Abstract
Background Shoulder pain resulting from subacromial impingement syndrome (SAIS) is a common problem with a relatively poor response to treatment. There is little research exploring physical therapists' perspectives on the management of the syndrome.
Objectives The study objective was to investigate physical therapists' perceptions and experiences regarding the use of exercise in the treatment of patients with SAIS.
Design This was a qualitative focus group study.
Methods Three 60- to 90-minute focus group sessions containing 6 to 8 experienced musculoskeletal physical therapists (total number=20) were conducted. Thematic content analysis was used to analyze transcripts and develop core themes and categories.
Results Exercise was seen as key in the management of SAIS. The overarching theme was the need to “gain buy-in to exercise” at an early stage. The main subtheme was patient education. Therapists identified the need to use education about SAIS etiology to foster buy-in and “sell” self-management through exercise to the patient. They consistently mentioned achieving education and buy-in using visual tools, postural advice, and sometimes a “quick fix” of pain control. Furthermore, experienced practitioners reported including educational interventions much earlier in treatment than when they first qualified. Therapists emphasized the need for individually tailored exercises, including: scapular stabilization; rotator cuff, lower trapezius, and serratus anterior muscle strengthening; and anterior shoulder and pectoralis minor muscle stretching. Quality of exercise performance was deemed more important than the number of repetitions that the patients performed.
Limitations Expanding the geographical area over which the focus groups were conducted and including therapists with less than 5 years of postgraduate experience may have strengthened the findings of this study.
Conclusion Experienced musculoskeletal physical therapists believe that exercise is central in treating patients with SAIS and that gaining patient buy-in to its importance, patient education, promoting self-management, and postural advice are central to the successful treatment of people with SAIS.
Physical therapy, in particular therapeutic exercise, is a common first-choice treatment for subacromial impingement syndrome (SAIS)1; however, the benefits of physical therapy exercises and their optimal clinical application remain unclear. This uncertainty is reflected not only in the wide range of approaches and exercise interventions used for SAIS but also in the subjectivity of their application.2,3 Consequently, the long-term outcome of conservative management of shoulder pain is reported to be poor.4,5
Exercise is used as a treatment modality in SAIS to relieve pain, reduce muscle spasm, promote tendon healing, reverse abnormal force-couple imbalances, restore pain-free joint range of motion, and ultimately improve function.6 However, physical therapists remain uncertain about the optimal exercise prescription regimen (ie, which muscles should be targeted, and how they should be strengthened with respect to mode, frequency, duration, intensity, and progression of shoulder exercise interventions).
The lack of standardized clinical guidelines for the management of SAIS has prompted the development of a number of evidence-based exercise protocols based on reviews of the literature.7–16 Kuhn,11 for example, suggested a standardized exercise protocol based on the findings from 10 randomized controlled trials (RCTs). However, it is not evident which types of exercise were best supported by the literature, and the suggested rehabilitation program appears to be a pragmatic, informal amalgamation of the reviewed trials' interventions. In a recent systematic review and meta-analysis of 16 RCTs, Hanratty et al13 concluded that although exercise was effective at reducing pain and improving function at both short- and longer-term follow-up, heterogeneity in the description and content of the exercise protocols prevented the development of specific exercise protocols for SAIS.
An RCT by Holmgren et al14 investigated a shoulder-specific loaded (ie, with resistance) exercise plan versus a control exercise plan of nonspecific, unloaded movement exercises for the neck and shoulder in 102 patients. This study concluded that rotator cuff eccentric strengthening exercises and eccentric/concentric exercises for the scapular stabilizers reduced the need for arthroscopic subacromial decompression at 3-month follow-up by two-thirds (63% in control group versus 20% in intervention group, P<.001). The authors stated that the exercise intervention used was developed with a combination of their clinical experience and latest scientific evidence.10,14–16 It is unclear, however, how the clinical component was established. Although some surveys and systematic reviews or RCTs have been published regarding the use of physical therapy treatments for the management of SAIS,2,3 there has been no published research that we are aware of that uses a rigorous research method to explore expert clinical experience and therapists' perceptions regarding the selection and effectiveness of exercises for patients with this condition. Furthermore, although the American Physical Therapy Association (APTA) Orthopaedic Section has published guidelines relating to adhesive capsulitis,17 there are no guidelines relating to the management of SAIS.
In summary, a number of pragmatically developed protocols are available for the management of SAIS. Some protocols have originated from poorly designed studies with a high risk of bias.13 In addition, although all have a subjective component, we have not been able to find any published research that explores practicing therapists' perceptions regarding the use and effectiveness of exercises in the management of SAIS. It is unclear, therefore, why or how the exercises included in the protocols were selected. Previous work by this research team13 neither revealed which exercises were best supported by the evidence nor provided enough data to inform physical therapists as to their dose, duration, or intensity. Consequently, this study sought to combine a formal examination of therapists' views and opinions with the results of a literature review13 in order to develop an exercise protocol that is evidence-based. The aims of this research, therefore, were to investigate 2 issues: (1) physical therapists' perceptions regarding the use and types of exercise commonly used in the management of SAIS and (2) their views on the appropriate choice and dosage of such exercises.
Method
Approach and Design
To address the aims of this study, a qualitative method of data collection (focus groups) and analysis (thematic content analysis) was adopted.
Participant Recruitment
Participants were identified using purposive sampling techniques to ensure the selection of therapists with the relevant experience and expertise. Potential participants were identified by contacting the managers of physical therapy departments and outpatient departments with the goal of recruiting physical therapists meeting the following inclusion criteria:
Having more than 5 years' postgraduate experience working with musculoskeletal conditions.
Working, on a daily basis, in a musculoskeletal role.
Willing to attend focus groups and consent to be audio and video recorded.
Two large hospital trusts in Northern Ireland (comprising 10 hospitals) and 4 hospitals and a large private practice in the Republic of Ireland were approached. This resulted in 3 focus groups, consisting of 6 to 8 physical therapists, being conducted in hospitals within the United Kingdom and Ireland.
Setting
The focus groups took place within the Belfast and Northern Health and Social Care Trusts in Northern Ireland and at a central location in Dublin, where therapists from 3 hospitals/clinics convened. In some instances, it was possible to recruit specialized upper limb physical therapists; however, in some hospitals, such practitioners did not exist.
Data Collection
An experienced focus group facilitator (M.McC.), who was not a physical therapist and therefore was considered to be unbiased, the main researcher (C.H.), and another member of the research team (J.McV. or D.K.) were present at each focus group. The focus group interviews and discussions were recorded on videotapes and audiotapes, which then were transcribed verbatim. Field notes also were taken.
Each group session began with a review of the study's aims and an explanation of the procedure by the facilitator. A semistructured format was used, utilizing the question schedule outlined in the Table, with encouragement for the participants to digress and fully explain or introduce new ideas and thoughts. When all key issues had been fully discussed and probed and no additional issues had been raised, the facilitator orally summarized the views expressed by the group. The participants were asked to endorse these points and add any other views not previously discussed. The focus group was terminated when the participants could not add anything further to the discussion. A written summary of the relevant focus group was posted to each participant.18,19 Participants were asked to respond if these summaries were inaccurate; no concerns were expressed. The transcripts also were checked by the facilitator. The research team discussed emerging themes after each focus group. As no new insights emerged from the third focus group, it was considered that data saturation had occurred and that no further focus groups needed to be convened.18–20
Questioning Schedule for Each Focus Group
Data Management
The main researcher (C.H.) audio-typed all manuscripts and compared the transcripts with the video recording to ensure that therapists were identified correctly. Although anonymized, all transcriptions were additionally password protected. The coded list of participants was kept in a secure data storage room at Ulster University.
Data Analysis
Data were analyzed by means of thematic content analysis.21–24 Although principally driven by key a priori themes drawn from the literature and clinical experience within the research team (eg, “progression,” “intensity” of exercises), the analysis was conducted to allow additional themes (eg, “buy-in,” “quick fixes”) to emerge inductively from the data. These approaches correspond, respectively, to the “directed” and “conventional” forms of content analysis described by Hsieh and Shannon.22
Details from field notes and recordings were used for analysis in conjunction with the transcribed script. Five members of the research team independently read and reread the transcripts to allow immersion in the data. Notes on broad content headings were made, followed by open coding of data. A consensus meeting was held to discuss each researcher's analysis, which also enabled agreement on key categories developed within each theme. One researcher (C.H.) then created categories and subcategories composed of common content, and repetitious and similar headings were combined by rereading the transcripts.20 Quotations within each category were grouped together. A second consensus meeting was held in which the researchers discussed a hierarchy of overarching themes, categories, and subcategories.
Maintenance of Rigor
The credibility, dependability, and transferability of the current findings were enhanced by the use of a number of recommended strategies.18,20,22–24 Two of the focus groups covered a large geographical area of Northern Ireland and included therapists from rural and urban areas, working in both private and public sectors, with postgraduate experience ranging from 5 years to more than 30 years.
The questioning schedule was developed by members of the research team (C.H., J.McV., and D.K.), as well as the facilitator (M.McC.). This approach increased dependability by familiarizing the team with the research objectives. It also increased credibility because the brainstorming and consensus method limits the influence of the possible biases of any one researcher. The content of the questioning schedule was developed after reflecting on the gaps within the existing literature.13 The questioning schedule was reviewed after the first focus group.
Credibility was improved during the data collection period by using an experienced but nontherapist qualitative researcher as the facilitator. Dependability was enhanced because data were monitored and interpreted by the whole team as they were collected. The focus groups were videotaped and audiotaped, the transcripts were transcribed verbatim, and nonverbal data (eg, nodding in agreement, body language) were input into the transcript. Participants were provided with a written summary of their focus group's discussion for verification or member checking.18,19 The credibility and dependability of the coding was ensured by an initial round of independent coding by each researcher, followed by a consensus meeting where emerging themes were discussed at length. The main researcher (C.H.) then compiled a hierarchy of themes based on this discussion, after which a second consensus meeting took place where researchers' findings were synthesized.18 Disagreements in the interpretation of the data were discussed until a majority consensus emerged. Figure 1 summarizes the strategies used to maintain rigor throughout each stage of the study.
Methods to promote rigor.
Ethical Conduct and Protection of Participants
All participants gave written informed consent. All data were anonymized, and the participants were referred to as PT01 through PT20. These designations (in parentheses) follow quotations from the participants.
Role of the Funding Source
The study was undertaken as part of a Department of Employment and Learning (United Kingdom) grant-funded PhD.
Results
Participants
A total of 20 physical therapists (18 female, 2 male) specializing in musculoskeletal practice and having at least 5 years' postgraduate experience were recruited. Additionally, all therapists had completed formal postgraduate training in manual therapy. The therapists worked in the National Health Service and private practice musculoskeletal outpatient departments (n=15), as well as in orthopedics (n=3), rheumatology (n=1), and sports medicine (n=1) clinics. Each focus group contained 6 to 8 participants and lasted 60 to 90 minutes. Commonly occurring themes and categories are summarized in Figure 2.
Key emerging themes and categories.
Overarching Theme: “Buy-In”
The main theme that emerged from the focus groups was that gaining buy-in from patients that physical therapy treatment, in particular, exercise, was essential. This concept was specifically mentioned on 21 occasions across all 3 focus groups. Furthermore, this theme permeated discussions on patient education, visual tools, the patient's desire for a quick fix, practitioner experience, and changing pain levels; it, therefore, was viewed as an overarching theme.
Specific discussions centered on the necessity for gaining buy-in at an early stage of treatment, as mentioned by PT15:
Unfortunately it's [managing SAIS] not a quick fix, and it takes a long time and is very progressive…so you have to really sell it early.
The therapists agreed that exercise was important because of the function of the shoulder and the interplay of the rotator cuff, scapular stability, and normal joint kinematics:
I think it's [exercise] the key…. If we want to get any long-term resolution of symptoms, exercise would be the mainstay of the program…. If you don't address it with exercise, you are not likely to win. (PT13)
Therapists also identified exercise as being important for patients with severe pain and limited movement.
I agree there with [PT03], commonly you find that obviously the patient is very sore and doesn't want to move, and that makes it worse; they develop secondary problems. So you've gotta really emphasize exercise and starting to move it [the shoulder]. (PT02)
Patient Education
There was general consensus that early patient education was the best way to successfully achieve buy-in:
I think the key thing is good education right at the start, more than even the specifics of exercise. I think if they are well educated that they can actually grasp it and clue into what you want to do. (PT01)
Under the theme of patient education, the therapists discussed why and how they educated their patients. They also discussed who applied education at different stages of treatment, comparing novice practitioners with those with more postgraduate experience.
Need for patient education.
It was apparent that patient education was considered essential to promote buy-in to exercise and longer-term self-management:
If you have [patients] well educated and you've shown them where it's happening, why it's happening, then they tend to take on board what you're saying. (PT05)
It's trying to get them to understand that unless you resolve the other issues, the postural issues or a muscle imbalance, that it's just going to happen all over again. (PT10)
It was clear that the therapists wanted to encourage patients to take responsibility for management:
So you're putting the onus back on them [the patient] to be proactive…to allow the patient to self-manage, that exercise is the key. (PT05)
The therapists also discussed and shared methods and phrases used in combination with exercise therapy to foster self-management, buy-in, and adherence, as the following excerpt from one of the focus groups illustrates:
I think, for people that are not complying with their exercise, I think you just have to lay the cards on the table and say, “Look, there's no point you coming here.” (PT06)
I basically tell my patients, “Look, I'm not giving you these for no reason, it's your responsibility to do these; it's your shoulder.” (PT09)
Whenever a patient says, “I'm too busy,” I gently say to them “Well, by choosing not to put this as your top priority, you are choosing to live with this…but by doing that, you are de-prioritizing this, but that's your choice, it's up to you.” (PT07)
Participants also identified 2 patient types with respect to buying in to exercise:
You have 2 sets of patients; some of them are highly motivated and do whatever it takes, and then [for some patients] you have to sell into it [to them] and say, “This is your injury, and this is your program,” so there are ones that want the quick fix and there are ones that know they have to do the work. (PT20)
The therapists also stated that passivity on the part of the patient was a reason for a lack of buy-in and unsuccessful long-term self-management:
There's no point in us wasting our time if they're not going to be compliant, so you're putting, again, the onus back on them to be proactive. (PT05)
Achieving patient education.
Patient education for long-term self-management was reported to focus on the use of visual tools to explain the pathology underlying subacromial impingement, and on the importance of postural education.
The use of visual tools to reinforce education was mentioned by nearly half (9/20) of the participants, with several others agreeing nonverbally with the statements being made. In particular, mirrors and skeleton models were mentioned as aids used to explain the causes of subacromial impingement and to encourage patient buy-in to exercise.
If we show them on a skeleton, they can actually relate how small that space is between the acromion and the humeral head, and if there is any enlargement—say in the tendon—and that space is closed down,…then they take it on board. (PT03)
It was interesting that the video function on patients' mobile phones was used as an educational aid and as a teaching tool to remind patients of the correct exercise technique:
I started videoing exercises that patients are doing on their phone…. It's a lot quicker than writing down and using PhysioTools [a computer program that produces exercise diagrams]. (PT06)
The need for education regarding the role of poor posture and how it can be linked to subacromial impingement was felt to be particularly important. One therapist mentioned that there is a typical posture to be seen in patients with this condition:
I would be looking at posture…typically with a shoulder impingement…the shoulder tends to sit very far forward, and they tend to have tight pecs [pectoral muscles] at the front of the chest and very long and stretched scapular muscles and [a] weak rotator cuff. (PT09)
As a group, participants agreed with this assessment and discussed the importance of initiating postural education early in treatment to gain buy-in, to help patients to understand their problem, to build a better foundation for further exercise, and to assist in long-term self-management:
You can do some very good exercise in retaining good posture and then putting quality movement then on top of quality posture, which is what I think the shoulder really needs on a regular basis. (PT18)
Lastly, the therapists mentioned how providing short-term pain relief, as a quick fix, helped to educate the patient about the longer-term effects of exercise and to gain buy-in from the start of treatment. This essentially demonstrates the longer-term outcomes if patients engage in the program:
I think it's important that there is some buy-in from the patient…. You can get buy-in if you give them immediate pain relief. (PT13)
The therapists mentioned ways in which they gave this pain relief:
I think you have to engage the patient to let them see by doing things…by moving their humeral head, by readjusting the position of their scapula, by simply trying to get them to correct their posture…to see—can this change their pain?…that they can feel some kind of difference, well, then it's going to be sold to them easier. (PT01)
Even though therapists were reluctant to give a passive quick fix to patients, they may do something that temporarily mimics the long-term results of exercise, such as taping of the shoulder blade, to encourage buy-in to the exercise treatment:
Show them that they can get some relief of pain…. I would also do the scapular work and strapping and show them that it will improve…. It is giving them short-term relief, but it's also getting them on board. (PT10)
If you realign and hold their scapula down, if there's weakness there, and they can move without a painful arc, and if they have a painful arc and you get them to push their arm down to engage deeper muscles and the pain goes away, that means exercise is going to work. (PT06)
Who provides patient education and when?
All groups noted that the background and experience of the practitioner influenced the treatment delivered to a patient with SAIS. There were 2 facets to this belief. First, treatments offered to patients depended on the type and level of postgraduate training of each physical therapist. Second, the longer physical therapists had been qualified, the less likely it was that they would try to give the patient a quick fix (except temporarily to gain buy-in) and the more they would educate the patient at the first session. This scenario placed the onus on the patient to buy-in to long-term self-management:
It can depend on what courses the physio [physical therapist] has been on…. That makes a difference. (PT05)
But the difference with experience…. I definitely would spend my first session trying to get that buy-in and educating for most of it. (PT18)
In the last 5 years since I qualified, that [buy-in] is definitely something that I have noted that has changed a lot. Now, in that first session, you would spend most of your time educating them and getting that buy-in rather than thinking “I've got to get in there and strengthen.” (PT17)
Exercise Prescription
These findings are best highlighted in relation to the second aim of the focus groups, that is, to determine participants' views on which types of exercises and exercise dosage should be used in the treatment of SAIS. There were 2 main categories: types of exercise and exercise dosage (Fig. 3).
Key findings relating to prescription of exercise.
Types of exercise.
There was general consensus across all groups regarding the need for individually tailored programs. Therapists agreed that it was difficult to adopt a “one size fits all” exercise approach:
I think it's hard to be prescriptive,…and I think we should be careful not to be prescriptive because it depends so much on the patient. (PT05)
I think we all recognize that every patient is different, and we all have different approaches. (PT12)
Despite this acknowledgment of the individuality of both the therapist and the patient, there was a consensus that exercises would start with postural “scapular setting” exercises and that pectoral muscle tightness and overall posture should be addressed before progressing to rotator cuff strengthening, core stability, and proprioceptive exercises:
We are doing things like stretches for the front of the shoulder and a lot of strengthening work for the scapular stability; it might be on your hands and knees; it might be one arm leaning on the wall, serratus anterior strengthening work, rotator cuff, proprioceptive exercises—those would be the main ones. (PT05)
My first emphasis…would be to see how you can get the pec [pectoral] muscles stretched out…getting them to what's called the scapular setting to set the scapula, the head of the humerus in a more normal anatomical position,…or I might bring out [a very light elastic strengthening band] and tie it to a door handle and get them to set their scapula and get them to come back into an extension and then external light rotation resistance. (PT09)
We all have said that we would start with scapular retractions, we would all work on rotator cuff strengthening and pec [pectoral muscle] stretches. (PT12)
There also was discussion about the use of functional exercises that better integrate with the patient's routine:
A certain part of doing your whole rehab is that it should be functional. It should be everyday activity. (PT10)
Especially if they are office-based work,…pain is a great reminder of posture and impingement. So if it is a scapulothoracic problem, then just ensuring that they go through their workstation and their chair and even things like, I tell them to get those little wrist supports for their keyboard, just making sure that their workstation is ergonomically friendly. I suppose if you spent all day in an office and you are like this [demonstrating slumped forward], just doing 10 minutes of thoracic exercises isn't going to change it. I would be thinking more of postural positions than thinking this is going to be your exercise [demonstrating shoulder flexion] (PT16).
Exercise dosage.
Several therapists made specific suggestions regarding the number of repetitions and sets they would prescribe, and these included 3 sets of 10 repetitions (PT06) or 3 sets of 5 repetitions (PT10 and PT07). One therapist (PT07) mentioned explaining to patients that “they start to tire towards the end of the second set and as they finish the third they are glad that they've finished and that they increase it as able.” There was general agreement with this statement in this focus group.
However, there were some conflicting opinions across the focus groups, with other therapists arguing that it was difficult to be prescriptive because it depended on the ability of the person to learn the exercise, fatigue, quality of exercise, muscle recruitment, and timing:
It's hard to put a time on how many treatments you are going to give them because it maybe is a rotator cuff centering or scapulohumeral; it's very much per patient, and it depends on their ability to learn that exercise. (PT15)
Furthermore, there were some general discussions about using a timed intervention, and suggestions about using lower intensity/resistance—such as light-resistance elastic strengthening band (PT06, PT16, and PT13) for rotator cuff strengthening. PT04 and PT06 reinforced this suggestion by explaining that the rotator cuff muscles are “controlling muscles”:
In the class, we do our circuit for a minute—so that's maybe the only objective thing I can say. But maybe within that minute some will do more reps [repetitions] than somebody else—but they have a minute to do that particular exercise before moving on. (PT05)
If you are strengthening your rotator cuff muscles, if there were no other barriers except for strengthening, you would want high reps [repetitions] and low resistance for those muscles. (PT06)
Discussion
This study had 2 aims. The first aim was to determine physical therapists' perceptions of the use of exercise in the management of SAIS, and the second aim was to determine their views on the nature and the dosage of the exercises that should be included in an exercise program for patients with SAIS.
The main themes derived from the analysis of the focus groups were: the importance of gaining buy-in from patients, patient education, how treatment approaches change with experience, and the role that pain control plays in allowing the therapist to gain and reinforce patient buy-in. Although the therapists stated that they would use exercise to promote self-management and place the onus on to the patient for longer-term recovery, they also often stated that they would gain buy-in by using intrinsic motivation strategies such as giving the patient a quick fix of pain relief.25 For example, they might use taping to simulate the effects of better scapular muscle control, thus demonstrating the effectiveness of exercises and reinforcing the need for long-term buy-in to exercises. This approach is supported by work by Sluijs et al,26 who investigated the association between patient adherence to exercise programs and characteristics of the patient, their, illness and the therapist. These authors26 surveyed 300 physical therapists working in musculoskeletal practice who reported that lower levels of adherence were linked to patients having low opinions about the value of therapeutic exercises. Brewer et al27 also demonstrated that higher levels of adherence may be related to positive beliefs that the exercise is effective.
In attempting to gain buy-in and promote increased awareness of self-efficacy, physical therapists need to effect behavioral change strategies. One model commonly used in health care settings is the Transtheoretical Model of Change.28 Awareness of this model highlights that change happens over time and that therapists may need to use different strategies—such as education, quick fix of pain relief, or promotion of self-management—depending on which stage the patient has reached (eg, precontemplation, contemplation, preparation). Although the therapists within this set of focus groups did not articulate any specific behavioral change models, they discussed the use of various strategies to gain buy-in from the patient—in effect, enabling the movement from precontemplation to preparation and action stages.
In applying behavioral change strategies and using educational tools, such as mobile phone technology, therapists should consider cultural and generational differences that may affect patients' readiness to learn and how they learn. Younger, more recently qualified therapists described videoing patient's exercises on their mobile phone rather than using more traditional paper-based exercise advice sheets. Although there is a perception that older adults are more reluctant to engage with mobile health technology, it appears that perceived usefulness and perceived ease of use are more important determinants of acceptance.28–30 As always, therapists should tailor their strategy to gain buy-in to the individual patient with due regard to his or her particular personal or cultural preferences.
Therapists in this focus group study stated that as they gained experience, they recognized the primacy of exercise in SAIS management. Slade et al31 used focus groups to investigate the perceptions and experiences of Australian physical therapists who use exercise to treat patients with chronic low back pain. Interestingly, some themes identified in our work reflect the findings of that study.31 In particular, these authors also identified that more experienced therapists felt increased confidence in “selling the merits of exercise for improving outcomes.” Additionally, therapists in the study by Slade et al31 identified a need to educate their patients about their injury and diagnosis. Rindflesch32 investigated patient education provided by therapists from acute care, inpatient rehabilitation, and outpatient care using focus group discussions. His article concluded that although APTA did not class patient education as a primary intervention, the American therapists who participated in the study disagreed and did not separate patient education from other primary modalities. The results of our study support the findings of Rindflesch,32 reinforcing that patient education forms a crucial part of therapy and is used to empower patients and encourage optimal self-management.
Exercise Prescription Findings
Conversations regarding exercise prescription were briefer and more limited than those exploring the psychological issues underpinning therapy. There was a general reluctance across all groups to state specific objective exercise prescription parameters. Participants in the focus groups reported that, due to the individualized nature of physical therapy treatment, standardized exercise prescription may not be possible. However, there were some common points of discussion.
The therapists stated that it was difficult to be prescriptive and that patients with SAIS needed an individually tailored exercise protocol. However, certain exercises were commonly mentioned—for example, anterior glenohumeral joint and pectoralis minor muscle stretches, scapular stability exercises/scapular setting, elastic strengthening bands, rotator cuff strengthening, 4-point kneeling proprioceptive exercises, and functional movements. Specific muscles mentioned in terms of strengthening were the serratus anterior, lower trapezius, and the rotator cuff. Reassuringly, the scapular stability training and progressive rotator cuff strengthening exercises using elastic bands described are similar to the interventions used in several well-conducted previously published studies.33–37
There was very little discussion that dealt directly with the prescription of exercise in terms of intensity, frequency, duration, number of repetitions, and stage of the disorder. Three therapists mentioned that they directed patients to perform 3 sets of 5 or 10 repetitions of each exercise; 5 therapists, however, disagreed with this direction and suggested that the focus should be more on the quality of exercise and the ability of the patient to avoid fatigue. There was some discussion about the usefulness of a timed intervention period in which patients could perform different numbers of repetitions, depending on individual ability. This approach appears to be a reflection of pragmatic clinical reality, as it had not been mentioned in previously reviewed article or protocols. With respect to intensity, the only aspect mentioned was that the rotator cuff, as controlling muscles, should be recruited using lower-intensity exercises (eg, using light-resistance elastic strengthening bands for strengthening exercises).
Our review of 16 RCTs conducted prior to this study concluded that heterogeneity in exercise parameters used, along with the variable quality of the data, prevented clarification regarding the nature or duration of an optimal exercise approach in SAIS.13 This belief also was reinforced by other authors who had attempted to define parameters for an evidence-based protocol.7–12 The reluctance of the therapists within these focus groups to commit to specific exercise parameters may further reflect this lack of a strong evidence-based protocol to direct treatment for SAIS.
Study Strengths
A number of qualitative methods could have been used to examine the experiences and perceptions of the physical therapists, such as the Delphi technique, one-to-one interviews, questionnaires, or a nominal group approach.38,39 The decision to use focus groups was based on consideration of the aims of the research, the strengths of focus group method, and consideration of the pros and cons of the other aforementioned techniques. Because, to our knowledge, there was no previous research in this area, the research team decided not to use a Delphi method or nominal group technique approach as an initial exploratory method because they are consensus methods39 and, therefore, are a less suitable means of eliciting a range of perspectives.
Focus groups are particularly suited to exploring perceptions and lived experiences.38 Their use allowed the researchers to select a purposive sample of therapists and to examine, in depth, issues relating to managing SAIS.19 The focus groups further allowed participants to reflect on, and clarify, their views in a dynamic group context.38,40 They also have the benefit of revealing how participants' views are developed during interactive discussion and through other forms of communication, such as anecdotes, jokes, and aspects of nonverbal behaviors. A varied range of information, therefore, can be gleaned via this method.
Study Limitations
Therapists in this study were selected by purposive sampling and were required to have had at least 5 years of postgraduate experience in treating musculoskeletal disorders. The exclusion of younger, more recently qualified therapists may have altered the outcome of the focus groups, particularly in relation to when and how to encourage patient buy-in, how they use quick-fix methods to gain buy-in, and how and why they prescribe certain exercises. Furthermore, therapists were reluctant to elaborate on the exercises that they prescribe and the treatment parameters used, probably due to the difficulty in generalizing about treatment interventions that are individualized by nature. This factor may have limited the clinical utility of the study findings.18 Furthermore, although this study crossed the borders of Northern Ireland and the Republic of Ireland, it involved a homogeneous Northern European population of practitioners. The findings of this study might have been strengthened had we been able to expand the geographical area of recruitment.
Future Research
This is the first qualitative study, to our knowledge, that has explored physical therapists' perceptions of the use of exercise in the management of SAIS. Further investigation of this topic with a broader sample of therapists and a stronger focus on the specifics of exercise prescription would be useful. The results of these focus groups will be used to develop an evidence-based exercise protocol for the management of SAIS to be tested in an RCT.
In conclusion, this study explored the experiences and perceptions of experienced physical therapists who use exercise to treat patients with SAIS. The therapists indicated that exercise was central to the management of SAIS, but that gaining buy-in from patients was essential. Other important interventions included patient education, postural advice, and pain control. The majority of participants were reluctant to describe a prescriptive regimen of exercise for those with SAIS; common exercises, however, were identified, such as scapular stability exercises, rotator cuff strengthening, and stretches for the anterior shoulder and pectoralis minor muscles.
Footnotes
Dr Hanratty, Mr Kerr, Dr McCracken, and Dr McVeigh provided concept/idea/research design. Dr Hanratty, Mr Kerr, Dr Wilson, Professor Sim, Professor Basford, and Dr McVeigh provided writing and data analysis. Dr Hanratty, Mr Kerr, Dr Wilson, Dr McCracken, and Dr McVeigh provided data collection. Dr Hanratty, Mr Kerr, and Dr McVeigh provided project management. Dr Hanratty provided participants and facilities/equipment. Dr McVeigh provided institutional liaisons. Dr Hanratty, Mr Kerr, Professor Sim, Professor Basford, and Dr McVeigh provided consultation (including review of manuscript before submission). The authors thank the physical therapists who took part in the focus groups.
The study was approved by the Ulster University Research Ethics Committee and the Office for Research Ethics Committee, Northern Ireland (ORECNI Ref: 11/NI/0026).
The study was undertaken as part of a Department of Employment and Learning (United Kingdom) grant-funded PhD.
- Received July 30, 2015.
- Accepted March 13, 2016.
- © 2016 American Physical Therapy Association
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