Comparison of SEP Exercises Versus SSMP With Tendon Loading & Resistance Exercise in Shoulder Pain.
Condition: Subacromial Pain Syndrome
MeSH terms: Shoulder Pain
Study type: Interventional

Summary: 
      Shoulder pain is one of the most prevalent and disabling musculoskeletal condition. A new
      diagnostic terminology used to describe shoulder pain is rotator cuff-related shoulder pain
      (RCRSP), as histological findings were similar in many of shoulder condition such as;
      subacromial impingement syndrome, subacromial pain syndrome and rotator cuff tendinopathy The
      objectives was to find the effectiveness of single exercise into pain program versus Shoulder
      Symptom Modification Procedure (SSMP) with early tendon loading, Heavy Slow Resistance
      exercise in patients with rotator cuff-related shoulder pain.

      The investigators will conducted a randomized clinical trail in out patient physiotherapy
      department at Thumbay hospitals Ajman, in patients with rotator cuff-related shoulder pain .
      After meeting the inclusion criteria, participants were randomized into Single exercises into
      pain program (SEP) (intervention group) or Shoulder Symptom Modification Procedure (SSMP)
      with early tendon loading, Heavy Slow Resistance exercise program (control group).

      A 13 weeks of outpatient musculoskeletal rehabilitation sessions consisting of 3 sessions per
      week will provided to both the groups. Intervention group will receive single exercises into
      pain by preforming resisted isometric shoulder abduction with TheraBand and progressed to
      functional rehabilitation, whereas control group will receive a combination of shoulder
      symptom modification to control the pain, early tendon loading to target the series elastic
      component of the muscle and heavy slow resistance program to target contractile component of
      the muscles and improve mechanical strength followed by functional rehabilitation.

      The investigators will measured Shoulder Pain and Disability Index (SPADI), Numerical Pain
      Rating Scales (NPRS), and Digital Wall (D-WALL) H-Sport Quality Of Life at the baseline
      assessment, 6th weeks and 13th weeks
    

Detailed description: 
      The Shoulder Symptom Modification Procedure (SSMP) is a series of mechanical techniques that
      are applied while the patient performs the activity or movement, with the aim of identifying
      a mechanical change that will alleviate and treat the symptoms and improve range of motion.
      This process involves identifying the movement, posture, or activity that reduces the
      patient's symptoms. SSMP is designed to identify a positive effect on symptoms by providing
      changes in position of the glenohumeral or scapulothoracic joints or thoracic spine. Besides,
      SSMP perhaps impact the symptoms related with RCRSP by altering rotator cuff muscle-tendon
      tension, changing the anatomical structure, and releasing the neuromodulation. Using Shoulder
      Symptom Modification Procedure (SSMP) can inspect the effect of thoracic spine posture,
      scapula posture in three different anatomical planes, and position of humeral head on
      shoulder joint symptoms. Moreover, it provides immediate direction for selecting one or more
      methods among the four mechanical techniques for treating RCRSP. The main goal of SSMP to
      treat, decrease symptoms and/or improving function and movement.

      Heavy slow resistance (HSR) training program includes repetitive gradual and slow contraction
      of the muscle during concentric, isometric and eccentric phases against a heavy weight, i.e.,
      1RM. In previous studies it was proven that the HSR training program used for a plantar
      fasciopathy was found to have superior results than stretching. Demonstrating Heavy Slow
      Resistance in eccentric form will target the contractile component of the muscles and improve
      mechanical strength. Besides HSR training is an alternative from traditional exercise
      physiotherapy, by emphasizing on heavy weights and slow reptation. Without sufficient power
      the muscle and tendons will have poor strength and endurance. A suggestion of static, sustain
      load with 5 reptation and 45 second hold, repeated 2-3 times per week will provide a
      beneficial outcome. Only one recent study showed a 15% increase in abduction due to adding
      heavy load eccentric training for individuals with unilateral subacromial impingement.

      Administration of early controlled and progressive tendon loading (EPTL) in rehabilitation
      practice is suggested to show a high and definite impact on healing and recovery of the
      tendon. In addition, there are various benefits related to EPTL, new evidence showed it help
      accelerates healing, alleviate joint restriction, and reduce the risk of re-tearing.
      Moreover, it has been stated that load exercises for mid-tendon or at the insertion sites of
      the Achilles tendon provide a better clinical outcome in any parts of the tendon. Besides,
      preforming isometrics in mid-range can reduce the pain in tendinopathy rehab progression.

      Furthermore, single exercises into pain (SEP) program is considered to be harmless, valid and
      has a valuable prescription as initial rehabilitation program. A recent study discussed the
      tendinopathy in lower limbs showed an immediate analgesic relief and increase in muscle
      strength after preforming single heavy-load isometric training program. Pain can be better
      used for navigate the symptom management to foster recovery. A "Traffic Light Pain Control
      graph" where a score of 3 out of 10 pain level is a good area to practice the exercise. In
      addition, a score of 4 out of 10 isn't harmful or can cause any damage. Although pain level
      should be tolerable and isn't increasing the next day. Additionally in Reactive
      tendinopathy/early tendon disrepair level, the load management helps the matrix of the tendon
      to resume a more normal structure. However, the clinical effectiveness of SEP on shoulder
      conditions is still sparce.

      Daily functional rehabilitation (FR) is needed for the individual with RCRSP to provide
      self-independence after the initial phases of physiotherapy. In the functional activity,
      daily living or sporting activities of the individuals are incorporated in an exercise form
      to train and facilitate pain free and efficient daily movement contingencies. a daily
      functional rehabilitation is needed to avoid any future harm, along with restoring the
      individuals to their best physical fitness statues. Core stabilization, postural alignment
      kinetic chain, scapular position, range of motion, pain and cardiovascular training are the
      main stay of current functional rehabilitation regimes. However little or no research
      studying the efficacy of functional training programs on the improvement of clinical outcomes
      of RCRSP. The fundamental reason for this research is that rotator cuff-related shoulder pain
      can cause a major complication with substantial implication on well-being. A study needed to
      be conducted to fuel the necessary advances in a newly approaches discovered recently to
      address and evaluate the clinical effectiveness of above approaches.

      Comparing these interventions may provide vital clues for shoulder rehabilitation in the
      management of RCRSP
    

Intervention name(s): Single exercise into pain (SEP) program; Shoulder Symptom Modification Procedure (SSMP); Functional Rehabilitation Program; EPTL; HSR
Intervention type(s): Behavioral; Behavioral; Behavioral; Behavioral; Behavioral
Intervention description(s): Baseline assessment & commencement of treatment: Resisted isometric shoulder abduction into pain (or lateral rotation or flexion into pain) against a wall, or Resisted shoulder abduction from 0 to 30° using moderate resistance from Theraband ( Prescribed High intensity loading to the tendon (85-90% iMVC) applied in 5 repetitions with a 45 secoud hold (3 times per week)).
Initial follow-up & progression: Resisted shoulder abduction into pain from 80 to 120° using light weight (Prescribed High intensity loading to the tendon (85-90% iMVC) applied in 5 repetitions with a 45 secoud hold (3 times per week)).
Second follow-up & progression: eccentric shoulder abduction into pain from 80 to 120° with progressively increasing repetition and weight, e.g. heavy Theraband or dumbbell.
Final assessment to identify any non-resolved functional limitations and progress eccentric exercises into pain as required
Functional rehabilitation program; [1] Finger on the sternum,[2A] Scapula modification [3] 'Humeral head' modification [4] Isometric (most painful movement) Heavy slow resistance (HSR): start from the mid-range and pain-free; Mostly targetted into exercise such as multi-stage pushing, pulling, lifting and carrying, throwing, kinetic chain exercises and aerobics. FR involved (i). Weight-shifting activities to enhance dynamic joint stability[18] .(ii). Proprioceptive neuromuscular facilitation exercises to stimulating stretch receptors located on the muscle or tendon units [18]. Using resistive tubing exercises in a functional position using PNF patterns; diagonal pattern 1: flexion, abduction, external rotation (10-15 repetition 2-3 sets). (iii) Plyometric exercise: (A) throwing motions; (B) push-up (10-15 repetition 2-3 sets) . (iv). Table slide (10-15 repetition 2-3 sets).; In EPTL it involves eccentric training in Full range (with dumbbells 15-10 RM) of Internal and external rotation at scapular plane elevation (0-45) degree and Flexion, Abduction, in full range (5 repetitions with a 45 second hold at slow speed) to target the series elastic component of the muscle .; In HSR it involves eccentric training in mid-range of motion (with dumbbells 15-10 RM) targeting the contractile component of the muscles and improving mechanical strength. Additionally, when there is 90% pain reduction on NPRS functional rehabilitation program start and they follow the same program as Group A.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Randomized control trial 13-weeks parallel non-inferiority study
Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
Primary purpose: Treatment
Keywords: Subacromial pain syndrome, Rotator cuff tendinopathy