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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
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Nuray Akkayaa,∗, Semih Akkayab , Harun R. Gungorb , Gokce Yaşara, Nilgun Simsir Atalaya and
Fusun Sahina
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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
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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-
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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].
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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.
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2. Materials and methods
2.1. Exercise program
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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-
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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.
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2.2. Evaluation parameters
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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.
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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.
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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].
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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.
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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
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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%)
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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%)
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2.3. Statistical analysis
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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.
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*: Values are presented in means ± standard deviations.
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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.
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3. Results
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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
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Enrollment
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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)
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Received un-weighted
pendulum exercise program
(n = 17)
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Allocation
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• Not attending exercise
program (n=1)
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Lost to follow-up (n=0)
Analysis
Follow-up
Received weighted pendulum
exercise program
(n = 18)
Analyzed
(n = 16)
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Analyzed
(n = 18)
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± 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◦ ,
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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).
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4. Discussion
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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
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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
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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
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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)
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Table 3
Pre and post-treatment ultrasonographic data of weighted and un-weighted pendulum exercise groups
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Table 4
Comparison of pretreatment and post-treatment narrowing of acromiohumeral distance in each group and between weighted and unweighted
pendulum exercises groups
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Pretreatment 0◦ −30◦ narrowing (cm)
Posttreatment 0◦ −30◦ narrowing (cm)
p
Pretreatment 0◦ −60◦ narrowing (cm)
Posttreatment 0◦ −60◦ narrowing (cm)
p
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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-
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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.
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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.
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5. Conclusion
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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.
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Conflict of interest
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The authors declare that they have no conflict of interest.
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Galley Proof
22/07/2016; 14:23
8
Pamukkale University Medical Faculty, Denizli, Turkey (No: 02).
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