Shoulder Surgery or Shoulder Exercise - Which is Better?

The original article about this study can be found here: http://www.bmj.com/content/344/bmj.e787

Effect of Specific Exercise Strategy on Need for Surgery in Patients with Subacromial Impingement Syndrome: Randomized Control Study

Shoulder pain can be caused by a number of factors. The most common factors of causes for shoulder pain include altered shoulders with the dysfunction of the rotator cuff, capsular tightness, poor posture, and overuse to sustained insensitive work. Conservative treatment is often the first choice for doctors. Conservative treatment includes corticosteroid injections or different physical therapy exercises or both. There have been limited studies done on what specific exercises done have been most effective. When conservative treatment fails, surgery is often encouraged. "Studies have compared different exercise programs with surgery and concluded that the two strategies have equivalent effects. A 65-80% success rate, improved shoulder function, and decreased pain have been reported after one year. These results challenge the need for surgery.”

This study consisted of patients 30-65 with a diagnosis of subacromial impingement syndrome. The specific exercise group had a program that  consisted of six different exercises: two eccentric exercises for the rotator cuff, three concentric/eccentric exercises for the scapula stabilizers, and a posterior shoulder stretch. Each strengthening exercise was repeated 15 times in three sets twice daily for eight weeks. The posterior shoulder stretch was performed for 30-60 seconds and repeated three times twice daily. From week eight to week 12, the exercises were repeated once a day. The exercises were individually adjusted and progressed with increased external load by using weights and elastic rubber band at the physical therapist visits once every other week during the whole rehabilitation period. The pain monitoring model was used to find the individual resistance for each patient. The patients were not allowed to exceed 5 on this 0-10 scale when they performed the exercises; however, they were recommended to feel some pain during loading. After completion of an exercise session, increased pain had to revert to levels before exercise before the next session; otherwise, the external load was decreased. Great emphasis was placed on teaching good posture and to maintain this position during the exercises. After completion of the specific exercise program (after 12 weeks), they recommended participants to maintain the daily home exercises for another two months. A more detailed description of the exercise program can be found in the appendix on bmj.com. The control exercise program consisted of six unspecific movement exercises for the neck and shoulder without any external load Each movement exercise was repeated 10 times, and each stretching exercise three times twice daily at home and once every other week at the physical therapist visits. The patients did the same program without any progression during the whole rehabilitation period. The unspecific exercise program was thought to have a limited effect in patients with subacromial impingement syndrome and therefore acted as a control. The specific exercise group had significantly greater improvement than the control exercise group in the primary outcome. The mean change in the disabilities of the arm, shoulder, and hand score was significantly higher in the specific exercise group than the control exercise group.

Patients with persistent subacromial impingement syndrome experience significantly greater improvements in shoulder function and pain after a specific exercise strategy over 12 weeks. In this randomized controlled study the specific exercise strategy, targeting the rotator cuff and scapula stabilizers, was compared with unspecific exercises. The exercise program influenced the patients’ choice about surgery as significantly more patients in the specific exercise group withdrew from the waiting list for surgery.

These positive results were achieved even though the participants had persistent symptoms that had not responded to at least three months of earlier conservative treatment (including exercise treatment) before inclusion.

Good adherence is required for a positive treatment effect. Because lack of time is a source of poor adherence, a small number of exercises is assumed to be beneficial for good adherence. This program consisted of only a few exercises, which could be completed in a reasonable time. In addition, regular follow-ups by the physical therapist focused on hands-on guidance to facilitate appropriate performance of the exercises. Guided exercise treatment has been shown to be important, especially early in the rehabilitation phase when the patient needs support dealing with pain and disability. Pain during loading was allowed, as recommended by the pain monitoring model,  and used to determine the progression of loading. The model was also used to support the patients in dealing with their experience of pain.