Effects of eccentric exercise in patients with subacromial impingement syndrome: a systematic review and meta-analysis

Robin Larsson, Susanne Bernhardsson, Lena Nordeman, Robin Larsson, Susanne Bernhardsson, Lena Nordeman

Abstract

Background: Subacromial impingement syndrome is a common problem in primary healthcare. It often include tendinopathy. While exercise therapy is effective for this condition, it is not clear which type of exercise is the most effective. Eccentric exercises has proven effective for treating similar tendinopathies in the lower extremities. The aim of this systematic review was therefore to investigate the effects of eccentric exercise on pain and function in patients with subacromial impingement syndrome compared with other exercise regimens or interventions. A secondary aim was to describe the included components of the various eccentric exercise regimens that have been studied.

Methods: Systematic searches of PubMed, Cochrane Library and PEDro by two independent authors. Included studies were assessed using the PEDro scale for quality and the Cochrane scale for clinical relevance by two independent authors. Data were combined in meta-analyses. GRADE was applied to assess the certainty of evidence.

Results: Sixty-eight records were identified. Seven studies (eight articles) were included, six were meta-analysed (n = 281). Included studies were of moderate quality (median PEDro score 7, range 5-8). Post-treatment pain was significantly lower after eccentric exercise compared with other exercise: MD -12.3 (95% CI - 17.8 to - 6.8, I2 = 7%, p < 0.001), but this difference was not clinically important. Eccentric exercise provided no significant post-treatment improvement in function compared with other exercise: SMD -0.10 (95% CI - 0.79 to 0.58, I2 = 85%, p = 0.76). Painful eccentric exercise showed no significant difference compared to pain-free eccentric exercise. Eccentric training regimes showed both similarities and diversity. Intervention duration of 6-8 weeks was almost as effective as 12 weeks.

Conclusions: Evidence of low certainty suggests that eccentric exercise may provide a small but likely not clinically important reduction in pain compared with other types of exercise in patients with subacromial impingement syndrome. It is uncertain whether eccentric exercise improves function more than other types of exercise (very low certainty of evidence). Methodological limitations of existing studies make these findings susceptible to change in the future.

Trial registration: PROSPERO CRD42019126917 , date of registration: 29-03-2019.

Keywords: Eccentric exercise; Eccentric training; Subacromial impingement syndrome, shoulder impingement syndrome; Subacromial pain syndrome.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Flow diagram of the selection process. Modified from Moher et al., 2009
Fig. 2
Fig. 2
Forest plot of post-treatment effects on pain, sub-grouped by treatment length of six to eight weeks and treatment length of 12 weeks. Dashed vertical line denotes minimal important difference (VAS 15 mm). IV = inverse-variance, VAS = visual analogue scale
Fig. 3
Fig. 3
Forest plot of intermediate to long-term (6–12 months) effects on pain. Dashed vertical lines denote minimal important difference (VAS 15 mm). IV = inverse-variance, VAS = visual analogue scale
Fig. 4
Fig. 4
Forest plot of post-treatment effects on function, sub-grouped by treatment length of six to eight weeks and treatment length of 12 weeks. Because the scales used in Dejaco 2017 and Holmgren 2012 go in the opposite direction (i.e. higher is better) than the ones used in the other studies, the mean values were multiplied by − 1. As a rule of thumb, a standardised mean difference of 0.2 represents a small difference, 0.5 a moderate, and 0.8 a large difference. IV = inverse-variance
Fig. 5
Fig. 5
Forest plot of intermediate to long-term effects on function. Because the scales used in Dejaco 2017 and Hallgren 2014 go in the opposite direction (i.e. higher is better) than the one used in the other study, the mean values were multiplied by − 1. As a rule of thumb, a standardised mean difference of 0.2 represents a small difference, 0.5 a moderate, and 0.8 a large difference. IV = inverse-variance

References

    1. Luime JJ, Koes BW, Hendriksen IJ, Burdorf A, Verhagen AP, Miedema HS, Verhaar JA. Prevalence and incidence of shoulder pain in the general population: a systematic review. Scand J Rheumatol. 2004;33(2):73–81. doi: 10.1080/03009740310004667.
    1. van der Windt D, Koes B, Boeke A, Deville W, De Jong BA, Bouter L. Shoulder disorders in general practice: prognostic indicators of outcome. Br J Gen Pract. 1996;46:519–523.
    1. Struyf F, Nijs J, Mollekens S, Jeurissen I, Truijen S, Mottram S, et al. Scapular-focused treatment in patients with shoulder impingement syndrome: a randomized clinical trial. Clin Rheumatol. 2013;32(1):73–85. doi: 10.1007/s10067-012-2093-2.
    1. Cools AM, Cambier D, Witvrouw EE. Screening the athlete's shoulder for impingement symptoms: a clinical reasoning algorithm for early detection of shoulder pathology. Br J Sports Med. 2008;42(8):628–635. doi: 10.1136/bjsm.2008.048074.
    1. Huisstede BM, Miedema HS, Verhagen AP, Koes BW, Verhaar JA. Multidisciplinary consensus on the terminology and classification of complaints of the arm, neck and/or shoulder. Occup Environ Med. 2007;64(5):313–319. doi: 10.1136/oem.2005.023861.
    1. Neer CS. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. J Bone Joint Surg Am. 1972;54(1):41–50. doi: 10.2106/00004623-197254010-00003.
    1. Rees JD, Wilson AM, Wolman RL. Current concepts in the management of tendon disorders. Rheumatology (Oxford) 2006;45(5):508–521. doi: 10.1093/rheumatology/kel046.
    1. Öhberg L, Lorentzon R, Alfredson H. Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up. Br J Sports Med. 2004;38(1):8–11. doi: 10.1136/bjsm.2001.000284.
    1. Miller BF, Olesen JL, Hansen M, Døssing S, Crameri RM, Welling RJ, et al. Coordinated collagen and muscle protein synthesis in human patella tendon and quadriceps muscle after exercise. J Physiol. 2005;567(Pt 3):1021–1033. doi: 10.1113/jphysiol.2005.093690.
    1. Iannotti JP. Evaluation of the painful shoulder. J Hand Ther. 1994;7(2):77–83. doi: 10.1016/S0894-1130(12)80075-5.
    1. Langberg H, Ellingsgaard H, Madsen T, Jansson J, Magnusson SP, Aagaard P, et al. Eccentric rehabilitation exercise increases peritendinous type I collagen synthesis in humans with Achilles tendinosis. Scand J Med Sci Sports. 2007;17(1):61–66.
    1. Mahieu NN, McNair P, Cools A, D'Haen C, Vandermeulen K, Witvrouw E. Effect of eccentric training on the plantar flexor muscle-tendon tissue properties. Med Sci Sports Exerc. 2008;40(1):117–123. doi: 10.1249/mss.0b013e3181599254.
    1. Rutland M, O'Connell D, Brismée J-M, Sizer P, Apte G, O'Connell J. Evidence-supported rehabilitation of patellar tendinopathy. N Am J Sports Phys Ther. 2010;5(3):166–178.
    1. Hanratty CE, McVeigh JG, Kerr DP, Basford JR, Finch MB, Pendleton A, et al. The effectiveness of physiotherapy exercises in subacromial impingement syndrome: a systematic review and meta-analysis. Semin Arthritis Rheum. 2012;42(3):297–316. doi: 10.1016/j.semarthrit.2012.03.015.
    1. Abdulla SY, Southerst D, Côté P, Shearer HM, Sutton D, Randhawa K, et al. Is exercise effective for the management of subacromial impingement syndrome and other soft tissue injuries of the shoulder? A systematic review by the Ontario protocol for traffic injury management (OPTIMa) collaboration. Man Ther. 2015;20(5):646–656. doi: 10.1016/j.math.2015.03.013.
    1. Kromer TO, Tautenhahn UG, de Bie RA, Staal JB, Bastiaenen CH. Effects of physiotherapy in patients with shoulder impingement syndrome: a systematic review of the literature. J Rehabil Med. 2009;41(11):870–880. doi: 10.2340/16501977-0453.
    1. Camargo PR, Avila MA, Alburquerque-Sendín F, Asso NA, Hashimoto LH, Salvini TF. Eccentric training for shoulder abductors improves pain, function and isokinetic performance in subjects with shoulder impingement syndrome: a case series. Rev Bras Fisioter. 2012;16(1):74–83. doi: 10.1590/S1413-35552012000100013.
    1. Bernhardsson S, Klintberg IH, Wendt GK. Evaluation of an exercise concept focusing on eccentric strength training of the rotator cuff for patients with subacromial impingement syndrome. Clin Rehabil. 2011;25(1):69–78. doi: 10.1177/0269215510376005.
    1. Jonsson P, Wahlström P, Ohberg L, Alfredson H. Eccentric training in chronic painful impingement syndrome of the shoulder: results of a pilot study. Knee Surg Sports Traumatol Arthrosc. 2006;14(1):76–81. doi: 10.1007/s00167-004-0611-8.
    1. Green S, Buchbinder R, Hetrick S. Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev. 2003;2:CD004258.
    1. Kelly SM, Wrightson PA, Meads CA. Clinical outcomes of exercise in the management of subacromial impingement syndrome: a systematic review. Clin Rehabil. 2010;24(2):99–109. doi: 10.1177/0269215509342336.
    1. Ortega-Castillo M, Medina-Porqueres I. Effectiveness of the eccentric exercise therapy in physically active adults with symptomatic shoulder impingement or lateral epicondylar tendinopathy: a systematic review. J Sci Med Sport. 2016;19(6):438–453. doi: 10.1016/j.jsams.2015.06.007.
    1. Valier AR, Averett RS, Anderson BE, Welch Bacon CE. The impact of adding an eccentric-exercise component to the rehabilitation program of patients with shoulder impingement: a critically appraised topic. J Sport Rehabil. 2016;25(2):195–201. doi: 10.1123/jsr.2014-0230.
    1. Dervey E, Marshall S, Rouse S. Eccentric exercise therapy in the treatment of subacromial impingement syndrome: a critical review. Int J Ther Rehabil. 2014;21(7):338–344. doi: 10.12968/ijtr.2014.21.7.338.
    1. Maenhout AG, Mahieu NN, De Muynck M, De Wilde LF, Cools AM. Does adding heavy load eccentric training to rehabilitation of patients with unilateral subacromial impingement result in better outcome? A randomized, clinical trial. Knee Surg Sports Traumatol Arthrosc. 2013;21(5):1158–1167. doi: 10.1007/s00167-012-2012-8.
    1. Holmgren T, Björnsson Hallgren H, Öberg B, Adolfsson L, Johansson K. Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomised controlled study. BMJ. 2012;344:e787. doi: 10.1136/bmj.e787.
    1. Moher D, Liberati A, Tetzlaff J, Altman DG. PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097. doi: 10.1371/journal.pmed.1000097.
    1. PEDro physiotherapy evidence database. Sydney, Australia. [cited 28 May 2018]. Available from: .
    1. Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M. Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther. 2003;83:713–721.
    1. Macedo LG, Elkins MR, Maher CG, Moseley AM, Herbert RD, Sherrington C. There was evidence of convergent and construct validity of physiotherapy evidence database quality scale for physiotherapy trials. J Clin Epidemiol. 2010;63:920–925. doi: 10.1016/j.jclinepi.2009.10.005.
    1. Furlan AD, Pennick V, Bombardier C, van Tulder M. 2009 updated method guidelines for systematic reviews in the Cochrane Back review group. Spine (Phila Pa 1976) 2009;34(18):1929–1941. doi: 10.1097/BRS.0b013e3181b1c99f.
    1. Vallés-Carrascosa E, Gallego-Izquierdo T, Jiménez-Rejano JJ, Plaza-Manzano G, Pecos-Martín D, Hita-Contreras F, et al. Pain, motion and function comparison of two exercise protocols for the rotator cuff and scapular stabilizers in patients with subacromial syndrome. J Hand Ther. 2018;31(2):227–237. doi: 10.1016/j.jht.2017.11.041.
    1. Greco T, Biondi-Zoccai G, Gemma M, Guérin C, Zangrillo A, Landoni G. How to impute study-specific standard deviations in metaanalyses of skewed continuous endpoints? World J Meta-Anal. 2015;3(5):215–224. doi: 10.13105/wjma.v3.i5.215.
    1. Hao Q, Devji T, Zeraatkar D, Wang Y, Qasim A, Siemieniuk RAC, et al. Minimal important differences for improvement in shoulder condition patient-reported outcomes: a systematic review to inform a BMJ rapid recommendation. BMJ Open. 2019;9(2):e028777. doi: 10.1136/bmjopen-2018-028777.
    1. Review Manager (RevMan) [Computer program]. Version 5.3. Copenhagen: The NordicCochrane Centre, The Cochrane Collaboration, 2014.
    1. Guyatt GH, Oxman AD, Kunz R, Vist GE, Falck-Ytter Y, Schunemann HJ, et al. What is “quality of evidence” and why is it important to clinicians? BMJ. 2008;336(7651):995–998. doi: 10.1136/.
    1. Chaconas EJ, Kolber MJ, Hanney WJ, Daugherty ML, Wilson SH, Sheets C. Shoulder external rotator eccentric training versus general shoulder exercise for subacromial pain syndrome: a randomized controlled trial. Int J Sports Phys Ther. 2017;12(7):1121–1133. doi: 10.26603/ijspt20171121.
    1. Blume C, Wang-Price S, Trudelle-Jackson E, Ortiz A. Comparison of eccentric and concentric exercise interventions in adults with subacromial impingement syndrome. Int J Sports Phys Ther. 2015;10(4):441–455.
    1. Dejaco B, Habets B, van Loon C, van Grinsven S, van Cingel R. Eccentric versus conventional exercise therapy in patients with rotator cuff tendinopathy: a randomized, single blinded, clinical trial. Knee Surg Sports Traumatol Arthrosc. 2017;25(7):2051–2059. doi: 10.1007/s00167-016-4223-x.
    1. Bateman M, Adams N. A randomised controlled feasibility study investigating the use of eccentric and concentric strengthening exercises in the treatment of rotator cuff tendinopathy. Arthritis Res Ther. 2015;17:259. doi: 10.1186/s13075-015-0768-1.
    1. Hallgren HC, Holmgren T, Oberg B, Johansson K, Adolfsson LE. A specific exercise strategy reduced the need for surgery in subacromial pain patients. Br J Sports Med. 2014;48(19):1431–1436. doi: 10.1136/bjsports-2013-093233.
    1. Salaffi F, Stancati A, Silvestri CA, Ciapetti A, Grassi W. Minimal clinically important changes in chronic musculoskeletal pain intensity measured on a numerical rating scale. Eur J Pain. 2004;8(4):283–291. doi: 10.1016/j.ejpain.2003.09.004.
    1. Roy JS, MacDermid JC, Woodhouse LJ. Measuring shoulder function: a systematic review of four questionnaires. Arthritis Rheum. 2009;61(5):623–632. doi: 10.1002/art.24396.
    1. van Kampen DA, Willems WJ, van Beers LWAH, Castelein RM, Scholtes VAB, Terwee CB. Determination and comparison of the smallest detectable change (SDC) and the minimal important change (MIC) of four-shoulder patient-reported outcome measures (PROMs) J Orthop Surg Res. 2013;8:40. doi: 10.1186/1749-799X-8-40.
    1. Ekeberg OM, Bautz-Holter E, Keller A, Tveitå EK, Juel NG, Brox JI. A questionnaire found disease-specific WORC index is not more responsive than SPADI and OSS in rotator cuff disease. J Clin Epidemiol. 2010;63(5):575–584. doi: 10.1016/j.jclinepi.2009.07.012.
    1. Holmgren T, Oberg B, Adolfsson L, Björnsson Hallgren H, Johansson K. Minimal important changes in the constant-Murley score in patients with subacromial pain. J Shoulder Elb Surg. 2014;23(8):1083–1090. doi: 10.1016/j.jse.2014.01.014.
    1. Crenshaw AG, Karlsson S, Styf J, Bäcklund T, Fridén J. Knee extension torque and intramuscular pressure of the vastus lateralis muscle during eccentric and concentric activities. Eur J Appl Physiol Occup Physiol. 1995;70(1):13–19. doi: 10.1007/BF00601803.
    1. Westing SH, Cresswell AG, Thorstensson A. Muscle activation during maximal voluntary eccentric and concentric knee extension. Eur J Appl Physiol Occup Physiol. 1991;62(2):104–108. doi: 10.1007/BF00626764.
    1. Peterson M, Butler S, Eriksson M, Svärdsudd K. A randomized controlled trial of eccentric vs. concentric graded exercise in chronic tennis elbow (lateral elbow tendinopathy) Clin Rehabil. 2014;28(9):862–872. doi: 10.1177/0269215514527595.
    1. Hyldahl RD, Olson T, Welling T, Groscost L, Parcell AC. Satellite cell activity is differentially affected by contraction mode in human muscle following a work-matched bout of exercise. Front Physiol. 2014;5:485. doi: 10.3389/fphys.2014.00485.
    1. Ojasto T, Häkkinen K. Effects of different accentuated eccentric loads on acute neuromuscular, growth hormone, and blood lactate responses during a hypertrophic protocol. J Strength Cond Res. 2009;23(3):946–953. doi: 10.1519/JSC.0b013e3181a2b22f.
    1. Ingwersen KG, Jensen SL, Sørensen L, Jørgensen HR, Christensen R, Søgaard K, et al. Three Months of Progressive High-Load Versus Traditional Low-Load Strength Training Among Patients with Rotator Cuff Tendinopathy: Primary Results from the Double-Blind Randomized Controlled RoCTEx Trial. Orthop J Sports Med. 2017;5(8). 10.1186/1749-799X-8-40.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe