A recent trial on ‘strengthening’ exercises for shoulder pain called the SExSI trial has just been published this week with some interesting results and even more interesting reactions and comments being thrown around on social media. In fact, its been really disappointing to see some individuals twist and contort what this trial shows just to try and have a cheap shot at strength exercise and a favourite saying of mine… ‘you can’t go wrong getting strong‘
In fact, I think it’s totally pathetic to see some well-known, influential physios gleefully misrepresenting my position on strengthening exercise for those in pain. But what I have found more astounding is those who are trying to claim that strengthening exercises don’t help those with pain, and some who think those who strongly advocate strengthening exercises for patients are the modern-day equivalents of those who advocate correct posture.
So in this blog, I’m going to discuss what this SExSI trial does and doesn’t tell us about strengthening exercises and shoulder pain, as well as defend the use and promotion of strengthening exercises in physiotherapy, and finally respond to some of the asinine comments about getting strong and those who advocate it.
However, before I begin I want to first congratulate the authors of the SExSI trial as I know it’s bloody hard to do research, but also for coming up with such a great acronym for the study. So the ‘SExSI trial’ which stands for Strengthening Exercise for Shoulder Impingement, randomised 200 people, aged between 18-65 who had long-lasting shoulder pain for an average of 10 months, to have either ‘usual physiotherapy’ or usual physiotherapy plus ‘three additional’ strengthening exercises over a 16 week period.
These three additional exercises were added one every 5 weeks and were 1) supported ER at 45º of scaption 2) scaption raises between 0-45º, and 3) unsupported ER again at 45º of scaption. They used rubber bands to add resistance and monitored the total time under tension using a sensor attached to the band.
They gave instructions to increase the resistance if subjects felt they could do more than the recommended reps and have no pain flare-up, or decrease it if they could not do the recommended reps or had a pain flare. They asked them to do 3 sets of the first exercise with 1-minute rest every day for the first 5 weeks, but as the 2nd and 3rd exercises were added they asked them to do just 2 sets per exercise every other day. The total time under tension for these exercises over the 16 week period was calculated to be an additional 12 hours which they suggested was optimal for muscle protein synthesis and strength gains (ref).
They used the SPADI as their primary outcome measure as well as measured the subject’s shoulder abduction and external rotation ‘strength’ using dynamometry. After 16 weeks 156 of the original 200 patients completed the trial and they found NO significant difference between SPADI scores or shoulder strength measurements between the two groups.
Their conclusions were “adding a large dose of shoulder strengthening exercise to current nonoperative care for long-standing subacromial shoulder impingement did not result in a superior outcome for shoulder-specific disability after 4 months.”
From this conclusion, it seems that some soft-skinned therapists and pasty professors who couldn’t deadlift their way out of a wet paper bag, or show you one end of a dumbbell from another are suggesting that strengthening exercises don’t help, or are not needed for those with shoulder pain.
First things first, this trial doesn’t actually show strengthening exercises don’t improve shoulder pain. In fact, this trial DOESN’T show ANY changes in strength OR pain levels at all. Call me old fashioned but I think for a strengthening exercise to be classed as a strengthening exercise it has to at least increase… strength.
If a resistance exercise doesn’t increase strength then it’s best called a… resistance exercise, and this may come as a shock to some physios and professors out there but not all resistance exercises increase strength. In fact, many do not.
Anyone who has tried to get stronger knows it takes more than just a few minutes of pulling a poxy physio band for a few weeks and also knows it’s not easy to do. In fact, trying to get stronger is hard as hell, requiring a lot of effort, intensity, volume, and most of all consistency.
Yes, there are some initial easier gained early increases in strength in the first few weeks of training, especially in those inexperienced to resistance-based exercises mostly due to neural adaptions (ref, ref). But to achieve significant tissue structural changes such as muscle hypertrophy (not hyperplasia as some professors who should know better are claiming as this only accounts for about 5% of muscle adaption in humans (ref, ref) requires regular intense resistance-based exercise, with sufficient dietary protein, rest, and recovery done over a long duration.
What the SExSi trial actually showed is that these particular exercises, at this dosage, in this population, does NOT increase shoulder strength or reduce shoulder pain, and that’s not surprising when we look a little closer at them.
The exercises in the SExSI trial did not strengthen the subjects because of the very low volume and I suspect insufficient intensity, but more likely just due to the fact they have pain because individuals in pain do not respond to stimuli such as touch, temperature and stress/strain the same as individuals without pain (ref). I also guess there may be an element of subject boredom, disinterest, and lack of motivation that may also have had an effect on why they didn’t improve in strength and pain levels.
The authors note that the subjects did not achieve anywhere near the total time under tension they wanted during the 16 weeks to achieve muscle protein synthesis. The aim was to get subjects to perform an additional 12 hours of time under tension, however, they only achieved on average just 2.9 hours, with 1.6 hours done in the first 5 weeks, 0.8 hours in the next 5 weeks, and just 0.6 hours for the last weeks. This equates to just 36 mins over the whole of the last 5 weeks, that’s just 7.2 mins a week, or 2.4 mins a session.
Again this is not surprising, because no one wants to do anything for a long time when in pain. However, I would NOT expect anyone with or without pain except for the most severely de-conditioned individual to get stronger by pulling a rubber band for just 2.4 mins 3 times a week. If it was this simple and easy to get stronger all our patients and everyone else would be walking around like Thor and looking like Arnold.
The ‘additional’ exercise group in the SExSI trial actually spent on average 16 mins a week LESS time exercising than the usual care group. This shows the subjects were not happy or engaged with their exercises for whatever reasons, maybe it was boredom, maybe it was pain, maybe it was lack of support from the physios etc who knows, either way, these exercises were just not done. To be fair the authors do attempt to adjust for this difference in their post hoc analysis, but I still suggest that these exercises were not done at any sufficient volume or intensity to make any meaningful tissue adaptions.
These exercises were also chosen to strengthen the rotator cuff muscles but only in a limited range of movement of just 45º of elevation to avoid aggravating pain. The assumption here is that the cuff muscles were the source of the subjects long-lasting shoulder pain and that restricting their range of movement and avoiding pain is the best way to help them.
In my experience, this is not the case at all. Maybe, these exercises are an option to start with for those with severe shoulder pain for the first few weeks, but not for 4 months solid. To ask subjects with long-lasting shoulder pain to only do 3 exercises, below 45º of elevation and avoid pain for 16 weeks is in my opinion not evidence-based progressive rehab. In fact, encouraging some pain during rehab has been seen to have beneficial effects in many chronic musculoskeletal painful conditions, including shoulder pain (ref, ref).
Also, remember this trial made no changes in subjects pain, and so it’s not surprising that there were no changes in their strength. It’s well known and well researched that pain inhibits muscle function (ref, ref, ref). Basically, it’s really hard to produce force/torque/power/work when it hurts (ref).
So what the SExSI trial found was three, limited range of movement, shoulder exercises, done at low volume over 4 months, avoiding pain does not improve shoulder strength or reduce pain. What this trial does NOT show is strengthening exercises don’t help people with shoulder pain.
Pathetic and Pedantic
I really just can’t understand some of the comments I’ve seen around this trial or the growing criticism of resistance-based exercises by some so-called evidence-based clinicians. I do understand that a few are genuinely trying to be fair and equal in their critique of all interventions, but many others are just trying to be edgy contrarians with their pathetic, petty, and pedantic comments and constant misrepresentations of those, like myself, who advocate and promote strengthening and resistance-based exercises a lot.
To claim those of us who promote and advocate getting stronger as PART of a patient-centred management approach are the modern-day equivalents of those who tell patients they need to improve their posture is a ridiculous comparison and a narrow-minded, reductionist view of the many benefits that resistance-based exercises have.
I find it ironic that those who seem to critique resistance-based exercises the most are often those who look like they use them the least. I also find it highly ironic that those who like to remind us that pain and pathology are multifactorial, and treatments and interventions for pain are multidimensional in their mechanisms of effect, only focus on the effects that resistance-based exercises have on tissue structure and patients pain levels when it suits their agenda.
Resistance-based exercises help pain, pathology, AND people via a multitude of pathways, process and mechanisms, both physiological and psychological. Resistance-based exercises affect people positively.
I am also struggling to contain my frustration with the increasing criticism of resistance-based exercise by some who think it doesn’t get the same level of critique as other interventions because I see the exact opposite. All I see on social media and in clinical practice are lots and lots of promotion and propaganda by clinicians for silly, over-complicated, pseudoscientific, active and passive interventions and very little advocacy for simple robust resistance exercise.
I argue that resistance-based exercises are one of the least used interventions within a lot of physiotherapy for many reasons such as lack of training, knowledge, confidence, and equipment. But also because they are seen by many physios to be not sexy, skilled, or sciencey enough to warrant their time or attention.
All too often I see and hear patients who have had months of massage, needling, cupping, pelvic tilting, and transverse abdominus clenching with little to no advice, guidance, or encouragement to do any robust generic resistance-based exercises or activities.
And yes, I am well aware that resistance-based exercises do not outperform any other type of exercise or even some of the pseudoscientific passive claptrap for reducing pain. But what resistance-based exercises DO outperform EVERYTHING else on is their effect on an individuals health, wellness, function and quality of life (ref, ref).
Despite some claims that strength-based exercises are not effective for pain, there are actually numerous studies (admittedly some better than others) that do demonstrate resistance-based exercises help reduce pain (ref, ref, ref). What a lot of these studies don’t prove is that resistance-based exercises actually get people stronger as this is often not measured or assessed.
These trials also don’t tell us HOW or WHY resistance-based exercises reduce pain or improve function. It may be more the act of doing them rather than the results. It could be the surrounding contextual and psychological factors around resistance-based exercises such as reducing feelings of fear and fragility, challenging beliefs and expectations, or improving pain self-efficacy that helps reduce pain, not the physiological effects of tissue adaptions such as muscle hypertrophy (ref).
I also know and accept that being strong or getting stronger is not sufficient to reduce either the intensity or frequency of pain experienced throughout life. I know this only too damn well myself as well as seeing many other strong people in pain, sometimes frequently, and sometimes lasting a long time.
However, what stronger people do have is significantly fewer risks of many diseases, illnesses, age-related disabilities, and other conditions which are often accompanied by pain. Being stronger may not prevent you from having pain in life, but it will equip you better for coping with and overcoming it.
There is also NO evidence that getting people stronger is either harmful or detrimental for many painful conditions, so again I really can’t understand why there is so much criticism, snarkiness, and bitterness towards a simple, cheap, and effective method of helping people in pain or with a disability, or those who advocate for it regularly and passionately. Personally, I think if some of these exercise contrarians used as much energy actually doing some resistance-based exercise as they do on questioning it they may find it more worthwhile.
So I’m going to continue on promoting the use of resistance and strength-based exercises in all those we see with pain or disability, and I will continue to use my phrase of ‘you can’t go wrong getting strong’ until I am blue in the face. And I really don’t give AF if some don’t like it because it’s a short, catchy, easily remembered, slogan, that fits beautifully on a nice cotton t-shirt, that grabs attention and promotes strength-based exercise to everyone.
Finally to those who critique the role of strength-based exercises in physiotherapy ask yourselves why you do this and carefully consider if what you are doing maybe detering clinicians and patients from engaging with it even more than they currently are?
Now I’m sure some will whine, moan, and even complain to the authorities about this blog as they have done before, but honestly, I don’t give AF again. Because if I have to spend my evenings writing blogs defending how being vocal, passionate, and biased towards strength-based exercise in physiotherapy is not wrong, I don’t want to be right.
As always thanks for reading