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The relationship between impingement and the applied exercise therapy is absolutely unclear. Is exercise 1 performed via elevation, scaption, or abduction? With or without pain? Are 30 repetitions of exercise 2 realizing the desired improvement in the trophic condition of the rotator cuff? I do not know any evidence for that. In the second part of the exercise program, strength exercises are prescribed. Was the strength, without physical therapist evaluation, decreased? Are we talking about absolute or duration strength, or does that make no difference? This nonfunctional exercise program lacks necessary components such as training of local stabilizers, improving scapular rhythm, and functional training.1,2
Ultrasound therapy can be a part of a plan of care for impingement, but only if complaints are caused by a localized tendinopathy, especially when calcilfications are present.3 To realize an appropriate local effect (possibly leading to a clinical effect), ultrasound should be applied 10 times in 2 weeks, not 10 times in 5 weeks.
The last therapy described concerns alternative medicine. I am surprised that Johansson and colleagues seem to embrace this therapy, including the alternative definitions such as Hegu, LI, and 0.5 cun (see Appendix 1). I would prefer to speak of myofascial trigger points, dry needling, or intramuscular stimulation to prevent a connection between physical therapy and alternative theories.4
In the study by Johansson et al, a non-specific patient group, 85 patients with impingement (medical diagnosis) but without diagnosis by a physical therapist, was "treated" with a nonspecific exercise protocol. In 41 patients, an additional specific (but just for the subgroup of patients with impingement caused by calcified tendinopathy) ultrasound treatment was applied, and 44 patients received alternative pain therapy as an extra treatment. The measurement was a nonreliable and nonvalidated combination of scores from 3 questionnaires. This nonspecific treatment had a positive effect, as shown in Table 3 and Figure 3. In 12 months, the combined scores increased from 62 to 91, a positive effect of 29%. Although the authors concluded that there was a statistical difference, Table 3 clearly shows that there was no clinically relevant difference.
The authors did well on the methodical part (design of the study) and on the medical part (inclusion criteria) but strongly underestimated physical therapist reasoning. This is the second trial about shoulder problems within a year in this journal in which physical therapist researchers prioritized fulfilling "research criteria" instead of "physical therapy criteria"5—a dangerous trend that might undermine our professional identity. In complex clinical situations, such as those involving the shoulder, we should focus on proper diagnosis before starting to perform effect studies.
Teacher in Physiotherapy
Saxion Hogeschool
Enschede, the Netherlands
g.koel{at}home.nl
References
In our study, several diagnostic tests were used in combination to increase the accuracy and precision. The chosen tests’ ability to raise the pressure in the subacromial space and to impinge on subacromial structures is scientifically supported.2–5 The exclusion criteria excluded, as far as possible, causes of secondary impingement. Therefore, we believe that the study was based on a rather homogenous group of patients with primary impingement. Additional individual factors, found both in medical history and in physical therapist examination, could be of a prognostic value when choosing treatment and should be taken into account. In our study, activity limitations and participation restrictions—due to pain, movement, and strength, for example—were noted and followed, but not separately analyzed and reported. However, these aspects were integrated into the questionnaires used in the study.
Because we are clinicians as well as researchers, the hypothesis of the study originated from our clinical encounters. The focus was to examine a possible difference between 2 procedures commonly used as additional interventions in everyday clinical practice for patients with impingement syndrome. The study was designed to facilitate implementation of the results.
Several questions were raised in relation to the described home exercises. In 2002, we published a systematic review of the treatment of subacromial pain6 in which only one study7 supported tentative evidence for efficacy of exercises. Another recent review1 also concluded that limited evidence exists to support the use of therapeutic exercises for patients with impingement syndrome. Consequently, there is no existing evidence guiding the design of a exercise program for these patients.
In part I of the exercise program, the first exercise is flexion. This should not cause pain related to the impingement, but a stretching sensation was preferred. The second part of the exercise program targeted strengthening of the rotator cuff muscles. These were uncomplicated exercises activating the rotator cuff muscles8,9 and were chosen from those exercises commonly used in clinical practice. The specific force improvement is included only as part of the Constant-Murley Shoulder Assessment (maximum abduction force in 90° of scaption) and is not reported. We agree that the program lacked functional exercises. Perhaps a more individualized and functional program, based on analyses of local stabilizers and scapulohumeral rhythm, could result in an even more effective treatment. That is, there are a great deal of future research challenges in this area.
In Sweden, acupuncture was approved by the Swedish National Board of Health and Welfare in 1984 to be used by registered medical professionals when treating patients with pain. To enable clinicians to reproduce the treatment, the acupuncture points were described by the anatomical location in combination with the more traditional way. This combined approach is the technique used in Sweden.
As pointed out in the "Discussion" section of our article, there is a limitation when using combined scoring systems. The clinical relevance for each patient is difficult to ascertain. However, there was a statistically significant difference between the 2 groups, demonstrating that when applied in addition to home exercises, acupuncture is better than ultrasound. This result is important, but must be integrated with patient preference as well as the expertise of the clinicians. This integration strengthens our professional identity instead of undermining it.
Physical Therapy Program
Department of Health and Society, Divison of Physical Therapy
Linköpings Universitet
S-581 83 Linköping, Sweden
Department of Neuroscience and Locomotion, Orthopedics and Sports Medicine
Linköpings Universitet
Department of Health and Society, Primary Care
Linköpings Universitet
Kajsa.Johansson{at}ihs.liu.se
References
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