Physiotherapy for soft tissue shoulder disorders: A systematic review of randomised clinical trials

Institute for Rehabilitation Research, Hoensbroek, Netherlands.
BMJ Clinical Research (Impact Factor: 14.09). 08/1997; 315(7099):25-30. DOI: 10.1136/bmj.315.7099.25
Source: PubMed


To assess the effectiveness of physiotherapy for patients with soft tissue shoulder disorders.
A systematic computerised literature search of Medline and Embase, supplemented with citation tracking, for relevant trials with random allocation published before 1996.
Patients treated with physiotherapy for disorders of soft tissue of the shoulder.
Success rates, mobility, pain, functional status.
Six of the 20 assessed trials satisfied at least five of eight validity criteria. Assessment of methods was often hampered by insufficient information on various validity criteria, and trials were often flawed by lack of blinding, high proportions of withdrawals from treatment, and high proportions of missing values. Trial sizes were small: only six trials included intervention groups of more than 25 patients. Ultrasound therapy, evaluated in six trials, was not shown to be effective. Four other trials favoured physiotherapy (laser therapy or manipulation), but the validity of their methods was unsatisfactory.
There is evidence that ultrasound therapy is ineffective in the treatment of soft tissue shoulder disorders. Due to small trial sizes and unsatisfactory methods, evidence for the effectiveness of other methods of physiotherapy is inconclusive. For all methods of treatment, trials were too heterogeneous with respect to included patients, index and reference treatments, and follow up to merit valid statistical pooling. Future studies should show whether physiotherapy is superior to treatment with drugs, steroid injections, or a wait and see policy.

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Available from: Geert J.M.G. van der Heijden
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    • "Despite rotator cuff disorders being such a common shoulder problem there is a lack of high quality studies upon which to base practice [11]. Numerous systematic reviews have been undertaken in relation to subacromial impingement syndrome, an umbrella term encompassing rotator cuff disorders, investigating the various plausible interventions including physiotherapy, corticosteroid injections and surgery but all identify the insufficiency of the evidence base when attempting to draw conclusions [12-17]. Specifically in relation to the rotator cuff, a recent systematic review, which included 4 randomised controlled trials, suggested that loaded exercise, i.e. exercise against gravity or resistance, in the treatment of this disorder was promising [18] but due to the paucity of research and methodological limitations of the included studies further research is warranted. "
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    ABSTRACT: Background Shoulder pain is the third most common reason for consultation with a physiotherapist and up to 26% of the general population might be expected to experience an episode at any one time. Disorders of the shoulder muscles and tendons (rotator cuff) are thought to be the commonest cause of this pain. The long-term outcome is frequently poor despite treatment. This means that many patients are exposed to more invasive treatment, e.g. surgery, and/or long-term pain and disability. Patients with this disorder typically receive a course of physiotherapy which might include a range of treatments. Specifically the value of exercise against gravity or resistance (loaded exercise) in the treatment of tendon disorders is promising but appears to be under-used. Loaded exercise in other areas of the body has been favourably evaluated but further investigation is needed to evaluate the impact of these exercises in the shoulder and particularly the role of home based or supervised exercise versus usual treatment requiring clinic attendance. Methods/Design A single-centre pragmatic unblinded parallel group randomised controlled trial will evaluate the effectiveness of a self-managed loaded exercise programme versus usual clinic based physiotherapy. A total of 210 study participants with a primary complaint of shoulder pain suggestive of a rotator cuff disorder will be recruited from NHS physiotherapy waiting lists and allocated to receive a programme of self-managed exercise or usual physiotherapy using a process of block randomisation with sealed opaque envelopes. Baseline assessment for shoulder pain, function and quality of life will be undertaken with the Shoulder Pain & Disability Index, the Patient Specific Functional Scale and the SF-36. Follow-up evaluations will be completed at 3, 6 and 12 months by postal questionnaire. Both interventions will be delivered by NHS Physiotherapist’s. An economic analysis will be conducted from an NHS and Personal Social Services perspective to evaluate cost-effectiveness and a qualitative investigation will be undertaken to develop greater understanding of the experience of undertaking or prescribing exercise as a self-managed therapy. Trial registration number ISRCTN84709751
    Full-text · Article · Apr 2012 · BMC Musculoskeletal Disorders
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    • "To date, a number of systematic reviews have evaluated the effectiveness of conservative treatment in shoulder disorders (Van der Heijden et al., 1997; Green et al., 1998; Desmeules et al., 2003; Green et al., 2003; Ejnisman et al., 2004; Grant et al., 2004; Gibson et al., 2004; Harniman et al., 2004; Michener et al., 2004; Faber et al., 2006; Trampas and Kitsios, 2006). Although there was some evidence of an additional benefit of MT with exercise in patients with shoulder impingement syndrome (SIS), conclusions from these reviews (Desmeules et al., 2003; Green et al., 2003; Michener et al., 2004; Faber et al., 2006; Trampas and Kitsios, 2006) were limited due to small number of studies including MT. "
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    ABSTRACT: A systematic review of randomised controlled trials (RCTs) was conducted to determine the effectiveness of manual therapy (MT) techniques for the management of musculoskeletal disorders of the shoulder. Seven electronic databases were searched up to January 2007, and reference lists of retrieved articles and relevant MT journals were screened. Fourteen RCTs met the inclusion criteria and their methodological qualities were assessed using the PEDro scale. Results were analyzed within diagnostic subgroups (adhesive capsulitis (AC), shoulder impingement syndrome [SIS], non-specific shoulder pain/dysfunction) and a qualitative analysis using levels of evidence to define treatment effectiveness was applied. For SIS, there was no clear evidence to suggest additional benefits of MT to other interventions. MT was not shown to be more effective than other conservative interventions for AC, however, massage and Mobilizations-with-Movement may be useful in comparison to no treatment for short-term outcomes for shoulder dysfunction.
    Full-text · Article · Jun 2009 · Manual therapy
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    • "Pain is a primary symptom in most shoulder disorders. In fact, shoulder pain has been a primary focus of systematic reviews looking at diagnosis [26], prognosis [6], and treatment effectiveness [27,28]. These reviews have emphasized the need for validated outcome measures to improve the validity of clinical trials addressing shoulder pain [27]. "
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    ABSTRACT: There is a lack of standardized tests that assess functional performance for sustained upper extremity activity. This study describes development of a new test for measuring functional performance of the upper extremity and neck and assesses reliability and concurrent validity in patients with shoulder pathology. A series of developmental tests were conducted to develop a protocol for assessing upper extremity tasks that required multi-level movement and sustained elevation. Kinematics of movement were investigated to inform subtask structure. Tasks and test composition were refined to fit clinical applicability criteria and pilot tested on 5 patients awaiting surgery for shoulder impingement and age-sex matched controls. Test-retest reliability was assessed on 10 subjects. Then a cohort of patients with mild to moderate (n = 17) shoulder pathology and 19 controls (17 were age-sex matched to patients) were tested to further validate the Functional Impairment Test-Hand, and Neck/Shoulder/Arm (FIT-HaNSA) by comparing it to self-reported function and measured strength. The FIT-HaNSA, DASH and SPADI were tested on a single occasion. Impairments in isometric strength were measured using hand-held dynamometry. Discriminative validity was determined by comparing scores to those of age-sex matched controls (n = 34), using ANOVA. Pearson correlations between outcome measures (n = 41) were examined to establish criterion and convergent validity. A test protocol based on three five-minute subtasks, each either comprised of moving objects to waist-height shelves, eye-level shelves, or sustained manipulation of overhead nuts/bolts, was developed. Test scores for the latter 2 subtasks (or total scores) were different between controls as compared to either surgical-list patients with shoulder impingement or a variety of milder shoulder pathologies (p < 0.01). Test 1 correlated the highest with the DASH (r = -0.83), whereas Test 2 correlated highest with the SPADI (r = -0.76). Initial data suggest the FIT-HaNSA provides valid assessment of impaired functional performance in patients with shoulder pathology. It discriminates between patients and controls, is related to self-reported function, and yet provides distinct information. Longitudinal testing is warranted.
    Full-text · Article · May 2007 · BMC Musculoskeletal Disorders
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