EVIDENCE-BASED TREATMENT METHODS FOR THE

MANAGEMENT OF SHOULDER IMPINGEMENT SYNDROME

AMONG DUTCH-SPEAKING PHYSIOTHERAPISTS:AN ONLINE, WEB-BASED SURVEY

Filip Struyf, PT, MSc, PhD,a Willem De Hertogh, PhD,b Joris Gulinck, PT, c and Jo Nijs, PhDd

a Doctor-Assistb Assistant Pro

Belgium.c Physiotherap

Belgium.d Associate Pr

Belgium.Submit reques

Artesis UniversityMerksem, Antwe

Paper submitte2012; accepted S

0161-4754/$3Copyright © 2http://dx.doi.o

720

ABSTRACT

Objective: The purpose of this study is to examine whether Dutch-speaking physiotherapists in Belgium report usingevidence-based practice methods for the treatment for patients with shoulder impingement syndrome (SIS).Methods: An online questionnaire, consisting of open-ended and multiple choice questions, was sent to Dutch-speaking members of the representative Belgian physiotherapists society that likely treated patients with shoulder pain.The electronic survey was sent to members of the Belgian Physiotherapists Society (AXXON) (n = 3877). Therapistswere asked to report interventions that they used for the treatment for patients with SIS. Survey responses wereinterpreted using current literature that supports various active treatments for SIS, including supervised exercise, homeexercise, and exercise therapy combined with manual therapy.Results: A total of 119 (3%) of the AXXON members completed the online survey (68 men; mean age, 38 years).Sixty-one percent of the respondents were manual therapists, and 36% were sports physiotherapists. Exercise therapywas the most often reported therapeutic intervention (96.6%). Manual mobilization was most frequently reported forthe treatment of SIS (94.1%), followed by postural training (85.7%) and stretching (76.5%). The remaininginterventions were applied by less than 54% of the responders.Conclusions: The results suggest that exercise therapy and manual therapy were reportedly used by mostphysiotherapists responding to this survey. These practices are in line with current evidence for the treatment of SIS. (JManipulative Physiol Ther 2012;35:720-726)

Key Indexing Terms: Evidence-based practice, shoulder impingement syndrome; Physical therapy

Shoulder impingement syndrome (SIS) is commonlyreferred to as painful arc syndrome, subacromialimpingement syndrome, supraspinatus syndrome,

swimmer's shoulder, or thrower's shoulder.1-5 Impinge-ment syndrome is broadly described as an encroachment ofthe subacromial tissues as a result of the narrowing of thesubacromial space. However, the literature describes bothsubacromial6 and internal impingement.7 Although the

ant, Artesis University College, Antwerp, Belgiumfessor, Artesis University College, Antwerp

ist, Artesis University College, Antwerp

ofessor, Vrije Universiteit Brussel, Brussels

ts for reprints to: Filip Struyf, PT, MSc, PhDCollege Antwerp, Van Aertselaerstraat 31; 2170rp, Belgium (e-mail: Fillip.struyf@vub.ac.be).d February 16, 2012; in revised form August 21eptember 17, 2012.6.00012 by National University of Health Sciencesrg/10.1016/j.jmpt.2012.10.009

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subacromial or external impingement is the mechanicalencroachment of soft tissue (bursa, rotator cuff tendons) inthe subacromial space,6 internal impingement comprisesencroachment of the rotator cuff tendons between thehumeral head and the scapular glenoid rim.7 Shoulderimpingement syndrome is commonly reported in thegeneral population and is a common cause of disability atwork and during daily activities,8,9 which represents amajor socioeconomic problem inWestern society, not in theleast because of its high incidence, prevalence, andrecurrence rates.8-10 After low back pain and neck pain,shoulder pain is the third most common musculoskeletalcomplaint encountered in clinical practice.11 Shoulderimpingement syndrome and rotator cuff tendinitis areconsidered to be the most common cause of shoulder painand disability.12-15 Shoulder impingement syndrome hasbeen reported to have various underlying pathomechanicalmechanisms, including internal impingement, externalimpingement, scapular dyskinesis, rotator cuff dysfunction,decreased muscle length, and impaired motor control of theshoulder region.4,9,16-24 Consequently, this results in a largevariability in applied therapeutic interventions.

721Struyf et alJournal of Manipulative and Physiological TherapeuticsEvidence-Based Physiotherapy in ImpingementVolume 35, Number 9

Sackett et al25 define evidence-based practice (EBP) asthe process of making clinical decisions based on anintegration of the best available evidence with patient valuesand clinical expertise. Several systematic reviews26-28 haveevaluated the effectiveness of physiotherapeutic interven-tions for patients with SIS. To facilitate the use of EBP,researchers have summarized these interventions intoclinical practice guidelines for clinicians. Current EBPguidelines are reported by Kuhn,26 who concluded thatexercise has a statistically and clinically important effect onpain reduction and functioning, but not on range of motionor muscle strength. In addition, from the available evidence,it is concluded that manual physical therapy combined withexercise therapy is better than exercise alone for patientswith SIS.29-31 Exercise therapy can be defined as the use ofactive or assisted exercises aimed at improving range ofmotion, strength, or dynamic neuromuscular control of jointmotion.28 Manual therapy can be defined as the use ofmanually and/or mechanically applied movement tech-niques to improve joint motion.28 However, the exactcontent of the interventions described in the literature isoften unclear. Manual therapy can include a variety oftechniques: joint mobilization and soft tissue mobilization(effleurage, friction, and kneading techniques).26 In addi-tion, other therapeutic interventions with varying effectshave been described in the literature: taping, laser therapy,shockwave, ultrasound, and electrotherapy.32-36

Because of the socioeconomic consequences of SIS, it isimportant that manual therapists engage in the mostefficient and effective management practices available forSIS. The importance of engaging in evidence-basedmethods for SIS becomes evident in light of strict healthinsurance guidelines and the increasingly high cost ofshoulder pain care.

To the best of the authors' knowledge, the scientificliterature does not provide information regarding theimplementation of evidence-based methods for patientswith SIS in physiotherapy practice. Therefore, the aim ofthis study was to examine whether Dutch-speakingphysiotherapists from Belgium report using methods thatare supported by current literature for the treatment ofpatients with SIS.

METHODS

ParticipantsAn online questionnaire in Dutch was developed to

provide insight in the daily practice of physiotherapists,specifically concerning their management of SIS and theimplementation of EBP. A link to this Web site–basedquestionnaire was sent on the 13th of January 2011 to allDutch-speaking members of the Belgian PhysiotherapistsSociety (AXXON) (n = 3877) who had the possibility oftreating patients with shoulder pain. This was achieved by

selecting all manual therapists, sports physiotherapists,neurologic therapists, and geriatric therapists. The northernpart of Belgium, Dutch-speaking Flanders, represents 58%of the population. This link remained active until the 13th ofMarch 2011 (2 months). Information on the content of thequestionnaire was provided before the physiotherapistsinitiated the online survey tool. By clicking the link,respondents provided their informed consent. The studyprotocol was reviewed and approved by the Medical EthicsCommittee of the UZ Brussel University Hospital, BrusselsFree University (Vrije Universiteit Brussel), approved onthe 15th October 2008 (ref: BUN B14320084388).

QuestionnaireThe questionnaire underwent pilot testing in 18

physiotherapists. In this test phase, participants wereasked to report feedback on each question. The followingphysiotherapeutic interventions were included in thequestionnaire: exercise therapy, manual mobilizations,cold and heath therapy, massage therapy, taping, posturaltraining, stretching, ultrasound therapy, laser therapy,electrotherapy, and shockwave therapy. The includedinterventions were based on current EBP for the treatmentof patients with SIS.17 Average time to complete the onlinesurvey was 5 minutes. Data from pilot testing were notincluded in the analysis.

In addition, the questionnaire explained that 2 possibleSIS types exist (internal and external), that they can havedifferent causes, and that many physiotherapeutic in-terventions are possible for the treatment of SIS.Participants were asked to list the physiotherapeuticinterventions that they usually apply in the treatment forpatients with SIS, in spite of the SIS causality. Participantshad to report what they actually “do” in practice, not whatthey “could or would do.”

The questionnaire itself consists of various parts. First,demographic questions were asked, including: sex, age,year of graduation, which university/college they attended,current type of physiotherapeutic work, number ofclinically active years, and location of the physiotherapist'splace of employment. Finally, their self-proclaimed spe-cialties/courses were registered. These questions weremultiple choice based but ended with an open question.This provided the respondents an opportunity to mentionevery possible answer without any restrictions. Allquestions were focused on the treatment for a patientwith SIS.

Second, a list with physiotherapeutic interventions isprovided. Participants were asked if they would apply theproposed physiotherapeutic interventions. They couldanswer “yes,” “no,” or “unknown.” This last option refersto the possibility that physiotherapists might be unfamiliarwith a certain type of intervention. If the answer was “yes,”they were offered a number of specifications, with again the

Table 1. Frequencies of applied therapeutic intervention in SIS

Yes n No n Unknown n

Exercise therapy 96.6% 115 3.4% 4 0.0% 0Mobilizing exercises 85.7% 102 10.1% 12 0.8% 1Concentric exercises 51.3% 61 44.5% 53 0.8% 1Isometric exercises 46.2% 55 45.4% 54 5.0% 6Eccentric exercises 81.5% 97 14.3% 17 0.8% 1Motor control training 80.7% 96 11.8% 14 4.2% 5Rotator cuff exercises 89.1% 106 7.6% 9 0.0% 0Scapular exercises 84.9% 101 10.9% 13 0.8% 1M. Biceps brachiiexercises

42.9% 51 51.3% 61 2.5% 3

Manual mobilizations 94.1% 112 5.0% 6 0.8% 1Glenohumeralmobilizations

87.4% 104 5.9% 7 0.8% 1

Scapulothoracicmobilization

84.0% 100 7.6% 9 2.5% 3

Acromioclavicularmobilization

62.2% 74 28.6% 34 3.4% 4

Cervicothoracicmobilization

73.1% 87 20.2% 24 0.8% 1

Cold therapy 47.1% 56 51.3% 61 1.7% 2Heat therapy 18.5% 22 79.8% 95 1.7% 2Manual muscular

techniques76.5% 91 19.3% 23 4.2% 5

Massage therapy 36.1% 43 39.5% 47 0.8% 1Cross stretching 47.1% 56 23.5% 28 5.9% 7Deep cross friction 52.9% 63 22.7% 27 0.8% 1

Posture focused therapy 85.7% 102 12.6% 15 1.7% 2Tape 49.6% 59 43.7% 52 6.7% 8Classic nonelastic tape 3.4% 4 46.2% 55 49.6% 59Kinesiotape/curetape/easytape

38.7% 46 10.1% 12 0.8% 1

McConnel tape 10.1% 12 28.6% 34 10.9% 13Stretching 76.5% 91 21.8% 26 1.7% 2Physiotechnic applications 53.8% 64 44.5% 53 1.7% 2Ultrasound therapy 47.1% 56 5.9% 7 0.8% 1Pain-focusedelectrotherapy

32.8% 39 21.0% 25 53.8% 64

Muscle stimulatingelectrotherapy

5.0% 6 48.7% 58 53.8% 64

Micro-ampere current 5.9% 7 34.5% 41 13.4% 16High intensity lasertherapy

3.4% 4 42.0% 50 8.4% 10

Low level laser therapy 3.4% 4 43.7% 52 6.7% 8Extracorporealshockwave therapy

11.8% 14 35.3% 42 6.7% 8

Fig 1. Bar chart of the reported therapeutic interventions for SIS

722 Journal of Manipulative and Physiological TherapeuticsStruyf et alNovember/December 2012Evidence-Based Physiotherapy in Impingement

possibility to answer “yes,” “no,” or “unknown.” Multipleanswers were possible (provided answers). The final surveywas created with LimeSurvey (Open Source project byCarsten Schmitz, Germany).

StatisticsAll data of were analyzed with the statistic program

SPSS, version 12.0 for Windows (SPSS, Chicago, IL).Descriptive statistics were used to analyze the frequency ofthe different treatment methods. With the help of crosstabsand χ2 statistics, possible associations between personalcharacteristics of the respondent and their choice for a

.

specific physiotherapeutic intervention were analyzed. P ≤.05 was accepted as statistical significant.

RESULTS

We received a response from 183 therapists. Amongthese, a total number of 119 (68 men) physiotherapistscompleted the survey. The average respondent was 38 yearsof age (SD, 12 years) and was working for 14 years (SD,11.8 years) as a physiotherapist.

Applied Interventions for the Treatment of SISExercise therapy was the most frequently chosen

therapeutic intervention in our sample: 96.6% of respondersindicated that they use exercise therapy for the treatment ofSIS. Within the broad scope of exercise therapy for SIS,rotator cuff training, together with mobilizing exercises andscapular retraining, is the leading strategies. Besidesexercise therapy, manual mobilizations are most oftenused for the treatment of SIS (94.1%). More specifically,glenohumeral and scapular mobilizations are used asmanual mobilization techniques for the treatment forpatients with SIS. The third and fourth most commonlyreported physiotherapeutic interventions for SIS includepostural training (85.7%) and stretching (76.5%) (Table 1).All other possible physiotherapeutic interventions wereapplied by less than 54% of the respondents. Figure 1shows the frequencies of the major therapeutic interven-tions presented in a bar chart. Regarding the appliedphysiotherapeutic interventions for patients with SIS, nosex differences were observed (all P values N .05).

Graduation Year/InstitutionRespondents were categorized in 4 groups of graduation:

1970 to 1979 (13.4%), 1980 to 1989 (22.7%), 1990 to 1999(14.3%), and 2000 to 2010 (49.6%). Results reveal thatthere is no statistically significant difference betweentherapists with the longest clinical experience in compar-

723Struyf et alJournal of Manipulative and Physiological TherapeuticsEvidence-Based Physiotherapy in ImpingementVolume 35, Number 9

ison with other graduation categories. The application ofelectrotherapy was different (P = .01) between the differentgraduation categories. Eighty-one percent of the physio-therapists who graduated between 1970 and 1979 reportedusing electrotherapy for the treatment of SIS, comparedwith 70% in the 1980-to-1989 category, 59% in the 1990-to-1999 category, and finally 39% in the most recentlygraduated respondents' group. When analyzing the datamore thoroughly, it was found that pain-relieving electro-therapy was more often used by senior physiotherapists,which accounted for the difference. No significant differ-ences were found between graduation type (master ofscience vs professional bachelor) or university degree vscollege degree.

Physiotherapeutic SpecializationAnalysis of the respondents' data addressing their

specialization showed that 61% of the respondents weremanual therapists; 36%, sports physiotherapists; 5%,neurologic physiotherapists; 4%, geriatric specialists; 3%,pediatric rehabilitation; and a few (4%) had specialized ininternal medicine or psychiatry. Eight percent reported notto have a specialization. When comparing the data of theapplied therapeutic intervention for SIS between thesespecializations, it was found that manual therapists (95.7%)more often report the use of exercise therapy for thescapular stabilizers than nonmanual therapists (73.7%) (P b.01). There is also a significant difference in the applicationsof manual mobilizations (P b .01) in general betweenmanual therapists and the remaining physiotherapists.Again, manual therapists (98.6%) reported significantlymore often to use manual mobilizations (85.0%).

When comparing sports physiotherapist with all remain-ing physiotherapists (ie, those not specialized in sportsphysiotherapy), it was found that sports physiotherapistsmore often reported to apply glenohumeral mobilizations asa sole manual technique (P = .03). In addition, the sportsphysiotherapists (82.4%) reported significantly more oftento apply deep cross friction techniques (82.4%; P = .03) andelectrotherapy (65.1%; P = .049) that the other specialties(58% and 44.9%, respectively).

Physiotherapists specialized in both manual therapy andsports physiotherapy reported using more electrotherapy(67.9%) than “pure” manual therapists (40.9%) (P = .03).This difference was likely due to the application ofextracorporeal shockwave therapy, which was mainlyused by sports physiotherapists (47.4% vs 11.8% in manualtherapists without sports specialization), with or without amanual therapy degree (P = .02). Manual therapists thatcombine sports physiotherapy also reported significantlymore (P = .04) deep cross frictions (81.8%) in contrast tomanual therapists without the specialization of sportsphysiotherapy (54.5%).

DISCUSSION

The objective of this study was to examine whetherDutch-speaking physiotherapists from Belgium reportusing evidence-based methods for the treatment of patientswith SIS. Based on the results of our respondents, it appearsthat they most frequently use exercise therapy and hands-onmanual therapy skills for the treatment for patients with SIS.All other possible interventions were applied by less than50% of the respondents. Electrotherapy was most oftenused in the physiotherapists who graduated between 1970and 1979. However, this is not in line with EBP.26,27 Thiscould emphasize the need of continuing education.

Several systematic reviews have evaluated the effec-tiveness of physiotherapy in SIS.26,27 The systematicreview of Faber et al27 demonstrated that with regard tothe improvement in functional limitations, there is evidencethat exercise is more effective than no intervention.27 Inaddition, several studies28 emphasized this conclusion byshowing statistically and clinically significant effects ofexercise therapy on pain reduction and functioning inpatients with SIS. The data from this systematic reviewstrongly suggest that supervised exercise, home exerciseprograms, exercise therapy combined with manual therapy,and exercise after subacromial decompressions demonstrateimprovements in pain.26

From all therapeutic options, exercise therapy is the mostfrequently chosen physiotherapeutic intervention for SIS byFlemish physiotherapists, being in linewith current publishedevidence. Within the broad scope of exercise therapy, areasonable amount of divergence in the preferred mode ofexercise is reported. Faber et al27 strongly suggested that thevarious exercise programs available are equally effective.Both the review of Kuhn24 and Faber et al27 reported thatmanual therapy augmented the effects of exercise. Manualtherapy included a variety of techniques: joint mobilizationand soft tissue mobilization (massage, friction, and kneadingtechniques). In line with exercise therapy, most respondingphysiotherapists reported to choose general manual mobili-zations (94.1%), and most of this group would chooseglenohumeral mobilizations (87.4%).

Massage techniques are only mentioned in combinationwith other possible interventions, which makes it difficult toget a clear isolated view on the effectiveness of thistreatment method. According to the present survey, most ofthe physiotherapists (76.5%) would indeed choose massagetechniques. Within these respondents, most (52.9%)reported to choose deep cross frictions; 47.1%, crossstretching; and only 36.1%, classic effleurages. In addition,no consensus exists on the application of cold and heattherapy. Likewise, only a minority reported to apply a coldand/or heat therapy.

The literature suggests that postural deviations such asan increase in the thoracic kyphosis angle are followed by adownwardly rotated, anteriorly tilted, and protracted

724 Journal of Manipulative and Physiological TherapeuticsStruyf et alNovember/December 2012Evidence-Based Physiotherapy in Impingement

scapula, which in turn leads to increased compression inthe subacromial space.4 The results of this survey showthat most of our study sample (85.7%) are aware of thesedeviations and their influence on SIS. In addition, tapeapplication was reported in less than 50% of therespondents. This is in line with the findings that tapingdoes not offer any extra value in terms of pain orfunction.32,37,38

As the application of electrotherapy in SIS showed asignificant difference between the different graduationcategories, one can suggest that there is an evolution fromusing passive strategies toward hands-on treatment com-bined with exercise therapy. This evolution is in line withthe current EBP suggesting that many of these electro-therapy devices are no more effective than placebotreatment.26 There is moderate evidence that ultrasoundtherapy is no more effective than placebo.27 In addition,the use of laser therapy does not offer any additionaladvantage for the treatment of the SIS in comparison withplacebo.27 Most of our sample comply with this: only6.3% of the participants reported using laser therapy for thetreatment of SIS.

Although there is strong evidence that extracorporealshockwave therapy is no more effective than placebo,27

only a minority (n = 14; 11.8%) apply this technique.No scientific evidence has been found for the effective-ness of pain-relieving, muscle-strengthening, or microampere electrotherapy in patients with SIS. However, theresults of this survey showed that up to 32.8% useanalgesic electrotherapy.

Study LimitationsThis study encountered several limitations. The

survey was sent to 3788 physiotherapists, and only183 therapists responded. This corresponds with a lowresponse rate (returned 5%, completed 3%). Variousexplanations for this low response rate can be given.First, not all 3788 members are still clinically active ortreat musculoskeletal disorders such as SIS. In addition,the possibility exists that only the physiotherapists withparticular interest in SIS responded to this survey, thusmay have biased responses thus making them notrepresentative of the entire group. In addition, theonline questionnaire was a part of an open newsletter tothese physiotherapists. This leaves the possibility thatseveral physiotherapists did not read this specific part.Low response rates in surveys among physiotherapistshave previously been noted. A study in whichphysiotherapy performance was compared with theevidence from systematic reviews in patients with kneeosteoarthritis demonstrated a 10% response rate, evenafter a reminder was received.39 Although a financialdiscount of 50% on a shoulder rehabilitation course wasoffered for the responding physiotherapist, our response

rate remained low, and this might be a threat to thevalidity of the data because the therapists that respondedmight have different practice patterns than the studypopulation. Finally, the time to complete was estimatedat 5 minutes (pilot testing), and we did not use remindere-mails or reminder newsletters, which both could haveincreased the response rate.

The responding physiotherapists might be aware of EBP,which could explain the high agreement of the currentapplied practice and EBP. As well, we did not measure theactual treatments used and had to rely on those reported;thus, it may be that those participating in this survey did notpractice in the same way they responded in the survey. Forthis survey, a number of factors may have contributed to thelow number of respondents: insufficient financial supportrequired for repeat and reminder mail-outs. In addition, thissurvey was obtained from one region (Dutch-speaking) ofBelgium; therefore, this may not represent all Belgianphysiotherapists. In addition, the results may not begeneralized to physiotherapists in other countries. Addi-tional survey studies should be performed in other regionsand countries. Because of the multifactorial nature of SIS, anoverview on the therapeutic interventions by the respon-dents only demonstrates a broad view on the treatmentbehavior of the responding physiotherapists. Althoughprevious literature overviews did not categorize interven-tions based on diagnosis, future studies should aim atcategorizing the applied interventions based on the type ofSIS. This would probably lead to greater variability in theresults. Finally, only 3% of the respondents were not sportsphysiotherapist or manual therapist. Although there was asignificant difference between manual therapists, sportsphysiotherapists, and other physiotherapists in appliedintervention, generalization of these results should, there-fore, be done with caution.

For this study, EBP is derived from the availableevidence in systematic reviews. Although the results fromthis survey are promising, much effort is still needed toenhance EBP among the Dutch-speaking physiotherapistsregarding the treatment of SIS. Future study should aim atdeveloping EBP guidelines and test these guidelines tothe existing physiotherapeutic performance in patientswith SIS.

CONCLUSION

Most of those responding to this survey report that theyuse methods for treatment of SIS that are in line with currentevidence in the literature. Flemish physiotherapist, espe-cially those specialized in manual or sports physiotherapy,reportedly implement evidence-based treatments for SIS.However, many respondents reported to use some kind ofelectrotherapeutic application, which is not in line withEBP. Further studies using a bigger target population withlarger response rates are warranted.

Practical Applications

• Most of the physiotherapists who chose to respondto this survey are in line with evidence basedpractice for the treatment of SIS.

• Those who do not specialize in either manual orsports physiotherapy comply less with EBP for thetreatment of SIS than others with these specialties.

725Struyf et alJournal of Manipulative and Physiological TherapeuticsEvidence-Based Physiotherapy in ImpingementVolume 35, Number 9

FUNDING SOURCES AND POTENTIAL CONFLICTS OF INTERESTNo funding sources or conflicts of interest were reported

for this study.

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