Subacromial impingement syndrome (IS) is a common disorder associated with functional impairment and disability of the shoulder. The aim of this study was to evaluate the efficacy of Vojta therapy (VT) techniques compared with standard therapy (ST) in patients with subacromial IS. A randomized controlled trial was performed, with 60 patients with IS (mean age, 61±12 years) randomized into two groups: ST (n=30) and ST plus Vojta therapy (SVT, n=30). Both received 15 treatment sessions over 4 weeks. Outcome measures included pain intensity, functionality, joint range of motion (RoM), strength, and quality of life measurements. The efficacy of both treatments was analysed, both comparatively and separately, immediately after completion of treatment and after 3 months. After the intervention, both groups showed statistically significant differences in visual analogue scale (
Subacromial impingement syndrome (IS) consists of an irritation of the rotator cuff tendons where they pass through the coracoacromial arch during shoulder elevation. This causes a narrowing acromiohumeral distance, which is thought to be the cause of subacromial IS-related pain in the anterolateral and upper shoulder, frequently reducing its functionality, mainly with regard to abduction, rotation, and flexion of over 60° (
Patient ages (range, 42–58 years) are typical for IS (
Initial treatment of IS is conservative in most cases (
Reflex locomotion or Vojta therapy (VT) consists of administering pressure to defined zones of the body with the patient in the prone, supine, or side-lying position to activate global and innate locomotive patterns or complexes, namely the creeping reflex and the rolling reflex. Both complexes provoke coordinated, rhythmic activation of the skeletal musculature throughout the entire body (
This is an analytical experimental study conducted as a randomized clinical trial with two parallel intervention levels: a control group and an experimental group. All patients were diagnosed with IS. All participants read and signed an informed consent form prior to study enrolment. The study protocol was approved by the local Ethical Committee of the Mancha Central Hospital and conducted in accordance with the Helsinki declaration. This project was retrospectively registered in
Sixty-five potentially eligible patients were recruited from IS associations from February 2015 through December 2016. Inclusion criteria for this study were: Patients aged between 18 and 85 years and diagnosed previously with IS, who fulfil at least three of the following criteria: (a) pain in active abduction (70°–120°), considered impingement +; (b) pain on palpation of any of the following osteotendinous insertions: infraspinatus, teres minor, supraspinatus, subscapularis, and biceps; (c) pain in any of the following isometric contractions: abduction (first 10°), internal rotation (in the anatomical position and with 90° elbow flexion), and shoulder flexion; (d) positive on the Neer and Hawkins tests (
The randomization sequence was generated using the programme EPIDAT ver. 4.2 (Xunta de Galicia, Galicia, Spain). The sequence consisted of random permutation blocks, each with four to six elements of length, to avoid imbalances in the groups in case of attrition. The sequence was concealed in sealed, serialised, opaque envelopes (
The patients that fulfilled all inclusion criteria and gave their informed consent to participate were assigned either to the control group or to the experimental group at random and with equal probability. Interventions in both groups were applied by the same physical therapist with 3-year experience in manual therapy and the management of musculoskeletal pain disorders. Both groups were provided with the same instructions regarding effectiveness of the treatment.
(a) Control group: standard therapy (ST) (~50 min/session):
- TENS (20 min, phase duration=0.10 μsec, frequency= 50 Hz). The intensity applied depended on the patient’s tolerance for the treatment (
- Kinesiotherapy. In stages: at first assisted (with isometric exercises), then free, and finally, with resistance, usually using elastic bands (
- Cryotherapy (5 min).
(b) Experimental group: standard plus VT (SVT) (VT, ~20 min/session): application of the reflex creeping complex, activating several stimulus points on the facial and the nuchal sides (
Changes in the following variables; pain (main result indicator), RoM, strength, functionality; and quality of life (QoL), were analysed using validated measurement scales. Pain intensity was assessed using a visual analogue scale (VAS=0: no pain, and VAS= 10: maximum pain) (
Data were analysed using IBM SPSS Statistics ver. 22.0 (IBM Co., Armonk, NY, USA), with an intention-to-treat analysis using the last-value-forward method. The results are expressed as means, standard deviations, and/or 95% CIs. The Kolmogorov–Smirnov test showed a normal distribution of the data. Separate 2×3 mixed model analysis of variances, with the group (experimental, control) as the between-subjects factor and time (baseline, postintervention at 4 weeks, and 3-month follow-up) as within-subject factors, were conducted to examine the effects of the intervention on VAS, DASH, and CMS as the dependent variables. The main hypothesis of interest was the group×time interaction.
Sixty-five consecutive patients were screened and 60 patients (61±12 years, 70% women) were eligible and agreed to participate.
The time factor (
The outcome for DASH, RoM, and strength of the affected limb (CMS) demonstrated a significant time factor (
In terms of QoL, ST led to improvements in two dimensions immediately after treatment: role-physical (
These results indicate that upon completion of either the standard or experimental therapy, as well as after the 3-month follow-up period for either treatment, patients noted improvements in pain, RoM, and strength. However, the results are clearly superior when VT is added to the treatment. Furthermore, improvements in functionality and QoL were only observed in patients receiving VT along with the ST.
Specifically, upon completion of SVT and after the 3-month follow-up, the decrease in pain experienced by patients as measured using the VAS scale was 3.0 and 4.2 points greater, respectively, than that experienced by patients in the control group. The literature contains several studies that have observed reductions in bodily pain at the end of ST according to the VAS scale. The efficacy of different modalities (ultrasound therapy, laser treatments, and therapeutic exercises) (
Indeed, our results from the DASH test show that functionality only improved after SVT, an improvement that was 3.5 points greater after the 3-month follow-up period. Likewise, at the end of the treatment period, changes in the role-physical subdomain of the SF-12 Survey were only observed in the SVT group, with these effects increasing by 17 points at the end of the 3-month follow-up. Other authors have made reference to improvements in functionality according to the DASH scale after applying strengthening exercises (
We also found that deficits in RoM and strength (as measured using the Constant-Murley Scale) improved in both groups, an improvement that was 26 points greater when VT was added to ST. Three months after the completion of treatment, these improvements were even greater—30 points—for the SVT group. Several authors have estimated a significant improvement of 15 points when patients perform exercises aimed specifically at the scapula and rotator cuff stabilisers compared to nonspecific exercises (
The most common modalities of physiotherapy used in the treatment of IS include electroanalgesics, TENS, ultrasound, cryotherapy, kinesitherapy, and exercise programmes. TENS is one of the least invasive techniques for treating pain and is the most used in our healthcare centre. Like other authors, we have argued for the positive effects achieved with TENS in reducing pain and increasing mobility (
The limitations of our study stem from its design, which did not include a nontreatment control group or a placebo group. Since the population sample was intentional, the data is not applicable to populations assigned to healthcare areas other than that used in our study. The lack of follow-up beyond 3 months is another limitation. It must also be noted that IS encompasses different pathologies with diverse anatomopathological origins; in fact, there is no consensus on the actual diagnosis of IS (
In conclusion, considering the number of athletes affected by subacromial IS, the growing number of athletes over 40 years old, the lack of curative treatments, and the side effects of many pharmacological pain treatments, more research in this field is necessary. In addition, the study of methods involving noninvasive interventions to achieve symptom relief is also crucial. In this study, we have evaluated for the first time the use of VT applied to IS. This procedure has been shown to be a safe and efficient conservative alternative, as it contributes to improving patient QoL with significant results that are superior to those of standard therapies, not only in the reduction of bodily pain, but also in the recovery of functionality, RoM, and strength. This new possibility, which would be accessible to any physiotherapeutic facility, could have a considerable economic and social impact, considering that it sustains and even improves patient functionality over time.
The authors received no financial support for this article.
No potential conflict of interest to this article was reported.
Consort flow chart.
Control group. (A) Application of transcutaneous electrical nerve stimulation current. Placement of four electrodes on the skin of the areas identified as the most painful (normally under the acromion and above the supraspinatus. Application of cathodes at the most painful points, and of the anodes near them. (B) Application of pulsating ultrasound. (C) Rehabilitation through kinesitherapy.
Experimental group. (A) Crawling reflex. Stimulation of the acromial area and the buttock on the nuchal side. (B) Rolling reflex, supine position. Stimulation of the pectoral area with head-guided resistance. (C) Rolling reflex, lateral position. Areas of stimulation: medial edge of the scapula and anterior superior iliac spine from the top side.
Characteristics of patients at baseline
Characteristic | Exp (N=30) | Con (N=30) | |
---|---|---|---|
Age (yr) | 58.5±13 | 63.5±10.5 | 0.105 |
| |||
Weight (kg) | 78.1±16.2 | 78.6±14.3 | 0.119 |
| |||
Height (cm) | 160.6±9.6 | 161±8.9 | 0.186 |
| |||
Body mass index (kg/m2) | 30.0±6.1 | 30.6±5.0 | 0.263 |
| |||
Progression time (mo) | 18.6±37.3 | 11.1±11.3 | 0.340 |
| |||
Gender | |||
Female | 19 (63.3) | 23 (76.7) | 0.260 |
Male | 11 (36.7) | 7 (23.3) | |
| |||
Level of education | |||
Primary | 25 (83.3) | 27 (90) | 0.220 |
Secondary | 4 (13.3) | 3 (10) | |
Advanced | 1 (3.3) | - | |
| |||
Employment status | 0.609 | ||
On leave | 1 (3.7) | - | |
Active | 8 (25.9) | 6 (20.7) | |
Retired | 8 (25.9) | 6 (20.7) | |
Homemaker | 11 (37.1) | 16 (51.7) | |
Unemployed | 2 (7.4) | 2 (6.9) | |
| |||
Type of work | 0.519 | ||
UL mobility | 23 (76.7) | 25 (83.3) | |
UL sedentary | 7 (23.3) | 5 (16.7) | |
| |||
Affected limb | 0.301 | ||
Left | 16 (53.3) | 12 (40) | |
Right | 14 (46.7) | 18 (60) | |
| |||
Dominant limb | 0.196 | ||
Yes | 12 (40) | 17 (56.7) | |
No | 18 (60) | 13 (43.3) | |
| |||
Analgesics | 0.999 | ||
Yes | 15 (50) | 16 (53.3) | |
No | 15 (50) | 14 (46.7) | |
| |||
Previous treatments | 0.467 | ||
None | 17 (56.7) | 15 (50) | |
Physiotherapy | 5 (16.7) | 6 (20) | |
Drugs | 4 (13.3) | 7 (23.3) | |
Drugs and physio | 4 (13.3) | 2 (6.7) | |
| |||
Sedentary habits | 0.999 | ||
Yes | 4 (13.3) | 3 (10) | |
No | 26 (86.7) | 27 (90) | |
| |||
No. of CV risk factors | 0.237 | ||
0 | 19 (63.3) | 16 (53.3) | |
1 | 7 (23.3) | 10 (33.3) | |
2 | 4 (13.3) | 2 (6.7) | |
3 | - | 2 (6.7) | |
| |||
Tobacco use | |||
Yes | 4 (13.3) | 2 (6.7) | |
No | 26 (86.7) | 28 (93.3) | |
| |||
Hypothyroidism | 0.492 | ||
Yes | 2 (6.7) | - | |
No | 28 (93.3) | 30 (100) | |
| |||
Mood disorders | 0.999 | ||
Yes | 3 (10) | 4 (13.3) | |
No | 27 (90) | 26 (86.7) | |
| |||
Neuromuscular disorders | 0.353 | ||
Yes | 1 (3.3) | 4 (13.3) | |
No | 29 (96.7) | 26 (86.7) | |
| |||
Osteoarticular diseases | 0.542 | ||
Yes | 24 (80) | 22 (73.3) | |
No | 6 (20) | 8 (26.7) |
Values are presented as mean±standard deviation or number (%).
Exp, experimental group; Con, control group; UL, upper limb; CV, cardiovascular.
Pain intensity and disability
Outcome | Group | Difference within groups | Difference between groups | |||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
|
|
| ||||||||||
Pre | Post | FU | Post minus Pre | FU minus Pre | Post | FU | ||||||
|
|
|
|
|
|
| ||||||
Exp (n=30) | Con (n=30) | Exp (n=30) | Con (n=30) | Exp (n=30) | Con (n=30) | Exp (n=30) | Con (n=30) | Exp (n=30) | Con (n=30) | Exp minus Con (n=60) | Exp minus Con (n=60) | |
VAS | 7.7±1.0 | 6.2±1.4 | 3.8±1.9 | 5.3±2.0 | 2.4±1.6 | 5.1±2.2 | −3.9 |
−1.0 |
−5.3 |
−1.1 |
1.5 |
2.8 |
| ||||||||||||
DASH | 57.0±14.7 | 50.0±15.1 | 33.1±15.0 | 49.5±19.9 | 27.6±14.8 | 49.5±21.2 | −23.9 |
−0.5±2.8 | −29.4 |
−0.5±3.1 | 16.5 |
21.9 |
| ||||||||||||
CMS affected | 25.1±7.5 | 34.3±9.7 | 56.1±14.4 | 39.2±13.6 | 63.9±12.8 | 42.7±15.1 | 31.0 |
4.9±2.1 | 38.9 |
8.4±2.3 | 16.9 |
21.2 |
| ||||||||||||
CMS unaffected | 71.0±14.8 | 72.0±12.5 | 74.9±13.8 | 73.1±11.5 | 76.3±12.4 | 71.4±12.8 | 3.9±1.1 | 1.1±1.1 | 5.3±1.6 | −0.6±1.6 | 1.9 (−4.9 to 8.7) | 4.9 (−1.8 to 11.7) |
Values are presented as mean±standard deviation or mean (95% confidence interval) difference between groups.
Exp, experimental group; Con, control group; Pre-post, pre and post treatment; FU, follow-up; VAS, visual analogue scale; DASH, disabilities of the arm, shoulder, and hand; CMS, Constant-Murley Scale.
Comparison of the evolution of joint pain, functionality, strength, and range of motion between the two groups under treatment (standard and experimental) after therapy completion and a 3-month follow-up
Variable | Standard | ||
---|---|---|---|
VAS basal-final Standard | −0.97 | 7.714 | <0.0001 |
VAS basal-final Standard+Vojta | −3.95 | ||
| |||
VAS basal-3 months Standard | −1.10 | 10.393 | <0.0001 |
VAS basal-3 months Standard+Vojta | −5.34 | ||
| |||
VAS final-3 months Standard | −0.14 | 3.477 | 0.001 |
VAS final-3 months Standard+Vojta | −1.43 | ||
| |||
DASH basal-final Standard | −0.30 | 6.489 | <0.0001 |
DASH basal-final Standard+Vojta | −24.58 | ||
| |||
DASH basal-3 months Standard | −0.52 | 6.476 | <0.0001 |
DASH basal-3 months Standard+Vojta | −29.41 | ||
| |||
DASH final-3 months Standard | −0.61 | 1.773 | 0.084 |
DASH final-3 months Standard+Vojta | −5.30 | ||
| |||
CMS affected basal-final Standard | 4.83 | −8.781 | <0.0001 |
CMS affected basal-final Standard+Vojta | 30.87 | ||
| |||
CMS affected basal-3 months Standard | 8.41 | −8.245 | <0.0001 |
CMS affected basal-3 months Standard+Vojta | 38.85 | ||
| |||
CMS affected final-3 months Standard | 3.55 | −0.089 | 0.930 |
CMS affected final-3 months Standard+Vojta | 7.84 | ||
| |||
CMS unaffected basal-final Standard | 0.99 | −2.280 | 0.029 |
CMS unaffected basal-final Standard+Vojta | 3.70 | ||
| |||
CMS unaffected basal-3 months Standard | −0.62 | −2.104 | 0.043 |
CMS unaffected basal-3 months Standard+Vojta | 5.36 | ||
| |||
CMS unaffected final-3 months Standard | −1.65 | −0.672 | 0.506 |
CMS unaffected final-3 months Standard+Vojta | 1.37 |
VAS, visual analogue scale; DASH, disabilities of the arm, shoulder, and hand; CMS, Constant-Murley Scale.
Hypothesis testing carried out with Student t-test for independent samples.