had no significant differences between groups.
Both groups experienced increased mechanical sensitivity when comparing pre- and post-intervention, but had no significant differences between groups.
Limitations of the study: 1.) participants did not have acute SIS, and therefore the results do not pertain to a more recent flare-up of SIS, and 2.) no long-term follow-up, as results were only taken after the 4-week intervention.
What’s most noteworthy of this study, however, is that despite improvements in pain and mechanical sensitivity, scapular kinematics have not significantly changed even after intervention. This suggests that improvements in pain and mechanical sensitivity cannot be explained by changes in scapular motion.
What this means:
With respect to this study, the addition of manual therapy did not provide any additional benefit in improving scapular kinematics, pain levels or mechanical sensitivity for patients with shoulder impingement syndrome. This suggests that exercise alone may suffice in addressing the issue. Segueing to some helpful exercises below:
REFERENCES:
Camargo PR, Alburquerque-Sendín F, Avila MA, Haik MN, Vieira A, Salvini TF. Effects of Stretching and Strengthening Exercises, With and Without Manual Therapy, on Scapular Kinematics, Function, and Pain in Individuals With Shoulder Impingement: A Randomized Controlled Trial. J Orthop Sports Phys Ther. 2015 Dec;45(12):984-97. doi: 10.2519/jospt.2015.5939. Epub 2015 Oct 15. PMID: 26471852.
Hip impingement: hip-targeted exercise versus hip-targeted exercise with trunk stabilization
Femoroacetabular hip impingement (FAI), best described as a pinching anterior hip pain. This article looks at another means of addressing the problem on top of the standard hip strengthening protocol.
Femoroacetabular impingement occurs when the femur repetitively abuts the rim of its socket (acetabulum), resulting in front hip pain, with long-term complications including possible labrum damage and osteoarthritis. The standard protocol has included stretching and strengthening the hip musculature to minimize this abutting; this article looks at a study that also incorporates trunk strengthening.
The study:
Aoyama et al performed a prospective, randomized controlled trial looking at 20 female participants with hip impingement, more specifically the effects of adding trunk stabilization exercises on top of a hip strengthening protocol.
The control group received the hip and pelvic girdle protocol, which consisted of gluteus medius/maximus strengthening and lumbopelvic awareness exercises.
The trunk stabilization exercise group received the same hip and pelvic girdle protocol, as well as additional exercises targeting the transverse abdominis and oblique musculature.
Outcome measures were recorded prior to treatment, at 4 weeks post-intervention and 8 weeks post-intervention. Measures included hip range of motion, strength and patient-reported pain levels.
The results:
The trunk group had significantly improved hip flexion range of motion at 4-wks post-intervention, compared to the control group.
The trunk group had significantly improved hip abduction strength at 4-wks post-intervention, with no significant improvement in the control group.
Patient-reported outcomes (iHOT12 and Vail hip scores) were significantly improved in both groups at 8-weeks post-intervention, though the trunk group had greater improvement than the control group.
What this means:
The primary limitations of this study included its small sample size (n=20) and all-female participant pool, which may compromise its applicability to a broader audience.
Regardless, the most noteworthy take-aways from the study’s results were the improvements in hip range of motion and strength at 4-wks post-intervention, which suggests that adding a trunk stabilization program, along with hip strengthening, can boost short-term outcomes.
REFERENCES:
Aoyama M, Ohnishi Y, Utsunomiya H, Kanezaki S, Takeuchi H, Watanuki M, Matsuda DK, Uchida S. A Prospective, Randomized, Controlled Trial Comparing Conservative Treatment With Trunk Stabilization Exercise to Standard Hip Muscle Exercise for Treating Femoroacetabular Impingement: A Pilot Study. Clin J Sport Med. 2019 Jul;29(4):267-275. doi: 10.1097/JSM.0000000000000516. PMID: 31241527; PMCID: PMC6613832.
Cubital tunnel syndrome: reviewing our conservative options
Leaning on your elbows too much can mean bad news, such as the onset of cubital tunnel syndrome. This week, we look at the conservative options available that address this condition.
With no promise of returning back to the office anytime soon, The LAB is continuing to see more problems associated with working from home, including cubital tunnel syndrome. Considered the second most common neuropathy of the upper extremity (first being carpal tunnel syndrome), cubital tunnel syndrome is caused by compression and irritation of the ulnar nerve, due to direct pressure on the inner elbow (near the “funny bone” region) or repetitive, maximal stretching into elbow flexion. This includes resting the elbows on a hard surface for long hours at a time.
The study:
Kooner et al performed a systematic review that looked at all conservative options for treating cubital tunnel syndrome. Twenty studies were included for analysis, with the most common outcome measures being patient-reported outcomes and nerve conduction studies. The average treatment duration was 3-months, with most intervention methods including education/activity modification, splinting, steroid/lidocaine injection, nerve mobilization/gliding, ultrasound, laser therapy, NSAIDs administration and physical therapy.
The results:
Two studies showed that activity modification and patient education alone resolved symptoms of 44-66% of patients after one year.
One study, a randomized controlled trial, compared activity modification/patient education with splinting and nerve gliding techniques. There were no significant differences between both groups, yet 90% of all participants demonstrated clinical improvement at 6-months.
One prospective cohort study looked at the effects of patients receiving splinting and activity modification over a 3-month period. Participants demonstrated improved questionnaire scores (DASH) and grip strength; 82% of patients became symptoms-free over a 2-year period.
One study showed no significant difference between steroid injections and placebo, with only 30% success rate for treatment.
Due to lack of heterogeneity, the systematic review had difficulty grouping which specific interventions trumped the others. There was also a lack of quality studies, and sample sizes were too small.
What it means:
Based on the studies, the author suggests that activity modification, patient education and splinting all prove to be among the most effective conservative means of addressing cubital tunnel syndrome.
Below are examples of exercises that also address cubital tunnel syndrome.
REFERENCES:
Kooner S, Cinats D, Kwong C, Matthewson G, Dhaliwal G. Conservative treatment of cubital tunnel syndrome: A systematic review. Orthop Rev (Pavia). 2019 Jun 12;11(2):7955. doi: 10.4081/or.2019.7955. PMID: 31281598; PMCID: PMC6589621.
Plantar fasciitis: the effects of manual therapy
Plantar fasciitis will affect 10% of the U.S. population. Research may support the use of manual physical therapy techniques when treating this common problem.
Plantar fasciitis can be a a real heel. Pun intended. Defined as inflammation of the connective tissue that supports the arch of the foot, it can be very debilitating if not addressed properly.
The study:
A systematic review performed by Mischke et al looks at the importance of manual physical therapy in the treatment of plantar fasciitis. Given the association between plantar fasciitis and limited ankle dorsiflexion range of motion, manual therapy is thought to play a key role in the improvement of symptoms and cause.
A comprehensive search was performed on online medical libraries, including MEDLINE, EMBASE, Cochrane, CINAHL and Rehabilitation & Sports Medicine Source. Quality assessment was performed using the PEDro scale to ensure all articles were randomized controlled trials discussing manual interventions for plantar fasciitis. Out of 1745 studies, 8 studies were included.
The results:
Of the 8 studies included, only 2 studies scored at least 7/10 points using the PEDro scale, underscoring the overall lack of quality studies. The two studies, however, depicted results favoring the use of manual therapy:
Study 1: Cleland et al (8/10 PEDro rating)
Electrophysical agents and exercise vs. manual therapy and exercise (impairment-based STM and joint mobilization)
The manual therapy group showed better pain levels (NPRS) at Week 4 and better functional levels (LEFS) at 6 months follow-up.
Study 2: Saban et al (7/10 PEDro rating)
STM, neural mobilization and self-stretching vs. US and self-stretching
The manual therapy group showed better pain levels (VAS) and better functional levels (FAA) at 6 weeks follow-up.
What it means:
Limitations of this study include 1.) the lack of quality studies used; 2.) questionable internal reliability of quality assessors; 3.) lack of detail on specific manual therapy techniques utilized, and 4.) lack of long-term follow-up, as most included studies were only for short-term results.
Nonetheless, the two randomized controlled trials with higher PEDro ratings showed favor towards manual therapy interventions in patients with plantar fasciitis. It is an area that warrants further research for finding specific manual therapy techniques and parameters with supportive, favorable long-term results.
Other than manual therapy, see below for examples of exercises that will also help treat this all-too-common problem.
REFERENCES:
Mischke JJ, Jayaseelan DJ, Sault JD, Emerson Kavchak AJ. The symptomatic and functional effects of manual physical therapy on plantar heel pain: a systematic review. J Man Manip Ther. 2017 Feb;25(1):3-10. doi: 10.1080/10669817.2015.1106818. Epub 2016 Apr 26. PMID: 28855787; PMCID: PMC5539575.
Forward head posture: addressing the neck versus mid-back
Being part of a sitting culture makes forward head posture with associated neck pain is almost inevitable, given the amount of hours we spend in front of a computer, on transportation, or while watching TV. We look at two different approaches towards improving forward head posture and neck pain .
Let’s face it. Work, transportation, and entertainment all require sitting. Our sitting culture is inevitable, and we can only remind ourselves to keep the body moving and changing positions. The so-called “forward head posture” that humans have adapted, especially with more technological advances that allow for less physical demand in the day-to-day life, is a big contributing factor towards neck and/or upper back pain.
The study:
Cho et al conducted a randomized controlled trial consisting of thirty-two participants with forward head posture (FHP), allocated into one of two groups:
Group 1: The cervical group: received cervical manual mobilization (C1-C2 flexion) with follow-up exercise
Group 2: The thoracic group: received thoracic manual mobilization (T1-T2 extension) with follow-up exercise
The treatment period was 4 weeks, with follow-up assessment at 4 and 6 weeks after the initial examination. Outcome measures included craniovertebral angle (CVA), cervical range of motion, numeric pain scale (NPRS), neck disability index (NDI), and global rating of change (GRC)
The results:
The thoracic group demonstrated significant improvement (p<0.05) in CVA, cervical extension, NPRS and NDI at 6-week follow-up when compared to the cervical group.
11/15 participants of thoracic group and 8/16 participants in cervical group showed a GRC score of +4 or higher at the 4-week follow-up.
Limitations of the study included a small sample size, limited long-term follow-up data and lack of specifics on manual therapy techniques used, including duration, frequency, type, etc.
What this means:
While both groups have demonstrated improved outcomes, the group that received upper thoracic extension treatment had better short-term outcomes in terms of CVA in the standing position, cervical extension range of motion, NPRS, NDI and GRC scores. Therefore, it’s important to address mid-back pre-positioning to minimize the amount of work required from the neck muscles that keep the head upright.
See below for examples of exercises to do between work breaks in front of a computer.
REFERENCES:
Cho J, Lee E, Lee S. Upper thoracic spine mobilization and mobility exercise versus upper cervical spine mobilization and stabilization exercise in individuals with forward head posture: a randomized clinical trial. BMC Musculoskelet Disord. 2017 Dec 12;18(1):525. doi: 10.1186/s12891-017-1889-2. PMID: 29233164; PMCID: PMC5727966.
Chronic low back pain: exercise, walking, or both?
The management of chronic low back pain has always been a popular issue. This article looks at a study comparing different forms of exercise and its impact on low back pain.
The great dread that is low back pain (LBP) will affect 80% of Americans at some point in their life. Especially since the coronavirus lockdown, The LAB has seen a sharp rise in LBP cases due to more people working on their laptops from home.
The study:
A randomized controlled trial by Suh et al looks at the impact of different exercise protocols on individuals with chronic low back pain (>3 months).
Group 1: Flexibility exercise (FE)
Group 2: Walking exercise (WE)
Group 3: Lumbar stabilization exercise (SE)**
Group 4: Lumbar stabilization combined with walking exercise (SWE)**
**SE exercises targeted the transverse abdominis, rectus abdominis, erector spinae, multifidus, internal obliques and quadratus lumborum.
All groups underwent their designated exercise program for 30-60 minutes, 5-6 times a week, for a period of 6 weeks. These exercises were performed on their own at home. All participants were also educated on optimal posture and the abdominal bracing method, which was encouraged to be used throughout exercise.
The main outcome measures were subjective pain (VAS) during rest and physical activity, while the secondary outcome measures included the Oswestry disability index questionnaire, Beck depression inventory, frequency of medicine use, strength of lumbar extensors and endurance of postural positions. These measures were taken just before the first session, 2 weeks after last session, and 6 weeks after last session.
The results:
All groups experienced significantly less pain during physical activity, improved scores in the Oswestry disability index and Beck depression inventory, after the 6-week program.
The FE and SE groups experienced significant less pain during rest after the 6-week program.
The WE and SWE groups had significant increase in postural endurance for prone, supine and sidelying positions.
What it means:
Limitations behind the study include the absence of a control group, lack of long-term follow-up, and a small sample size (n=48).
All groups, despite their differences in exercise programs, experienced positive outcomes with respect to low back pain and tolerance to everyday physical activities. While this reiterates the benefits of general exercise for the low back, the author believes the study’s positive findings may also be attributed to the education that all participants received on optimal posture with ideal pelvic alignment for lumbar lordosis and activation of erector spinae, as well as the abdominal bracing method to maintain activation of the transverse abdominis and internal oblique musculature.
See below for examples of low back pain exercises.
REFERENCES:
Suh JH, Kim H, Jung GP, Ko JY, Ryu JS. The effect of lumbar stabilization and walking exercises on chronic low back pain: A randomized controlled trial. Medicine (Baltimore). 2019 Jun;98(26):e16173. doi: 10.1097/MD.0000000000016173. PMID: 31261549; PMCID: PMC6616307.
Shoulder impingement: lifting things the right way
We emphasize the importance of scapular stabilization with particular attention to the serratus anterior to treat and/or prevent shoulder impingement syndrome.
No one ever taught us to walk, stand up, reach overhead, or pick up objects in any specific way. The goal is always to just do it and go about your life. Our movement strategy choices in all of these day-to-day activities accumulate towards longevity or degeneration of musculoskeletal health. The serratus anterior is a key muscle when it comes to treating/preventing shoulder impingement and related injuries.
The serratus anterior muscle is important particularly in its role of posteriorly tilting the scapula, which prevents “winging” and decrease in the subacromial space when raising the arm up. In other words, this muscle should be strong and engaging whenever you reach overhead, load the arm, lift or carry objects above the waist. Escamilla et al states that “if normal scapular movements are disrupted by abnormal scapular muscle firing patterns, weakness, fatigue, or injury, the shoulder complex functions less efficiency and injury risk increases”.
See below for examples of neuromuscular activation and strength training of the serratus anterior.
REFERENCES:
Escamilla RF, Yamashiro K, Paulos L, Andrews JR. Shoulder muscle activity and function in common shoulder rehabilitation exercises. Sports Med. 2009;39(8):663-685. doi:10.2165/00007256-200939080-00004.
Chronic ankle instability: overlooking a key player
While there are many factors that contribute to recurrent ankle sprains, we look into a a systematic review that analyzes the reactive time of the peroneal muscle, a key player in preventing inversion sprains.
Labor Day + social distancing = some form of outdoorsy event. And with more physical activity on uneven terrain, ankle sprains and instability have become another 2020 topic of interest. While ankle inversion sprains are so common that people have generally used the RICE protocol to self-treat (rest, ice, compress, elevate), it’s important to note that about 70% of people who sustain an ankle sprain will most likely have recurrent sprains, which can turn into the condition known as chronic ankle instability (CAI). While several factors can contribute to such a long-term condition, including changes in proprioception, loss of ligamentous integrity and balance deficits, the peroneal muscle and its role in ankle stability is the point of interest in this week’s powwow.
The study:
A recent systematic review with meta-analysis used an electronic search in PubMed Central and EBSCOhost to make correlations between ankle sprains and decrease in peroneal reaction time (PRT). Studies were included if three criteria were met: 1.) they measured PRT in subjects with ankle sprains using a mechanical platform; 2.) they were compared with a control group or with an uninvolved contralateral limb, and 3.) effect size calculations were provided.
The results:
All involved limbs versus both uninvolved side and control group showed a moderate-to-large PRT deficit (effect size = 0.67, p<0.0001, indicating significant difference in results between PRT of involved side versus uninvolved side or control group with low likelihood that results are muddled by chance). The greatest delay in PRT were seen amongst subjects with chronic ankle instability.
What it means:
If you had an ankle sprain in the past, chances are likely that your peroneal muscle, a key player that counters inversion sprains, may have a delayed reaction time when put to the test. Therefore, if you’re wondering why you keep rolling your ankle, it might be a good idea to do some reactive training for your peroneals.
The vid below shows examples of stability and reactive training to make sure ankle sprains stay a thing of the past.
REFERENCES:
Hoch MC, McKeon PO. Peroneal reaction time after ankle sprain: a systematic review and meta-analysis. Med Sci Sports Exerc. 2014 Mar;46(3):546-56. doi: 10.1249/MSS.0b013e3182a6a93b.
Tech neck: hands-on treatment, supervised exercise, or exercise on your own?
Learn which treatment methods work best when dealing with neck pain. Our chosen study highlights the power of combined supervised therapeutic exercise and hands-on manual therapy.
As COVID-19 pushes more people to work from home, we’re seeing much more cases of neck pain due to incorrect ergonomic setup and associated postural faults. While research continues to support conservative treatment methods, much debate still lies in what game plan per se yields the most positive outcomes for this population.
The study:
A randomized controlled trial of 60 participants who reported neck pain and presented with “forward head posture rounded shoulders posture” sought the effects of hands-on manual therapy (MT), stability exercises (SE) and home exercise programs (HEP), over a six-week period.
Group 1: Received MT and performed SE (3 times a week, supervised)
Group 2: Performed SE (3 times a week, supervised)
Group 3: Performed HEP (control group)
Data would be collected pre-, post-, and 1-month after intervention.
The results:
Statistically significant changes (p<0.05) were noted for the following:
Group 1 had significantly improved pain levels post-intervention and even better reports at the 1-month follow-up.
Groups 1 and 2 demonstrated significantly improved Progressive Iso-inertial Lifting Evaluation (PILE) scores (aka capacity to lift heavy things) post-intervention compared to pre-intervention.
Groups 1 and 2 also demonstrated significantly improved “forward head posture rounded shoulders posture”, measured by favorable shoulder and head angles post-intervention, compared to pre-intervention.
Group 3 participants had no significant change in symptoms, function or postural alignment throughout the study.
What this means:
People with non-specific, generalized neck pain may benefit from a combination of hands-on manual therapy and a supervised stability exercise program, as the study shows it can improve pain levels, function and postural alignment. Another important observation is that Group 3, which only partook in an unsupervised home exercise program, showed no significant improvement in symptoms. In other words, exercise can be otherwise useless if not performed correctly.
See the vid below for examples of tech neck neutralizing exercises.
REFERENCES:
Fathollahnejad K, Letafatkar A, Hadadnezhad M. The effect of manual therapy and stabilizing exercises on forward head and rounded shoulder postures: a six-week intervention with a one-month follow-up study. BMC Musculoskelet Disord. 2019;20(1):86. Published 2019 Feb 18. doi:10.1186/s12891-019-2438-y
Tennis elbow: get a corticosteroid injection, wait it out, or physical therapy?
Got tennis elbow? Research shows that physical therapy may be the best-fit short- and long-term treatment option for this annoying condition.
Since COVID-19, we’ve seen two things: more people working from home, and more people hitting the tennis courts. The commonality between the two? Tennis elbow.
Tennis elbow, or lateral epicondylitis, characterized by outer elbow pain often associated with repetitive overuse of the wrist extensors, will affect 50% of all tennis players, but accounts for only 5% of all reported cases—meaning tennis elbow can most definitely happen to even those who never pick up a racket (ie. those who use a computer mouse all day).
The study:
A randomized controlled trial study by Bisset et al compared three different approaches to treating tennis elbow. 198 participants were allocated into three different groups:
Group 1: The wait-and-see group, or control group (participants received no treatment);
Group 2: The injection group (participants received a corticosteroid injection);
Group 3: The physical therapy group (participants received eight physical therapy sessions over six weeks)
The results:
By six weeks, the injection group had the greatest improvements in pain levels and pain-free grip force when compared to both the wait-and-see group and physical therapy group.
By six weeks, the physical therapy group, which combined elbow manipulation and exercise, showed greater improvements in pain levels and grip strength when compared to the wait-and-see group.
AFTER six weeks, 72% of participants in the injection group experienced a significant regression of outcomes, with increased pain and weakened grip strength.
After one year, the physical therapy and wait-and-see groups continued to experience improved function and grip strength, with outcomes more successful than the injection group.
What it means:
Physical therapy and corticosteroid injections show improved patient outcomes compared to waiting things out in the short term (within six weeks), but in the long term, injections may be inferior to physical therapy and waiting things out. Caution is advised if choosing to receive a corticosteroid injection, as the study showed 72% of participants experiencing a regression of symptoms.
Short-term winner: corticosteroid injection > physical therapy > wait-and-see
Long-term winner: physical therapy > wait-and-see > corticosteroid injection
Conclusively, the research data suggests that physical therapy is the best-fit treatment option for tennis elbow, since it shows favorable short- and long-term outcomes, as well as being the safer option, when compared to corticosteroid treatment and waiting things out.
Check out our video below to see some examples of mid-stage tennis elbow rehab exercises.
REFERENCES:
Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. Br Med J. 2006;333:939–941. doi: 10.1136/bmj.38961.584653.AE.