Arthroscopic Surgery Versus Supervised Exercises in Patients With Rotator Cuff Disease (Stage II Impingement Syndrome): A Prospective, Randomized, Controlled Study in 125 Patients With a 2 1/2-Year Follow-Up.

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Brox JI, Gjengedal E, Uppheim G, et al (Department of Physical Medicine and Rehabilitation, Ullevaal University Hospital; Department of Surgery, Lovisenberg Hospital; Norwegian Armed Forces, Joint Medical Services, Research and Data Branch, Research Forum, Ullevaal University Hospital, Oslo; Division for Physiotherapy Science, University of Bergen, Bergen, Norway), J Shoulder Elbow Surg. 1999;8:102-111.

This randomized clinical trial compared the effectiveness of arthroscopic surgery, supervised exercises, and a placebo laser intervention in patients with rotator cuff disease (impingement syndrome stage II). Inclusion criteria included pain in the shoulder for at least 3 months that was resistant to outpatient physical therapy and nonsteroidal and steroidal anti-inflammatory medication, dysfunction or painful arc on abduction, normal glenohumeral range of movement, pain on 2 of the 3 isometric or eccentric tests, and a positive impingement sign and test. Of the 444 patients referred to the study, 125 agreed to participate in the study and were randomly assigned to a group receiving one of the following interventions: arthroscopic surgery, supervised exercise, or placebo laser. The median age of the participants was 48 years.

Subjects in the surgery group received an arthroscopic bursectomy with resection of the anterior and lateral part of the acromion and the coracoacromial ligament. Postoperative rehabilitation began on the first postoperative day. Patients visited a physical therapist where they lived; therefore, rehabilitation was not standardized.

Subjects who were randomized into the supervised exercises and placebo with laser groups were all treated by the same experienced physical therapist. Exercises consisted of relaxed repetitive movements (rotation, flexion and extension, and abduction and adduction) performed for approximately 1 hour per day. Patients were supervised twice per week. Resistance was gradually added to strengthen the short shoulder rotators and scapular stabilizing muscles. The exercises were continued for 3 to 6 months with supervision being gradually reduced. The patients also received 3 lessons covering the anatomy and function of the shoulder, pain management, and ergonomic advice. Subjects receiving the placebo intervention were given in 12 sessions of exposure to a detuned soft laser twice per week.

Follow-up measurements were made at 3 and 6 months after treatment by an examiner who was unaware of group assignments. At the 2 1/2-year follow-up, the examiner was aware of the intervention received. The main outcome criterion was the Neer Shoulder Score, which consists of pain, muscle strength, reaching, stability, active range of motion, and radiographic evaluations. Secondary outcome variables were pain level during activity, at rest, and at night, and disability in 16 categories of activity.

At 2 1/2-year follow-up, 113 subjects (90%) were evaluated. Fifteen subjects (50%) in the placebo group and 11 subjects (22%) in the supervised exercise group had surgery because of failed treatment. Of the subjects who had treatment as planned, there was no significant difference in success between the surgery (26 of 38) and exercise groups (27 of 44). However, there was a significant difference between these 2 groups and the placebo group.

The authors concluded that, after 2 1/2-years of follow-up, both arthroscopic surgery and supervised exercises are better interventions than the placebo and that there was no significant difference between the 2 active interventions. They recommended that patients who do not improve on a supervised exercise regimen should be considered for surgery.

Brian G Leggin, PT, OCS Penn Therapy and Fitness University of Pennsylvania Health System Philadelphia, Pa