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“You have (rotator cuff related) shoulder pain, and to treat it, I recommend exercise.” A scoping review of the possible mechanisms clinicians use to underpin exercise therapy
Abstract
Background
Exercise is considered to be both essential and at the forefront of the management of rotator cuff-related shoulder pain (RCRSP). Despite this, many fail to substantially improve with exercise-based treatment. Hence, expanding the current knowledge about the possible mechanisms of exercise for RCRSP is critical.
Objective
To synthesise the range of mechanisms proposed for exercise in people with RCRSP.
Design
Scoping review
Methods
A systematic search of the Physiotherapy Evidence Database (PEDro) was conducted from inception to July 3, 2022. Two reviewers conducted the search and screening process and one reviewer extracted the data from each study. Randomised clinical trials using exercise for the management of RCRSP of any duration were included. The PEDro search terms used were “fitness training”, “strength training”, “stretching, mobilisation, manipulation, massage”, “upper arm, shoulder, or shoulder girdle”, “pain”, and “musculoskeletal”. Data were analysed using quantitative and qualitative approaches.
Results
626 studies were identified and 110 were included in the review. Thirty-two unique mechanisms of exercise were suggested by clinical trialists, from which 4 themes emerged: 1) neuromuscular 2) tissue factors 3) neuro-endocrine-immune 4) psychological. Neuromuscular mechanisms were proposed most often (n = 156, 77%). Overall, biomedical mechanisms of exercise were proposed in 95% of cases.
Conclusions
The causal explanation for the beneficial effect of exercise for RCRSP in clinical research is dominated by biomedical mechanisms, despite a lack of supporting evidence. Future research should consider testing the mechanisms identified in this review using mediation analysis to progress knowledge on how exercise might work for RCRSP.
... Despite physiotherapists broadly embracing exercise therapy, in both historical and modern contexts, the pre-eminent position of exercise for RCRSP (Dube et al., 2023;Littlewood et al., 2023;Page et al., 2016), and other musculoskeletal conditions such as hip and knee osteoarthritis (Henriksen et al., 2024;Holden et al., 2023;Hunter & Hall, 2023), has come under increasing scrutiny. Critics appropriately assert that exercise does not appear to be held to the same standards as other treatments, such as manual therapy, surgery, and acupuncture, when considering its modest effects and low certainty of evidence (Naunton et al., 2020;Steuri et al., 2017), lack of demonstrated efficacy (Bennell et al., 2010), and importantly uncertainty regarding the causal pathways through which it may confer a therapeutic benefit (Powell et al., 2022b). Moreover, no evidence has emerged to define the best exercise approach (including exercise type, dose, level of supervision, duration etc.) for helping an individual with RCRSP (Littlewood et al., 2015;Malliaras et al., 2020;McConnell et al., 2022). ...
... resistance exercise, motor control exercise, and stretching exercise) to manage an individual with RCRSP poses a conundrum for clinicians. There are many exercise approaches available to help an individual with RCRSP, and it is typical to see two or more different approaches combined together in the same programme (Powell et al., 2022b). In this review, we focus on two of the most popular exercise approaches for RCRSP: progressive resistance exercise and motor control, or movement facilitation exercise (Powell et al., 2022a(Powell et al., , 2022b. ...
... There are many exercise approaches available to help an individual with RCRSP, and it is typical to see two or more different approaches combined together in the same programme (Powell et al., 2022b). In this review, we focus on two of the most popular exercise approaches for RCRSP: progressive resistance exercise and motor control, or movement facilitation exercise (Powell et al., 2022a(Powell et al., , 2022b. Most current metaanalyses report no sustained significant difference between specific motor control exercise and general resistance exercise for RCRSP Shire et al., 2017). ...
Background
Exercise therapy is a popular non‐surgical treatment to help manage individuals with rotator cuff‐related shoulder pain (RCRSP) and is recommended in all clinical practice guidelines. Due to modest effect sizes, low quality evidence, uncertainty relating to efficacy, and mechanism(s) of benefit, exercise as a therapeutic intervention has been the subject of increasing scrutiny.
Aims
The aim of this critical review is to lay out where the purported uncertainties of exercise for RCRSP exist by exploring the relevant quantitative and qualitative literature. We conclude by offering theoretical and practical considerations to help reduce the uncertainty of delivering exercise therapy in a clinical environment.
Results and Discussion
Uncertainty underpins much of the theory and practice of delivering exercise therapy for individuals with RCRSP. Nonetheless, exercise is an often‐valued treatment by individuals with RCRSP, when provided within an appropriate clinical context. We encourage clinicians to use a shared decision‐making paradigm and embrace a pluralistic model when prescribing therapeutic exercise. This may take the form of using exercise experiments to trial different exercise approaches, adjusting, and adapting the exercise type, load, and context based on the individual's symptom irritability, preferences, and goals.
Conclusion
We contend that providing exercise therapy should remain a principal treatment option for helping individuals with RCRSP. Limitations notwithstanding, exercise therapy is relatively low cost, accessible, and often valued by individuals with RCRSP. The uncertainty surrounding exercise therapy requires ongoing research and emphasis could be directed towards investigating causal mechanisms to better understand how exercise may benefit an individual with RCRSP.
... [12][13][14][15] Overall, patients perceive exercise as a good choice for managing their shoulder pain, 16 and it is the most implemented treatment by physical therapists. 17 However, despite exercise being an effective, accessible and low-cost intervention with few adverse effects, 18 there are still some barriers to its implementation within clinical practice. 19 20 First, there is inappropriate content reporting about exercise programmes within published clinical trials, both in the description of the exercises itself, the dosage and the rules implemented for the progression and regression in exercise load, 21 22 thus leading to uncertainty about the better type of exercises and the optimal dosage. ...
... 25 For all these reasons, there is a need for more randomised controlled trials with better content reporting of exercise programmes 21 22 that investigate the utility of the implementation of new technologies to improve patients' adherence, 25 and thus optimising treatment effectiveness. 18 The main hypothesis of this randomised controlled trial is that the implementation of a home-based exercise programme using multimedia animations is better regarding improvements in shoulder disability than a traditional paper-based one. As secondary objectives, the hypothesis is that multimedia animations will also improve patients' paint intensity, expectations, satisfaction and adherence. ...
Introduction Rotator cuff-related shoulder pain (RCRSP) is the most common cause of shoulder pain. Currently, exercise is proposed as the first-line treatment for patients suffering from RCRSP. However, adherence to therapeutic exercise programmes can be poor in the long term in a home setting. The aim of this study is to evaluate the effects of adding video animations to a traditional paper-based exercise programme.
Methods and analysis A single-centre, randomised, open-labelled clinical trial will be conducted in a hospital in Spain. Adults aged between 18 and 80 years diagnosed with RCRSP who meet the eligibility criteria will be included. Patients (n=132) will be randomised into two groups, with both receiving paper-based exercises, and the experimental group will also be provided with video animations. The participants will receive seven face-to-face physical therapy sessions and will be asked to perform the exercises at home for 6 months. The primary outcome measure will be the Shoulder Pain and Disability Index, measured at baseline, 3 weeks, 3 months (primary analysis) and 6 months. Secondary outcomes will be the patient’s pain intensity during the last week (rest, during movement and at night); expectations of improvement; satisfaction with treatment; impression of improvement; perceived usability, usefulness and satisfaction of multimedia animations; and adherence to exercises. Generalised least squares regression models with an autoregressive-moving average lag one correlation structure will be implemented, with an intention-to-treat analysis.
Ethics and dissemination This study has been approved by the ethics committee of Hospital Universitario Fundación Alcorcón (Madrid, Spain), reference number CI18/16. All participants will sign an informed consent. The results will be published in a peer-reviewed scientific journal.
Trial registration ClinicalTrials.gov, NCT05770908.
... Therapeutic exercise loading is the mainstay of conservative treatment and appears to be a powerful tool in the hands of clinicians to improve pain, mobility, and shoulder function in individuals with nonspecific shoulder pain [12]. Several mechanisms are thought to explain the benefits of exercise in nonspecific shoulder pain [13]. The most frequently mentioned neuromuscular mechanism suggests that strengthening the rotator cuff muscles inhibits pain [14]. ...
... The most frequently mentioned neuromuscular mechanism suggests that strengthening the rotator cuff muscles inhibits pain [14]. Other mechanisms proposed are tissue factors (e.g., tendon remodelling, blood flow improvement, etc.), neuro-endocrine immunity (e.g., exercise-induced hypoalgesia, central and peripheral nervous system adaptations, etc.), and physiological mechanisms (e.g., improvements in self-efficacy and coping with pain, etc.) [13,15]. ...
Nonspecific shoulder pain" encompasses various non-traumatic musculoskeletal shoulder disorders, diverging from diagnostic terminologies that refer to precise tissue-oriented clinical diagnosis. Blood flow restriction (BFR) training, involving partial arterial inflow and complete venous outflow restriction, has exhibited acute hypoalgesic effects primarily in healthy populations by increasing their pain thresholds. This study aims to examine whether a single BFR session with low-load exercises can alleviate pain perception among nonspecific shoulder pain patients. Conducted as a single-blind crossover randomised clinical trial, 48 adults (age range: 18 to 40) presenting with nonspecific shoulder pain will partake in two trial sessions. Random assignment will place participants into BFR or sham BFR groups and ask them to perform one exercise with BFR. Subsequently, participants will complete a shoulder girdle loading regimen comprising six exercises. The second session will involve participants switching treatment groups. Pain pressure thresholds (PPTs), shoulder pain and disability via the shoulder pain and disability index (SPADI), maximal voluntary isometric contraction (MVIC) of shoulder external rotators, pain during active abduction, and peak pain during shoulder external rotation will be evaluated using the numeric pain rating scale (NPRS). Immediate post-exercise assessments will include patient-perceived pain changes using the global rating of change scale (GROC) and participant-rated perceived exertion (RPE), employing a modified Borg's scale (Borg CR10) post-BFR or sham BFR exercise session. Each session will encompass three assessment periods, and a combination of mixed-effect models and descriptive statistics will underpin the analysis. Pending approval from the Cyprus National Bioethics Committee, this protocol has been registered in ClinicalTrials.gov (Registration number: NCT05956288). Conclusion: The anticipated outcomes of this study illuminated the acute effects of BFR training on pain perception within the context of nonspecific shoulder pain, potentially advancing strategies for managing pain intensity using BFR techniques.
... Эффективное комплексное лечение ХБОП должно обязательно включать методы физиотерапии (ФТ) и реабилитации [66,67]. Принципиальное значение придается регулярным физическим упражнениям и лечебной физкультуре (ЛФК), направленным на коррекцию биомеханических расстройств и восстановление функции пораженных мышц плечевого пояса. ...
... Одновременно с НПВП необходимо применять немедикаментозные методы лечения (ФТ, ЛФК) [66,67]. Если основным диагнозом является ОА ПС, АКС с поражением или без поражения околосуставных тканей, следует как можно раньше назначить препараты из группы SYSADOA (например, курс в/м инъекций Алфлутопа). ...
Chronic shoulder pain (CSP) is a clinical syndrome associated with inflammatory and degenerative musculoskeletal changes, characterized by pain in the shoulder that persists for at least 3 months, arising or aggravated by functional activity in this area. The frequency of CSP in the modern population reaches 20–33%, it is one of the leading causes of severe suffering, disability and seeking for medical attention.
The main causes of CSP are shoulder rotator impingement syndrome (subacromial impingement syndrome), calcific tendinitis, adhesive capsulitis, shoulder and acromioclavicular joint osteoarthritis. Accurate diagnosis of these diseases is necessary for the correct choice of treatment. Differential diagnosis is carried out using tests that evaluate the function of the shoulder joint and the rotator cuff muscles (Neer, Speed, Hawkins tests, etc.), as well as using instrumental methods (ultrasound, magnetic resonance tomography, X-ray). In CSP, it is necessary to exclude septic, oncological, visceral, systemic rheumatic and other diseases, as well as musculoskeletal pathology of the cervical spine, upper chest and back, which can cause pain in the shoulder region.
Therapy for diseases that cause CSP should be personalized and complex, aimed at maximum pain control and restoration of function. For this purpose, non-steroidal anti-inflammatory drugs, local injection therapy with glucocorticoids, hyaluronic acid, and platelet-rich plasma are used. In some cases, muscle relaxants, antidepressants, anticonvulsants, local injections of botulinum toxin type A are indicated. Physiotherapy and medical rehabilitation methods play a fundamental role in the treatment of CSP.
... High quality clinical practice guidelines across various musculoskeletal disorders recommend the choice of treatment, among others, should be guided by an assessment of psycho-social factors to support the physical examination (Lin et al., 2020). However, only few studies have focused on the influence of psycho-social factors on the effect of exercise-based treatment in populations with shoulder disorders and uncertainty remains regarding the relevance of these factors with respect to treatment effect in patients with HSD and shoulder symptoms (Powell et al., 2022). Therefore, the proposed mechanism of exercise-based treatment effect for people with shoulder disorders, including populations with HSD and shoulder symptoms, is dominated by a biological explanation in clinical research (Warby et al., 2016;Powell et al., 2022). ...
... However, only few studies have focused on the influence of psycho-social factors on the effect of exercise-based treatment in populations with shoulder disorders and uncertainty remains regarding the relevance of these factors with respect to treatment effect in patients with HSD and shoulder symptoms (Powell et al., 2022). Therefore, the proposed mechanism of exercise-based treatment effect for people with shoulder disorders, including populations with HSD and shoulder symptoms, is dominated by a biological explanation in clinical research (Warby et al., 2016;Powell et al., 2022). ...
Background:
Shoulder symptoms are common in patients with hypermobility spectrum disorders (HSD), but few studies focus on identifying factors associated with treatment effects.
Aim:
To identify baseline and clinical characteristics associated with a better outcome 16 weeks after starting an exercise-based treatment in patients with HSD and shoulder symptoms.
Design:
Exploratory secondary analysis of data from a randomised controlled trial.
Method:
Self-reported treatment outcome was reported as change between baseline and follow-up after 16 weeks of high-load or low-load shoulder strengthening. Multiple linear and logistic regressions were used to investigate associations of patient expectations of treatment effect, self-efficacy, fear of movement, and symptom duration with change in shoulder function, shoulder pain, quality of life, and patient reported health change. All regression models were performed firstly with adjustments for covariates (age, sex, body mass index, hand dominance, treatment group, and baseline score of the outcome variable) and secondly with additional adjustments for exposure variables.
Results:
Expectations of complete recovery were associated with an increased odds of perceiving an important improvement in physical symptoms after a 16-week exercise-based treatment program. Higher self-efficacy at baseline seemed to be associated with improved shoulder function, shoulder pain and quality of life. A higher fear of movement seemed to be associated with increased shoulder pain and decreased quality of life. A longer symptom duration was associated with decreased quality of life.
Conclusion:
Expectations of complete recovery, higher self-efficacy, lower fear of movement and shorter symptom duration seem to be important for better treatment outcomes.
... There has been contention that RCRSP is a more suitable designation than traditional diagnoses rooted in pathoanatomic and structural pathologies [4]. This is because pinpointing a specific structure as the primary source of a patient's shoulder pain remains highly challenging [5]. ...
Background: Rotator cuff-related shoulder pain (RCRSP) is a prevalent musculoskeletal issue, encompassing various shoulder conditions. While exercise typically forms the foundation of conservative treatment, there exists ongoing discourse regarding the effectiveness and role of passive treatments. International guidelines recommend initial conservative management, with surgery considered only after failed conservative treatment. However, recent studies reveal discrepancies between recommended practices and actual clinical management. The aim of the study was to assess current practices in managing RCRSP among Greek physiotherapists, with a focus on understanding the alignment of these practices with international guidelines for conservative treatment. Methods: A cross-sectional survey was conducted among Greek physiotherapists to assess current practices in managing RCRSP. The survey, adapted from previous studies, collected demographic data and assessed clinical reasoning through a vignette-based approach. Responses were analyzed for alignment with guideline-recommended care. Results: Out of over 9000 contacted physiotherapists, 163 responded. A majority expressed a specific interest in shoulder pain (85%). Patient education (100%) and exercise (100%) were widely endorsed, with limited support for imaging (44%), injection (40%), and surgery (26%). Younger respondents were less inclined towards surgical referral (p = 0.001). Additionally, adjunctive interventions like mobilization (66%) and massage therapy (58%) were commonly employed alongside exercise and education. Treatment duration typically ranged from 6 to 8 weeks, with exercises reviewed weekly. Conclusions: The study highlights a consistent preference for conservative management among Greek physiotherapists, aligning with international guidelines. However, there are variations in practice, particularly regarding adjunctive interventions and exercise prescription parameters. Notably, there is a disparity between recommended and actual use of certain modalities.
... cordance with the established training program. According to [42], "a new exercise will show effects after six weeks, with a 30% improvement if performed three times a week." ...
The purpose of this study is to determine the effect of windmill arm exercises on 50-meter freestyle swimming speed. Methods. This research used an experimental method with a one-group pre-test-post-test research design. Sampling used a total sampling technique with 45 junior swimmers as participants. The data collection method used the 50-meter freestyle swimming test in both the pre-test and post-test. This research used the t-test for analysis. Results. Based on the results of this research, the calculated t-value is 20.364. This t-value (20.364) is compared to the critical value of t (2.000) at a significance level of α = 0.05 with a degree of freedom df = n − 1 = 44. Thus, tht_hth (20.364) > ttt_ttt (2.000), and based on the table for α = 0.05, a significance level of 0.05 is obtained. This indicates a significant effect on improving the 50-meter freestyle swimming speed of the sample group. Conclusions. Thus, the null hypothesis (H0) is rejected, and the alternative hypothesis (Ha) is accepted. Findings. The alternative hypothesis (Ha) states that windmill arm exercises affect 50-meter freestyle swimming speed in junior swimmers.
... This could be explained because the change in pain signaling pathways leading to an increased responsiveness of nociceptive neurons to their normal input referred as pain sensitization. Therefore, patients may not respond to traditional exercise in an early phase or stage of treatment [38][39][40][41]. A recent meta-analysis showed that pain sensitization has a high rate in patients with musculoskeletal chronic shoul-der pain, and this may lead to worse clinical outcomes after first-line treatment [6]. ...
Objective: The aim of this study was to assess at 6-month and 1-year follow-up the effect of graded motor imagery (GMI) in addition to usual care on the affective and clinical outcomes in patients with chronic shoulder pain.
Methods: A pre–post-intervention single-group study was conducted. One hundred forty-eight patients with chronic shoulder pain were included. All participants received a 6-week GMI program in addition to usual care. The primary outcome assessed was pain intensity using visual analog scale (VAS), the secondary outcomes were fear of movement with the Tampa Scale of Kinesiophobia (TSK), catastrophization with the pain catastrophization scale (PCS), shoulder flexion active range of motion (AROM) with a goniometer, and central sensitization with the central sensitization inventory (CSI). All outcomes were assessed at baseline and 6-month and 1-year follow-up.
Results: At 6 months, GMI showed to be statistically significant for all outcomes assessed (p<0.001). At 1-year follow-up, the VAS showed a decrease of 3.3 cm (p<0.001), TSK showed a decrease of 16.1 points (p<0.001), PCS showed a decrease of 17.4 points (p<0.001), AROM showed an increase of 29.9° (p<0.001), and CSI showed a decrease of 17.9 (p<0.001).
Conclusions: At medium- and long-term follow-up, the individuals who received the GMI program in addition to usual care showed a clinically and statistically significant change for all outcomes assessed. Further studies, including clinical trials, are needed to confirm our findings.
... A combination of various factors, from neuromuscular, neuroendocrine-immune, and psychosocial mechanisms, may have played a role. 47 However, we cannot draw conclusions on the effect of exercise based on the current study, because we did not include a control group. Nevertheless, we can conclude that pain provocation during one exercise seems not to be necessary in the treatment of chronic RCRSP to achieve beneficial results. ...
Purpose
Exercise therapy is the first-line treatment in rotator cuff-related shoulder pain (RCRSP), and diverse types of exercise seem effective. However, it is not still clear if painful exercise should be allowed or avoided during exercises. The objective of this study was to investigate if exercise into pain is more effective than no pain in RCRSP.
Patients and Methods
A randomized controlled trial was conducted in a physiotherapy clinic in Belgium. Forty-three participants with chronic RCRSP were randomly allocated to G1 (exercising into pain) or G2 (exercising without pain) in a 12-week intervention with 6-month follow-up. Primary outcome was the Shoulder Pain and Disability Index (SPADI); secondary outcomes were pain intensity, fear-avoidance beliefs, fear of pain, quality of life, strength, and range of motion. Outcomes were measured at baseline (T0), after 9 weeks (T1), 12 weeks (T2), and 6 months (T3) from the first session and analysed with linear mixed models.
Results
No between-group difference in SPADI (time-by-group interaction, p = 0.25) up to 6 months was found, with mean difference (G1-G2) at T1 = 5.78 (CI95%: −3.43,14.59; p = 0.33), at T2 = 0.93 (CI95%: −7.20,9.05; p = 0.82), at T3 = 4.15 (CI95%: −2.61,10.92; p = 0.33). No between-group differences were found for any other outcomes.
Conclusion
Pain provocation seems not to be necessary in RCRSP for achieving successful treatment effect in pain and disability reduction, fear-related beliefs, and quality of life up to 6 months.
Trial Registration
ClinicalTrials.gov NCT04553289.
... However, three studies showed statistical differences in shoulder ABD strength when comparing patients with RCRSP to an AG (McClure, Michener & Karduna, 2006;Ueda et al., 2020;Choi & Chung, 2023), whilst only Kolber et al. found no statistical differences (Kolber et al., 2017). This contrast might be explained as the study sample in the latter were weight training participants, hence this discrepancy may be justified as exercise is considered to be both essential and at the forefront of the management of RCRSP (Powell et al., 2022), this could explain why these patients did not present shoulder ABD strength deficit. Also, the age mean in this study was 27 compared to McClure, Michener & Karduna (2006), Ueda et al. (2020) and Choi & Chung (2023), where the age mean was 50.5, 45.2 and 65.7, respectively, as shoulder pain generally increases past 50 (Leong et al., 2019;Hodgetts et al., 2021) this fact might also increase the likelihood of statistical differences between studies. ...
Background
The methods previously proposed in the literature to assess patients with rotator cuff related shoulder pain, based on special orthopedic tests to precisely identify the structure causing the shoulder symptoms have been recently challenged. This opens the possibility of a different way of physical examination.
Objective
To analyze the differences in shoulder range of motion, strength and thoracic kyphosis between rotator cuff related shoulder pain patients and an asymptomatic group.
Method
The protocol of the present research was registered in the International Prospective Register of Systematic Review (PROSPERO) (registration number CRD42021258924). Database search of observational studies was conducted in MEDLINE, EMBASE, WOS and CINHAL until July 2023, which assessed shoulder or neck neuro-musculoskeletal non-invasive physical examination compared to an asymptomatic group. Two investigators assessed eligibility and study quality. The Newcastle Ottawa Scale was used to evaluate the methodology quality.
Results
Eight studies ( N = 604) were selected for the quantitative analysis. Meta-analysis showed statistical differences with large effect for shoulder flexion (I2 = 91.7%, p < 0.01, HG = −1.30), external rotation (I2 = 83.2%, p < 0.01, HG = −1.16) and internal rotation range of motion (I2 = 0%, p < 0.01, HG = −1.32). Regarding to shoulder strength; only internal rotation strength showed statistical differences with small effect (I2 = 42.8%, p < 0.05, HG = −0.3).
Conclusions
There is moderate to strong evidence that patients with rotator cuff related shoulder pain present less shoulder flexion, internal and external rotation range of motion and less internal rotation strength than asymptomatic individuals.
... Research has been conducted investigating the mechanisms proposed by clinical trialists for the beneficial effect of exercise for RCRSP, persistent low back pain and knee osteoarthritis (Beckwee et al., 2013;Powell et al., 2022;Wun et al., 2020). Despite this, to the best of the authors knowledge, no research to date has explored the beliefs of practising physiotherapists regarding the possible causal mechanisms of exercise therapy for managing RCRSP. ...
Background and aims:
This cross-sectional international survey explored the beliefs of physiotherapists regarding the possible mechanisms of benefit of exercise for rotator cuff-related shoulder pain (RCRSP). Clinical practice guidelines recommend physiotherapists use exercise as a primary treatment to help people with RCRSP, but the explanations provided to patients by physiotherapists regarding its mechanism of effect is unknown.
Materials and methods:
Registered physiotherapists were surveyed about 'how and why' they believe exercise provides a clinical benefit for people with RCRSP. Information was also gathered about commonly used exercise types and preferred diagnostic labels. The survey was designed and reported in concordance with Consensus-Based Checklist for Reporting of Survey Studies guidelines.
Results:
Four hundred and eighty physiotherapists from forty-nine countries completed the survey. Psychosocial and biomedical mechanisms of exercise were evenly selected by participants. Improving muscle strength, muscle endurance, pain self-efficacy and reducing kinesiophobia, and fear avoidance beliefs were the most common individual mechanisms thought to underpin exercise therapy for RCRSP. Rotator cuff-related shoulder pain was the most commonly used diagnostic label.
Discussion and conclusion:
Physiotherapists hold beliefs regarding exercise mechanisms that is largely concordant with the current evidence base, which is commendable. Future research should consider the patients perspective and consider testing commonly selected mechanisms of exercise, such as shoulder muscle strength, pain self-efficacy and kinesiophobia as possible mediators of recovery.
Context : Limited information exists regarding the immediate and short-term effects of scapula retraction exercises (SREs) on acromiohumeral distance (AHD) in subacromial pain syndrome (SPS). This study’s 2 main objectives were to investigate (1) the immediate effect of the SRE on AHD at varying shoulder abduction angles in patients with SPS and healthy controls and (2) the effect of the 8-week SRE program on AHD in patients with SPS. Design : Cross-sectional and pre–post intervention designs were utilized on this study. Methods : Twenty-one patients with SPS and age-matched healthy controls were included. First, AHD at 0°, 30°, 45°, 60°, and 90° of active shoulder abductions were recorded during (1) resting upper quadrant posture and (2) while participants were performing SREs. Patients then underwent an 8-week progressive SRE program. AHD measures, pain intensity (visual analog scale), and disability (Shoulder Pain and Disability Index) were recorded at baseline and 8 weeks. AHD were analyzed using mixed-model analyses of variance. Pain and disability were analyzed using paired samples t test. Results : The immediate effect of the SREs revealed a significant angle-by-exercise-by-group interaction for the AHD values ( F 3,155 = 3.956, P = .009, ). Pairwise comparisons yielded that the SRE increased AHD values in patients with SPS ( P < .05), yet it did not affect healthy controls ( P > .05). Besides, the SRE program revealed a significant angle-by-time interaction for the AHD values ( F 3,054 = 9.476, P < .001, ). AHD increased at all elevation angles, and pain and disability improved over time ( P < .05). Conclusion : SREs immediately affect AHD in patients with SPS but not in healthy populations. Moreover, SREs applied in progressive abduction angles improve pain, functionality, and AHD values in patients with SPS.
Purpose:
To evaluate the effectiveness of trigger point manual therapy (TPMT) in treating rotator cuff related shoulder pain (RCRSP).
Methods:
Randomized controlled trials that compared the effects of TPMT with no or other conservative treatments in patients with RCRSP were included. Primary outcomes were shoulder pain intensity and function. Secondary outcomes were pressure pain threshold (PPT) and number of myofascial trigger points (MTrPs). The Cochrane Risk of Bias 2.0 tool, PEDro scale and GRADE approach were employed.
Results:
Ten studies were included in this systematic review and seven in the meta-analysis. Very low to low quality of evidence showed no statistically significant difference between TPMT and other conservative treatments in rest and activity pain reduction in the short term (3 days to 12 weeks), and the difference in shoulder function was statistically significant in favor of TPMT. Furthermore, TPMT was found to be effective in the improvement of PPT and the inactivation of active MTrPs in the short term.
Conclusion:
TPMT may be equally effective as other passive treatments for the pain reduction in patients with RCRSP in the short term, and slightly more effective for functional improvement. TPMT seems to be effective to treat the active MTrPs in RCRSP.
Registration number:
CRD42023409101.
Background
Patients are key stakeholders of clinical research, and their perspectives are relevant for researchers when planning and conducting clinical trials. Numerous aspects of trial process can influence participants’ experiences. Their experiences within a trial can impact retention rates. Poor treatment adherence may bias treatment effect estimates. One way to improve recruitment and adherence is to design trials that are aligned with patients’ needs and preferences. This study reports a process evaluation of the Otago MASTER feasibility trial.
Objectives
Our aims were to investigate the patients’ perceptions of the trial interventions through individual interviews.
Methods
Twenty-five participants were recruited for the feasibility trial and were allocated to two groups: tailored or standardised exercise. Sixteen participants agreed to take part in individual semi-structured interviews. Interviews were transcribed verbatim, and all interviews were analysed thematically using an iterative approach.
Results
Our key findings suggest participants: (1) took part in the study to access healthcare services and contribute to research; (2) valued interventions received; (3) reported certain barriers and facilitators to participate in the trial; and (4) highlighted areas for improvement when designing the full trial.
Conclusion
Participants volunteered to access healthcare and to contribute to research. Participants valued the personalised care, perceived that their engagement within the trial improved their self-management and self-efficacy behaviour, valued the time spent with clinicians, and the empathetic environment and education received. Facilitators and barriers will require careful consideration in the future as the barriers may impact reliability and validity of future trial results.
Background:
Subacromial pain syndrome (SAPS), the most common cause of shoulder pain, can be treated through different treatments with similar effects. Therefore, in terms of deciding on the right treatment fit, patient preferences need to be understood. We aimed to identify treatment characteristics that delineate interventions (attributes) and corresponding sets of specific categorical range (attribute-levels) for SAPS.
Methods:
This multiple method study systematically reviewed both qualitative and quantitative studies on patient preferences for treatment of SAPS, which informed semi-structured interviews with nine clinicians and 14 patients. The qualitative data from the interviews was analyzed using the framework analysis formulated by Ritchie and Spencer. Attributes and attribute levels of the systematic review and interviews were summarized and categorized.
Results:
The search resulted in 2.607 studies, 16 of which met the eligibility criteria. The review identified 120 potential attributes, which were synthesized into 25 potential attributes. Fourteen new potential attributes were identified through the interviews, equaling a total of 39 attributes across 11 categories. Levels for 37 attributes were identified through systematic review and interviews, we were unable to identify levels for two attributes.
Conclusions:
This study identified attributes and attribute levels for the treatment of SAPS. There was a discrepancy in the frequency of the represented attributes between the literature and interviews. This study may improve the understanding of patient preferences for the treatment of SAPS and help individualize care. Our study informs a future discrete choice experiment and supports shared decision-making in clinical practice.
Introduction Musculoskeletal shoulder pain (MSP) is a common condition frequently treated in an outpatient setting by a physical therapy rehabilitation team. Treatment teams can consist of physical therapists (PTs) with or without physical therapist assistants (PTAs). It is currently unknown how different physical therapy team compositions can impact patient outcomes in the outpatient setting. The purpose of this study is to examine how the addition of PTAs to a physical therapy treatment team would impact clinical outcomes when treating patients with MSP in the outpatient setting. Methods This study is a retrospective cohort analysis comparing clinical outcomes for pain, active range of motion (AROM), and disability for patients with MSP when treated by physical therapy treatment teams with or without the presence of PTAs. Inclusion criteria were patients treated for MSP in an outpatient physical therapy clinic without a history of shoulder surgery. Depending on the rehabilitation team composition, patients were divided into a PT-only group or a PTA group. Results Total patients (n = 238) had a mean age of 62.6 ± 12.6 years (median: 64 years) with a mean total number of physical therapy visits of 7.8 ± 4.9 visits (median: 7.0 visits). Of the entire cohort, the PT-only group had 100 patients and the PTA group had 138 patients. There was no significant difference in the magnitude of pain improvement (mean: 1.5 versus 1.9 points, p = 0.177), the magnitude of abduction AROM improvement (mean: 17.6 versus 13.9 degrees, p = 0.173), and the magnitude of disability improvement (mean: 18.9 versus 13.4 percentage points, p = 0.221) between the PT-only group and the PTA group. However, the PT-only group had significantly fewer total visits as compared to the PTA group (6.7 versus 8.6 visits, p < 0.001). Conclusion The addition of PTAs to a rehabilitation team when treating patients with MSP in the outpatient setting does not appear to adversely impact pain, AROM, or disability outcomes. However, patients treated only by PTs had significantly less visits with similar outcomes. More research is needed to determine the interplay between cost, healthcare utilization, and patient outcomes to maximize quality care.
Objective:
Rotator cuff-related shoulder pain is the most common form of shoulder pain. Exercise therapy is a first-line recommended treatment for rotator cuff-related shoulder pain. However, the causal mechanisms underpinning the beneficial effects of exercise for rotator cuff-related shoulder pain are not well understood. Moreover, how individuals with lived experience of rotator cuff-related shoulder pain believe exercise helped or did not help is unknown. This study aimed to gain insights into how individuals with rotator cuff-related shoulder pain believe exercise influenced their shoulder pain and identify the clinical conditions that promoted or inhibited their beliefs.
Methods:
This qualitative study was underpinned by a critical realist approach to thematic analysis. Participants were recruited using hybrid purposive and convenience sampling techniques. Each participant attended an online semistructured interview. The data were coded by 2 members of the research team (JKP & NC) and verified by a third (BS). Recruitment continued until theoretical sufficiency was achieved. Participants reviewed and validated preliminary causal explanations.
Results:
Three causal explanations were consistently expressed by 11 participants to explain the benefits of exercise therapy: (1) shoulder strength; (2) changes to psycho-emotional status; and (3) exercise has widespread health effects. However, the activation of these causal mechanisms depended on (1) the presence of a strong therapeutic relationship; (2) the provision of a structured and tailored exercise program; and (3) experiencing timely clinical progress.
Conclusions:
Participants believed exercise improved their shoulder pain through associated health benefits, improved shoulder strength, and psychoemotional variables. Whether an exercise program was able to cause a clinical improvement for an individual with rotator cuff-related shoulder pain was contingent on clinical contextual features. Thus, the clinical context that an exercise program is delivered within may be just as important as the exercise program itself.
Impact:
Exercise is a recommended primary, first-line intervention to manage rotator cuff-related shoulder pain. The results of this study suggest that a positive experience and outcome with exercise for rotator cuff-related shoulder pain is contingent on several clinical contextual features, such as a strong therapeutic relationship. The clinical context an exercise program is prescribed and delivered should be considered by clinicians.
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).
The physiological effects of physical exercise are ubiquitously reported as beneficial to the cardiovascular and musculoskeletal systems. Exercise is widely promoted by medical professionals to aid both physical and emotional wellbeing; however, mechanisms through which this is achieved are less well understood. Despite numerous beneficial attributes, certain types of exercise can inflict significant significant physiological stress. Several studies document a key relationship between exercise and immune activation. Activation of the innate immune system occurs in response to exercise and it is proposed this is largely mediated by cytokine signalling. Cytokines are typically classified according to their inflammatory properties and evidence has shown that cytokines expressed in response to exercise are diverse and may act to propagate, modulate or mitigate inflammation in musculoskeletal health. The review summarizes the existing literature on the relationship between exercise and the immune system with emphasis on how exercise-induced cytokine expression modulates inflammation and the immune response.
Clinicians suggest that rehabilitation of Subacromial Impingement Syndrome (SIS) should target improving movement patterns to ensure better clinical outcomes. Understanding changes in onset time of activation patterns and associated changes in clinical outcomes could improve our understanding of rehabilitation strategies. In this prospective longitudinal study, we examined neuromuscular firing patterns and clinical features before and after a standardized physiotherapy program in subjects diagnosed with SIS. Electromyography (EMG) recordings of eleven shoulder muscles were taken at the initial and discharge consultation in 34 male volunteers diagnosed with SIS. EMG recording was performed during flexion, scaption, and abduction at slow, medium, and fast speeds with a loaded (3 kg) and unloaded arm, as well as rotational motion, rotational strength, pain, and shoulder function. Completion of standardized shoulder physiotherapy program for SIS resulted in improvements in clinical outcomes. Resulted showed inconsistent differences of onset time of activation mainly in some of the periscapular muscles for all movements. No differences were seen on the EMG recordings for rotator cuff muscles. Differences in range of motion, strength and function were shown. Despite some changes in onset time of activation, this study was not able to demonstrate consistent changes of onset time of activation of the periscapular and rotator cuff muscles.
Background:
A strong recommendation against subacromial decompression surgery was issued in 2019. This leaves nonoperative care as the only treatment option, but recent studies suggest that the dose of strengthening exercise is not sufficient in current nonoperative care. At this point, it is unknown if adding more strengthening to current nonoperative care is of clinical value.
Purpose:
To assess the effectiveness of adding a large dose of shoulder strengthening to current nonoperative care for subacromial impingement compared with usual care alone.
Study design:
Randomized controlled trial; Level of evidence, 1.
Methods:
In this double-blinded, pragmatic randomized controlled trial, we randomly allocated 200 consecutive patients referred to orthopaedic shoulder specialist care for long-standing shoulder pain (>3 months), aged 18 to 65 years and diagnosed with subacromial impingement using validated criteria, to the intervention group (IG) or control group (CG). Outcome assessors were blinded, and participants were blinded to the study hypothesis as well as to the treatment method in the other group. The CG received usual nonoperative care; the IG underwent the same plus an add-on intervention designed to at least double the total dose of shoulder strengthening. The primary outcome was the Shoulder Pain and Disability Index (SPADI; 0-100) at 4-month follow-up, with 10 points defined as the minimal clinically important difference. Secondary outcomes included shoulder strength, range of motion, health-related quality of life, and the Patient Acceptable Symptom State (PASS).
Results:
Intention-to-treat and per-protocol analyses showed no significant or clinically relevant between-group differences for any outcome. From baseline to 4-month follow-up, SPADI scores improved in both groups (intention-to-treat analysis; IG, -22.1 points; CG, -22.7 points; between-group mean difference, 0.6 points [95% CI, -5.5 to 6.6]). At 4 months after randomization, only 54% of the IG and 48% of the CG (P = .4127) reached the PASS. No serious adverse events were reported.
Conclusion:
Adding a large dose of shoulder strengthening to current nonoperative care for patients with subacromial impingement did not result in superior shoulder-specific patient-reported outcomes. Moreover, approximately half of all randomized patients did not achieve the PASS after 4 months of nonoperative care, leaving many of these patients with unacceptable symptoms. This study showed that adding more exercise is not a viable solution to this problem.
Registration:
NCT02747251 (ClinicalTrials.gov identifier).
The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement, published in 2009, was designed to help systematic reviewers transparently report why the review was done, what the authors did, and what they found. Over the past decade, advances in systematic review methodology and terminology have necessitated an update to the guideline. The PRISMA 2020 statement replaces the 2009 statement and includes new reporting guidance that reflects advances in methods to identify, select, appraise, and synthesise studies. The structure and presentation of the items have been modified to facilitate implementation. In this article, we present the PRISMA 2020 27-item checklist, an expanded checklist that details reporting recommendations for each item, the PRISMA 2020 abstract checklist, and the revised flow diagrams for original and updated reviews.
The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement, published in 2009, was designed to help systematic reviewers transparently report why the review was done, what the authors did, and what they found. Over the past decade, advances in systematic review methodology and terminology have necessitated an update to the guideline. The PRISMA 2020 statement replaces the 2009 statement and includes new reporting guidance that reflects advances in methods to identify, select, appraise, and synthesise studies. The structure and presentation of the items have been modified to facilitate implementation. In this article, we present the PRISMA 2020 27-item checklist, an expanded checklist that details reporting recommendations for each item, the PRISMA 2020 abstract checklist, and the revised flow diagrams for original and updated reviews.
Purpose: Low back pain (LBP) is the leading cause of disability worldwide. Clinical research advocates
using the biopsychosocial model (BPS) to manage LBP, however there is still no clear consensus regarding
the meaning of this model in physiotherapy and how best to apply it. The aim of this study was to investigate
how physiotherapy LBP literature enacts the BPS model.
Material and methods: We conducted a critical review using discourse analysis of 66 articles retrieved
from the PubMed and Web of Science databases.
Results: Analysis suggest that many texts conflated the BPS with the biomedical model [Discourse 1:
Conflating the BPS with the biomedical model]. Psychological aspects were almost exclusively conceptualised
as cognitive and behavioural [Discourse 2: Cognition, behaviour, yellow flags and rapport]. Social
context was rarely mentioned [Discourse 3: Brief and occasional social underpinnings]; and other broader
aspects of care such as culture and power dynamics received little attention within the texts [Discourse 4:
Expanded aspects of care].
Conclusion: Results imply that multiple important factors such as interpersonal or institutional power
relations, cultural considerations, ethical, and social aspects of health may not be incorporated into
physiotherapy research and practice when working with people with LBP.
To determine whether subacromial space (i.e. acromiohumeral distance; AHD, and/or occupation ratio percentage) differs between people with subacromial pain syndrome (SAPS) and those without. To investigate whether there is a correlation between subacromial space and pain or disability in adults with SAPS and whether temporal changes in pain or disability are accompanied by changes in subacromial space. Systematic review and meta-analysis. Fifteen studies with a total of 775 participants were included. Twelve studies were of high quality and three studies were of moderate quality using the modified Black and Downs checklist. There was no between group difference in AHD in neutral shoulder position (mean difference [95% CI] 0.28 [−0.13 to 0.69] mm), shoulder abduction at 45° (−0.02 [−0.99 to 0.96] mm) or 60° (−0.20 [−0.61 to 0.20] mm). Compared to the control group, a greater occupation ratio in neutral shoulder position was demonstrated in participants with SAPS (5.14 [1.87 to 8.4] %). There was no consistent pattern regarding the correlation between AHD and pain or disability in participants with SAPS, and no consistent increase in subacromial space with improvement in pain or disability over time. The results suggest that surgical (e.g. sub-acromial decompression) and non-surgical (e.g. manual therapy, taping, stretching and strengthening) management of subacromial pain syndrome should not focus solely on addressing a potential decrease in subacromial space, but also on the importance of other biopsychosocial factors.
Background
Sedentary lifestyle is a major risk factor for noncommunicable diseases such as cardiovascular diseases, cancer and diabetes. It has been estimated that approximately 3.2 million deaths each year are attributable to insufficient levels of physical activity. We evaluated the available evidence from Cochrane systematic reviews (CSRs) on the effectiveness of exercise/physical activity for various health outcomes.
Methods
Overview and meta-analysis. The Cochrane Library was searched from 01.01.2000 to issue 1, 2019. No language restrictions were imposed. Only CSRs of randomised controlled trials (RCTs) were included. Both healthy individuals, those at risk of a disease, and medically compromised patients of any age and gender were eligible. We evaluated any type of exercise or physical activity interventions; against any types of controls; and measuring any type of health-related outcome measures. The AMSTAR-2 tool for assessing the methodological quality of the included studies was utilised.
Results
Hundred and fifty CSRs met the inclusion criteria. There were 54 different conditions. Majority of CSRs were of high methodological quality. Hundred and thirty CSRs employed meta-analytic techniques and 20 did not. Limitations for studies were the most common reasons for downgrading the quality of the evidence. Based on 10 CSRs and 187 RCTs with 27,671 participants, there was a 13% reduction in mortality rates risk ratio (RR) 0.87 [95% confidence intervals (CI) 0.78 to 0.96]; I² = 26.6%, [prediction interval (PI) 0.70, 1.07], median effect size (MES) = 0.93 [interquartile range (IQR) 0.81, 1.00]. Data from 15 CSRs and 408 RCTs with 32,984 participants showed a small improvement in quality of life (QOL) standardised mean difference (SMD) 0.18 [95% CI 0.08, 0.28]; I² = 74.3%; PI -0.18, 0.53], MES = 0.20 [IQR 0.07, 0.39]. Subgroup analyses by the type of condition showed that the magnitude of effect size was the largest among patients with mental health conditions.
Conclusion
There is a plethora of CSRs evaluating the effectiveness of physical activity/exercise. The evidence suggests that physical activity/exercise reduces mortality rates and improves QOL with minimal or no safety concerns.
Trial registration
Registered in PROSPERO (CRD42019120295) on 10th January 2019.
Objectives:
To compare the effects of spinal thrust-manipulation and electrical dry needling (TMEDN-group) to nonthrust peripheral joint/soft-tissue mobilization, exercise and interferential current (NTMEX-group) on pain and disability in patients with subacromial pain syndrome (SAPS).
Design:
Randomized, single-blinded, multi-center, parallel-group trial.
Methods:
Patients with SAPS were randomized into the TMEDN group (n=73) or the NTMEX group (n=72). Primary outcomes included the shoulder pain and disability index (SPADI) and the numeric pain rating scale (NPRS). Secondary outcomes included Global Rating of Change (GROC) and medication intake. The treatment period was 6 weeks; with follow-up at 2 weeks, 4 weeks, and 3 months.
Results:
At 3 months, the TMEDN group experienced greater reductions in shoulder pain and disability (P<0.001) compared to the NTMEX group. Effect sizes were large in favor of the TMEDN group. At 3 months, a greater proportion of patients within the TMEDN group achieved a successful outcome (GROC≥+5) and stopped taking medication (P<0.001).
Conclusion:
Cervicothoracic and upper rib thrust-manipulation combined with electrical dry needling resulted in greater reductions in pain, disability and medication intake than nonthrust peripheral joint/soft-tissue mobilization, exercise and interferential current in patients with SAPS. These effects were maintained at 3 months. J Orthop Sports Phys Ther, Epub 28 Aug 2020. doi:10.2519/jospt.2021.9785.
Objective
Synthesize evidence regarding effectiveness of progressive and resisted or non-progressive and non-resisted exercise compared with placebo or no treatment, in rotator cuff related pain.
Data sources
English articles, searched in Cochrane CENTRAL, MEDLINE, EMBASE and CINAHL databases up until May 19, 2020.
Methods
Randomized controlled trials in people with rotator cuff related pain comparing either progressive and resisted exercise or non-progressive and non-resisted exercise, with placebo or no treatment were included. Data extracted independently by two authors. Risk of bias appraised with the Cochrane Collaboration tool.
Results
Seven trials (468 participants) were included, four trials (271 participants) included progressive and resisted exercise and three trials (197 participants) included non-progressive or non-resisted exercise. There was uncertain clinical benefit for composite pain and function (15 point difference, 95% CI 9 to 21, 100-point scale) and pain outcomes at >6 weeks to 6 months with progressive and resisted exercise compared to placebo or no treatment (comparison 1). For non-progressive or non-resisted exercise there was no significant benefit for composite pain and function (4 point difference, 95% CI −2 to 9, 100-point scale) and pain outcomes at >6 weeks to 6 months compared to placebo or no treatment (comparison 2). Adverse events were seldom reported and mild.
Conclusions
There is uncertain clinical benefit for all outcomes with progressive and resisted exercise and no significant benefit with non-progressive and non-resisted exercise, versus no treatment or placebo at >6 weeks to 6 months. Findings are low certainty and should be interpreted with caution.
Exercise is a core treatment for persistent non-specific low back pain (NSLBP), but results from randomised controlled trials (RCTs) of exercise typically show only small to moderate standardised mean differences (SMDs) compared to non-exercise controls. The choice of primary outcome, and relationship to the specific targets of exercise may influence this. This systematic review aimed to explore whether primary outcomes match the exercise treatment targets used in NSLBP RCTs and the potential impact of matching on SMDs.
Included RCTs were conducted with patients with persistent NSLBP, compared exercise to no exercise, with sample sizes >60 per arm. Screening, data extraction and risk of bias assessment were independently undertaken by paired reviewers. Of 19272 initial titles, 27 RCTs were included with 31 treatment targets and 6 primary outcome domains identified. Only 25% of included RCTs had primary outcomes that matched the treatment targets. SMDs of exercise versus comparison arms were observed to be larger in the matched (SMD 0.54 (95% CI 0.23 to 0.85), p=0.0006) compared to the unmatched category (SMD 0.22 (95% CI 0.01, 0.44) p=0.04) but this difference was not statistically significant (p=0.10). These exploratory findings may have implications for future teams developing RCTs of exercise for NSLBP and warrant further investigation in larger datasets.
Objective
To investigate the effect on shoulder pain and disability of teaching patients with shoulder pain how to undertake a home-based exercise program.
Design
A randomized controlled trial conducted from September 2015 to January 2016.
Setting
Participants’ home.
Participants
Sixty participants with shoulder pain who were waiting for physiotherapeutic treatment.
Interventions
The control group (n = 30) received minimal education about their shoulder condition and instructions to continue their activities as normal. The intervention group (n = 30) received a two-month home exercise program with one-hour sessions delivered by a physiotherapist to begin and one month after the program for exercise instructions.
Main measures
The primary outcome was change in the Shoulder Pain and Disability Index (SPADI). The secondary outcomes included change in the numeric pain rating scale and medication intake for pain relief.
Results
The patients’ average age was 54.3 (13.8) years. SPADI scores at baseline were 60.9 (16.5) in the intervention and 64.7 (15.3) in the control group. After two months, the SPADI scores decreased to 18.8 (28.6) and to 61.4 (24.0), respectively, in the intervention and control groups with an estimated mean difference of 40.0, effect size: 1.61. The intervention group showed a reduced pain intensity (estimated mean difference: 3.7, effect size: 2.43) and medication intake (chi-square: 0.001). The number needed to treat was 1.2 for one patient to have a SPADI score <20.
Conclusion
Teaching patients with shoulder pain how to undertake a home-based exercise program improved shoulder function and reduced pain intensity and medication intake over two months.
Background
Exercise interventions are frequently recommended for patients with rotator cuff disease, but poor content reporting in clinical trials of exercise limits interpretation and replication of trials and clinicians’ ability to deliver effective exercise protocols. The Consensus on Exercise Reporting Template (CERT) was developed to address this problem.
Objective
To assess completeness of content reporting of exercise interventions in randomised controlled trials for patients with rotator cuff disease and the inter-rater reliability of the CERT.
Design
Critical appraisal.
Methods
Independent pairs of reviewers applied the CERT to all 34 exercise trials from the most recent Cochrane Review evaluating the effect of manual therapy and exercise for patients with rotator cuff disease. We used the CERT Explanation and Elaboration Statement to guide assessment of whether each of the 19-item criteria were clearly described (score 0–19; higher scores indicate better reporting). Percentage agreement and the prevalence and bias adjusted kappa (PABAK) coefficient were used to measure inter-rater reliability.
Results
The median CERT score was 5 (range 0–16). Percentage agreement was high for 15 items and acceptable for 4 items. The PABAK coefficient indicated excellent (5 items), substantial (11 items) and moderate (3 items) inter-rater agreement.
Conclusion
The description of exercise interventions for patients with rotator cuff disease in published trials is poorly reported. Overall, the inter-rater reliability of the CERT is high/acceptable. We strongly encourage journals to mandate use of the CERT for papers reporting trial protocols and results investigating exercise interventions.
Objectives Rotator cuff-related shoulder pain (RCRSP) is a common upper limb complaint. It has been suggested that this condition is more common among people with cardiometabolic risk factors. This systematic review has synthesised evidence from case–control, cross-sectional and cohort studies on the association between metabolic syndrome (MetS) and RCRSP.
Design and data sources Five medical databases (MEDLINE, EMBASE, SCOPUS, CINAHL and AMED) and reference checking methods were used to identify all relevant English articles that considered MetS and RCRSP. Studies were appraised using the Newcastle-Ottawa Scale (NOS). Two reviewers performed critical appraisal and data extraction. Narrative synthesis was performed via content analysis of statistically significant associations.
results Three cross-sectional, two case–control and one cohort study met the inclusion criteria, providing a total of 1187 individuals with RCRSP. Heterogeneity in methodology and RCRSP or MetS definition precluded a meaningful meta-analysis. Four of the included studies identified associations between the prevalence of MetS and RCRSP. Studies consistently identified independent cardiometabolic risk factors associated with RCRSP. All studies were level III evidence.
summary and conclusion The low-moderate quality evidence included in this review suggests an association between MetS and RCRSP. Most studies demonstrated moderate quality on appraisal. The direction of association and cardiometabolic factors influencing should be investigated by longitudinal and treatment studies. These preliminary conclusions and clinical utility should be treated with caution due to limitations of the evidence base.
We propose a new conceptualization of pain by incorporating advancements made by phenomenologists and cognitive scientists. The biomedical understanding of pain is problematic as it inaccurately endorses a linear relationship between noxious stimuli and pain, and is often dualist or reductionist. From a Cartesian dualist perspective, pain occurs in an immaterial mind. From a reductionist perspective, pain is often considered to be “in the brain.” The biopsychosocial conceptualization of pain has been adopted to combat these problematic views. However, when considering pain research advancements, paired with the work of phenomenologists’ and cognitive scientists’ advanced understanding of perception, the biopsychosocial model is inadequate in many ways. The boundaries between the biological, psychological, and social are artificial, and the model is often applied in a fragmented manner. The model has a limited theoretical foundation, resulting in the perpetuation of dualistic and reductionist beliefs. A new framework may serve to better understand and treat pain. In this paper, we conceptualize pain as a 5E process, arguing that it is: Embodied, Embedded, Enacted, Emotive, and Extended. This perspective is applied using back pain as an exemplar and we explore potential clinical applications. With enactivism at the core of this approach, pain does not reside in a mysterious immaterial mind, nor is it an entity to be found in the blood, brain, or other bodily tissues. Instead, pain is a relational and emergent process of sense-making through a lived body that is inseparable from the world that we shape and that shapes us.
Background:
Studies have emphasized the importance of the presence of myofascial trigger points (MTrPs) in patients with rotator cuff pathologies and the high frequency of MTrPs in rotator cuff muscles.
Objective:
Evaluate the effectiveness of the treatment of active MTrPs in patients with rotator cuff pathologies.
Methods:
Fifty-three patients with rotator cuff tear were randomized into two groups. All patients received the same standard conservative treatment twice a week for 6 weeks. Patients in Group 1 additionally received ischemic compression (IC) of MTrPs. Pain, range of motion (ROM), function, and anxiety and depression were assessed. MTrPs in rotator cuff muscles were assessed manually, and the number of MTrPs on the shoulder complex was counted.
Results:
There were no significant differences between the groups in terms of changes in resting/activity/night pain, ROM, function, or anxiety and depression (p> 0.05). Pain scores improved only in Group 1. However, the total number of MTrPs was significantly decreased in Group 1 (p= 0.001).
Conclusion:
A six-week course of IC helps treat active MTrPs. A standard conservative treatment program reduced pain and increased function; the addition of MTrP treatment did not improve clinical outcomes in patients with rotator cuff pathologies.
Context:
Impaired scapular kinematics is commonly reported in patients with subacromial impingement syndrome (SIS). Various therapeutic interventions designed to improve scapular kinematics and minimize pain and disability have been described in the literature. However, the short- and long-term benefits of these interventions are unclear.
Objective:
To determine the effects of specific short- and long-term therapeutic interventions on scapular kinematics and disability in patients with SIS.
Data sources:
We searched PubMed, CINAHL, and SPORTDiscus databases from their origins to January 2018 using a combination of the key words scapular kinematics AND ( shoulder dysfunction OR subacromial impingement) and conducted a manual search by reviewing the references of the identified papers.
Study selection:
Studies were included if (1) preintervention and postintervention measures were available; (2) patient-reported outcomes were reported; (3) scapular kinematics measures at 90° of ascending limb elevation in the scapular plane were included; (4) SIS was diagnosed in participants or participants self-reported symptoms of SIS; (5) they were original clinical studies published in English; and (6) the sample sizes, means, and measure of variability for each group were reported.
Data extraction:
Seven studies were found. Sample sizes, means, and standard deviations of scapular upward rotation, posterior tilt, and internal rotation at 90° of ascending limb elevation on the scapular plane and the Disabilities of the Arm, Shoulder, and Hand scores were extracted.
Data synthesis:
Standardized mean differences between preintervention and postintervention measures with 95% confidence intervals (CIs) were calculated. We observed that the Disabilities of the Arm, Shoulder, and Hand scores improved (mean difference = 0.85; 95% CI = 0.54, 1.16) but did not observe changes in scapular upward rotation (mean difference = -0.04; 95% CI = -0.31, 0.22), posterior tilt (mean difference = -0.09; 95% CI = -0.32, 0.15), or internal rotation (mean difference = 0.06; 95% CI = -0.19, 0.31).
Conclusions:
The short- and long-term therapeutic interventions for SIS improved patient-reported outcomes but not scapular kinematics. The identified improvements in shoulder pain and function were not likely explained by changes in scapular kinematics.
Objective:
The aim of the present study was to compare the effectiveness of kinesio taping (KT) treatments and conventional physical therapy (PT) modalities that are applied to reduce pain and improve physical movements and functions of patients with sub acromial impingement syndrome (SIS).
Materials and methods:
Forty patients were randomly divided into two equal groups. The first group was assigned KT plus home exercise program (HEP) for 15 days. The second group was given 15 sessions of PT and HEP. Patients were assessed using active joint range of motion (ROM), Visual Analogue Scale (VAS; rest, movement, and night pain), the Society of the American Shoulder and Elbow Surgeons Evaluation (ASESS-100), Constant-Murley (C-M) scale, and Western Ontario Rotator Cuff (WORC) index at before and after treatment and at the end of the study (first month control visit).
Results:
Physical therapy was found to be more effective than KT when these two treatment modalities were assessed based on ASESS-100, WORC index values, night pain, and movement pain. PT and KT treatments have similar effects in active ROM, rest pain, and C-M scale. At the end of the study, they were found to have similar effects except the night pain value. PT was found to be more effective for night pain than KT.
Conclusion:
Physical therapy was concluded to be more effective after treatment. The application of KT does not appear to be an alternative treatment method for SIS, but it can provide a potential supportive care for SIS. However, the outcomes suggest that KT can provide a remarkable benefit.
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.
Traditional pain models that describe tissue pathology as a source of nocioceptive input directly linked with pain expression, have been insufficient for assessing and treating musculoskeletal pain. The need for pain to be avoided or alleviated as much as possible during physical activity has recently been challenged, with a paradigm shift from traditional biomedical models of pain towards a biopsychosocial model of pain. The aim of the review is to provide an understanding on the potential mechanisms behind exercise, and to build on this into discussing the additional theoretical mechanisms of painful exercises. Central and peripheral pain mechanisms, the immune system and affective aspects of pain are described. This review focuses on these three mechanisms as these systems appear to respond differently to painful stimulus, compared with necessitating pain-free exercises. They are discussed in relation to the biological effect of exercise for people with chronic pain, with a broader overview of possible mechanisms behind the potentially additional beneficial effect of allowing painful exercises for individuals with chronic musculoskeletal pain. This additional mechanistic consideration could be used to help clinicians in the prescription of therapeutic exercise and for researchers to advance knowledge for such a globally burdensome condition.
Background Impaired patient-reported shoulder function and pain, external-rotation strength, abduction strength, and abduction range-of-motion (ROM) is reported in patients with subacromial impingement (SIS). However, it is unknown how much strength and ROM improves in real-life practice settings with current care. Furthermore, outcomes of treatment might depend on specific rehabilitation parameters, such as the time spent on exercises (exercise-time), number of physiotherapy sessions (physio-sessions) and number of corticosteroid injections, respectively. However, this has not previously been investigated. The purpose of this study was to describe changes in shoulder strength, ROM, patient-reported function and pain, in real-life practice settings, and explore the association between changes in clinical core outcomes and specific rehabilitation parameters. Methods Patients diagnosed with SIS at initial assessment at an outpatient hospital clinic using predefined criteria’s, who had not undergone surgery after 6 months, were included in this prospective cohort study. After initial assessment (baseline), all patients underwent treatment as usual, with no interference from the investigators. The outcomes Shoulder Pain and Disability Index (SPADI:0–100), average pain (NRS:0–10), external rotation strength, abduction strength and abduction ROM, pain during each test (NRS:0–10), were collected at baseline and at six month follow-up. Amount of exercise-time, physio-sessions and steroid-injections was recorded at follow-up. Changes in outcomes were analyzed using Wilcoxon Signed-Rank test, and the corresponding effect sizes (ES) were estimated. The associations between changes in outcomes and rehabilitation parameters were explored using multiple regression analyses. Results Sixty-three patients completed both baseline and follow-up testing. Significant improvements were seen in SPADI (19 points, ES:0.53, p
Background:
Shoulder pain affects up to 67% of the population at some point in their lifetime with subacromial pain syndrome (SAPS) representing a common etiology. Despite a plethora of studies there remains conflicting evidence for appropriate management of SAPS.
Purpose:
To compare outcomes, for individuals diagnosed with SAPS, performing a 6-week protocol of eccentric training of the shoulder external rotators (ETER) compared to a general exercise (GE) protocol.
Study design:
Randomized controlled trial.
Methods:
Forty-eight individuals (mean age 46.8 years + /-17.29) with chronic shoulder pain, and a clinical diagnosis of SAPS were randomized into either an experimental group performing ETER or a control group performing a GE program. The intervention lasted for six weeks, and outcomes were measured after three weeks, six weeks, and again at six months post intervention.
Results:
The primary outcome of function, measured by the Western Ontario Rotator Cuff Index, demonstrated a significant interaction effect derived from a multilevel hierarchical model accounting for repeated measures favoring the experimental group at week 3: 14.65 (p=.003), Week 6: 17.04 (p<.001) and six months: 15.12 (p=.007). After six months, secondary outcome measures were improved for Numeric Pain Rating Scale levels representing pain at worst (p=.006) and pain on average (p=0.02), external rotator (p<.001), internal rotator (p=0.02), and abductor strength (p<.001). There were no statistically significant differences in secondary outcome measures of Global Rating of Change, Active Range of Motion, the Upper Quarter Y Balance Test and strength ratios after six months.
Conclusion:
An eccentric program targeting the external rotators was superior to a general exercise program for strength, pain, and function after six months. The findings suggest eccentric training may be efficacious to improve self-report function and strength for those with SAPS.
Level of evidence:
2b.
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).
Objective:
The aim of this study was to compare the short term effects of home exercise program and virtual reality exergaming in patients with subacromial impingement syndrome (SAIS).
Methods:
A total of 30 patients with SAIS were randomized into two groups which are Home Exercise Program (EX Group) (mean age: 40.6 ± 11.7 years) and Virtual Reality Exergaming Program (WII Group) (mean age: 40.33 ± 13.2 years). Subjects were assessed at the first session, at the end of the treatment (6 weeks) and at 1 month follow-up. The groups were assessed and compared with Visual Analogue Scale (based on rest, activity and night pain), Neer and Hawkins Tests, Scapular Retraction Test (SRT), Scapular Assistance Test (SAT), Lateral Scapular Slide Test (LSST) and shoulder disability (Shoulder Pain and Disability Index (SPADI)).
Results:
Intensity of pain was significantly decreased in both groups with the treatment (p < 0.05). The WII Group had significantly better results for all Neer test, SRT and SAT than the EX Group (p < 0.05).
Conclusion:
Virtual reality exergaming programs with these programs were found more effective than home exercise programs at short term in subjects with SAIS.
Level of evidence:
Level I, Therapeutic study.
Chronic musculoskeletal pain (CMP) refers to ongoing pain felt in the bones, joints and tissues of the body that persists longer than 3 months. For these conditions, it is widely accepted that secondary pathologies or the consequences of persistent pain, including fear of movement, pain catastrophizing, anxiety and nervous system sensitization appear to be the main contributors to pain and disability. While exercise is a primary treatment modality for CMP, the intent is often to improve physical function with less attention to secondary pathologies. Exercise interventions for CMP which address secondary pathologies align with contemporary pain rehabilitation practices and have greater potential to improve patient outcomes above exercise alone. Biopsychosocial treatment which acknowledges and addresses the biological, psychological and social contributions to pain and disability is currently seen as the most efficacious approach to chronic pain. This clinical update discusses key aspects of a biopsychosocial approach concerning exercise prescription for CMP and considers both patient needs and clinician competencies. There is consensus for individualized, supervised exercise based on patient presentation, goals and preference that is perceived as safe and non‐threatening to avoid fostering unhelpful associations between physical activity and pain. The weight of evidence supporting exercise for CMP has been provided by aerobic and resistance exercise studies, although there is considerable uncertainty on how to best apply the findings to exercise prescription. In this clinical update, we also provide evidence‐based guidance on exercise prescription for CMP through a synthesis of published work within the field of exercise and CMP rehabilitation.
Background
Knowledge of injury patterns, an essential step towards injury prevention, is lacking in youth handball.
Aim
To investigate if an increase in handball load is associated with increased shoulder injury rates compared with a minor increase or decrease, and if an association is influenced by scapular control, isometric shoulder strength or glenohumeral range of motion (ROM).
Methods
679 players (14–18 years) provided weekly reports on shoulder injury and handball load (training and competition hours) over 31 weeks using the SMS, phone and medical examination system. Handball load in a given week was categorised into (1) <20% increase or decrease (reference), (2) increase between 20% and 60% and (3) increase >60% relative to the weekly average amount of handball load the preceding 4 weeks. Assessment of shoulder isometric rotational and abduction strength, ROM and scapular control was performed at baseline and midseason.
Results
An increase in handball load by >60% was associated with greater shoulder injury rate (HR 1.91; 95% CI 1.00 to 3.70, p=0.05) compared with the reference group. The effect of an increase in handball load between 20% and 60% was exacerbated among players with reduced external rotational strength (HR 4.0; 95% CI 1.1 to 15.2, p=0.04) or scapular dyskinesis (HR 4.8; 95% CI 1.3 to 18.3, p=0.02). Reduced external rotational strength exacerbated the effect of an increase above 60% (HR 4.2; 95% CI 1.4 to 12.8, p=0.01).
Conclusions
A large increase in weekly handball load increases the shoulder injury rate in elite youth handball players; particularly, in the presence of reduced external rotational strength or scapular dyskinesis.
Objectives:
To assess the efficacy of three different exercise programmes in treating rotator cuff tendinopathy/shoulder impingement syndrome.
Design:
Parallel group randomised clinical trial.
Setting:
Two out-patient NHS physiotherapy departments in Manchester, United Kingdom.
Participants:
120 patients with shoulder pain of at least three months duration. Pain was reproduced on stressing the rotator cuff and participants had full passive range of movement at the shoulder.
Interventions:
Three dynamic rotator cuff loading programmes; open chain resisted band exercises (OC) closed chain exercises (CC) and minimally loaded range of movement exercises (ROM).
Main outcomes:
Change in Shoulder Pain and Disability Index (SPADI) score and the proportion of patients making a Minimally Clinically Important Change (MCIC) in symptoms 6 weeks after commencing treatment.
Results:
All three programmes resulted in significant decreases in SPADI score, however there were no significant differences between the groups. Participants making a MCIC in symptoms were similar across all groups, however more participants deteriorated in the ROM group. Dropout rate was higher in the CC group, but when only patients completing treatment were considered more patients in the CC group made a meaningful reduction in pain and disability.
Conclusions:
Open chain, closed chain and range of movement exercises all seem to be effective in bringing about short term changes in pain and disability in patients with rotator cuff tendinopathy. ISRCTN76701121.
Introduction:
Loss of workdays is the main societal cost related to shoulder disorders with nine lost workdays per six months on average. The most common shoulder disorder is subacromial impingement syndrome (SIS), but it remains unknown if SIS is also a leading cause of shoulder-related loss of worktime. We aimed to investigate the incidence of workdays lost due to SIS during the six months following a SIS diagnosis in specialised care.
Methods:
Among 157 consecutive patients diagnosed with SIS in secondary care, 129 (82%) completed a structured six-month follow-up interview. Job status, average working hours and sick leave due to SIS were recorded. Only patients holding a job (n = 58) and patients who lost their job due to SIS (n = 8) were considered to be at risk of losing workdays, leaving 66 patients in the at-risk group. The number of lost workhours due to SIS was calculated and normalised to full-time workdays, and incidences of lost workdays were estimated using Poisson regressions.
Results:
In total, 1,781 workdays were lost. The mean number of lost workdays per six months was 27 days (95% confidence interval (CI): 18-40) for patients at risk (n = 66), corresponding to 14 days on average (95% CI: 9-21 days) for the entire cohort (n = 129). A total of 33 patients were responsible for all loss of workdays.
Conclusions:
We found that an average of 27 workdays (> 5 work weeks) were lost due to SIS during the first six months after the diagnosis in patients who were otherwise fit to work. This is three times higher than the nine days previously reported for shoulder problems in general, indicating that productivity loss in patients diagnosed with SIS is a major concern.
Funding:
none.
Trial registration:
not relevant.
Synopsis:
Progressive resistance exercise, in isolation or in combination with other noninvasive therapies such as therapeutic touch, is the first-line approach to managing nontraumatic rotator cuff-related shoulder pain (RCRSP). Resistance exercise may be effective for people with RCRSP secondary to improving mechanical features of the shoulder, including strength, kinematics, and muscle timing and activation. However, strength gains are often small and clinically unimportant when measured during clinical trials. In this Viewpoint, we argue that clinicians should (1) continue to prescribe resistance exercise when managing RCRSP, and (2) embrace the broad biological mechanisms underpinning the efficacy of resistance exercise. Any benefit is governed by more than simple mechanical changes. The clinical message must go beyond the idea that the patient's weak, deconditioned, or frail shoulder is the basis of his or her pain, and all the patient needs to do is to get strong. J Orthop Sports Phys Ther 2021;51(4):156-158. doi:10.2519/jospt.2021.10199.
Mediation analyses of randomised controlled trials can be used to investigate the mechanisms by which health interventions cause outcomes. In this article we provide a brief introduction to mediation analysis in the context of randomised controlled trials. We introduce common target effects, causal assumptions, estimation approaches, and illustrate these concepts using a published mediation analysis of the Systolic Blood Pressure Intervention Trial (SPRINT). Well-conducted mediation analyses of randomised trials can provide meaningful insights to guide clinical and policy decisions.
Objective
The objective of this study was to review and synthesize qualitative research studies exploring the experiences of individuals living with shoulder pain to enhance understanding of the experiences of these individuals as well as facilitate health care developments.
Methods
A meta-ethnographic approach was adopted to review and synthesize eligible published qualitative research studies. The findings from each included study were translated into one another using the Noblit and Hares 7-stage process. A systematic search of 11 electronic databases was conducted in March 2020. Methodological quality was assessed using the Critical Appraisal Skills Programme (CASP) appraisal tool.
Results
Nineteen studies were included in the meta-synthesis. Included articles explored the lived experiences as well as treatment-related experiences of participants. All of the included articles were deemed to be of high methodological quality. Three themes were identified: (1) negative emotional, social, and activity impact (“It has been a big upheaval”), (2) developing an understanding (“Why is it hurting so much?”), and (3) exercise (“Am I going to go through a lot of pain in moving it…?”). Across the included studies, the severe emotional and physical impact of shoulder pain was a core finding. Many people sought a “permanent” solution involving surgery. Openness to other treatment options was influenced by factors including understanding of pain, prior experiences, and treatment expectations.
Conclusion
These findings deepen understanding of the impact of shoulder pain on peoples’ lives and provide novel insight into the experience of treatment. Enhanced awareness of people’s experiences of shoulder pain and treatment is crucial for clinicians when planning and implementing evidence-based recommendation.
Impact
To the knowledge of the authors, this is the first qualitative evidence synthesis to explore the treatment-related experiences of individuals with shoulder pain. Shoulder surgery was considered by many as the only means to achieve a more permeant resolution of symptoms.
Lay Summary
Shoulder pain causes emotional and physical turmoil that can permeate every facet of life. People’s understanding of their shoulder pain appears to be deeply rooted in a biomechanical view of pain, which influences their expectations relating to diagnosis and treatment.
Background
Exercise is recommended for the management of chronic low back pain (CLBP). Trialists have proposed numerous mechanisms to explain why exercise improves pain and function in people with CLBP, but these are yet to be synthesised.
Objective
To synthesise the proposed mechanisms of benefit for exercise in people with CLBP.
Design
Review.
Methods
The Physiotherapy Evidence Database (PEDro) was searched from inception to July 2019. Randomised controlled trials of adults with CLBP, indexed in PEDro as ‘fitness training’, were included. Two reviewers independently screened and extracted data from each study. Data were analysed quantitatively and qualitatively using thematic analysis.
Results
186 studies were identified and 110 were included in the analysis. Thirty-six studies (33%) did not provide a mechanism of benefit for exercise in people with CLBP. Of the remaining studies, most provided more than one mechanism, from which 33 unique mechanisms were identified. These were grouped into five themes which, from most to least common, were: neuromuscular (n = 105 (44%)); psychosocial (n = 87 (36%)); neurophysiological (n = 22 (9%)); cardiometabolic (n = 15 (6%)); and tissue healing (n = 12 (5%)). The effects of these proposed mechanisms on outcomes for people with CLBP were seldom examined.
Conclusions
This review identified a variety of mechanisms proposed in clinical trials to explain why ‘fitness training’ works for people with CLBP, but these mechanisms were seldom tested. Randomised controlled trials investigating the mediating effects of these mechanisms may be warranted to better understand why exercise works for CLBP.
Objective
To review and assess the methodological quality of randomised controlled trials that test physical therapy interventions for low back pain.
Study Design and Setting
Systematic review of trials of physical therapy interventions to prevent or treat low back pain (of any duration or type) in participants of any age indexed on the Physiotherapy Evidence Database (PEDro). Existing PEDro scale ratings were used to evaluate methodology quality.
Results
This review identified 2215 trials. The majority of trials were for adults (n=2136, 96.4%), low back pain without specific aetiology (n=1863, 84.1%), and chronic duration (n=947, 42.8%). The quality of trials improved over time, however most were at risk of bias. Less than half of the trials concealed allocation to intervention (n=813, 36.7%), used intention-to-treat principles (n=778, 35.1%), blinded assessors (n=810, 36.6%), participants (n=174, 7.9%) and therapists (n=39, 1.8%). These findings did not vary by type of therapy.
Conclusion
The majority of trials that test physical therapy interventions for low back pain have methodological limitations that could bias treatment effect estimates. Greater attention to simple methodological features, such as allocation concealment and the reporting of intention-to-treat effects, would improve the quality of trials testing physical therapy interventions for low back pain.
Background
Rotator cuff tendinopathy is a common and disabling cause of shoulder pain. While conservative treatment is recommended as initial management, recent findings suggest that general practitioners and rheumatologists do not consistently align with recommended care. This study aimed to survey Australian physiotherapists to explore the extent to which recommended management is being applied.
Methods
A cross-sectional online survey.
Results
Five hundred and two Australian physiotherapists completed the survey. Results demonstrated the majority of physiotherapists provide conservative management consistent with guideline recommendations, through delivery of exercise and education, comparable to management by physiotherapists in the United Kingdom, Belgium and the Netherlands. Parameters and construction of exercise treatment programs were highly variable within the cohort, qualitative analysis highlighting varied reasoning underpinning these management decisions.
Conclusions
Australian physiotherapists are broadly consistent with providing recommended management, however heterogeneity exists in the methods and parameters of treatment delivery.
Objectives:
To perform a systematic review of clinical practice guidelines (CPGs) and semantic analysis of specific clinical recommendations for the management of rotator cuff disorders in adults.
Data sources:
A systematic bibliographic search was conducted up until May 2018 in Medline, Embase and PeDro databases, in addition to twelve clinical guidelines search engines listed on the AGREE Thrust website.
Study selection:
Nine CPGs on the management of rotator cuff disorders in adults and/or workers, available in English or French and published from January 2008 onward, were included and screened by two independent reviewers.
Data extraction:
CPGs methodology was assessed with the AGREE II tool. A semantic analysis was performed to compare the strength of similar recommendations based on their formulation. The recommendations were categorized in a standardized manner considering the following four levels: "Essential", "Recommended", "May be recommended" and "Not recommended".
Data synthesis:
Methodological quality was considered high for three CPGs and low for six. All CPGs recommended active treatment modalities, such as an exercise program in the management of rotator cuff disorders. Acetaminophen and/or NSAIDs prescription and corticosteroid injections were presented as modalities that may be recommended to decrease pain. Recommendations related to medical imagery and surgical opinion varied among the guidelines. The most commonly recommended return to work strategies included intervening early, use of a multidisciplinary approach and adaptation of work organization.
Conclusions:
Only three CPGs were of high quality. The development of more rigorous CPGs is warranted.
Background
Competitive swimmers are exposed to enormous volumes of swim training that may overload the soft tissue structures and contribute to shoulder pain. An understanding of training factors associated with the injury is needed before practice guidelines can be developed.
Objectives
To investigate the relationship between swim-training volume and shoulder pain and to determine swim-training volume and shoulder pain prevalence across the life span of the competitive swimmer.
Data Sources
Relevant studies within PubMed, Web of Science, and MEDLINE.
Study Selection
Studies that assessed the relationship between a defined amount of swim training and shoulder pain in competitive swimmers.
Data Extraction
Twelve studies (N = 1460 participants) met the criteria. Swimmers were grouped by age for analysis: young (<15 years), adolescent (15–17 years), adult (18–22 years), and masters (23–77 years).
Data Synthesis
Adolescent swimmers showed the highest rates of shoulder pain (91.3%) compared with other age groups (range = 19.4%–70.3%). The greatest swim-training volumes were reported in adolescent (17.27 ± 5.25 h/wk) and adult (26.8 ± 4.8 h/wk) swimmers. Differences in exposure were present between swimmers with and those without shoulder pain in both the adolescent ( P = .01) and masters ( P = .02) groups. In adolescent swimmers, the weekly swim-training volume ( P < .005, P = .01) and years active in competitive swimming ( P < .01) correlated significantly with supraspinatus tendon thickness, and all swimmers with tendon thickening experienced shoulder pain.
Conclusions
Evidence suggests that swim-training volume was associated with shoulder pain in adolescent competitive swimmers (level II conclusion). Year-round monitoring of the athlete's swim training is encouraged to maintain a well-balanced program. Developing athletes should be aware of and avoid a sudden and large increase in swimming volume. However, additional high-quality studies are needed to determine cutoff values in order to make data-based decisions regarding the influence of swim training.
Objectives:
This study aims to investigate and compare the efficacy of platelet-rich plasma (PRP) injection, corticosteroid injection, and physical therapy in addition to exercise treatment on pain, shoulder functions, and quality of life in patients with subacromial impingement syndrome (SAIS).
Patients and methods:
Ninety patients (37 males, 53 females; mean age 48.99 years; range, 33 to 60 years) who were diagnosed as Stage 2 SAIS were included in the study. Patients were randomized into three groups. PRP injection was administered into the subacromial space of the affected shoulder in group 1, corticosteroid injection was administered in the subacromial joint space in group 2, and 10 sessions of physical therapy were given in group 3 five times weekly including transcutaneous electrical nerve stimulation, ultrasound, and hot packs. Moreover, an exercise program was administered in all groups. Visual Analog Scale (VAS) was used to determine the resting and moving shoulder pain; while the Shoulder Disability Questionnaire, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire, and the University of California, Los Angeles Shoulder Rating Scale (UCLA SRS) were used to evaluate the functionality of patients. Quality of life was analyzed using a generic Short Form 36 (SF-36).
Results:
All scores improved in all three groups compared with the period before treatment. Comparison of the groups showed higher scores in group 1 compared to groups 2 and 3 at week eight on QuickDASH, UCLA SRS, VAS at rest and during activity, and SF-36 pain subgroup scores.
Conclusion:
All three treatment modalities were effective in the treatment of SAIS. However, we suggest that the inexpensive and noninvasive methods of physical therapy and exercise should be the first preferred treatment in SAIS owing to causing no adverse events.
Background:
Disorders of the rotator cuff are a common musculoskeletal pain presentation in the general population, and treatment by a physiotherapist is often prescribed. In 2011, 2016, surveys of physiotherapy practice in the United Kingdom (UK) were performed, which reported that advice and exercise were the most common treatment strategies used. The aim of this current survey was to examine current physiotherapy practice in Belgium and The Netherlands, with consideration of differences between physiotherapists who were members of a shoulder network and physiotherapists who were not.
Methods:
During February/March 2018, a cross-sectional online survey was conducted in Belgium and The Netherlands.
Results:
505 physiotherapists completed the survey. Advice (n = 362/505), isotonic exercises (n = 302/505) and scapular stabilisation exercises (n = 359/505) were the most common treatment modalities for patients with rotator cuff disorders. Physiotherapists not part of a shoulder network group more commonly integrated mobilization (n = 66/254 SN, n = 125/251 N-SN), electrotherapy (n = 1/254 SN, n = 19/251 N-SN) and massage (n = 48/254 SN, n = 89/251 N-SN) compared to those who were member of the group.
Conclusion:
Advice and exercise were the most common treatment prescriptions, which aligns with recommendations from current research evidence. Practice differs between physiotherapists involved with a shoulder network group compared to those who are not.
Objectives: To investigate the severity and effect on quality of life (QOL) of various types of pain in healthy volunteers.
Methods: A total of 384 subjects (male: 158, female: 226, average age: 63 years) were included in a prospective cohort study (Yakumo study). Shoulder pain, low back pain (LBP), sciatica, knee pain, and the American Shoulder and Elbow Surgeons (ASES) shoulder score were evaluated with SF-36.
Results: The prevalences of shoulder pain, LBP, sciatica, and knee pain were 42%, 44%, 16%, and 48%, respectively, with similar severities of pain. Shoulder pain visual analogue scale (VAS) and ASES shoulder scores were significantly correlated with SF-36 domains. Subjects with poor physical QOL had significantly higher VAS scores for all pain types and a lower ASES shoulder score. Shoulder pain VAS was also significantly related to poor mental QOL. Multivariate regression analysis adjusted for age and gender showed that shoulder pain VAS (OR: 1.25, p < 0.05) and 10-m gait speed (OR: 1.82, p < 0.05) were significant independent risk factors for poor physical QOL.
Conclusions: Only shoulder pain of similar severity to other pain and shoulder complaints impacted both on physical and mental QOL. The severity of shoulder pain was an independent risk factor for poor physical QOL.
Background:
Mulligan mobilization techniques cause pain and affect the function in patients with Rotator cuff syndrome.
Objective:
The aim of the study was to investigate the effect of Mulligan mobilization on pain and quality of life in individuals with Rotator cuff syndrome.
Methods:
This study was conducted on 30 patients with Rotator cuff syndrome. The patients were randomized into Mulligan and control group. All the patients participating in this study were treated with conventional physiotherapy. Additionally, the Mobilization with movement (MWM) technique was used in the Mulligan group. Visual Analog Scale (VAS), Disabilities of the Arm, Shoulder, and Hand (DASH), goniometer for the normal range of motion (ROM) and Short Form-36 (SF-36) questionnaires were used for assessment.
Results:
Statistically significant improvement was found in the post-treatment VAS, DASH, SF-36, and ROM values significantly improved in both groups (p< 0.05). However, the Mulligan group showed much better results when compared to the control group in ROM, VAS, DASH (p< 0.05). In the SF-36 questionnaire, significant results were obtained for both groups, except the social function parameter. For the SF-36 parameters, both groups performed equally.
Conclusions:
Mulligan mobilization was more effective than general treatment methods for pain as well as normal joint motion, DASH scoring and some parameters of SF-36 compared with general treatment methods.
The diversity of models of care in contemporary musculoskeletal physical therapy can be confusing for patients and practicing clinicians. There is, however, a common theme to many of these seemingly disparate models of care: symptom modification. Symptom modification aims at reducing symptoms and improving function with a variety of clinical approaches. This Viewpoint explores the role of symptom modification in rehabilitation and specifically addresses (1) symptom modification within the kinesiopathological model of pain, (2) symptom modification in clinical practice, and (3) potential commonality in seemingly divergent models of clinical practice.
J Orthop Sports Phys Ther 2018;48(6):430–435. doi:10.2519/jospt.2018.0608
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.
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.
Study design:
Parallel-group intervention with repeated measures.
Introduction:
Shortening of the pectoralis minor (PM) may contribute to alterations in scapular kinematics.
Purpose of the study:
To evaluate the effects of a stretching protocol on function, muscle length, and scapular kinematics in subjects with and without shoulder pain.
Methods:
A sample of 25 patients with shoulder pain and 25 healthy subjects with PM tightness performed a daily stretching protocol for 6 weeks. Outcome measures included Disabilities of the Arm, Shoulder, and Hand questionnaire, PM length, and scapular kinematics.
Results:
Disabilities of the Arm, Shoulder, and Hand scores decreased (P < .05) in the patient group at post-intervention. No differences (P > .05) were found for PM length in both groups. Scapular anterior tilt increased (P < .05) at 90° of flexion in the healthy group.
Discussion:
This study demonstrated that a daily home stretching protocol significantly decreases pain and improves function in subjects with shoulder pain. The mechanism responsible for these improvements does not appear directly related to PM muscle length or scapula kinematics, suggesting that other neuromuscular mechanisms are involved.
Conclusion:
The PM stretching protocol did not change the PM length or scapular kinematics in subjects with or without shoulder pain. However, pain and function of the upper limbs improved in patients with shoulder pain.
Level of evidence:
2b.
Background:
Management of rotator cuff disease often includes manual therapy and exercise, usually delivered together as components of a physical therapy intervention. This review is one of a series of reviews that form an update of the Cochrane review, 'Physiotherapy interventions for shoulder pain'.
Objectives:
To synthesise available evidence regarding the benefits and harms of manual therapy and exercise, alone or in combination, for the treatment of people with rotator cuff disease.
Search methods:
We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 3), Ovid MEDLINE (January 1966 to March 2015), Ovid EMBASE (January 1980 to March 2015), CINAHL Plus (EBSCO, January 1937 to March 2015), ClinicalTrials.gov and the WHO ICTRP clinical trials registries up to March 2015, unrestricted by language, and reviewed the reference lists of review articles and retrieved trials, to identify potentially relevant trials.
Selection criteria:
We included randomised and quasi-randomised trials, including adults with rotator cuff disease, and comparing any manual therapy or exercise intervention with placebo, no intervention, a different type of manual therapy or exercise or any other intervention (e.g. glucocorticoid injection). Interventions included mobilisation, manipulation and supervised or home exercises. Trials investigating the primary or add-on effect of manual therapy and exercise were the main comparisons of interest. Main outcomes of interest were overall pain, function, pain on motion, patient-reported global assessment of treatment success, quality of life and the number of participants experiencing adverse events.
Data collection and analysis:
Two review authors independently selected trials for inclusion, extracted the data, performed a risk of bias assessment and assessed the quality of the body of evidence for the main outcomes using the GRADE approach.
Main results:
We included 60 trials (3620 participants), although only 10 addressed the main comparisons of interest. Overall risk of bias was low in three, unclear in 14 and high in 43 trials. We were unable to perform any meta-analyses because of clinical heterogeneity or incomplete outcome reporting. One trial compared manual therapy and exercise with placebo (inactive ultrasound therapy) in 120 participants with chronic rotator cuff disease (high quality evidence). At 22 weeks, the mean change in overall pain with placebo was 17.3 points on a 100-point scale, and 24.8 points with manual therapy and exercise (adjusted mean difference (MD) 6.8 points, 95% confidence interval (CI) -0.70 to 14.30 points; absolute risk difference 7%, 1% fewer to 14% more). Mean change in function with placebo was 15.6 points on a 100-point scale, and 22.4 points with manual therapy and exercise (adjusted MD 7.1 points, 95% CI 0.30 to 13.90 points; absolute risk difference 7%, 1% to 14% more). Fifty-seven per cent (31/54) of participants reported treatment success with manual therapy and exercise compared with 41% (24/58) of participants receiving placebo (risk ratio (RR) 1.39, 95% CI 0.94 to 2.03; absolute risk difference 16% (2% fewer to 34% more). Thirty-one per cent (17/55) of participants reported adverse events with manual therapy and exercise compared with 8% (5/61) of participants receiving placebo (RR 3.77, 95% CI 1.49 to 9.54; absolute risk difference 23% (9% to 37% more). However adverse events were mild (short-term pain following treatment).Five trials (low quality evidence) found no important differences between manual therapy and exercise compared with glucocorticoid injection with respect to overall pain, function, active shoulder abduction and quality of life from four weeks up to 12 months. However, global treatment success was more common up to 11 weeks in people receiving glucocorticoid injection (low quality evidence). One trial (low quality evidence) showed no important differences between manual therapy and exercise and arthroscopic subacromial decompression with respect to overall pain, function, active range of motion and strength at six and 12 months, or global treatment success at four to eight years. One trial (low quality evidence) found that manual therapy and exercise may not be as effective as acupuncture plus dietary counselling and Phlogenzym supplement with respect to overall pain, function, active shoulder abduction and quality life at 12 weeks. We are uncertain whether manual therapy and exercise improves function more than oral non-steroidal anti-inflammatory drugs (NSAID), or whether combining manual therapy and exercise with glucocorticoid injection provides additional benefit in function over glucocorticoid injection alone, because of the very low quality evidence in these two trials.Fifty-two trials investigated effects of manual therapy alone or exercise alone, and the evidence was mostly very low quality. There was little or no difference in patient-important outcomes between manual therapy alone and placebo, no treatment, therapeutic ultrasound and kinesiotaping, although manual therapy alone was less effective than glucocorticoid injection. Exercise alone led to less improvement in overall pain, but not function, when compared with surgical repair for rotator cuff tear. There was little or no difference in patient-important outcomes between exercise alone and placebo, radial extracorporeal shockwave treatment, glucocorticoid injection, arthroscopic subacromial decompression and functional brace. Further, manual therapy or exercise provided few or no additional benefits when combined with other physical therapy interventions, and one type of manual therapy or exercise was rarely more effective than another.
Authors' conclusions:
Despite identifying 60 eligible trials, only one trial compared a combination of manual therapy and exercise reflective of common current practice to placebo. We judged it to be of high quality and found no clinically important differences between groups in any outcome. Effects of manual therapy and exercise may be similar to those of glucocorticoid injection and arthroscopic subacromial decompression, but this is based on low quality evidence. Adverse events associated with manual therapy and exercise are relatively more frequent than placebo but mild in nature. Novel combinations of manual therapy and exercise should be compared with a realistic placebo in future trials. Further trials of manual therapy alone or exercise alone for rotator cuff disease should be based upon a strong rationale and consideration of whether or not they would alter the conclusions of this review.
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.