Supervised exercises compared with radial extracorporeal shock-wave therapy for subacromial shoulder pain: 1-year results of a single-blind randomized controlled trial

Shoulder specific exercise therapy is effective in reducing chronic shoulder pain: A network meta-analysis

BACKGROUND

Exercise therapy (ET) is frequently an early treatment of choice when managing shoulder pain, yet evidence on its efficacy to expedite recovery is inconsistent. Moreover, the value of adding adjunct therapies (i.e. injections, manual therapy, electrotherapy) to ET is currently unclear. This study combined both direct and indirect evidence across studies on the effectiveness of ET with/without adjunct therapies compared to usual medical care for adults with chronic shoulder pain.

METHODS AND FINDINGS

Using a network meta-analysis, randomized control trials comparing ET along with adjunct therapies were identified in MEDLINE, Embase, CINAHL, Sportdiscus, CENTRAL, Conference Proceedings Citation Index-Science, clinicaltrials.gov, and association websites. Outcomes included pain, range of motion (ROM), and health-related quality of life (HRQL) measures in adult patients with chronic shoulder pain. Data analysis used a Frequentist hierarchical model. CINeMA tool assessed the confidence in the results and Cochrane Risk of Bias tool assessed quality of studies. 54 studies primarily from Europe (40.38%) included 3,893 participants who were followed up to 52 weeks. Shoulder-specific ET (Mean difference (MD) = -2.1; 95% confidence interval (CI) = -3.5 to -0.7) or in combination with electro-physical agents (MD = -2.5; 95% CI = -4.2 to -0.7), injections (MD = -2.4; 95% CI = -3.9 to-1.04) or manual therapy (MD = -2.3; 95% CI = -3.7 to -0.8) decreased pain compared to usual medical care. Trends with ROM and HRQL scores were seen; however, only Manual Therapy (MD = -12.7 and 95% CI = -24.4 to -1.0) achieved meaningfully important changes. Sensitivity analysis excluding studies with high risk of bias showed similar results, with exception of injections that did not reach significance (MD = -1.3; 95% CI = -4.3 to 1.7).

CONCLUSION(S)

Shoulder-specific ET provided pain relief up to 52 weeks. Adjunct therapies to shoulder-specific ET added little value in reducing pain. The quality of evidence varied between moderate and very low.

The effect of extracorporeal shock-wave therapy on pain in patients with various tendinopathies: a systematic review and meta-analysis of randomized control trials

OBJECTIVES

Tendinopathy is a common condition that affects the body's tendon structures, causing discomfort, restricted movement, and reduced functionality. In this study, we looked at how extracorporeal shock wave therapy (ESWT) affected pain levels in individuals with various forms of tendinopathy around the world.

DESIGN

This study is a comprehensive review and meta-analysis of previously published randomized controlled trials. To gather relevant data, the researchers performed keyword searches in international databases, including PubMed (Medline), Scopus, Web of Sciences, Cochrane Central Register of Controlled Trials (CENTRAL), Research Registers of ongoing trials (ClinicalTrials.gov), as well as Embase. The search was conducted up until March 2023. The quality of the selected articles was assessed using the Cochrane risk-of-bias method for randomized trials (RoB2).

RESULTS

Based on the results of the meta-analysis, which included 45 clinical studies, the use of ESWT was found to have a significant impact on reducing pain in various conditions. The standardized mean difference (SMD) in patients with plantar fasciitis (PF) was reduced by 1.63 (SMD: -1.63, 95% CI: -3.04, -0.21; I2: 77.36%; P heterogeneity: 0.0001). For lateral epicondylitis (LE), the SMD was 0.63 (SMD: -0.63, 95% CI: -1.11, -0.16; I2: 67.50%; P heterogeneity: 0.003). In the case of chronic Achilles tendinopathy, the SMD was 1.38 (SMD: -1.38, 95% CI: -1.66, -1.10; I2: 96.44%; P heterogeneity: 0.0001). Additionally, in individuals with rotator cuff tendinopathy, the SMD for pain reduction was 2.37 units (SMD: -2.37, 95% CI: -3.58, -1.15; I2: 98.46%; P heterogeneity: 0.0001).

CONCLUSION

This study suggests that ESWT can be a highly effective therapy option for relieving pain in people with tendinopathy. Nonetheless, it is encouraged to make additional recommendations based on high-quality clinical research and more accurate information in order to define the optimal therapeutic options for each type of tendinopathy.

Additional Effect of Extracorporeal Shockwave Therapy with Lidocaine Injection on Clinical and MRI Findings in Frozen Shoulder: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Trial

INTRODUCTION

Frozen shoulder is a very common musculoskeletal condition and the evidence related to the additional effects of extracorporeal shockwave therapy (ESWT) with intra-articular (IA) lidocaine injection in individuals with frozen shoulder is rare. Therefore, this study aims to compare and investigate the additional effects of extracorporeal shockwave therapy (ESWT) with intra-articular (IA) lidocaine injection in a frozen shoulder.

METHODS

Sixty eligible participants with frozen shoulder were included and the active group (n = 30, age 52.12 ± 5.2 years) received a lidocaine injection (1% lidocaine (Xylocaine) and 2cc (80 mg) methylprednisolone acetate) with active ESWT (3.5 bar air pressure and 2000 pulses with an energy flux density (EFD) ¼ 0.16 mJ/mm2) three sessions a week for 4 weeks. The placebo group (n = 30, age 53.56 ± 5.5 years) received lidocaine injection with placebo treatment (a special head that blocked the shock waves) three sessions a week for 4 weeks. Both groups received progressive resistance exercises (PRE) to the shoulder muscles. The primary outcome was pain intensity, measured with the visual analogue scale. The other outcome measures were the thickness of the coracohumeral ligament (CHL) measured by magnetic resonance imaging (MRI), abduction, and lateral rotation range of motion (ROM), functional disability, kinesiophobia, depression status, and quality of life. Participants were assessed at baseline, after 4 weeks, 8 weeks, and at 6-month follow-up.

RESULTS

The post-intervention at 4 weeks showed an improvement of 2.0 (CI 95% 1.71-2.28) in the active group compared to the placebo group. Similar effects were noted after 8 weeks (2.2) (CI 95% 1.91-2.48) and at the 6-month (1.9) (CI 95% 1.61-2.18) follow-up. Similar improvements were also found in the thickness of the CHL ligament (0.6) (CI 95% 0.46-0.73), abduction and lateral rotation (ROM) (- 23.6) (CI 95% - 27.47 to -19.72), (- 18.10) (CI 95% - 19.72 to - 16.47), functional disability (16.2) (CI 95% 14.85-17.54), kinesiophobia (11.0 (CI 95% 10.21-11.98), depression status (4.4) (CI 95% 4.03-4.76) and quality of life (0.9) (CI 95% 0.79-1.00) (p = 0.001) at the 6-month follow-up period, where mean estimates and their confidence intervals all included worthwhile effects. There were no adverse reactions or side effects noted in either the active or placebo groups during and after the treatment.

CONCLUSIONS

The study concluded that the addition of extracorporeal shockwave therapy after intra-articular lidocaine injection improves pain, functional disability, range of motion, kinesiophobia, depression status, and quality of life in people with frozen shoulder.

TRIAL REGISTRATION

https://ctri.nic.in , identifier; CTRI/2020/04/024834 prospectively registered on 24/04/2020.

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.

Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness

Background

Tendinopathy is a common, painful and functionally limiting condition, primarily managed conservatively using exercise therapy.

Review questions

(i) What exercise interventions have been reported in the literature for which tendinopathies? (ii) What outcomes have been reported in studies investigating exercise interventions for tendinopathy? (iii) Which exercise interventions are most effective across all tendinopathies? (iv) Does type/location of tendinopathy or other specific covariates affect which are the most effective exercise therapies? (v) How feasible and acceptable are exercise interventions for tendinopathies?

Methods

A scoping review mapped exercise interventions for tendinopathies and outcomes reported to date (questions i and ii). Thereafter, two contingent systematic review workstreams were conducted. The first investigated a large number of studies and was split into three efficacy reviews that quantified and compared efficacy across different interventions (question iii), and investigated the influence of a range of potential moderators (question iv). The second was a convergent segregated mixed-method review (question v). Searches for studies published from 1998 were conducted in library databases (n = 9), trial registries (n = 6), grey literature databases (n = 5) and Google Scholar. Scoping review searches were completed on 28 April 2020 with efficacy and mixed-method search updates conducted on 19 January 2021 and 29 March 2021.

Results

Scoping review - 555 included studies identified a range of exercise interventions and outcomes across a range of tendinopathies, most commonly Achilles, patellar, lateral elbow and rotator cuff-related shoulder pain. Strengthening exercise was most common, with flexibility exercise used primarily in the upper limb. Disability was the most common outcome measured in Achilles, patellar and rotator cuff-related shoulder pain; physical function capacity was most common in lateral elbow tendinopathy. Efficacy reviews - 204 studies provided evidence that exercise therapy is safe and beneficial, and that patients are generally satisfied with treatment outcome and perceive the improvement to be substantial. In the context of generally low and very low-quality evidence, results identified that: (1) the shoulder may benefit more from flexibility (effect sizeResistance:Flexibility = 0.18 [95% CrI 0.07 to 0.29]) and proprioception (effect sizeResistance:Proprioception = 0.16 [95% CrI -1.8 to 0.32]); (2) when performing strengthening exercise it may be most beneficial to combine concentric and eccentric modes (effect sizeEccentricOnly:Concentric+Eccentric = 0.48 [95% CrI -0.13 to 1.1]; and (3) exercise may be most beneficial when combined with another conservative modality (e.g. injection or electro-therapy increasing effect size by ≈0.1 to 0.3). Mixed-method review - 94 studies (11 qualitative) provided evidence that exercise interventions for tendinopathy can largely be considered feasible and acceptable, and that several important factors should be considered when prescribing exercise for tendinopathy, including an awareness of potential barriers to and facilitators of engaging with exercise, patients' and providers' prior experience and beliefs, and the importance of patient education, self-management and the patient-healthcare professional relationship.

Limitations

Despite a large body of literature on exercise for tendinopathy, there are methodological and reporting limitations that influenced the recommendations that could be made.

Conclusion

The findings provide some support for the use of exercise combined with another conservative modality; flexibility and proprioception exercise for the shoulder; and a combination of eccentric and concentric strengthening exercise across tendinopathies. However, the findings must be interpreted within the context of the quality of the available evidence.

Future work

There is an urgent need for high-quality efficacy, effectiveness, cost-effectiveness and qualitative research that is adequately reported, using common terminology, definitions and outcomes.

Study registration

This project is registered as DOI: 10.11124/JBIES-20-00175 (scoping review); PROSPERO CRD 42020168187 (efficacy reviews); https://osf.io/preprints/sportrxiv/y7sk6/ (efficacy review 1); https://osf.io/preprints/sportrxiv/eyxgk/ (efficacy review 2); https://osf.io/preprints/sportrxiv/mx5pv/ (efficacy review 3); PROSPERO CRD42020164641 (mixed-method review).

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) HTA programme and will be published in full in HTA Journal; Vol. 27, No. 24. See the NIHR Journals Library website for further project information.

Extracorporeal Shock Wave Therapy vs. Corticosteroid Local Injection in Shoulder Impingement Syndrome : A Three-Arm Randomized Controlled Trial

OBJECTIVE

The aim of this study was to examine the effects of combining extracorporeal shock wave therapy or local corticosteroid injections with a conventional physical therapy (CPT) program for patients with shoulder impingement syndrome.

DESIGN

This was a prospective single-blinded, randomized controlled study.

METHODS

Sixty patients with unilateral shoulder impingement syndrome >3 mos were allocated to group A (a 4-wk program of CPT plus a single local corticosteroid injection of 40 mg triamcinolone acetonide mixed with 1% xylocaine, n = 20), group B (CPT only, n = 20), and group C (CPT plus extracorporeal shock wave therapy, 2000 impulses, 0.2-0.3 mJ/mm 2 , one session per week for 3 wks, n = 20). Subacromial space, shoulder pain and disability index, and shoulder range of motion were assessed at baseline and 4 and 12 wks posttreatment.

RESULTS

There were no between-group differences at 4 wks. At the 12-wk follow-up, no significant differences were found between groups A and B. There was a significant difference in favor of group C compared with group A with the expectation of shoulder internal rotation and subacromial space. Group C was also superior to group B in all outcomes except for subacromial space.

CONCLUSION

The addition of extracorporeal shock wave therapy to CPT induced more noticeable intermediate-term effects than CPT plus local corticosteroid injection or CPT alone.

Bibliometric and visualized analysis of scientific publications on rehabilitation of rotator cuff injury based on web of science

Background

Since the discovery of rehabilitation as an intervention for rotator cuff injury, its impact on the recovery of rotator cuff injury has attracted crucial attention, and the number of related studies is increasing worldwide. There were no bibliometric and visualized analysis studies in this field. This study aimed to investigate the research hotpots and trends in the rehabilitation of rotator cuff injury via bibliometric and visualized analysis and to identify the future development of clinical practice.

Method

The publications regarding rehabilitation of rotator cuff injury from inception to December 2021 were obtained from the Web of Science Core Collection database. The trends of publications, co-authorship and co-occurrence analysis and visualized analysis were carried out using Citespace, VOSviewer, Scimago Graphica software, and R Project.

Results

A total of 795 publications were included in this study. The number of publications significantly increased yearly. The United States published the highest number of related papers and the papers published by the United States had the highest citations. The University of Laval, the University of Montreal and Keele University were the top 3 most contributive institutions. Additionally, the Journal of Shoulder and Elbow Surgery was the journal with the highest number of publications. The most common keywords were "rotator cuff", "rehabilitation", "physical therapy", "management", and "telerehabilitation".

Conclusion

The total number of publications has shown a steady upward trend. The cooperation between countries globally was still relatively lacking, and therefore it is necessary to strengthen cooperation between different countries and regions to provide conditions for multi-center, large sample, and high-quality research. In addition to the relatively mature rehabilitation of rotator cuff injury such as passive motion or exercise therapy, telerehabilitation has also attracted much attention with the progress of science.

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.

Combined extracorporeal shockwave therapy and exercise for the treatment of tendinopathy: A narrative review

Tendinopathy is a chronic degenerative musculoskeletal disorder that is common in both athletes and the general population. Exercise and extracorporeal shockwave therapy (ESWT) is among the most common treatments used to mediate tendon healing and regeneration. The review presents the current understanding of mechanisms of action of ESWT and exercise in isolation and briefly synthesises evidence of their effectiveness for various tendinopathies. The central purpose of the review is to synthesize research findings investigating the combination of ESWT and exercise for five common tendinopathies (plantar heel pain, rotator cuff, lateral elbow, Achilles, and patellar tendinopathy) and provide recommendations on clinical applicability. Collectively, the available evidence indicates that ESWT combined with exercise in the form of eccentric training, tissue-specific stretching, or heavy slow resistance training are effective for specific tendinopathies and can therefore be recommended in treatment. Whilst there are at present a limited number of studies investigating combined EWST and exercise approaches, there is evidence to suggest that the combination improves outcomes in the treatment of plantar heel pain, Achilles, lateral elbow, and rotator cuff tendinopathy. However, despite overall positive outcomes in patellar tendinopathy, the combined treatment has not been shown at present to offer additional benefit over eccentric exercise alone.

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.

Noninvasive management of soft tissue disorders of the shoulder: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration

OBJECTIVES

Objective of this study is to develop an evidence-based guideline for the noninvasive management of soft tissue disorders of the shoulder (shoulder pain), excluding major pathology.

METHODS

This guideline is based on high-quality evidence from seven systematic reviews. Multidisciplinary experts considered the evidence of effectiveness, safety, cost-effectiveness, societal and ethical values, and patient experiences when formulating recommendations. Target audience is clinicians; target population is adults with shoulder pain.

RESULTS

When managing patients with shoulder pain, clinicians should (a) rule out major structural or other pathologies as the cause of shoulder pain and reassure patients about the benign and self-limited nature of most soft tissue shoulder pain; (b) develop a care plan in partnership with the patient; (c) for shoulder pain of any duration, consider low-level laser therapy; multimodal care (heat/cold, joint mobilization, and range of motion exercise); cervicothoracic spine manipulation and mobilization for shoulder pain when associated pain or restricted movement of the cervicothoracic spine; or thoracic spine manipulation; (d) for shoulder pain >3-month duration, consider stretching and/or strengthening exercises; laser acupuncture; or general physician care (information, advice, and pharmacological pain management if necessary); (e) for shoulder pain with calcific tendinitis on imaging, consider shock-wave therapy; (f) for shoulder pain of any duration, do not offer ultrasound; taping; interferential current therapy; diacutaneous fibrolysis; soft tissue massage; or cervicothoracic spine manipulation and mobilization as an adjunct to exercise (i.e., range of motion, strengthening and stretching exercise) for pain between the neck and the elbow at rest or during movement of the arm; (g) for shoulder pain >3-month duration, do not offer shock-wave therapy; and (h) should reassess the patient's status at each visit for worsening of symptoms or new physical, mental, or psychological symptoms, or satisfactory recovery.

CONCLUSIONS

Our evidence-based guideline provides recommendations for non-invasive management of shoulder pain. The impact of the guideline in clinical practice requires further evaluation.

SIGNIFICANCE

Shoulder pain of any duration can be effectively treated with laser therapy, multimodal care (i.e., heat/cold, joint mobilization, range of motion exercise), or cervicothoracic manipulation and mobilization. Shoulder pain (>3 months) can be effectively treated with exercises, laser acupuncture, or general physician care (information, advice, and pharmacological pain management if necessary).

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.

Participant characteristics are poorly reported in exercise trials in tendinopathy: A systematic review

OBJECTIVE

To evaluate the reporting of eligibility criteria and baseline participant characteristics in randomised controlled trials investigating the effects of exercise interventions in tendinopathy.

METHODS

Randomised controlled trials investigating the effects of exercise therapy compared to a non-exercising intervention in upper and lower limb tendinopathy were included. Data extraction was categorised into the following domains: participant demographics, tendinopathy descriptors, general health, participant recruitment and eligibility criteria.

RESULTS

The review included the following tendinopathies: Achilles (n = 9), gluteal (n = 2), lateral elbow tendinopathy (n = 15), patellar (n = 3) plantar (n = 3), and rotator cuff (n = 13). Age, sex, duration of symptoms and symptom severity were commonly reported across the review, while prior history of tendinopathy was poorly reported (6/45). Variables such as physical activity level (17/45), sleep (0/45), psychological factors (2/45), medication at baseline (8/45), co morbid health complaints (10/45) and sociodemographic factors (11/45) were poorly reported across the included studies. Substantial variation existed between studies in the specific eligibility criteria used.

CONCLUSION

The findings of this systematic review demonstrate that participant characteristics are poorly reported in exercise trials in tendinopathy. To improve effectiveness of exercise interventions in tendinopathy, improved reporting of participant characteristics may allow better comparisons and targeted interventions for specific subgroups.

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.

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.

Conservative treatment for patients with subacromial impingement: Changes in clinical core outcomes and their relation to specific rehabilitation parameters

Background

Impaired patient-reported shoulder function and pain, external-rotation strength, abduction strength, and abduction range-of-motion (ROM) is reported in patients with subacromial impingement (SIS). However, it is unknown how much strength and ROM improves in real-life practice settings with current care. Furthermore, outcomes of treatment might depend on specific rehabilitation parameters, such as the time spent on exercises (exercise-time), number of physiotherapy sessions (physio-sessions) and number of corticosteroid injections, respectively. However, this has not previously been investigated. The purpose of this study was to describe changes in shoulder strength, ROM, patient-reported function and pain, in real-life practice settings, and explore the association between changes in clinical core outcomes and specific rehabilitation parameters.

Methods

Patients diagnosed with SIS at initial assessment at an outpatient hospital clinic using predefined criteria’s, who had not undergone surgery after 6 months, were included in this prospective cohort study. After initial assessment (baseline), all patients underwent treatment as usual, with no interference from the investigators. The outcomes Shoulder Pain and Disability Index (SPADI:0–100), average pain (NRS:0–10), external rotation strength, abduction strength and abduction ROM, pain during each test (NRS:0–10), were collected at baseline and at six month follow-up. Amount of exercise-time, physio-sessions and steroid-injections was recorded at follow-up. Changes in outcomes were analyzed using Wilcoxon Signed-Rank test, and the corresponding effect sizes (ES) were estimated. The associations between changes in outcomes and rehabilitation parameters were explored using multiple regression analyses.

Results

Sixty-three patients completed both baseline and follow-up testing. Significant improvements were seen in SPADI (19 points, ES:0.53, p < 0.001) and all pain variables (median 1–1.5 points, ES:0.26–0.39, p < 0.01), but not in strength and ROM (ES:0.9–0.12, p > 0.2). A higher number of physio-sessions was significantly associated with larger improvements in external rotation strength (0.7 Newton/session, p = 0.046), and higher exercise-time was significantly associated with decrease in average pain (−0.2 points/1,000 min, p = 0.048).

Discussion

Patient-reported function and pain improved after six months of current care, but strength and ROM did not improve. This is interesting, as strengthening exercises is part of most current interventions. While two significant associations were identified between self-reported rehabilitation parameters and outcomes, the small gains per physio-session or 1,000 min of exercise-time reduces the clinical relevance of these relationships. Collectively, the findings from this study indicate room for improvement of the current rehabilitation of SIS, especially with regard to core clinical outcomes, such as strength and range of motion.

The Effectiveness of Multimodal Care for the Management of Soft Tissue Injuries of the Shoulder: A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

OBJECTIVE

The purpose of this systematic review was to evaluate the effectiveness of multimodal care for the management of soft tissue injuries of the shoulder.

METHODS

We conducted a systematic review and searched MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Central Register of Controlled Trials from 1990 to 2015. Two independent reviewers critically appraised studies using the Scottish Intercollegiate Guidelines Network criteria. We used best evidence synthesis to synthesize evidence from studies with low risk of bias.

RESULTS

We screened 5885 articles, and 19 were eligible for critical appraisal. Ten randomized controlled trials had low risk of bias. For persistent subacromial impingement syndrome, multimodal care leads to similar outcomes as sham therapy, radial extracorporeal shock-wave therapy, or surgery. For subacromial impingement syndrome, multimodal care may be associated with small and nonclinically important improvement in pain and function compared with corticosteroid injections. For rotator cuff tendinitis, dietary-based multimodal care may be more effective than conventional multimodal care (exercise, soft tissue and manual therapy, and placebo tablets). For nonspecific shoulder pain, multimodal care may be more effective than wait list or usual care by a general practitioner, but it leads to similar outcomes as exercise or corticosteroid injections.

CONCLUSIONS

The current evidence suggests that combining multiple interventions into 1 program of care does not lead to superior outcomes for patients with subacromial impingement syndrome or nonspecific shoulder pain. One randomized controlled trial suggested that dietary-based multimodal care (dietary advice, acupuncture, and enzyme tablets) may provide better outcomes over conventional multimodal care. However, these results need to be replicated.

Shoulder impingement syndrome: a systematic review of clinical trial participant selection criteria

BACKGROUND

Shoulder impingement syndrome (SIS) is a common diagnosis for patients with pain and dysfunction of the shoulder. Variations in the signs and symptoms might lead to uncertainty regarding the definition of SIS. The aim of this review is to explore the participant selection criteria used in the literature when investigating SIS and to assess differences in criteria among treating professions.

METHODS

This is a PRISMA systematic review of publications from 2009 to 2014 from MEDLINE, PubMed, The Cochrane Library, Embase, Scopus and CINAHL.

RESULTS

Ninety-seven articles met inclusion criteria for this review. Twenty-five different surgical and nonsurgical treatments were investigated. Impingement-specific index tests were used in all studies. Exclusion index tests were used in 62% of studies. Twenty index tests were identified. Radiological investigations were reported in 53% of all studies, of which a further 53% reported using two or more radiological investigations.

CONCLUSIONS

This systematic review has illustrated that studies investigating SIS test for various signs and symptoms, which is in keeping with describing the condition as a 'syndrome'. However, there are inconsistencies in participant selection criteria between health disciplines, highlighting a need for harmonization of the selection criteria in the form of an international editorial consensus.

Radial extracorporeal shockwave therapy for the treatment of finger tenosynovitis (trigger digit)

Introduction

Stenosing tenosynovitis that is characterized by the inability to flex the digit smoothly, usually leads to prolonged rehabilitation or surgery.

Study design

This case series is a retrospective cohort study.

Purpose

The aim of this case series was to evaluate the effectiveness of radial extracorporeal shockwave therapy (rESWT) for the treatment of stenosing tenosynovitis of the digital flexor tendon (trigger digit).

Methods

A retrospective analysis of 44 patients (49 fingers) treated with an individually adapted rESWT protocol was conducted. Trigger digit pain and function were evaluated at baseline and 1-, 3-, and 12-months posttreatment. Recurrence and pretreatment symptom duration were analyzed.

Results

Significant reductions in pain scores and functional improvement were found between baseline and all follow-up assessments (P<0.001). Pretreatment symptom duration was significantly correlated with the number of rESWT sessions required (r=0.776, P<0.001) and 1-year posttreatment pain score (r=0.335, P=0.019).

Conclusion

This study provides initial evidence that rESWT is an effective treatment for trigger digit, but randomised controlled trials are required to provide further evidence of this effect.

Is Extracorporeal Shockwave Therapy Combined With Isokinetic Exercise More Effective Than Extracorporeal Shockwave Therapy Alone for Subacromial Impingement Syndrome? A Randomized Clinical Trial

Study Design Single-blind randomized trial. Background Extracorporeal shockwave therapy (ESWT) has been shown to produce good results in the treatment of subacromial impingement syndrome (SAIS). The efficacy of a combined administration of ESWT and isokinetic exercise (IE) has not yet been studied. Objectives To evaluate the efficacy of focused ESWT combined with IE for the rotator cuff versus focused ESWT alone in the treatment of SAIS. The secondary objective was to assess the isokinetic torque recovery (external rotation at 210°/s, 180°/s, and 120°/s). Methods Thirty participants with SAIS were randomly assigned to a focused-ESWT group or focused ESWT-plus-IE group. Subjects of both groups received 3 treatment sessions of focused ESWT over a period of 10 days. Participants in the second group also received IE for 10 therapy sessions. Outcome measures were the Constant-Murley score (CMS), the visual analog scale (VAS), and isokinetic parameters (peak torque and total work calculated from 5 repetitions) measured with the isokinetic test. Subjects were assessed at baseline, 10 days after the last treatment session with focused ESWT, and after 2 months of follow-up. Results At 2 months posttreatment, participants in the focused ESWT-plus-IE group showed significantly less pain (focused-ESWT VAS, 3.4 ± 0.8 versus focused ESWT-plus-IE VAS, 1.5 ± 0.5; P<.001) and greater improvement in functionality (focused-ESWT CMS, 75.9 ± 6.7 versus focused ESWT-plus-IE CMS, 92.1 ± 6.3; P<.001) and muscle endurance than the subjects in the focused-ESWT group. Conclusion In subjects with SAIS, combined administration of focused ESWT and IE for the rotator cuff resulted in greater reduction of pain, as well as superior functional recovery and muscle endurance in the short to medium term, compared with ESWT alone. Level of evidence Therapy, 2b.

TRIAL REGISTRATION

unregistered 2011 trial. J Orthop Sports Phys Ther 2016;46(9):714-725. Epub 5 Aug 2016. doi:10.2519/jospt.2016.4629.

Efficacy of exercise therapy in workers with rotator cuff tendinopathy: a systematic review

Objective:

To perform a systematic review of randomized controlled trials (RCTs) on the efficacy of therapeutic exercises for workers suffering from rotator cuff (RC) tendinopathy.

Methods:

A literature search in four bibliographical databases (Pubmed, CINAHL, EMBASE, and PEDro) was conducted from inception up to February 2015. RCTs were included if participants were workers suffering from RC tendinopathy, the outcome measures included work-related outcomes, and at least one of the interventions under study included exercises. The methodological quality of the studies was evaluated with the Cochrane Risk of Bias Assessment tool.

Results:

The mean methodological score of the ten included studies was 54.4%±17.2%. Types of workers included were often not defined, and work-related outcome measures were heterogeneous and often not validated. Three RCTs of moderate methodological quality concluded that exercises were superior to a placebo or no intervention in terms of function and return-to-work outcomes. No significant difference was found between surgery and exercises based on the results of two studies of low to moderate methodological quality. One study of low methodological quality, comparing a workplace-based exercise program focusing on the participants' work demands to an exercise program delivered in a clinical setting, concluded that the work-based intervention was superior in terms of function and return-to-work outcomes.

Conclusion:

There is low to moderate-grade evidence that therapeutic exercises provided in a clinical setting are an effective modality to treat workers suffering from RC tendinopathy and to promote return-to-work. Further high quality studies comparing different rehabilitation programs including exercises in different settings with defined workers populations are needed to draw firm conclusions on the optimal program to treat workers.

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.

Radial Shock Wave Devices Generate Cavitation

BACKGROUND

Conflicting reports in the literature have raised the question whether radial extracorporeal shock wave therapy (rESWT) devices and vibrating massage devices have similar energy signatures and, hence, cause similar bioeffects in treated tissues.

METHODS AND FINDINGS

We used laser fiber optic probe hydrophone (FOPH) measurements, high-speed imaging and x-ray film analysis to compare fundamental elements of the energy signatures of two rESWT devices (Swiss DolorClast; Electro Medical Systems, Nyon, Switzerland; D-Actor 200; Storz Medical, Tägerwillen, Switzerland) and a vibrating massage device (Vibracare; G5/General Physiotherapy, Inc., Earth City, MO, USA). To assert potential bioeffects of these treatment modalities we investigated the influence of rESWT and vibrating massage devices on locomotion ability of Caenorhabditis elegans (C. elegans) worms.

RESULTS

FOPH measurements demonstrated that both rESWT devices generated acoustic waves with comparable pressure and energy flux density. Furthermore, both rESWT devices generated cavitation as evidenced by high-speed imaging and caused mechanical damage on the surface of x-ray film. The vibrating massage device did not show any of these characteristics. Moreover, locomotion ability of C. elegans was statistically significantly impaired after exposure to radial extracorporeal shock waves but was unaffected after exposure of worms to the vibrating massage device.

CONCLUSIONS

The results of the present study indicate that both energy signature and bioeffects of rESWT devices are fundamentally different from those of vibrating massage devices.

CLINICAL RELEVANCE

Prior ESWT studies have shown that tissues treated with sufficient quantities of acoustic sound waves undergo cavitation build-up, mechanotransduction, and ultimately, a biological alteration that "kick-starts" the healing response. Due to their different treatment indications and contra-indications rESWT devices cannot be equated to vibrating massage devices and should be used with due caution in clinical practice.

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

Background

Subacromial shoulder pain is a common complaint. Radial Extracorporeal Shock Wave Therapy (rESWT) has being increasingly used to treat calcific and non-calcific tendinosis, although there is no evidence of the effectiveness of rESWT in non-calcific tendinosis of the rotator cuff. A randomised single blind study showed that the short-term effect of supervised exercises (SE) was significantly better than rESWT on subacromial shoulder pain, but both groups improved. In a clinical trial on achilles tendinopathy rESWT improved the effectiveness of treatment with eccentric loading. The objective of this present study is to evaluate if rESWT in addition to SE is more effective in improving shoulder pain and function compared with sham rESWT and SE in patients with subacromial shoulder pain.

Methods/Design

This is a double blind, randomised sham-controlled trial which is performed at the shoulder clinic at the Department of Physical Medicine and Rehabilitation in Oslo University Hospital, Norway. One-hundred-forty-four patients with subacromial shoulder pain lasting at least 3 months, age from 25 to 70 years old are included in the trial. Patients are randomly allocated in 1:1 ratio to receive either rESWT or sham rESWT once a week in addition to SE once a week for the initial 4 weeks. Subsequently SE are provided twice a week for 8 weeks. The primary outcome measure is a change in the Shoulder Pain and Disability Index (SPADI) at 24 weeks follow-up. Secondary outcomes include return to work, pain at rest and on activity, function, and health related quality of life. The patients, the physiotherapist providing the exercise regimen and the outcome assessor are blinded to group assignment. The physiotherapist providing the rESWT is not blinded.

Discussion

Because of the extensive use of rESWT in the treatment of subacromial shoulder pain the results of this trial will be of importance and have impact on clinical practice.

Trial registration

ClinicalTrials.gov NCT01441830

Effectiveness of passive physical modalities for shoulder pain: systematic review by the Ontario protocol for traffic injury management collaboration

BACKGROUND

Shoulder pain is a common musculoskeletal condition in the general population. Passive physical modalities are commonly used to treat shoulder pain. However, previous systematic reviews reported conflicting results.

PURPOSE

The aim of this study was to evaluate the effectiveness of passive physical modalities for the management of soft tissue injuries of the shoulder.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Central Register of Controlled Trials were searched from January 1, 1990, to April 18, 2013.

STUDY SELECTION

Randomized controlled trials (RCTs) and cohort and case-control studies were eligible. Random pairs of independent reviewers screened 1,470 of 1,760 retrieved articles after removing 290 duplicates. Twenty-two articles were eligible for critical appraisal. Eligible studies were critically appraised using the Scottish Intercollegiate Guidelines Network criteria. Of those, 11 studies had a low risk of bias.

DATA EXTRACTION

The lead author extracted data from low risk of bias studies and built evidence tables. A second reviewer independently checked the extracted data.

DATA SYNTHESIS

The findings of studies with a low risk of bias were synthesized according to principles of best evidence synthesis. Pretensioned tape, ultrasound, and interferential current were found to be noneffective for managing shoulder pain. However, diathermy and corticosteroid injections led to similar outcomes. Low-level laser therapy provided short-term pain reduction for subacromial impingement syndrome. Extracorporeal shock-wave therapy was not effective for subacromial impingement syndrome but provided benefits for persistent shoulder calcific tendinitis.

LIMITATIONS

Non-English studies were excluded.

CONCLUSIONS

Most passive physical modalities do not benefit patients with subacromial impingement syndrome. However, low-level laser therapy is more effective than placebo or ultrasound for subacromial impingement syndrome. Similarly, shock-wave therapy is more effective than sham therapy for persistent shoulder calcific tendinitis.

Treatments for shoulder impingement syndrome: a PRISMA systematic review and network meta-analysis

Many treatments for shoulder impingement syndrome (SIS) are available in clinical practice; some of which have already been compared with other treatments by various investigators. However, a comprehensive treatment comparison is lacking. Several widely used electronic databases were searched for eligible studies. The outcome measurements were the pain score and the Constant-Murley score (CMS). Direct comparisons were performed using the conventional pair-wise meta-analysis method, while a network meta-analysis based on the Bayesian model was used to calculate the results of all potentially possible comparisons and rank probabilities. Included in the meta-analysis procedure were 33 randomized controlled trials involving 2300 patients. Good agreement was demonstrated between the results of the pair-wise meta-analyses and the network meta-analyses. Regarding nonoperative treatments, with respect to the pain score, combined treatments composed of exercise and other therapies tended to yield better effects than single-intervention therapies. Localized drug injections that were combined with exercise showed better treatment effects than any other treatments, whereas worse effects were observed when such injections were used alone. Regarding the CMS, most combined treatments based on exercise also demonstrated better effects than exercise alone. Regarding surgical treatments, according to the pain score and the CMS, arthroscopic subacromial decompression (ASD) together with treatments derived from it, such as ASD combined with radiofrequency and arthroscopic bursectomy, showed better effects than open subacromial decompression (OSD) and OSD combined with the injection of platelet-leukocyte gel. Exercise therapy also demonstrated good performance. Results for inconsistency, sensitivity analysis, and meta-regression all supported the robustness and reliability of these network meta-analyses. Exercise and other exercise-based therapies, such as kinesio taping, specific exercises, and acupuncture, are ideal treatments for patients at an early stage of SIS. However, low-level laser therapy and the localized injection of nonsteroidal anti-inflammatory drugs are not recommended. For patients who have a long-term disease course, operative treatments may be considered, with standard ASD surgery preferred over arthroscopic bursectomy and the open surgical technique for subacromial decompression. Notwithstanding, the choice of surgery should be made cautiously because similar outcomes may also be achieved by the implementation of exercise therapy.

Efficacy and safety of extracorporeal shock wave therapy for orthopedic conditions: a systematic review on studies listed in the PEDro database

BACKGROUND

Extracorporeal shock wave therapy (ESWT) is an effective and safe non-invasive treatment option for tendon and other pathologies of the musculoskeletal system.

SOURCES OF DATA

This systematic review used data derived from the Physiotherapy Evidence Database (PEDro; www.pedro.org.au, 23 October 2015, date last accessed).

AREAS OF AGREEMENT

ESWT is effective and safe. An optimum treatment protocol for ESWT appears to be three treatment sessions at 1-week intervals, with 2000 impulses per session and the highest energy flux density the patient can tolerate.

AREAS OF CONTROVERSY

The distinction between radial ESWT as 'low-energy ESWT' and focused ESWT as 'high-energy ESWT' is not correct and should be abandoned.

GROWING POINTS

There is no scientific evidence in favour of either radial ESWT or focused ESWT with respect to treatment outcome.

AREAS TIMELY FOR DEVELOPING RESEARCH

Future randomized controlled trials should primarily address systematic tests of the aforementioned optimum treatment protocol and direct comparisons between radial and focused ESWT.

Shockwave treatment for musculoskeletal diseases and bone consolidation: qualitative analysis of the literature

Shockwave treatment is an option within orthopedics. The exact mechanism through which shockwaves function for treating musculoskeletal diseases is unknown. The aim of this study was to make a qualitative analysis on the effectiveness of shockwave treatment among patients with musculoskeletal pathological conditions and pseudarthrosis. Searches were conducted in the Cochrane Library, Medline and Lilacs databases. Thirty-nine studies that reported using shockwave treatment for musculoskeletal diseases were found. Their results varied greatly, as did the types of protocol used. The studies that evaluated the effectiveness of shockwave treatment for lateral epicondylitis, shoulder tendinopathy, knee osteoarthrosis, femoral head osteonecrosis and trochanteric bursitis reported inconsistent results for most of their patients. Those that evaluated patients with calcifying tendinopathy, plantar fasciitis, Achilles tendinopathy, patellar tendinopathy and pseudarthrosis showed benefits. Shockwave treatment is a safe and non-invasive method for chronic cases in which conventional techniques have been unsatisfactory and should be used in association with other treatment methods for tendinopathy. Further quality studies are needed.

Pain management of hemiplegic shoulder pain post stroke in patients from Nanjing, China

We selected 106 hemiplegic patients with shoulder pain hospitalized after stroke from three hospitals in Nanjing, China between February 2007 and January 2012. All patients had complete clinical data sets and accounted for 45.5% of the inpatients because of stroke. Results showed that the number of patients with hemiplegic shoulder pain post stroke increased yearly, attacking mainly males 50-69 years of age. Of 106 patients, there were 60 cases (56.6%) of adhesive capsulitis, 19 (17.9%) of shoulder subluxation, 14 (13.2%) of complex regional pain syndrome, and 13 (12.6%) of central pain. The main symptoms were shoulder pain (100%), limit of shoulder mobility (98.1%), and adhesion of the scapula (56.6%). MRI of the shoulder showed tendon and ligament lesions (57.1%) and rotator cuff tear (38.1%). 53.8% of central pain was related to the thalamus, in addition to the basal ganglia, brain stem, and cerebellopontine angle. Shoulder pain, upper limb motor function, and function independence were significantly improved after comprehensive rehabilitation. In particular, electroacupuncture based on basic physical therapy exhibited efficacy on shoulder tion and complex regional pain syndrome. Multiple linear regression results showed a negative relationship of efficacy of pain management with the attack period of shoulder pain, involvement of the posterior limb of the internal capsule, and duration between onset and rehabilitation treatment, but a positive correlation with pain-related education, pain regression period, and pain diagnosis.

Scapular muscle rehabilitation exercises in overhead athletes with impingement symptoms: effect of a 6-week training program on muscle recruitment and functional outcome

BACKGROUND

Previous research has identified some specific exercises to correct scapular muscle balance and onset timing in healthy subjects. However, evidence for their effectiveness in overhead athletes with impingement symptoms has been lacking until now.

HYPOTHESIS

A 6-week exercise program consisting of previously selected exercises is able to improve muscle activation and onset timing during shoulder elevation. This program may also change pain and functionality levels in overhead athletes with mild impingement symptoms.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Forty-seven overhead athletes with mild impingement symptoms (25 men and 22 women) were enrolled in this study. Before and after the 6-week training program, the Shoulder Pain and Disability Index (SPADI) score was individually obtained and maximum voluntary isometric contraction (MVIC) values were determined by surface electromyography. Mean muscle activation levels, muscle ratio data, and muscle onset timing were assessed for the upper (UT), middle (MT), and lower (LT) trapezius and serratus anterior (SA) muscle during arm elevation in the scapular plane.

RESULTS

Forty participants completed the exercise program. The SPADI scores significantly decreased from 29.86 ± 17.03 during initial assessment to 11.7 ± 13.78 during postmeasurements (P < .001). The 3 trapezius muscle parts showed increased MVIC values and decreased activation levels during arm elevation, whereas this was not the case for the SA muscle. After the training program, UT/SA significantly decreased, whereas UT/MT and UT/LT did not change (P < .05). No differences in muscle timing between pre- and postmeasurements could be identified. The LT showed significant earlier activation compared with UT (-0.47; P < .001) and MT (-0.49; P < .001). The serratus anterior showed significant earlier activation compared with the UT (-0.74; P < .001), MT (-0.76; P < .001), and LT muscles (F = 0.27; P = .046).

CONCLUSION

This is the first longitudinal study to demonstrate that previously selected exercises (1) improve pain and function based on SPADI scores, (2) reduce relative trapezius muscle activation, and (3) alter UT/SA ratios. However, they were unable to change the timing of the scapular muscles during arm elevation when compared before and after a 6-week training program in overhead athletes with mild impingement symptoms.

Effectiveness of soft tissue massage and exercise for the treatment of non-specific shoulder pain: a systematic review with meta-analysis

OBJECTIVE

To determine the effectiveness of exercise and soft tissue massage either in isolation or in combination for the treatment of non-specific shoulder problems.

METHODS

Database searches for articles from 1966 to December 2011 were performed. Studies were eligible if they investigated 'hands on' soft tissue massage performed locally to the shoulder or exercises aimed at improving strength, range of motion or coordination; non-surgical painful shoulder disorders; included participants aged 18-80 years and outcomes measured included pain, disability, range of motion, quality of life, work status, global perceived effect, adverse events or recurrence.

RESULTS

Twenty-three papers met the selection criteria representing 20 individual trials. We found low-quality evidence that soft tissue massage was effective for producing moderate improvements in active flexion and abduction range of motion, pain and functional scores compared with no treatment, immediately after the cessation of treatment. Exercise was shown by meta-analysis to produce greater improvements than placebo, minimal or no treatment in reported pain (weighted mean=9.8 of 100, 95% CI 0.6 to 19.0) but these changes were of a magnitude that was less than that considered clinically worthwhile. Exercise did not produce greater improvements in shoulder function than placebo, minimal or no treatment (weighted mean=5.7 of 100, 95% CI -3.3 to 14.7).

CONCLUSION

There is low-quality evidence that soft tissue massage is effective for improving pain, function and range of motion in patients with shoulder pain in the short term. Exercise therapy is effective for producing small improvements in pain but not in function or range of motion.

Radial extracorporeal pressure pulse therapy for the primary long bicipital tenosynovitis a prospective randomized controlled study

Long bicipital tenosynovitis is regarded as one of the common causes of shoulder pain and dysfunction. The traditional therapeutic approach includes a variety of conservative treatments, but these treatments are not substantiated, owing to the lack of proven clinical efficacy. Radial extracorporeal shock wave therapy (rESWT) uses a pneumatically generated and radially propagating low-energy pressure pulse and has been clinically shown to be a new alternative form of treating refractory soft tissue inflammation. While treating patients suffering from long bicipital tenosynovitis, a randomized, controlled trial was conducted to analyze the effects of radial shock wave therapy on pain and function. Seventy-nine adults with long bicipital tenosynovitis were randomized to receive either active (1500 pulses, 8 Hz, 3 bars) or sham treatment through four sessions that were held once a week. All of these adults were assessed before treatment and at time intervals of 1, 3 and 12 months since the completion of the treatment. The outcomes were measured through the visual analogue scale (VAS) and L'Insalata shoulder questionnaire. Mean VAS in the rESWT group showed significant and sustained reduction from 5.67 ± 1.32 at baseline to 2.58 ± 1.49 at one month, 1.83 ± 1.25 at three months and 1.43 ± 0.94 at 12 months from baseline, whereas the sham group's mean VAS was 6.04 ± 0.97 before treatment and stabilized at 5.57 ± 0.84 at 12 months. Similar trends were found for the function scores. Mean scores were increased after rESWT from 60.57 ± 6.91 at baseline to 79.85 ± 6.59 at 1 month and 83.44 ± 5.21 at 12 months from baseline. Both pain and function scores showed significant differences between the two groups (p < 0.001). The rESWT group consisted of "invalid conservative treatment subgroup" and "none conservative treatment subgroup." Both groups showed good recovery and prognosis. Therefore, we recommend rESWT in treating primary long bicipital tenosynovitis.