Published Comment in the Annals of Internal Medicine Regarding Subacromial Impingement

Comments and Responses
Management of the Unilateral Shoulder Impingement Syndrome

TO THE EDITOR: On the surface, Rhon and colleagues’ thoughtful study (1) shows the effectiveness of subacromial corticosteroid injection and manual physical therapy to treat the shoulder impingement syndrome (SIS). However, several factors complicate the comparison of manual physical therapy with medical intervention and perhaps limit this study’s otherwise valuable contribution.

First, the manual therapy approach used in this study was well-described here and elsewhere (2).  However, physical therapists in clinical practice typically assess the presence and quality of symptoms in relation to patient movement and position, not according to a pathoanatomical diagnosis such as SIS; therefore including the manual therapy intervention as a treatment for SIS may be misleading.  Emphasis should have been placed on the idea that manual therapy is a treatment for the mechanical stresses that may lead to SIS, while a corticosteroid injection has a more direct effect on the structures that have been injured.  

Second, manual physical therapists continually reassess and adjust treatment on the basis of the patient’s symptomatic changes structured as a test–retest model (establish a baseline, do an intervention, and then retest to look for change from the baseline). This model has been validated (3) and is the common thread linking many assessment approaches used by all types of physical therapists. This model differs from a physician’s typical assessment and treatment in that therapists spend more time (generally 2 to 3 sessions weekly for at least 4 weeks) observing patients move and their response to various noninvasive interventions.

Third, this study may not have sufficiently emphasized the patient education process. Many musculoskeletal conditions involving the shoulders have high recurrence rates (4), particularly when the mechanism of injury is progressive and thought to result from repetitive overuse of the injured area. In these frequent cases, resolution and recurrence of symptoms may simply be part of the natural history of the condition; short-term pain control and improved functionality would not be the ultimate goal of intervention. Physical therapists educate their patients to become their own “self-assessors” and learn how and when to use appropriate self-treatment techniques as developed through the assessment approach used when deciding on suitable manual techniques.

Finally, corticosteroid injection and manual physical therapy often work in synergy: The former decreases inflammation, and the latter decreases the mechanical stress that may have caused the symptoms in the first place. Including a third group that received both interventions might have allowed for a more clinically relevant comparison.

Christopher Leib, DPT, CSCS, Cert MDT, COMT
Pain Relief and Physical Therapy; Havertown, Pennsylvania

Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=L14-0450.

References
1. Rhon DI, Boyles RB, Cleland JA. One-year outcome of subacromial corticosteroid injection compared with manual physical therapy for the management of the unilateral shoulder impingement syndrome: a pragmatic randomized trial. Ann Intern Med. 2014;161:161-9. [PMID: 25089860] doi:10.7326/M13-2199
2. Rhon DI, Boyles RE, Cleland JA, Brown DL. A manual physical therapy approach versus subacromial corticosteroid injection for treatment of shoulder impingement syndrome: a protocol for a randomised clinical trial. BMJ Open. 2011;1:e000137. [PMID: 22021870] doi:10.1136/bmjopen-2011-000137
3. Cook CE, Showalter C, Kabbaz V, O'Halloran B. Can a within/between-session change in pain during reassessment predict outcome using a manual therapy intervention in patients with mechanical low back pain? Man Ther. 2012;17:325-9. [PMID: 22445052] doi:10.1016/j.math.2012.02.020
4. Luime JJ, Koes BW, Miedem HS, Verhaar JA, Burdorf A. High incidence and recurrence of shoulder and neck pain in nursing home employees was demonstrated during a 2-year follow-up. J Clin Epidemiol. 2005;58:407-13. [PMID: 15862727]

Don’t Be an Absolutist!

When it comes to strength and conditioning, fitness and the movement arts, it is not uncommon to find individuals arguing with each other about the BEST practice to rule them all. Whether Crossfit, yoga, Pilates, Zumba, running, triathlon training, etc., it is not difficult to find loyalists that absolutely identify themselves as a practitioner of one method (a Crossfitter, a yogi, a cyclist, a runner, etc.). In my opinion, this mindset is very limiting. No matter how versatile a specific method of training may be, the human body is way too complex not be open-minded to a wide variety of training practices. The concept of finding balance in the body is vast and goes way beyond building physical capacity by training a variety of movements. I will agree that a keystone to a good movement practice should be incorporating a wide variety of movements, therefore, practices such as Crossfit, yoga, and Pilates, have an advantage for optimal movement over single activity movement practices such as running and cycling; however, the idea of variety must be discussed beyond simply what movements are being done and instead be contemplated in regards to the specific focus of the movement based on specific goals. This idea of specificity, is unlikely to be accomplished in a holistic manner with one movement practice. Factors such as intensity, speed, breathing, environment, and competition all play vital roles in how similar movements effect an individual, and many times these factors are in opposition within different practices. For example, many of the movements performed in Crossfit and yoga are very similar in their fundamentals, however, I don’t think many would argue that the environment, intensity, breath focus, and speed of motion are very different. In these instances, it is common to look at the differences in these practices and decide that one practice fits you better than another based on the identity you have created for yourself. In this instance, it may seem sensible to say that yoga is best for me because “I like a low key environment and I do not want to lift weights”, or Crossfit is up my alley because “yoga is for girls, or I thrive in a competitive environment where exercise intensity is a major focus”. My intention here is not to deny that individuals have differences and that some are more suited to certain environments than others, but simply to point out two major factors in this line of thinking:

1. Exclusively training one style of movement, inherently limits you in areas of movement that differ from that particular style. So basically, if you train one element of movement too much an opposite element suffers. In the above example, that means if you are always training at a high intensity, you may find it difficult to down regulate your system, and instead be in a constant state of physical and emotional stress. On the other end of the spectrum, if calming, lower-intensity, body weight movements are the only elements in your practice, your body will not be prepared for tasks where short-duration, high-intensity effort is necessary (i.e. sprinting across the street, lifting furniture, etc.) and injury can often result.
2. Regardless of how individuals label themselves physically, daily life creates obstacles that incorporate a versatility of movement and emotional demands that no single practice can optimally prepare you for. Our bodies work best when our systems (musculoskeletal, nervous, cardiovascular, hormonal, etc) are in balance. That means that elements that you feel most comfortable with, may be the elements that need the LEAST training.

With this in mind, I leave you with this sentiment. Be open-minded in your approach to movement, and you will find you have more potential and versatility than you once thought.

Check out this video demonstration utilizing Pilates-based training to enhance Crossfit-style movements: https://www.youtube.com/watch?v=73ytC877ggg&feature=youtu.be

Are you Really Extending Your Hips?

Powerful hip extension and posterior chain strengthening, are currently all the rage in the strength and conditioning world; and with good reason. There are few things more functional for athletic and daily movement than effective hip extension. Therefore movements such as deadlifts, squats, lunges, bridges, kettlebell swings, etc, should be a staple in any balanced performance and/or function-based exercise regimen . The problem here (and it’s a big one) is subtle differences in how you execute these movements can be the difference between getting the intended benefit improving hip extension capacity or creating dysfunction by further imbalancing your body. The execution in which I am referring deals mostly with the pelvic position maintained during any of these movements. If the pelvis does not maintain (or begin in) a neutral position the hips will not fully extend. Instead the lumbar spine will create the extension to allow one to stand upright, perpetuating an anterior rotation of the pelvis which by definition is a position of over-shortened hips flexors/lumbar extensors, and over-lengthened hip extensors/abdominals. As muscles work best in mid-range when they are neither over-shortened nor over-lengthened, none of these muscle groups are working well in this situation. Furthermore, this lack of muscle balance and control leads to excess joint compression, especially in the areas of the lower lumbar spine (L4-L5; L5-S1) and the anterior (front) knee and hip. This crucial factor, makes it imperative to assess one’s ability to understand and maintain this neutral spine position in all the static positions involved in all the aforementioned movements. These positions include standing, the bottom of a squat, half kneeling or the bottom of a lunge, a hip hinge position (bottom of deadlift or kettlebell swing), etc. You get the idea. Basically the movement needs to be deconstructed to see if pelvic neutrality is able to be achieved and maintained in all static components of the movement being performed.  If one is having difficulty finding and maintaining these static positions, there is very little chance that the position will be maintained during high velocity, high load, high volume dynamic movements. Once pelvic neutrality can be mastered with static positioning, a gradual increase in velocity, load, and volume can be added, with the focus still be central to the pelvic position.  Sound confusing, see the video below:
https://www.youtube.com/watch?v=4KNnfClUpFg

SIGN UP: Positions and Transitions: Linking Performance Enhancement with Injury Prevention.


Are chronic injuries hindering your progress in your athletic endeavors? Have you reached a plateau in your current athletic performance? Have you been injured in the past when exercising? Is fear of injury preventing you from starting an exercise regimen? If you answered YES to any of these questions, SIGN UP TO RESERVE YOUR SPOT FOR THIS INTERACTIVE WORKSHOP TODAY!!!

By attending this workshop you will:
Learn and practice how to assess and manage the physical limitations getting in the way of optimal performance
Learn why you get injured
Learn and practice strategies to prevent injury

Instructor:               
Chris Leib is a licensed Doctor of Physical Therapy and Certified Strength and Conditioning Specialist with nearly a decade of experience in treating movement dysfunctions and enhancing human performance.  Dr. Leib has a versatile movement background with a variety of certifications as both a physical therapist and fitness professional. Combining the worlds of therapy and fitness, Chris is uniquely qualified to help you get the most out of your body, while allowing you to sustain optimal physical health and longevity.

Education and Certifications:
Doctorate of Physical Therapy from the University of Scranton
Certified Strength and Conditioning Specialist by the National Strength and Conditioning Association
Crossfit Level 1 Coach
Crossfit Mobility Coach
Functional Movement Screen Level 1 and 2 Certified
Certified Orthopedic Manual Therapist through Maitland Australian Physiotherapy Seminars
Certified in Mechanical Diagnosis and Treatment through the McKenzie Institute

Where: Crossfit Advance
When: February 8, 2015; 12-2pm
Contact info:
leibc2@gmail.com
www.movementprofessional.com
PLEASE SEND AN EMAIL TO SIGN UP!

Cost: $30/person