Yi Jin Bang Exercise Versus Usual Exercise Therapy for the Treatment of Subacromial Pain Syndrome: a Pilot Randomized Controlled Trial
Phase: NA
Conditions: Subacromial Pain Syndrome
Sponsor: Chinese University of Hong Kong

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The Effects of Yi Jin Bang Exercise on Shoulder 
Health of Adults 
 
Date: 12/19/2021 
 
 
 
 
 
 
 
 
 
 
 

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1. Project Objectives and Long-term Significance  
Shoulder pain is the third most common type of musculoskeletal disorder after back and neck 
pain in primary care (Van Der Heijden, 1999; Steuri et al., 2017). The prevalence of shoulder 
pain has been reported between 7% and 26% in the general population, with a life prevalence 
of up to 67% (Luime et al., 2004). The most common cause of shoulder pain is subacromial 
pain syndrome (SAPS), accounting for 44-60% of all shoulder disorders (Van Der Windt et al., 
1995). Pain caused by SAPS can cause functional impairment and heavy social burden 
(Littlewood et al., 2012). Before recommending surgery, exercise therapy should be used as 
the first choice to treat SAPS (Kromer et al., 2009; Diercks et al., 2014; Haik et al., 2016). 
Several systematic reviews suggested that supervised exercise therapy can effectively 
improve the function and pain of patients with SAPS (Haik et al., 2008; Kuhn, 2009), while 
several other systematic reviews illustrated that the equal effectiveness of supervised 
exercises and home-based exercises (Desmeules et al., 2003; Kromer et al., 2009). Supervised 
exercise therapy requires substantial and specific resources and may be difficult to apply 
clinically (Karlsson et al., 2014). Thus, a home-based self-training program may allow 
individuals to treat SAPS with affordable and easily accessible treatments.        
    
The use of complementary and alternative medicine treatment is growing continuously (Su & 
Li, 2011). Yi Jin Bang is a form of mind-body exercise and was developed in Hong Kong in 
the 1950s based on the principle of traditional Chinese mind-body exercise “Yi Jin Jing”. In 
Chinese, Yi means change, Jin means tendons and sinews, while Bang means stick. As with 
all other Chinese medical exercise, the focus of Yi Jin Bang is on the cultivation of Qi 
(energy), which is assumed to harmonize mind and body and so might reduce pain (Von Trott 
et al., 2009). After reorganizing by physiotherapists, Yi Jin Bang has now become an 
easy-to-learn exercise program. Many scientific studies have demonstrated the effectiveness 
of mind-body exercises on pain, such as yoga, Tai Chi, and Qigong (Rendant et al., 2011; 
Cramer et al., 2013; Hall et al., 2017). However, the efficacy of Yi Jin Bang exercise in SAPS 

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is not scientifically evaluated. 
 
Objectives 
To compare the effectiveness of ten weeks of home-based Yi Jin Bang exercise, versus 
home-based stretching and strengthening exercise, and versus waitlist control on pain, 
disability, flexibility, and muscular endurance in adults with SAPS. This study hypothesized 
that home-based Yi Jin Bang exercise and home-based stretching and strengthening exercise 
have similar effects in reducing pain and disability and improving flexibility and muscular 
endurance for individuals with SAPS. 
 
Long Term Impact 
The presence of pain in the shoulder can lead to limits on work and/or recreational and 
domestic activity, thus bring a heavy burden of disease to both the individual and society (Van 
Den Dolder et al., 2014). Among people with shoulder pain, SAPS has the highest prevalence 
(Van Der Windt et al., 1995). Although the effectives of non-surgical supervised exercise 
therapy on SAPS has been demonstrated (Haik et al., 2008; Kuhn, 2009), people begin to 
support the use of self-training as the cost of supervised exercise therapy increasing (Werner 
et al., 2002). As an easy-to-learn exercise, Yi Jin Bang exercise may be more economic and 
more flexible in space compared to supervised exercise protocols. Our empirical evidence 
accumulated from the feedbacks of Yi Jin Bang practitioners found the positive effect in 
treating SAPS, however, scientific evidence has yet to be confirmed from randomized 
controlled trial studies. If proven, Yi Jin Bang exercise can be recommended to patients and 
physiotherapists, as a low-cost, flexible and easy to learn exercise in the treatment of SAPS. 
In a long run, medical cost can be reduced, family economic burden can be lower, and the 
quality of life of people can be improved.    
 
2. Background of Research  

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Work done by others 
Shoulder pain is one of the most frequent musculoskeletal pain, with the point prevalence has 
been reported between 7% and 26% (Luime et al., 2004). The cumulative incidence of 
shoulder pain in general medical practice is estimated to be 29.3 per 1000 patients-years 
(Greving et al., 2012). Shoulder pain can cause severe disability and loss of quality of life 
because it interferes with many activities of daily life (Ginn & Cohen, 2005). There is little 
information about the costs associated with healthcare use and lost productivity in patients 
with shoulder pain, but it is considered considerable (Kuijpers et al., 2006). Among the 
common causes of shoulder pain, SAPS is the most common cause, accounting for 44-60% of 
all shoulder pains (Van Der Windt et al., 1995). SAPS is characterized by pain and functional 
restrictions that are exacerbated with repetitive arm activities at or above shoulder level (Haik 
et al., 2016).  
 
The main goals of treatment for patients with SAPS are to reduce pain-related common 
impairments and improve upper limb function (Steuri et al., 2017). It has been determined that 
15-28% of patients with SAPS may eventually require surgery (Bang & deyle, 2000). 
Commonly prescribed conservative treatment for SAPS includes corticosteroid injections, 
non-steroidal anti-inﬂammatory drugs, stretching and strengthening exercises, and physical 
therapy modalities (Senbursa et al., 2007). No evidence is available to indicate that the 
effectiveness of surgery is better than conservative treatment for patients with SAPS 
(Kvalvaag et al., 2017). A systematic review by Haik et al. (2016) suggested that exercise 
therapy aimed at restoring flexibility and strength of scapular muscles and the rotator cuff 
should be recommended to the first-line treatment for patients with SAPS before undergoing 
surgical treatment. Besides, this systematic review indicated that low-level laser therapy, 
pulsed electromagnetic ﬁeld and tape are ineffective in treating SAPS. In another 
meta-analytical study which investigated the effectiveness of conservative treatment for pain, 
function, and range of motion (ROM) in adults with SAPS (Steuri et al., 2017), there revealed 

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that exercise therapy should be considered for all adults with SAPS, and the addition of 
manual therapy, tape, laser and extracorporeal shockwave therapy might have a little benefit. 
In addition, the meta-analysis reported that nonsteroidal anti-inflammatory drugs or 
corticosteroid injection can be a useful alternative only when exercise therapy is not possible.  
 
Exercise therapy is considered to be the most valuable method for treating shoulder disorders 
and is the cornerstone of physical therapy treatment (Van Der Heijden, 1999), with several 
systematic reviews have reported its clinically and statistically effects on pain and function in 
patients with SAPS (Kromer et al., 2009; Kuhn, 2009; Haik et al., 2016). It remains unknown 
whether exercise therapy should be performed with or without supervision (Van Den Dolder 
et al., 2014). Several systematic reviews indicated that supervised exercises are effective in 
improving pain and function in patients with SAPS (Kuhn, 2009; Abdulla et al., 2015; Haik et 
al., 2016), while several other systematic reviews concluded that home-based unsupervised 
exercises are as effective as supervised exercises (Desmeules et al., 2003; Kromer et al., 
2009). However, supervised training requires substantial and specific resources and may be 
difficult to apply clinically (Karlsson et al., 2014). In addition, the increasing cost of 
supervised exercise therapy also supports the use of home-based self-training protocols 
(Werner et al., 2002). 
 
The use of complementary and alternative medicine treatment is growing continuously (Su & 
Li, 2011). Yi Jin Bang exercise is a stretching exercise that is beneficial to the mind and body. 
It was created in the 1950s in Hong Kong, according to the principle of traditional Chinese 
mind-body exercise Yi Jin Jing. In Chinese, Yi means change, Jin means tendons and sinews, 
while Bang means stick. Although there is no scientific research evaluating the effects of Yi 
Jin Bang exercise on pain, there are many scientific studies that have examined the effects of 
other mind-body exercises (e.g., Qigong, Tai Chi, yoga) on pain. Rendant et al. (2011) 
reported that six months of supervised Qigong training was more effective than no treatment 

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on pain in patients with chronic shoulder pain, and improvements in the Qigong group were 
comparable with those in the supervised exercise therapy group. Besides, Skoglund et al. 
(2011) indicated that six weeks of video-based Qigong training can improve neck-shoulder 
pain compared with no treatment. In a recent meta-analysis by Hall et al. (2017), Tai Chi was 
found effective in the short time for reducing pain and disability in patients with arthritis. A 
meta-analysis by Cramer et al. (2013) evaluated the effectiveness of yoga on low back pain, 
which found strong and moderate evidence for short-term effects and long-term effects of 
yoga in the treatment of low back pain, respectively. Moreover, a randomized controlled trial 
found that nine weeks of supervised yoga training was effective in treating chronic neck pain 
(Michalsen et al., 2012). Up to date, no studies have evaluated the effectiveness of Yi Jin 
Bang on the treatment of SAPS. Therefore, the purpose of this study is to evaluate the effects 
of Yi Jin Bang exercise on adults with SAPS in terms of pain, disability, flexibility, and 
muscular endurance. 
  
3. Research Plan and Methodology 
This will be a three-arm parallel-group randomized controlled trial with blinded outcome 
assessors. The trial comprises ten weeks of intervention. Participants will be randomly 
assigned into one of the following three groups: Yi Jin Bang group (group 1), usual exercise 
therapy group (group 2), or waitlist control group (group 3). The Yi Jin Bang group will 
practice an active, low-intensity home-based Yi Jin Bang exercise routine. The exercise 
therapy group will do a home-based stretching and strengthening training program. 
Participants in the waitlist control group will remain on a waiting list and will be provided 
either Yi Jin Bang training or usual exercise therapy after ten weeks. Pain, disability, 
flexibility, and muscular endurance will be evaluated before treatment, after the first treatment 
session, and after ten weeks in all three groups. 
 
Participants 

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This study will recruit 18-65 years old adults with symptoms of SAPS. Participants will be 
eligible if they meet all the following criteria: (1) aged 18 to 65 years old; (2) pain during 
overhead activities; (3) pain during active movements of the shoulder; (4) pain in the last 
three months; (5) Hawkins-Kennedy impingement test positive; (6) painful arc test positive; 
(7) infraspinatus muscle test positive. Participants will be excluded if they exhibited any of 
following criteria: (1) a history of fracture-dislocation of the shoulder; (2) full-thickness 
rotator cuff tear; (3) a history of shoulder surgery; (4) inflammatory of the vertebrae; (5) 
shoulder trauma in the last month; (6) any physical treatment for shoulder pain in the past 
month. Eligibility will be determined by two licensed physiotherapists through performing the 
clinical examination prior to entry into the study. Participants in this study will be recruited 
through mass email. Before the study, participants will be provided with consent forms, and 
then sign them. They will also be told that they can withdraw from the study at any time. 
Ethical approval for conducting research will be sought from the ethics committee. 
 
In terms of sample size, the effect size of the ROM exercise on the Shoulder Pain and 
Disability Index (SPDI) score found in a previous randomized control trial is adopted (Heron 
et al., 2017). Therefore, based on the estimation of sample size by G*Power (effect size: 0.5; 
α: 0.05; power: 0.80), a sample size of 14 individuals per group will be needed. Considering a 
20% drop rate, we estimated that 18 participants per group will be needed.  
 
Procedures 
Participants will be randomly assigned to one of the following three groups: Yi Jin Bang, 
usual exercise therapy, or control group. Two experimental groups will do home-based Yi Jin 
Bang exercise and home-based exercise therapy for ten weeks, respectively. The control 
group will receive no treatment during the period of ten weeks. In addition, during the 
intervention, participants should not take any other physical therapy, exercise therapy, or 
medication on the shoulder. 

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Yi Jin Bang Group 
Each participant in this group will do a home-based Yi Jin Bang exercise program four times a 
week for ten consecutive weeks, which consists of ten minutes of warm-up, 18 minutes of Yi 
Jin Bang exercise (ten exercises), and ten minutes of cool-down. To learn how to conduct the 
home-based exercise session, each participant will be invited to one introductory session 
before starting the prescribed exercise program. Two experienced Yi Jin Bang instructors will 
lead the introductory session. Besides, in order to monitor participants’ adherence and help 
them to conduct self-training, we will use the Zoom Meeting application. Zoom can capture 
and record participants’ movements through the webcam. During the introduction sessions, 
we will teach participants how to use Zoom. Furthermore, we will provide support for 
adherence to the home exercise sessions through telephone calls or e-mail every two weeks. 
 
Usual Exercise Therapy Group 
Among exercise therapy in the treatment of SAPS, stretching and strengthening protocols are 
often used (Ludewig & Borstad, 2003). Therefore, participants in this group will do a 
standardized home-based stretching and strengthening exercise program four times per week 
for ten weeks, which is set up according to a previous study (McClure et al., 2004). This 
self-training program includes four stretching and seven strengthening exercises, which has 
been demonstrated that can be effective in reducing pain and improving function in patients 
with SAPS. For strengthening exercises, elastic bands will be used. To learn how to conduct 
the self-training program, each participant in this group will also be invited to one 
introductory session before starting the prescribed exercise training. Two certificated 
physiotherapists will lead the introductory session. In addition, a video demonstration clip 
will be given to each participant to provide a home reference, and the Zoom Meeting 
application will be used to help monitor the exercise. We will also provide support for 
adherence to the home self-training program through telephone calls or e-mail every two 

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weeks. 
 
Waitlist Control Group 
Participants in the waitlist control group will be informed that they will receive either Yi Jin 
Bang training or exercise therapy after ten weeks have passed. This will be done only for 
motivational reasons and not for evaluation. 
 
Outcome Measures 
All assessments will be performed at baseline, after the first treatment session, and after ten 
weeks of intervention, except the disability test only performed at baseline and after ten 
weeks. Onsite assessments will include the completion of study questionnaires, flexibility 
tests, and muscular endurance tests. A research staff member will present at each collect point 
to assist participants to complete the self-report questionnaire. Because of the nature of the 
treatment, it will be rarely impossible to blind participants, Yi Jin Bang instructors, and 
physiotherapists. However, assessors will be blinded to group assignments when collecting 
outcome measures.  
 
Functional Disability 
Functional disability will be measured using the SPADI. This is a self-reported questionnaire 
assessing pain and functional status, which consists of five questions regarding pain and eight 
questions regarding disability. Each question is scored from 0 to 10, and the total score ranges 
from 0 to 100. Greater scores represent higher levels of pain and disability. The SPADI has 
provided good psychometric with the test-retest reliability has been reported range from 0.84 
to 0.91 (Roy et al., 2009). 
 
Pain Intensity 
Pain intensity will be measured on an 11 points numerical rating scale (Huskisson et al., 1976). 

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Participants will be asked to place a vertical mark on a horizontal line to indicate their current 
pain degree in rest and activity, where 0 for no pain and 10 for unbearable pain. 
 
Flexibility 
According to the method described by Norkin & White (2016), active flexion and abduction 
ROMs will be measured while the participant in standing position by a standard goniometer. 
The maximum ROM of three repetitions in each movement will be used for analyzing. 
Besides, back scratch test will measure participants’ ROM by measuring the distance between 
the middle fingertip of the upper hand and the middle fingertip of the lower hand. 
 
Muscular Endurance 
Muscular endurance will be measured using elastic bands. During the test, the participant will 
in standing position, with the test shoulder off the table and the arm perpendicular to the floor. 
The participant will be instructed to horizontally abduct his/her arm to 90 degrees at a 
cadence of 30 beats per minute. Repetitions will be performed until the participant is fatigued, 
indicated by one of the following conditions: the inability to hold the arm at the top of the arc 
for the required duration (1 second), compensation with elevation of entire upper torso, or 
verbal report of the inability to continue. 
 
Statistical Analysis 
All values will be reported as mean ± SD. Two-way analysis of variance (ANOVA) with 
repeated measure (2 times × 3 groups) will be used to analyze differences at baseline and at 
ten-week post-intervention. Differences between the change within each group will be 
examined by one-way ANOVA. Post hoc tests will be used when necessary, to verify the 
pair-wise differences between means. The α level of p < 0.05 will be considered statistically 
significant for all comparisons. All statistical procedures will be performed by SPSS software. 
 

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