Pain relief due to physiotherapy doesn’t change the motor function of the shoulder

Relationship between pain and proprioception among individuals with rotator cuff-related shoulder pain

BACKGROUND

Individuals with rotator cuff-related shoulder pain (RCRSP) have altered proprioception. The relationship between shoulder pain and proprioception is not well understood.

PURPOSE

This study aimed to investigate the relationship between shoulder pain and proprioception.

STUDY DESIGN

This was a cross-sectional comparative study.

METHODS

Twenty-two participants with RCRSP (mean age 27.6 ± 4.8 years) and 22 matched pain-free participants (23.4 ± 2.5 years) performed two upper limb active joint position sense tests: (1) the Upper Limb Proprioception Reaching Test (PRO-Reach; reaching toward seven targets) in centimeters and (2) Biodex System at 90% of maximum internal rotation in degrees. Participants performed three memorization and three reproduction trials blindfolded. The proprioception error (PE) is the difference between the memorized and estimation trials. Pain levels were captured pre- and post-evaluation (11-point Likert Numerical Pain Rating Scale). Relationships between PE and pain were investigated using independent t-tests and Spearman rank correlations.

RESULTS

Overall, 22.7% RCRSP participants indicated an increase in pain following the PRO-Reach (X̅ increase of 1.4 ± 1.5 points), while 59% did so with the Biodex (X̅ increase of 2.3 ± 1.8 points), reflecting a clinically important increase in pain. Weak-to-moderate correlations between pain and PEs were found with the Biodex (r = 0.39-0.53) and weak correlations with the PRO-Reach (r = -0.26 to 0.38). Concerning PEs, no significant differences were found between groups with the Biodex (p = 0.32, effect size d = -0.31 [-0.90 to 0.29]). The RCRSP participants demonstrated lower PEs with the PRO-Reach in elevation compared to pain-free participants (global X̅ = 4.6 ± 1.2 cm vs 5.5 ± 1.5 cm; superior 3.8 ± 2.1 cm vs 5.7 ± 2.9 cm; superior-lateral nondominant targets 4.3 ± 2.2 cm vs 6.1 ± 2.8 cm; p = 0.02-0.05, effect size d = 0.72-0.74 [0.12-1.3]).

CONCLUSIONS

Individuals with RCRSP demonstrated better upper limb proprioception in elevation, suggesting a change to interoception (sensory reweighting) in the presence of pain.

Proprioception: How is it affected by shoulder pain? A systematic review

INTRODUCTION

Proprioception encompasses the submodalities of joint position sense (JPS), kinesthesia, sense of force, and velocity. Owing to the vast mobility of the shoulder, it heavily relies on an intact sense of proprioception. Moreover, shoulder injuries are associated with a decreased sense of proprioception. What remains unclear is how shoulder proprioception is affected by pain and competing nociceptive senses.

PURPOSE OF THE STUDY

To summarize the literature evaluating the relationship between pain and shoulder proprioception.

METHODS

A literature review was conducted from inception until 22 October 2018, using electronic databases (PubMed, Web of Science, Scopus, EBSCO, CINAHL, and Embase). Retrieved citations were screened for eligibility, and methodological quality was assessed using the Newcastle-Ottawa Scale (NOS).

RESULTS

Eleven studies were included (n = 447 participants with shoulder pain, n = 20 with experimentally induced pain [EIP]/n = 600 painful shoulders and n = 20 [EIP]). The mean methodological quality of the studies was good (76%). Five studies investigated active JPS, four investigated passive JPS, six investigated kinesthesia, sense of force was measured in one study, and no study investigated sense of velocity. There is moderate evidence for impaired kinesthesia and low evidence for reduced sense of force among painful shoulders. Conflicting evidence is seen for the other proprioceptive submodalities.

CONCLUSION

The overall impact of pain on shoulder JPS remains unclear, while moderate evidence for an affected sense of kinesthesia is possible. There is low evidence for an impaired sense of force among painful shoulders. Standardization between studies is lacking, limiting the range of our conclusions. Further investigation is required into well-controlled and pain-induced studies to better understand the influence of pain on shoulder proprioception.

Can a Conservative Rehabilitation Strategy Improve Shoulder Proprioception? A Systematic Review

CONTEXT

Proprioception deficits contribute to persistent and recurring physical disability, particularly with shoulder disorders. Proprioceptive training is thus prescribed in clinical practice. It is unclear whether nonsurgical rehabilitation can optimize shoulder proprioception.

OBJECTIVES

To summarize the available evidence of conservative rehabilitation (ie, nonsurgical) on proprioception among individuals with shoulder disorders.

EVIDENCE ACQUISITION

PubMed, Web of Science, and EBSCO were systematically searched, from inception until November 24, 2019. Selected articles were systematically assessed, and the methodological quality was established using the Dutch Cochrane Risk of Bias Tool and the Newcastle-Ottawa Quality Assessment Scale. The Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were utilized for this review. The conservative treatments were categorized as follows: (1) conventional therapy, (2) proprioceptive training, (3) elastic kinesiology tape, and (4) other passive therapies.

EVIDENCE SYNTHESIS

Twelve articles were included, yielding 58 healthy control shoulders and 362 shoulders affected by impingement syndrome, glenohumeral dislocations, nonspecific shoulder pain, rotator cuff dysfunction, or subluxation poststroke. The level of agreement between the evaluators was excellent (84.9%), and the studies were evaluated to be of fair to excellent quality (risk of bias: 28.5%-100%). This review suggests, with moderate evidence, that proprioceptive training (upper-body wobble board or flexible foil training) can improve proprioception in the midterm. No decisive evidence exists to suggest that conventional therapy is of added value to enhance shoulder proprioception. Conflicting evidence was found for the improvement of proprioception with the application of elastic kinesiology tape, while moderate evidence suggests that passive modalities, such as microcurrent electrical stimulation and bracing, are not effective for proprioceptive rehabilitation of the shoulder.

CONCLUSIONS

Proprioceptive training demonstrates the strongest evidence for the effective rehabilitation of individuals with a shoulder proprioceptive deficit. Elastic kinesiology tape does not appear to affect the sense of shoulder proprioception. This review suggests a possible specificity of training effect with shoulder proprioception.

Effect of using the Flexi-Bar tool on erector spinae muscle activation under different standing weight-bearing conditions

OBJECTIVES

The Flexi-Bar and Bodyblade are oscillatory tools used in rehabilitation centers worldwide to enhance muscle activity. Because of a lack of reports on the Flexi-Bar, this study focused on erector spinae (ES) muscle activation under different conditions.

METHODS

Twelve university students (age 21 ± 2.5 years old) were recruited in this study and were tested while using a loaded Flexi-Bar for 10 seconds. Comparison between muscle activation on the right and left sides in the cervical, thoracic, and lumbar regions was measured by electromyography during two-leg and one-leg (left and right) standing.

RESULTS

The results showed that during oscillation using the right hand, the right cervical muscles showed significantly higher activation levels than the left cervical muscles, while the thoracic and lumbar regions showed significantly higher muscle activities on the left side.

CONCLUSION

The current study showed that the Flexi-Bar might be used for muscle activation and reeducation, as well as for specific exercise therapy in spinal muscle imbalance.

Patients with Subacromial Pain Syndrome Present no Reduction of Shoulder Proprioception: A Matched Case-Control Study

BACKGROUND

Shoulder pain is common among patients with musculoskeletal pain and the prevalence of patients with subacromial pain syndrome (SAPS) is high. Despite the high prevalence, there is a lack of an extensive evaluation of the proprioception acuity in patients with SAPS. Knowledge of the proprioceptive deficit would assist clinicians in the proper treatment and may offer an alternative explanation for the mechanisms underlying SAPS, which are poorly understood.

OBJECTIVE

To compare the proprioceptive function of the shoulder in patients with SAPS and matched controls.

STUDY DESIGN

Matched case-control study.

SETTING

Physical Functional Rehabilitation Service of an outpatient clinic.

PARTICIPANTS

A total of 32 consecutive patients with SAPS who sought physical therapy for shoulder pain and 32 healthy participants (control group) matched for age, sex, and handedness.

INTERVENTIONS

All participants completed a questionnaire containing sociodemographic information, pain intensity and characteristics, the Numerical Pain Rating Scale, and the Shoulder Pain and Disability Index.

MAIN OUTCOME MEASUREMENTS

The proprioceptive assessment was performed through kinesthesia, passive joint position sense (PJPS), and the active joint position sense (AJPS).

RESULTS

The groups showed no statistically significant differences in kinesthesia, PJPS, and AJPS for internal or external rotation. The proprioceptive acuity was not associated with pain intensity or functional disability in patients with SAPS.

CONCLUSIONS

Participants with SAPS did not present proprioceptive deficits in a pain-free motion of medial and lateral rotation when compared to their matched controls. The proprioceptive deficit may not be involved with the mechanisms underlying SAPS and seems not to interfere with the clinical outcomes of patients with SAPS.

LEVEL OF EVIDENCE

Level III.

Specific or general exercise strategy for subacromial impingement syndrome-does it matter? A systematic literature review and meta analysis

Background

Exercise is frequently suggested as a treatment option for patients presenting with symptoms of subacromial impingement syndrome. Some would argue implementing a specific exercise strategy with special focus on correction of kinematic deficits would be superior to general exercise strategy. There is however a lack of evidence comparing such exercise strategies to determine which is the most effective in the treatment of subacromial impingement syndrome. The aim of this review is to evaluate whether implementing specific exercise strategies involving resistive exercises are more effective than a general exercise strategy for the treatment of patients with subacromial impingement syndrome.

Methods

Randomized controlled trials were identified through an electronic search on PubMed/MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science and PEDro. In addition, article reference lists and Clinicaltrials.gov were searched. Studies were considered eligible if they included interventions with resistive specific exercises as compared to general resistance exercise. Four reviewers assessed risk of bias and methodological quality guided by Cochrane recommendations. Results were synthesised qualitatively or quantitatively, where appropriate.

Results

Six randomized controlled trials were included with 231 participants who experienced symptoms of subacromial impingement syndrome. Four studies evaluated the effectiveness of specific scapular exercise strategy and two studies evaluated the effectiveness of specific proprioceptive strategy. Five studies were of moderate quality and one study was of low quality. No consistent statistical significant differences in outcomes between treatment groups were reported in the studies. Standardized mean difference (SMD) for pain was SMD −0.19 (95% CI −0.61, 0.22) and SMD 0.30 (95% CI −0.16, 0.76) for function.

Conclusions

There is insufficient evidence to support or refute the effectiveness of specific resistive exercise strategies in the rehabilitation of subacromial impingement syndrome. More high quality research is needed to accurately assess this. This review provides suggestions on how to improve the methodological design of future studies in this area.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-017-1518-0) contains supplementary material, which is available to authorized users.

Manual therapy and exercise for rotator cuff disease

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.

The effects of shoulder injury on kinaesthesia: a systematic review and meta-analysis

The aim of this systematic review was to synthesize the evidence for changes for proprioceptive variables consisting of movement and position sense in participants with glenohumeral musculoskeletal disorders. Five databases were searched until 13th August 2013. Methodological quality was assessed and meta-analyses were performed for active and passive joint reposition sense (AJPS and PJPS) and movement sense, determined with threshold to detection of passive motion (TTDPM). The search yielded 17 studies, four of which were classified as having high methodological quality, seven as moderate and six as low quality. For participants with post-traumatic glenohumeral instability, pooled findings indicate moderate evidence for higher TTDPM for involved shoulders compared to control groups and the contralateral uninvolved side, indicating decreased movement sense. For AJPS and PJPS there was moderate to limited evidence for significant increased errors for involved compared to uninvovled shoulders, but not when compared to the control groups. Limited evidence was found for decreased AJPS acuity for patients with chronic rotator cuff pain and for patients with unspecified shoulder pain compared to healthy controls. Movement sense is most likely to be impaired after shoulder injury involving post-traumatic instability when compared to the contralateral shoulder and to controls, while deficits for AJPS and PJPS are more likely to be evident compared to the contralateral shoulder in participants with glenohumeral musculoskeletal disorders.