Value of a clinical test of sub-acromial impingement to predict response to physiotherapy with dynamic humeral centering: A preliminary study

Abstract

BACKGROUND:

Dynamic humeral centering (DHC) is a physiotherapy modality that aims to prevent sub-acromial impingement of rotator cuff tendons. We recently developed a new clinical manoeuver – the Viggo-Cochin test – to enhance the ability of the Neer test to detect sub-acromial impingement. Here we hypothesised whether the DHC effect may differ between individuals with positive and negative Viggo-Cochin test results.

OBJECTIVE:

To assess the association between DHC and Viggo-Cochin test results.

METHODS:

Individuals with shoulder pain due to sub-acromial impingement underwent the Neer and Viggo-Cochin tests at baseline. They were assessed before and after DHC by the Shoulder Pain and Disability Index (SPADI). A positive response to DHC was defined as a 20% reduction in the SPADI.

RESULTS:

We included 50 individuals (53 shoulders). The response to DHC did not differ by Neer test result at baseline: OR 0.73 [95% CI 0.22–2.38] ( $p=$ 0.601). By contrast, the response to DHC was 5-fold higher with a positive than negative Viggo-Cochin test result: OR 5.11 [95% CI 1.47–17.78] ( $p=$ 0.010).

CONCLUSIONS:

We found a higher clinical response to DHC with a positive than negative Viggo-Cochin test result at baseline in individuals with shoulder pain due to rotator cuff disease.

Keywords

Shoulder pain sub-acromial impingement dynamic humeral centering physiotherapy clinical test

1. Introduction

Shoulder disorders are frequent in the adult population [1, 2, 3]. Rotator cuff disorders are the main cause of chronic shoulder pain [4, 5]. Sub-acromial impingement of rotator cuff tendons can be responsible for shoulder pain [6, 7]. Clinical tests for detecting impingement have been proposed [8, 9, 10]. The most commonly used tests are the Neer, Hawkins and Yocum tests.

We recently developed a new clinical maneuver to enhance the ability to detect sub-acromial impingement in individuals with shoulder pain [11]. This is a two-phase maneuver with a counter test involving elevation in lateral rotation that we called the Viggo-Cochin test. First, the arm positioned in medial rotation is passively elevated in the scapular plane. With the presence of shoulder pain in the first part, the second part of the test is performed, consisting of passive elevation of the arm not in medial rotation but in lateral rotation. The result is considered positive when shoulder pain is no longer produced by the second passive elevation. Therefore, the test is a test of negativity. A positive Viggo-Cochin test result corresponds to a painful first part of the test without any pain during the second part. Other situations indicate a negative result. We provided information on metrological properties and showed higher intra-observer reproducibility with the Viggo-Cochin than Neer test in the same study population. The value of the kappa coefficient was 0.60 and 0.34 respectively.

Physiotherapy is recommended to treat persisting shoulder pain due to rotator cuff disease [12, 13, 14, 15]. Systematic reviews agree with an overall effect of physiotherapy in this indication [16, 17, 18]. However, some authors concluded low-quality evidence and small-sized effects preventing any definitive conclusion [17]. The low-quality evidence is mainly due to methodological limitations including high risk of bias for outcomes, low-powered trials and non-representative sampling of study populations. The small-sized reported effects of physiotherapy may also depend on heterogeneous clinical profiles of included individuals. Furthermore, trials assessed a large diversity of physiotherapy modalities with unequal awaited effectiveness.

Dynamic humeral centering (DHC) is a physiotherapy modality for sub-acromial impingement syndrome [19, 20]. DHC consists of a selective solicitation of depressors of the humeral head, pectoralis major and latissimus dorsi during active abduction of the arm in the scapular plane. Therefore, DHC can be considered specifically adapted to the impingement mechanism that contributes to shoulder pain due to rotator cuff disease. Its effectiveness has been demonstrated in this indication [21, 22]. Effect sizes were higher in individuals with positive than negative Neer test results, but differences were not statistically significant [23]. An underpowered study design and the metrological properties of the Neer test could explain the lack of significance.

Because the Viggo-Cochin test aims to detect sub-acromial impingement and DHC is a physiotherapy modality for sub-acromial impingement syndrome, here we hypothesised that the effect of DHC may differ between participants with positive and negative Viggo-Cochin test results. We investigated the response to DHC according to Viggo-Cochin test results, with the Neer test as a reference. DHC may be more effective in patients with a positive than negative Viggo-Cochin test result. Thus, our results may be useful for clinical practice. The Viggo-Cochin test could be of interest to select patients for DHC and contribute to prescribing the best exercises according to clinical profiles of patients with rotator cuff-related shoulder pain.

1.1 Participants and methods

1.1.1 Study design

This was a registry study with planned treatment and assessment [24]. Individuals gave their written informed consent to participate. The study was approved by an ethics committee (GCS Ramsay Santé for Education and Research Scientific Orientation Committee IORG0009085, approval number COS-RGDS-2019-12-004-PETROVER-D).

1.1.2 Participants

Patients referred to our unit for rehabilitation with a diagnosis of rotator cuff-related shoulder pain, were invited to participate. They underwent clinical examination and had x-ray imaging of the shoulder. Clinical examination included medical history, physical neck and shoulder examination and neurological examination. Inclusion criteria were age $\geqslant$ 18 years, shoulder pain for $>$ 1 month, normal passive range of motion, and at least a positive response to provocative tests such as the Jobe, Neer, Yocum and Hawkins manoeuvers. The Jobe test is used in clinical practice for diagnosing supraspinatus tendinopathy or tears that are involved in sub-acromial impingement syndrome [25]. The Neer, Yocum and Hawkins tests are used to detect sub-acromial impingement [8, 9, 10]. We excluded individuals with gleno-humeral arthropathy or calcification on x-ray imaging, previous surgery of the shoulder, shoulder instability using gleno-humeral mobilization, humeral fracture, local corticosteroids injections in the last 30 days, inflammatory joint disease and neoplastic disorders. Other exclusion criteria were evidence of a painful acromioclavicular joint during palpation and neurological or cervical disease. The criterion of cervical disease was self-reported neck pain with or without radiating pain in the arm, or painful neck mobilization during physical examination.

1.1.3 Outcomes assessment

Participants were clinically assessed by the same assessor. Participants were unaware of the study hypothesis. Assessment was performed at baseline before physiotherapy and at follow-up after physiotherapy. At the first visit, clinical data were sex, age, pain duration, levels of pain and disability, and sub-acromial impingement test results. Pain and disability were assessed with the Shoulder Pain and Disability Index (SPADI) [26, 27]. The SPADI is a self-administered questionnaire consisting of subscales for pain (0–28 points) and disability (0–72 points). A score of 100 indicates the highest impairment. Along with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and the Constant-Murley scale, the SPADI is the most common outcome measure used in clinical trials to assess the effects of physiotherapy in rotator cuff disease [27]. We previously showed that the SPADI has very good test-retest reliability (intraclass coefficient correlation 0.95) and the highest responsiveness as compared with the DASH questionnaire and Constant-Murley scale. Here, the SPADI was the standard criterion. The SPADI questionnaire was completed by the participants just before starting and then after concluding the DHC intervention. Because the SPADI is a self-reporting questionnaire, the assessor was not involved in assessing the clinical response after the DHC intervention.

Each participant underwent both Neer and Viggo-Cochin tests [11]. Tests were performed in the standing position. The Neer test consisted of passive arm elevation in the scapular plane with the thumb pointing downwards. Shoulder pain between 60 and 120 degrees of passive antero-lateral elevation indicated a positive result. The Viggo-Cochin test has 2 parts. First, the arm positioned in medial rotation was passively elevated in the antero-lateral scapular plane. With the presence of shoulder pain in the first part, the second part of the test was performed and consisted of passive elevation of the arm not in medial rotation but conversely, with the thumb pointing upwards. The result was considered positive when shoulder pain was no longer produced by the second passive elevation. Therefore, a positive Viggo-Cochin test result corresponded to a painful first part of the test without any pain during the second part. Other situations indicated a negative result.

1.1.4 Dynamic humeral centering

DHC physiotherapy was performed for 6 weeks in 15 supervised individual outpatient sessions [21, 22]. The DHC program was divided into 2 successive parts. The first part consisted of learning the lowering of the humeral head during passive arm elevation in the scapular plane by the physiotherapist. It included muscular control of the scapula, perception of the passive lowering of the humeral head in the gleno-humeral joint, active contraction of the pectoralis major and latissimus dorsi, perception of the lowering effect and co-contraction of these muscles during passive abduction of the shoulder in painless range of motion. The second part aims at co-contraction of the pectoralis major and latissimus dorsi during active abduction of the shoulder using manual and visual control by the physiotherapist. At the end of the program patients were asked to perform home exercises. Exercises involved 10 lowerings of the humeral head by co-contraction of the pectoralis major and latissimus dorsi, arm by the side, 3 times a day.

1.2 Statistical analysis

Quantitative variables are expressed as mean and standard deviation (SD) or median and interquartile range (IQR). Categorical variables are expressed as count and relative frequency in percentage. Algo-functional improvement of the participants at the end of the intervention was defined as 20% reduction from the SPADI at baseline. Therefore, responders to DHC were participants with a reduction in SPADI of at least 20%. This value was established on the basis of a provisional baseline 0- to 100-point SPADI close to 50 [11], taking into account a 8- to 13-point clinical important difference [28, 29]. Comparisons involved Wilcoxon signed rank and Mann Whitney tests. Statistical significance was established at $P<$ 0.05, using Holm correction as required [30]. The probability of response to DHC according to results of clinical tests was tested by simple logistic regression, estimating odds ratios (ORs) and 95% confidence intervals (CIs). Statistical analyses involved using XLSTAT v2020 (Addinsoft 2020. XLSTAT statistical and data analysis solution, Paris, France; https://www.xlstat.com).

2. Results

We included 50 individuals (53 shoulders) (Table 1). At baseline, the Neer test was positive for 36 shoulders and the Viggo-Cochin test for 20 shoulders.

Table 1
Baseline characteristics of the study population (50 participants; 53 shoulders)

Age, year, mean (SD)	59 (11)
Female, $n$ (%)	35 (70)
Pain duration, months, median (IQR)	12 (15.2)
Positive Neer test, $n$ (%)	36 (67.9)
Positive Viggo-Cochin test, $n$ (%)	20 (37.7)
Shoulder Pain and Disability Index (0 to 100),	47.8 (18.5)
mean (SD)

IQR, interquartile range.

Considering the total study population, the mean (SD) SPADI was reduced (improved) after DHC: 37.2 (22.6) versus 47.2 (18.4) at baseline ( $P=$ 0.002). There were 21 (42%) responders at follow-up.

At baseline, the SPADI was higher with a positive versus negative Neer test result (Table 2). The difference persisted at follow-up. However, change from baseline in SPADI expressed as a percentage did not differ by Neer test results. The probability of a DHC response in patients with positive versus negative Neer test result was 0.73 [95% CI 0.22–2.38] ( $P=$ 0.601).

Table 2

Clinical results (Shoulder Pain and Disability Index [SPADI]) after dynamic humeral centering (DHC) program in shoulders with rotator cuff disease by Neer test result at baseline ( $n=$ 53)

SPADI, 0 to 100	Positive Neer test ( $n=$ 36)	Negative Neer test ( $n=$ 17)	$P$ value
Baseline, mean (SD)	53.6 (15.6)	35.8 (18.6)	0.003
Follow-up, mean (SD)	42.7 (23)	27.6 (18.6)	0.048
Change, %, median (IQR)	15.0 (53.2)	19.6 (98.2)	0.935
Responders to DHC, $n$ (%)	12 (33)	8 (47)

IQR, interquartile range. Responders to DHC $=$ reduction of at least 20% in total SPADI.

Table 3

Clinical results (SPADI) after DHC program in shoulders with rotator cuff disease by Viggo-Cochin test results at baseline ( $n=$ 53)

SPADI, 0 to 100	Positive Viggo-Cochin test ( $n=$ 20)	Negative Viggo-Cochin test ( $n=$ 33)	$P$ value
Baseline, mean (SD)	53.1 (15.9)	44.4 (19.4)	0.180
Follow-up, mean (SD)	30.4 (24.2)	41.6 (21.1)	0.180
Change, %, median (IQR)	61.5 (59.6)	10 (55.3)	0.024
Responder to DHC, $n$ (%)	12 (60)	9 (27)

IQR, interquartile range. Responders to DHC $=$ reduction of at least 20% in total SPADI.

Conversely, the SPADI did not differ between participants with a positive or negative Viggo-Cochin test result, but change in SPADI significantly differed at follow-up according to the test results (Table 3). At follow-up, the proportion of responders was higher with a positive than negative Viggo-Cochin test result at baseline. The probability of a DHC response was increased with a positive than negative Viggo-Cochin test result at baseline: OR 5.11 [95% CI 1.47–17.78] ( $P=$ 0.010).

3. Discussion

In this study, we examined the value of the Viggo-Cochin test to predict response to DHC in individuals with persisting shoulder pain due to rotator cuff disease. The probability of a DHC response was higher with a positive than negative Viggo-Cochin test result at baseline. Use of the Neer test did not allow for such a prediction.

The DHC is a well-described modality, with demonstrated effectiveness [21]. It has been specifically developed to prevent sub-acromial impingement. Because sub-acromial impingement is one of the possible pathogenic factors of rotator cuff disease, response to DHC may depend on the pathophysiological mechanism profile of the patient. The so-called profile of sub-acromial impingement was observed in 38% included shoulders based on the Viggo-Cochin test. This clinical maneuver is a test aimed at triggering the patient’s shoulder pain involving the antero-lateral elevation of the arm and medial rotation of the shoulder [11]. Both movements are associated with high sub-acromial pressure and sub-acromial space reduction, key factors in sub-acromial impingement [31, 32, 33, 34]. Conversely, lateral rotation of the shoulder prevents high sub-acromial pressure and is not as much associated with sub-acromial space reduction [31, 33]. The second part of the test in lateral rotation of the arm is a differentiating maneuver. It aims at eliminating other causes of shoulder pain induced by mobilization but not specific to sub-acromial impingement. Therefore, shoulder pain induced by antero-lateral elevation and medial rotation, which disappears in lateral rotation, corresponds to a positive test result and could be highly evocative of shoulder pain due to sub-acromial impingement.

We found 42% responders to DHC in the total study population. This finding underlines the heterogenous profiles of patients we included in the study on the basis of usual diagnostic criteria of impingement syndrome. Of note, we found more than 60% response to DHC among patients with a positive Viggo-Cochin test result. For these patients, change in SPADI was $>$ 60%. Such a change was not observed in patients with a negative Viggo-Cochin test result or in those with a positive or negative Neer test result. Therefore, we reinforce the hypothesis that the effect of DHC differs between patients with positive and negative Viggo-Cochin test results and that DHC is more effective in patients with a positive than negative test result.

We observed a higher SPADI change and higher percentage of response to DHC with a negative than positive Neer test result, although not significant. An explanation may be that baseline SPADI values were significantly lower in patients with a negative than positive Neer test result. Higher initial disability was previously found associated with lower therapeutic effects in rotator cuff disorders [35]. The higher percentage of response to DHC among patients with a negative than positive Neer test result may also be related to low ability of the maneuver to detect sub-acromial impingement. The lack of significant difference indicating low ability of Neer test to predict response to DHC agrees with previous results [23]. The difference in response to DHC according to Neer test results we found in a previous trial failed to reach statistical significance. Therefore, whether the Neer test can be used to predict response to DHC in patients with rotator cuff-related shoulder pain is uncertain.

Conversely, the Viggo-Cochin test could be useful in clinical practice to select physiotherapy modalities in individuals with shoulder pain due to rotator cuff disease and to propose DHC for some of them. Some information from previous randomized trials favoured physiotherapy modalities on the basis of their objective interest for the person. As compared with no intervention, strengthening has been found effective [36]. DHC was found more effective than simple mobilization [21]. A greater effect has also been demonstrated with the association of strengthening, stretching and mobilization as compared with strengthening and stretching only [37]. This finding suggests an adjuvant effect of mobilization. Supervision by a physiotherapist provided better results than home exercises [38]. This knowledge allows for an evidence-based use of physiotherapy for shoulder pain due to rotator cuff disease, including strengthening and DHC, associated with stretching and mobilization, and initial supervision by a physiotherapist. The indication for DHC could be reinforced in this strategy by the positive results of the clinical maneuver we developed.

Although we provide information of interest for the physiotherapeutic approach, our study has some limitations. It was based on a registry analysis and cannot be considered a prospective cohort with high level of evidence. The study included 53 shoulders, which can be considered a small sample. Home exercises were recommended at the end of the DHC program but adherence, which may have affected the therapeutic response, was not recorded. Further investigations should include a larger representative study population to ascertain external validity and sound methodology to avoid bias in assessing therapeutic response.

4. Conclusions

We found a higher clinical response to DHC with a positive than negative initial Viggo-Cochin test at baseline. This clinical maneuver could be of interest to predict response to DHC in individuals with shoulder pain due to rotator cuff disease. Further investigations are needed to increase the level of evidence of our findings.

Footnotes

Conflict of interest

The authors have no conflict of interest to declare.

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Value of a clinical test of sub-acromial impingement to predict response to physiotherapy with dynamic humeral centering: A preliminary study

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSIONS:

Keywords

1. Introduction

1.1 Participants and methods

1.1.1 Study design

1.1.2 Participants

1.1.3 Outcomes assessment

1.1.4 Dynamic humeral centering

1.2 Statistical analysis

2. Results

Table 1 Baseline characteristics of the study population (50 participants; 53 shoulders)

4. Conclusions

Footnotes

Conflict of interest

References

Table 1
Baseline characteristics of the study population (50 participants; 53 shoulders)