Supervised Training Compared With No Training or Self-training in Patients With Subacromial Pain Syndrome: A Systematic Review and Meta-analysis

Is exercise therapy the right treatment for rotator cuff-related shoulder pain? Uncertainties, theory, and practice

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.

Effects of elastic band resistance training on the physical and mental health of elderly individuals: A mixed methods systematic review

OBJECTIVES

Elastic band resistance training in elderly individuals can improve physical fitness and promote mental health in addition to other benefits. This systematic review aimed to review, summarize, and evaluate quantitative, qualitative, and mixed methodological studies on the use of elastic band resistance training in elderly individuals, and to investigate the influence of elastic band resistance training on the physical and mental health of elderly individuals, as well as their preferences and obstacles in training.

METHODS

A convergent separation approach was used to synthesize and integrate the results, specifically the mixed systematic review approach recommended by the Joanna Briggs Institute. The extensive search strategy included electronic database searches in the Cochrane Library, PubMed, Embase, Web of Science, Google Scholar, MEDLINE, and CINAHL. The researchers rigorously screened the literature, extracted and analyzed the data, and evaluated the quality of the included studies using the Mixed Methods Appraisal Tool (MMAT).

RESULTS

Twenty-eight studies were included, of which 25 were quantitative studies, 2 were qualitative studies, and 1 was a mixed-methods study. A total of 1,697 subjects were investigated across all studies. Quantitative evidence supports the notion that elastic band resistance training can improve upper and lower limb flexibility, endurance, upper strength, physical balance, and cardiopulmonary function and enhance the mental health of elderly individuals. Participants in the qualitative study reported some preferences and obstacles with band resistance training, but most participants reported physical benefits.

CONCLUSIONS

Despite the heterogeneity between studies, this review is the first systematic review to comprehensively evaluate the effectiveness of elastic band resistance training in older adults. It not only shows the influence of elastic band resistance training on the physical and mental health of the elderly, but also emphasizes the preference and obstacles of elderly individuals face.

Comparing Telerehabilitation and Home-based Exercise for Shoulder Disorders: A Systematic Review and Meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to quantitatively compare the effects of telerehabilitation and home-based exercise for shoulder disorders.

DATA SOURCES

We conducted a search for eligible studies in PubMed, EMBASE, Web of Science, Cochrane Library, and MEDLINE databases following Preferred Reporting Items for Systematic Review and Meta-analyses guidelines.

STUDY SELECTION

Independent reviewers selected randomized controlled trials that compared the effects of telerehabilitation and home-based exercise in individuals with shoulder disorders.

DATA EXTRACTION

Two reviewers independently conducted data extraction and assessed the risk of bias using the Cochrane Risk of Bias tool.

DATA SYNTHESIS

A total of 7 studies with 508 participants were included. Compared with home-based exercise, telerehabilitation showed superior improvements in range of motion (flexion: standardized mean difference [SMD] 0.35, 95% confidence interval [CI] 0.14 to 0.56; abduction: SMD 0.37, 95% CI 0.16 to 0.58; external rotation: SMD 0.43, 95% CI 0.22 to 0.64; internal rotation: SMD 0.33, 95% CI 0.08 to 0.58), functional outcomes (Shoulder Pain and Disability Index: SMD -0.37, 95% CI -0.61 to -0.12; shortened Disabilities of the Arm, Shoulder and Hand questionnaire: mean difference [MD] -4.51, 95% CI -8.70 to -0.32), and quality of life (EuroQol Five Dimensions Questionnaire: MD 0.04, 95% CI 0.01 to 0.07). Telerehabilitation was not different from home-based exercise in terms of pain relief (SMD -0.19, 95% CI -0.60 to 0.23). Subgroup analysis demonstrated that telerehabilitation provided significant pain relief when sustained for over 12 weeks (SMD -0.46, 95% CI -0.81 to -0.11).

CONCLUSIONS

Telerehabilitation is more effective than home-based exercise in improving range of motion, functional outcomes, and quality of life for patients with shoulder disorders. Telerehabilitation significantly outperforms home-based exercise in relieving pain when continued for over 12 weeks.

Rotator cuff disorders: An updated survey of current (2023) UK physiotherapy practice

BACKGROUND

Clinical guidelines recommend treatment by a physiotherapist for people with shoulder pain due to rotator cuff disorder. Despite this recommendation, research evidence supporting the effectiveness of treatment by a physiotherapist is uncertain. While developing a randomised controlled trial to test the effectiveness of treatment by a physiotherapist for people with shoulder pain due to rotator cuff disorders, we first aimed to understand current practice as a basis for defining usual care.

METHODS

An online survey was developed based on a clinical vignette used in a previous survey exploring physiotherapy practice for people with shoulder pain due to rotator cuff disorder. UK-based physiotherapists were invited to complete the survey via X and email across professional networks.

RESULTS

One Hundred Seventy complete responses were received. 167 (98%) respondents would offer advice/education to patients with shoulder rotator cuff disorders; 146 (86%) would use isotonic exercise (including concentric/eccentric strengthening); 20 (12%) would offer a corticosteroid injection; 7 (4%) would use joint mobilisation. 168/169 (99%) would offer in-person assessment; 115 (68%) expect to deliver treatment over three to four sessions. Fifty percent agreed there is uncertainty about the effectiveness of physiotherapy treatment for patients with shoulder rotator cuff disorders. Seventy six percent agreed that patients with this condition can recover without physiotherapy intervention.

CONCLUSIONS

Exercise and advice remain the most common treatments offered by physiotherapists for people with shoulder pain due to rotator cuff disorder. Corticosteroid injections are infrequently considered. Uncertainty about the effectiveness of treatment by a physiotherapist for shoulder pain due to rotator cuff disorder is evident.

Changes in pain and disability in patients with shoulder pain after three months of digitally delivered exercise and patient education

OBJECTIVE

To describe and examine potential predictors of changes in pain and disability in patients with shoulder pain who have completed 3 months of digitally delivered treatment comprising exercise and patient education.

DESIGN

Retrospective cohort study (clinicaltrials.org Nr: NCT05402514).

SUBJECTS

Patients with shoulder pain who completed treatment (n = 682).

METHODS

Primary outcome was change in shoulder pain (numerical rating scale 0-10; minimal clinical important change: at least 2 points). Pain and disability were reported on the Shoulder Pain and Disability Index. Changes in outcomes were analysed with paired sample t-tests. Association with potential predictors (sex, age, education, body mass index, physical activity, symptom duration, baseline pain/function, and treatment adherence) were explored with linear regression models Results: Statistically significant improvements were found for all treatment outcomes. Minimal clinically important change in pain was reached by 54.5% (n = 372). Higher baseline level of symptoms, short symptom duration, and high treatment adherence were associated with greater changes.

CONCLUSION

Patients with shoulder pain reported significant reductions in pain and disability following treatment, but the clinical relevance of the improvements has not been confirmed. Satisfactory treatment adherence, higher baseline pain and shorter symptom duration predicted larger improvements. A control group is needed to evaluate the actual effect of the treatment.

Manual Therapy and Exercise Have Similar Outcomes to Corticosteroid Injections in the Management of Patients With Subacromial Pain Syndrome: A Systematic Review and Meta-Analysis

Subacromial pain syndrome (SAPS) is the most frequent diagnosis in patients with shoulder pain presenting with persistent pain and significant functional decline. Although exercise and manual therapy (EMT) and corticosteroid injections provide first-line treatment options, evidence for the best management of SAPS remains inconclusive. We aimed to evaluate the effectiveness of EMT compared with corticosteroid injections on disability, recovery rates, and pain in patients with SAPS through a systematic review and meta-analysis approach. PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Physiotherapy Evidence Database (PEDro), ScienceDirect, the Cochrane Library, and grey literature databases were searched. Only randomized controlled trials evaluating the effectiveness of EMT alone or as an additive intervention compared to corticosteroid injections were included. Methodological quality was evaluated with the PEDro score and certainty of evidence with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. In total, 8 trials with 946 patients were included. EMT presented no difference in disability compared with corticosteroid injections at very short- (standardized mean difference {SMD}: 0.19; 95%CI: -0.20, 0.58), short- (SMD: -0.16; 95%CI: -0.58, 0.25), mid- (SMD: -0.14; 95%CI: -0.44, 0.16), and long-term (SMD: 0.00; 95%CI: -0.25, 0.25) follow-up. No difference was found between the comparators in self-perceived recovery at very short- (risk ratio: 0.93; 95%CI: 0.71, 1.21) and mid- (risk ratio: 0.98; 95%CI: 0.90, 1.07) follow-up and in pain rating at very short- (SMD: -0.18; 95%CI: -0.73, 0.38), short- (SMD: 0.05; 95%CI: -0.26, 0.37), and long-term (SMD: 0.04; 95%CI: -0.26, 0.34) follow-ups. The addition of corticosteroid injections to EMT provided no better results in shoulder disability compared with EMT (SMD: 0.45; 95%CI: -0.47, 1.37) or corticosteroid injections alone (MD: 2.70; 95%CI: -7.70, 13.10) in the mid-term. Based on very low to moderate certainty of evidence, EMT has similar effects to corticosteroid injections on improving all outcomes in patients with SAPS at all follow-up periods. Based on low certainty of evidence the combination of both interventions does not change the treatment outcome compared with each intervention alone.

Reducing Shoulder Complaints in Employees with High Occupational Shoulder Exposures: A Cluster-Randomised Controlled Study (The Shoulder-Café Study)

PURPOSE

To evaluate if a group-based Shoulder-Café intervention could reduce shoulder complaints more effectively than an individual-based control intervention in employees with shoulder complaints and high occupational shoulder exposures.

METHODS

A cluster-randomised controlled study of 109 participants from 60 companies in Central Denmark Region. Companies were randomised and allocated to either Shoulder-Café or control intervention. Participants in both interventions received a pamphlet on home-based shoulder exercises and a pamphlet with general information on reducing occupational shoulder exposures. They also had their occupational shoulder exposures assessed. Shoulder-Café participants additionally received three café-meetings with casual discussion, clinical shoulder evaluation, education about shoulder anatomy and occupational shoulder exposures, supervised exercises, workplace-oriented counselling, and an optional workplace visit. The primary outcome measure was the Oxford Shoulder Score (OSS) at 6-month follow-up. Secondary outcome measures were the OSS at 12 months, Fear-Avoidance Beliefs Questionnaire - Physical Activity at 6 and 12 months, and Patients' Global Impression of Change at 6 months. The study also included seven supplementary outcome measures.

RESULTS

Both groups improved from baseline to 6 months with respect to the primary outcome (P < 0.01). No group differences were found for the primary outcome (mean difference (MD) [95% confidence interval]: 0.3 [- 1.6; 2.2]) or secondary outcomes. The supplementary outcomes "felt informed about handling shoulder complaints" and "felt informed about reducing occupational exposures" at 6 months, and "Patients' Global Impression of Change" and "overall satisfaction" at 12 months favoured the Shoulder-Café intervention.

CONCLUSION

The Shoulder-Café intervention did not reduce shoulder complaints more effectively than the control intervention.

TRIAL REGISTRATION

The trial was registered at Clinicaltrials.gov on 19 May 2017 (ID: NCT03159910).

Diagnosis, prevention and treatment of common shoulder injuries in sport: grading the evidence - a statement paper commissioned by the Danish Society of Sports Physical Therapy (DSSF)

This statement paper summarises and appraises the evidence on diagnosis, prevention, and treatment of common shoulder injuries in sports. We systematically searched Medline and Embase. The Grading of Recommendations Assessment, Development and Evaluation tool was applied to evaluate the overall quality of evidence.For diagnosis, we included 19 clinical tests from mixed populations. Tests for anterior instability, biceps-labrum complex injuries and full subscapularis rupture had high diagnostic accuracy (low to moderate quality of evidence).For prevention, the Oslo Sports Trauma Research Center, the Shoulder Control, the FIFA 11+ shoulder injury prevention programmes, and a baseball-specific programme (range of motion, stretching, dynamic stability and strengthening exercises) showed moderate to large effect size in reducing the risk of shoulder injury compared with no intervention (very low to moderate quality of evidence).For treatment, a rehabilitation programme including stretching, ice packs, electrotherapy and compression, and strengthening exercises showed a large effect size in reducing pain and disability compared with no intervention in athletes with subacromial impingement syndrome (very low to moderate quality of evidence). For the treatment of supraspinatus tendinopathy, hyperthermia treatment (heating the skin to 38°C-40°C) resulted in large effect size in reducing pain and disability compared with ultrasound or pendular swinging and stretching exercises (moderate quality of evidence). Strengthening exercise alone or in combination with stretching exercises promoted a large effect in reducing shoulder pain (cohort studies, no comparators) (very low quality of evidence). The quality of evidence for most estimates was low to moderate, indicating that future high-quality research may alter our recommendations for clinical practice.

Comparison of Manual Therapy Technique to Therapeutic Exercise in the Treatment of Patients With Subacromial Impingement Syndrome: A Randomized Clinical Trial

OBJECTIVE

The purpose of this study was to compare the effects of manual therapy to therapeutic exercise on shoulder pain, disability, and range of motion (ROM) in patients with subacromial impingement syndrome (SAIS).

METHODS

Sixty patients with SAIS were randomly assigned into the manual therapy (MT) and therapeutic exercise (TE) groups. Patients in the MT group were treated with joint mobilization, which was applied to the glenohumeral, acromioclavicular, sternoclavicular and scapulothoracic joints, and trigger point (TrP) inactivation using ischemic compression. Patients in the TE group performed therapeutic exercises. Shoulder pain, disability and active ROM (elevation, external rotation, and internal rotation) were assessed by the visual analog scale, the Shoulder Pain and Disability Index, and a goniometer, respectively. The outcomes were measured at baseline, after the intervention, and 1 month after the intervention.

RESULTS

After the treatment, both groups had significant improvements in shoulder pain, disability, and ROM (P < .05). The MT group experienced a greater reduction in shoulder pain than the TE group (P < .001). However, in disability and ROM, both groups exhibited similar improvements in post-treatment and follow-up periods.

CONCLUSION

Both MT and TE were effective in improving shoulder pain, disability, and ROM in patients with SAIS. Greater improvement in shoulder pain was observed in the MT group.

Promoting Adherence to Joint Exercise Using the Donation Model: Proof via a Motion-Detecting Mobile Exercise Coaching Application

PURPOSE

Maintaining or increasing user adherence to digital healthcare services is of great concern to service providers. This study aims to verify whether the donation model is an effective strategy to increase adherence to physical exercise using a mobile application.

MATERIALS AND METHODS

A total of 5618 users of a motion-detecting mobile exercise coaching application participated in a donation or self-reward exercise challenge with the same exercise protocol. The workout consisted of 50 squats daily for 14 days. The user's exercise was monitored through a smartphone camera, providing real-time visual and audio feedback. In the donation group, 6 USD was donated to the economically disadvantaged if a participant completed their workout each day. In the self-reward group, three people who completed the program and 20 people who completed ≥12 days of exercise were randomly selected and provided with goods worth 60 USD and 4.3 USD of online currency, respectively.

RESULTS

The average daily exercise completion rate (% of participants who completed daily exercise) in the donation group was 1.8 times higher than that of the self-reward group (donation, 41.7%; self-reward, 22.7%; p<0.0001). The donation group completed more days of the program (donation, 5.8; self-reward, 3.2; p<0.0001). The completion rate of both groups decreased with time and decreased most on day two (donation, -9.9%; self-reward, -14.5%).

CONCLUSION

The donation model effectively promoted adherence to mobile app-based exercise. This donation model is expected to effectively enhance user adherence to digital healthcare services.

Increased shoulder pain across an exercise session and subsequent shoulder exercise: a prospective cohort study

Background

Shoulder complaints are common and the recommended first-line treatment is exercise therapy. However, it remains unknown if increased shoulder pain after an exercise session is a barrier for subsequent exercise dose, particularly in people with high fear-avoidance beliefs. Such knowledge could indicate ways to optimise shoulder rehabilitation. The aim was to examine whether increased shoulder pain across an exercise session was associated with a lower subsequent exercise dose, and if high fear-avoidance beliefs exaggerated this association.

Methods

We conducted a prospective cohort study using data from a randomised controlled trial in Central Denmark Region 2017–2019. Participants were employees (n = 79) with shoulder complaints and high occupational shoulder exposures. The intervention was a home-based or partly supervised exercise programme lasting 2–3 months. Linear mixed models were used to examine the associations between change in shoulder pain and exercise dose (number of repetitions, progression level (1–3), resistance level (1–3), and time until next exercise session [days]).

Results

At baseline, the participants had a median pain intensity at rest of 2 on a numerical rating scale (0–10). For a 1-cm increase in pain on a visual analogue scale (0–10 cm) during an exercise session, the subsequent number of repetitions, progression level and resistance level were − 1.3 (95% confidence interval [CI] − 3.4 to 0.9), 0.0 (95% CI − 0.1 to 0.0) and − 0.0 (95% CI − 0.1 to 0.0), respectively. Likewise, the time until next exercise session was − 0.6 (95% CI − 2.4 to 1.3) days for a 1-cm increase. There were no interactions with fear-avoidance beliefs.

Conclusion

Increased pain across an exercise session was not associated with subsequent exercise dose, regardless of fear-avoidance beliefs, among employees with shoulder complaints and high occupational shoulder exposures.

Trial registration

The trial was registered at Clinicaltrials.gov 19/05/2017 (ID: NCT03159910).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05674-2.

Short-term effectiveness of high-load compared with low-load strengthening exercise on self-reported function in patients with hypermobile shoulders: a randomised controlled trial

OBJECTIVES

To investigate the short-term effectiveness of high-load versus low-load strengthening exercise on self-reported function in patients with hypermobility spectrum disorder (HSD) and shoulder symptoms.

METHODS

A superiority, parallel-group, randomised trial (balanced block randomisation, electronic concealment) including adult patients (n=100) from primary care with HSD and shoulder pain and/or shoulder instability ≥3 months. Patients received 16 weeks of shoulder exercises (three sessions/week): HEAVY (n=50, full-range, high-load, supervised twice/week) or LIGHT (n=50, neutral/mid-range, low-load, supervised three times). The primary outcome was the 16-week between-group difference in self-reported function measured with the Western Ontario Shoulder Instability Index (WOSI, scale 0-2100, 0=best, minimal important difference 252 points). Secondary outcomes were self-reported measures including quality of life and clinical tests including shoulder muscle strength and range of motion. An intention-to-treat analysis with multiple imputation was conducted by a blinded biostatistician using linear regression.

RESULTS

93 of 100 patients (93%) completed the 16-week evaluation. The mean WOSI score between-group difference significantly favoured HEAVY (-174.5 points, 95% CI -341.4 to -7.7, adjusted for age, sex, baseline score, clustering around clinic). The secondary outcomes were inconclusive, but patients in HEAVY were less likely to have a positive shoulder rotation test >180°, and more likely to rate an important improvement in physical symptoms. There were no serious adverse events, but HEAVY was associated with more transient muscle soreness (56% vs 37%) and headaches (40% vs 20%).

CONCLUSION

High-load shoulder strengthening exercise was statistically superior to low-load strengthening exercise for self-reported function at 16 weeks and may be used in primary care to treat patients with HSD and shoulder pain and/or instability to improve shoulder function in the short term. Further studies are needed to confirm the clinical relevance, and patients should be supported to manage associated minor adverse events.

TRIAL REGISTRATION NUMBER

NCT03869307.

Comprehensive supervised heavy training program versus home training regimen in patients with subacromial impingement syndrome: a randomized trial

Background

There is no consensus on the best training regimen for subacromial impingement syndrome (SIS). Several have been suggested, but never tested.

The purpose of the study is to compare a comprehensive supervised training regimen (STR) based on latest evidence including heavy slow resistance training with a validated home-based regimen (HTR). We hypothesized that the STR would be superior to the HTR.

Methods

Randomised control trial with blinded assessor. 126 consecutive patients with SIS were recruited and equally randomised to 12 weeks of either supervised training regimen (STR), or home-based training regimen (HTR). Primary outcomes were Constant Score (CS) and Shoulder Rating Questionnaire (SRQ) from baseline and 6 months after completed training. Results were analyzed according to intention-to treat principles. The study was retrospectively registered in ClinicalTrials.gov. Date of registration: 07/06/2021. Identification number: NCT04915430.

Results

CS improved by 22.7 points for the STR group and by 23,7 points for the HTR (p = 0.0001). The SRQ improved by 17.7 and 18.1 points for the STR and the HTR groups respectively (p = 0.0001). The inter-group changes were non-significant. All secondary outcomes (passive and active range of motion, pain on impingement test, and resisted muscle tests) improved in both groups, without significant inter-group difference.

Conclusion

We found no significant difference between a comprehensive supervised training regimen including heavy training principles, and a home-based training program in patients with SIS.

Usefulness of Cochrane Reviews in Clinical Guideline Development-A Survey of 585 Recommendations

The Danish Health Authority develops clinical practice guidelines to support clinical decision-making based on the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system and prioritizes using Cochrane reviews. The objective of this study was to explore the usefulness of Cochrane reviews as a source of evidence in the development of clinical recommendations. Evidence-based recommendations in guidelines published by the Danish Health Authority between 2014 and 2021 were reviewed. For each recommendation, it was noted if and how Cochrane reviews were utilized. In total, 374 evidence-based recommendations and 211 expert consensus recommendations were published between 2014 and 2021. Of the 374 evidence-based recommendations, 106 included evidence from Cochrane reviews. In 28 recommendations, all critical and important outcomes included evidence from Cochrane reviews. In 36 recommendations, a minimum of all critical outcomes included evidence from Cochrane reviews, but not all important outcomes. In 33 recommendations, some but not all critical outcomes included evidence from Cochrane reviews. Finally, in nine recommendations, some of the important outcomes included evidence from Cochrane reviews. In almost one-third of the evidence-based recommendations, Cochrane reviews were used to inform clinical recommendations. This evaluation should inform future evaluations of Cochrane review uptake in clinical practice guidelines concerning outcomes important for clinical decision-making.