Exercise Into Pain in Subacromial Shoulder Pain

Exercise Into Pain in Subacromial Shoulder Pain: a Randomized Controlled Trial

The aim of the randomized clinical trial is to investigate if "exercising into pain" gives better results in term of clinical outcomes compared to a non-painful exercise program.

Exercise therapy is the first choice of treatment in the treatment of subacromial shoulder pain (SSP). Guidelines suggest exercise therapy for at least three months and research underlines the importance of progressive loaded exercise therapy at high dosage. However, it is not clear which is the best type of exercise and if pain should be provoked or avoided during exercise. Recent research found that painful exercises are beneficial in short term on pain and function in patients with different kinds of chronic musculoskeletal pain. The aim is to investigate if one painful exercise can give better and faster results in the management of SSP than non-painful program.

Inclusion Criteria:

• shoulder pain for at least 3 months, elicited in the anterolateral shoulder region
• at least 3 out of 5 of the following tests positive: Neer test, Hawkins-Kennedy, Jobe, painful arc, external resistance test
• resting pain should be at 2/10 maximum on verbal numerical pain rating scale (NPRS)

Exclusion Criteria:

• bilateral shoulder pain
• corticosteroid injections 6 weeks prior to the study
• pregnancy, inability to understand spoken or written Dutch
• clinical signs of full-thickness rotator cuff tears (positive external and internal rotation lag tests and drop arm test)
• evidence of adhesive capsulitis
• previous cervical, thoracic or shoulder surgery; recent fractures or dislocations on the painful shoulder
• primary complaint of spinal pain or signs of central nervous system involvement or signs of cervical nerve root involvement; reproduction of shoulder pain with cervical rotation or axial compression
• primary diagnosis of acromioclavicular pathology, shoulder instability
• a radiologically confirmed fracture or previous medical imaging confirming the presence of calcification larger than 5 mm
• presence of competing pathologies (inflammatory arthritis, neurological disorders, fibromyalgia, malignancy, psychiatric illness, osteoporosis, hemophilia, rheumatic polymyalgia)
• more than 4h of training in sport overhead shoulder activities per week