Subacromial Impingement in

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14 Νοε 2013 (πριν από 3 χρόνια και 8 μήνες)

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Subacromial

Impingement in
the SCI
Population

By: Sara Walsh, SPT

Ithaca College

Objectives



Review of Background Information



Evidence Based Practice



MCH



Why Do We Care?


40
-
70
% of
pts

in the SCI population have should pain
1



70
% of these cases are due to chronic impingement
syndrome
1



Pain is related to every day activities repetitive and
nearly exclusive use of UEs



The least of their worries



We can help!

Under the Surface


What can impinge structures?

o
Acromion

o
Coracoacromial

ligament


What can become impinged

o
Supraspinatus tendon

o
Infraspinatus

tendon

o
Long head of biceps tendon

o
Subacromial

bursa

Causes


Extrinsic Factors

o
Shape of acromion

o
Thickening of
coracoacromial

ligament


Intrinsic Factors

o
Overuse (inflammation, fibrosis, thickening)


Altered muscle
activity: Makes
coracoacromial

space
smaller

o
Increased Upper Trap

o
Decreased
Serratus

Anterior

o
Tight
Pec

Minor/posterior capsule tightness


Altered scapular and humeral kinematics

o
Humeral superior translation

o
Decreased upward rotation

o
Decreased posterior tipping of scapula

o
Scapular
and humeral internal rotation



Exercise Vs. Surgery


Comparable results between exercise & surgical intervention
(stage
1
and
2
impingement)



Post
-
surgical non
-
weight bearing/ROM precautions

o
Six weeks

o
Would render patient dependent for most tasks (dressing,
txr
, mobility)




Cost
-
Effective



Prevent from happening again



Level of Evidence: Moderate: B

o
Limitations


Able bodied
population
2
,
3


Possible
bias
2
,
3


Some patients declined (
8
/
84
.)
2

50
% of exercise group had
surgery
3







Evidence


Haar
2


05
,
Brox

3


99

o
Randomized Controlled Trials


Study Designs:

o
RCTs


Surgery, PT, (placebo)


Outcome Measures:

o
Constant Score
2

(pain, ADLs, ROM, strength,)
Neer

Shoulder
Score
3

(pain,
function, ROM, radiological
eval
)


Results:

o
At
1
year
2
/
2.5
yrs
3

both groups made clinically significant improvements
that were not significantly different from each other (MCID)


Treatment


Rotator Cuff & Scapular
-
Focused
Strengthening/Stretching



Strengthening: SA, MT, LT, ER

o
Resistance bands



Stretches: UT,
Pec

Major,
Pec

Minor, Long Head
Biceps, Post Capsule of GH Jt.



Clinically Meaningful changes: MCID

o
Meaningful to patient, provider, & third party payer


Evidence


Cardoso
4
2009
, Michener
5

2004
, Lombardi
6

2008
,
Ludewig
7

2003
,
Mulroy
8

2011
,
Nawoczenski
9

2006
, McClure
10

2004
,



Study Designs:

o
Systematic Review
4
,
5
, RCT
5
,
6
,
7
,
8

Non
-
randomized cohort study w. an
asymptomatic control group and treatment
group
9
,
repeated
measures
10



o
Follow Up:

Tested at baseline &
8
wks
6
,
7
,
8
/
12
wks
8
/
6
wks
10


o
Outcome Measures:


VAS
: effect size:
0.84
(pain w. movement)
6


SRQ

effect size:
0.77
7


Average
2
x MCID for VAS &
WUSPI

8


57
% of treatment group demonstrated improvements in WUSPI scores
at MCID threshold (decreased pain & increased function)
9


average close to double MDC/MCID
UPENN Shoulder Scale
10


Evidence Cont.

o
Results:


Overall, the treatment groups had increased function and decreased
pain


Positive changes maintained at
6
month follow up
9


o
Level of Evidence: Moderate (B
)


Limitations
:

o
SRs
from ‘
00
-

08
4

o
SR’s
through

03
5

o
Able bodied
6

o
Only men, follow up varied from
8
-
12
wks
,
onlyl

61
% filled out
activity
log
7

o
High attrition, only
83
% had clinical signs of SAIS
8

o
pain not eliminated in all patients
, asymptomatic control group,
could have been social interaction that caused improvement,
no control
9

o
high attrition (
33
%,) no control
10

HEP


Progressive Resistance Exercises & Stretching



Effect Sizes



MDC Values

o
Minimally detectable change



Transportation



Ongoing medical expenses

o
Fewer number of clinic visits



Realistic



Level of Evidence: Moderate (B)

Evidence


Ludewig
7


03
, Nawoczenski
9


06
, Mulroy
8

11
,
McClure
10


04

Internal (GH) Vs.
Subacromial

Impingement


Strength of Recommendation: Weak

o
Only
2
articles




internal rotation test

o
Pt

standing w. PT behind
pt
, arm in
90
abd

&
80
ER, isometric ER & IR tests,

o
Pos

test: strong ER, weak
IR
11




Posterior impingement test

o
Pt

supine,
abd

amr

90
-
100
degrees in
10
-
15
degrees of
ext
, maximally ER
shld

o
Pos

test: c/o deep pain in post shld
12




Differentiating b/w these
2
diagnoses effects the plan of care

o
SAIS: avoid
90
-
120
degrees

o
Internal Impingement: avoid push downs



Decrease costs by reducing misguided treatments



Evidence


Meister
11
, Zaslav
12


Level of Evidence

o
Exploratory Cohort
11
,
12


Reference Standard

o
Arthoscopy
11
,
12


Stats

o
Post Impingement Test: sensitivity:
94.6
, specificity:
100


Probability of an internal impingement dx
inc

from
23
%
-
87
%
11

o
Internal Rotation Test: sensitivity:
88
, specificity:
96
, +LR:
22
12



Weak Level of Evidence:

o
Limitations


Older data (‘
93
-

99
,) athletes
11


Used subjects who failed conservative treatment, no blinding
12

Diagnosing Stages
1
&
2


Current diagnostic tests are not useful

o
Hawkins Kennedy,
Neer
,
Jobe
, Painful Arc Test

o
Screening or Confirmation



Lack of consistency



Does not change the action of the clinician

o
Treat the impairments



Combos of tests lacked consistency as well



Thorough history & objective exam



Physical Therapy/Occupational Therapy as a diagnostic tool

Evidence


Papdonikolakis
13


11
, Calis
14


00
, Park
15


05
,
Michener
16


09
, Silva
17


08


Level of Evidence

o
Systematic review of exploratory cohorts
13
, exploratory cohorts
13
,
14
,
15
,
16



Reference Standard

o
Subacromial

injection test
14

o
Arthroscopy
15
,
16

o
MRI
17




Evidence Cont.


Stats

o
Painful arc sensitivity:
32
%
12
-
75
%
15

o
Accuracy:
52
(
infraspinatus

test)
-
72
% (HK)
13

o
Combo of tests: pretest
-
post test probabilities move
from
29
%
-
54
%
16


Any combo of
3
(HK,
Neer
, Painful Arc,
Jobe

Ext rot resisted test)



Limitations: Weak Level of Evidence

o
Different gold standards used (
arthorscopy
, US, MRI, SITS: makes
comparison of results difficult

o
Articles prior to ‘
10
13

o
No blinding
14

o
No measurement of reproducibility, athletes w. painful multidirectional
laxity
15

o
Heterogenious

sample, wide CI,
16

o
Not all possible tests
17


Diagnosing Stage
3
-
Complete
Tear of Supraspinatus Tendon


Drop Arm Test is recommended to diagnose stage
3



Rule in the diagnosis

o
Acceptable specificity levels



Motivates immediate referral to MD as surgery is
indicated



Early identification is cost effective as it eliminates
unnecessary PT/OT treatment

Evidence


Calis


00
14
, Park ’
05
15


Level of Evidence

o
Exploratory Cohorts
14
,
15




Reference Standard

o
Arthroscopy
14
,
15


Stats

o
Specificity:
88
%
13
,
100
%
15

o
Sensitivity:
7
%
13
,
27
%
15


Weak Level of Evidence: Limitations

o
No blinding
14

o
No measurement of reproducibility, athletes w. painful multidirectional
laxity
15



Prognosis


Overall dearth of evidence

Subacromial

Steroid
Injections


Prognosis at six
wks

vs.
2
yrs.

o
Beneficial short term, detrimental long term




Clinicians should be mindful that this subgroup is
more likely to fail conservative treatment and
require surgery



Level of Evidence: Weak

o
Limitations


No inception point, no multivariate analysis
18


Small sample size (
104
) broad inception point, short follow up, diffs in
MRI protocols, US reliability/validity not assessed
19


No studies on
wc

users



Evidence


Cummins
18


09
, Ekberg
19


10



Level of evidence

o
RCT follow up
18
,
19



Methods

o
Steroid injection followed by best practice PT protocol for
4
wks

w
6
wk
,
3
mo
,
6
mo
,
1
yr
, &
2
yr

ASES (
84
% follow up each time)
18

o
6
wk

follow up w SPADI, Global Assessment Score
19



Stats

o
2
steroid injections increase odds of failing non
-
op
tmt

& needing surgery at
2
yrs
: RR=
6.4
OR=
15.3
18

o
At
6
wks
,
pts

who had
2
injections were
2.3
x more likely to
inc

Global
Assessment Score (OR:
2.3
)
19

Age


Can not be used as a prognostic factor




Level of Evidence: Weak

o
Limitations


Small sample size, short follow up, diffs in MRI protocols, US
reliability/validity not assessed, able bodied


Unclear inception point, small sample size, missing values, able
bodied


Fuzzy inception point, able bodied


Evidence


Ekberg
19


10
, Engebretsen
20


10
, Kennedy
21


06



Level of Evidence

o
RCT follow ups
19
,
20
,
21



Methods

o
6
wk

follow up w SPADI
19

o
1
yr

follow up w SPADI
20

o
12
wk

follow up w SPADI & DASH
21



Stats

o
Age OR=
1.03
(
0.99
-
1.07
)
19

o
Age: OR=
1.0
(
0.95
-
1.1
)
20

o
Age
40
-
60
w
4
other risk factors accounted for
1
/
3
of the ox (high SPADI score)
21

Unemployed at Baseline



Assoc. w. poor
pt
-
reported health status in short term
and for not working in the long term



Preventative Care

o
Work site evaluations/education


Ergonomics


Body Mechanics



Level of Evidence

o
Limitations


Small sample size, broad inception point, short follow up, differences in MRI
protocols, US reliability/validity not assessed
19


No clear inception point, small sample size
20


Evidence


Ekberg
19


10
, Engebretsen
20


10



Level of Evidence

o
RCT follow ups
19
,
20



Methods

o
6
wk

follow up w SPADI
19

o
1
yr

follow up w SPADI
20



Stats

o
On sick leave: OR:
0.34 18
decreased likelihood of patient reported good
health status at
6
wks
19

o
Work status: OR:
3.5
(not working at baseline
-
3.5
more likely to not be working
at
1
yr

follow up)
20

What can be done at
MCH?




Screening
of
pt’s

for SAIS using history and exam

o
SCI
popn
,
wc

users, and others



Encourage
exercise vs.
surgery



Educate on what to expect in the out patient setting



Diagnosis: Evidence based or not



Educate
about risks/benefits of corticoid steroid injections



Edu

on age



Unemployed
at baseline



Prevention: all
wc

users
-
appropriate posture

Work Cited

1.
Curtis KA,
Drysdale

GA,
Lanze

RD, et al. Shoulder pain in
sheelchair

users with tetraplegia and paraplegia.
Arch
Phys

Med
Rehabi
l
.
1999
;
80
:
453
-
457

2.

Haahr

J,
Østergaard

S, Andersen J, et al. Exercises versus arthroscopic decompression in patients with
subacromial

impingement: a
randomised
, controlled study in
90
cases with a one year follow up.

Annals Of The Rheumatic
Diseases

[serial online]. May
2005
;
64
(
5
):
760
-
764
.

3.
Brox

J,
Gjengedal

E, Staff P, et al. Arthroscopic surgery versus supervised exercises in patients with rotator cuff disease
(stage II impingement syndrome): a prospective, randomized, controlled study in
125
patients with a
2 1
/
2
-
year follow
-
up.

Journal Of Shoulder And Elbow Surgery / American Shoulder And Elbow Surgeons ... [Et Al.]

[serial online]. March
1999
;
8
(
2
):
102
-
111
.

4.
Cardoso de Souza M,
Trajano

Jorge R, Jones A, Lombardi
Júnior

I,
Natour

J. Progressive resistance training in patients with
shoulder impingement syndrome: literature
review.
Reumatismo

[serial online]. April
2009
;
61
(
2
):
84
-
89
.

5.
Lori
A. Michener, Matthew K.
Walsworth
,
Evie

N.
Burnet,J

Hand
Ther
.
2004
Apr

Jun;
17
(
2
):
152

164
.

doi
:

10.1197
/j.jht.
2004.02.00

6.
Lombardi I,
Magri

A,
Fleury

A, Da Silva A,
Natour

J. Progressive resistance training in patients with shoulder impingement
syndrome: a randomized controlled trial.

Arthritis And Rheumatism

[serial online]. May
15
,
2008
;
59
(
5
):
615
-
622
.

7.
Ludewig

P,
Borstad

J. Effects of a home exercise
programme

on shoulder pain and functional status in construction
workers.

Occupational And Environmental Medicine

[serial online]. November
2003
;
60
(
11
):
841
-
849
.

8.
Mulroy

S, Thompson L, Gordon J, et al. Strengthening and optimal movements for painful shoulders (STOMPS) in chronic
spinal cord injury: a randomized controlled
trial.
Physical

Therapy

[serial online]. March
2011
;
91
(
3
):
305
-
324

9.
Nawoczenski

D, Ritter
-
Soronen

J, Wilson C, Howe B,
Ludewig

P. Clinical trial of exercise for shoulder pain in chronic spinal
injury.

Physical Therapy

[serial online]. December
2006
;
86
(
12
):
1604
-
1618

10.
Philip
W. McClure, Jason
Bialker
, Nancy Neff, Gerald Williams, Andrew
Karduna
.
Phys

Ther
.
2004
September;
84
(
9
):
832

848

11.
Meister K, Buckley B,
Batts

J. The posterior impingement sign: diagnosis of rotator cuff and posterior
labral

tears secondary to
internal impingement in overhand
athletes.
American

Journal Of Orthopedics (Belle Mead, N.J.)

[serial online]. August
2004
;
33
(
8
):
412
-
415

12.
Zaslav

K. Internal rotation resistance strength test: a new diagnostic test to differentiate intra
-
articular pathology from outlet
(
Neer
) impingement syndrome in the
shoulder.
Journal

Of Shoulder And Elbow Surgery / American Shoulder And Elbow
Surgeons ... [Et Al.]

[serial online]. January
2001
;
10
(
1
):
23
-
27



Work Cited Cont.

13.

Papadonikolakis

A, McKenna M,
Warme

W, Martin B,
Matsen

F. Published evidence relevant to the diagnosis of impingement
syndrome of the shoulder.

The Journal Of Bone And Joint Surgery. American Volume

[serial online]. October
5
,
2011
;
93
(
19
):
1827
-
1832

14.
Caliş

M,
Akgün

K,
Birtane

M,
Karacan

I,
Caliş

H,
Tüzün

F. Diagnostic values of clinical diagnostic tests in
subacromial

impingement syndrome.

Annals Of The Rheumatic Diseases
[serial online]. January
2000
;
59
(
1
):
44
-
47

15.
Park H, Yokota A, Gill H, El
Rassi

G, McFarland E. Diagnostic accuracy of clinical tests for the different degrees of
subacromial

impingement syndrome.

The Journal Of Bone And Joint Surgery. American Volume

[serial online]. July
2005
;
87
(
7
):
1446
-
1455
.

16.
Michener L,
Walsworth

M,
Doukas

W, Murphy K. Reliability and diagnostic accuracy of
5
physical examination tests and
combination of tests for
subacromial

impingement.
Archives

Of Physical Medicine And Rehabilitation

[serial online]. November
2009
;
90
(
11
):
1898
-
1903

17.
Silva L,
Andréu

J,
Fernández
-
Castro M, et al. Accuracy of physical examination in
subacromial

impingement
syndrome.

Rheumatology (Oxford, England)

[serial online]. May
2008
;
47
(
5
):
679
-
683
.

18.
Cummins C,
Sasso

L, Nicholson D. Impingement syndrome:

temporal outcomes of
nonoperative

treatment.

Journal Of Shoulder
And Elbow Surgery / American Shoulder And Elbow Surgeons ...

[Et Al.]

[serial online].

March
2009
;
18
(
2
):
172
-
177
.


19.
Ekeberg

O,
Bautz
-
Holter

E,
Juel

N,
Engebretsen

K,
Kvalheim

S,
Brox

J. Clinical, socio
-
demographic and radiological predictors of
short
-
term outcome in rotator cuff disease.

BMC Musculoskeletal Disorders

[serial online]. October
15
,
2010
;
11
:
239
.

20.
Engebretsen

K,
Grotle

M,
Bautz
-
Holter

E,
Ekeberg

O,
Brox

J. Predictors of shoulder pain and disability index (SPADI) and work
status after
1
year in patients with
subacromial

shoulder pain.

BMC Musculoskeletal Disorders

[serial online]. September
23
,
2010
;
11
:
218

21.
Kennedy C,
Manno

M, Beaton D, et al. Prognosis in soft tissue disorders of the shoulder: predicting both change in disability and
level of disability after treatment.

Physical Therapy

[serial online]. July
2006
;
86
(
7
):
1013
-
1032