Physical Therapy Reviews 2006; 11: 125–142

EXERCISE AND MANUAL THERAPY FOR THE

TREATMENT OF IMPINGEMENT SYNDROME OF THE
SHOULDER: A SYSTEMATIC REVIEW

ATHANASIOS TRAMPAS1 AND ATHANASIOS KITSIOS2

1
Thessaloniki, Greece
2
Department of Physical Education and Sports Science, Aristotelio
University of Thessaloniki, Thessaloniki, Greece

‘Impingement syndrome’ is a generic term for rotator cuff lesions encompassing all stages of
tendon disease. The fundamental aim of this review was to assess whether the quality of
randomised controlled trials (RCTs) on this specific topic has improved during the last 3 years.
A computer-aided search of databases was carried out from 2003 to 2005, using a combination
of key words. Five RCTs were critically appraised using the PEDro scale and the American
College of Sports and Medicine guidelines. The mean quality score of the included trials was
6.2, ranging from 4 to 8 points out of a possible 10. There is moderate evidence that supports
the use of therapeutic exercises alone in reducing pain and function, whereas there is limited
evidence to support the effectiveness of both manual and exercise therapy in combination.
Future studies should better define impingement syndrome, based upon well-designed
research methodology and the use of validated measurement tools.

Keywords: Subacromial impingement syndrome, therapeutic exercises, manual therapy,

randomised controlled trials (RCTs)

INTRODUCTION individuals younger than 25 years but may occur at

‘Impingement syndrome’ is a generic term for rotator
cuff lesions encompassing all stages of tendon disease
from early inflammation through degeneration and
eventually partial or complete tears. Anatomical
anomalies, particularly type III hook-shaped
acromions or congenital subacromial stenosis, may
predispose to impingement syndrome.1 Acromial
morphology appears to have a predictive value in
determining the success of conservative measures and
the need for surgery in patients with impingement
syndrome.2 The rotator cuff, especially supraspinatus,
maintains the subacromial space by depressing the
head of the humerus to prevent superior translation
during abduction and elevation movements.3
Neer4 has classified three progressive pathological
stages of impingement: stage 1 usually occurs in
© W. S. Maney & Son Ltd 2006
any age in those who are engaged in excessive use of
upper limbs. The pathological changes are oedema
and haemorrhage of the subacromial bursa. Stage 2 is
characterised by thickening and fibrosis; in stage 3,
rotator cuff tears, biceps’ ruptures, and bone changes
are observed. If impingement continues, the condi-
tion becomes chronic, producing thickening and
fibrosis of the bursa and tendinitis of the cuff. Stage 2
disease is commonly seen in patients between 25–40
years of age. Stage 3 results from further impinge-
ment, producing degeneration or complete or incom-
plete tears of the rotator cuff. These more advanced
changes are usually seen in patients over 40 years old.
Although some clinical criteria for impingement
syndrome have been proposed,5 none has received the
level of acceptance required to make it useful as a
study selection criterion for the present review. This
DOI 10.1179/108331906X99065
126 TRAMPAS AND KITSIOS
was one of the main outcomes of the last literature
review conducted by Desmeules et al.6 for impinge-
ment syndrome treated with exercises and manual
therapy. The authors concluded that future trials
should better define shoulder impingement syn-
drome, presenting the inclusion and exclusion criteria
of the included studies in detail. It was, therefore,
decided that it would be appropriate for this review to
assess studies dealing with any of the impingement-
related diagnoses (e.g. tendinitis or bursitis), and to
compare the inclusion and exclusion criteria used to
the findings of previous recent systematic reviews6,7 as
a criterion to assess whether the degree to which the
quality of definition for impingement syndrome has
improved or not during the last 2.5 years to provide
more homogeneous study populations.
Van der Windt et al.8 investigated the incidence and
management of intrinsic shoulder disorders in Dutch
general practice, and evaluated which patient charac-
teristics were associated with specific diagnostic cate-
gories. In 11 general practices (35,150 registered
patients), all consultations concerning shoulder com-
plaints were registered during a period of 1 year.
Patients with an intrinsic shoulder disorder who had
not consulted their general practitioner for the com-
plaint during the preceding year (incident cases) were
asked to participate in an observational study.
Participants completed a questionnaire regarding the
nature and severity of their complaints. The general
practitioners recorded data on diagnosis and therapy.
The cumulative incidence of shoulder complaints in
general practice was estimated to be 11.2/1000
patients/year. Rotator cuff tendinitis was the most fre-
quently recorded disorder and it was found to be
around 3.2–4.2 per 1000 persons/year (29%).
Maitland indicated that the word ‘manipulation’ can
be used in two ways. First, as a general term to refer to
all passive movements used in the treatment of muscu-
loskeletal disorders including ‘manipulation technique’.
Maitland then went on to define the term ‘mobilisa-
tion’, providing a more detailed and specific definition
than that provided earlier by Kaltenborn.9 Manual
therapy requires that the therapist apply an external
force to the patient to produce a desirable amount of
deformation of the targeted joint connective tissues,
and a relative displacement of the bones at either end of
the joint in accordance with the load–displacement
relationship of the targeted tissues. According to Le-T
et al.10 manipulation techniques are mainly used for
adhesive capsulitis (under anaesthesia) and, for patients
with impingement syndrome grade I manual therapy
must be the primary choice for management.11
It has long been recognised that exercise can have a
beneficial effect in treating pain. Fordyce et al.12
showed that the benefits of exercise could have a
direct effect on the quality of life for the chronic pain
patient by means of operant conditioning or of pain
behaviours, that may be increased or decreased.
Therapeutic exercise is the most extensively investi-
gated form of rehabilitation, and may be defined as a
series of specific movements for the purpose of train-
ing or developing the body through systemic practice,
or as a bodily exertion for the promotion of physical
health.13 Therapeutic exercise encompasses many
well-known exercise strategies such as rehabilitating
the functional demands of the muscle system, enhanc-
ing cardiovascular fitness, or improving joint and
muscle flexibility.14 The therapeutic exercise pro-
grammes have generally consisted of stretching the
anterior and posterior shoulder girdle, muscle relax-
ation techniques, motor learning to normalise dys-
functional patterns of motion, and strengthening the
rotator cuff and scapular muscles. Improvements in
pain, patient satisfaction, levels of disability and func-
tional loss, strength, shoulder range of motion, pain
with subacromial compression, and overall shoulder
use have been demonstrated with therapeutic exercise
programmes.7
There is a small number of literature reviews evalu-
ating the effectiveness of exercise and manual therapy
for impingement syndrome. Van der Heijden15 con-
cluded that knowledge of the effect of all methods in
the field of physiotherapy on long-term outcome or
recurrence of shoulder disorder is lacking. Based on
three of the studies listed in the recent review by
Desmeules et al.,6 van der Heijden15 also concluded
that very limited evidence supports the effectiveness
of therapeutic exercises or manual therapy. An earlier
review by van der Heijden et al.16 reached similar con-
clusions. According to Philadelphia Panel evidence-
based clinical practice guidelines,17 the investigators
were unable to make any conclusions regarding the
effectiveness of therapeutic exercises for shoulder
pain because poorly defined inclusion criteria and
non-validated outcomes were used. Only one study18
related to therapeutic exercises was included and
reviewed. In both systematic reviews by van der
Heijden,15,16 there was an attempt to evaluate physio-
therapy interventions on shoulder pain or non-specific
shoulder pathology but with inconsistent findings.
Therefore, it is strongly believed that future reviews
on the effectiveness of physiotherapy should focus on
specific treatment methods and properly defined clin-
ical syndromes; otherwise, the results have limited use
for clinical practice, because without specific diagnoses
there is insufficient guidance for the development of
treatment programmes.
Following the same pattern, Green et al.19 reviewed
common physiotherapy interventions for shoulder
pain. The authors tried to sub group trials into type
 TREATMENT OF IMPINGEMENT SYNDROME OF THE SHOULDER: A SYSTEMATIC REVIEW
of disorder for analysis and the methods sections of
all identified trials were reviewed independently
according to predetermined criteria by two reviewers.
When the two reviewers disagreed, discussion was
facilitated in order to reach consensus; if this failed,
the trial was sent to a third reviewer for arbitration, as
suggested by the Cochrane Collaboration guidelines.
Twelve trials used exercise and/or manual therapy
(mobilisation, manipulation) as therapeutic modali-
ties. Trial populations were generally small, with
many trials underpowered to demonstrate a differ-
ence between groups if one was present; hence, the
results may be biased by Type II error (the failure to
demonstrate a difference which is in truth present, or
false negatives). There was substantial clinical hetero-
geneity with respect to the interventions tested; hence,
few trials could be combined in meta-analysis to
reach an overall conclusion about the effect of physio-
therapy interventions for shoulder disorders. A super-
vised exercise regimen has been demonstrated to be of
significant benefit in both the short and longer term.
Due to differences in outcome scales, and use of a
combination of change scores and final values, results
for pain could not be combined; however, the two tri-
als conducted in participants with rotator cuff disease
both demonstrated a significant difference in reduc-
tion of pain at 3–4 weeks for the exercise plus mobili-
sation group, over the group performing exercise
alone.20,21 The difference between groups with respect
to range of motion, strength and function are based
on only one of the three trials, but demonstrate bene-
fit of adding mobilisation to exercise.
Another published systematic review was con-
ducted by Desmeules et al.6 Studies were included if
they were randomised, controlled trials, related to
impingement syndrome, rotator cuff tendinitis, or
bursitis, and one of the treatments included therapeu-
tic exercise or manual therapy. Two independent
observers reviewed the methodological quality of the
studies using an assessment tool developed by the
Cochrane Musculoskeletal Injuries Group, but this
tool has not been yet formally validated. There was
limited evidence to support the effectiveness of man-
ual therapy and therapeutic exercise to treat the
impingement syndrome. Some of the included stud-
ies: (i) did not clarify the existence of shoulder
impingement syndrome in the sample; (ii) contained a
proportion of patients without impingement syn-
drome; or (iii) used a sample of patients who had
undergone subacromial decompression surgery. More
methodologically sound studies are needed to evalu-
ate further these interventions, since the quality of the
included studies was low to very low. Future trials
need to define shoulder impingement syndrome bet-
ter, and to exclude the main clinical shoulder condi-
127
tions that can be distinguished from it, such as the
‘frozen shoulder’ or neurological conditions. Also,
further validation of outcome measures applied to
patients with shoulder impingement syndrome is nec-
essary. Even though there is no gold standard for
evaluating shoulder disorders such as shoulder
impingement syndrome, the use of validated func-
tional outcomes is necessary to evaluate fully the
patient’s condition and progression. The use of pain,
range of motion, and strength as secondary outcome
measures seems to be acceptable, and their basic con-
struct validity for the evaluation of a musculoskeletal
disorder is acceptable. However, there is a need to val-
idate the qualities of these outcome measures fully.
The most recent systematic review on impingement
syndrome was conducted by Michener et al.7 The pur-
pose of this systematic review was to examine the evi-
dence for rehabilitation strategies for patients with
shoulder impingement syndrome – specifically, the
effectiveness of non-surgical, non-pharmacological
treatment procedures. Two examiners used a quality
checklist developed according to the guidelines of
Sackett et al.22 Agreement between the two examiners
was assessed to determine the presence of a discrepancy
of greater than one quality point on any single quality
checklist item. If a discrepancy existed, the single item
was discussed to reach consensus. Therapeutic exercise
was indicated as an effective intervention for patients
with shoulder impingement syndrome as opposed to no
treatment or placebo treatment. Furthermore, manual
therapy combined with therapeutic exercise appeared to
provide better outcomes than therapeutic exercise
alone, but the evidence was unclear as to the specific
joint mobilisation techniques that may provide benefit.
The authors also investigated the use of acupuncture,
laser therapy and ultrasound, and concluded that the
evidence was limited and that the results of the studies
were conflicting when compared to exercise or manual
therapy. Therefore, it is considered appropriate to con-
duct systematic reviews focused on specific treatment
methods with the aim of developing treatment guide-
lines and the aforementioned combinations would also
be an objective for the present review.
Despite the fact there is a positive physiological
effect of therapeutic exercise and orthopaedic manual
therapy, there is insufficient clinical information on
the effectiveness of these interventions for shoulder
pain and, more specifically, for shoulder impingement
syndrome. These results concur with recent system-
atic reviews on physical rehabilitation interventions
for painful shoulders.6,7,15,17 The reasons for equivocal
results are varied; authors reporting positive findings
have been criticised for not employing proper controls
or for the absence of an appropriate statistical analy-
sis. In contrast, literature producing negative results
128 TRAMPAS AND KITSIOS

has been rebutted by proponents of manual therapy 1. The study was concerned with the effectiveness of
on the basis of improper patient selection or inade- exercise therapy and manual therapy (as defined) and
quate skill on the part of the therapist. in the treatment of impingement syndrome only.
Although the shoulder pain literature is extensive, there
2. Subjects should have been diagnosed with impinge-
is an urgent need to conduct well-designed studies. Special
ment-related pain; studies with shoulder pain as the
attention to the characteristics of the therapeutic applica-
only inclusion criterion that stated a significant
tion is needed in the field of rehabilitation. For example,
number of subjects had shoulder impingement
the types of exercise used, adequate exercise intensity, and
syndrome were included.
progression, need to be clarified according to patient-spe-
cific classification of physical dysfunction, needs and 3. At least one of the treatments was therapeutic exercise
treatment goals.17 The effectiveness of manual therapy is or manual therapy supervised or given by a
influenced by the types of manoeuvres used, the approach physiotherapist.
adopted, years of experience of the therapist, number and
4. Other interventions typical of physiotherapy (thermo-
size of the muscles involved, the patient position used,
therapy, cryotherapy, electrotherapy, massage, trans-
pressure exerted, rhythm and progression, and frequency
verse friction), as well as medical interventions (e.g.
and duration of the treatment sessions.23
arthroscopic subacromial decompression) could have
Due to the wide clinical importance of impingement
been used, but therapeutic exercises and/or manual
syndrome incidence, and the extensive use of manual
therapy had to be identified as the main treatment.
therapy techniques and exercises for its treatment, it
was felt necessary by the authors to conduct a system- 5. Outcome measures included not only pain, strength
atic review on the effects of these interventions on and range of movement (ROM), but also functional
shoulder impingement syndrome. Furthermore, there is tests, functional questionnaires and self-perceived
no systematic review identified in the literature focused change in symptoms. These outcome measures have
specifically on the effectiveness of manual and exercise been evaluated and used in previous studies.20,21,25
therapy over the past 2.5 years. This paper provides an
6. Each article was published in the English language.
update on the review by Desmeules et al.6 in order to
Since the number of journals published in languages
assess whether the quality of the most recent studies has
other than English indexed in electronic databases
improved and, if appropriate, to revise recommenda-
such as MEDLINE and EMBASE is limited, there is
tions on evidence-based practice in this area.
a small possibility that relevant trials might have been
Although RCTs are considered to be the best design
missed.
for control of validity and precision, flaws in their
design and conduct can result in overestimation or 7. Only RCTs in full text were included.
underestimation of treatment effects, and conse-
8. Time limits were included concerning the year of pub-
quently can lead to false positive or false negative
lication: from 2003 up to date, since the last review on
results and conclusions.24 To minimise such problems,
this topic was published in 2003.
this review placed special attention on the quality of
the methods of the selected studies.
Diagnostic criteria
The following diagnostic criteria were identified, which
METHODOLOGY
were relevant to the clinical features of shoulder
impingement syndrome:
The main objectives of this paper were to: (i) deter-
mine if manual therapy and therapeutic exercises are 1. Age: 18–66 years old, working age.
effective approaches for the treatment of the impinge-
2. Symptom duration: more than 1 month.
ment syndrome of the shoulder; (ii) determine the
characteristics of the therapeutic intervention used in 3. Active or passive range of motion: often normal,
the field of rehabilitation (e.g. the types of interven- with the exception of movements that stretch the
tion used, adequate intensity and progression) in posterior glenohumeral capsule, which is
order to address specific protocols; and (iii) investi- sometimes limited.
gate how treatment outcomes.
4. Resisted tests: positive resisted tests of the rotator-
cuff muscles.
Criteria for selecting studies for this review
5. Painful arc: Jobe test26/Speed test.27
Clinical studies were selected for inclusion if they met
6. Impingement test: Lidocaine injection/Neer test.4
the following criteria:
 TREATMENT OF IMPINGEMENT SYNDROME OF THE SHOULDER: A SYSTEMATIC REVIEW
7. Other tests: Yocum test.27
8. Impingement signs: (i) passive overpressure at full
shoulder flexion with scapula stabilised; (ii) passive
internal rotation at 90° flexion; (iii) Neer sign;
(iv) passive abduction 90° and horizontal adduction–
abduction; (v) forced elevation and internal rotation;
and (vi) Kennedy-Hawkins sign.28
9. Other signs: (i) resistant to physiotherapy; (ii) resist-
ant to NSAIDs and steroids; (iii) pain at the
shoulder; (iv) primary impingement syndrome; (v)
limited functional movement patterns; (vi) ‘impinge-
ment pain’; (vii) no or disappointing results of > 6
months of conservative treatment; (viii) shoulder
complaints of any source; (ix) shoulder pain
reproduced by active shoulder movements; (x) pain
at rest for more than 1 year; and (xi) ‘isolated
shoulder disease’.
These diagnostic criteria, as well as the exclusion criteria
below, were selected based on the two most recent
published systematic reviews.6,7 According to the
literature, the most reliable clinical test for impingement
syndrome was found to be the Kennedy-Hawkins test,28
although none of the previous diagnostic methods is
adequately validated to define this pathology.
Criteria for excluding studies from this review
Instability, rotator-cuff tears or rupture, adhesive cap-
sulitis, acromioclavicular joint pathology, cervical
pathology (e.g. herniated disc), radiological/imaging
findings, workmen’s compensation claim were the
main exclusion criteria for this review. Other exclusion
criteria specified were: subjects with shoulder pain with
serious medical problems (e.g. advanced cancer, heart
failure), definable neurological abnormalities (e.g.
peripheral neuropathy, hemiplegia), disorders with bony
lesions (e.g. osteoporosis, fracture), and significant men-
tal disorders (e.g. psychosis, mania, major depression).
Finally, subjects with rheumatic disease or absence of
pain aggravation on active, functional movement tests (i.e.
indicating non-organ symptoms) were also excluded.
Non-randomised, controlled, clinical trials and
controlled before and after studies, studies in abstract
form, articles on technique descriptions, diagnostic
tests, outcome reliability, or other topics that did not
describe manual and exercise therapy of the shoulder
as an intervention were excluded.
Types of intervention
Studies using manual techniques and therapeutic exer-
cises were all included in the review. In the studies, these
129
techniques might be used individually, in tandem, or in
combination with other treatment agents in what is called
multimode care. For example, mobilisation plus exercise
can be used in combination with heat therapy and ultra-
sound. All studies used comparison groups that could be
either a control group (placebo control, active control, or
no-treatment control) or various other treatment groups.
The control interventions were placebo mobilisation,
exercise, other therapeutic interventions, or no treatment.
Studies describing manipulation while the patient
was under anaesthesia, or manual therapies that were
not directed at influencing joint function (e.g. trac-
tion) were excluded, as were studies using interven-
tions in a field other than physiotherapy, except if
therapeutic exercise or manual therapy were one of
the main treatment applications.
Types of outcome measure
As outlined by van der Heijden,15 there is no gold stan-
dard that provides a valid and reliable estimate for clini-
cally relevant changes in patients with shoulder disorders.
For this reason, RCTs were considered as having relevant
outcome measures if they included the following most
important outcomes: pain, strength/endurance, func-
tional loss or disability. Disability was found to be a sig-
nificant outcome for shoulder disorders,29 and so was
used for this systematic review. Physiological outcomes
of physical examination (e.g. range of motion and mus-
cle flexibility), generic health status and other symptoms
such as medication use and side-effects were consid-
ered secondary outcomes. They were also extracted
since their correlation with the clinical status of the
patient is controversial but not poor.30 There were no
restrictions on the type of tool used in the studies to
measure these outcomes, as there were no universally
accepted tools available; however, a number of studies
used validated tools.
Although data on all reported outcomes were
extracted, pain relief and strength were the primary out-
comes commonly available across most of the reports
and these had to be explicitly patient-oriented. Details
of the timing of the outcome assessments as well as data
on side-effects of treatments were recorded.
Methodological quality
The best way of selecting high-quality physical ther-
apy trials for a systematic review has not yet been
determined. Most of the available scales for assessing
the validity of randomised, controlled trials derive a
summary score by adding the scores (with or without
differential weights) for each item. While this
130 TRAMPAS AND KITSIOS

Table 1. Evaluation of the validity of physiotherapy interventions according to the PEDro scale

1 Eligibility criteria were specified

2 Subjects were randomly allocated to groups (in a crossover study, subjects were randomly allocated an order in which
treatments were received)
3 Allocation was concealed
4 The groups were similar at baseline regarding the most important prognostic indicators
5 There was blinding of all subjects
6 There was blinding of all therapists who administered the therapy
7 There was blinding of all assessors who measured at least one key outcome
8 Measures of at least one key outcome were obtained from more than 85% of the subjects initially allocated to groups
9 Subjects for whom outcome measures were available received the treatment or control condition as allocated or,
where this was not the case, data for at least one key outcome were analysed by ‘intention to treat’
10 The results of between-group statistical comparisons are reported for at least one key outcome
11 The study provides both point measures and measures of variability for at least one key outcome

Slightly more detail on some of these items is provided in the PEDro tutorial and can be assessed at
<http://www.pedro.fhs.usyd.edu.au/scale_item.html#scale_2>.

approach offers appealing simplicity, it is not sup-
ported by empirical evidence.31,32 Notably, scales with
multiple items and complex scoring systems take
more time to complete than simple approaches. They
have not been shown to provide more reliable assess-
ments of validity;33 they may carry a greater risk of
confusing the quality of reporting with the validity of
the study; they are more likely to include criteria that
do not directly measure internal validity; and they are
less likely to be transparent to users of the review. For
these reasons, it is preferable to use simple approaches
for assessing validity that can be fully reported (i.e.
how each trial scored on each criterion).
A simple approach to evaluate the validity of phys-
iotherapy interventions is the PEDro scale (Table 1).
The scale is called the PEDro scale because it was ini-
tially developed to rate quality of RCTs on the
Physiotherapy Evidence Database, and is considered
to assess physiotherapy interventions adequately.
Therefore, these criteria are also considered suitable
for this review, because in the assessment of method-
ological quality of intervention research for shoulder
impingement pain, they determine the shortcomings
in the design and reporting of trials that evaluated
common interventions.
The PEDro scale is an 11-item scale designed for rat-
ing methodological quality of RCTs. Each satisfied item
(except for item 1, which, unlike other scale items, per-
tains to external validity) contributes one point to the
total PEDro score (range, 0–10 points). The scale has
been used to rate the quality of over 3000 RCTs in the
PEDro database.34 The scale is based on the Delphi con-
sensus technique. There is evidence for discriminative
validity for three of the scale items – randomisation,35
concealed allocation.32,35 The other items are reported to
have face validity36 but are yet to be validated by other
means. According to Maher et al.37 the reliability of
some PEDro scale items was only ‘fair’ or ‘moderate’,
but can be improved when consensus ratings were used.
Furthermore, the precision of the PEDro scale also
should be considered by users of the PEDro database.
None of the scale items had perfect reliability for the
consensus ratings (consensus ratings are displayed on
the PEDro database); thus, users need to understand
that the PEDro scores contain some error. Although it is
not possible to blind patients to exercise and manual
therapy, the authors chose to award a point to trials
clearly stating that patients were given minimal infor-
mation about the differences between interventions,
and this was the only adjustment made in accordance
with the methods used by Busch et al.,38 who reviewed
exercise training in patients with fibromyalgia.
In order to take a more comprehensive look at the
methodological quality, the trials were categorised
according to the following criteria:
1. High quality trials. At least 6 of the methodological
criteria met plus internal validity of ≥4/7.
2. Moderate quality trials. At least 5 of the method-
ological criteria met plus internal validity of ≥3/7.
3. Low quality trials. Five or less of the methodological
criteria met plus internal validity of < 3/7.
Items 2, 3, 5, 6, 7, 8, 9 assess internal validity; items 1
and 4 assess descriptive validity; items 10 and 11
assess statistical validity. Each trial was assessed
independently by two examiners (AT and AK). If a
discrepancy existed, the single item was discussed to
reach consensus. The researchers were not blinded to
 TREATMENT OF IMPINGEMENT SYNDROME OF THE SHOULDER: A SYSTEMATIC REVIEW 131

Table 2. American College of Sports Medicine guidelines39

MUSCLE STRENGTHENING
Frequency of 2–3 days per week, at least one set of 8–12 repetitions at the 8–12 repetitions maximum of each exercise using any type of
exercise that can be progressed over time performing both the concentric and the eccentric phase of the exercises in a controlled manner

FLEXIBILITY TRAINING
Controlled static stretch held for a given duration, intensity to a position of mild discomfort for 10–30 s; 6-s contraction followed by 10–30 s
assisted stretch for PNF, 3–4 repetitions of each stretch on two (minimum) or more days of the week

the title, authors, or journal title of the trials. If the sion) in order to address specific protocols.
disagreements persisted, a third reviewer (Carol
Shacklady) arbitrated. It is worth noting, that despite
Search strategy
some differences on methodological score, there were no
disagreements between the reviewers on which study was
The search strategy was based on combination of the
of low, moderate or high quality.
major key words: impingement syndrome, rotator
cuff, tendonitis, bursitis, exercise, manual therapy,
mobilisation, randomised controlled trial. Keywords
Quality of treatment protocols
and medical subject headings related to the condition
and potential treatment were identified prior to initi-
According to Philadelphia Panel evidence-based clin-
ating the search. Citation indexing was used to track
ical practice guidelines,17 the investigators were unable
referencing and key authors in the field conference
to make any conclusions regarding the effectiveness
abstracts were reviewed.
of therapeutic exercise for shoulder pain because
Extensive literature searches in texts and via com-
poorly defined inclusion criteria and non-validated
puter databases provided the material for review. The
outcomes were used. Furthermore, there were no
databases chosen were AMED, CINAHL, EMBASE
studies evaluating the effectiveness of manual therapy
and MEDLINE.
for non-specific shoulder pain. In this review, the
Subject headings (MeSH) and key words included
quality of exercise used in trials was assessed using the
anatomical terms, disorder or syndrome terms, treat-
American College of Sports Medicine guidelines39 for
ment terms, and methodological terms consistent
exercise dose (Table 2). This was complicated due to
with those advised by the Cochrane Back Group.
the variety of exercises used and the insufficiently
Specifically the following search-strategies were used
detailed programmes. Therefore, the exercise quality
for MEDLINE, EMBASE, CINAHL and AMED:
for each trial was determined based on the predomi-
nant exercise used. Those fulfilling the American 1. Shoulder Pain/
College of Sports Medicine39 criteria for muscle 2. Shoulder Impingement Syndrome/
strengthening and flexibility were classified as being 3. Rotator Cuff/
‘high quality exercises’. Those not meeting the criteria 4. exp Bursitis/
were ‘low quality exercises’. Exercise quality was con- 5. [(shoulder$ or rotator cuff) adj5 (bursitis
sidered ‘unclear’ if the dose was not mentioned or or frozen or impinge$ or tendinitis or
insufficient information was provided. tendonitis or pain$)].mp.
The quality of stabilisation exercises is not
6. rotator cuff.mp.
accounted for in the American College of Sports
7. or/1–6
Medicine guidelines. For this reason, it was elected to
include those trials using dynamic stabilisation within 8. exp Rehabilitation/
the strengthening category (Table 3). A similar 9. exp Physical Therapy Techniques/
approach to evaluate the quality of exercises for low- 10. exp Musculoskeletal Manipulations/
back pain has been previously reported by Liddle et 11. exp Exercise Movement Techniques/
al.40 Finally, since no guidelines were found in the lit- 12. (rehabilitat$ or physiotherap$ or physical
erature regarding the quality and dose of manual therap$ or manual therap$ or exercis$
therapy, there is an attempt in this review to deter- or mobili$).mp.
mine the characteristics of this therapeutic applica- 13. or/9–12
tion in the field of rehabilitation (e.g. the types of 14. Clinical trial.pt
manoeuvres used, adequate intensity and progres- 15. random$.mp.
132 TRAMPAS AND KITSIOS

Table 3. Treatment programmes for each of the included studies

Study LUDEWIG & BORSTAD (2003)46

Type of intervention (1) Symptomatic subjects with impingement syndrome (intervention group). (2) Symptomatic control
(no treatment). (3) Asymptomatic control (no treatment)
Setting Home exercise programme
Frequency Stretches: 5 repetitions. Exercise protocol: 3 times per week
Intensity Stretches: 30 s. Exercise protocol: 3 SETS of 10 repetitions 1st week, 15 repetitions 2nd week, 20 repetitions
3rd week, then increased resistance
Duration 3 weeks in total
Quality of exercise High quality for both strengthening and stretching exercises

Study HAAHr et al. (2005)45

Type of intervention (1) Control (training) group: Heat, cold packs, soft-tissue treatments and exercises. Exercise protocol: active
training of the periscapular muscles and strengthening of the stabilising muscles of the shoulder joint (the
rotator cuff). This was done within the limits of pain. (2) Surgery group: bursectomy with partial resection of
the antero-inferior part of the acromion and the coracoacromial ligament
Setting Hospital setting and home exercise programme afterwards
Frequency 3 times/week (first 2 weeks), twice/week (next 3 weeks), once/week (last 7 weeks). Then instructed to follow the
programme twice or three times weekly
Intensity Not stated
Duration 19 sessions, 60 min each. 12 weeks in total
Quality of exercise Unclear quality

Study JOHANSSON et al. (2005)49

Type of intervention (1) A group that received acupuncture (n = 44) and (2) a group that received ultrasound (n = 41). Both
interventions were given by physical therapists twice a week for 5 weeks in addition to a home exercise
programme (2-step programme)
Setting Home exercise programme (2 steps): first step, restore motion; second step, strengthen the rotator cuff muscles
Frequency First step: every day (2 exercises). Second step: every other day (6 exercises – 5 isometric, 1 concentric)
Intensity First step: 1 SET of 20 and 30 repetitions, respectively. Second step: 1 SET of 10 repetitions for the
5 stabilising exercises and 2 SETS of 15 repetitions for the concentric strengthening exercise
Duration First step: weeks 1–5. Second step: weeks 4–5
Quality of exercise Low quality exercises

Study CITAKER et al. (2005)47

Type of intervention (1) Hot-packs, manual mobilisation, and Theraband exercises were performed in the mobilisation group
patients and (2) hot-packs, PNF and Theraband exercises were performed in the PNF group
Setting Not stated
Frequency No details given
Intensity No details given
Duration 20-session treatment followed by 3 weeks of Theraband exercises
Quality of exercise Unclear quality

Study WALTHER et al. (2004)48

Type of intervention (1) Standardised self-training: centring and stretching exercises (elastic Theraband). Guidance by a
physiotherapist for a maximum of 4 sessions. (2) Conventional physiotherapy: 10 sessions of physiotherapy
consisting of centring training for the rotator cuff (stretching if necessary). (3) Functional brace: functional
shoulder brace
Setting Standardised self-training: at home. Conventional physiotherapy: in a physiotherapy department
Frequency Standardised self-training: at least 5 times per week, 10–15 min. Conventional physiotherapy: 2–3 times per week
Intensity Standardised self-training: 7 strengthening exercises (the majority of them 1 SET of 10 repetitions) and
1 stretching exercise of the neck (twice for 15 s). Conventional physiotherapy: no details given
Duration 12 weeks
Quality of exercise The quality of the exercises described was high

Each programme was evaluated according to the ACSM guidelines.39 The programmes fulfilling the criteria of the ACSM were scored
as ‘high quality’ exercises in contrast to those not meeting the criteria and characterised as ‘low quality’ exercises. Exercise quality was
considered ‘unclear’ if insufficient information was presented. Manual therapy programmes were used to address specific protocols,
since no guidelines were found in the literature for manual therapy and shoulder disorders.
 TREATMENT OF IMPINGEMENT SYNDROME OF THE SHOULDER: A SYSTEMATIC REVIEW
16. [(single or double) adj (blind$ or
mask$)].mp.
17. placebo$.mp.
18. or/14-17
19. 7 and 13 and 18
A similar search strategy was followed in another
review, according to the principles of the Cochrane
Musculoskeletal Review Group.41 Abstracts from
proceedings and unpublished trials were not included.
Data presentation and analysis
The following data were extracted from each study:
methodological quality assessment, methods of inter-
nal validity, number of patients included in each arm,
causes of impingement, types of intervention, number
of sessions, types of outcome measures, timing of out-
come assessment, the authors’ conclusions about the
effectiveness of the interventions, and the reviewers’
score. Also data on the characteristics of the study
population (such as type, location and duration of
pain, age and gender) and on the manual therapy and
exercise regimen (such as frequency, intensity, dura-
tion and setting) were extracted. The protocol con-
tained a special data extraction form designed by the
authors and based on the guidelines of the Cochrane
Library.42 This form listed the data items to be
extracted from each of the primary studies and was
used to facilitate the comparison process (Table 4).
According to the reviewers, the studies were clini-
cally heterogeneous with respect to the type of the
interventions and the outcomes. Furthermore, the out-
comes were poorly presented in three of the five studies
so that pooling was not possible. In these instances, a
qualitative review was performed where possible (best
evidence synthesis) by attributing various levels of
evidence of the effectiveness of mobilisation and exercise
therapy, taking into account the participants, interven-
tions, outcomes, and methodological quality of the origi-
nal studies.42 In addition, qualitative analysis was carried
out, using the levels of evidence listed below which have
been used in a previous systematic review:43
1. Strong evidence denoted consistent findings in
multiple high quality RCTs.
2. Moderate evidence denoted findings in a single,
high quality RCT or consistent findings in
multiple low-quality trials.
3. Limited evidence indicated a single low-quality RCT.
4. Conflicting evidence denoted inconsistent results
in multiple RCTs.
5. No evidence meant no studies were identified.
133
6, Evidence of adverse effect was used for trials that
showed lasting negative changes.
Sensitivity analysis exploring the results when high
quality was redefined using other thresholds44 was
also performed.
RESULTS
The computerised literature search strategies located
302 citations. Of these, 192 were excluded immedi-
ately from their abstract because they were considered
irrelevant to this review and 105 of the remainder
were also excluded because they did not fulfil the
selection criteria – either they defined manual and
exercise therapy differently from the definition given
in this systematic review, or they did not define the
interventions at all. The mean quality score of the
included trials was 6.2, ranging from 4 to 8 points out
of a total of a possible 10 points (Table 5).
Five randomised, controlled trials were included in this
systematic review; all were published in English. Three of
the studies were undertaken in Europe, one in the US and
one in Asia. One RCT was identified from AMED, one
from CINAHL, two from EMBASE, one from MED-
LINE. One study included subjects from both genders.45
Ludewig and Borstad46 included only males (one female
volunteered but did not meet the clinical inclusion crite-
ria). Construction workers as used in this study are gener-
ally 98% male, and it is uncertain if response to exercises
would be similar in female workers. In the rest of the stud-
ies, gender was not specified and there was no reference to
the male:female ratio.47–49
Only one study investigated the effectiveness of both
manual and exercise therapy,47 one investigated the
effectiveness of exercise to control (placebo) treatment,46
two examined the effectiveness of exercise to other
treatments,45,48 and one investigated the effectiveness of
exercises in combination with other conventional
treatments.49
None of the studies included patients with acute symp-
toms (duration < 3 weeks). One study49 included patients
with subacute symptoms (duration at least 2 months) and
two studies45,46 included patients with chronic symptoms
(5 years of intermittent symptoms and symptoms
between 6 months and 3 years, respectively). In the study
by Citaker et al.47 the duration of symptoms for the
included subjects was not mentioned.
Three studies adequately defined shoulder impinge-
ment syndrome, according to the diagnostic criteria
reported by Desmeules et al.6 and Michener et al.7
Two of these studies had also the best methodological
score,46,49 whilst the third study by Haahr et al.45 was
of moderate methodological quality. The other two
134 TRAMPAS AND KITSIOS

Table 4. Summary data for RCTs evaluated

Study HAAHR et al. (2005)45

Participants Ninety consecutive patients with subacromial impingement agreed to participate. Forty-five cases were randomised to
conservative treatment and 45 to surgical treatment. In the physiotherapy group, 42 persons (93%) were followed for
12 months with the main outcome measure. (Constant-Murley score). In the surgery group, 40 persons (89%) had complete
follow-up data. The two groups were very similar with respect to demographic characteristics, though a slightly
greater proportion within the surgery group had been on sick leave owing to shoulder pain within the past 3 years
Inclusion criteria Diagnostic criteria: the presence of shoulder pain, pain on abduction of the shoulder with painful arch, a positive
impingement sign (Hawkins sign) and a positive impingement test (relief of pain within 15 min after injection of local
anaesthetic [bupivacaine 5 ml] into the subacromial space). Eligibility criteria: fulfilment of all diagnostic criteria,
report of shoulder symptoms between 6 months and three years (because surgery in general was not offered to cases
with symptoms of shorter duration), and aged 18–55 years. Previous treatment with rest, non-steroidal anti-
inflammatory drugs, subacromial injection, and physiotherapy was allowed. Normal passive glenohumeral movement
was a requirement
Exclusion criteria Impaired rotation in the glenohumeral joint, a history of acute trauma, previous surgery or previous fracture in the
proximity of the affected shoulder, known osteoarthritis in the acromioclavicular or glenohumeral joints,
calcifications exceeding 2 cm in the rotator cuff tendons, or signs of a rupture of the cuff or cervical root syndromes
Follow-up periods At baseline and at 3, 6 and 12 months
Outcomes Pain, disability, strength, ROM (Constant-Murley score) – Another set of questions (PRIM) and information on job
title and workplace (measurement tool?)
Authors’ conclusions Surgical treatment of rotator cuff syndrome with subacromial impingement was not superior to physiotherapy
with training. There is a need for larger scale studies with sufficient numbers of participants to allow for stratification
into subgroups with different baseline levels of disability

Study JOHANSSON et al. (2005)49

Participants Eighty-five patients with clinical signs of impingement syndrome. The subjects were recruited from 3 urban primary
health care centres in the county of Ostergotland, Sweden, from March 1997 to June 2000. Aged 30–65 years
Inclusion criteria Typical history: pain located in the proximal lateral aspect of the upper arm (C5 dermatome), especially during arm
elevation; a positive Neer impingement test (subacromial injection of anaesthetic); at least 2 months’ duration of the
current episode; additionally three of the following four inclusion criteria should be positive: (i) Hawkins-Kennedy
impingement sign; (ii) Jobe supraspinatus muscle test (in 90° of abduction in the scapular plane); (iii) Neer
impingement sign; and (iv) painful arc between 60° and 120° of active abduction
Exclusion criteria Radiological findings: malignancy, osteoarthritis of the glenohumeral joint, skeletal abnormalities decreasing the
subacromial space (bony spurs, osteophytes), known or suspected polyarthritis, rheumatoid arthritis, or diagnosed
fibromyalgia. Previous fractures. Dislocation of the glenohumeral joint or the clavicular joints. History or current
clinical findings of instability. Suspicion of frozen shoulder and pain during intra-articular mobilisation. Problems
from the cervical spine. Having received any of the treatment alternatives in the study earlier for the current problem.
Having received a corticosteroid injection during the last 2 months for the current problem. A clinical picture of
ruptured rotator cuff. Acute subacromial bursitis. Communication problems
Follow-up periods Baseline, after treatment and at 3, 6 and 12 months
Outcomes Three disease-specific shoulder assessment scales: the CM Score, the Adolfsson-Lysholm Shoulder Score (AL Score)
and the University of California at Los Angeles End-Result Score (UCLA Score)
Authors’ conclusions The results suggest that acupuncture is more efficacious than ultrasound when applied in addition to home exercises,
but the influence of psychosocial factors is unknown, because no instrument covering this area was used

Study WALTHER et al. (2004)48

Participants Sixty consecutive patients (aged 25–66 years) with painful disabling impingement syndrome of the shoulder (Neer I
and II) were recruited
Inclusion criteria Diagnosis of subacromial impingement was established by clinical examination, radiographs of the shoulder in three
planes, and ultrasound. The Neer test (subacromial injection of 10 ml pure bupivacaine) was positive in all patients
Exclusion criteria Concomitant cervical radiculopathy, frozen shoulder, full-thickness tear of the rotator cuff, disorders of the
acromioclavicular joint, degenerative arthritis of the glenohumeral joint, calcifying tendinitis, shoulder instability,
post-traumatic disorders, and involvement in workers’ compensation claims
Follow-up periods At 6 and 12 weeks after the initial visit
Outcomes Constant-Murley score, which includes pain, activities of daily living, pain-free range of motion, and muscle power.
Also pain intensity was recorded (VAS) and a diary was used to document the frequency of therapy, the frequency
of self-training, and the usage of the brace, as well as the inability to work and additional medication
Authors’ conclusions An analysis of the sub-items of the Constant-Murley score showed that the functional brace led to a significant
improvement in strength compared with groups 1 and 2. All other sub-items did not show any significant difference
among the three groups. Initial concerns that the brace may compromise shoulder mobility did not prove to be true.
A reason might be the effects on neuromuscular mechanisms, such as proprioceptive feedback transmitted by
cutaneous receptors and the reduction in the levels of pain

(continued on next page)

 TREATMENT OF IMPINGEMENT SYNDROME OF THE SHOULDER: A SYSTEMATIC REVIEW 135

Table 4. (continued) Summary data for RCTs evaluated

Study CITAKER et al. (2005)47

Participants Forty patients were equally randomised. Mean age: 52.8 ± 9.86 years, mobilisation group; 55.5 ± 8.55 years, PNF
group. Impingement-related, diagnosed clinically and radiologically documented. None of the patients in the study
underwent surgical procedures, physical treatments or rehabilitation programmes before the study. Patients were not
treated with local steroid injections previously. The patients did not to take oral analgesics during the experimental
period. No further details were stated about the patients, such as demographic characteristics, but it was mentioned
that they were in accordance with those in the literature
Inclusion criteria Not defined
Exclusion criteria Not defined
Follow-up periods Not clarified
Outcomes Pain (Visual Analogue Scale), range of motion (goniometer) and University of California at Los Angeles (UCLA)
criteria, before and after treatment at night and day
Authors’ conclusions Mobilisation and PNF methods are both effective, but mobilisation is a painless technique and, therefore, was better
tolerated than PNF; this was the main difference between the techniques

Study LUDEWIG & BORSTAD (2003)46

Participants Ninety-two patients(all male): intervention (n = 34), control-symptomatic (n = 33), control-asymptomatic groups
(n = 28). Groups had similar demographic variables (age, height, weight, overhead work, years in trade)
Inclusion criteria Occupational exposure to overhead work more than 1 year, minimum of 130° active abduction, referred pain to
C5–C6 dermatome above the deltoid insertion, two positive impingement tests (Neer, Hawkins/Kennedy, Yocum,
Jobe and/or Speeds tests) and two positive out of three additional tests: (i) a painful arc on active scapular plane
abduction of the arm; (ii) tenderness to palpation of the biceps or rotator cuff tendons; and (iii) pain with one or
more resisted glenohumeral joint motions (flexion, abduction, internal rotation, or external rotation)
Exclusion criteria History of rotator cuff surgery. History of glenohumeral dislocation, or other traumatic injury to the shoulder.
Periscapular or cervical pain during arm elevation. Shoulder symptoms by a cervical assessment
Follow-up periods In an average of 10 weeks. Seven subjects were lost to follow-up, four (11.8 %) in the exercise intervention group,
and three control subjects (one symptomatic [3%] and two asymptomatic [8%])
Outcomes Shoulder Rating Questionnaire and 10 modified questions using the format of Shoulder Pain and Disability Index
(all self-reported outcome measures)
Authors’ conclusions A home exercise programme could be effective in reducing symptoms and improving the self-reported functional
status in construction workers. High compliance subjects were also those who showed the most consistent
improvement and increases in repetitions and resistance. Further study assessing more objective measures of the
physiological effects of the exercise intervention would be beneficial since physiological variables are less likely
impacted by possible placebo effects

The table lists the data items to be extracted from each of the primary studies and used to facilitate the comparison process.

studies47,48 used only one and three diagnostic criteria,
respectively (Table 4). In both of these studies, it was
mentioned that the diagnosis of impingement syndrome
was based on radiographs and clinical examination
without stating any further details.
One study46 compared the effectiveness of exercises
with two control groups receiving no treatments (one
symptomatic and one asymptomatic group). The purpose
of this investigation was to compare the results with
healthy subjects from the same population. There was evi-
dence that a home exercise programme can be effective in
reducing symptoms and improving function in this popu-
lation, but subjects in the intervention group did not
obtain similar scores to the asymptomatic group. Subjects
in the intervention group showed significant improve-
ments from pretest to post-test in their functional scores
(Shoulder Rating Questionnaire and Shoulder Pain and
Disability Index), while control subjects remained essen-
tially stable, resulting in an interaction of group and time
(F = 9.12; P < 0.001). Despite this, at post-test, all symp-
tomatic subjects’ average Shoulder Rating Questionnaire
scores remained significantly below those of the asympto-
matic group. In another study by Walther et al.45 the effec-
tiveness of therapeutic exercises versus physiotherapy and
bracing was evaluated. All three groups showed a signifi-
cant improvement in shoulder function and reduction in
pain, with no significant differences among the three
groups. This confirms the effect of muscular strengthen-
ing of the rotator cuff, either by physiotherapy or by
guided self-training. The authors concluded that from the
economic point of view, self-training with supervision to a
maximum of 4 sessions is superior to conventional phys-
iotherapy with about 30 sessions. However, for this to be
successful, competent instruction as well as good compli-
ance by the patient, is mandatory. If this cannot be
secured, conventional physiotherapy should follow the
principles of centring the humeral head.
Another study47 compared mobilisation and
Theraband exercises versus proprioceptive neuromuscu-
lar facilitation (PNF) and Theraband exercises again. In
both groups, subjects were also treated with the applica-
tion of hot packs. The authors sought to evaluate whether
136 TRAMPAS AND KITSIOS

Table 5. The PEDro scoring of the included RCTs.

Study Citaker et al. Haahr et al. Johansson et al. Ludewig & Borstad Walther et al.
(2005)47 (2005)45 (2005)49 (2003)46 (2004)48

1 Yes Yes Yes Yes Yes

2 ? No Yes Yes ?
3 Yes Yes Yes Yes Yes
4 No No No No No
5 No No No No No
6 No No Yes Yes Yes
7 ? Yes Yes Yes Yes
8 ? ? Yes Yes ?
9 Yes Yes Yes Yes Yes
10 Yes Yes Yes Yes Yes
Quality of the trial Low (4/11) Moderate (6/11) High (9/11) High (9/11) Moderate (7/11)

The PEDro scoring of the included RCTs. Item 1(listed in Table 1) is not included, since this item pertains to external validity.
Consequently, item 1 from Table 5 corresponds to item 2 (randomisation) from Table 1, etc.

mobilisation techniques were more effective and clinically
useful than PNF; both were found to be effective, but
mobilisation is a painless technique and, therefore, was
better tolerated than PNF. This was the only difference
between the two groups. The authors came to this conclu-
sion as the decrease in pain complaints was found to be
more significant (after treatment, during night and day, at
rest and after activity) in the mobilisation rather than the
PNF group. However, since no statistically significant dif-
ference between the groups was found with regard to sub-
jective pain intensity when pre- and post-treatment values
were compared.
Haahr et al.45 compared the effects of exercises aimed at
strengthening of the stabilisers and decompressors of the
shoulder (in conjunction with hot packs, cold packs, and
soft tissue treatments of the shoulder) to the effects of sub-
acromial arthroscopic surgery, and found surgery for
rotator cuff syndrome with subacromial impingement
was not superior to physiotherapy. Even though the
authors found better outcome scores in the surgery group,
they were reluctant to recommend surgery in cases with
stage II impingement. There is a need for trials with suffi-
cient numbers of participants to be stratified into sub-
groups before more rigorous definitive recommendations
are made. Johansson et al.49 compared manual acupunc-
ture and continuous ultrasound, both applied in addition
to a home exercise programme. At the first treatment visit,
patients received instructions from the physical therapist
and practiced the exercises in part one of the programme.
They were instructed to perform the programme daily for
5 weeks. After the first half of the treatment period, the
patients received instruction and practiced the second
part of the exercise programme. Compliance with the
exercise programme was monitored by a home exercise
adherence log. The results of this study suggested that
acupuncture is more effective than ultrasound when used
in conjunction with home exercises; for this reason,
acupuncture plus exercises should be advocated over
ultrasound when treating patients with impingement
syndrome.
Outcomes
Pain intensity was the primary outcome in four of the
five studies. One of these studies was of high method-
ological quality,49 two were of moderate quality,45,48
and one was of low quality.47 All used the Visual
Analogue Scale (VAS) as the pain measurement
instrument. In two of the previous studies, pain was
assessed as a separate outcome47,48 as well as part of
functional questionnaires. Citaker et al.47 recorded
pain intensity during the day and night, whether the
patients were active or motionless, as well as before
and after treatment. They reported that there was a
significant reduction in pain intensity in both treat-
ment groups for patients suffering from stage II and
stage III impingement syndrome, but there was no sig-
nificant difference between the groups (pain scores post-
treatment: mobilisation, 1.50 ± 2.30, P < 0.002; PNF
1.85 ± 2.64, P < 0.001). Mobilisation is a painless tech-
nique and the authors concluded that it was better tol-
erated than PNF. This was the only positive finding
with regards to pain intensity measured with VAS,
and it is not supported by the other measures for pain
in the same study. Walther et al.48 compared a home
exercise programme with physiotherapy and bracing.
They investigated pain intensity at rest, at night and
during load, and at 6 and 12 weeks after the initial
visit. All three treatment groups showed a significant
reduction in pain intensity, at night as well as during
rest periods, and while under stress (P < 0.05) during
the study but again there were no statistically signifi-
cant differences between groups at any time.
 TREATMENT OF IMPINGEMENT SYNDROME OF THE SHOULDER: A SYSTEMATIC REVIEW
Furthermore, in the other two studies by Johansson et
al.49 and Haahr et al.45 and in the others described
above, pain was also measured as an outcome as an
integral component of the outcome measurement.
The Constant-Murley questionnaire used in three
studies, two of moderate45,48 and one of high method-
ological quality,49 measures pain intensity on a VAS (as
an item for the questionnaire); these results showed sig-
nificant reduction in the treatment groups, but no dif-
ferences between them. Johansson et al.49 did not
provide sufficient information with regards to pain
intensity, only the mean score from all three question-
naires, reporting that both treatment groups improved
during the study (P < 0.001). Haahr et al.45 presented
the subscores of the different variables measured with
the Constant-Murley questionnaire. The mean
change for pain in both groups ranged from 2.8 to 3.8
(VAS: 0, maximum; 15, no pain), but no statistically
significant differences were found.
Strength was another important outcome used in
these studies as a correlate of pain intensity; in all
cases, strength was not assessed as a separate variable
but measured as a subscore of a questionnaire also
assessing other outcome variables. The University of
California at Los Angeles (UCLA) criteria were used
in a low47 and a high quality study.49 In both studies,
the authors reported that the total UCLA score was
significantly better for the treatment groups, but no
further details were given for the subscore. Haahr et
al.45 used the Constant-Murley score to assess strength
at 3, 6 and 12 months follow-up (P < 0.71, P < 0.88,
P < 0.96, respectively) but changes were not statisti-
cally significant between the two groups. In a moderate
quality study by Walther et al.48 Constant-Murley
scores showed that the group treated with bracing had
significantly better strength gains than the exercise and
the physiotherapy groups at 12 weeks’ follow-up.
The functional status of patients was measured in
all of these studies using a variety of questionnaires as
measurement tools. Results indicated that manual
and exercise therapy were more effective (but not sig-
nificantly) in increasing the functional status of the
patients compared to other treatment modalities. In
four studies, self-perceived changes in symptoms were
measured using different questionnaires as measure-
ment tools. The high quality study by Ludewig and
Borstad46 measured the functional levels of construc-
tion workers using two types of questionnaires with
self-reported measures of pain and disability; the
Shoulder Rating Questionnaire and 10 modified
questions of the Shoulder Pain and Disability Index.
The results showed significant improvements for the
treatment group over the course of treatment, but
scores remained significantly below the asymptomatic
controls at all follow-up periods. The analysis of dif-
137
ferences between the subjects in the intervention and
the symptomatic control groups showed the signifi-
cantly improved Shoulder Rating Questionnaire
scores in the intervention group (F = 7.66; P < 0.01).
Satisfaction scores also showed a significant interac-
tion of group and time with significant improvements
in satisfaction in the intervention group (F = 8.97; P
< 0.001). Similar patterns of responses across groups
were also noted for work-related pain and disability
scores, with significant interactions of group and time
(F = 13.95, P < 0.001; F = 9.16, P < 0.001, respec-
tively). In a second high quality study by Johansson et
al.,49 the authors used the Adolfsson-Lysholm
Shoulder Score with high intra-observer reliability for
impingement syndrome; this scale is purely patient
self-assessment. This trial also used the UCLA crite-
ria (as described above) including both objective and
subjective evaluations (function, satisfaction, pain in
daily activities); the results indicated that both treat-
ments were equally effective in reducing symptoms.
UCLA criteria were also used in a low quality study
by Citaker et al.47 which reported that 95% of ‘good’
results were obtained by performing mobilisation and
65% by performing PNF (P < 0.001). Finally, in a
study with moderate methodological quality,45 the
patients completed a follow-up questionnaire after 1
year of the initial visit; this included a self-assessment
measure of pain and discomfort in daily activities and
in work-related activities and found no group differ-
ences. The scale had been used previously in a Danish
project on research and intervention in monotonous work
(PRIM).50 The Constant-Murley score used in three stud-
ies45,48,49 is a joint measure of four subscores: (i) pain mea-
sured on a visual analogue scale (VAS); (ii) limitations in
activities of daily living; (iii) active range of motion in four
directions in the shoulder joint; and (iv) isometric shoul-
der strength measured in kilograms with a portable
muscle strength analyser. In the study by Haahr et
al.45 the mean improvement in Constant-Murley score
in the physiotherapy group was 23.0 (95% confidence
interval [CI], 16.9–29.1), and in the surgery group the
improvement was 18.8 (95% CI, 11.5–26.1). Two
patients in the physiotherapy group and eight in the
surgery group had a reduction in the Constant-Murley
score. However, there were no differences at any follow-
up point, neither did the results suggest any trends dur-
ing the study period. Johansson et al.49 gave no specific
details on the Constant-Murley score, but Walther et
al.48 found that there was a significant improvement in
the Constant-Murley score within 12 weeks in all three
groups (P < 0.05); however, there were no differences in
improvements between the three groups.
Range of motion as a separate outcome was evalu-
ated only in a low quality study by Citaker et al.47
using a goniometer as a measurement tool. In the
138 TRAMPAS AND KITSIOS
mobilisation group, the changes of ROM values were
highly significant for flexion (P < 0.001) and moderately
significant (P < 0.01) for abduction, external rotation
and internal rotation in stage 2 impingement. In con-
trast, in the PNF group, the changes were highly signifi-
cant for flexion (P < 0.001) and moderately significant
(P < 0.01) for abduction, external rotation, internal rota-
tion and hyperextension in stage 2 impingement. Finally,
in stage 3 impingement flexion, abduction and external
rotation were statistically significant in both groups (P <
0.05). The active range of motion for flexion was also
evaluated in two moderate quality studies.45,48 Both stud-
ies measured ROM as subscore for the Constant-
Murley score, indicating no statistically significant
differences among the groups.
Quality of exercise and manual therapy
Two trials, one of high methodological quality46 and
one of moderate quality48 adequately described the
type of exercises used. Ludewig and Borstad46
reported that a home programme of strengthening
and stretching exercises could be effective in reducing
pain and disability of construction workers. These
authors reported details for setting, frequency, inten-
sity and duration of their programme, and quality
based on the ACSM39 criteria proved to be high. A
high quality of exercise programme was also used by
Walther et al.,48 who concluded that a home exercise
programme (fully described duration, intensity and fre-
quency) could be equally as effective as conventional
physiotherapy and bracing in improving pain and func-
tion. Johansson et al.49 also gave a full description of
their treatment programme, but the quality compared to
the ACSM39 guidelines was considered to be low. Haahr
et al.45 showed one basic limitation in describing their
programmes, since no details were provided with regards
to the intensity of the exercise protocol; thus, the quality
of the exercise programme was unclear. Finally, Citaker
et al.47 had several limitations in presenting the treat-
ment protocols; no details were given for frequency,
quality and intensity of the PNF patterns, and the
Godman pendulum home exercises used in the trial. For
these reasons the quality of the exercises was unclear.
Furthermore, the authors gave no information on the
type of mobilisation manoeuvres used; thus, no conclu-
sions could be extrapolated from this review regarding
the quality of manual therapy.
DISCUSSION
The results of the current review showed that exercise
therapy in combination with other treatments is effective
in reducing pain in patients with impingement syn-
drome. There is no evidence to support the effective-
ness of manual therapy alone for the treatment of
impingement syndrome. However, there is moderate
evidence that supports the use of therapeutic exercises
alone in reducing pain and function. Finally, there is
limited evidence to support the effectiveness of com-
bined manual and exercise therapy for the treatment
of shoulder impingement syndrome. These results are
in keeping with two previous systematic reviews.6,7
However, because the trials investigated were clini-
cally too heterogeneous with regard to patients’ char-
acteristics, control treatments and co-interventions, it
is difficult to determine definitively the effectiveness
of manual and exercise therapy alone in patients with
shoulder impingement syndrome.
There is limited evidence to support the use of exer-
cise and manual therapy to improve strength in
patients with impingement syndrome. None of the
studies evaluated strength as a separate outcome, but
only as part of functional questionnaires. Four stud-
ies, one of high,49 two of moderate,45,48 and one of
low47 methodological quality showed a significant
improvement in several types of questionnaire which
included strength as an item. Only one study of mod-
erate quality by Walther et al.48 presented the sub-
scores of the included variables, and showed no
significantly better results for bracing compared to
exercises with regards to power/strength.
None of the studies evaluated interventions using
subjects with acute impingement syndrome indicating
a need for further research in this area. One study49
used subjects with subacute symptoms and showed
that exercises were not superior to bracing or physio-
therapy. In chronic impingement syndrome, there is
moderate evidence to support the use of exercises
alone, since two studies, one of high46 and one of
moderate45 quality showed that exercises significantly
improved the symptoms compared to no treatment;
however, exercise was not superior to surgery. Haahr
et al.45 reported adverse effects for both exercises and
surgery, indicating some degree of caution may be
required with these treatments.
The use of functional outcomes is necessary to evalu-
ate the patient’s condition and progress fully. The only
functional questionnaire to have been approved by the
executive committee of the European Society for
Surgery of the Shoulder and Elbow51 is the Constant-
Murley score, which has been used in three of the stud-
ies in the current review.45,48,49 The UCLA criteria were
used in two studies.47,49 Although these questionnaires
seemed appropriate, data on their construct, content
and criterion validity are currently lacking. Other self-
perceived changes in symptoms were evaluated by the
Shoulder Rating Questionnaire and 10 modified ques-
 TREATMENT OF IMPINGEMENT SYNDROME OF THE SHOULDER: A SYSTEMATIC REVIEW
tions of the Shoulder Pain and Disability Index.46 The
first of these questionnaires has good reliability but its
validity and responsiveness have not been previously
reported, whilst the modified questions were not vali-
dated at all. Beyond this, the PRIM score used by
Haahr et al.45 and the Adolfsson-Lysholm shoulder
score used by Johansson et al.,49 as secondary measure-
ment tools, did not appear to be sufficiently validated.
Moreover, the strengthening and stretching pro-
gramme studies were too heterogeneous with regards
to intensity, frequency and duration, and no general
recommendations can be made. Two studies, one of
high46 and one of moderate48 quality described
stretching and strengthening programmes based on the
ACSM guidelines,39 whilst the quality of the pro-
grammes used in the rest of the studies was unclear.
Furthermore, it is still not possible to make any recom-
mendations concerning the type of manual therapy
which is effective in treating impingement syndrome of
the shoulder, since the only study including this inter-
vention was of low quality,47 and the manoeuvres used
were not described at all.
Finally, this review confirmed the lack of uniformity in
defining and evaluating the shoulder impingement syn-
drome. Based on these findings, impingement syndrome
typically affects people between the age of 18–65 years,45–49
and the Hawkins sign45,49 and Neer test46,48,49 are the
most widely used diagnostic tests; usually, a painful
arc is observed, and the duration of symptoms, in
most cases, is longer than 2 months.45–48 Future stud-
ies should include more complete details of the clini-
cal examination used resulting in a better-defined
clinical pathology.
Common limitations in the studies reviewed included:
1. Outcome measures demonstrated poor or unmeasured
reliability and/or validity.
2. Many trials had poor design and potential type-2
errors in both data acquisition and analysis.
3. Randomisation procedures were poor or inadequate.
4. The majority of clinical trials do not provide sufficient
details to allow the studies to be replicated.
5. Descisions on the effectiveness of manual therapy and
exercises are confounded by interventions which
include other elements of physical therapy treatment,
such as ultrasound, acupuncture and hot/cold packs.
Sensitivity analysis
After re-scoring positively those validity items, which
had been scored as ‘don’t know’, only one study of
139
moderate methodological quality48 would have been
redesignated as of higher quality. It could be assumed
that Walther et al.48 had adequate allocation conceal-
ment, and that intention-to-treat analysis was used.
The quality of the other studies by Haahr et al.45 and
Citaker et al.47 with criteria scored as ‘don’t know’
would remain the same. The overall conclusions of
this review are, therefore, sensitive to change in favour
of exercise therapy, since there would then be strong
evidence (in contrast of moderate evidence) to sup-
port its effectiveness. Similarly, if only high quality
studies were included in this analysis, the same con-
clusion would have been reached, but there would be
no evidence to support the effectiveness of manual
therapy.
Methodological flaws
Methodological flaws were seen in both high and low
quality trials. The most important was the lack of
blinding of patients.45–49 If participants are aware of
which intervention they are to receive, they may
respond differently according to their own prefer-
ences and expectations. They may have more faith in a
treatment that appears to be active than in one that
appears to be passive. Similarly, if the outcome asses-
sors have a preference for one treatment over another,
and know which subjects have received which treat-
ment, they may consciously or subconsciously over-
rate the improvement in the group receiving the
‘preferred’ treatment. Thus, another important
methodological flaw was the lack of blinded outcome
assessors detected in all studies except the one trial by
Ludewig and Borstad.46 Furthermore, blinding of ther-
apists performing the treatment involves ensuring that
therapists were unable to discriminate whether individ-
ual subjects have or have not received the treatment. In
physiotherapy, however, blinding of the care provider
is not feasible in most cases and for this reason no
specific attention was paid to this methodological
flaw (although obvious in all trials).
The lack of description of drop-outs was another
methodological flaw and it is related to attrition bias.
Two studies47,48 did not mention any drop-outs. Haahr
et al.45 identified drop-outs, but did not clarify
whether these subjects were included in an intention-
to-treat analysis or not. Only two studies stated the
exact number of patients who withdrew, and included
these in an intention-to-treat analysis, although in
each case the results of the study were not affected.46,49
Patients sometimes withdraw from studies because they
have recovered or they follow other interventions dur-
ing the treatment period; others might drop-out
because they deteriorate, or are not satisfied with the
140 TRAMPAS AND KITSIOS
treatment. Given this, it is necessary to report the num-
bers and the reasons for drop-outs in each study group.
Another problem appears to be the randomisation
procedure. Most publications lack information about
the allocation of patients to study groups: only stating
that the patients were divided ‘randomly’, or similar
expressions. Thus, readers have no information on
which to determine the degree of potential bias. For
example, the use of concealed allocation,49 the selec-
tion of a slip of paper indicating group assignment,46
or allocating patients on an alternating basis are sus-
ceptible to (selection) bias. Unfortunately, it is not
known whether this problem is limited to reporting
only, or whether less valid procedures were used.
Finally, power analysis was undertaken in the two stud-
ies of high methodological quality,46,49 whereas in the rest
of the studies it was not mentioned. Moreover, in the
study by Ludewig and Borstad,46 only male workers
were included, and it is not certain if response to
exercise would be similar in female workers.
Additionally, the majority of subjects in the study
experienced chronic, intermittent shoulder symp-
toms, with 3 years as the average time since initial
onset of symptoms. More acute subjects may
respond differently to a similar exercise programme.
CONCLUSIONS
This systematic review identified five studies that
assessed the effectiveness of manual and exercise therapy
in the treatment of shoulder impingement syndrome.
Although there were methodological flaws which pre-
clude strong conclusions, it appears that manual and
exercise therapy may be more effective than other inter-
ventions in the treatment of shoulder impingement syn-
drome, especially in respect of short-term effects. This
finding is based on limited data at this time.
Specifically, analysis of the existing data indicates:
(i) strengthening and stretching exercises are effective
approaches in subacute and chronic shoulder
impingement syndrome patients; (ii) there is no
strong evidence of the effectiveness of manual therapy
in acute, subacute and chronic shoulder impingement
syndrome; and (iii) there is no evidence establishing
the effectiveness of exercises and manual therapy in
acute shoulder impingement syndrome patients. In
addition, further research on the long-term effective-
ness of manual and exercise therapy techniques in
acute, subacute or chronic impingement syndrome of
the shoulder is still warranted.
Multimodal care, including mobilisation and exer-
cises, appears to be beneficial for pain relief and func-
tional improvement, but the evidence is limited.
Moreover, the evidence did not favour manual therapy
alone, or in combination with various other types of
treatment, for pain, function and disability; in con-
trast, exercises were effective in combination with
other treatments, such as ultrasound, acupuncture
and hot/cold packs, for pain and functional status. It
was not possible to determine which type and dosage
of exercise or technique and dosage of manual ther-
apy was more beneficial, or if certain subgroups bene-
fited more from one form of care than another.
Although the Visual Analogue Scale was the pri-
mary measurement tool for pain intensity, the use of
functional outcomes was also necessary to evaluate
fully the patient’s condition and progression. The
Constant-Murley score appeared to be the most
appropriate, and it is the only one to have been
approved by the executive committee of the European
Society for Surgery of the Shoulder and Elbow.51
Despite this, current knowledge on construct, content
and criterion validity is not sufficient.
Implications for research
The emphasis of future randomised, controlled trials
should be on specific therapeutic methods, such as well-
defined therapeutic exercise programmes or a manual
therapy regimen. This would assist in establishing the
effectiveness of these techniques and allow clinicians to
take an evidence-based practice approach when treating
patients.
Most methodological problems such as sample size of
study populations, blinding of assessors, can be improved
with better design, but some appear unavoidable or diffi-
cult to prevent, such as blinding of patients. Thus, the pre-
sent studies do not offer sufficient evidence for strong
conclusions to be drawn. Future research should ade-
quate design and control in all trials.
Future trials need to define shoulder impingement
syndrome better, and further validation of outcome
measures applied to patients suffering from this
pathology is necessary. More studies are needed in
order to evaluate the effectiveness of manual therapy
for shoulder impingement syndrome, since there was
only one report of low methodological quality. It is
also necessary that future trials should compare the
effectiveness of manual and exercise techniques in
shoulder impingement syndrome with other com-
monly accepted treatments for the same condition.
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Available from: <http://www.secec.org>

ATHANASIOS TRAMPAS MSc (for correspondence)

Physiotherapist, 25 Sakelaridi str 54248, Thessaloniki, Greece
Tel: +302310320804; E-mail: glossa2004@yahoo.com

ATHANASIOS KITSIOS PhD

Postgraduate Programme Leader, Department of Physical Education and Sports Science, Aristotelio University of Thessaloniki,
8 Tseliou str 54454, Thessaloniki, Greece
Tel: +302310992244; E-mail: a.kitsios@phed.auth.gr