A Review of Systematic Reviews of the Effectiveness of Conservative Interventions for Rotator Cuff Tendinopathy

Shoulder mobility and strength impairments in patients with rotator cuff related shoulder pain: a systematic review and meta analysis

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.

'If he thought that I was going to go and hurt myself, he had another thing coming': Treatment experiences of those with large to massive rotator cuff tears and the perspectives of healthcare practitioners

OBJECTIVE

To explore the treatment experiences of those diagnosed with large to massive rotator cuff tears and the perspectives of healthcare practitioners providing their care.

DESIGN

A qualitative descriptive study using reflexive thematic analysis.

SETTING

In-person focus groups were undertaken in a clinical setting (private practice [n = 1]; public outpatient [n = 2]). Semi-structured interviews were conducted online via Microsoft Teams.

PARTICIPANTS

Patients diagnosed with these tears (n = 12) and healthcare practitioners (n = 11).

RESULTS

Two interlinking themes were identified based on the care received and provided for patients with symptomatic large to massive rotator cuff tears:1) Positive treatment experiences and management: Education, clear communication and reassurance around prognosis were the foundation of positive patient-clinician care. Sub-themes of pain relief, exercise prescription and confidence in their pathway underpinned this experience. This proficiency in care was affirmed by some healthcare practitioners who spoke about the importance of confidence and experience in their management plan even in times of poor progress.2) Negative treatment experiences and management: Uncertainty, delays and exacerbation of pain flawed the patient-clinician care. Sub-themes of inappropriate pain relief, inappropriate exercise prescription and uncertainty impacted their care. Some healthcare practitioners acknowledged knowledge gaps led to uncertainty especially when choosing the next step of care and were quick to escalate care to deflect this uncertainty.

CONCLUSIONS

The findings suggest discordance exists between the patient's experiences and expectations when the delivery of care was by less experienced and confident healthcare practitioners in the management of this condition. This highlights the need for improved education and support for healthcare practitioners.

To allow or avoid pain during shoulder rehabilitation exercises for patients with chronic rotator cuff tendinopathy-Study protocol for a randomized controlled trial (the PASE trial)

BACKGROUND

Rotator cuff (RC) tendinopathy is the most reported shoulder disorder in the general population with highest prevalence in overhead athletes and adult working-age population. A growing body of evidence support exercise therapy as an effective intervention, but to date there are no prospective randomized controlled trials addressing pain as an intervention variable.

METHODS

A single-site, prospective, pragmatic, assessor-blinded randomized controlled superiority trial. Eighty-four patients aged 18-55 years with chronic (symptom duration over 3 months) RC tendinopathy are randomized 1:1 to receive shoulder exercise during which pain is either allowed or avoided. The intervention period lasts 26 weeks. During that period, participants in both groups are offered 8 individual on-site sessions with an assigned sports physiotherapist. Participants perform home exercises and are provided with a pain and exercise logbook and asked to report completed home-based exercise sessions and reasons for not completing sessions (pain or other reasons). Patients are also asked to report load and the number of sets and repetitions per sets for each exercise session. The logbooks are collected continuously throughout the intervention period. The primary and secondary outcomes are obtained at baseline, 6 weeks, 26 weeks, and 1 year after baseline. The primary outcome is patient-reported pain and disability using the Shoulder PAin and Disability Index (SPADI). Secondary outcomes are patient-reported pain and disability using Disability Arm Shoulder and Hand short-form (Quick DASH), and shoulder pain using Numeric Pain Rating Scale. Objective outcomes are shoulder range of motion, isometric shoulder muscle strength, pain sensitivity, working ability, and structural changes in the supraspinatus tendon and muscle using ultrasound.

DISCUSSION

The results of this study will contribute knowledge about the treatment strategies for patients with RC tendinopathy and help physiotherapists in clinical decision-making. This is the first randomized controlled trial comparing the effects of allowing pain versus avoiding pain during shoulder exercises in patients with chronic RC tendinopathy. If tolerating pain during and after exercise proves to be effective, it will potentially expand our understanding of "exercising into pain" for this patient group, as there is currently no consensus.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05124769. Registered on August 11, 2021.

Is there 'trustworthy' evidence for using manual therapy to treat patients with shoulder dysfunction?: A systematic review

The primary objective of this review was to create a 'trustworthy,' living systematic review and meta-analysis for the application of manual therapy interventions in treating patients with shoulder dysfunction. Included studies were English-language randomized controlled trials published between 1/1/2010 and 8/3/2023, with searches performed in: PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), CINHAL, ProQuest Nursing & Allied Health, EBSCO Medline, and PEDro. The population of focus included adults 18 years and older with musculoskeletal impairments related to shoulder dysfunction. Our primary outcomes included pain and region-specific outcome measures. We excluded trials, including participants having shoulder dysfunction resulting from surgery, radicular pain, instability/dislocation, fracture, lymphedema, and radiation. Our screening methodology was based upon a previously published 'trustworthy' systematic review protocol. This included the application of our PICOTS criteria in addition to screening for prospective clinical trial registration and following of prospective intent, as well as assessment of PEDro scores, risk-of-bias ratings, GRADE scoring, and examination of confidence in estimated effects. Twenty-six randomized controlled trials met our PICOTS criteria; however, only 15 of these were registered. Only three were registered prospectively. Two of these did not have discussions and conclusions that aligned with their primary outcome. The remaining single study was found to have a high risk-of-bias, meaning the remainder of the protocol could not be employed and that no randomized controlled trials could undergo further assessment or meta-analysis. The results of this systematic review indicate there are no 'trustworthy' randomized controlled trials examining the effectiveness of manual therapy interventions for the treatment of patients with shoulder dysfunction, as defined by the prospectively established methodology. Therefore, these findings signal that creating a 'trustworthy,' living systematic review on this clinically relevant topic is not yet possible due to a lack of 'trustworthy' randomized controlled trials.

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).

Barriers and facilitators related to self-management of shoulder pain: a systematic review and qualitative synthesis

OBJECTIVE

The objective of this review was to identify barriers and facilitators related to self-management from the perspectives of people with shoulder pain and clinicians involved in their care.

DATA SOURCES

CINAHL, MEDLINE, PsycINFO, SPORTDiscus, Embase, ProQuest Health, Web of Science, and Scopus were searched from inception to March 2022.

REVIEW METHODS

A meta-aggregative approach to the synthesis of qualitative evidence was used. Two independent reviewers identified eligible articles, extracted the data, and conducted a critical appraisal. Two reviewers independently identified and developed categories, with validation by two further researchers. Categories were discussed among the wider research team and a comprehensive set of synthesized findings was derived.

RESULTS

Twenty studies were included. From the perspective of patients, three synthesized findings were identified that influenced self-management: (1) support for self-management, including subthemes related to patient-centred support, knowledge, time, access to equipment, and patient digital literacy; (2) personal factors, including patient beliefs, patient expectations, patient motivation, pain, and therapeutic response; and (3) external factors, including influence of the clinician and therapeutic approach. From the perspective of clinicians, two synthesized findings were identified that influenced self-management: (1) support for self-management, including education, patient-centred support, patient empowerment, time, and clinician digital literacy; and (2) preferred management approach, including clinician beliefs, expectations, motivation, therapeutic approach, and therapeutic response.

CONCLUSION

The key barriers and facilitators were patient-centred support, patient beliefs, clinician beliefs, pain, and therapeutic response. Most of the included studies focused on exercise-based rehabilitation, and therefore might not fully represent barriers and facilitators to broader self-management.

Rating the Quality of Smartphone Apps Related to Shoulder Pain: Systematic Search and Evaluation Using the Mobile App Rating Scale

Background

The successful rehabilitation of musculoskeletal pain requires more than medical input alone. Conservative treatment, including physiotherapy and exercise therapy, can be an effective way of decreasing pain associated with musculoskeletal pain. However, face-to-face appointments are currently not feasible. New mobile technologies, such as mobile health technologies in the form of an app for smartphones, can be a solution to this problem. In many cases, these apps are not backed by scientific literature. Therefore, it is important that they are reviewed and quality assessed.

Objective

The aim is to evaluate and measure the quality of apps related to shoulder pain by using the Mobile App Rating Scale.

Methods

This study included 25 free and paid apps—8 from the Apple Store and 17 from the Google Play Store. A total of 5 reviewers were involved in the evaluation process. A descriptive analysis of the Mobile App Rating Scale results provided a general overview of the quality of the apps.

Results

Overall, app quality was generally low, with an average star rating of 1.97 out of 5. The best scores were in the “Functionality” and “Aesthetics” sections, and apps were scored poorer in the “Engagement” and “Information” sections. The apps were also rated poorly in the “Subjective Quality” section.

Conclusions

In general, the apps were well built technically and were aesthetically pleasing. However, the apps failed to provide quality information to users, which resulted in a lack of engagement. Most of the apps were not backed by scientific literature (24/25, 96%), and those that contained scientific references were vastly out-of-date. Future apps would need to address these concerns while taking simple measures to ensure quality control.

Home training with or without joint mobilization compared to no treatment: a randomized controlled trial

[Purpose] To investigate if joint mobilization in patients with subacromial pain syndrome has additional benefits to a home training program on shoulder function and pain, and to compare home training to no physical therapy. [Participants and Methods] Eighty-nine primary care patients (mean age 45 years) with subacromial pain syndrome during an average of 23 weeks. Home training was performed twice a day during a 12 week period. One of the intervention groups received add-on shoulder joint mobilization to the home training. A third group did not receive any physical therapy. Constant-Murley score, pain and active range of motion was evaluated at baseline, 6 weeks, 12 weeks and 6 months. [Results] The total Constant-Murley score revealed no significant differences between groups at any time point. All groups improved over time. The add-on joint mobilization group reached clinical important change at 12 weeks. The subscale pain showed that both intervention groups reported less pain after 12 weeks compared to the reference group. [Conclusion] Home training is not superior to no treatment evaluated with the total Constant-Murley score. However, home training with or without add-on joint mobilization may decrease pain compared to no treatment.

Use of a Portable Inertial Measurement Unit as an Evaluation Method for Supraspinatus Muscle: Proposed Normative Values

Treatment protocols do not specify an appropriate weight for rehabilitating the shoulder joint. The purpose of this study was to establish normative values for the shoulder abduction range of motion and recommended weights to be used in the rehabilitation process after injury to the supraspinatus muscle. Fifty-eight volunteers were assessed using the DyCare system. A test was conducted by lifting the arm to a 90° angle and having the participants lift different weights. The range of motion was similar for both sexes, suggesting that sex had no influence on this variable. Regarding the use of weights, men did not show as much stability in their movement execution, with a high dispersion seen in values between zero and three kilograms of weight, reaching a maximum weight of six kilograms. However, women showed good joint stability from the beginning of the test, with values that remained constant as weight increased up to a maximum of five kilograms. In conclusion, no major differences were observed in supraspinatus muscle injury recovery according to sex. However, differences were observed in the amount of weight that was necessary and appropriate to allow the participants to recover their muscular strength and avoid relapses.

Efficacy of mobilization with movement (MWM) for shoulder conditions: a systematic review and meta-analysis

Objective: To assess the effects of mobilization with movement (MWM) on pain, range of motion (ROM), and disability in the management of shoulder musculoskeletal disorders. Methods: Six databases and Scopus, were searched for randomized control trials. The ROB 2.0 tool was used to determine risk-of-bias and GRADE used for quality of evidence. Meta-analyses were performed for the sub-category of frozen shoulder and shoulder pain with movement dysfunction to evaluate the effect of MWM in isolation or in addition to exercise therapy and/or electrotherapy when compared with other conservative interventions.Results: Out of 25 studies, 21 were included in eight separate meta-analyses for pain, ROM, and disability in the two sub-categories. For frozen shoulder, the addition of MWM significantly improved pain (SMD -1.23, 95% CI -1.96, -0.51)), flexion ROM (MD -11.73, 95% CI -17.83, -5.64), abduction ROM (mean difference -13.14, 95% CI -19.42, -6.87), and disability (SMD -1.50, 95% CI (-2.30, -0.7). For shoulder pain with movement dysfunction, the addition of MWM significantly improved pain (SMD -1.07, 95% CI -1.87, -0.26), flexion ROM (mean difference -18.48, 95% CI- 32.43, -4.54), abduction ROM (MD -32.46, 95% CI - 69.76, 4.84), and disability (SMD -0.88, 95% CI -2.18, 0.43). The majority of studies were found to have a high risk of bias. Discussion: MWM is associated with improved pain, mobility, and function in patients with a range of shoulder musculoskeletal disorders and the effects clinically meaningful. However, these findings need to be interpreted with caution due to the high levels of heterogeneity and risk of bias. Level of Evidence: Treatment, level 1a.

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

OBJECTIVE

To study the effects of supervised training in adults with subacromial pain syndrome.

DATA SOURCES

Embase, MEDLINE, Cochrane Library, Cumulative Index to Nursing and Allied Health, and Physiotherapy Evidence Database were searched from inception to March 2020.

STUDY SELECTION

Independent reviewers selected randomized controlled trials comparing supervised training with (1) no training or (2) self-training in adults with subacromial pain syndrome lasting for at least 1 month. Critical outcomes were shoulder pain, function, and patient-perceived effect. Important outcomes included other potential benefits and adverse events at 3-month follow-up.

DATA EXTRACTION

Two independent reviewers extracted data for the meta-analysis. Risk of bias was assessed using the Cochrane Risk of Bias tool 1, and certainty of evidence was evaluated using the Grades of Recommendation Assessment, Development, and Evaluation (GRADE).

DATA SYNTHESIS

Ten studies (n=597, 43% female) were included. Supervised training resulted in larger improvements than no training on pain (at rest: n=286; mean difference [MD], 1.68; 95% confidence interval [CI], 0.31-3.06 on 0-10 scale; during movement: n=353; MD, 1.84; 95% CI,0.91-2.76), function (n=396; standardized MD, 0.30; 95% CI, 0.07-0.52), and patient-perceived effect (n=118; risk ratio, 1.43; 95% CI, 0.87-2.34). Supervised training had potential benefits regarding quality of life, return to work, dropout, and training adherence, albeit more patients reported mild, transient pain after training. Supervised training and self-training showed equal improvements on pain (n=44) and function (n=76), with no data describing patient-perceived effect. Certainty of evidence was low for critical outcomes and low-moderate for other outcomes.

CONCLUSIONS

Supervised training might be superior to no training and equally effective as self-training on critical and important outcomes. Based on low-moderate certainty of evidence, these findings support a weak recommendation for supervised training in adults with subacromial pain syndrome.

French physiotherapy management of rotator cuff related shoulder pain: An observational study

BACKGROUND

Rotator cuff related shoulder pain (RCRSP) is a common and disabling cause of shoulder pain contributing to great socio-economic costs. Conservative management is recommended as first-line treatment, with studies performed in the United Kingdom, Belgium, the Netherlands and Australia finding practice generally consistent with guideline recommendations. Current French guidelines for management of RCRSP were published more than a decade ago, and it is unknown if French physiotherapists manage RCRSP in line with the current guideline recommendations. The aim of this survey is to evaluate if management delivered by French physiotherapists for RCRSP is in line with the current evidence.

METHODS

A cross-sectional online survey was conducted and disseminated through various social media platforms and a mailing list from December 2018 to March 2019.

RESULTS

Two hundred and six French physiotherapists completed the survey. The results demonstrated that the majority of physiotherapists provide care consistent with recommended guideline management, through the delivery of exercise and education. Ideology and specific parameters of treatment delivery, particularly exercise treatment, were highly variable among the cohort, but comparable to findings among physiotherapists in the United Kingdom, Belgium, the Netherlands and Australia.

CONCLUSION

French physiotherapists are broadly consistent with providing guideline recommended care of RCRSP; however, heterogeneity exists in the ideals and practice of specific treatment delivery, particularly within exercise management.

Effectiveness of conservative therapy in tendinopathy-related shoulder pain: A systematic review of randomized controlled trials

OBJECTIVE

Systematic review investigated efficacy of conservative therapy on pain and function in people with tendinopathy-related shoulder pain.

METHODS

Searches were conducted on six databases. All randomized controlled trials investigating efficacy of any conservative therapy on pain and function in people with tendinopathy-related shoulder pain were included. Estimates for each specific conservative therapy were presented as weighted mean differences (WMDs) or mean differences (MDs), with 95% confidence intervals (CIs). Quality of the evidence was assessed using GRADE.

RESULTS

Five randomized controlled trials were included. Extracorporeal shock-wave therapy (ESWT) was effective on pain at short-term (i.e., ≤3 months) when compared with control (WMD = -1.7 out of 101 points, -3.1 to -0.3; n = 158). Individual trials also suggested effects of non-steroidal anti-inflammatory drugs (NSAIDs) (-13.7 to -2.3; n = 365) and extracorporeal radial pressure pulse therapy (rESWT) (-40.0 to -27.0; n = 79). Laser therapy and ESWT were not effective on pain and function at short-term, respectively. No trials investigated medium- or long-term effects, and quality of the evidence ranged from low to very low quality.

CONCLUSIONS

Conservative therapies currently available for the rotator cuff management and biceps tendinopathy are not supported by low to very-low quality evidence.

Physical therapy for tendinopathy: An umbrella review of systematic reviews and meta-analyses

OBJECTIVE

To summarize evidence in the last decade regarding the efficacy of physical therapy interventions to treat tendinopathy, as a single disease entity, as determined in systematic reviews (SRs) and/or meta-analyses (MAs).

METHODS

Electronic search of PubMed, PEDro, and Scopus database was performed from year 2010 to January 2020. The methodological quality of the identified studies was assessed using the AMSTAR 2 tool. Studies scoring 9 points or higher were further analyzed using GRADE principles.

RESULTS

40 SRs and/or MAs were included in qualitative synthesis, whereas only 5 MAs were included in quantitative synthesis. Low-level laser therapy (LLLT) intervention showed a pooled improvement in pain reduction of 1.53 cm; 95% CI, [1.14, 1.91] (I² = 1.9%, p = 0.361) on visual analogue scale, and grip strength of 9.59 kg; 95% CI, [5.90, 13.27].

CONCLUSIONS

Moderate-quality evidence may support these following interventions: LLLT revealed a statistically and potentially clinically significant improvement in pain and function on the short-term. Extracorporeal shockwave therapy showed a statistically significant enhancement in pain and function at all follow-up durations; however, its clinical significance was undetermined. Eccentric exercise was supported by qualitative evidence only. Caution is advised when interpreting results due to possible pathological differences in tendinopathy at each region.

Kinesiophobia Is Associated With Pain Intensity and Disability in Chronic Shoulder Pain: A Cross-Sectional Study

OBJECTIVE

Kinesiophobia is a clinically relevant factor in the management of chronic musculoskeletal pain. The aim of this study was to explore the cross-sectional association between kinesiophobia and both pain intensity and disability among individuals with chronic shoulder pain.

METHODS

A total of 65 participants with chronic unilateral subacromial shoulder pain were recruited from 3 primary care centers. The Shoulder Pain and Disability Index assessed pain intensity and disability. The Tampa Scale for Kinesiophobia short form assessed the presence of kinesiophobia. A linear multivariable regression analysis evaluated the potential association between kinesiophobia and range of movement free of pain with pain intensity and disability. The analysis was adjusted for sex and age.

RESULTS

In the linear multivariable regression analysis, only greater kinesiophobia (standardized β = 0.35, P < .01) and sex (standardized β = -0.29, P < .01) contributed to explain 19% of the variance in shoulder pain and disability scores.

CONCLUSION

This cross-sectional study provides preliminary evidence about the association between kinesiophobia and pain intensity and disability among individuals with chronic shoulder pain. However, our findings only contributed to explain 19% of the variance in shoulder pain and disability scores.

The Effectiveness of Ischemic Compression Technique on Pain and Function in Individuals With Shoulder Pain: A Systematic Review

OBJECTIVE

To systematically review current literature to determine the effectiveness of the ischemic compression (IC) technique on pain and function in individuals with shoulder pain.

METHODS

This review was conducted according to recommendations of Preferred Reporting Items for Systematic Reviews and Meta-Analyses and the Cochrane Collaboration for Systematic Reviews; a search was performed in the electronic databases PubMed, Cumulative Index to Nursing and Allied Health Literature, SPORTDiscus, Physiotherapy Evidence Database, and Web of Science. Randomized clinical trials and quasi-randomized clinical trials were included, and the methodological quality was evaluated through the Physiotherapy Evidence Database scale.

RESULTS

The search found 572 studies; of these, 71 were selected by title and, subsequently, 29 were selected through abstract analyses. After critical analyses, 5 studies were included. The methodological quality ranged from 4 (reasonable) to 9 (excellent) points. Pain was assessed by all studies using the visual analog scale, Global Perceived Effect scale, Numerical Rating Scale, pressure pain threshold, or Perceived Amelioration Numerical Scale. Function was evaluated by 3 studies through the Shoulder Pain and Disability Index; Neck Disability Index; American Shoulder and Elbow Surgeons Standardized Shoulder Assessment; and Disabilities of the Arm, Shoulder, and Hand questionnaires. The studies showed that the IC technique produces immediate and short-term positive effects for pain, and positive short-term effects for shoulder function in individuals with shoulder pain.

CONCLUSION

The IC technique seems to be beneficial for pain and shoulder function. However, caution is needed when considering this evidence owing to the limited quality of some studies, the few articles found, and the lack of standardization of the application parameters of the technique to facilitate its reproducibility.

External rotator strength deficits in non-athletic people with rotator cuff related shoulder pain are not associated with pain intensity or disability levels

BACKGROUND

Strength deficits are often reported in people with rotator cuff related shoulder pain. However, these have mainly been tested in athletic populations and pain interference with testing has not been considered.

OBJECTIVES

To examine strength without pain interference in non-athletic people with rotator cuff related shoulder pain and its association with pain intensity and disability.

DESIGN

Cross-sectional study.

METHODS

Sixty-seven participants with rotator cuff related shoulder pain were assessed for isometric strength of shoulder external rotator and internal rotator muscles without pain interference with a hand-held dynamometer. Strength was normalized (%body weight). Differences in external and internal rotation strength and external:internal rotator strength ratio between symptomatic and asymptomatic sides were examined (Independent t-tests, Wilcoxon rank sum tests). Spearman's rank correlation coefficients were used to examine associations between strength and pain and disability levels.

RESULTS

There was no significant difference in internal rotator strength normalized to body weight between symptomatic and asymptomatic sides. There was a significant difference in external rotator strength normalized to body weight (p < .001) and external:internal ratio (p < .001) between sides. No significant correlations were found between strength and pain or disability levels.

CONCLUSION

Non-athletic people with rotator cuff related shoulder pain had external rotator strength deficits without pain interference during strength testing, which were not associated with pain and disability levels.

Altered Scapular Time Series in Individuals With Subacromial Pain Syndrome

Altered scapular movement in subacromial pain syndrome has been demonstrated using discrete data reduction approach. However, this approach does not consider the data collinearity and variability, and scapular translations are poorly investigated in symptomatic individuals. The purpose of this study was to investigate the scapular rotation and translation of asymptomatic individuals and those with subacromial pain syndrome during arm motions using principal component analysis. Scapulothoracic kinematics were evaluated in 47 participants with subacromial pain syndrome and 50 asymptomatic individuals. The symptomatic group had increased range of scapular anterior/posterior tilt during arm elevation (P = .01, effect size = .59) and arm lowering (P < .01, effect size = .61), and increased range of scapular forward/backward translation during arm lowering (P < .01, effect size = .60) compared with the asymptomatic group. In addition, the symptomatic group had a reduced difference in anterior tilt angular velocities between the early-arm and mid-arm lowering phases and between the mid- and late-arm lowering phases compared with the asymptomatic group (P = .03, effect size = .44). This study demonstrated that scapular anterior/posterior tilt motion and angular velocity and scapular forward/backward translation of symptomatic individuals were different from asymptomatic individuals when considering the entire arm movement.

April 2020 Letter to the Editor-in-Chief

Letter to the Editor-in-Chief of JOSPT as follows: "Can 'Strong' Recommendations Be Made for Exercise and Manual Therapy in Treating Subacromial Shoulder Pain?" with Authors' Response J Orthop Sports Phys Ther 2020;50(4):216-217. doi:10.2519/jospt.2020.0202.

An Update of Systematic Reviews Examining the Effectiveness of Conservative Physical Therapy Interventions for Subacromial Shoulder Pain

OBJECTIVE

To update a systematic review published in 2013 that focused on evaluating the effectiveness of interventions within the scope of physical therapy, including exercise, manual therapy, electrotherapy, and combined or multimodal approaches to managing shoulder pain.

DESIGN

Umbrella review.

LITERATURE SEARCH

An electronic search of PubMed, Web of Science, and CINAHL was undertaken. Methodological quality was assessed using the AMSTAR (A MeaSurement Tool to Assess systematic Reviews) checklist for systematic reviews.

STUDY SELECTION CRITERIA

Nonsurgical treatments for subacromial shoulder pain.

DATA SYNTHESIS

Sixteen systematic reviews were retrieved. Results were summarized qualitatively.

RESULTS

A strong recommendation can be made for exercise therapy as the first-line treatment to improve pain, mobility, and function in patients with subacromial shoulder pain. Manual therapy may be integrated, with a strong recommendation, as additional therapy. There was moderate evidence of no effect for other commonly prescribed interventions, such as laser therapy, extracorporeal shockwave therapy, pulsed electromagnetic energy, and ultrasound.

CONCLUSION

There is a growing body of evidence to support exercise therapy as an intervention for subacromial shoulder pain. Ongoing research is required to provide guidance on exercise type, dose, duration, and expected outcomes. A strong recommendation may be made regarding the inclusion of manual therapy in the initial treatment phase. J Orthop Sports Phys Ther 2020;50(3):131-141. Epub 15 Nov 2019. doi:10.2519/jospt.2020.8498.

The Effectiveness of an Upper Extremity Neuromuscular Training Program on the Shoulder Function of Military Members With a Rotator Cuff Tendinopathy: A Pilot Randomized Controlled Trial

INTRODUCTION

Shoulder pain, a leading reason to consult a physician or physiotherapist, continues to be a challenge to rehabilitate, particularly with a military population. A rotator cuff (RC) tendinopathy, the most important source of shoulder pain, is one of the leading reasons for sick leave or a discharge from active military service. Research encourages the use of exercise prescription for the management of a RC tendinopathy, however the ideal method of delivery (group setting versus one-on-one) remains uncertain. The purpose of this single-blind (evaluator) pilot randomized clinical trial was to compare two 6-week rehabilitation programs, a newly developed group-supervised neuromuscular training program and usual one-on-one physiotherapy care, on the pain and symptoms of Canadian soldiers affected by a RC tendinopathy.

MATERIALS AND METHODS

Thirty-one soldiers with the Canadian Armed Forces were randomly assigned to (1) a group-supervised neuromuscular training program (UPEx-NTP) or; (2) one-on-one usual physiotherapy care (UPC). The primary outcome was the Disability of Arm, Hand and Shoulder (DASH) questionnaire. Secondary outcomes included the Western Ontario Rotator Cuff (WORC) Index, pain levels at rest, and maximum isometric voluntary contractions (MIVC) of the abductors and external (lateral) rotators of the affected shoulder. Both were assessed at baseline (T0), 6 (T6) and 12 (T12) weeks. Analysis included two-way repeated measures of variance for intention-to-treat (ITT) and per-protocol analyses.

RESULTS

Eighty military members with a RC tendinopathy were contacted, resulting in 31 participants who were randomized for their active intervention, in the UPEx-NTP or UPC, respectively. No significant group (p ≥ 0.16) or group × time interactions (p ≥ 0.11) were found for either ITT or per-protocol analyses. A statistically significant time effect (p < 0.001) was established for the DASH and WORC, showing that both groups improved over time.

CONCLUSIONS

Our preliminary data demonstrates that both rehabilitation approaches, grounded in active exercises, were not statistically different from each other, and derived similar benefits over time for a military population. This suggests that a group intervention for a RC tendinopathy has potential to be just as effective as a one-on-one approach for a military population, an interesting avenue for an active working population. Larger sample sizes and further investigation are warranted regarding the cost and clinical resource benefits of a supervised group approach.

Exploring the Business Case for Improving Quality of Care for Patients With Chronic Rotator Cuff Tears

BACKGROUND AND OBJECTIVES

Currently, management of patients presenting with chronic rotator cuff tears in Alberta is in need of quality improvements. This article explores the potential impact of a proposed care pathway whereby all patients presenting with chronic rotator cuff tears in Alberta would adopt an early, conservative management plan as the first stage of care; ultrasound investigation would be the preferred tool for diagnosing a rotator cuff tear; and only patients are referred for surgery once conservative measures have been exhausted.

METHODS

We evaluate evidence in support of surgery and conservative management, compare care in the current state with the proposed care pathway, and identify potential solutions in moving toward optimal care.

RESULTS

A literature search resulted in an absence of indications for either surgical or conservative management. Conservative management has the potential to reduce utilization of public health care resources and may be preferable to surgery. The proposed care pathway has the potential to avoid nearly Can $87 000 in public health care costs in the current system for every 100 patients treated successfully with conservative management.

CONCLUSION

The proposed care pathway is a low-cost, first-stage treatment that is cost-effective and has the potential to reduce unnecessary, costly surgical procedures.

Rotator CUFF disorders: A survey of current physiotherapy practice in Belgium and the Netherlands

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.

Screening of the cervical spine in subacromial shoulder pain: A systematic review

BACKGROUND

Subacromial shoulder pain is a common clinical presentation with much diagnostic uncertainty. Some of this uncertainty relates to the involvement of the cervical spine as a source or contribution to subacromial shoulder pain. Currently, there is no accepted method of screening of the cervical spine in the presence of subacromial shoulder pain, which risks patients receiving misguided and/or ineffective interventions.

OBJECTIVE

To evaluate approaches used to screen the cervical spine in patients with subacromial shoulder pain.

DESIGN

Systematic review of randomized controlled trials.

METHODS

Electronic searches of PEDro and MEDLINE to December 2016 were conducted. Randomized controlled trials evaluating the effectiveness of interventions within the current scope of physiotherapy comprising of adult patients complaining of subacromial shoulder pain were included. Data relating to the method of cervical spine screening were extracted and synthesized categorically.

RESULTS

One hundred and two studies were included. Twenty-six (25.5%) were categorized as "No method of screening undertaken or reported," 49 (48.0%) were categorized as "Localized cervical spine symptoms and/or radiculopathy/radicular pain," nine (8.8%) were categorized as "Cervical examination," two (2.0%) were categorized as "Manual testing," two (2.0%) were categorized as "History of cervical surgery," and 14 (13.7%) were categorized as using "Combined approaches."

CONCLUSION

Examination of the cervical spine in patients with subacromial shoulder pain is variable in randomized controlled trials. In many instances, no or minimal attempts to screen were undertaken or reported. This has potential research and management implications and further research is indicated to facilitate development of this aspect of examination.

Effectiveness of a tailored rehabilitation versus standard strengthening programme for patients with shoulder pain: a protocol for a feasibility randomised controlled trial (the Otago MASTER trial)

INTRODUCTION

Exercise therapy is the treatment of choice for the management of patients with shoulder subacromial pain. However, we do not know whether a tailored rehabilitation programme is more effective than a standardised strengthening programme. The aim of this feasibility trial is to assess: (1) participant recruitment rate, (2) the proportion of participants enrolled from the total number screened, (3) adherence to the rehabilitation programme, (4) drop-out rates, (5) obtain estimates of adverse reactions to treatment, (6) obtain estimates of intervention effects in order to inform the sample size of the fully-powered randomised controlled trial, (7) conduct a preliminary cost-effectiveness analysis of the standardised strengthening and the tailored rehabilitation interventions.

METHODS

The MAnagement of Subacromial disorders of The shouldER (MASTER) trial, is a two-arm, patient-blinded and assessor-blinded, randomised controlled feasibility trial. Participants will be randomly allocated into one of the interventions group: tailored or standardised rehabilitation. To obtain estimates of intervention effects, we will compare changes in pain and shoulder-related disability scores between the two intervention groups using a repeated mixed-model analysis of variance, with alpha set at 0.05, and power at 80%. Since this is a feasibility study, we will not adjust alpha for multiple comparisons. To determine whether it is feasible to conduct the full trial, we will consider 75% CI as the probability threshold at 3-month follow-up.

ETHICS AND DISSEMINATION

This study was approved by the University of Otago Ethics Committee (Ref: H17/080). Findings from this study will be presented at national and international conferences, and will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ANZCTR: 12617001405303.

Subacromial impingement syndrome - What does this mean to and for the patient? A qualitative study

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.

Rotator cuff disorders: a survey of current (2016) UK physiotherapy practice

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.

Proposal and Evaluation of a Telerehabilitation Platform Designed for Patients With Partial Rotator Cuff Tears: A Preliminary Study

Objective

To propose and evaluate the effectiveness of a telerehabilitation platform designed for patients with rotator cuff (RC) tears.

Methods

During the first study phase, a virtual service platform that included information on RC tear pathology, joint care, and a series of instructions regarding therapeutic exercise was designed and created. Subsequently, in the clinical phase, a quasi-experimental study was performed. The platform was tested on patients and evaluated at baseline and at 1, 2, 3, and 6 months with respect to their pain levels and functionality on the Constant-Murley (CM) scale.

Results

Eleven patients were included, 5 women and 6 men, with a median age of 55 years (range, 42–68 years). Pain diminished from a baseline value of 64 mm (range, 40–80 mm) to 16 mm (range, 0–30 mm) at 6 months (p<0.001). Points on the CM scale rose from a baseline value of 54 points (range, 51–66 points) to 85 points (range, 70–100 points) at 6 months (p=0.001). Functionality in daily living and work activities, movement, and strength exhibited significant changes at 6 months (p<0.05).

Conclusion

Significant changes were observed in pain and functionality in this group of participants who used a telerehabilitation platform. To the best of our knowledge, this is the first study that included a specific program for RC tears.

A self-managed single exercise programme versus usual physiotherapy treatment for rotator cuff tendinopathy: a randomised controlled trial (the SELF study)

Objectives:

To evaluate the clinical effectiveness of a self-managed single exercise programme versus usual physiotherapy treatment for rotator cuff tendinopathy.

Design:

Multi-centre pragmatic unblinded parallel group randomised controlled trial.

Setting:

UK National Health Service.

Participants:

Patients with a clinical diagnosis of rotator cuff tendinopathy.

Interventions:

The intervention was a programme of self-managed exercise prescribed by a physiotherapist in relation to the most symptomatic shoulder movement. The control group received usual physiotherapy treatment.

Main outcome measures:

The primary outcome measure was the Shoulder Pain & Disability Index (SPADI) at three months. Secondary outcomes included the SPADI at six and twelve months.

Results:

A total of 86 patients (self-managed loaded exercise n=42; usual physiotherapy n=44) were randomised. Twenty-six patients were excluded from the analysis because of lack of primary outcome data at the 3 months follow-up, leaving 60 ( n=27; n=33) patients for intention to treat analysis. For the primary outcome, the mean SPADI score at three months was 32.4 (SD 20.2) for the self-managed group, and 30.7 (SD 19.7) for the usual physiotherapy treatment group; mean difference adjusted for baseline score: 3.2 (95% Confidence interval -6.0 to +12.4 P = 0.49). By six and twelve months there remained no significant difference between the groups.

Conclusions:

This study does not provide sufficient evidence of superiority of one intervention over the other in the short-, mid- or long-term and hence a self-management programme based around a single exercise appears comparable to usual physiotherapy treatment.