Galley Proof 22/07/2016; 14:23 File: bmr–1-bmr737.tex; BOKCTP/xhs p. 1 1 Journal of Back and Musculoskeletal Rehabilitation -1 (2016) 1–8 DOI 10.3233/BMR-160737 IOS Press Effects of weighted and un-weighted pendulum exercises on ultrasonographic Acromiohumeral distance in patients with subacromial impingement syndrome Department of Physical and Rehabilitation Medicine, Pamukkale University, Denizli, Turkey Department of Orthopedics and Traumatology, Pamukkale University, Denizli, Turkey fv er b si o a n Nuray Akkayaa,∗, Semih Akkayab , Harun R. Gungorb , Gokce Yaşara, Nilgun Simsir Atalaya and Fusun Sahina un co rre ct ed pr oo Abstract. BACKGROUND: Although functional results of combined rehabilitation programs are reported, there have been no reports studying the effects of solo pendulum exercises on ultrasonographic measurements of Acromiohumeral distance (AHD). OBJECTIVE: To investigate the effects of weighted and un-weighted pendulum exercises on ultrasonographic AHD and clinical symptoms in patients with subacromial impingement syndrome. METHODS: Patients with subacromial impingement syndrome were randomized to performing weighted (1.5 kilograms hand held dumbbell, N = 18) or un-weighted (free of weight, N = 16) pendulum exercises for 4 weeks, 3 sessions/day. Exercises were repeated for each direction of shoulder motion in each session (ten minutes). Clinical situation was evaluated by Constant score and Shoulder Pain Disability Index (SPADI). Ultrasonographic measurement of AHD at 0◦ , 30◦ and 60◦ shoulder abduction was performed. All clinical and ultrasonographic evaluations were performed at the beginning of the exercise program and at end of 4 weeks exercise program. RESULTS: Thirty-four patients (23 females, 11 males; mean age 41.7 ± 8.9 years) were evaluated. Significant clinical improvements were detected in both exercise groups between pre and post-treatment evaluations (p < 0.05). There was no significant difference for pre and post-treatment AHD measurements at 0◦ , 30◦ , and 60◦ shoulder abduction between groups (p > 0.05). There was no significant difference for pre and post-treatment narrowing of AHD (narrowing of 0◦ –30◦ , and 0◦ –60◦ ) between groups (p > 0.05). CONCLUSION: While significant clinical improvements were achieved with both weighted and un-weighted solo pendulum exercises, no significant difference was detected for ultrasonographic AHD measurements between exercise groups. Keywords: Acromiohumeral distance, ultrasonography, subacromial impingement syndrome, pendulum exercises, codman exercises ∗ Corresponding author: Nuray Akkaya, Department of Physical and Rehabilitation Medicine, Pamukkale University, Denizli 20070, Turkey. Tel.: +90 258 296 4995/536 820 4501; Fax: +90 258 296 6001; E-mail: [email protected]. 1. Introduction 1 Shoulder impingement syndrome described as the impingement of subacromial soft tissues underneath the acromial arch especially in overhead positions of arm, is one of the most frequently diagnosed clinical conditions among the causes of the shoulder pain [1,2]. Both anatomic and biomechanical factors play an im- 2 c 2016 – IOS Press and the authors. All rights reserved ISSN 1053-8127/16/$35.00 3 4 5 6 7 Galley Proof 22/07/2016; 14:23 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 104 n 18 si o 17 er 16 fv 15 agnosed as subacromial impingement syndrome were asked to take part in the study and informed consent forms were obtained from the volunteers. Ethical committee approval was received from local ethical committee. Random number generator of computer was used for randomization by a physician (NSA). Study was conducted at a outpatient clinic of Department of Physical Medicine and Rehabilitation. Although there have been no strict guidelines to diagnose subacromial impingement syndrome in the literature, exclusion and inclusion criteria from previous studies evaluating the effects of rehabilitation programs were used [6]. Inclusion criteria were described as follows; one sided shoulder pain for a duration of 4 to 24 weeks, painful range of motion in either abduction or flexion, positive impingements test (Neer or Hawkins), and presence of either painful isometric external rotation or abduction, or positive Jobe test [17–19]. Our exclusion criteria were chronic shoulder pain more than 6 months, history of shoulder trauma (including upper extremity fractures), shoulder instability, calcific tendinitis, adhesive capsulitis, rotator cuff tear, cervical pathology (myelopathy and radiculopathy), other pathologies of upper extremity (including contractures and peripheral nerve injuries), systemic musculoskeletal disorders, cardiac problems precluding rehabilitation programs, uncompliant patients leaving the exercise program for 2 days in a week. One of our exclusion criteria was posterior capsular contracture. It was reported that posterior capsular contractures limiting crossover adduction and flexion may accompany impingement syndrome in some patients [8,20]. In these patients, pendulum exercises alone are not effective without posterior capsule stretching exercises. Therefore, these patients were not included in the study. During examination of shoulder, patients with limitation of motion in 3 active movements of 4 positions were diagnosed as having posterior capsular contractures. These positions are flexion (more than 15◦ limitation of range of motion (ROM)), internal rotation during abduction (more than 15◦ of limitation of ROM), horizontal abduction (more than 15◦ limitation of ROM), and reaching lower scapular pole while hand is on the back (limitation of ROM more than 10 centimeters in contrast to contralateral side) [6]. pr 14 ed 13 ct 12 rre 11 co 10 portant role in the etiology of shoulder impingement syndrome [3]. It is postulated that narrowing of the subacromial space along with the abduction of shoulder causes dynamic changes in this space, and rehabilitation protocols towards normalization of subacromial space should improve the outcomes [4–8]. Reorganization of disrupted shoulder kinematics, posture exercises, strengthening of rotator cuff muscles are all some of the conservative treatment options advised in the literature for subacromial impingement patients. However, most of the studies reported the results of combination therapies including multiple exercises. Effects of different shoulder positions on acromiohumeral distance (AHD) measurements were studied in healthy volunteers and these studies suggested a need to investigate the effects of isolated exercises on subacromial space width in impingement patients [9–11]. Early intervention of joint mobilization in patients with painful shoulder plays an important role for preservation of shoulder kinematics, and prevention of adhesions [12]. Since Codman’s pendulum exercises suggested in early periods of painful shoulder provide increase on range of motion and perfusion of nutritional substances, and decrease in pain with an effect of distraction and oscillation, pendulum exercises take part in most of the rehabilitation programs [13,14]. Although many shoulder rehabilitation programs include pendulum exercises, guidelines are limited to determine the choice of weighted or un-weighted pendulum exercises. Moreover effect of weighted and unweighted pendulum exercises on AHD is obscure. Ultrasonography (US) has been reported to be a valid and reliable tool for measurement of AHD and for evaluation of results of various treatment modalities [6,15]. Change in AHD following combined rehabilitation programs was reported previously [6,16]. However there have been no reports studying the effects of solo pendulum exercises on AHD. Our hypothesis were that the pendulum exercises would lead to improvement in shoulder function and AHD. Furthermore effects of weighted and un-weighted pendulum exercises on AHD would be different. Therefore, we aimed to ascertain the effects of weighted and unweighted solo pendulum exercises on ultrasonographic measurements of AHD and clinical symptoms in patients with subacromial impingement syndrome. un 8 9 N. Akkaya et al. / Pendulum and Acromiohumeral distance oo 2 File: bmr–1-bmr737.tex; BOKCTP/xhs p. 2 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 55 2. Materials and methods 2.1. Exercise program 105 56 Our research was planned as a prospective, randomized, controlled, and single blinded study. Patients di- Patients were randomized to performing weighted pendulum exercises or performing un-weighted pen- 106 57 107 Galley Proof 22/07/2016; 14:23 File: bmr–1-bmr737.tex; BOKCTP/xhs p. 3 N. Akkaya et al. / Pendulum and Acromiohumeral distance 3 Fig. 1. Ultrasonographic imaging of acromio humeral distance. (A) Measurement of acromio humeral distance at 0◦ shoulder abduction; (B) Measurement of acromio humeral distance at 30◦ shoulder abduction; (C) Measurement of acromio humeral distance at 60◦ shoulder abduction. a, Acromion. h, Humerus. 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 2.2. Evaluation parameters 140 2.2.1. Pain level Visual analog scale (score 0 means no pain; score of 10 means the worst pain) was used to quantify the pain level during night, activity and inactivity periods. 141 142 143 n si o er fv 115 116 2.2.3. Functional status Shoulder Pain Disability Index (SPADI) questionnaire was used to evaluate functional status of the patients. SPADI scores pain in the previous week (5 headings) and disability (8 headings) and composed of 13 questions with 2 subscales. In two subscales, answers were scored in between 0 (no pain or disability) and 10 (worst pain and disability), and the sum of the scores was recorded. Total SPADI score varies in between 0 and 100, and higher scores refer to worse shoulder pain and function [22,23]. All clinical evaluations were performed just before the beginning of the exercise program and following the completion of the 4 weeks of the program by the same physician (FS) blinded to therapy group. oo 114 pr 113 2.2.2. Range of motion Shoulder active flexion, abduction, and internal and external rotation were measured using goniometer. Range of motion of these active movements were recorded and scored according to Shoulder Constant score (between 0 to 40) [21]. ed 112 ct 111 rre 110 dulum exercises. All groups were trained for the restriction of daily activities including upper limb activities above the head, restriction of heavy object lifting, lying on affected side during the night). Ice pack applications were encouraged 3 times daily for 10 minutes each. Patients were allowed to use oral paracetamol up to 4 grams. Amount of medication consumption were questioned in each visit of the patient weekly, and recorded as the daily use count of 500 mg acetaminophen tablets. Pendulum exercises were prescribed to the patients for 4 weeks, 3 times daily. In each session (ten minutes), exercises were repeated for each direction of shoulder motion. Handouts of schematic diagrams for exercises were distributed to the patients and the first session was applied under the supervision of a physician to standardize the trunk and hip positions of the patients during exercises. Patients were positioned with the healthy arm resting on the table, and they hang down the side of impingement for free motion with the movement of trunk slightly back and forth or right and left respectively corresponding to pendulum exercises of abduction and adduction, and flexion and extension. Weighted pendulum exercise group performed exercises with a 1.5 kilograms of weight (hand held dumbbell) while un-weighted pendulum exercise group performed exercises free of weight [12]. Physical examinations of the patients were performed weekly and adherence of the patients to the exercise program was checked from the charts that were distributed to the patients. co 109 un 108 2.2.4. Ultrasonographic imaging The US examinations were performed using a sonographic scanner (Logiq P5, GE, Healthcare) and 5– 12 MHz linear probe just before the beginning of the exercise program and just after the completion of the 4 weeks of exercise program. Ultrasonographic measurement of sub-acromial space was performed by placing US probe in between acromion and humeral head longitudinally on lateral side of the shoulder, and tangential interval in between hyperechoic structures (edge of the acromion and humeral head) was measured and recorded. This interval has been referred as entrance of sub-acromial space in the literature [6]. US measurements were performed while 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 Galley Proof 22/07/2016; 14:23 4 File: bmr–1-bmr737.tex; BOKCTP/xhs p. 4 N. Akkaya et al. / Pendulum and Acromiohumeral distance Table 1 Comparison of demographic data between weighted and un-weighted pendulum exercises groups Age (years)∗ Body mass index (kg/m2 )∗ Symptom duration (months)∗ Daily shoulder activity score∗ Gender F M Occupation Desk job Laborer Housewife Retired Side of impingement Right Left History of shoulder trauma No Yes Weighted group (N = 18) 42.9 ± 8.5 (25–55) 27.3 ± 3.9 (21.2–34.1) 7.2 ± 4.3 (2–12) 1.2 ± 1.5 (0–6) Unweighted group (N = 16) 40.4 ± 9.4 (24–55) 26.5 ± 5.3 (19.5–38.5) 6.6 ± 4.1 (2–12) 2.2 ± 2.1 (0–7) 12 (66.7%) 6 (33.3%) 11 (68.8%) 5 (31.2%) 6 (33.3%) 5 (27.8%) 7 (38.9%) 0 6 (37.5%) 4 (25%) 4 (25%) 2 (12.5%) 12 (66.7%) 6 (33.3%) 9 (56.3%) 7 (43.7%) 15 (83.3%) 3 (16.7%) 13 (81.3%) 3 (18.8%) 0.420 si o The data were analyzed with Statistical Package for Social Sciences software (SPSS Version 17, Chicago, IL, USA). Descriptive statistics are given as mean ± standard deviation, frequency, and percentage. Interclass correlation coefficient (confidence interval 95%) 191 192 193 194 195 196 197 198 199 200 201 205 206 207 208 ed ct 189 190 rre 188 co 186 187 un 184 185 er 204 183 fv 2.3. Statistical analysis 182 oo 203 181 0.874 pr 202 the patient was sitting and the elbow flexed at 90◦ , and recorded at 0◦ , 30◦ , and 60◦ of shoulder active abduction (Fig. 1). To obtain shoulder neutral rotation and avoid shoulder internal rotation while performing the measurements, forearm of the patient was maintained in pronation. To standardize measurements during active shoulder abduction at 30◦ and 60◦ , a custom apparatus (Otto Bock, Acro Asist, Arm Abduction Orthosis, Germany) stabilized to body of the patient at thoracic level with velcro straps was utilized, and 30◦ and 60◦ -angle pillows were inserted underarm, respectively (Fig. 2). Measurements in each position (0◦ , 30◦ , 60◦ of abduction) were repeated 3 times and average values were recorded. Narrowing of AHD from 0◦ to 30◦ at pretreatment evaluation (0◦ pretreatment AHD −30◦ pretreatment AHD) and post-treatment evaluation (0◦ post-treatment AHD −30◦ post-treatment AHD) were calculated. Same calculations were made for narrowing of AHD from 0◦ to 60◦ at pretreatment and post-treatment evaluations. The observer performing US measurements (NA) was blinded to exercise programs of the patients. US measurements were repeated at least two hours later to test the intra-rater reliability. 180 n 0.533 *: Values are presented in means ± standard deviations. 179 p 0.443 0.597 0.175 0.384 0.897 Fig. 2. Placement of custom made apparatus for standardization of arm position. Figure represents the position at 60◦ shoulder abduction. was used for intra-observer reliability of US measurements. The groups (mean values) were compared using Mann Whitney U test or Chi-square tests, where appropriate. Wilcoxon test was used for comparison of pretreatment and post-treatment results of each group. Statistical significance was set at p < 0.05. 214 3. Results 215 One patient from un-weighted pendulum group was excluded from the study because of the incompliance to exercise schedule at first week (Fig. 3). Thirty-four patients (23 females and 11 males; mean age 41.7 216 209 210 211 212 213 217 218 219 Galley Proof 22/07/2016; 14:23 File: bmr–1-bmr737.tex; BOKCTP/xhs p. 5 N. Akkaya et al. / Pendulum and Acromiohumeral distance Enrollment 5 Patients invited (n = 54) Assessed for eligibility (n = 45) Excluded (n =10) • Not meeting inclusion criteria (n= 6) • Declined to participate (n= 2) • Declined, other reason (n=2) Randomized: (n = 35) n Received un-weighted pendulum exercise program (n = 17) si o Allocation er • Not attending exercise program (n=1) oo fv Lost to follow-up (n=0) Analysis Follow-up Received weighted pendulum exercise program (n = 18) Analyzed (n = 16) pr Analyzed (n = 18) 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 ct 223 rre 222 co 221 ± 8.9 (24–55) years) were completed the exercise schedule. Eighteen patients were in weighted pendulum group and 16 patients were in un-weighted pendulum group. Dominant side was right hand in all patients. There was no statistically significant difference in between patients concerning demographic data (p > 0.05, Table 1). Significant improvement was detected in both weighted and un-weighted pendulum exercise groups between before treatment and after treatment evaluations in terms of night, activity and rest VAS scores, and SPADI scores (p < 0.05, Table 2). There was no significant difference between two groups concerning daily acetaminophen consumption (p = 0.772). Intra-observer reliabilities were high for ultrasonographic AHD measurements at 0◦ , 30◦ , and 60◦ shoulder abductions (ICC = 0.988, ICC = 0.988, and ICC = 0.985, respectively; p = 0.001). There was no statistically significant difference between groups in terms of pre and post treatment measurements of AHD during 0◦ , 30◦ , and 60◦ shoulder abduction (p > 0.05, Table 3). In addition, there was no statistically significant difference between pre and post treatment measurements of AHD during 0◦ , 30◦ , un 220 ed Fig. 3. Flow diagram of the study. and 60◦ shoulder abduction in each group (p > 0.05, Table 3). There was no statistically significant difference between groups in terms of narrowing of AHD at pre and post treatment evaluations (p > 0.05, Table 4). In addition, there was no statistically significant difference for narrowing of AHD in each group between pre and posttreatment evaluations (p > 0.05, Table 4). 244 245 246 247 248 249 250 251 4. Discussion 252 According to results of this study evaluating the effects of weighted or un-weighted pendulum exercises on pain, functional status, and ultrasonographic AHD measurements in subacromial impingement patients, a significant improvement was achieved in both weighted and un-weighted pendulum exercise groups in terms of pain and functional scores following 4 weeks of exercise program, while no significant difference was detected neither between groups nor in specific group for ultrasonographic AHD measurements. Savoie et al. [16] studied effects of 6 week rehabilitation program with movement training consisting of 253 254 255 256 257 258 259 260 261 262 263 264 Galley Proof 22/07/2016; 14:23 6 File: bmr–1-bmr737.tex; BOKCTP/xhs p. 6 N. Akkaya et al. / Pendulum and Acromiohumeral distance Table 2 Pre and post-treatment clinical data of weighted and unweighted pendulum exercises groups Un-weighted group (N = 16) 4.0 ± 2.6 (0–7) 2.5 ± 2.7 (0–8) 0.003 5.9 ± 2.1 (2–9) 3.8 ± 2.6 (0–9) 0.001 3.1 ± 2.5 (0–6) 1.7 ± 0.9 (0–3) 0.005 39.8 ± 1.0 (36–40) 39.8 ± 1.0 (36–40) 1 62.9 ± 29.9 (24–125) 43.4 ± 35.2 (2–119) 0.001 1.8 ± 0.9 (0–3) p 0.905 0.463 0.851 0.347 0.144 0.721 0.772 0.772 0.825 0.597 0.772 si o n Weighted group (N = 18) 5.1 ± 3.2 (0–9) 2.6 ± 2.8 (0–9) 0.001 6.6 ± 1.2 (4–8) 3.5 ± 2.2 (0–8) 0.001 2.4 ± 2.1 (0–6) 0.9 ± 1.2 (0–3) 0.006 40.0 ± 0 (0–40) 40.0 ± 0 (0–40) 1 62.0 ± 21.5 (27–113) 32.4 ± 18.7 (8–66) 0.001 1.6 ± 0.8 (0–3) Pretreatment VAS night Posttreatment VAS night p Pretreatment VAS activity Posttreatment VAS activity p Pretreatment VAS rest Posttreatment VAS rest p Pretreatment constant Score Posttreatment constant Score p Pretreatment SPADI score Posttreatment SPADI score p Daily asetominophen use Unweighted group (N = 16) 1.13 ± 0.18 (0.84–1.54) 1.13 ± 0.17 (0.95–1.57) 0.501 1.07 ± 0.19 (0.77–1.59) 1.10 ± 0.16 (0.91–1.54) 0.205 1.03 ± 0.21 (0.77–1.57) 1.04 ± 0.20 (0.78–1.56) 0.068 p 0.851 0.986 0.878 0.670 0.851 0.986 ed pr oo fv Weighted group (N = 18) 1.12 ± 0.23 (0.75–1.65) 1.11 ± 0.20 (0.78–1.57) 0.887 1.05 ± 0.19 (0.55–1.29) 1.06 ± 0.19 (0.55–1.29) 0.257 1.03 ± 0.19 (0.69–1.42) 1.05 ± 0.22 (0.69–1.46) 0.571 Pretreatment 0◦ AHD (cm) Posttreatment 0◦ AHD (cm) p Pretreatment 30◦ AHD (cm) Posttreatment 30◦ AHD (cm) p Pretreatment 60◦ AHD (cm) Posttreatment 60◦ AHD (cm) p er Table 3 Pre and post-treatment ultrasonographic data of weighted and un-weighted pendulum exercise groups rre ct Table 4 Comparison of pretreatment and post-treatment narrowing of acromiohumeral distance in each group and between weighted and unweighted pendulum exercises groups un co Pretreatment 0◦ −30◦ narrowing (cm) Posttreatment 0◦ −30◦ narrowing (cm) p Pretreatment 0◦ −60◦ narrowing (cm) Posttreatment 0◦ −60◦ narrowing (cm) p 265 266 267 268 269 270 271 272 273 274 275 276 277 Weighted group (N = 18) 0.07 ± 0.09 (−0.09–0.25) 0.06 ± 0.11 (−0.15–0.32) 0.266 0.09 ± 0.11 (−0.07–0.37) 0.06 ± 0.14 (−0.21–0.41) 0.144 shoulder control exercises, strengthening, stretching, and patient education on functional status and AHD of 25 patients with subacromial pain syndrome and reported significant improvement of functional status and AHD measurements of patients following rehabilitation. Since we aimed to evaluate effects of pendulum exercises on AHD, strengthening and stretching exercises were not included in our program. Following patient education, ice treatment and 4 weeks of weighted or un-weighted pendulum exercise program, significant improvement was achieved for both groups in terms of functional status and pain severity, however, there was no difference for AHD in both Unweighted group (N = 16) 0.06 ± 0.11 (−0.13–0.24) 0.02 ± 0.07 (−0.11–0.19) 0.171 0.09 ± 0.13 (−0.13–0.24) 0.09 ± 0.11 (−0.09–0.34) 0.918 p 0.772 0.484 0.851 0.621 groups between pre and post treatment measurements in our study. Indifference of AHD measurements while functional status of patients improving might be due to exclusion of strengthening -especially strengthening with humeral depressors- and stretching exercises in our program composed of solely pendulum exercises. Duration of our exercise program was four weeks and shorter than the 6 week program of Savoie et al. [16]. Length of our exercise program which might be insufficient to achieve ultrasonographic AHD difference might be the another reason for detection of insignificant AHD alterations. Superior translation of humeral head along with deltoid muscle activity accompanying the first part of ab- 278 279 280 281 282 283 284 285 286 287 288 289 290 291 Galley Proof 22/07/2016; 14:23 File: bmr–1-bmr737.tex; BOKCTP/xhs p. 7 N. Akkaya et al. / Pendulum and Acromiohumeral distance 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 n 303 si o 302 er 301 fv 300 oo 299 Therefore, patients with posterior capsule contracture were excluded from our study. Following patient education and 4 weeks of weighted or un-weighted pendulum exercise program, significant improvement was achieved for both groups in terms of clinical and functional status of patients while there was no difference in AHD measurements in our study. Lack of ultrasonographic supraspinatus tendon thickness or echogenicity evaluations is one of the limitations of our study. Changes in tendon might have resulted in insignificant AHD changes along with significant improvements in clinical and functional status. Although pendulum exercises have not provided an increase in AHD, facilitation of entrance of nutritional substances into joint space and removal of waste, and suppression of inflammation by this way might have resulted in improvement clinical status of the patients. Lack of radiographic evaluation of acromion morphologic characteristics and classification according to Bigliani is another limitation of our study [25]. Future researches are needed to highlight the effects of anatomical variations on outcomes of pendulum exercises. Use of standard 1.5 kg weight for weighted pendulum exercises could be another limitation. Calculation of weight for pendulum exercises according to the body weight of each patient might be an effective method to achieve AHD change. Again there is need for the future studies to detect the optimal weight for pendulum exercises to attain the AHD improvement. Another limitation of our study was small number of patients. There is a need for future studies with large number of patients. pr 298 ed 297 ct 295 296 rre 294 duction is proposed to be responsible for narrowing of AHD in a review evaluating biologic mechanisms of subacromial impingement syndrome [21]. Studies evaluating muscle activity by use of electromyography (EMG) were conducted in the literature taking into consideration that muscle activity during exercises might affect AHD. In a research studying muscle activity around shoulder during pendulum exercises with superficial EMG, no difference was detected between muscle activity during pendulum exercises and during continuous passive motion [24]. Ellsworth et al. [12] studied effects of weighted (1.5 kg) pendulum exercises on EMG activities of deltoid and infraspinatus muscles in 9 patients with shoulder pathology (one shoulder impingement, others have different shoulder pathologies such as superior labral anterior posterior repair, acromioclavicular joint decompression etc.) and in 17 volunteers without shoulder problems. Addition of weight had no significant effect on an increase in deltoid and infraspinatus muscles EMG activity for both groups in their study. However, more latent relaxation in supraspinatus and upper trapezius muscles was reported for patients with shoulder problems during pendulum exercises of Codman [12]. Since we did not make use of EMG in our study, we cannot comment on the effects of muscle activity on AHD. Desmeules et al. [6] studied correlation between functional status before and after rehabilitation and AHD changes in 7 patients with impingement and 13 healthy volunteers. Patient education, ice application, rotator cuff elastic band exercise, scapula-thoracic and glenohumeral control exercises, and posterior capsule stretching exercises in case of posterior capsule contracture were prescribed for 4 weeks in a total of 12 cessions, and AHD measurements with US were performed at 0◦ , 45◦ and 60◦ of shoulder abduction before and after the rehabilitation protocol in their study. Significant decrease in pretreatment AHD measurements was detected in impingement group between 0◦ (12.0 ± 1.9 mm) and 45◦ (9.5 ± 2.7 mm), and between 0 ◦ and 60◦ (9.6 ± 2.3 mm; p < 0.001). Following prescribed rehabilitation protocol, although functional status of the patients was detected to be better, there was no statistically significant improvement. In addition, they reported correlation between decrease in AHD narrowing and improvement in shoulder functional scores [6]. In contrast to the research conducted by Desmeules et al. [6] strengthening and stretching exercises were not included in our rehabilitation protocol since the effects of weighted and un-weighted pendulum exercises on AHD were studied in our research. co 293 un 292 7 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 5. Conclusion 375 According to results of this study evaluating effects of 4 week weighted or un-weighted solo pendulum exercises without strengthening and stretching, no significant difference was detected in terms of measurements of AHD while significant improvements achieved in terms of pain and functional status in impingement patients. Further researches are needed to explain the mechanism that how weighted and un-weighted solo pendulum exercises improve functional status of patients without apparent change in AHD measurements. 376 377 378 379 380 381 382 383 384 385 Conflict of interest 386 The authors declare that they have no conflict of interest. 388 387 Galley Proof 22/07/2016; 14:23 8 Pamukkale University Medical Faculty, Denizli, Turkey (No: 02). [3] 400 401 [4] 402 403 [5] 404 405 406 [6] 407 408 409 410 [7] 411 412 413 414 [8] 415 416 417 [9] 418 419 420 421 [10] 422 423 424 425 426 427 [11] si o 399 er 397 398 fv [2] oo 396 pr 395 van der Windt DA, Koes BW, de Jong BA, et al. Shoulder disorders in general practice: Incidence, patient characteristics, and management. Ann Rheum Dis. 1995; 54: 959–964. Neer CS II. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: A preliminary report. J Bone Joint Surg Am. 1972; 54: 41–50. van der Heijden GJ. Shoulder disorders: A state of the art review. Baillieres Clin Rheumatol. 1999; 13: 287–309. Bigliani LU, Levine WN. Subacromial impingement syndrome. J Bone Joint Surg Am. 1997; 79: 1854–1868. Chen SK, Simonian PT, Wickiewicz TL, et al. Radiographic evaluation of glenohumeral kinematics: A muscle fatigue model. J Shoulder Elbow Surg. 1999; 8: 49–52. Desmeules F, Minville L, Riederer B, et al. Acromio-humeral distance variation measured by ultrasonography and its association with the outcome of rehabilitation for shoulder impingement syndrome. Clin J Sport Med. 2004; 14: 197–205. Horrigan JM, Shellock FG, Mink JH, et al. Magnetic resonance imaging evaluation of muscle usage associated with three exercises for rotator cuff rehabilitation. Med Sci Sports Exerc. 1999; 31: 1361–1366. Kamkar A, Irrgang JJ, Whitney SL. Nonoperative management of secondary shoulder impingement syndrome. J Orthop Sports Phys Ther. 1993; 17: 212–224. Graichen H, Hinterwimmer S, von Eisenhart-Rothe R, et al. Effect of abducting and adducting muscle activity on glenohumeral translation, scapular kinematics and subacromial space width in vivo. J Biomech. 2005; 38: 755–760. Hinterwimmer S, Von Eisenhart-Rothe R, Siebert M, et al. Influence of adducting and abducting muscle forces on the subacromial space width. Med Sci Sports Exerc. 2003; 35: 2055– 2059. White CE, Dedrick GS, Apte GG, et al. The effect of isometric shoulder internal and external rotation on the acromiohumeral distance. Am J Phys Med Rehabil. 2012; 91: 193–199. ed [1] 394 Ellsworth AA, Mullaney M, Tyler TF, et al. Electromyography of selected shoulder musculature during un-weighted and weighted pendulum exercises. N Am J Sports Phys Ther. 2006; 1: 73–79. [13] Aktas I, Akgun K, Cakmak B. Therapeutic effect of pulsed electromagnetic field in conservative treatment of subacromial impingement syndrome. Clin Rheumatol. 2007; 26: 1234–1239. [14] Kisner C, Colby LA. Therapeutic exercises: Foundations and techniques. 3rd ed. Philadelphia PA: FA Davis Co; 1996. [15] Maenhout A, Van Eessel V, Van Dyck L, et al. Quantifying acromiohumeral distance in overhead athletes with glenohumeral internal rotation loss and the influence of a stretching program. Am J Sports Med. 2012; 40: 2105–2012. [16] Savoie A, Mercier C, Desmeules F, et al. Effects of a movement training oriented rehabilitation program on symptoms, functional limitations and acromiohumeral distance in individuals with subacromial pain syndrome. Man Ther. 2015; 20: 703–708. [17] Hawkins RJ, Kennedy JC. Impingement syndrome in athletes. Am J Sports Med. 1980; 8: 151–158. [18] Neer CS II. Impingement lesions. Clin Orthop. 1983; 173: 70–77. [19] Jobe FW, Jobe CM. Painful athletic injuries of the shoulder. Clin Orthop. 1983; 173: 117–124. [20] Michener LA, McClure PW, Karduna AR. Anatomical and biomechanical mechanisms of subacromial impingement syndrome. Clin Biomech (Bristol, Avon). 2003; 18: 369–379. [21] Constant CR, Murley AHG. A clinical method of functional assessment of the shoulder. Clin Orthop. 1987; 214: 160–164. [22] Bumin G, Tuzun EH, Tonga E. The Shoulder Pain and Disability Index (SPADI): Cross-cultural adaptation, reliability and validity of the Turkish version. J Back Musculoskeletal Rehabil. 2008; 21: 57–62. [23] MacDermid JC, Solomon P, Prkachin K. The shoulder pain and disability index demonstrate factor, construct and longitudinal validity. BMC Musculoskelet Disord. 2006; 7: 12. [24] Dockery ML, Wright TW, LaStayo PC. Electromyography of the shoulder: An analysis of passive modes of exercise. J Orthopedics. 1998; 21; 1181–1184. [25] Bigliani LU, Levine WN. Current concepts reviewsubacromial impingement syndrome. J Bone Joint Surg Am. 1997; 79: 1854–1868. n References ct 393 [12] rre 392 Ethical board registration number co 390 391 N. Akkaya et al. / Pendulum and Acromiohumeral distance un 389 File: bmr–1-bmr737.tex; BOKCTP/xhs p. 8 428 429 430 431 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 447 448 449 450 451 452 453 454 455 456 457 458 459 460 461 462 463 464 465 466 467 468 469 470