Does the addition of motor control or strengthening exercises to education result in better outcomes for rotator cuff-related shoulder pain? A multiarm randomised controlled trial

Will my shoulder pain get better? - secondary analysis of data from a multi-arm randomised controlled trial

OBJECTIVE

To determine whether higher level or improvements over time in pain self-efficacy (PSE) and expectations of intervention effectiveness lead to better outcomes and whether the intervention used to manage rotator cuff related shoulder pain (RCRSP) impacts PSE and expectations over time.

DESIGN

Secondary analysis of data from a randomised controlled trial.

PARTICIPANTS

123 individuals (48 [15] years old; 51% female) with RCRSP.

INTERVENTIONS

Participants randomised into one of three 12-weeks interventions (education; education and motor control exercises; education and strengthening exercises).

MAIN OUTCOME MEASURES

QuickDASH and Western Ontario Rotator Cuff Index (WORC) were administered at baseline and 12 weeks. Pain self-efficacy was assessed at 0 and 6 weeks. Patients' expectations regarding intervention effectiveness were assessed before randomisation and after the first and the last intervention sessions. NparLD were used for the analyses. A time effect indicated a significant change in patients' expectations or PSE over time, while a resolution effect indicated a significant difference in patients' expectations or PSE between those whose symptoms resolved and those whose did not.

RESULTS

Patients' expectations (-3 to 3) increased over time (0.33/3 [0.19 to 0.77]). Overall expectations were higher for those who experienced symptom resolution based on the WORC (0.19/3 [0.05 to 0.33]). PSE increased over time (5.5/60 [3.6 to 7.4]). Overall PSE was higher for those who experienced symptom resolution based on the WORC (7.0 [3.9 to 10.1]) and the QuickDASH (4.9 [1.7 to 8.2]).

CONCLUSION

Clinicians should consider monitoring PSE and patients' expectations as they are important indicators of outcome. CONTRIBUTION OF THE PAPER.

The Efficacy of Exercise Therapy for Rotator Cuff-Related Shoulder Pain According to the FITT Principle: A Systematic Review With Meta-analyses

OBJECTIVE: To evaluate the efficacy of exercise interventions with differing frequency, intensity, type, and time (FITT) on shoulder pain and disability in people with rotator cuff-related shoulder pain (RCRSP). DESIGN: Intervention systematic review with meta-analyses. LITERATURE SEARCH: Electronic searches were conducted up to May 2023. STUDY SELECTION CRITERIA: Randomized controlled trials (RCTs) comparing the effects of exercise interventions differing in prescription according to the FITT principle, in people with RCRSP. DATA SYNTHESIS: Separate meta-analyses comparing exercise type (specific versus nonspecific exercise) and intensity (high versus low) were conducted. Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) was used to evaluate the certainty of evidence. RESULTS: Twenty-two RCTs (n = 1281) were included. There was moderate-certainty evidence that motor control exercise programs, when compared to nonspecific exercise programs, significantly reduced disability in the short (SMD: -0.29; 95% CI: -0.51, -0.07; n = 323; 7 RCTs) and medium terms (SMD: -0.33; 95% CI: -0.57, -0.09; n = 286; 5 RCTs), but not pain in the short term (SMD: -0.19; 95% CI: -0.41, 0.03; n = 323; 7 RCTs). Uncertainties remained regarding other exercise types (eccentric and scapula-focused exercise programs) versus nonspecific exercise programs, and exercise intensity due to low- to very low-certainty evidence. No trials were identified that compared different frequencies or times. CONCLUSION: For adults with RCRSP, motor control exercise programs were probably slightly superior to nonspecific exercise programs. However, it is unclear if the effects were due to motor control exercise or to other program characteristics such as progression and tailoring. J Orthop Sports Phys Ther 2024;54(8):499-512. Epub 7 June 2024. doi:10.2519/jospt.2024.12453.

One and Done? The Effectiveness of a Single Session of Physiotherapy Compared With Multiple Sessions to Reduce Pain and Improve Function and Quality of Life in Patients With a Musculoskeletal Disorder: A Systematic Review With Meta-analyses

OBJECTIVE

To compare single and multiple physiotherapy sessions to improve pain, function, and quality of life (QoL) in patients with musculoskeletal disorders (MSKDs).

DATA SOURCES

AMED, Cinahl, SportsDiscus, Medline, Cochrane Register of Clinical Trials, Physiotherapy Evidence Database, and reference lists.

STUDY SELECTION

Randomized controlled trials (RCTs) comparing single and multiple physiotherapy sessions for MSKDs.

DATA EXTRACTION

Two reviewers extracted data and assessed risk of bias and certainty of evidence using Cochrane Risk of Bias tool 2.0 and Grading of Recommendation Assessment, Development, and Evaluation.

DATA SYNTHESIS

Six RCTs (n=2090) were included (conditions studied: osteoporotic vertebral fracture, neck, knee, and shoulder pain). Meta-analyses with low-certainty evidence showed a significant pain improvement at 6 months in favor of multiple sessions compared with single session interventions (3 RCTs; n=1035; standardized mean difference [SMD]: 0.29; 95% CI: 0.05 to 0.53; P=.02) but this significant difference in pain improvement was not observed at 3 months (4 RCTs; n=1312; SMD: 0.39; 95% CI: -0.11 to 0.89; P=.13) and at 12 months (4 RCTs; n=1266; SMD: -0.05; 95% CI: -0.49 to 0.39; P=.82). Meta-analyses with low-certainty evidence showed no significant differences in function at 3 (4 RCTs; n=1583; SMD: 0.05; 95% CI: -0.11 to 0.21; P=.56), 6 (4 RCTs; n=1538; SMD: 0.06; 95% CI: -0.12 to 0.23; P=.53) and 12 months (4 RCTs; n=1528; SMD: 0.08; 95% CI: -0.08 to 0.25; P=.30) and QoL at 3 (4 RCTs; n=1779; SMD: 0.08; 95% CI: -0.02 to 0.17; P=.12), 6 (3 RCTs; n=1206; SMD: 0.03; 95% CI: -0.08 to 0.14; P=.59), and 12 months (4 RCTs; n=1729; SMD: -0.03; 95% CI: -0.12 to 0.07; P=.58).

CONCLUSIONS

Low certainty meta-analyses found no clinically significant differences in pain, function, and QoL between single and multiple physiotherapy sessions for MSKD management for the conditions studied. Future research should compare the cost-effectiveness of those different models of care.

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.

A cross-sectional observational study comparing individuals with a symptomatic full-thickness rotator cuff tear with age-matched controls

Background

A full-thickness rotator cuff tear (FTRCT) is defined as a complete tear of one of the four rotator cuff muscle tendons (supraspinatus, infraspinatus, subscapularis or teres minor). This condition can lead to pain and reduced function. However, not all FTRCT are symptomatic. A better understanding of the characteristics that lead some individuals with FTRCT to experience pain is fundamental to improve strategies used to manage this condition. This level II descriptive study aimed to explore potential sociodemographic, anatomical, psychosocial, pain sensitivity, biomechanical and neuromuscular variables that may differ between individuals with symptomatic FTRCT and age-matched individuals with asymptomatic shoulders.

Methods

In this cross-sectional observational study, adults aged 50 to 80 years of age, either with symptomatic FTRCT or no shoulder pain, were recruited via convenience sampling. Participants filled out questionnaires on sociodemographic and psychosocial variables. Then, various tests were performed, including pain pressure threshold, shoulder range of motion, shoulder muscle strength, shoulder ultrasound and radiologic examination, and sensorimotor functions testing. Each variable was compared between groups using univariate analyses (independent t-tests, Mann-Whitney U tests, exact probability Fisher tests). Significance was set at 0.05.

Results

FTRCT (n = 30) and Control (n = 30) groups were comparable in terms of sex, age, and number of comorbidities. The symptomatic FTRCT group showed a higher proportion of smokers (P = .026) and more participants indicated consuming alcohol or drugs more than they meant to (P = .010). The FTRCT group had a significantly higher prevalence of glenohumeral osteophytes (48% vs. 17%; P = .012). Participants in the FTRCT group were significantly more stressed (P = .04), anxious (P = .003) and depressed (P = .002). The FTRCT group also showed significantly higher levels of pain catastrophisation (P < .001) and sleep disturbance (P < .001). The FTRCT group showed significantly lower range of motion for flexion (P < .001), and external rotation at 0° (P < .001) and 90° (P < .001) of abduction. Isometric strength in both abduction and external rotation were weaker (P = .005) for the FTRCT group.

Conclusion

Sociodemographic, anatomical, psychosocial and biomechanical variables showed statistically significant differences between the FTRCT and Control groups.

Experiences of physiotherapists considering virtual reality for shoulder rehabilitation: A focus group study

Introduction

Shoulder pain is common and associated with substantial morbidity. Different treatment strategies are being prescribed with equivocal results. Virtual reality (VR) is a novel technology and emerging research suggests that VR may be a promising alternative to current treatments. Prior to effectiveness research or any large-scale introduction, VR-applications require appropriate scrutiny including feasibility- and acceptability of clinicians and patients. Therefore, the aim of this study was to collect experiences of physiotherapists after using immersive VR.

Methods

A qualitative interpretive design was used to explore physiotherapists' experiences related to the use of VR for people with shoulder symptoms. 17 physiotherapists were asked to use VR at home for five days prior to a focus group interview. Data from the focus group interviews were analyzed using a six-phase process of thematic analysis.

Results

Three main themes were identified, each divided into subthemes. The main themes were: 1. VR as an extension of contemporary physiotherapy care: physiotherapists were positive about the potential of VR and its applicability in daily care. 2. Physiotherapist uncertainties of future care using VR: participants expressed concerns about their professional identity, particularly as patients engage in independent home exercises. 3. Physiotherapist's requirements for implementation of VR: participants shared their needs for evidence regarding the effectiveness and parameters such as frequency, dosage and intensity of the VR intervention.

Conclusion

Physiotherapists were positive about VR as an intervention tool. However, they felt more knowledge is needed about parameters of VR. The findings of this study inform researchers and technology developers about optimal design of interventions and applications using VR.

"Restoring That Faith in My Shoulder": A Qualitative Investigation of How and Why Exercise Therapy Influenced the Clinical Outcomes of Individuals With Rotator Cuff-Related Shoulder Pain

OBJECTIVE

Rotator cuff-related shoulder pain (RCRSP) is the most common form of shoulder pain. Exercise therapy is a first-line recommended treatment for RCRSP. However, the causal mechanisms underpinning the benefits of exercise for RCRSP are not well understood. Moreover, how individuals with lived experience of RCRSP believe exercise helped or did not help them is unknown. This study aimed to gain insights into how individuals with RCRSP believe exercise influenced their shoulder pain and identify the clinical conditions that promoted or inhibited their beliefs.

METHODS

This qualitative study was underpinned by a critical realist approach to thematic analysis. Participants were recruited using hybrid purposive and convenience sampling techniques. Each participant attended an online semi-structured interview. The data were coded by 2 members of the research team (J.K.P. and N.C.) and verified by a third (B.S.). Recruitment continued until theoretical sufficiency was achieved. Participants reviewed and validated preliminary causal explanations.

RESULTS

Three causal explanations were consistently expressed by 11 participants to explain the benefits of exercise therapy: (1) shoulder strength; (2) changes to psychoemotional status; and (3) exercise has widespread health effects. However, the activation of these causal mechanisms depended on (1) the presence of a strong therapeutic relationship; (2) the provision of a structured and tailored exercise program; and (3) experiencing timely clinical progress.

CONCLUSION

Participants believed exercise improved their shoulder pain through associated health benefits, improved shoulder strength, and psychoemotional variables. Whether an exercise program was able to cause a clinical improvement for an individual with RCRSP was contingent on clinical contextual features. Thus, the clinical context that an exercise program is delivered within may be just as important as the exercise program itself.

IMPACT

Exercise is a recommended first-line intervention to manage RCRSP. The results of this study suggest that a positive experience and outcome with exercise for RCRSP is contingent on several clinical contextual features, such as a strong therapeutic relationship. The clinical context that an exercise program is prescribed and delivered within should be considered by clinicians.

Exercise for rotator cuff tendinopathy: Proposed mechanisms of recovery

Rotator cuff (RC) tendinopathy is a common recurrent cause of shoulder pain, and resistance exercise is the first-line recommended intervention. Proposed causal mechanisms of resistance exercise for patients with RC tendinopathy consist of four domains: tendon structure, neuromuscular factors, pain and sensorimotor processing, and psychosocial factors. Tendon structure plays a role in RC tendinopathy, with decreased stiffness, increased thickness, and collagen disorganization. Neuromuscular performance deficits of altered kinematics, muscle activation, and force are present in RC tendinopathy, but advanced methods of assessing muscle performance are needed to fully assess these factors. Psychological factors of depression, anxiety, pain catastrophizing, treatment expectations, and self-efficacy are present and predict patient-reported outcomes. Central nervous system dysfunctions also exist, specifically altered pain and sensorimotor processing. Resisted exercise may normalize these factors, but limited evidence exists to explain the relationship of the four proposed domains to trajectory of recovery and defining persistent deficits limiting outcomes. Clinicians and researchers can use this model to understand how exercise mediates change in patient outcomes, develop subgroups to deliver patient-specific approach for treatment and define metrics to track recovery over time. Supporting evidence is limited, indicating the need for future studies characterizing mechanisms of recovery with exercise for RC tendinopathy.