Research Review by Dr. Shawn Thistle©


Dec. 2005

Study Title:

Effects of acupuncture versus ultrasound in patients with impingement syndrome: Randomized clinical trial


Johansson KM, Adolfsson LE, Foldevi MO

Publication Information:

Physical Therapy 2005; 85(6): 490-501.


Shoulder impingement, normally presenting as pain during shoulder motion felt at the front or side of the shoulder, is a common complaint in clinical practice occurring in patients of all ages. Controversy exists in the literature regarding the pain generating structure, and the best method of assessment and diagnosis for this condition.

Treatment of this bothersome condition has traditionally been variable and diverse, including modalities such as IFC, electrotherapy, ultrasound, and cryotherapy, as well as manual therapies (including joint and soft tissue work), analgesics and anti-inflammatory medications, and rehabilitative exercises. No definitive answer exists in the literature regarding the best treatment for this condition, and as most manual therapists will attest, a combination of therapies is normally most efficacious.

This Swedish study compared and evaluated the effectiveness of two commonly used strategies for patients with impingement syndrome:
  1. acupuncture with exercise
  2. continuous ultrasound with exercise
Patients were included in the study if the following conditions were met:
  • they were between the age of 30-65
  • they had a typical history of pain at the anterior or lateral aspect of the shoulder/upper arm, especially with shoulder movement
  • a positive Neer impingement test - confirmed with anesthetic injection into the subacromial space (i.e. pain disappears with local injection)
  • 3 of 4 additional clinical tests were positive: Hawkins-Kennedy impingement sign, Jobe supraspinatus muscle test, Neer impingement sign, and painful arc between 60-120° shoulder abduction
Eighty-five patients (average age 49) were randomized into these two groups - each undergoing a 5 week, 10 treatment trial of therapy with 3, 6, and 12 month follow-ups to see how long the effects lasted.

Acupuncture treatments were standardized and involved 5 needles inserted into points commonly used to treat shoulder pain (4 local and 1 distal). The needles were manually stimulated twice during each 30 minute treatment. The ultrasound intervention was also standardized (1MHz and 1W/cm2 settings) and applied with gel coupling for 10 minutes in each treatment.

A two-stage home exercise program was given to all patients which involved specific rotator-cuff exercises performed with low resistance and high repetitions.

The main outcome measure was an amalgamated score derived from three different scales (Constant-Murley Shoulder Assessment, Adolfsson-Lysholm Shoulder Score, and the UCLA Score). This to me represents the biggest drawback of this study. Despite all three scales being previously validated, their combination has never been investigated, and represents a strange decision in this particular study.

One other drawback of this study is the lack of a true control group (i.e. a group receiving no treatment), which is compounded the lack of credible evidence regarding the natural history of shoulder impingement.

The unusual choice of outcome measure notwithstanding, the results of this study were as follows:
  • both groups experienced reduction in symptoms during the treatment period
  • the acupuncture group experienced greater improvement at all follow-up times than the ultrasound group
  • no adverse reactions occurred in either treatment group

Conclusions & Practical Application:

This randomized clinical trial showed that treatment with acupuncture and exercise was superior with ultrasound in exercise in a group of patients with shoulder impingement. Further study is warranted to determine the best treatment frequency, point selection, and exercise interventions to best benefit these patients.