Key Points

A specific motor-control exercise approach can reduce shoulder pain and kinesiophobia and increase shoulder function.
The exercise program did not exceed the minimal clinically important difference.
Reducing kinesiophobia could be an important treatment target and this can be done with motor control exercise.

BACKGROUND & OBJECTIVE

Subacromial impingement syndrome has become one of the primary labels of shoulder pain (1). The primary aim of this randomized controlled trial was to compare the short-term effectiveness of a specific exercise program with that of a general exercise program for individuals with rotator cuff-related shoulder pain (RCRSP).

A secondary aim was to identify possible causal mechanisms underpinning the effectiveness of the exercise programs. The reason for conducting this clinical trial was because it remains unknown if there is a superior exercise approach for people with RCRSP and exactly HOW exercise might be of benefit.

Subacromial impingement syndrome has become one of the primary labels of shoulder pain.

A focused, controlled, highly supervised, tactile assisted, exercise approach could reduce fear of movement in people with shoulder pain.

METHODS

This was a single-blind randomized controlled trial with two parallel groups. Group 1 (experimental group):

In addition to usual care (NSAIDs), participants in the experimental group participated in a 5-week, two times per week, supervised, specific exercise program.
The exercises were based on the premise of motor and scapular control and were aimed at restoring optimal movement of the shoulder blade (see video).

SPECIFIC EXERCISE PROGRAMME IN ADULTS WITH SUBACROMIAL IMPINGEMENT SYNDROME

Group 2 (control group):

In addition to usual care (NSAIDs), participants in the control group participate in a 5-week, two times per week, supervised, general exercise program.
The exercises involved general strengthening, stretching and mobility exercise of the shoulder complex.
The aim of these exercises was to restore strength, mobility and coordination of the shoulder, and to centralise the humeral head in the glenoid fossa.

The primary outcome measure was the shoulder pain and disability index (SPADI). Secondary outcome measures were pain and kinesiophobia.

RESULTS

A total of 52 participants were recruited, 26 in each group.
The specific exercise group (group 1) was significantly better than the general exercise group after five weeks, but the difference did not exceed the minimal clinically important difference (MCID). Interestingly, the specific intervention reduced kinesiophobia significantly more than the general intervention, and this did exceed the MCID.
Mediation analyses showed that the benefit of the specific exercise program was explained by improvements in kinesiophobia and pain on movement.

LIMITATIONS

This study had a small sample size of 52 participants. I would like to see this replicated in a cohort twice as large. The short follow-up of five weeks is curious, although they said they were only interested in short-term effectiveness. Where would both groups be at 12 weeks, 6 months and 1 year? It’s unknown, but the effect often becomes washed out the longer the follow-up is.

CLINICAL IMPLICATIONS

What are the take homes? Virtually every big review and RCT published over the past 5 years has been a bad outcome for motor control exercise (2) so this is a nice counter-point trial. However, and this is crucial, the specific intervention did not exceed the MCID for the primary outcome measure. This means the specific intervention might look better when running the statistics on software (e.g. SPSS), but the person facing us might not be able to tell the difference.

What I found interesting in this study was the effect of the intervention on kinesiophobia. The specific intervention dramatically reduced kinesiophobia levels, whereas the control intervention barely changed it. I wonder how much of this was facilitated by the gentle-gentle approach of motor control exercises and the hands on and close attention given by the exercise supervisor. I can absolutely see how a focused, controlled, highly supervised, tactile assisted, exercise approach could reduce fear of movement in people with shoulder pain. I also happen to think this can be done without caring about the scapula and this has been shown in qualitative research (3).

Kinesiophobia was shown to mediate the effectiveness of the specific exercise program, but again, I think if the primary aim of an exercise program was to reduce kinesiophobia, this could be done with many exercise approaches, as we see in the low back pain literature (4). In summary, this is a cool study that shows the possible importance of reducing kinesiophobia and that motor control exercise of the shoulder is a viable way of achieving this.

+STUDY REFERENCE

Gutierrez Espinoza H, Araya-Quintanilla F, Pinto-Concha S, Valenzuela-Fuenzalida J, Lopez-Gil J, Ramirez-Velez R (2023) Specific versus general exercise programme in adults with subacromial impingement syndrome: a randomised controlled trial. BMJ Open Sport Exerc Med, 9(3).

SUPPORTING REFERENCE

Ostör AJK, Richards CA, Prevost AT, et al. Diagnosis and relation to general health of shoulder disorders presenting to primary care. Rheumatology (Oxford) 2005;44:800–5.
Shire, A.R., et al., Specific or general exercise strategy for subacromial impingement syndrome-does it matter? A systematic literature review and meta analysis. BMC Musculoskelet Disord, 2017. 18(1): p. 158.
Powell, J.K., et al., "Restoring that Faith in my Shoulder": A Qualitative Investigation of how and why Exercise Therapy Influenced the Clinical Outcomes of Individuals with Rotator Cuff-Related Shoulder Pain. Phys Ther, 2023.
Wood, L., et al., Pain catastrophising and kinesiophobia mediate pain and physical function improvements with Pilates exercise in chronic low back pain: a mediation analysis of a randomised controlled trial. J Physiother, 2023. 69(3): p. 168-174.