Is radial Extracorporeal Shock Wave Therapy (rEWST) combined with supervised exercises (SE) more effective than sham rESWT and SE in patients with subacromial shoulder pain? Study protocol for a double-blind randomised, sham-controlled trial

Does additional extracorporeal shock wave therapy improve the effect of isolated percutaneous radiofrequency coblation in patients with insertional Achilles tendinopathy? Study protocol for a randomized controlled clinical trial

BACKGROUND

No conclusive evidence recommends a prior treatment for insertional Achilles tendinopathy (IAT). It is theorized that both percutaneous radiofrequency coblation and extracorporeal shockwave therapy (ESWT) relieve pain within the insertion. However, no clinical evidence shows that either treatment promotes the regeneration of the tendon or if the combination of these 2 interventions offers better function and less pain than one therapy.

METHODS

The study is a randomized, controlled trial with patients allocated in a 1:1 ratio to one of two parallel groups. Patients with insertional Achilles tendinopathy who are not satisfied with the effect of conservative treatment will be screened. A minimum of 38 patients will be enrolled after deciding to participate in the trial on an informed basis. Then the intervention group and the control group perform radial ESWT and sham-ESWT respectively at 6 months after percutaneous radiofrequency coblation. The primary outcome will be the Victorian Institute of Sports Assessment Achilles (VISA-A) Score. Secondary outcome measures will be Foot and Ankle Outcome Score (FAOS) scale, visual analog scale (VAS), Tegner Score, and MRI ultra-short echo time (UTE) T2* value. The assessments will occur in 6 months, 1 year, and 2 years, post-operatively. The differences between the 2 groups will be conducted as intention-to-treat basis.

DISCUSSION

We aim to investigate if radiofrequency coblation associated with ESWT can provide more encouraging imaging findings as well as functional and clinical outcomes regarding the treatment of the IAT comparing to the single radiofrequency coblation treatment.

TRIAL REGISTRATION

ChiCTR1800017898; pre-results. Registered on 20 August 2018.

Use of Behavior Change Techniques Alongside Exercise in the Management of Rotator Cuff-Related Shoulder Pain: A Scoping Review

OBJECTIVES

The aims of this scoping review were to: (1) determine the frequency and types of behavior change techniques (BCTs) and education utilized in trials investigating exercise interventions for rotator cuff related shoulder pain (RCRSP); (2) subcategorize the BCTs and education found in the trials to summarize all behavior change approaches reported by trials; and (3) compare the frequency, types, and subcategories of BCTs and education utilized in the clinical guidelines for managing RCRSP between the trials.

METHODS

Data sources included Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Ovid EMBASE, CINAHL Plus, Google Scholar and PubMed, which were searched from inception to June 2020. Trials assessing exercise interventions for RCRSP were included. Three authors independently determined eligibility and extracted data. The frequency and types of BCTs and education in the trials and clinical practice guidelines were reported and compared descriptively. Two authors assessed the content of the BCTs to develop subcategories.

RESULTS

Most trials reported including at least 1 type of BCT (89.2%), which was most commonly feedback and monitoring (78.5%). There were many different approaches to the BCTs and education; for example, feedback and monitoring was subcategorized into supervised exercise, exercise monitoring, and feedback through external aids, such as mirrors. Clinical guidelines recommend supervision, goal setting, activity modification, pain management recommendations, information about the condition, and exercise education.

CONCLUSION

Although over two-thirds of trials reported including a BCT alongside exercise interventions for RCRSP, the breadth of these interventions is limited (supervision is the only common one). Future trialists should consider using any type of BCT that may improve exercise adherence and outcomes.

IMPACT

The findings of this review have: (1) identified gaps in the literature; and (2) contributed to the design of future exercise interventions for RCRSP.

Shockwave therapy associated with progressive exercises in rotator cuff tendinopathy: a clinical trial protocol

The aim of the present study is to determine whether adding shockwave therapy (SWT) to a progressive exercise program improves shoulder pain and function in individuals with rotator cuff tendinopathy (RC tendinopathy). Ninety patients diagnosed with rotator cuff tendinopathy will be randomly allocated into two groups: active SWT plus a progressive exercise program or placebo SWT plus a progressive exercise program. Primary outcomes will be measured using the Constant-Murley Score function questionnaire and by assessing patient-reported pain intensity with the numerical pain rating scale. The secondary outcomes will be measured using the Global Perceived Effects Scale and Shoulder Pain and Disability Index. All the outcomes will be measured immediately after the end of treatment and at 3-month follow-up.

Shoulder patients in primary and specialist health care. A cross-sectional study

OBJECTIVES

Shoulder pain is a prevalent problem and has a considerable impact on the use of primary and specialist health care in Norway. It is important to improve short-term recovery and reduce long-term consequences regarding pain and disability, the high costs of treatment and the amount of sick-leave. Treatment for non-specific shoulder pain is mainly non-operative. The aims of this study were to investigate if there are differences in main characteristics, pain and disability (SPADI-score) and psycho-social factors between patients in primary and specialist health care.

METHODS

This cross-sectional study included patients consulting physiotherapy in primary health care and patients at an outpatient clinic in specialist health care. Well-known and tested questionnaires for these populations were used and variables were divided into clinical, sociodemographic, psycho-social, and shoulder pain and disability. Descriptive statistics were applied. Two-sample t-test and linear regression were used for continuous data whereas chi-square tests and logistic regression were applied to test differences in categorical data between the two study populations.

RESULTS

Two hundred and 36 patients were recruited from primary health care (FYSIOPRIM, Physiotherapy In Primary Care) and 167 from specialist health care. Patients in primary health care reported less regular use of pain medication (30.7 vs. 61.3%) and fewer patients had symptom duration >12 months (41.9 vs. 51.0%). Furthermore, they reported lower pain intensity, less shoulder pain and disability (SPADI-score), lower scores on psycho-social factors, but higher on expectations of recovery.

CONCLUSIONS

Patients with shoulder pain treated in primary health care and in specialist health care are different according to factors such as duration of symptoms, pain and disability, and some of the psycho-social variables. However, the differences are small and the variations within the two study samples is large. Patients treated in primary health care seemed to be less affected and to have higher expectations concerning their recovery. However, based on our results we may question why many patients are referred to specialist health care rather than continuing treatment in primary health care.

Comparison of low-level laser treatment and extracorporeal shock wave therapy in subacromial impingement syndrome: a randomized, prospective clinical study

The aim of this study was to compare the efficacy of low-level laser treatment (LLLT) and extracorporeal shock wave therapy (ESWT) in the treatment of subacromial impingement syndrome (SIS). Seventy-one patients with subacromial impingement were randomly assigned to LLLT (n = 37) and ESWT (n = 34) groups. The patients received a total of 15 sessions of LLLT or once a week for 3 sessions of ESWT. All patients, before treatment, at the end of treatment, and 3 months after treatment, were evaluated with range of motion (ROM), visual analogue pain scale (VAS pain), Shoulder Pain and Disability Index (SPADI), Beck Depression and Anxiety Inventories, the Short Form Health Survey (SF-36), and Pittsburgh Sleep Quality Index (PSQI). In both groups, there was a significant improvement in all outcome measures (p < 0.05) except the mental health score in the LLLT group. ESWT group showed more improvements in terms of SPADI disability and total scores, PSQI, and physical-mental health scores at the end of treatment (p < 0.05). The improvement in VAS pain day and SPADI scores at the third month was significantly more evident in the ESWT group (p < 0.05). Both LLLT and ESWT treatments are effective in the treatment of SIS in the short-medium term and can be used in clinical practice. Future larger prospective clinical trials are needed to investigate the long-term efficacy and optimal treatment protocol of LLLT and ESWT in SIS.

Shock wave therapy for rotator cuff disease with or without calcification

BACKGROUND

Shock wave therapy has seen widespread use since the 1990s to treat various musculoskeletal disorders including rotator cuff disease, but evidence of its efficacy remains equivocal.

OBJECTIVES

To determine the benefits and harms of shock wave therapy for rotator cuff disease, with or without calcification, and to establish its usefulness in the context of other available treatment options.

SEARCH METHODS

We searched Ovid MEDLINE, Ovid Embase, CENTRAL, ClinicalTrials.gov and the WHO ICTRP up to November 2019, with no restrictions on language. We reviewed the reference lists of retrieved trials to identify potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and controlled clinical trials (CCTs) that used quasi-randomised methods to allocate participants, investigating participants with rotator cuff disease with or without calcific deposits. We included trials of comparisons of extracorporeal or radial shock wave therapy versus any other intervention. Major outcomes were pain relief greater than 30%, mean pain score, function, patient-reported global assessment of treatment success, quality of life, number of participants experiencing adverse events and number of withdrawals due to adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted data and assessed the certainty of evidence using GRADE. The primary comparison was shock wave therapy compared to placebo.

MAIN RESULTS

Thirty-two trials (2281 participants) met our inclusion criteria. Most trials (25) included participants with rotator cuff disease and calcific deposits, five trials included participants with rotator cuff disease and no calcific deposits, and two trials included a mixed population of participants with and without calcific deposits. Twelve trials compared shock wave therapy to placebo, 11 trials compared high-dose shock wave therapy (0.2 mJ/mm² to 0.4 mJ/mm² and above) to low-dose shock wave therapy. Single trials compared shock wave therapy to ultrasound-guided glucocorticoid needling, ultrasound-guided hyaluronic acid injection, transcutaneous electric nerve stimulation (TENS), no treatment or exercise; dual session shock wave therapy to single session therapy; and different delivery methods of shock wave therapy. Our main comparison was shock wave therapy versus placebo and results are reported for the 3 month follow up. All trials were susceptible to bias; including selection (74%), performance (62%), detection (62%), and selective reporting (45%) biases. No trial measured participant-reported pain relief of 30%. However, in one trial (74 participants), at 3 months follow up, 14/34 participants reported pain relief of 50% or greater with shock wave therapy compared with 15/40 with placebo (risk ratio (RR) 1.10, 95% confidence interval (CI) 0.62 to 1.94); low-quality evidence (downgraded for bias and imprecision). Mean pain (0 to 10 scale, higher scores indicate more pain) was 3.02 points in the placebo group and 0.78 points better (0.17 better to 1.4 better; clinically important change was 1.5 points) with shock wave therapy (9 trials, 608 participants), moderate-quality evidence (downgraded for bias). Mean function (scale 0 to 100, higher scores indicate better function) was 66 points with placebo and 7.9 points better (1.6 better to 14 better, clinically important difference 10 points) with shock wave therapy (9 trials, 612 participants), moderate-quality evidence (downgraded for bias). Participant-reported success was reported by 58/150 people in shock wave therapy group compared with 35/137 people in placebo group (RR 1.59, 95% CI 0.87 to 2.91; 6 trials, 287 participants), low-quality evidence (downgraded for bias and imprecision). None of the trials measured quality of life. Withdrawal rate or adverse event rates may not differ between extracorporeal shock wave therapy and placebo, but we are uncertain due to the small number of events. There were 11/34 withdrawals in the extracorporeal shock wave therapy group compared with 13/40 withdrawals in the placebo group (RR 0.75, 95% CI 0.43 to 1.31; 7 trials, 581 participants) low-quality evidence (downgraded for bias and imprecision); and 41/156 adverse events with extracorporeal shock wave therapy compared with 10/139 adverse events in the placebo group (RR 3.61, 95% CI 2.00 to 6.52; 5 trials, 295 participants) low-quality evidence (downgraded for bias and imprecision). Subgroup analyses indicated that there were no between-group differences in pain and function outcomes in participants who did or did not have calcific deposits in the rotator cuff.

AUTHORS' CONCLUSIONS

Based upon the currently available low- to moderate-certainty evidence, there were very few clinically important benefits of shock wave therapy, and uncertainty regarding its safety. Wide clinical diversity and varying treatment protocols means that we do not know whether or not some trials tested subtherapeutic doses, possibly underestimating any potential benefits. Further trials of extracorporeal shock wave therapy 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. A standard dose and treatment protocol should be decided upon before further research is conducted. Development of a core set of outcomes for trials of rotator cuff disease and other shoulder disorders would also facilitate our ability to synthesise the evidence.

The effectiveness of extracorporeal shockwave treatment in subacromial impingement syndrome and its relation with acromion morphology

Objective

The aim of this study was to evaluate the effectiveness of the extracorporeal shock wave therapy in the subacromial impingement syndrome and its relationship with the acromion morphology.

Methods

Thirty patients (24 women, 6 men) with subacromial impingement were evaluated. The average age of patients was 53.6 ± 9.8 years (range 39–80). Patients were divided into 3 groups according to the acromion morphology. ESWT 1500 at 0.12 am mL/mm² violence was applied once a week for 3 weeks. Shoulder pain and disability index (SPADI) was used to assess function and pain scores of the patients. The evaluations were made prior to and 12 weeks after the ESWT.

Results

Thirteen shoulders had type 1 acromion, 11 shoulders type 2 acromion and 6 shoulders type 3 acromion. After ESWT, the SPADI pain score decreased from 16.1 ± 5.1 (7–25) to 10.4 ± 4.9 (1–20); SPADI functional score decreased from 37.3 ± 19.8 (5–70) to 26.7 ± 17.5 (1–60); SPADI total score decreased from 53.4 ± 24.5 (14–95) to 37.1 ± 21.6 (2–74) (p < 0.05; paired t test). In each group better functional outcomes were achieved after ESWT (p < 0.05; paired t test). There were no differences between the groups according to functional outcome both before and after the ESWT treatment (p > 0.05, one way ANOVA test).

Conclusion

ESWT was found to be effective in the treatment of impingement syndrome both for pain and functional outcome in the early period regardless of acromion morphology.

Level of evidence

Level IV, Therapeutic study.

Effectiveness of Radial Extracorporeal Shock Wave Therapy (rESWT) When Combined With Supervised Exercises in Patients With Subacromial Shoulder Pain: A Double-Masked, Randomized, Sham-Controlled Trial

BACKGROUND

Subacromial shoulder pain is a common complaint, and radial extracorporeal shock wave therapy (rESWT) is increasingly used to treat this condition. Although many therapists use rESWT in combination with supervised exercises, no studies have evaluated the additional effect of rESWT with supervised exercises for subacromial shoulder pain.

PURPOSE

To assess whether rESWT is more effective than sham rESWT when combined with supervised exercises for improving pain and function in patients with subacromial shoulder pain.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Patients between 25 and 70 years of age with subacromial shoulder pain with and without calcification in the rotator cuff lasting at least 3 months were assessed for eligibility; 143 patients were recruited. Participants were allocated (1:1) by computer-generated randomization in blocks of 20 to receive either rESWT or sham rESWT in addition to supervised exercises. The rESWT and sham rESWT were performed once a week with additional supervised exercises once a week for the first 4 weeks. The following 8 weeks, the patients received supervised exercises twice a week. The primary outcome was change in the Shoulder Pain and Disability Index (SPADI) after 24 weeks. Patients and outcome assessors were masked to group assignment.

RESULTS

At 24 weeks, participants in both the sham group and the rESWT group had improved ( P < .001) in SPADI score compared with baseline (-23.9 points [SD, 23.8 points] and -23.3 points [SD, 25.0 points], respectively), but there were no differences between the groups (mean difference 0.7; 95% CI, -6.9 to 8.3; P = .76). Prespecified subgroup analysis of patients with calcification in rotator cuff showed that the rESWT group had a greater improvement in SPADI score after 24 weeks (mean difference -12.8; 95% CI, -24.8 to -0.8; P = .018).

CONCLUSION

Radial ESWT offered no additional benefit to supervised exercises in the treatment of subacromial shoulder pain after 24 weeks, except in the subgroup of patients with calcification in the rotator cuff. Registration: NCT01441830 ( ClinicalTrials.gov identifier).