Effects of Yi Jin Bang Exercise and Usual Exercise Therapy in Adults With Subacromial Pain Syndrome
Condition: Subacromial Pain Syndrome
MeSH terms: Syndrome; Somatoform Disorders
Study type: Interventional

Summary: 
      Shoulder pain is the third most common type of musculoskeletal disorder after back and neck
      pain in primary care. The prevalence of shoulder pain has been reported between 7% and 26% in
      the general population, with a life prevalence of up to 67%. The most common cause of
      shoulder pain is subacromial pain syndrome (SAPS), accounting for 44-60% of all shoulder
      disorders. Pain caused by SAPS can cause functional impairment and heavy social burden.
      Before recommending surgery, exercise therapy should be used as the first choice to treat
      SAPS. Several systematic reviews suggested that supervised exercise therapy can effectively
      improve the function and pain of patients with SAPS, while several other systematic reviews
      illustrated that the equal effectiveness of supervised exercises and home-based exercises.
      Supervised exercise therapy requires substantial and specific resources and may be difficult
      to apply clinically. 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. 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 exercises, 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. 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. However, the efficacy of Yi Jin Bang exercise in SAPS is not
      scientifically evaluated. Therefore, the purpose of the present study is 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.
    

Detailed description: 
      BACKGROUND

      Shoulder pain is one of the most frequent musculoskeletal pain, with the point prevalence has
      been reported between 7% and 26%. The cumulative incidence of shoulder pain in general
      medical practice is estimated to be 29.3 per 1000 patients-years. Shoulder pain can cause
      severe disability and loss of quality of life because it interferes with many activities of
      daily life. There is little information about the costs associated with healthcare use and
      lost productivity in patients with shoulder pain, but it is considered considerable. Among
      the common causes of shoulder pain, SAPS is the most common cause, accounting for 44-60% of
      all shoulder pains. SAPS is characterized by pain and functional restrictions that are
      exacerbated with repetitive arm activities at or above shoulder level.

      The main goals of treatment for patients with SAPS are to reduce pain-related common
      impairments and improve upper limb function. It has been determined that 15-28% of patients
      with SAPS may eventually require surgery. Commonly prescribed conservative treatment for SAPS
      includes corticosteroid injections, non-steroidal anti-inﬂammatory drugs, stretching and
      strengthening exercises, and physical therapy modalities. No evidence is available to
      indicate that the effectiveness of surgery is better than conservative treatment for patients
      with SAPS. A systematic review 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, there revealed 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, with several systematic reviews have
      reported its clinically and statistically effects on pain and function in patients with SAPS.
      It remains unknown whether exercise therapy should be performed with or without supervision.
      Several systematic reviews indicated that supervised exercises are effective in improving
      pain and function in patients with SAPS, while several other systematic reviews concluded
      that home-based unsupervised exercises are as effective as supervised exercises. However,
      supervised training requires substantial and specific resources and may be difficult to apply
      clinically. In addition, the increasing cost of supervised exercise therapy also supports the
      use of home-based self-training protocols.

      The use of complementary and alternative medicine treatment is growing continuously. 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. A study found that six
      months of supervised Qigong training was more effective than no treatment 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, another study indicated that six weeks of
      video-based Qigong training can improve neck-shoulder pain compared with no treatment. In a
      recent meta-analysis, Tai Chi was found effective in the short time for reducing pain and
      disability in patients with arthritis. A meta-analysis 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. 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.

      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

      This study will recruit 18-65 years old adults with symptoms of SAPS. 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.
      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.

      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.

      Statistical analysis

      All values will be reported as mean ± SD. Two-way analysis of variance (ANOVA) with repeated
      measures (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.
    

Intervention name(s): 10-week home-based Yi Jin Bang exercise program; 10-week home-based usual exercise therapy program
Intervention type(s): Behavioral; Behavioral
Intervention description(s): 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.; Among exercise therapy in the treatment of SAPS, stretching and strengthening protocols are often used . 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. This program 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.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: shoulder disorders; rehabilitation; exercise therapy; self-training; mind-body exercise; randomized controlled trial