Journal of Hand Therapy 31 (2018) 227e237

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Journal of Hand Therapy

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JHT READ FOR CREDIT ARTICLE #543.

Scientific/Clinical Article

Pain, motion and function comparison of two exercise protocols

for the rotator cuff and scapular stabilizers in patients with
subacromial syndrome
Eva Vallés-Carrascosa PT a, Tomás Gallego-Izquierdo PT, PhD a, José Jesús Jiménez-Rejano PT, PhD b,
Gustavo Plaza-Manzano PT, PhD c, Daniel Pecos-Martín PT, PhD a, Fidel Hita-Contreras MD, PhD d,
Alexander Achalandabaso Ochoa PT, PhD d, *
a
Department of Physical Therapy and Nursing, Universidad de Alcalá de Henares, Spain
b
Faculty of Physical Therapy, Nursing and Podiatry, Universidad de Sevilla, Spain
c
Department of Physical Medicine and Rehabilitation, Universidad Complutense de Madrid, Spain
d
Department of Health Sciences, Universidad de Jaén, Spain

a r t i c l e i n f o a b s t r a c t

Article history: Study Design: Randomized clinical trial.

Received 4 August 2017 Introduction: Eccentric exercise (EE) was shown to be an effective treatment in tendinopathies. However,
Received in revised form the evidence of its effectiveness in subacromial syndrome (SS) is scarce. Moreover, consensus has not
23 October 2017
been reached on whether best results for SS are obtained by means of EE with or without pain.
Accepted 27 November 2017
Available online 10 January 2018
Purpose of the Study: The purpose of this is to compare the effect on pain, active range of motion (AROM),
and shoulder function of an exercise protocol performed with pain <40 mm Visual Analog Scale (VAS)
and without pain, in patients with SS.
Keywords:
Eccentric exercise
Methods: Twenty-two subjects (mean age: 59 years [Q1 ¼ 48.50-Q3 ¼ 70], 54.5% women) were ran-
Shoulder impingement domized into a not-painful EE group (NPEE; G0: n ¼ 11) and a painful EE group (PEE; G1: n ¼ 11). The
Pain management intervention lasted 4 weeks. Pain was recorded using VAS; AROM was measured using a goniometer; and
Function management shoulder function using the modified Constant-Murley Score (CMS) before and after intervention.
Results: All dependent variables improved significantly in both groups (P < .05): NPEE VAS median:
pretest ¼ 55.0 posttest ¼ 28.0; CMS median: pretest ¼ 36.0 posttest ¼ 65.0. PEE VAS median: pretest ¼ 37.0
posttest ¼ 12.0; CMS median: pretest ¼ 35.0 posttest ¼ 59.0. The comparison between groups showed no
significant differences, with small effect size values (VAS ¼ 0.09; CMS ¼ 0.21; AROM ¼ 0.12-0.43).
Discussion: In contrast to the previous findings, our results suggest that PEE do not add benefit in SS
patients compared to NPEE.
Conclusion: Our results suggest that both interventions are effective in terms of pain, function, and
shoulder AROM. Furthermore, PEE does not provide greater benefits. Further studies are needed with
long-term follow-up to reinforce these results.
Ó 2017 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved.

Introduction disorders.2 It represents a considerable impact on health, being

recurrent and having low recovery rates.4 Subacromial syndrome
Shoulder pain, with a prevalence of 47%,1-3 is the third most (SS), which comprised impingement of rotator cuff tendons, bursa,
common cause for seeking medical care in musculoskeletal or ligaments alterations in the subacromial space and responsible

Conflict of interest: All named authors hereby declare that they have no conflicts
The study protocol was approved by the Comisión de Investigación y Ensayos
of interest to disclose.
Clínicos del Hospital de Manises (Spain), by the Human Research Committee of the
Clinical trial registration number: ACTRN12616000196448.
Hospital La Fe (Spain) and by the Human Research Committee of the Universidad de
* Corresponding author. Department of Health Sciences (b-3/010), University of
Alcalá (Spain), and registered in Australian New Zealand Clinical Trials Registry
Jaén, Campus Las Lagunillas s/n, 23071 Jaén, Spain. Tel.: þ34 670 596145; fax: þ34
(ACTRN12616000196448). The authors certify that they have no affiliations with or
953 211875.
financial involvement in any organization or entity with a direct financial interest in
E-mail address: [email protected] (A. Achalandabaso Ochoa).
the subject matter or materials discussed in the article.

0894-1130/$ e see front matter Ó 2017 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jht.2017.11.041
228 E. Vallés-Carrascosa et al. / Journal of Hand Therapy 31 (2018) 227e237

Table 1
Exercise protocol

Instructions Rotator cuff exercise Scapular stabilization exercise

EE of supraspinatus ER and IR exercise (Figs. 2 Dynamic Hug exercise Inferior Glide exercise UT stretch (Fig. 6)
(Fig. 1) and 3) (Fig. 4) (Fig. 5)
Material Weights Elastic band and rolled- Elastic band A firm supportive surface
up towel
Starting position Upright sitting position. Standing with the towel Standing position with Upright sitting position Sitting with a neutral
UL in “full-can” position between the UL and trunk the spine against the wall, with the arm abducted to cervical position.
(Reinold et al., 2007), in (to decrease the activity knees slightly bent, and 45 (in scapular plane)
the plane of the scapula of the deltoid, the feet at shoulder width. with fist clenched on a
and ER of the GH joint to supraspinatus tendon Starting at 45 elbow F, firm supportive surface.
prevent compression of strain, and pain), and 90 60 ABD, and 45 GH IR.
the greater tubercle elbow F.46
against the subacromial
surface (Ronai, 2005); GH
joint abducted 45 (not
starting at 90 to avoid
impingement
exacerbation) and
complete elbow E.43-46
Implementation Slowly take UL to ADD. To Perform ER of GH Horizontal F of GH Applying pressure with Perform lateral cervical
make the exercise (maximum 45 ) and back drawing an arc with the the fist in the direction of bending until feeling a
eccentric, go back to to the starting position. hands (hugging action). arm adduction and stretching (not painful).
starting position with a Upon completion of the When the hands come inferiorly depress the Ditto with left cervical
pulley system, from corresponding sets, the into contact with each scapula and maintaining bending.
which the contralateral same exercise is carried other (maximum the position for 5 s.51
UL will pull a rope to raise out toward the IR of the scapular protraction),
the ipsilateral UL.30 shoulder (maximum 45 ). slowly return to the
In both exercises, there is starting position.48-50
an eccentric phase and
concentric phase.42,43,47
Parameters Sets: 3 Both Sets: 3 Sets: 3 Reps: 3
Reps: 10 Sets: 3 Reps: 10 Reps: 10 Each stretch is held for
Reps: 10 Each contraction is held 30 s.
for 5 s.

UT ¼ upper trapezius; EE ¼ eccentric exercise; ER ¼ external rotation; IR ¼ internal rotation; UL ¼ upper limb; GH ¼ glenohumeral; ABD ¼ abduction; ADD ¼ adduction.

for 45%-65% of cases of shoulder pain,1,5-7 has an incidence of about Certain studies have questioned the effectiveness of EE in inser-
2.8% in subjects aged over 30 years and 15% in subjects over 70 tional tendinopathy.26 Frizziero et al.24 reflected how EE in achilles
years.2 Symptoms and dysfunction occur mostly in lifting positions tendinopathy appeared to be effective when the affected portion of
and movements of the upper limb (UL), which can affect the quality the tendon was the midportion, rather than the insertional portion.
of life and socioeconomic aspects,8 with frequent medical sick For SS, since it is most often associated with insertional tendinop-
leave.2,9,10 athy of the supraspinatus, the possibility of this promoting differing
There are electromyographic studies that evidence changes in results has been assessed.5,24 However, certain studies support the
range of motion and muscular synchrony deficits in patients with influence of other factors such as an unsuitable combination be-
SS, which would justify an exercise protocol in its therapeutic tween the load profile and range of motion when loading24 or a
approach11,12: decreased muscle activity of the middle and lower misdiagnosis of subjects, due to the complexity thereof.2,10,27,28
portion of the serratus anterior and rotator cuff, delayed activation While certain studies find no significant differences between EE
of the middle and lower trapezius, and excess activation of the and concentric exercise in SS,29 several studies support the EE
upper trapezius and middle deltoid; and in many cases, the application5,6,24,30 and occasionally have shown that surgery can be
shortening of the pectoralis minor.8,11,13-15 Several studies report avoided.5
that conservative treatment is generally recommended as a first Regarding the implementation of EE, there is no evidence on the
option for SS, physical exercise being the most used.1,12,13,16,17 This role of pain during exercise. Although a relationship between pain
helps to improve the clinical symptoms of most patients, and there during exercise and beneficial results has been sought,5 it is
are no statistically significant differences between the effectiveness currently unknown whether this relationship exists or not.5,24 This
of conservative and surgical treatments (the latter involving a statement is supported by the lack of consensus on the differing
greater risk and cost) in the long term.7,18-20 Exercise is intended to results when performing the exercises with or without pain in
improve the pain, strength,9 and neuromuscular control and to cases such as achilles and patellar tendinopathies and SS. Moreover,
restore the articular pain-free ROM; even in certain cases of com- the few studies on EE in SS are subject to limitations such as the lack
plete rotator cuff tear (although the tear is not solved without of a control group, which makes it difficult to extrapolate the results
surgery), shoulder function could be restored.2,21 Holmgren et al.22 to the population.5,6,30
argue that the combination of exercises to strengthen the rotator Factors such as the heterogeneity of interventions, no protocol
cuff and scapular stabilization optimizes rehabilitation and mini- description,1,5,9,10,13 scarcity of and lack of consensus on pain
mizes the risk of injury and is recommended over placebo treat- studies, and EE in SS in both the scientific literature and clinical
ment and no treatment.19 As for the type of exercise, in the last practice promoted the implementation of this work. The main
decade, eccentric exercise (EE) is being studied as an effective objective is to determine whether there are differences in terms of
treatment option in achilles and patellar tendinopathies.5,6,22-25 pain and shoulder active range of motion (AROM), following the
Although similar histological changes have been found in rotator implementation of an EE program with and without pain in pa-
cuff tendinopathy, there is less evidence on the effectiveness in SS.5 tients with SS. The secondary objective is to determine whether
 E. Vallés-Carrascosa et al. / Journal of Hand Therapy 31 (2018) 227e237 229

Fig. 1. Eccentric exercise of supraspinatus.

there are differences in shoulder function between the 2 groups training sessions per week, each session lasting approximately 30
after the intervention. In addition, the aim is to establish the short- minutes. After baseline, subjects were randomly assigned into not-
term effectiveness of the protocol in order to guide clinical practice painful EE group (0 mm on the Visual Analog Scale [VAS]) or painful
in patients with SS. EE group (<40 mm on the VAS). Both groups completed the tests 1
day after completing the program.
Methods
Participants
Experimental approach to the problem
Subjects with SS who visited health centers in Chiva, Cheste, and
A prospective, parallel-group, randomized clinical trial was Buñol, belonging to the Hospital de Manises (Valencia, Spain), be-
conducted. This study used a 4-week EE program comprising 5 tween March 9, 2016, and May 9, 2016, were recruited by

Fig. 2. External rotation exercise.

230 E. Vallés-Carrascosa et al. / Journal of Hand Therapy 31 (2018) 227e237

Fig. 3. Internal rotation exercise.

rehabilitation physicians and physiotherapists of the research team, Outcome measures

according to selection criteria.
Inclusion criteria were patients (men and women) aged be- The primary outcomes of this study were shoulder pain and
tween 25 and 70 years old, referred to a physiatrist, and to reha- AROM. Shoulder function was evaluated as a secondary outcome.
bilitation services after visiting the medical center with a diagnosis
of SS and painful arc upon active lifting of the UL (between 60 and Shoulder pain
120 of abduction).2
Exclusion criteria were patients with rotator cuff tears, patients The intensity of shoulder pain was recorded during everyday
who undergone surgery of the shoulder in the last 3 months, those activities by VAS (0 mm no pain; 10 mm worst pain imagin-
with frozen shoulder, shoulder prosthesis, fibromyalgia, or malig- able).31,32 A value <30 mm was considered mild, 31-54 mm mod-
nant neoplasm, and a history of rheumatic or chronic inflammatory erate, and > 55 mm severe.33
disease.6,29
Subjects were evaluated by research team rehabilitation doc- AROM of the glenohumeral joint
tors with more than 10 years of experience. The study was
approved by the Committee on Research and Clinical Trials of the A universal goniometer was used to measure AROM to assess
Manises Hospital, the Clinical Research Ethics Committee of La Fe, flexion, the patient was placed supine, bending hips and knees
and by the Animal Research Ethics Committee of the University of 45 34 and the UL to assess supported on the stretcher.34-36 For
Alcalá. Prior to inclusion in the study, all participants signed external and internal rotation, the patient was placed in the same
informed consent approved by “the University of Alcalá Institu- position but with the UL to assess at 45 abduction (not starting at
tional Review Board.” 90 abduction because the maximum infrathreshold AROM of some

Fig. 4. Dynamic hug exercise.

 E. Vallés-Carrascosa et al. / Journal of Hand Therapy 31 (2018) 227e237 231

Pain, AROM, and shoulder function were assessed before the

intervention and 1 day after the last session. All these measures
have been used previously as outcome measures to evaluate the
effectiveness of an active therapy on SS.1,5,8,22,26,29,30,42

Randomization

Patients who were referred to rehabilitation and who met the

inclusion criteria and signed the consent were recruited for the
study. After initial assessment, they were randomized to the not-
painful EE group (G0) and the painful EE group (G1). In the
assignment process, 22 sealed opaque envelopes, mixed together
inside a box, were used. Eleven envelopes had “G0” written inside
and the other 11, “G1.” Patients were diagnosed and referred to
rehabilitation by a rehabilitation physician, after signing the
informed consent form. A physiotherapist not involved in the
recruitment and treatment process opened an envelope at random
and wrote down in a list the group to which the patient belonged.
Patient intervention began immediately after the inclusion visit.
Each group was treated by a physiotherapist with experience in
Fig. 5. Inferior glide exercise.
rehabilitation. All participants were asked not to reveal the infor-
mation to other possible study members.
subjects was below 90 ) and 90 elbow flexion; the wrist in a
neutral position.34,36,37 The abduction was recorded with the pa- Intervention: exercise protocol
tient in an upright sitting position, with the spine supported on a
high-backed chair to avoid trunk compensation. The subject, with G1 was instructed to perform an exercise protocol (Table 1) that
the elbow extended, actively raised the UL in the coronal plane with included EE of the rotator cuff, with a load causing painful imple-
the thumb toward the ceiling to allow necessary external rotation mentation (no more than 40 mm on the VAS), scapular stability
to avoid the impact of the greater tuberosity in the acromial pro- exercises, and stretching of the upper trapezius. G0 carried out
cess.35,36 For adduction assessment, the patient was placed in the the same exercise protocol but with a load that would allow
same position but starting at 30 shoulder flexion and full elbow VAS ¼ 0 mm during the test.
extension. For extension, the patient was placed prone with the There is no consensus on the optimal frequency of exercise or
head placed on the stretcher facial hole, extended elbow, and duration of the intervention, which vary from once a week to daily
pronated forearm.38 exercise and from 3 to 22 weeks, respectively.13 Blume et al.29
indicate that the most significant improvements in strength,
Shoulder function function, and AROM appear in the first 5 weeks of intervention,
Ylinen et al.7 argue that if exercise is appropriate, pain and function
Shoulder function was analyzed using the amended Constant- can be improved in just 3-8 weeks.
Murley Score (CMS) assessing pain (15 points), activities of daily According to the scientific evidence and clinical experience, the
living (20 points), and AROM (40 points). Strength was not frequency of intervention in this study was 5 times per week
assessed, considering that the subject’s initial position can influ- (Monday through Friday) and the duration 4 weeks, under the
ence the direction of the action and to alter muscle strength supervision of physiotherapists of the research team. Upper
(finding differences in consecutive measurements of the same trapezius stretching lasted 30 seconds and was applied 3 times in
subject, even using the same instrument), so the maximum score each session, with 30 seconds rest between each repetition.6,9,16
was 75 points (the higher the score the greater the shoulder Three sets of 10 repetitions were performed for strengthening ex-
function).22,35,39,40 Holmgren et al.41 found that 17 points is the ercises,6,9,16,26,47 resting between series for twice the duration of a
minimally clinically important difference. series.

Fig. 6. Upper trapezius stretch.

232 E. Vallés-Carrascosa et al. / Journal of Hand Therapy 31 (2018) 227e237

Fig. 7. Flow diagram of patients.

The rotator cuff exercises were performed with the affected UL30 The normality of the variables was studied using the Shapiro-
and scapular stabilizer exercises and upper trapezius stretching on Wilk test. First, a descriptive analysis of the variables such as age,
both sides. sex, and pretest and posttest values, and difference between pretest
and posttest of the dependent variables was performed, showing
Sample size determination the median and first and third quartiles in cases where the quan-
titative variables did not adjust to normal, the mean and standard
The sample size was based on the studies available on SS and deviation in those where they adjusted, and the absolute frequency
exercise. A sample of 9 subjects was used in a pilot study by Jonsson and percentage in sex. Subsequently, the initial homogeneity of the
et al.30 On the other hand, the pilot study by Bernhardsson et al.5 2 treatment groups was checked; in the case of quantitative vari-
included 10 subjects. In a number of cases under Camargo et al.,16 ables, the Mann-Whitney U test was used, and in the case of the sex
the sample consisted of 20 subjects. The sample size was calcu- variable, Pearson’s chi-squared test was used since the assumptions
lated using MedCalc 16.4. The minimum sample size was sought to necessary for implementation were met. Then, considering each
allow detection of significant differences between the 2 groups group in isolation pretest vs posttest values of the dependent var-
subjected to different treatments (2-tailed test) with a power of iables were compared, using the Wilcoxon signed-rank test. We
80% and a 5% alpha error. Using the data provided by Holmgren then proceeded to contrast the values of the difference between
et al.,22 for obtaining statistical significant differences between 2 pretest and posttest in the 2 groups using the Mann-Whitney U
groups, 10 subjects per group are necessary making a total of 20
patients. Finally, a total of 22 patients were enrolled in the trial.
Table 3
Results for the VAS, the AROM, and CM scalea
Statistical analysis
Variables NPEE PEE P value

Statistical analysis was performed using SPSS for Windows VAS pretest 55.0 (48.0; 68.0) 37.0 (32.0; 79.0) .358
ROM pretest
(Version 23.0) and “per intent-to-treat” analysis (no subject was
Flexion 120.0 (110.0; 140.0) 115.0 (110.0; 130.0) .765
lost). A confidence interval of 95% (P value <.05) was considered. Extension 40.0 (30.0; 60.0) 30.0 (30.0; 50.0) .338
Abduction 90.0 (70.0; 120.0) 90.0 (70.0; 120.0) .869
Adduction 15.0 (10.0; 30.0) 20.0 (10.0; 20.0) .865
Table 2 External rotation 30.0 (30.0; 40.0) 40.0 (30.0; 65.0) .120
Baseline demographics for both groups Internal rotation 38.0 (35.0; 48.0) 50.0 (40.0; 50.0) .078
CM scale pretest 36.0 (22.0; 45.0) 35.0 (22.0; 47.0) .895
Characteristics NPEE (n ¼ 11) PEE (n ¼ 11) P value
VAS posttest 28.0 (18.0; 37.0) 12.0 (3.0; 30.0) .057
Gender 8 (72.7%)b 4 (36.4%)b .087 ROM posttest
Agea 57.0 (49.0; 70.0) 60.0 (47.0; 70.0) .816 Flexion 160.0 (151.0; 170.0) 150.0 (140.0; 160.0) .128
Weight (kg)a 70.0 (59.0; 84.0) 73.0 (66.0; 76.0) .793 Extension 60.0 (50.0; 60.0) 60.0 (50.0; 60.0) .939
Height (cm)a 162.0 (155.0; 168.0) 163.0 (158.0; 174.0) .974 Abduction 130.0 (110.0; 180.0) 110.0 (100.0; 140.0) .209
BMI (kg/m2)a 26.57 (23.34; 29.14) 26.81 (24.89; 28.91) .718 Adduction 30.0 (30.0; 30.0) 30.0 (30.0; 30.0) .544
Duration 12.0 (6.0; 18.0) 8.0 (5.0; 13.0) .426 External rotation 75.0 (60.0; 85.0) 80.0 (69.0; 85.0) .869
symptoms (mo)a Internal rotation 70.0 (65.0; 70.0) 68.0 (62.0; 68.0) .121
CM scale posttest 65.0 (55.0; 69.0) 59.0 (50.0; 68.0) .490
BMI ¼ body mass index; NPEE ¼ not-painful eccentric exercise group; PEE ¼ painful
eccentric exercise group. VAS ¼ Visual Analog Scale; AROM ¼ active range of motion; CM ¼ Constant-Murley;
a
Values are median (1st quartile 1; 3rd quartile). NPEE ¼ not-painful eccentric exercise group; PEE ¼ painful eccentric exercise group.
b a
Absolute frequency and percentage. Values are median (1st quartile; 3rd quartile).
 E. Vallés-Carrascosa et al. / Journal of Hand Therapy 31 (2018) 227e237 233

Table 4 The pretests of the dependent variables showed no significant

Differences between baseline (pre) and evaluation after intervention (post) for each differences between groups (P > .05) (Table 3), so both were ho-
group
mogeneous at baseline. The Mann-Whitney U test revealed no
Variable Median (Q1; Q3)b P value differences between the 2 groups in the posttests of variables
NPEE (P > .05) (Table 3).
VAS The comparison of the pretest values with respect to posttest
Pre 55.0 (48.0; 68.0) .003a
values, considering each group in isolation, showed that there were
Post 28.0 (18.0; 37.0)
ROM flexion statistically significant differences between these values in both
Pre 120.0 (110.0; 140.0) .003a groups: for both G0 and G1, the VAS and CMS improved signifi-
Post 160.0 (151.0; 170.0) cantly (P < .01), as well as the AROM (P < .05) (Table 4).
ROM extension Finally, comparison of the differences between pretest and
Pre 40.0 (30.0; 60.0) .017a
Post 60.0 (50.0; 60.0)
posttest of the 2 groups showed that both groups improved simi-
ROM abduction larly in all dependent variables, without significant differences
Pre 90.0 (70.0; 120.0) .005a between groups (P > .05) (Fig. 8).
Post 130.0 (110.0; 180.0) The between-group effect size revealed small values in all cases
ROM adduction
(VAS ¼ 0.09; Constant-Murley [CM] scale ¼ 0.21; AROM ¼ 0.12-
Pre 15.0 (10.0; 30.0) .011a
Post 30.0 (30.0; 30.0) 0.43), with small differences between the 2 groups at the descrip-
ROM external rotation tive level (Table 5).
Pre 30.0 (30.0; 40.0) .003a
Post 75.0 (60.0; 85.0) Discussion
ROM internal rotation
a
Pre 38.0 (35.0; 48.0) .003
Post 70.0 (65.0; 70.0) The results of this study suggest that our exercise protocol
CM scale applied over 4 weeks in patients with SS, with or without pain
Pre 36.0 (22.0; 45.0) .003a during exercise (VAS < 5 mm) presents similar results in VAS,
Post 65.0 (55.0; 69.0)
AROM, and CMS. No statistically significant differences were found
PEE
VAS between the groups; however in isolation, both improved signifi-
Pre 37.0 (32.0; 79.0) .003a cantly in all variables.
Post 12.0 (3.0; 30.0)
ROM flexion EE with or without pain
Pre 115.0 (110.0; 130.0) .003a
Post 150.0 (140.0; 160.0)
ROM extension Despite many authors support that painful EEs are associated
Pre 30.0 (30.0; 50.0) .007a with good results due to interference with nerves growing or a
Post 60.0 (50.0; 60.0) better tissue response to repair mechanisms,23,30 there is no
ROM abduction
consensus on whether exercises for the treatment of tendino-
Pre 90.0 (70.0 ; 120.0) .007a
Post 110.0 (100.0 ; 140.0) pathies such as rotator cuff, achilles, patellar, or lateral epicondyle
ROM adduction tendinopathies should be conducted with or without pain. To the
Pre 20.0 (10.0; 20.0) .005a authors’s knowledge, this study is the first to compare the effec-
Post 30.0 (30.0; 30.0) tiveness of painful and painless EE in terms of pain, AROM, and
ROM extenal rotation
Pre 40.0 (30.0; 65.0) .003a
shoulder function in SS. The results have been favorable in both
Post 80.0 (69.0; 85.0) groups, and the painful EE does not appear to offer an advantage.
ROM internal rotation These results are consistent with the study by da Cunha et al.,54
Pre 50.0 (40.0; 50.0) .003a which was considered the first study to make the comparison in
Post 68.0 (62.0; 68.0)
subjects with patellar tendinopathy. In this study, the presence of
CM scale
Pre 35.0 (22.0; 47.0) .003a pain was not harmful in the cases presented, and neither was it so
Post 59.0 (50.0; 68.0) for the subjects included in the review of Achilles tendinopathy by
VAS ¼ visual analog scale; ROM ¼ range of motion; CM ¼ Constant-Murley; NPEE ¼
Frizziero et al.24 nor for subjects with SS according to Bernhardsson
not-painful eccentric exercise group; PEE ¼ painful eccentric exercise group. et al.5
a
Statistically significant differences (P < .05).
b
Values are Median (1st Quartile; 3rd Quartile). Role of EE in terms of favorable results

test. Effect size was also calculated using the procedure described The results of this study question whether the importance lies in
by Grissom.52,53 the relationship between pain and positive results5,30 or in the
relationship between EE (painful or not) and positive results.6,47,54
Results In this study, G1 was instructed to perform the exercise with
VAS < 50 mm, coinciding with the RCTs (randomized clinical trials)
Twenty-six patients with SS were selected for eligibility to on exercise in SS by Holmgren et al.22 and Maenhout et al.,47 and in
participate in the study. Prior to allocation, 4 patients were the pilot studies by Jonsson et al.30 and Bernhardsson et al.5
excluded for the reasons given in the patient flowchart (Fig. 7). A Camargo et al.6 and McClure et al.43 differed as they failed to
total of 22 patients with a median age of 59 years (Q1 ¼ 48.50; specify the allowed pain intensity, only stating that exercises
Q3 ¼ 70), 54.5% women, met the inclusion criteria, signed informed should be performed without substantial pain or fatigue. Like our
consent, and were randomized to G0 (n ¼ 11) and G1 (n ¼ 11). After study results, these have achieved beneficial effects regardless of EE
4 weeks of intervention, all subjects completed the program being performed with or without pain. All this is in line with the
without suffering any adverse effects (Fig. 7). findings of the study by da Cunha et al.,54 in which there were no
Table 2 shows baseline characteristics, which were similar in differences between subjects who performed painful exercise and
both groups (P > .05). those who perceived no pain.
234 E. Vallés-Carrascosa et al. / Journal of Hand Therapy 31 (2018) 227e237

Fig. 8. Results comparison between groups preintervention and postintervention: VAS (A), ROM F (B), ROM E (C), ROM Abd (D), ROM Add (E), ROM ER (F), ROM IR (G) and CM
scale (H). VAS ¼ Visual Analog Scale; ROM ¼ range of motion; F ¼ flexion; E ¼ extension; Abd ¼ abduction; Add ¼ adduction; ER ¼ external rotation; IR ¼ internal rotation;
CM ¼ Constant-Murley; Pre ¼ preintervention; Post ¼ postintervention.
 E. Vallés-Carrascosa et al. / Journal of Hand Therapy 31 (2018) 227e237 235

Table 5 Supplementary data

Between-group differences and effect size

Variable NPEE PEE P-value Effect Supplementary data related to this article can be found at
Median (Q1; Q3)b Median (Q1; Q3)b
size https://doi.org/10.1016/j.jht.2017.11.041.
VAS differencea 26.0 (15.0; 34.0) 29.0 (19.0; 40.0) .718 0.09
ROM differencea
Flexion 40.0 (20.0; 50.0) 30.0 (10.0; 37.0) .372 0.22 References
Extension 10.0 (0.0; 30.0) 20.0 (10.0; 30.0) .395 0.21
Abduction 20.0 (5.0; 60.0) 10.0 (10.0; 30.0) .547 0.15 1. Osteras H, Torstensen TA. The dose-response effect of medical exercise therapy
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 E. Vallés-Carrascosa et al. / Journal of Hand Therapy 31 (2018) 227e237 237

JHT Read for Credit

Quiz: #543

Record your answers on the Return Answer Form found on the b. the presence or absence of partial thickness tears of the
tear-out coupon at the back of this issue or to complete online supraspinatus tendon on MRI
and use a credit card, go to JHTReadforCredit.com. There is c. the ages of the subjects
only one best answer for each question. d. the presence or absence of resting pain
#4. The exercise regime included
#1. Outcome measures included a. isolated subscapularis strengthening
a. CMS b. scapular stabilization
b. ROM c. deltoid strengthening
c. VAS score d. self-mobilization of the glenohumeral joint
d. all of the above #5. Neither approach proved better than the other
#2. The study design was a. false
a. case study series b. true
b. retrospective chart reviews
c. RCTs When submitting to the HTCC for re-certification, please batch your
d. large cohort analysis JHT RFC certificates in groups of 3 or more to get full credit.
#3. The difference in groups was
a. the presence or absence of pain when performing the
eccentric exercises
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prohibited without permission.