Subacromial Impingement Syndrome: Vojta Therapy vs Standard Treatment

Subacromial Impingement Syndrome: Efficacy of Vojta Therapy Compared to Standard Physiotherapy Treatment

Impingement Syndrome (IS) is the most common alteration of the shoulder's articular complex of diverse etiology. Forty to 50% of those affected seek medical attention due to the pain; in half of these cases, the pain persists a year after the first medical appointment. It represents a sizeable drain on healthcare resources and a loss of productivity. Initial treatment of IS is generally conservative and includes a wide range of procedures and educational protocols. If conservative treatment fails, arthroscopy may be recommended for decompression. The standard treatment (ST) applied in the Quintanar de la Orden Physiotherapy Unit (UFQO), located within the healthcare area of Toledo, Spain, is prescribed by a rehabilitation specialist. It consists of one or more of the following procedures: transcutaneous electrical nerve stimulation (TENS), ultrasound therapy, kinesiotherapy, and cryotherapy.

Reflex Locomotion - or Vojta - Therapy, is a physiotherapeutic procedure that entails all the components of human locomotion. It consists of applying stimuli to certain areas of the body with the patient in various positions in order to produce a neurophysiological facilitation of both the central nervous system and the neuromuscular system, activating global and innate locomotive patterns or complexes, namely the Creeping Reflex and the Rolling Reflex. Both complexes provoke a certain coordination of striated muscle throughout the entire body. This enables a change from pathological patterns to alternative physiological patterns that are painless, efficient, and functional, by means of generating significant global effects, including the axial extension of the spine, correct positioning of the shoulder girdle, and activation of the abdominal musculature, all of which are altered by shoulder pathologies. Therefore, because of the high prevalence of IS and the lack of scientific studies on physiotherapeutic interventions on the shoulder, the investigators decided to conduct a clinical trial on the utility of Vojta Therapy in the treatment of IS. The investigators hoped to improve on the studies published to date, which vary greatly in methodological quality and use small sample sizes and heterogeneous populations. Moreover, no published studies have examined the use of Vojta Therapy in relation to shoulder pathologies in general, or to IS in particular.

Study Overview

• Status: Completed
• Conditions: Subacromial Impingement Syndrome; Vojta Therapy
• Intervention / Treatment: Procedure: Vojta therapy after standard therapy; Procedure: Standard therapy

Detailed Description

Sample size: The necessary sample size was calculated taking into account that for the main result indicator (level of pain), the investigators expected to find an improvement of at least 2 points with the implementation of Vojta. The investigators therefore assumed a variability of 2.5 points (standard deviation) on the pain scale, a value previously estimated in patients suffering shoulder pain in the same healthcare area. In order to detect this difference with a power of 80% (β error=20%) and a 95% confidence interval (α error=5%), it was necessary to recruit 25 patients per group. Assuming an attrition rate no higher than 20%, the final sample size required was 60 patients (30 per group).

Explanatory variables

• Sociodemographic: Gender, age, employment status, and type of work.
• Anthropometric: Weight, height, and body mass index (BMI) (kg/m2).
• Anamnesis: Dominant upper limb affected, tobacco use, current and/or previously suffered illnesses, surgical history of the shoulder, previous treatments of the shoulder and diagnostic tests conducted, analgesic use.
• Experimental treatment: Standard Therapy (ST) vs. Standard plus Vojta Therapy (SVT).

Administration and evaluation of therapy

• Initial evaluation: First, the evaluating physiotherapist took down the patient's medical history on an evaluation sheet; they then proceeded to administer the CMS and gave the patient the self-administered VAS and DAS scales, along with the SF-12 survey. Finally, a physiotherapist from the health clinic applied the assigned treatment (15 sessions for 3 weeks, independent of therapy type).
• Therapeutic intervention: experimental group vs active compared group.
• Second evaluation: After 15 sessions, carried out by the evaluating physiotherapist. Identical to the baseline evaluation.
• Third evaluation: Three months after the initial evaluation.

Validated measurement scales to evaluate results:

• VAS Scale: A universal method for evaluating pain, with maximum reproducibility among observers, a good relation to descriptive scales, and high sensitivity and reliability. The patient marks the pain intensity on a scale graded from 0 ("no pain") to 10 cm ("unbearable pain").
• DASH (Disabilities of the Arm, Shoulder, and Hand) Questionnaire: The most commonly used questionnaire to globally evaluate the functionality of the upper limbs from the patient's perspective. It consists of 30 objective questions, has excellent reproducibility, high sensibility, good internal consistency, and a high sensitivity to changes. It is graded from 0 to 100 (with a higher score indicating greater disability).
• Constant-Murley Scale (CMS): An evaluation system of shoulder functionality more commonly used in Europe and the United States. It assesses pain, functionality, strength, and joint range of motion. The subjective assessment section evaluates pain, daily activities, and sleep disturbances (maximum score=35) while the objective assessment section measures joint range of motion (with a goniometer) and shoulder strength (with a dynamometer).
• SF-12 Health Survey: A shortened version of the SF-36, this survey has a high internal consistency, validity, and reliability. It is the most widely used health measurement in the medical field. Using 12 categories, it evaluates 8 positive and negative dimensions of physical and mental health, and, by extension, of quality of life: physical functioning, role-physical, bodily pain, general health, vitality, social functioning, role-emotional, and mental health. The scale goes from 0 to 100 (the higher the score, the better the quality of life).

VAS, DASH, and SF-12 are all self-administered tests. They were given to each patient three times: after signing the informed consent form, at the end of the 15 therapy sessions, and 12 weeks after the start of the therapy. The CMS was likewise administered to each patient three times - the day of the initial evaluation, after 15 treatment sessions, and 12 weeks after the start of treatment - by 3 evaluating physiotherapists who had no knowledge of the assigned groups and who had not been involved with the patients' treatment. The evaluating therapists all had previous experience administering the CMS, thus guaranteeing interobserver validity.

• Study Type: Interventional
• Enrollment (Actual): 60
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Spain
  • Toledo
    • Quintanar de la Orden, Toledo, Spain

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child; Adult; Older Adult
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

The patients had to fulfill at least three of the following criteria:

• Pain in active Abd (70-120º), considered impingement +.
• Pain on palpation of any of the following osteotendinous insertions: infraspinatus, teres minor, supraspinatus, subscapularis, and biceps.
• Pain in any of the following isometric contractions: Abd (first 10º), internal rotation (in the anatomical position and with 90º elbow flexion), and shoulder flexion.
• Positive on the Neer test.
• Positive on Hawkins test.
• Nighttime shoulder pain.

Exclusion Criteria: Signs of a full thickness rotator cuff tear, acute inflammation or cervical radicular pain, calcification of the cuff tendons, glenohumeral instability, previous shoulder surgery, limited passive joint balance, pain due to suspected visceral or infectious process, shoulder pain of neurological origins, bilateral involvement, physiotherapeutic treatment in the past 6 months, aged <18, refusal to participate in the study, and physical and/or psychological dependence.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Double

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Standard plus Vojta therapy (SVT); The physiotherapist's hands produce the activation with no need for medication or external equipment, thus guaranteeing the patient's safety.this therapy is able to change pathological patterns to painless patterns that reduce the use of energy caused by movement difficulty. The end result is to facilitate movement without strain.	Procedure: Vojta therapy after standard therapy; Vojta Therapy ~20 minutes/session: Application of the Reflex Creeping complex, activating several stimulus points on the facial and the nuchal sides (Figure 3a), and then the activation of the Reflex Rolling complex in both the supine position and with the patient lying on his or her side, alternating between nuchal and facial stimulation and guiding from the head.
Active Comparator: Standard therapy (ST); It consists of one or more of the following procedures: transcutaneous electrical nerve stimulation (TENS), ultrasound therapy, kinesiotherapy, and cryotherapy.	Procedure: Standard therapy; ~50 minutes/session: TENS Current (20 minutes, phase duration=0.10 microseconds, frequency=50 Hz). The intensity applied depended on the patient's tolerance for the treatment (Figure 2a).; Pulsating ultrasound (5 minutes around the shoulder, frequency=1MHz, intensity=1 W/cm2) (Figure 2b).; Kinesiotherapy. In stages: at first assisted (with isometric exercises), then free, and finally, with resistance, usually with elastic bands (Figure 2c).; Cryotherapy (5 minutes).

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Pain by VAS. Main result indicator. "Change" is being assessed	Pain is measured with VAS Scale (a self-administered test). Pain graduation by VAS scale: intensity is graded from 0 ("no pain") to 10 cm ("unbearable pain"). VAS scale was given to each patient three times: after signing the informed consent form, at the end of the 15 therapy sessions, and 12 weeks after the start of the therapy.	Through study completion, an average of 1 year and a half
Pain by CMS. Main result indicator. "Change" is being assessed	Pain is also measured with and Constant-Murley Scale (CMS). Maximum score for CSM measurement=35 The CMS was administered three times: the day of the initial evaluation, after 15 treatment sessions, and 12 weeks after the start of treatment - by 3 evaluating physiotherapists who had no knowledge of the assigned groups and who had not been involved with the patients' treatment.	Through study completion, an average of 1 year and a half

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Joint range of motion. "Change" is being assessed	Joint of range was determined with CMS, which CMS was administered three times: the day of the initial evaluation, after 15 treatment sessions, and 12 weeks after the start of treatment - by 3 evaluating physiotherapists who had no knowledge of the assigned groups and who had not been involved with the patients' treatment. Maximum score for CSM measurement=35	Through study completion, an average of 1 year and a half
Strength. "Change" is being assessed	Strength was also measured with CMS. Again, CMS was administered the day of the initial evaluation, after 15 treatment sessions, and 12 weeks after the start of treatment - by 3 evaluating physiotherapists who had no knowledge of the assigned groups and who had not been involved with the patients' treatment. Maximum score for CSM measurement=35	Through study completion, an average of 1 year and a half
Functionality by DASH. "Change" is being assessed	Functionality was determined by means of DASH questionaire (Disabilities of the Arm, Shoulder, and Hand). DASH was given to each patient three times: after signing the informed consent form, at the end of the 15 therapy sessions, and 12 weeks after the start of the therapy. DASH is graded from 0 to 100 (with a higher score indicating greater disability)	Through study completion, an average of 1 year and a half
Functionality by CMS. "Change" is being assessed	Functionality was also determined by means of Constant-Murley Scale (CMS). Anew, CMS was administered: the day of the initial evaluation, after 15 treatment sessions, and 12 weeks after the start of treatment - by 3 evaluating physiotherapists who had no knowledge of the assigned groups and who had not been involved with the patients' treatment. Maximum score for CSM measurement=35	Through study completion, an average of 1 year and a half
Quality of life. "Change" is being assessed	Quality of life was evaluated with SF-12 Health Survey (the shortened version of the SF-36). SF-12 was also given three times: after signing the informed consent form, at the end of the 15 therapy sessions, and 12 weeks after the start of the therapy. It goes from 0 to 100 (the higher the score, the better the quality of life)	Through study completion, an average of 1 year and a half

Collaborators and Investigators

• Sponsor: Castilla-La Mancha Health Service
• Collaborators: Complejo Hospitalario La Mancha Centro
• Investigators: Study Chair: Inmaculada Tello Díaz-Maroto, Universidad Autonoma de Madrid; Study Chair: Jorge Lucas Torres de la Guía, Centro de Salud Quintanar de la Orden; Study Chair: Carmen Jiménez-Antona, Universidad Rey Juan Carlos de Madrid

Study record dates

Study Major Dates

• Study Start (Actual): August 1, 2013
• Primary Completion (Actual): February 1, 2015
• Study Completion (Actual): December 1, 2016

Study Registration Dates

• First Submitted: May 12, 2019
• First Submitted That Met QC Criteria: September 22, 2019
• First Posted (Actual): September 25, 2019

Study Record Updates

• Last Update Posted (Actual): September 25, 2019
• Last Update Submitted That Met QC Criteria: September 22, 2019
• Last Verified: September 1, 2019

More Information

Terms related to this study

• Keywords: Subacromial Impingement Syndrome; Vojta therapy; pain
• Additional Relevant MeSH Terms: Pathologic Processes; Wounds and Injuries; Disease; Joint Diseases; Musculoskeletal Diseases; Rupture; Shoulder Injuries; Tendon Injuries; Syndrome; Rotator Cuff Injuries; Shoulder Impingement Syndrome
• Other Study ID Numbers: SIS-VT

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: No

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No