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1 non-surgical modalities. Non-surgical treatment is used
Department of General
Practice, Erasmus MC—
University Medical Center
Rotterdam, Rotterdam,
The Netherlands
2
Arthritis Research Campaign
National Primary Care Centre,
Keele University, Keele, UK
3
Department of Rehabilitation
Medicine, Erasmus MC—
University Medical Center
Rotterdam, Rotterdam,
The Netherlands
Correspondence to
Dr Bionka M A Huisstede,
Department of Rehabilitation,
Erasmus MC—University
Medical Center Rotterdam,
Room H-016, PO Box 2040,
Rotterdam 3000 CA,
The Netherlands;
BMA.Huisstede@gmail.com
Accepted 13 October 2013
Published Online First
11 November 2013
To cite: Gebremariam L,
Hay EM, van der Sande R,
et al. Br J Sports Med
2014;48:1202–1208.
Gebremariam L, et al. Br J Sports Med 2014;48:1202–1208. doi:10.1136/bjsports-2012-091802
Subacromial impingement syndrome—effectiveness
of physiotherapy and manual therapy
Lukas Gebremariam,1 Elaine M Hay,2 Renske van der Sande,1 Willem D Rinkel,3
Bart W Koes,1 Bionka M A Huisstede1,3
ABSTRACT
Background The subacromial impingement syndrome
(SIS) includes the rotator cuff syndrome, tendonitis and
bursitis of the shoulder. Treatment includes surgical and
to reduce pain, to decrease the subacromial
inflammation, to heal the compromised rotator cuff and
to restore satisfactory function of the shoulder. To select
the most appropriate non-surgical intervention and to
identify gaps in scientific knowledge, we explored the
effectiveness of the interventions used, concentrating on
the effectiveness of physiotherapy and manual therapy.
Methods The Cochrane Library, PubMed, EMBASE,
PEDro and CINAHL were searched for relevant systematic
reviews and randomised clinical trials (RCTs). Two
reviewers independently extracted data and assessed the
methodological quality. A best-evidence synthesis was
used to summarise the results.
Results Two reviews and 10 RCTs were included. One
RCT studied manual therapy as an add-on therapy to
self-training. All other studies studied the effect of
physiotherapy: effectiveness of exercise therapy,
mobilisation as an add-on therapy to exercises,
ultrasound, laser and pulsed electromagnetic field.
Moderate evidence was found for the effectiveness of
hyperthermia compared to exercise therapy or ultrasound
in the short term. Hyperthermia and exercise therapy
were more effective in comparison to controls or placebo
in the short term (moderate evidence). For the
effectiveness of hyperthermia, no midterm or long-term
results were studied. In the midterm, exercise therapy
gave the best results (moderate evidence) compared to
placebo or controls. For other interventions, conflicting,
limited or no evidence was found.
Conclusions Some physiotherapeutic treatments seem
to be promising (moderate evidence) to treat SIS, but
more research is needed before firm conclusions can be
drawn.
INTRODUCTION
The subacromial impingement syndrome was
included as one of the 23 disorders classified as spe-
cific disorders in the complaints of the arm, neck
and/or shoulder (CANS) model. The CANS model
was developed by 47 experts in the field of upper-
extremity disorders. These experts were delegates
from 11 medical and paramedical professional asso-
ciations. Multidisciplinary agreement was achieved
on the term, definition and classification of CANS.
The model was developed to help professionals clas-
sify patients unambiguously in order to improve
multidisciplinary cooperation and make data of scien-
tific studies better comparable. CANS entities are
common. The disorders are painful, disabling and a
Review
burden on healthcare resources.1 Women are more
affected than men.2 3 In 19% of the patients, the dis-
comforts were chronic.2 Of those with chronic
CANS, 56% reported discomforts of the shoulder. In
general practice, 85% of patients with shoulder pain
were diagnosed with rotator cuff tendinopathy; 74%
showed signs of impingement.4 One of the specific
disorders mentioned in the CANS model is, as afore-
mentioned, the subacromial impingement syndrome.
Within this model, the term ‘subacromial impinge-
ment syndrome’ includes the rotator cuff syndrome
—tendonitis of the m. infraspinatus, m. supraspinatus
and m. subscapularis—and bursitis of the shoulder
area. For this study, we followed this consensus.
Patients with SIS suffer from pain, weakness and loss
of movement of the affected shoulder.5 The occur-
rence of SIS is associated with highly repetitive work,
forceful exertion in work, awkward postures and
high psychosocial job demand.6
Surgical and non-surgical strategies are used to
treat SIS. An article on the effectiveness of postsur-
gical interventions for SIS has already been pub-
lished.7 The goal of non-surgical treatment is to
decrease the subacromial inflammation, reduce the
pain, allow healing of the compromised rotator
cuff and restore satisfactory function of the shoul-
der.8 To help physicians select the most appropriate
non-surgical intervention and to identify gaps in
scientific knowledge, we explored the effectiveness
of these interventions. Articles on the evidence for
effectiveness of extracorporeal shock wave therapy
and medication (oral, injected and patched) have
been published elsewhere.9 10 This article concen-
trates on the effectiveness of physiotherapy and
manual therapy as treatment for SIS.
METHODS
Search strategy
The Cochrane Library, PubMed, EMBASE, PEDro
and CINAHL were searched up to March 2009.
Keywords related to SIS and interventions were
included. Online supplementary appendix 1 shows
the complete search strategy.
Inclusion criteria
Systematic reviews and randomised clinical trials
(RCTs) were included if they fulfilled all of the fol-
lowing criteria: (A) SIS, not caused by an acute
trauma or any systemic disease as described in the
definition of CANS, was studied (B) an intervention
for treating SIS was evaluated, (C) results on pain,
function or recovery were reported and (D) a
follow-up period of ≥2 weeks was reported. There
were no language restrictions.
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Review
After the full-text articles were included, we divided the
included studies into different treatment groups for which separ-
ate reviews could be conducted. One of these groups concerned
physiotherapeutic interventions. In this review, only studies were
included in which physiotherapeutic interventions were com-
pared to placebo, no treatment or another non-surgical
treatment.
Study selection
Two reviewers (BMAH and LG) independently applied the
inclusion criteria to select potentially relevant studies from the
title, abstracts and full-text articles, respectively. A consensus
method was used to solve any disagreements concerning inclu-
sion of studies, and a third reviewer (BWK) was consulted if dis-
agreement persisted.
Categorisation of the relevant literature
Relevant articles are categorised under three headers: Systematic
reviews describes all (Cochrane) reviews; Recent RCTs contains
all RCTs published after the search date of the systematic review
on the same intervention; and Additional RCTs describes all
RCTs concerning an intervention that has not yet been
described in a systematic review.
Data extraction
Two pairs of authors (RvdS/LG and BMAH/WDR) independ-
ently extracted data from the included articles. Information was
collected on the study population, interventions and outcome
measures. A consensus procedure was used to solve any dis-
agreement between the authors. Results were reported in the
short term (≤3 months), midterm (4–6 months) and long term
(>6 months).
Methodological quality assessment
Two reviewers (LG, M S Randsdorp) independently assessed the
methodological quality of each RCT using Furlan’s 12 criteria
(table 1).11 Each item was scored as ‘yes’, ‘no’ or ‘unclear’.
‘High quality’ was defined as a ‘yes’ score of ≥50%. A consen-
sus procedure was used to solve disagreement between the
reviewers.
In a (Cochrane) review, the use of a methodological quality
assessment is a standard procedure. We describe the methodo-
logical quality scale/criteria that were used in the review and
Table 1 Methodological quality assessment: assessing the risk of bias
A 1. Was the method of randomisation adequate?
B 2. Was the treatment allocation concealed?
C Was knowledge of the allocated interventions adequately prevented during
the study?
3. Was the patient blinded to the intervention?
4. Was the care provider blinded to the intervention?
5. Was the outcome assessor blinded to the intervention?
D Were incomplete outcome data adequately addressed?
6. Was the dropout rate described and acceptable?
7. Were all randomised participants analysed in the group to which they
were allocated?
E 8. Are reports of the study free of suggestion of selective outcome reporting?
F Other sources of potential bias:
9.Were the groups similar at baseline regarding the most important
prognostic indicators?
10. Were cointerventions avoided or similar?
11. Was the compliance acceptable in all groups?
12. Was the timing of the outcome assessment similar in all groups?
2 of 8
used the authors’ definitions of high and low quality for the
included studies.
Data synthesis
A quantitative analysis of the studies was not possible due to the
heterogeneity of the outcome measures. Therefore, we sum-
marised the results using best-evidence synthesis.12–14 The
article was included in the best-evidence synthesis only if a com-
parison was made between the groups and the level of signifi-
cance was reported. The results of the study were labelled
‘significant’ if one of the three outcome measures on pain, func-
tion or recovery reported significant results.
The levels of evidence for effectiveness are given in box 1.
RESULTS
Characteristics of the included studies
The initial search resulted in five reviews from the Cochrane
library. Through PubMed 5 reviews and 215 RCTs, through
EMBASE 21 reviews and 193 RCTs, through CINAHL 141
reviews/RCTs and through PEDro 0 reviews and 13 RCTs were
identified. Finally, 2 reviews and 10 RCTs were included.
The first systematic review of Green et al15 included nine
RCTs (n=525) on acupuncture for shoulder pain versus placebo
or other interventions. One of these RCTs compared ultrasound
to acupuncture. The second systematic review of Green et al16
included 26 RCTs exploring physiotherapy versus placebo or
other interventions for various shoulder discomforts; 10 RCTs
(n=575) reported on physiotherapy to treat SIS.
The characteristics of the included studies are listed in online
supplementary appendix 2A–C. A flow chart of the literature
search is found in online supplementary appendix 3.
Methodological quality assessment
The results of the methodological quality assessment are pre-
sented in table 2.
Five (of the 10 included) RCTs were of high quality. The
most prevalent methodological flaws were: (1) care provider not
blinded and (2) unclear whether allocation was concealed.
The RCT included from the review of Green et al15 on acu-
puncture was of high quality. In this review, a methodological
quality list was used consisting of 10 items as presented in the
Cochrane handbook. The other systematic review of Green
et al16 on physiotherapeutic interventions used a methodo-
logical scoring list of 11 items. All 11 RCTs in this review
Box 1 Levels of evidence
Strong evidence: consistent (ie, when ≥75% of the trials report
the same findings) positive (significant) findings within multiple
higher quality randomised clinical trials (RCTs).
Moderate evidence: consistent positive (significant) findings
within multiple lower quality RCTs and/or one high-quality RCT.
Limited evidence for effectiveness: positive (significant) findings
within one low-quality RCT.
Conflicting evidence: provided by conflicting (significant)
findings in the RCTs (<75% of the studies reported consistent
findings)
No evidence: RCT(s) available, but no (significant) differences
between the intervention and control groups were reported.
Gebremariam L, et al. Br J Sports Med 2014;48:1202–1208. doi:10.1136/bjsports-2012-091802
Gebremariam L, et al. Br J Sports Med 2014;48:1202–1208. doi:10.1136/bjsports-2012-091802

Table 2 Methodological quality scores of the included recent and additional randomised clinical trials (RCTs)
Incomplete Free of Timing of
outcome Incomplete suggestions of Compliance the
Blinding? data outcome selective Similarity of Cointerventions acceptable outcome
Adequate Allocation Blinding? Blinding? Outcome addressed? data? ITT outcome baseline avoided or in all assessment Maximum Score Per
Reference randomisation? concealment? Patients? Caregiver? assessors? Dropouts? analysis? reporting? characteristics? similar? groups? similar? score study cent

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Giombini et al17 + + − − + + + + ? + + + 12 9 75
Johansson et al18 + ? − − + + + + + + + + 12 9 75
Aktas et al19 + + + − + + − + + ? ? + 12 8 67
Dickens et al20 + ? − − + + + + ? + ? + 12 7 58
Lombardi et al21 + ? − − + + + + ? − ? + 12 6 50
Senbursa et al22 ? ? − − − + + + + ? + + 12 6 50
Walther et al23 ? ? − − ? + ? + + + ? + 12 5 42
Werner et al24 ? ? − − ? + + + − ? + + 12 5 42
Sauders25 + ? ? − + ? ? + + ? ? + 12 5 42
Cheng and Hung26 ? ? − − ? + − + + ? ? + 12 4 33
Methodological quality scores of Green et al16*
Random Concealed Blind Blind Blind Adequate Between-group Intention-to-treat Baseline Specification of Availability of point Score Score Per
allocation? allocation? participants? therapists? assessors? follow-up? comparisons? analysis? comparability? eligibility criteria? estimates and measures of maximum study cent
variability of primary
outcome measures?
Nykanen27 + − + + + + + − + + + 11 9 82
Saunders28 + ? + + + − + + + + + 11 9 82
Vecchio et al29 + − + + + + + − + + + 11 9 82
Berry et al30 + − − − + + + − + + + 11 7 64
Conroy and Hayes31 + − − − + + + − + + + 11 7 64
Dal Conte et al32 + − + + − + + − + + − 11 7 64
Bang and Deyle + − − − − + + − + + + 11 6 55
et al33
Brox et al34 + − − − + − + + + − + 11 6 55
Perron and + − − − + + + − + − + 11 6 55
Malouin35
Methodological quality scores of Green et al 200515†
Random Concealed Blind Blind Blind Adequate Between-group Intention-to-treat Baseline Specification of Availability of point Score Score Per
allocation? allocation? subjects? therapists? assessors? follow−up? comparisons? analysis? comparability? eligibility criteria? estimates and measures of maximum study cent
variability of primary
outcome measures?
Berry30 + − − n.p. + + + − + + + 10 7 70
*Based on the PEDro scale (specifically designed and validated for the assessment of validity for trials of physiotherapy interventions) http://ptwww.cchs.usyd.edu.au/pedro/.
†Based on the Cochrane Reviewer’s Handbook (Alderson et al36).
+, Yes; −, no; ?, unclear/unsure.
ITT, intention-to-treat.

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scored ≥50% on the quality assessment and were classified as
high quality.
Effectiveness of physiotherapeutic interventions for SIS
The evidence for effectiveness of the various physiotherapeutic
interventions for SIS is reported in table 3.
EFFECTIVENESS OF EXERCISE
Exercise versus placebo
Systematic review
One high-quality RCT34 (n=80) compared exercise (ie, super-
vised low-resistance exercises) to placebo laser as treatments for
SIS. After 2.5 years, all pain scores found no significant differ-
ences between the two groups. At 6 months, ‘good or excellent
function’ was found to be significantly better in favour of exer-
cise (relative risk (RR) 2.45 (95% CI 1.24 to 4.86)).
There is moderate evidence in favour of the effectiveness of
exercise versus placebo laser in the midterm and no evidence in
the long term.
Table 3 Evidence for the effectiveness of physiotherapy and
manual therapy for subacromial impingement syndrome
*In favour of.
+, limited evidence found; ++, moderate evidence found; +++, strong evidence
found; ±, conflicting evidence for effectiveness; CWH, clinic-based work hardening;
FU, follow-up; NE, no evidence found for effectiveness of the treatment: RCT(s)
available, but no differences between the intervention and control groups were
found; SR, systematic review; RCT, randomized clinical trial; WWH, workplace-based
work hardening.
4 of 8
Exercise versus control
Recent RCTs
One high-quality trial37 investigated the effectiveness of indivi-
dualised physiotherapy plus a home exercise programme (tissue
and joint mobilisation, exercise, postural advice, strapping and
very occasionally electrotherapy) versus controls (waiting for
shoulder surgery; n=84) to treat SIS. At 6 months of follow-up,
the mean improvement on the Constant score was better for the
treatment group, but no statistical comparison was made
between the groups. Significantly more patients in the control
group required surgery versus the physiotherapy group
(p=0.0008).
Another high-quality study21 compared physiotherapy ( pro-
gressive muscle training programme, twice a week for 8 weeks)
to controls in patients with SIS (n=60), with both groups
being on a surgery waiting list. At 2 months of follow-up, the
study group showed significantly better improvement versus
the controls for ‘pain at rest’, ‘pain during movement’, DASH
(Disability of Arm, Shoulder and Hand) 2 score and DASH 3
score ( p=0.001, 0.001, 0.007 and 0.013, respectively). The
physiotherapy group used significantly fewer analgesics and
non-steroidal anti-inflammatory drugs versus the controls
( p<0.041 and p<0.01, respectively). The range of movement
measurements showed significantly better improvement in the
physiotherapy group versus the controls for abduction and
extension ( p=0.001 and p=0.032, respectively), but there
were no significant differences on flexion, medial and lateral
rotations.
There is moderate evidence for the effectiveness of exercises
versus controls for SIS in the short term and midterm.
Exercise versus treatment with a hyperthermia machine
Recent RCT
A high-quality study17 (n=25) compared exercise ( pendular
swinging and stretching, twice a day (5 min) to treatment with
a hyperthermia machine (heat application, 434 MHz, one
session (30 min) 3 times/week for 4 weeks). At 6 weeks, signifi-
cantly better results were found in favour of the hyperthermia
group on the pain scores ( p=0.04) and the Constant score
( p=0.03).
There is moderate evidence that hyperthermia is more effect-
ive than exercise in the short term.
Exercise versus shoulder brace
Recent RCT
One low-quality recent RCT23 (n=40) compared conventional
physiotherapy (stretching, centring (exercises to centre the
humeral head), strengthening, 10 sessions) to a functional shoul-
der brace for SIS. There were no significant differences between
the groups on the pain scores and the Constant score at
12 weeks of follow-up.
There is no evidence for the effectiveness of exercise versus
shoulder brace in the short term.
Exercise versus ultrasound
Recent RCT
A high-quality study17 (n=23) compared exercise (ie, pendular
swinging plus stretching) to ultrasound (1 MHz, 2 w/cm², three
times a week) for supraspinatus tendinopathy. No significant dif-
ferences between the groups were found on pain and the
Constant score at 6 weeks of follow-up.
We found no evidence for the effectiveness of exercise versus
ultrasound in the short term.
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Review

Exercise versus physiotherapy There is limited evidence for the effectiveness of manual
Recent RCT therapy plus self-training versus self-training alone in the short
Two low-quality recent RCTs compared self-training (ie, exer- term.
cises using an elastic band) with formally supervised physiother-
apy for SIS.
EFFECTIVENESS OF ULTRASOUND
In the first study24 (n=40), physiotherapy consisted of
Ultrasound versus placebo
strengthening exercises for the rotator cuff. At 12 weeks of
Systematic review
follow-up, significant differences were found on the Constant
Two RCTs comparing ultrasound to placebo were included in
score within the groups. No significant differences were found
the review of Green et al.16 One high-quality RCT30 (n=24)
between the groups.
found no significant differences between both groups on pain at
In the second study23 (n=40), physiotherapy consisted of stretch-
4 weeks of follow-up, range of abduction at 2 weeks or recovery
ing, centring and strengthening exercises. At 12 weeks of follow-up,
(or substantial improvement) in the short term.
no significant results were found between the two groups for ‘rest
Another high-quality study27 (n=72) found no significant differ-
pain’, ‘pain at night’, ‘pain at load’ or the Constant score.
ences between the groups on pain, range of abduction (unknown
There is no evidence for the effectiveness of self-training
follow-up) or function at 4 or 12 months of follow-up.
versus physiotherapy in the short term.
We found no evidence for the effectiveness of ultrasound
versus placebo in the short term, midterm and long term.
Workplace-based hardening versus clinical-based hardening
Additional RCT
Ultrasound versus hyperthermia
A low-quality study26 (n=103) compared workplace-based work
Recent RCT
hardening (WWH, ie, biomechanics and ergonomic education
A high-quality RCT17 (n=26) compared ultrasound (US
plus shoulder stretch, scapular control exercise and shoulder
(1 MHz 2 W/cm2, 1 session (15 min) 3 times/week for 4 weeks))
strengthening exercise) with clinic-based work hardening
to treatment with a hyperthermia machine (heat application,
(CWH, ie, conventional training) for rotator cuff tendinitis. At
434 MHz, 1 session (30 min) 3 times/week for 4 weeks).
4 weeks of follow-up, significant changes in favour of WWH
Significant differences between the groups were found in
between the groups were found on shoulder flexion ( p=0.015)
favour of the hyperthermia group on the pain scores (p=0.045)
and on the Shoulder Pain and Disability Index score ( p=0.034).
and the Constant score ( p=0.04).
There is limited evidence that WWH is more effective than
There is moderate evidence that ultrasound is less effective
CWH in the short term.
than hyperthermia in the short term.

EFFECTIVENESS OF MOBILISATION
Mobilisation as add-on therapy to exercise
Systematic review
One high-quality RCT33 (n=49) compared mobilisation as an
add-on therapy to exercise (flexibility and strength training) for
SIS. After 3 weeks, significant differences were found on pain in
favour of the exercise plus mobilisation group (weighted mean dif-
ference (WMD) −186.23 (95% CI −319.33 to −53.13)) and on
the composite strength score (WMD 173.67 (95% CI 64.79 to
282.55)). A significant difference was found on function in favour
of the exercise group (WMD 4.96 (95% CI 1.30 to 8.62)).
Another high-quality RCT31 (n=14) compared mobilisation
as an add-on therapy to exercise (ie, hot packs, active ROM,
stretching, strengthening, soft tissue mobilisation and educa-
tion). At 3 weeks of follow-up, the group that received mobilisa-
tion as an add-on therapy showed significantly better results on
pain (WMD −32.07 (95% CI −58.04 to −6.10)). No significant
differences were found on the range of abduction, elevation,
internal or external rotation.
There is conflicting evidence for the effectiveness of mobilisa-
tion as an add-on therapy to exercise versus exercise alone in the
short term.
EFFECTIVENESS OF MANUAL THERAPY
Manual therapy as an add-on therapy to self-training
Recent RCT
One recent high-quality RCT22 (n=30) compared self-training
(ie, active ROM, stretching, strengthening exercise programme)
with and without manual therapy (ie, joint and soft tissue
mobilisation, techniques, ice applications) for SIS. At 12 weeks
of follow-up, significant results on pain (no p value given) in
favour of the manual group were found.
Ultrasound plus ionthophoresis with acetic acid versus
placebo
Systematic review
One high-quality RCT35 (n=22) compared ultrasound plus
ionthophoresis to placebo for calcific tendinitis. No significant
differences between the groups were found on improvement in
abduction after treatment (follow-up time not given) or on
improvement in change in calcium deposit after treatment.
There is no evidence for the effectiveness of ultrasound plus
ionthophoresis versus placebo.
Ultrasound versus corticosteroid injection
Systematic review
One high-quality study30 (n=24) compared ultrasound to a
steroid injection (40 mg methylprednisolone plus 2 mL 2% lig-
nocaine using the anterior approach into the shoulder joint) for
rotator cuff problems. No significant differences were found
between both groups on pain or range of abduction at 2 weeks
of follow-up, and for treatment success (success or failure of the
treatment at the end of 4 weeks, defined as a need for a steroid
injection).
There is no evidence for the effectiveness of ultrasound
versus steroid injections in the short term (4 weeks).
Ultrasound versus acupuncture
Systematic review
One high-quality RCT30 (n=24) compared ultrasound (10 min,
8 sessions) to acupuncture (once a week with moxibustion) for
rotator cuff lesions. There were no significant differences
between the two treatments for postintervention pain, range of
abduction and success rate in the short term.

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Recent RCTs
A high-quality study18 (n=85) compared ultrasound (twice a
week for 5 weeks, 10 treatment sessions of 10 min, mode:
1 MHz, 1 W/cm2) to acupuncture (needle placement at 4 local
points, 10 sessions, in addition to home exercises for both
groups) for SIS. There were no significant differences between
the groups measured by a combined score, which included the
University of California—Los Angeles Shoulder Rating Scale,
the Adolfsson-Lysholm Shoulder Score and the Constant score
at 3, 6 and 12 months of follow-up.
There is no evidence for the effectiveness of ultrasound
versus acupuncture (both in addition to home exercises) in the
short term, midterm and long term.
EFFECTIVENESS OF LASER THERAPY
Laser versus placebo
Systematic review
Two RCTs compared laser therapy to placebo.
A high-quality RCT28 (n=24) found significant improvement
(defined as excellent or good results) in the placebo group
versus the laser group (27 sessions, 9×3 min) at 3 weeks of
follow-up in the treatment of supraspinatus tendinitis.
In another high-quality RCT29 (n=35), no significant differ-
ences in the treatment of rotator cuff tendinitis were found
between the groups (laser, 830 nm: 10 min 2 times/week for
8 weeks versus placebo) on pain scores or ‘range of movement’
at 8 weeks of follow-up.
There is conflicting evidence for laser therapy versus placebo
in the short term.
Laser versus ultrasound
Recent RCT
One low-quality study25 (n=24) studied low-power (30 J/cm2)
laser therapy versus ultrasound (1.5 W/cm2, pulsed 1:4) versus
controls for supraspinatus tendonitis. At 3 weeks of follow-up, a
significant reduction in favour of laser versus ultrasound or
versus controls was found on pain (90% vs 58% vs 50%,
respectively; p<0.01) and improvement of muscle force (no
exact data given: p<0.01). For disability, significant differences
were found in favour of laser versus controls, but not between
the other treatments (no exact data were given).
There is limited evidence for the effectiveness of low-power
laser therapy versus ultrasound or versus controls for supraspi-
natus tendinosis in the short term.
EFFECTIVENESS OF PULSED ELECTROMAGNETIC FIELD
(PEMF)
PEMF versus placebo
Systematic review
A high-quality study32 (n=60) compared pulsed electromagnetic
field (PEMF) with sham PEMF for SIS. Significant differences
between the groups were reported on ‘no pain at the end of
treatment’ (6 days) in favour of the PEMF group (RR 19.00
(95% CI 1.16 to 312.42)) and after 4–6 weeks post-treatment
(RR 39.00 (95% CI 2.46 to 617.81)).
Recent RCT
Another high-quality trial19 (n=46) compared PEMF with sham
PEMF, both in combination with non-surgical treatment (ie,
Codman’s pendulum exercises, exercises, cold pack and meloxi-
cam) in patients with SIS. On rest pain, the Constant scores and
the Shoulder Disability Questionnaire, no significant differences
between the groups were found at 3 weeks of follow-up.
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There is conflicting evidence for the effectiveness of PEMF
versus placebo in the short term.
DISCUSSION
SIS is a common and challenging health problem for patients
and healthcare providers. The present review provided data on
the evidence for the effectiveness of manual therapy and several
physiotherapeutic interventions for SIS.
Exercise therapy
Moderate evidence was found in favour of patients who
received exercise therapy when compared with patients on a
surgical waiting list in the short term and midterm, and also
when compared with patients who had placebo laser in the
midterm. Unfortunately, because of the lack of detailed descrip-
tion of baseline characteristics and exercise protocols used (eg,
intensity, duration, frequency and load), the current evidence is
not fully validated and difficult to interpret in relation to use in
clinical practice.
In the trial of Giombini et al,17 more benefit was found (mod-
erate evidence) in favour of the effectiveness of hyperthermia
treatment versus exercise to treat supraspinatus tendinopathy in
the short term. Because these results were yielded by one small
study (n=37) that included only athletes, the results must be
interpreted with caution. Athletes may have a higher pain
threshold. The blinding of patients may be an issue in this RCT,
regarding the special group athletes are. It may be useful to
study the effect of hyperthermia in a more general population
suffering from SIS.
Ultrasound and laser therapy
For ultrasound and laser therapy, we found conflicting levels
of evidence: conflicting evidence was found for the effective-
ness of ultrasound therapy versus placebo in the short term,
and no evidence in the midterm and long term. Furthermore,
conflicting evidence was found for laser therapy versus
placebo. In contrast to these findings, limited evidence was
found in favour of laser versus ultrasound in the short term.
No evidence was found for ultrasound versus acupuncture in
addition to home exercises in the short term, midterm and
long term. However, more research is needed before a firm
conclusion can be drawn. Future trials should concentrate on
results not only in the short term but also in the midterm and
long term.
The present review has some limitations. First, there is a
lack of an unambiguous definition for SIS. Therefore, we used
a wide-ranging search strategy, although it is based on the
description of the SIS definition in the CANS model.
Although SIS can be defined as a symptomatic irritation of
the rotator cuff and subacromial bursa in the limited subacro-
mial space, the diagnostic criteria and aetiology of SIS remain
debatable. We used the criteria of Furlan et al11 to assess the
methodological quality of the recent and additional RCTs.
The Furlan criteria are recommended by the Cochrane Back
Review Group (CBRG) and are used widely in systematic
reviews of musculoskeletal disorders.7 9 38–40 The methodo-
logical quality assessment of the RCTs included in the reviews
and our methodological quality assessment of the recent and
additional RCTs differ greatly, for example, we defined a
study as ‘high quality’ when the study scored ≥50% on the
quality assessment. There is empirical evidence from a meth-
odological study conducted with data from the CBRG that a
compliance threshold of less than 50% of the criteria is asso-
ciated with bias.41 Therefore, we also used a cut-off point of
 Downloaded from http://bjsm.bmj.com/ on March 9, 2018 - Published by group.bmj.com
50%. However, in the Cochrane reviews, no clear definition
is given as to whether the study is considered to be of high or
low quality. Even though the advised threshold for methodo-
logical quality was chosen arbitrarily, a threshold of, for
example, 40% would have minimally altered the conclusions
of this review: only one study25 would be upgraded to high
quality. When 60% is taken as a cut-off point, the conclusions
would weaken on exercise therapy20 21 34 and manual therapy
plus self-training.22 A risk of bias can be introduced by categor-
ising some of the studies as high-quality studies. Second, a study
with a small sample size (ie, n=14)31 can be underpowered in
numbers but categorised as high-quality studies.17 30 31 Another
weakness of some included studies33 42 is the wide range of CIs
reported, although a significant difference is found. Outcome
measures may not be that strong and might even have no clin-
ical significance. The dosage, frequency and methods of the
therapies differ between studies when compared with each
other. Therefore, the results must be viewed with caution.
Despite this, we decided to include these smaller studies, in
order to make this review more complete and to provide the
next step for future, larger studies. We used a best-evidence
synthesis as data synthesis. Although classification on the levels
of evidence is arbitrary, conducting a best-evidence synthesis is
often used throughout the literature.13 14 43
CONCLUSION
In conclusion, only one RCT on manual therapy was included
in this review. Limited evidence for the effectiveness of
manual therapy as an add-on therapy to self-training was
found. All other studies included in this review concentrated
on physiotherapy. Conflicting levels of evidence were found
for the effectiveness of laser therapy and ultrasound. For
mobilisation as an add-on therapy to exercises, conflicting
evidence for effectiveness was found for the short term.
Further, although we found the best results for hyperthermia
compared to exercise therapy or ultrasound in the short
term (moderate evidence), hyperthermia and exercise therapy
were found to be more effective in comparison to controls or
placebo in the short term (moderate evidence). For the effect-
iveness of hyperthermia, no midterm or long-term results
were studied. In the midterm, exercise therapy gave the
best results (moderate evidence) compared to placebo or con-
trols, whereas for the long term no evidence was found.
However, because of the lack of a detailed description of the
exercise protocols used, the current evidence is difficult to
interpret in relation to use in clinical practice. Therefore,
future RCTs studying exercise therapy should also concen-
trate on the (long-term) effect of different exercise protocols,
including the intensity, duration, frequency and load of the
exercises.
What is known about the subject?
Different non-surgical interventions to treat the
subacromial impingement syndrome (SIS), ranging from oral
medication and physiotherapy to corticosteroid injections or
extracorporeal shock wave therapy, are applied in clinical
practice.
Gebremariam L, et al. Br J Sports Med 2014;48:1202–1208. doi:10.1136/bjsports-2012-091802
Review
What this study adds to existing knowledge?
▸ This study provides an evidence-based overview of the
effectiveness of physiotherapeutic interventions and manual
therapy to treat SIS.
▸ Moderate evidence was found for the effectiveness of
hyperthermia compared to exercise therapy or ultrasound in
the short term. Hyperthermia and exercise therapy were
more effective in comparison to controls or placebo in the
short term (moderate evidence).
▸ In the midterm, exercise therapy gave the best results
(moderate evidence) compared to placebo or controls. For
other interventions, conflicting, limited or no evidence was
found.
▸ In future RCTs, more detailed descriptions of the exercise
protocols used are needed in order to interpret the results in
relation to the use in clinical practice.
Acknowledgements We thank M S Randsdorp for her participation in the quality
assessment.
Contributors LG was involved in the literature search, data collection, data
interpretation, methodological quality assessment and writing of the article. EMH
and BWK contributed to the data interpretation and critical revision of the article for
important intellectual content. RvdS and WDR were involved in the data
interpretation and writing of the article. BMAH was involved in the literature search,
data collection, data interpretation and critical revision of the article for important
intellectual content, as well as approval of the version to be published. All authors
discussed the results and commented on the manuscript.
Funding This research was funded by Fonds Nuts Ohra.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
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Subacromial impingement syndrome−−

effectiveness of physiotherapy and manual
therapy
Lukas Gebremariam, Elaine M Hay, Renske van der Sande, Willem D
Rinkel, Bart W Koes and Bionka M A Huisstede

Br J Sports Med2014 48: 1202-1208 originally published online

November 11, 2013
doi: 10.1136/bjsports-2012-091802

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http://bjsm.bmj.com/content/48/16/1202

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Supplementary Supplementary material can be found at:

Material http://bjsm.bmj.com/content/suppl/2013/11/11/bjsports-2012-091802.
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Topic Articles on similar topics can be found in the following collections

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Physiotherapy (245)
Degenerative joint disease (239)
Musculoskeletal syndromes (431)

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