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Physiotherapists’ recommendations for examination and treatment of rotator cuff related shoulder pain: A consensus exercise

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BACKGROUND: Disorders associated with the rotator cuff are regarded as the most common shoulder pain presentation. The range of diagnostic terms used to explain this problem reflect uncertainty in relation to causative mechanisms, diagnosis, prognosis, and the most effective treatments. The aim of this consensus exercise was to facilitate a shared understanding as a means of reducing mixed messages, informing clinical practice and providing a foundation for future research. METHODS: Nine physiotherapists with clinical and academic expertise in shoulder pain participated in an online and face-to-face consensus exercise. RESULTS: This consensus exercise suggests specific factors in the history and physical examination that might raise the index of suspicion of Rotator Cuff Related Shoulder Pain. The suggestions for non-surgical management include a minimal number of exercises prescribed to challenge the functional deficit of the patient over a minimum 12-week period. Apart from aiding exclusion of red flag pathology, imaging is not regarded as useful unless the patient does not respond as expected. Steroid injections wouldn't be considered a first-line intervention unless pain was severe and preventing engagement with exercise. CONCLUSION: This consensus exercise provides a benchmark for clinical reflection while highlighting areas of uncertainty that still exist and require further research.
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Physiotherapy Practice and Research 40 (2019) 87–94
DOI:10.3233/PPR-190129
IOS Press
87
Physiotherapists’ recommendations for
examination and treatment of rotator cuff
related shoulder pain: A consensus exercise
Chris Littlewooda,, Marcus Batemanb, Clare Connorc, Jo Gibsond, Ian Horsleye, Anju Jaggif,
Val Jonesg, Adam Meakinshand Martin Scotti
aArthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences
and Keele Clinical Trials Unit, Keele University, Staffordshire, UK
bDerby Shoulder Unit, University Hospitals Derby & Burton NHS Foundation Trust, Derby, UK
cAneurin Bevan University Health Board, Caerleon, UK
dLiverpool Upper Limb Unit, Royal Liverpool University Hospital, Liverpool, UK
eEnglish Institute of Sport, Manchester, UK
fRoyal National Orthopaedic Hospital, Middlesex, UK
gSheffield Shoulder and Elbow Unit, Sheffield Teaching Hospital NHS Trust, Sheffield, UK
hWest Herts Shoulder Service, West Hertfordshire Hospital Trust, St Albans Herts, Spire Healthcare,
Spire Bushey Hospital, Hertfordshire, UK
iNottingham Shoulder & Elbow Unit, Nottingham University Hospitals NHS Trust, Nottingham, UK
Abstract.
BACKGROUND: Disorders associated with the rotator cuff are regarded as the most common shoulder pain presentation.
The range of diagnostic terms used to explain this problem reflect uncertainty in relation to causative mechanisms, diagnosis,
prognosis, and the most effective treatments. The aim of this consensus exercise was to facilitate a shared understanding as
a means of reducing mixed messages, informing clinical practice and providing a foundation for future research.
METHODS: Nine physiotherapists with clinical and academic expertise in shoulder pain participated in an online and
face-to-face consensus exercise.
RESULTS: This consensus exercise suggests specific factors in the history and physical examination that might raise the
index of suspicion of Rotator Cuff Related Shoulder Pain. The suggestions for non-surgical management include a minimal
number of exercises prescribed to challenge the functional deficit of the patient over a minimum 12-week period. Apart from
aiding exclusion of red flag pathology, imaging is not regarded as useful unless the patient does not respond as expected.
Steroid injections wouldn’t be considered a first-line intervention unless pain was severe and preventing engagement with
exercise.
CONCLUSION: This consensus exercise provides a benchmark for clinical reflection while highlighting areas of uncertainty
that still exist and require further research.
Keywords: Rotator cuff, diagnosis, exercise, physiotherapy
Corresponding author: Chris Littlewood, Research Institute
for Primary Care and Health Sciences, Keele University, Stafford-
shire, UK. Tel: +44 1782 734832; E-mail: c.littlewood@keele.
ac.uk.
1. Introduction
Many patients consult healthcare professionals
complaining of shoulder pain, with disorders associ-
ated with the rotator cuff (subacromial impingement,
subacromial pain, rotator cuff related shoulder pain
ISSN 2213-0683/19/$35.00 © 2019 – IOS Press and the authors. All rights reserved
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88 C. Littlewood et al. / Physiotherapists’ recommendations for RCRSP
(RCRSP) and other synonyms) widely regarded as the
most common presentation [1, 2]. The wide range of
diagnostic or descriptive terms used to explain this
common clinical presentation reflect uncertainty in
relation to understanding of the pathology, diagnosis,
prognosis, and the most effective treatment options
[1, 3–5]. A range of diagnostic tests, including imag-
ing, and a range of different treatment options are
available including exercise programmes, manual
therapy, corticosteroid injections and surgery [6].
Based on recent randomised controlled trials and
systematic reviews, where clinical intervention is
required, exercise is recommended as the first-line
intervention of choice with comparable outcomes but
at a lower cost and with fewer associated risks than
surgical management. [7, 8]. Despite this, there is lit-
tle research evidence to inform what constitutes an
effective exercise programme in terms of the type of
exercise, the number of sets, repetitions, acceptable
pain levels, duration and setting [9, 10]. A previ-
ous systematic review has suggested that inclusion of
some level of resistance seems to matter although the
optimal level is unclear; the optimal number of rep-
etitions is also unclear but higher repetitions might
confer superior outcomes; higher number of sets of
exercise are preferable to lower number of sets but
the optimal frequency is unknown; most programmes
should demonstrate clinically significant outcomes
by 12 weeks [9]. So, although there is some guidance
available, there still remains a number of significant
unknowns [9]. This is important because it might
mean that suboptimal exercise prescription leads to
patients moving on to more costly, invasive and risky
interventions, including corticosteroid injections and
surgery, which are of questionable effectiveness [8,
11, 12]. This concern is justified when it is recog-
nised that the practice of physiotherapists across the
UK with regards to exercise prescription is highly
variable [6, 13].
In 2012 a group of international physiothera-
pists reported their consensus on physiotherapy for
shoulder pain [14]. This guidance recommended:
active exercise prescribed in relation to the clinical
assessment and not the structural pathology; mild to
moderate pain (<4/10 on VAS) secondary to the exer-
cise was acceptable but must subside within 12 hours;
the quality of the performance of exercise was cru-
cial and exercise should be performed with optimal
scapular positioning and control without abnormal
compensatory trunk movement; exercises should be
simple and slow and unloaded to begin with, pro-
ceeding gradually to loaded and faster exercises; the
number of exercises should be limited to a maximum
of four, and dose and progressions should be indi-
vidualised [14]. Aspects of this consensus reflect the
emerging evidence, however in view of the limited
progress in understanding the most appropriate ter-
minology, approach to diagnosis, understanding of
prognosis, and optimal exercise approach and con-
tinued conflicting messages within the literature, the
purpose of this paper was to undertake an updated
consensus process. The aim was to enable a shared
understanding of this common shoulder pain pre-
sentation as a means of reducing mixed messages,
informing physiotherapy practice and providing a
basis on which future research could be developed.
2. Methods
In December 2017 the lead author, a physio-
therapist, approached nine further physiotherapists
recognised for their clinical and academic expertise
in the management of shoulder pain. Of the nine
approached, eight accepted and formed the consen-
sus group. The physiotherapist who declined did not
offer reasons for not participating.
Subsequent to this, the lead author circulated
electronically a list of questions broadly based on
approaches taken by other consensus groups [15] and
invited commentary from the group. This resulted in
a refined list of questions that would be used as the
basis for this consensus process (Table 1).
Following agreement, questions were recirculated
to the group, and comments were requested. At
the end of this stage, the lead author summarised
responses. For example, where two comments had
similar purpose and meaning they were amalgamated,
without any attempt to interpret the initial responses.
After this the group were asked to confirm that the
summarised document was a fair summary of their
inputs.
The group met face-to-face at the annual British
Elbow & Shoulder Society meeting in Glasgow in
June 2018 with a view to generating a consensus state-
ment. Each of the comments, in turn, was presented to
the group who were asked to vote whether they agreed
with the comment or not. A majority response, i.e.5/
9, meant that the comment was carried forward and
included in the narrative summary.
It was agreed that although a comment carried
through to the narrative summary was reflective of the
majority of the group, it does not necessarily reflect
the view of all individuals all of the time.
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C. Littlewood et al. / Physiotherapists’ recommendations for RCRSP 89
Table 1
List of questions on which the consensus exercise was based
Question
1 What key information is required from the history to raise the index of suspicion of this
classification or diagnosis over other shoulder pain presentations?
2 Do you consider age, gender and occupation as relevant factors within your diagnostic reasoning
with regard to ‘rotator cuff syndrome’?
3 What key information is required from the physical examination to confirm this classification or
diagnosis?
4 What is the role of imaging in confirming this classification or diagnosis?
5 What is the preferred terminology for this shoulder pain classification?
6 In summary, what is ‘rotator cuff syndrome’?
7 How do you explain ‘rotator cuff syndrome’ to your patients?
8 What is/ are the preferred methods of treatment?
9 Do you consider the role of lifestyle, e.g. sedentary behaviour, and metabolic factors, e.g. obesity
when assessing and treating patients with this pain presentation?
10 If exercise is prescribed, what are the preferred parameters guiding this prescription?
– Type of exercise and the factors that inform this
– Number of sets and repetitions and the factors that inform this
– Frequency of exercise and the factors that inform this
– Number of exercises and the factors that inform this
– Intensity/ effort of exercise and the factors that inform this
– Painful versus painless and the factors that inform this
– Duration of exercise
11 Which factors or characteristics do you see as important indicators of prognosis?
12 What is the expected prognosis of ‘rotator cuff syndrome’?
3. Results
The results are summarised in Table 2 with a full
narrative description.
3.1. What key information is required from the
history to raise the index of suspicion of this
classification or diagnosis over other
shoulder pain presentations?
The majority opinion of the group was that pain
should be broadly over the deltoid and upper arm
region to raise the suspicion of this sub-group of
shoulder pain. If there is complaint of subluxation
or dislocation as the primary problem, then the index
of suspicion would be reduced. For this sub-group
of shoulder pain, pain is activity related (better or
worse), typically worse reaching overhead or behind
the back, with minimal pain at rest except when lying
on the affected shoulder. Pain in the neck, repro-
duction of shoulder pain on movement of the neck,
and distal neurovascular symptoms would reduce the
index of suspicion.
3.2. Do you consider age, gender and
occupation as relevant factors within your
diagnostic reasoning with regard to ‘rotator
cuff syndrome’? If so, why and how?
The majority opinion of the group was that changes
in occupation or participation demands rather than
occupation alone were relevant in raising the index
of suspicion of RCRSP. Majority opinion on other
factors was not reached.
3.3. What key information is required from the
physical examination to confirm this
classification or diagnosis?
The majority opinion of the group was that there
should be no significant loss (>50%) of passive
range of movement in any direction, particularly
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90 C. Littlewood et al. / Physiotherapists’ recommendations for RCRSP
Table 2
Summary of recommendations
History Examination Treatment Prognosis
Factors increasing index of
suspicion of RCRSP:
Factors increasing index of
suspicion of RCRSP:
Progressive loading of upper
limb and kinetic chain with
a minimal number of
exercises (3),
incorporating graded
exposure to painful
movements or graded
activity guided by
acceptable symptom
response
Prognosis is likely to be
favourable but this will take
a minimum of 12 weeks,
but further improvement
may be expected up to 24
weeks
Pain over the deltoid/ upper arm
Familiar pain is reproduced with
resisted testing of the shoulder,
usually abduction and lateral
rotation
Activity related
Minimal pain at rest except when
lying on affected side
Imaging not recommended as a
first line investigation unless
red flag pathology suspected,
for example tumour or fracture Individualised exercise
should be prescribed in
relation to specific
functional difficulty, broken
down in to component parts
Referral for investigation or
orthopaedic opinion would
be considered for patients
whose symptoms remain
unacceptable despite an
appropriate period of
engagement with an
exercise based management
approach or if the patient
remains anxious or
unconvinced about the
treatment approach.
Associated with changes in load
from a specific activity or
repetitive use. Consider
changes in occupation or
participation demands.
Factors reducing index of
suspicion of RCRSP:
Factors reducing index of
suspicion of RCRSP:
The exercise programme
should be a minimum of 12
weeks’ duration
Complaint of subluxation or
dislocation
Significant loss (>50%) of
shoulder passive range of
movement in any direction,
particularly external rotation
A corticosteroid injection
would not be considered as
a first-line intervention
unless the pain was severe
or not improving with
exercise
Pain in the neck
Distal neurovascular symptoms Reproduction of shoulder pain on
movement of the neck Consider relevance of sleep,
nutrition, alcohol, physical
activity, and smoking
Presence of neurological signs
external rotation. Typically, familiar pain should
be reproduced with loading/ resisted testing, usu-
ally abduction and lateral rotation. In keeping with
findings from the history to raise the index of this sub-
group of shoulder pain, movement of the neck should
not produce or abolish the shoulder pain and there
should be no neurological signs, including upper limb
mechano-sensitivity tests.
3.4. What is the role of imaging in confirming
this classification or diagnosis?
The majority opinion of the group was that imag-
ing is useful to rule out red flag pathology if the
index of suspicion is raised during the history and
physical examination, e.g. tumour or fracture or if
suspected dislocation. In the absence of stiffness
and with a consistent history, as described above,
the group consensus was that imaging would not be
indicated initially due to the poor correlation between
pain and structural pathology. Imaging findings do
not influence non-surgical management options and
could potentially be a barrier to patient engagement,
but imaging may have a role if patients do not follow
the expected trajectory of improvement.
3.5. What is the preferred terminology for this
shoulder pain classification?
The majority opinion of the group was that RCRSP
or weak and painful shoulder were the preferred
descriptors but this depends on context, including
who we are communicating with and what the patient
has been told before. The majority opinion of the
group was that healthcare professionals, including
GPs, orthopaedic surgeons, radiologists, physiother-
apist, should now avoid using the term ‘impingement‘
but it is clear that discourse is still needed regarding
the most useful term(s).
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C. Littlewood et al. / Physiotherapists’ recommendations for RCRSP 91
3.6. In summary, what is ‘rotator cuff syndrome’?
The majority opinion of the group conceptualised
RCRSP as symptoms of pain and signs of weakness
related to the rotator cuff when loaded, and movement
related shoulder pain without significant stiffness.
3.7. How do you explain ‘rotator cuff syndrome’
to your patients?
The majority opinion of the group was that this
could be explained as ’an issue with the muscles
and tendons of the shoulder, they’re lacking strength,
capacity, tolerance and fitness that’s why they com-
plain when you lift your arm.’
3.8. What is/are the preferred methods of
treatment?
The majority opinion of the group was that loading
through exercise, including progressions and regres-
sions, within acceptable symptom response, was the
preferred approach to treatment. Progressive loading
of upper limb and kinetic chain was advocated by
the majority incorporating graded exposure to painful
movements or graded activity. Cognitive behavioural
principles may need to be adopted if there is evidence
of avoidance behaviour.
A steroid injection would not be considered as a
first-line intervention by the majority unless the pain
was severe or not improving with exercise over an
acceptable period of time (e.g. 6 to 12 weeks). Beyond
a programme of physiotherapist-led exercise, fur-
ther referral for investigation or orthopaedic opinion
would be considered for patients whose symptoms
remain unacceptable despite an appropriate period
of engagement with an exercise based management
approach or if the patient remains anxious or uncon-
vinced about the treatment approach.
3.9. Do you consider the role of lifestyle, e.g.
sedentary behaviour, and metabolic factors,
e.g. obesity when assessing and treating
patients with this pain presentation?
The majority opinion of the group was that assess-
ment of sleep, nutrition, alcohol, physical activity,
and smoking should be conducted with promotion of
change where relevant to the patient. However, how to
recognise, implement and support behaviour change
remains unclear but the majority opinion of the group
was that brief interventions should be incorporated to
make every contact count with regard to lifestyle and
musculoskeletal health.
3.10. If exercise is prescribed, what are the preferred
parameters guiding this prescription?
3.11. Type of exercise and the factors that inform
this
The majority opinion of the group was to use iso-
metric, isotonic or eccentric exercise according to
what is most acceptable to the patient while still pro-
viding sufficient stimulus to challenge what is weak
and work to fatigue. The majority opinion was to
prescribe exercise to challenge specific functional
difficulty but break down into component parts within
limits of acceptable symptom response and to stage
loading according to patient’s ability and symptom
irritability. Majority opinion on more specific param-
eters was not reached.
3.12. Number of sets and repetitions and the
factors that inform this
The majority opinion of the group was that this
should be individualised based on acceptable symp-
tom response and functional requirement, e.g. speed
vs sustained. Majority opinion on more specific
parameters was not reached.
3.13. Frequency of exercise and the factors that
inform this
The majority opinion of the group was that if
patients are exercised to the point of muscle fatigue,
exercise on alternate days. If heavy load or plyomet-
ric exercises are included, this should be limited to
exercise over two to three sessions per week. Majority
opinion on more specific parameters was not reached.
3.14. Number of exercises and the factors that
inform this
The majority opinion of the group was that a
minimal number of different exercises, rarely more
than three, should be prescribed. Exercises should be
adapted to address the specific functional difficulties
that the patient reports and be developed in the con-
text of their physical capabilities, functional deficits
and available time to devote to exercise.
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92 C. Littlewood et al. / Physiotherapists’ recommendations for RCRSP
3.15. Intensity/effort of exercise and the factors
that inform this
The majority opinion of the group was that this
should be adapted according to patient specific
acceptable symptom response.
3.16. Painful versus painless and the factors that
inform this
The majority opinion of the group was that exercise
could provoke pain providing that it settles suffi-
ciently to enable the patient to perform the next set of
exercises shortly afterwards within a session. How-
ever, pain provocation was not seen as an essential
feature of the exercise as long as the patient is being
challenged by the exercise.
3.17. Duration of exercise
The majority opinion of the group was that an
exercise programme should be adhered to over a min-
imum of 12 weeks, but sometimes a longer period, up
to 24 weeks, will be required.
3.18. Which factors or characteristics do you see
as important indicators of prognosis?
The majority opinion of the group was that a num-
ber of factors might be relevant including patients’
attitudes regarding pain and exercise, fear avoidance,
litigation, lifestyle factors, e.g. smoking, sedentary
behaviour, diet, alcohol, educational levels, multiple
pain sites, level of baseline pain and disability, pre-
vious experience and response to treatment, patient
expectations regarding recovery and physiotherapy,
co-morbidities, levels of self-efficacy, psychological
distress, and social circumstances, e.g. employment,
social engagement and hobbies.
3.19. What is the expected prognosis of ‘rotator
cuff syndrome’?
The majority opinion of the group was that
patients, and other clinical colleagues, should be
advised that the prognosis is likely to be favourable
but this will take a minimum of 12 weeks, but further
improvement may be expected up to 24 weeks.
4. Discussion
This consensus exercise has resulted in suggestions
regarding patient history and physical examination
findings that might raise the index of suspicion of
RCRSP as well as suggestions regarding prognosis
and suggested terminology to describe this common
presentation to patients and clinical colleagues. Fur-
ther suggestions related to non-surgical management
are reported as well as factors that might influence
the response to this. In summary, the suggestions for
non-surgical management include a minimal number
of exercises prescribed to challenge the functional
deficit of the patient over a minimum 12-week period.
Unless there is concern about red flag pathology
then imaging was not regarded as useful unless the
patient did not respond as expected. Similarly, steroid
injections would not be considered as a first-line
intervention unless pain was severe and preventing
engagement with exercise.
The caution regarding use of imaging expressed
through this consensus approach is unsurprising
given the now well recognised lack of association
between such findings, structural diagnosis and the
pain that patients complain of (4, 16). Similar cau-
tion with regards to use of steroid injection is also
not surprising given contemporary research evidence
highlighting concerns about this treatment approach
for patients with RCRSP (17, 18).
The dearth of evidence to inform the specific pre-
scription parameters of an exercise programme for
RCRSP has been recognised (9). The findings from
this consensus exercise are broadly in agreement
with the scant research evidence-based guidance and
there is overlap with the previous consensus exercise
undertaken by physiotherapists in 2012 (14) in terms
of history, physical examination, use of imaging and
exercise as the mainstay of treatment.
There is some divergence between the consensus
reports with regards to the specifics of exercise pre-
scription though with, arguably, a more progressive
approach suggested via this current consensus exer-
cise. There is also divergence with regardsto expected
response time and prognosis, with this current con-
sensus exercise suggesting a minimum of 12-weeks
required, often longer, depending on patient factors
including baseline levels of pain and disability, expec-
tations of physiotherapy, social circumstances etc.
Also within this current consensus exercise there was
recognition of the potential for lifestyle factors to
influence the onset and persistence of RCRSP. Iden-
tification of such lifestyle factors, including smoking
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C. Littlewood et al. / Physiotherapists’ recommendations for RCRSP 93
and physical activity, were seen as important although
the optimal way to address these factors within a
physiotherapy setting was less clear.
One clear finding from this current consensus exer-
cise is the lack of agreement on the specific exercise
prescription parameters including type and dose of
exercise. Given the lack of research evidence this is
perhaps unsurprising but given the widespread recog-
nition now that exercise should be the mainstay of
treatment for RCRSP this is a clear gap that needs
to be addressed through well-designed, adequately
powered, randomised controlled trials. However, it
should be recognised that RCRSP affects a diverse
and heterogenous population and therefore it is ques-
tionable whether a homogeneous type or dosage of
exercise will be found. Evaluations that are required
include comparison of different types of exercise, e.g.
standardised versus individualised, painful versus
non-painful, while controlling for other parameters
that might influence outcome such as dose of exer-
cise (sets and repetitions). Furthermore, evaluation
of the comparative effectiveness of different doses
should ensure that other factors including the type
of exercise, are adequately controlled to enable a
valid comparison. Once a guiding framework, rather
than a prescriptive recipe, for the optimal prescrip-
tion parameters has been established then it would be
appropriate to evaluate this against other approaches,
including ‘wait-and-see’, to establish whether any
effects of exercise, and other approaches, are due to
reasons other than natural history and placebo.
Further evaluation could focus on approaches to
optimise exercise adherence, approaches to identify
and address relevant psychosocial factors, evaluation
of the impact of lifestyle factors and whether impor-
tant diagnostic and prognostic factors upon which to
stratify care for RCRSP can be identified.
4.1. Implications
This report is by no means definitive in its recom-
mendations but provides an opportunity for clinicians
and researchers to reflect on their own current practice
and consider the differences between the approaches
described in this paper and their own approach. This
process offers the potential to consider such ques-
tions as; ‘why do we do what we do?’ and ‘why do
we believe what we believe?’ Hence, the paper pro-
vides a benchmark for reflection and a stimulus to
challenge practice while at the same time highlight-
ing the many areas of uncertainty that still exist in
this area and require further research.
4.2. Limitations
This is a report of a consensus developed through
consultation with physiotherapists who have clini-
cal and academic expertise in shoulder pain. Such
processes are necessarily reflective of the individu-
als involved and are not necessarily generalisable.
Furthermore, consensus was based on achieving a
majority through a voting system based on agree-
ment or not. When aiming to synthesise complex
processes into a digestible report, such compromises
are necessary.
5. Conclusion
The findings from this consensus exercise suggest
clear features in the history and physical examination
that raise the index of suspicion of RCRSP. Further-
more, suggestions have been made about preferred
terminology and factors that might impact on progno-
sis. In the absence of suspicion of red flag pathology,
caution regarding the use of imaging was suggested
because the findings do not inform initial treatment
choices and could be nocebic. Exercise is recognised
as the mainstay of treatment for RCRSP with agree-
ment that a minimal number of exercises should be
prescribed to challenge the functional deficit of the
patient over a minimum of 12-week period. How-
ever, there was little agreement beyond this. This is
reflective of the dearth of research evidence available
to inform optimal exercise prescription for RCRSP.
Given the widespread recognition now that exercise
should be the mainstay of treatment for RCRSP this
is a clear gap that needs to be addressed through
well-designed, adequately powered, randomised con-
trolled trials.
Conflict of interest
CL, MB, IH, AJ, JG, AM have taught and lec-
tured nationally and internationally on the shoulder
and received payment for this.
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... Regarding RCRSP diagnosis, no standardized diagnostic criteria are currently available. 32 Some proposals for diagnosing RCRSP have been published, 13,15,33,34 but in no study a strong enough methodology was used enabling the proposed diagnostic criteria to be accepted as universal for this clinical condition. This fact, added to the need to accurately differentiate RCRSP from other shoulder clinical conditions, justified the aim of this study which was therefore to identify the most relevant clinical descriptors for RCRSP based on the opinion of an international panel of experts with a high level of clinical, teaching, and research experience. ...
... 64,65 In addition, RCRSP is more prevalent in individuals who have performed overhead activities for a long time. 66À69 Regarding the location of the pain, the experts agreed that the most frequent area reported by those with RCRSP is the deltoid region, which is in line with a previous consensus report 34 and experimental pain models. 70 Pain reaching the forearm has also been reported in people with RCRSP. ...
... 90 The absence of neurological symptoms was reported by experts to be indicative of RCRSP, which agrees with a previous consensus report. 34 Collecting sufficient data during the subjective examination can help to rule out a neurological component to the generation of symptoms. 91 ...
Article
Background There is a lack of standardized criteria for diagnosing Rotator Cuff Related Shoulder Pain (RCRSP). Objective To identify the most relevant clinical descriptors for diagnosing RCRSP. Methods A Delphi study was conducted through use of an international physical therapists expert panel. A 3-round Delphi survey involving an international panel of physical therapists experts with extensive clinical, teaching, and research experience was conducted. A search equation was performed in Web of Science, along with a manual search, to find the experts. The first round was composed of items obtained from a previous pilot Delphi study along with new items proposed by the experts. Participants were asked to rate items across six clinical domains using a five-point Likert scale. An Aiken's Validity Index ≥ 0.7 was considered indicative of group consensus. Results Fifteen experts participated in the Delphi survey. After the three rounds, consensus was reached on 18 clinical descriptors: 10 items were included in the “subjective examination” domain, 1 item was included in the “patient-reported outcome measures” domain, 3 items in the “diagnostic examination” domain, 2 items in the “physical examination” domain”, and 2 items in the “functional tests” domain. No items reached consensus within the “special tests” domain. The reproduction of symptoms in relation to the application of load, the performance of overhead activities, and the need of active and resisted movement assessment were some of the results with greatest consensus. Conclusion In this Delphi study, a total of 18 clinical descriptors across six clinical domains were agreed upon for diagnosing RCRSP.
... Shoulder pain is the third most common musculoskeletal (MSK) condition reported in primary care, with about 4% of adults attending their GP with new shoulder pain each year [1,2]. The most common diagnosis is rotator cuff-related shoulder pain (RCRSP), a term that encompasses a spectrum of conditions including; subacromial pain (impingement) syndrome, rotator cuff tendinopathy, as well as partial and full-thickness rotator cuff tears [3,4]. The general prognosis is highly variable, with 40% of individuals reporting persistent symptoms beyond 1 year [5]. ...
... Approaches to the management of shoulder pain vary widely amongst healthcare providers (HCPs) [7,8]. Although recent shoulder pain treatment recommendations/guidelines, developed to guide Physiotherapists [3], and GPs [9], both recommend against the early use of imaging for non-traumatic shoulder pain due to its lack of correlation with structural pathology [10,11], there is a continued over-reliance on this approach amongst GPs [12]. Similar inconsistencies are noted in relation to treatment strategies. ...
... This lack of consensus has been highlighted previously [4], with numerous studies highlighting the varied opinions and practices of HCPs in relation to the management of shoulder pain [12,19,[53][54][55]. The reasons for this variation is likely to be multifactorial, influenced by the impact of inconsistent research findings, a lack of high quality clinical practice guidelines [56], different guidelines and recommendations produced by and targeted to individual HCP discipline groups [3,9], and also the individual role and expertise of the HCP with different levels of training and emphases in professional education. It was highlighted in one recent survey that physiotherapists are more likely to prescribe physical therapy as the 1st line treatment for rotator cuff tears, and surgeons are more likely to recommend surgery [19]. ...
Article
Objective: To review and synthesize qualitative research studies exploring the experiences of Healthcare Providers (HCPs) of managing shoulder pain. Methods: A meta-ethnographic approach was adopted to review and synthesize eligible studies. The findings from each included study were translated into one another using Noblit and Hares' seven-stage process. A systematic search of eleven electronic databases was conducted in February 2021. Methodological quality was assessed using the CASP Appraisal Tool. Results: Ten studies were included in the meta-synthesis, all deemed of high methodological quality. Three themes were identified; (1) Lack of consensus: "we all have different approaches." (2) Challenges to Changing Practice: It's "really hard to change and switch to a different approach," (3) Getting "Buy in" to Treatment: "…so you have to really sell it early". Conclusion: Healthcare providers working with people with shoulder pain struggle to reconcile, often conflicting, research recommendations with their own clinical experience, beliefs and patient expectations. These findings help explain the continued lack of consensus on how best to manage shoulder pain in clinical practice.IMPLICATIONS FOR REHABILITATIONHealthcare providers (HCPs) working with people with shoulder pain struggle to resolve conflicts between evidence-based recommendations, clinical experience, their own shoulder pain beliefs and patient expectations and preferences.Stronger collaboration across professional disciplines is needed to address the current lack of consensus on the management of shoulder pain.Many HCP's find it difficult to engage patients with shoulder pain in exercise and they work hard to "sell" this approach to patients using strategies such as education, shared decision making and therapeutic alliance.
... Demand for effective conservative management of shoulder conditions reflects its prevalence as the third most common musculoskeletal (MSK) condition seen in United Kingdom (UK) [1] with one-year prevalence among a global survey reported to be between 4.7 and 46.7% [2]. Clinicians may be challenged by the scope of possible structural diagnoses, the changing nomenclature used to describe the experience of pain, distress and loss of function, and the application of recommended management strategies [3]. ...
Article
Objective: To assess the effects of mobilization with movement (MWM) on pain, range of motion (ROM), and disability in the management of shoulder musculoskeletal disorders. Methods: Six databases and Scopus, were searched for randomized control trials. The ROB 2.0 tool was used to determine risk-of-bias and GRADE used for quality of evidence. Meta-analyses were performed for the sub-category of frozen shoulder and shoulder pain with movement dysfunction to evaluate the effect of MWM in isolation or in addition to exercise therapy and/or electrotherapy when compared with other conservative interventions. Results: Out of 25 studies, 21 were included in eight separate meta-analyses for pain, ROM, and disability in the two sub-categories. For frozen shoulder, the addition of MWM significantly improved pain (SMD -1.23, 95% CI -1.96, -0.51)), flexion ROM (MD -11.73, 95% CI -17.83, -5.64), abduction ROM (mean difference -13.14, 95% CI -19.42, -6.87), and disability (SMD -1.50, 95% CI (-2.30, -0.7). For shoulder pain with movement dysfunction, the addition of MWM significantly improved pain (SMD -1.07, 95% CI -1.87, -0.26), flexion ROM (mean difference -18.48, 95% CI- 32.43, -4.54), abduction ROM (MD -32.46, 95% CI - 69.76, 4.84), and disability (SMD -0.88, 95% CI -2.18, 0.43). The majority of studies were found to have a high risk of bias. Discussion: MWM is associated with improved pain, mobility, and function in patients with a range of shoulder musculoskeletal disorders and the effects clinically meaningful. However, these findings need to be interpreted with caution due to the high levels of heterogeneity and risk of bias. Level of evidence: Treatment, level 1a.
... [6][7][8] For example, there is an over-reliance on unnecessary shoulder imaging 6 9 10 and subacromial decompression surgery, 11 despite evidence that these are not warranted. 12 13 The use of image-guided Strengths and limitations of this study ► We will use a comprehensive search strategy to identify clinical practice guidelines for atraumatic shoulder conditions that fulfil our inclusion criteria by searching bibliographical databases Ovid MEDLINE and Ovid Embase using a filter designed to maximise sensitivity and by also searching the online guideline repositories and other grey literature sources. ► Our review will compare methods and recommendations made across different guidelines. ...
Article
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Introduction Shoulder conditions are a major cause of morbidity in the general population. Many clinical practice guidelines (CPGs) for shoulder conditions have been developed. Their purpose is to provide evidence-based recommendations to assist clinicians in providing optimal care to maximise patient outcomes. The aim of this systematic review is to identify, appraise, and compare the content and quality of CPGs for atraumatic shoulder conditions. Methods and analysis CPGs for atraumatic shoulder conditions will be included provided they make recommendations about diagnosis and/or management, are identified by their authors as a guideline and are consistent with the Appraisal of Guidelines for Research and Evaluation (AGREE) II definition of a guideline. A systematic search of electronic databases, online guideline repositories and the websites of relevant professional societies will be conducted to identify eligible CPGs. Search terms relating to shoulder conditions (eg, ‘adhesive capsulitis’, ‘rotator cuff’ and ‘bursitis’) will be combined with a validated search filter for CPGs. Pairs of independent reviewers will determine eligibility of CPGs identified by the search. Quality appraisal of included CPGs will be performed using the AGREE II instrument. Recommendations from each CPG and how they were determined will be extracted and compared across similar CPGs. Results from this systematic review will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. Ethics and dissemination Ethical approval is not required for this systematic review. The results from this study will be published in a peer-reviewed journal and disseminated to professional societies that publish shoulder CPGs, clinical policy groups, clinicians, researchers and consumers. PROSPERO registration number CRD42020182723.
... Or to the substantial heterogeneity in diagnostic criteria used for patients with subacromial shoulder pain (Lin et al., 2011;Smith et al., 2009). From a clinical perspective, clinicians need to address several functional deficits with a sophisticated manner and with a minimum number of exercises (Littlewood et al., 2019). As alterations in scapular muscle activity in patients with shoulder pain and dysfunction are not uniform (Kinsella and Pizzari, 2017), clinicians are expected to prescribe the most effective exercises based on individual patient's characteristics and subsequently progress the treatment plan by selecting more complex exercises during more demanding rehabilitation phases (Moeller et al., 2014). ...
Article
Background Elevation and push up (Pu) exercises are considered to be beneficial for the rehabilitation of shoulder complex pathology. Despite their clinical utility, there is a lack of evidence comparing scapulothoracic muscles recruitment during these exercises. Objective To evaluate the EMG activity of upper trapezius (UT), Lower Trapezius (LT), Upper Serratus anterior (USa) and Lower Serratus anterior (LSa) muscles during a variety of elevation and Pu exercises. Methods Thirteen healthy participants (non, athlete, male, mean ± standard deviation; age: 21.1± 1.8 years; height: 1.80 m± 0.04; weight: 79± 12 kg) were assessed. EMG data was collected during Scaption, wall slide and elevation with external rotation with and without load. Pu classic, Pu plus (PuP) on stable/unstable surfaces and Pu with shoulder internal rotation were also assessed. Results UT had a significant higher activity during ‘Scaption load’ (p<.05) and LT in ‘EleEr load’ and ‘Scaption load’ (p<.05). USa and LSa had a significant higher activity on ‘PuP unstable surface’ and ‘PuP internal rotation’ compared to elevation exercises (p<.05). Scaption had greater activity ratio compared to the other exercises on UT/LT (p<.05). Pu variations had lower results in UT/USa and UT/LSa ratios compared to shoulder elevation exercises (p<.05). Conclusions Elevation exercises produce significant effects on upper and lower trapezius activation while Pu exercises on Sa muscles. Wall slide exercise notes the lowest activation in all muscles. A descending order of muscle activity during different variations of elevation and Pu exercises is provided in order to guide exercise selection in everyday clinical practice.
... Total number of exercises per session has been shown to predict adherence to homebased exercise among participants with musculoskeletal pain (i.e. three or fewer was predictive) [37]. The concept of providing simple exercises to improve selfefficacy and assist with adherence levels is outlined in the Health Beliefs Model [34] and recommended in expert consensus for various musculoskeletal conditions [38,39]. Fourth, providing individualised advice about acceptable pain seemed to be important information that facilitated self-manage. ...
Article
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Background Although telehealth is becoming more popular for delivery of care for individuals with musculoskeletal pain, to our knowledge telehealth has not been used to manage Achilles tendinopathy. This research aimed to explore the experience of participants and physiotherapists with gym-based exercise interventions for Achilles tendinopathy monitored via videoconference. Methods A qualitative, interpretive description design was performed using semi-structured interviews (8 participants) and a focus group (7 physiotherapists). Participants and physiotherapists were interviewed about their experiences of the use of telehealth during a gym-based exercise intervention incorporating different calf load parameters for Achilles tendinopathy. We employed an inductive thematic analysis approach to analyse the data. Results Three themes identified from both participants and physiotherapists included i) acceptability of telehealth; ii) enablers to adherence with telehealth; and iii) barriers to adherence with telehealth. Two extra themes arose from participants regarding adherence with gym-based exercise, including enablers to adherence with the exercise intervention, and barriers to adherence with the exercise intervention. Both participants and physiotherapists expressed overall satisfaction and acceptability of telehealth monitoring of gym-based exercise. Conclusion Gym-based exercise intervention for Achilles tendinopathy involving weekly telehealth monitoring was acceptable to both participants and physiotherapists. Potential enablers and barriers were identified that may improve adherence to this type of intervention.
Article
Rotator cuff related disorders (RCRD) are common. Exercise-based rehabilitation can improve outcomes, yet uncertainty exists regarding the characteristics of these exercises. This scoping review paper summarises the key characteristics of the exercise-based rehabilitation of rotator cuff related disorders (RCRD). An iterative search process was used to capture the breadth of current evidence and a narrative summary of the data was produced. 57 papers were included. Disagreement around terminology, diagnostic standards, and outcome measures limits the comparison of the data. Rehabilitation should utilise a biopsychosocial approach, be person-centred and foster self-efficacy. Biomedically framed beliefs can create barriers to rehabilitation. Pain drivers in RCRSD are unclear, as is the influence of pain during exercise on outcomes. Expectations and preferences around pain levels should be discussed to allow the co-creation of a programme that is tolerated and therefore engaged with. The optimal parameters of exercise-based rehabilitation remain unclear; however, programmes should be individualised and progressive, with a minimum duration of 12 weeks. Supervised or home-based exercises are equally effective. Following rotator cuff repair, rehabilitation should be milestone-driven and individualised; communication across the MDT is essential. For individuals with massive rotator cuff tears, the anterior deltoid programme is a useful starting point and should be supplemented by functional rehabilitation, exercises to optimise any remaining cuff and the rest of the kinetic chain. In conclusion, exercise-based rehabilitation improves outcomes for individuals with a range of RCRD. The optimal parameters of these exercises remain unclear. Variation exists across current physiotherapy practice and post-operative rehabilitation protocols, reflecting the wide-ranging spectrum of individuals presenting with RCRD. Clinicians should use their communication and rehabilitation expertise to plan an exercise-based program in conjunction with the individual with RCRSD, which is regularly reviewed and adjusted.
Article
Background Rotator cuff related shoulder pain (RCRSP) knowledge is an important contributor to compliance with clinical practice guidelines and providing best practice care. However, there are no validated instruments for measuring health literacy levels among people with RCRSP. This study aimed to design a valid and reliable instrument to measure RCRSP health literacy and use it to evaluate an education intervention for people with RCRSP. Methods Development of the patient knowledge questionnaire (PKQ‐RCRSP) included three phases. Phase 1 was developed based on available literature and input from expert clinicians, researchers and patients. Face validity, pilot testing and readability assessment were also undertaken. In Phase 2, internal consistency and predictive validity were assessed in people with RCRSP and other shoulder pain diagnoses. In Phase 3, RCRSP health literacy was assessed. Result Face validity was acceptable and pilot testing identified minor accuracy issues that were corrected. Literacy level was rated as ‘difficult to read’ which reflects the medical terminology within the questionnaire. Internal consistency was very good and 81% of questions demonstrated acceptable predictive validity. Health literacy was heterogeneous depending on the question with less than 40% of respondents answering correctly for questions related to the indications, process and the known benefits of RCRSP surgery. Conclusion The PKQ‐RCRSP demonstrated acceptable face validity, predictive validity and reliability (internal consistency) in assessing RCRSP health literacy. Health literacy among our small sample was poor for questions related to surgery for RCRSP.
Article
Background: Rotator cuff related shoulder pain (RCRSP) is a common and disabling cause of shoulder pain contributing to great socio-economic costs. Conservative management is recommended as first line treatment, with studies performed in the United Kingdom (UK), Belgium, Netherlands and Australia finding practice generally consistent with guideline recommendations. Current French guidelines for management of RCRSP were published more than a decade ago and it is unknown if French physiotherapists manage RCRSP in line with current guideline recommendations. The aim of this survey is to evaluate if management delivered by French physiotherapists for RCRSP is in line with the current evidence. Methods: A cross-sectional online survey was conducted and disseminated through various social media platforms and a mailing list from December 2018 to March 2019. Results: Two hundred and six French Physiotherapists completed the survey. Results demonstrated that the majority of physiotherapists provide care consistent with recommended guideline management, through the delivery of exercise and education. Ideology and specific parameters of treatment delivery, particularly exercise treatment, were highly variable among the cohort, but comparable to findings among physiotherapists in the United Kingdom, Belgium, the Netherlands and Australia. Conclusion: French physiotherapists are broadly consistent with providing guideline recommended care of RCRSP, however heterogeneity exists in the ideals and practice of specific treatment delivery, particularly within exercise management.
Article
Introduction: The tendons of the rotator cuff are major sources of shoulder pain. This study aimed to compare the effects of low molecular-weight hyaluronic acid with physiotherapy (PT) in patients with supraspinatus tendinopathy (ST). Methods: We carried out a parallel two-group randomized comparative clinical trial in an outpatient clinic of physical medicine and rehabilitation at a teaching hospital. In total, 51 patients (31 women) aged 20 to 55 years with ST were randomly allocated to subacromial hyaluronate injection (n = 28) and PT (n = 23) groups. For the hyaluronate group, we administered a single injection of 2 mL (20 mg) hyaluronate 1% (500 to 700 kDa). For PT, we prescribed three sessions of treatment per week for 12 weeks, totaling 36 sessions including rotator cuff activation exercises. The primary outcome was shoulder pain in the visual analog scale. The secondary outcomes included the range of movement and the disability score of the shoulder, and a World Health Organization questionnaire on quality of life. We did the measurements at the baseline and at one, four, and 12 weeks after intervention. Results: The results showed that both interventions were beneficial in the management of ST. However, hyaluronate was more effective in reducing shoulder pain at rest and during activities (both P < 0.001, effect size = 0.52 and 0.68, respectively). The two interventions similarly decreased patients' disability (P = 0.196). Hyaluronate improved shoulder motion and the quality of life better than PT. Conclusion: In the treatment of ST, low molecular-weight hyaluronate is more effective than PT, at least for three months. Particularly, hyaluronate is more successful in alleviating pain.
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Objective To assess the efficacy of arthroscopic subacromial decompression (ASD) by comparing it with diagnostic arthroscopy, a placebo surgical intervention, and with a non-operative alternative, exercise therapy, in a more pragmatic setting. Design Multicentre, three group, randomised, double blind, sham controlled trial. Setting Orthopaedic departments at three public hospitals in Finland. Participants 210 patients with symptoms consistent with shoulder impingement syndrome, enrolled from 1 February 2005 with two year follow-up completed by 25 June 2015. Interventions ASD, diagnostic arthroscopy (placebo control), and exercise therapy. Main outcome measures Shoulder pain at rest and on arm activity (visual analogue scale (VAS) from 0 to 100, with 0 denoting no pain), at 24 months. The threshold for minimal clinically important difference was set at 15. Results In the primary intention to treat analysis (ASD versus diagnostic arthroscopy), no clinically relevant between group differences were seen in the two primary outcomes at 24 months (mean change for ASD 36.0 at rest and 55.4 on activity; for diagnostic arthroscopy 31.4 at rest and 47.5 on activity). The observed mean difference between groups (ASD minus diagnostic arthroscopy) in pain VAS were −4.6 (95% confidence interval −11.3 to 2.1) points (P=0.18) at rest and −9.0 (−18.1 to 0.2) points (P=0.054) on arm activity. No between group differences were seen between the ASD and diagnostic arthroscopy groups in the secondary outcomes or adverse events. In the secondary comparison (ASD versus exercise therapy), statistically significant differences were found in favour of ASD in the two primary outcomes at 24 months in both VAS at rest (−7.5, −14.0 to −1.0, points; P=0.023) and VAS on arm activity (−12.0, −20.9 to −3.2, points; P=0.008), but the mean differences between groups did not exceed the pre-specified minimal clinically important difference. Of note, this ASD versus exercise therapy comparison is not only confounded by lack of blinding but also likely to be biased in favour of ASD owing to the selective removal of patients with likely poor outcome from the ASD group, without comparable exclusions from the exercise therapy group. Conclusions In this controlled trial involving patients with a shoulder impingement syndrome, arthroscopic subacromial decompression provided no benefit over diagnostic arthroscopy at 24 months. Trial registration Clinicaltrials.gov NCT00428870.
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Background: Arthroscopic sub-acromial decompression (decompressing the sub-acromial space by removing bone spurs and soft tissue arthroscopically) is a common surgery for subacromial shoulder pain, but its effectiveness is uncertain. We did a study to assess its effectiveness and to investigate the mechanism for surgical decompression. Methods: We did a multicentre, randomised, pragmatic, parallel group, placebo-controlled, three-group trial at 32 hospitals in the UK with 51 surgeons. Participants were patients who had subacromial pain for at least 3 months with intact rotator cuff tendons, were eligible for arthroscopic surgery, and had previously completed a non-operative management programme that included exercise therapy and at least one steroid injection. Exclusion criteria included a full-thickness torn rotator cuff. We randomly assigned participants (1:1:1) to arthroscopic subacromial decompression, investigational arthroscopy only, or no treatment (attendance of one reassessment appointment with a specialist shoulder clinician 3 months after study entry, but no intervention). Arthroscopy only was a placebo as the essential surgical element (bone and soft tissue removal) was omitted. We did the randomisation with a computer-generated minimisation system. In the surgical intervention groups, patients were not told which type of surgery they were receiving (to ensure masking). Patients were followed up at 6 months and 1 year after randomisation; surgeons coordinated their waiting lists to schedule surgeries as close as possible to randomisation. The primary outcome was the Oxford Shoulder Score (0 [worst] to 48 [best]) at 6 months, analysed by intention to treat. The sample size calculation was based upon a target difference of 4·5 points (SD 9·0). This trial has been registered at ClinicalTrials.gov, number NCT01623011. Findings: Between Sept 14, 2012, and June 16, 2015, we randomly assigned 313 patients to treatment groups (106 to decompression surgery, 103 to arthroscopy only, and 104 to no treatment). 24 [23%], 43 [42%], and 12 [12%] of the decompression, arthroscopy only, and no treatment groups, respectively, did not receive their assigned treatment by 6 months. At 6 months, data for the Oxford Shoulder Score were available for 90 patients assigned to decompression, 94 to arthroscopy, and 90 to no treatment. Mean Oxford Shoulder Score did not differ between the two surgical groups at 6 months (decompression mean 32·7 points [SD 11·6] vs arthroscopy mean 34·2 points [9·2]; mean difference -1·3 points (95% CI -3·9 to 1·3, p=0·3141). Both surgical groups showed a small benefit over no treatment (mean 29·4 points [SD 11·9], mean difference vs decompression 2·8 points [95% CI 0·5-5·2], p=0·0186; mean difference vs arthroscopy 4·2 [1·8-6·6], p=0·0014) but these differences were not clinically important. There were six study-related complications that were all frozen shoulders (in two patients in each group). Interpretation: Surgical groups had better outcomes for shoulder pain and function compared with no treatment but this difference was not clinically important. Additionally, surgical decompression appeared to offer no extra benefit over arthroscopy only. The difference between the surgical groups and no treatment might be the result of, for instance, a placebo effect or postoperative physiotherapy. The findings question the value of this operation for these indications, and this should be communicated to patients during the shared treatment decision-making process. Funding: Arthritis Research UK, the National Institute for Health Research Biomedical Research Centre, and the Royal College of Surgeons (England).
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Background Chronic musculoskeletal disorders are a prevalent and costly global health issue. A new form of exercise therapy focused on loading and resistance programmes that temporarily aggravates a patient’s pain has been proposed. The object of this review was to compare the effect of exercises where pain is allowed/encouraged compared with non-painful exercises on pain, function or disability in patients with chronic musculoskeletal pain within randomised controlled trials. Methods Two authors independently selected studies and appraised risk of bias. Methodological quality was evaluated using the Cochrane risk of bias tool, and the Grading of Recommendations Assessment system was used to evaluate the quality of evidence. Results The literature search identified 9081 potentially eligible studies. Nine papers (from seven trials) with 385 participants met the inclusion criteria. There was short- term significant difference in pain, with moderate quality evidence for a small effect size of −0.27 (−0.54 to −0.05) in favour of painful exercises. For pain in the medium and long term, and function and disability in the short, medium and long term, there was no significant difference. Conclusion Protocols using painful exercises offer a small but significant benefit over pain-free exercises in the short term, with moderate quality of evidence. In the medium and long term there is no clear superiority of one treatment over another. Pain during therapeutic exercise for chronic musculoskeletal pain need not be a barrier to successful outcomes. Further research is warranted to fully evaluate the effectiveness of loading and resistance programmes into pain for chronic musculoskeletal disorders. PROSPERO registration CRD42016038882
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The 2016 Warwick Agreement on femoroacetabular impingement (FAI) syndrome was convened to build an international, multidisciplinary consensus on the diagnosis and management of patients with FAI syndrome. 22 panel members and 1 patient from 9 countries and 5 different specialties participated in a 1-day consensus meeting on 29 June 2016. Prior to the meeting, 6 questions were agreed on, and recent relevant systematic reviews and seminal literature were circulated. Panel members gave presentations on the topics of the agreed questions at Sports Hip 2016, an open meeting held in the UK on 27-29 June. Presentations were followed by open discussion. At the 1-day consensus meeting, panel members developed statements in response to each question through open discussion; members then scored their level of agreement with each response on a scale of 0-10. Substantial agreement (range 9.5-10) was reached for each of the 6 consensus questions, and the associated terminology was agreed on. The term 'femoroacetabular impingement syndrome' was introduced to reflect the central role of patients' symptoms in the disorder. To reach a diagnosis, patients should have appropriate symptoms, positive clinical signs and imaging findings. Suitable treatments are conservative care, rehabilitation, and arthroscopic or open surgery. Current understanding of prognosis and topics for future research were discussed. The 2016 Warwick Agreement on FAI syndrome is an international multidisciplinary agreement on the diagnosis, treatment principles and key terminology relating to FAI syndrome.
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Background: The ability of injection of corticosteroids into the subacromial space to relieve pain ascribed to rotator cuff tendinosis is debated. The number of patients who have an injection before one gets relief beyond what a placebo provides is uncertain. Questions/purposes: We asked: (1) Do corticosteroid injections reduce pain in patients with rotator cuff tendinosis 3 months after injection, and if so, what is the number needed to treat (NNT)? (2) Are multiple injections better than one single injection with respect to pain reduction at 3 months? Methods: We systematically searched seven electronic databases for randomized controlled trials of corticosteroid injection for rotator cuff tendinosis compared with a placebo injection. Eligible studies had at least 10 adults and used pain intensity as an outcome measure. The Hedges's g as adjusted pooled standardized mean difference (SMD) (which expresses the size of the intervention effect in each study relative to the total variability observed among pooled studies) and NNT were calculated at assessment points less than 1 month, 1-2 months, and 2-3 months. The protocol of this study was registered at the international prospective register of systematic reviews. Eleven studies of 726 patients satisfied our criteria for data pooling. Three studies containing 292 patients used repeat injections. A random effects model was used owing to substantial heterogeneity among studies. The funnel plot indicated the possibility of some missing studies, but Orwin's fail-safe N and Duval and Tweedie's trim and fill suggested that missing studies would not significantly affect the results. Results: Corticosteroid injection did not reduce pain intensity in adult patients with rotator cuff tendinosis more than a placebo injection at the 3-month assessment. A small transient pain relief occurred at the assessment between 4 and 8 weeks with a SMD of 0.52 (range, 0.27-0.78) (p < 0.001). At least five patients must be treated for one patient's pain to be transiently reduced to no more than mild. Multiple injections were not found to be more effective than a single injection at any time. Conclusions: Corticosteroid injections provide-at best-minimal transient pain relief in a small number of patients with rotator cuff tendinosis and cannot modify the natural course of the disease. Given the discomfort, cost, and potential to accelerate tendon degeneration associated with corticosteroids, they have limited appeal. Their wide use may be attributable to habit, underappreciation of the placebo effect, incentive to satisfy rather than discuss a patient's drive toward physical intervention, or for remuneration, rather than their utility. Level of evidence: Level I, therapeutic study.
Article
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Background/aim Shoulder pain is a major musculoskeletal problem. We aimed to identify which baseline patient and clinical characteristics are associated with a better outcome, 6 weeks and 6 months after starting a course of physiotherapy for shoulder pain. Methods 1030 patients aged ≥18 years referred to physiotherapy for the management of musculoskeletal shoulder pain were recruited and provided baseline data. 840 (82%) provided outcome data at 6 weeks and 811 (79%) at 6 months. 71 putative prognostic factors were collected at baseline. Outcomes were the Shoulder Pain and Disability Index (SPADI) and Quick Disability of the Arm, Shoulder and Hand Questionnaire. Multivariable linear regression was used to analyse prognostic factors associated with outcome. Results Parameter estimates (β) are presented for the untransformed SPADI at 6 months, a negative value indicating less pain and disability. 4 factors were associated with better outcomes for both measures and time points: lower baseline disability (β=−0.32, 95% CI −0.23 to −0.40), patient expectation of ‘complete recovery’ compared to ‘slight improvement’ as ‘a result of physiotherapy’ (β=−12.43, 95% CI −8.20 to −16.67), higher pain self-efficacy (β=−0.36, 95% CI −0.50 to −0.22) and lower pain severity at rest (β=−1.89, 95% CI −1.26 to −2.51). Conclusions Psychological factors were consistently associated with patient-rated outcome, whereas clinical examination findings associated with a specific structural diagnosis were not. When assessing people with musculoskeletal shoulder pain and considering referral to physiotherapy services, psychosocial and medical information should be considered. Study registration Protocol published at http://www.biomedcentral.com/1471-2474/14/192.
Article
Background: Shoulder pain is a common musculoskeletal presentation, with disorders of the rotator cuff (RC) regarded as the most frequent cause. Conservative treatment is often the initial management; however, findings from a previous survey showed considerable variations in clinical practice, including the use of modalities that are not supported in the literature, suggesting that research is not impacting on practice. The present study aimed to survey current UK physiotherapy practice for the management of RC disorders and to determine whether this has changed over the 5-year period since the last survey was conducted. Methods: A cross-sectional online survey of UK physiotherapists was conducted. Results: One hundred and ninety-one respondents completed the survey which showed that advice/education and some form of exercise therapy are most commonly used as a management strategy for RC disorders. There is a lack of agreement however regarding exercise prescription. The survey suggests less use of passive modalities, indicating that practice has advanced over the last 5 years in line with the current evidence. Conclusions: The present study has highlighted that the clinical practice of the survey respondents was in line with current recommendations from research. Hence, in contrast to the survey conducted 5 years previously, research appears to be impacting on practice, which is a positive finding.
Article
Background: Structured exercise has been reported as the current treatment of choice for patients diagnosed with subacromial impingement syndrome (SIS). However, it has been suggested that this diagnostic term and the language used to explain this condition might negatively influence patient expectations and serve as a barrier to engagement with exercise, hence compromising clinical outcomes. Aim: To explore how patients rationalise their shoulder pain following a diagnosis of SIS and how this understanding might impact on their perception of physiotherapy and engagement with exercise. Design: A qualitative study using semi-structured interviews and analysed using the Framework method. Setting: One NHS Physiotherapy department in South Yorkshire, England. Participants: Nine patients diagnosed with SIS were purposively sampled from those referred to the outpatient physiotherapy department by the orthopaedic team (consultant surgeons and registrars). Results: Three main themes were generated: (1) The diagnostic experience, (2) Understanding of the problem, (3) Expectation of the treatment required; with one subtheme: (3b) Barriers to engagement with physiotherapy. Conclusion: The findings from this study suggest that diagnosis of shoulder pain remains grounded in a biomedical model. Understanding and explaining pain using the subacromial impingement model seems acceptable to patients but might have significant implications for engagement with and success of physiotherapy. It is suggested that clinicians should be mindful of the terminology they use and consider its impact on the patient's treatment pathway with the aim of doing no harm with the language used.
Article
Introduction: Rotator cuff related shoulder pain (RCRSP) is an over-arching term that encompasses a spectrum of shoulder conditions including; subacromial pain (impingement) syndrome, rotator cuff tendinopathy, and symptomatic partial and full thickness rotator cuff tears. For those diagnosed with RCRSP one aim of treatment is to achieve symptom free shoulder movement and function. Findings from published high quality research investigations suggest that a graduated and well-constructed exercise approach confers at least equivalent benefit as that derived from surgery for; subacromial pain (impingement) syndrome, rotator cuff tendinopathy, partial thickness rotator cuff (RC) tears and atraumatic full thickness rotator cuff tears. However considerable deficits in our understanding of RCRSP persist. These include; (i) cause and source of symptoms, (ii) establishing a definitive diagnosis, (iii) establishing the epidemiology of symptomatic RCRSP, (iv) knowing which tissues or systems to target intervention, and (v) which interventions are most effective. Purpose: The aim of this masterclass is to address a number of these areas of uncertainty and it will focus on; (i) RC function, (ii) symptoms, (iii) aetiology, (iv) assessment and management, (v) imaging, and (vi) uncertainties associated with surgery. Implications: Although people experiencing RCRSP should derive considerable confidence that exercise therapy is associated with successful outcomes that are comparable to surgery, outcomes may be incomplete and associated with persisting and recurring symptoms. This underpins the need for ongoing research to; better understand the aetiology, improve methods of assessment and management, and eventually prevent these conditions.