Evidence Based Interventions for Shoulder Pain

Original Editor - Naomi O'Reilly

Top Contributors - Naomi O'Reilly, Rachael Lowe and Haseeb Ur Rehman  

Introduction

A wide range of both conservative and surgical interventions are currently used to treat shoulder pain. Some research suggests that surgery offers better outcomes than non-operative treatments in some conditions [1]; while others have argued that non-operative interventions produce equivalent outcomes to surgery [2][3][4]. Multiple systematic reviews relating to the effectiveness of conservative interventions for shoulder pain have been published, albeit current evidence is not sufficient to allow definitive conclusions on conservative treatment [3][5][6][7]. The primary aim of conservative management of shoulder pain is to reduce pain and improve function through correction of modifiable physical impairments [8].

Education

Education plays a great role in the management of individuals with shoulder pain. The physiotherapist needs to provide a careful explanation to reassure the patient that no serious disease or injury has been found. Great care is needed to select appropriate, non-threatening words that will not be misinterpreted by the patient and providing biomechanical information about the shoulder that is not evidence-based can add to their concerns. It is important to avoid reinforcing individuals fears about the threatening processes that might be going on as these fears or concerns can act as a barrier to recovery and need to be properly addressed. An essential component of treatment for individuals with shoulder pain is to encourage active self-management. The primary aim is to help patients resume normal activities as far as possible, as soon as possible. Advice can be effectively supported by offering simple evidence-based educational materials.

Exercise Therapy

Exercise has a useful role to play and incorporating loaded exercises is safe and not detrimental to outcome [3]. In rotator cuff tendinopathy, both home and supervised exercise programmes have been found to be more effective than no intervention or placebo and as effective as minimal comparators, e.g. functional brace, or active comparators, e.g. multimodal physiotherapy, surgery [3].

More recently, there has been increasing interest in exercise rehabilitation as a means to manage partial and full thickness tears of the rotator cuff by specifically addressing weakness and functional deficits. Recent studies have suggested that patients opting for physiotherapy have demonstrated high satisfaction, an improvement in function, and success in avoiding surgery[5][9].

However, optimal parameters of exercise and load have yet to be determined as has the mechanism by which therapeutic response occurs [3]. Consensus on dosage, frequency, method of delivery, acceptable pain tolerance, inter-exercise activity levels, and specific exercise inclusion has not been achieved.[10][11][12][13] There is a definite need for further well-planned randomized controlled trials investigating the efficacy of exercise in the management in relation to specific shoulder conditions and to determine the optimal therapeutic exercise parameters. Read more about Therapeutic Exercise for the Shoulder...

Level 2 - Confidence A

  • Effective in terms of short-term recovery in rotator cuff disease, and longer-term benefit with respect to function [6]
  • Effective for pain reduction and function restoration in impingement (11 trials) [7]

Passive Treatments

Evidence suggests that passive treatment modalities such as manual therapy, electrotherapy, taping should be avoided as mono-therapy but can in some instances provide some additional benefit when utilised in conjunction with therapeutic exercise programs. The effectiveness of passive treatment modalities may be both modality and condition specific. [14]

Manual Therapy

Evidence suggests that manual therapy, broadly defined as "..the use of hands in a curative and healing manner or a hands-on technique with therapeutic intent..." is beneficial for at least some patients with shoulder pain, is more effective when used in combination with exercise but has limited evidence as a stand-alone treatment option. Manual therapy refers to manipulation (a low-amplitude, high-velocity movement at the limit of joint range that takes the joint beyond the passive range of movement), mobilisation (joint movement within the normal range of motion) and massage (manual manipulation or mobilisation of soft tissues).

Multiple reports in the recent peer-reviewed literature suggest that manipulative techniques aimed at cervicothoracic and thoracic spine, used in conjunction with exercise produce superior benefits in patients with subacromial and/or rotator cuff related shoulder pain. The quality of evidence in this area is limited and further research is warranted to determine the extent and nature of the relationship between thoracic manipulation and shoulder pain. Review your Manual Therapy Techniques for the Shoulder...

Level 2 - Confidence B

  • Benefits appear to be mostly short-term and about the same as injection [6]
  • High grade better than low grade in the long-term, end-range and MWM better than mid-range [15]
  • Mobilisation plus exercise better than exercise alone, but only at the shortest follow-up [15]
  • For manual therapy in general with common shoulder disorders, excluding neurogenic disorders [16]

The following Case Studies examine the role of Manual Therapy on Shoulder Pain;

Taping

The application of taping has been recommended for many therapeutic reasons including joint stabilization, changing and controlling posture at a joint, facilitation or inhibition of muscle activity, improved muscular effort, enhanced sensorimotor control, cutaneous stimulation, pain modulation via altered sensory input, increasing motoneurone excitability, increasing joint torque. and enhance proprioception [17][18][19][20][21].

Postural Taping

Increased thoracic kyphosis, forward shoulder posture, and a protracted, elevated, anteriorly tilted, and downwardly rotated scapula has been associated with both a forward head or ‘‘slouched’’ posture and has been suggested leads to a reduction in glenohumeral movement and is implicated in a number of shoulder conditions. Research suggests that postural taping produced significantly less forward head posture , less forward shoulder posture, smaller kyphosis, less lateral scapular displacement , less elevated scapula position, less forward sagittal position, increased pain-free range of shoulder flexion, and increased pain-free range of scapular plane abduction, as compared to when measured with placebo taping in both symptomatic and asymptomatic subjects and may be useful for short-term improvement in the range of shoulder flexion and scapular plane abduction. [21]

Level 2 - Confidence D

  • Kinesio Tape vs. Sham in 42 subjects - Did not help impingement pain [22]
  • 17 baseballers with impingement pain - Increased post scap tilt @ 30 & 60 elevation AND increase lower trap activity in the 60-30 lowering range [23]

Electrotherapy Modalities

Electrical stimulation agents and thermal agents are most often used in physiotherapy for pain management. However, non-thermal agents, such as pulsed ultrasound, have been reported as having an analgesic effect. There is limited evidence for the efficacy of most electrotherapy modalities in the management of shoulder pain.

Laser

Systematic reviews consistently conclude that the evidence does not support the effectiveness of laser therapy compared to other interventions.[24] While Low Level Laser (LLL) does not appear to have strong evidence as a stand-alone treatment, there is limited evidence to suggest that LLL reduces pain and is a viable pain-modifying treatment and consequently may accelerate improvement of physical function, possibly by controlling inflammation or stimulating tendon repair, with the end result being reduced pain and more rapid improvement when added to an exercise-based treatment programme. It has also been suggested that LLL may have a more pronounced effect on shoulder function if the benefit of pain relief is used specifically to optimize parameters of exercise. [25] Research also suggests that LLL treatment is a safe and effective pain treatment option in comparison to corticosteroid injection, particularly for rotator Cuff tendinopathy, and as such should be offered before proceeding with injection therapy.[24][25] Further high-quality trials are required to determine the effect of laser, in particular directly compared with pharmaceuticals. [6][25]

Level 2 - Confidence B

  • LLL to placebo showed significantly better shoulder function at end of treatment (p < 0.0001) [25]
  • LLL superior to sham LLL
  • Short term (2 Week Benefit) vs. placebo RR 3.71 (1.89-7.28) [6]

Ultrasound

Currently, multiple systematic reviews do not support the effectiveness of ultrasound when utilised for shoulder pain (mixed diagnosis), adhesive capsulitis, subacromial or rotator cuff related shoulder pain.[6][24] There is some evidence that ultrasound results in improvement compared to placebo when specifically used for pain in calcific lesions of the rotator cuff.[6]

Shockwave Therapy

There is some evidence for reduction of pain and improved function with shockwave therapy in calcific tendonitis and it has been suggested to be used as an alternative to surgery in the event that conservative treatment has not been effective in relieving pain and other symptoms.[26][27][28][29] Another study has demonstrated the beneficial effect of shockwave therapy over conservative physiotherapy for adhesive capsulitis to reduce pain[30], however, the results of this study should be interpreted with caution as the "conservative physiotherapy" intervention was not described."

References

  1. Moosmayer S Lund G Seljom U, et al. Comparison between surgery and physiotherapy in the treatment of small and medium-sized tears of the rotator cuff: A randomised controlled study of 103 patients with one-year follow-up. J Bone Joint Surg Br. 2010;92(1):83–91.
  2. Brox JI, Gjengedal E, Uppheim G, Bøhmer AS, Brevik JI, Ljunggren AE, Staff PH. J Shoulder Elbow Surg. 1999 Mar-Apr; 8(2):102-11.
  3. 3.0 3.1 3.2 3.3 3.4 Littlewood C, Ashton J, Chance-Larsen K, May S, Sturrock B. Exercise for rotator cuff tendinopathy: a systematic review. Physiotherapy. 2012 Jun 1;98(2):101-9.
  4. Beard DJ, Rees JL, Cook JA, Rombach I, Cooper C, Merritt N, Shirkey BA, Donovan JL, Gwilym S, Savulescu J, Moser J. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. The Lancet. 2017 Nov 20
  5. 5.0 5.1 Edwards P, Ebert J, Joss B, Bhabra G, Ackland T, Wang A. Exercise rehabilitation in the non-operative management of rotator cuff tears: a review of the literature. International journal of sports physical therapy. 2016 Apr;11(2):279.
  6. 6.0 6.1 6.2 6.3 6.4 6.5 6.6 Green S, Buchbinder R, Hetrick S. Physiotherapy interventions for shoulder pain. Cochrane Database systematic Review The Cochrane library. 2006;3.
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  9. Ainsworth R, Lewis J, Conboy V. A prospective randomized placebo-controlled clinical trial of a rehabilitation programme for patients with a diagnosis of massive rotator cuff tears of the shoulder. Shoulder & Elbow. 2009 Jul 1;1(1):55-60.
  10. Haahr JP, Andersen JH. Exercises may be as efficient as subacromial decompression in patients with subacromial stage II impingement: 4-8-years' follow-up in a prospective, randomized study. Scand J Rheumatol. 2006;35:224-8.
  11. Ketola S, Lehtinen J, Rousi T, Nissinen M, Huhtala H, Konttinen YT, et al. No evidence of long-term benefits of arthroscopic acromioplasty in the treatment of shoulder impingement syndrome: Five- year results of a randomised controlled trial. Bone & joint research. 2013;2:132-9.
  12. Kukkonen J, Joukainen A, Lehtinen J, Mattila KT, Tuominen EK, Kauko T, et al. Treatment of non- traumatic rotator cuff tears: A randomised controlled trial with one-year clinical results. The bone & joint journal. 2014;96-B:75-81.
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  14. Yu H, Côté P, Shearer HM, Wong JJ, Sutton DA, Randhawa KA, Varatharajan S, Southerst D, Mior SA, Ameis A, Stupar M. Effectiveness of passive physical modalities for shoulder pain: systematic review by the Ontario protocol for traffic injury management collaboration. Physical therapy. 2015 Mar 1;95(3):306-18.
  15. 15.0 15.1 Favejee, M. M., B. M. A. Huisstede, and B. W. Koes. "Frozen shoulder: the effectiveness of conservative and surgical interventions—systematic review." British journal of sports medicine 45.1 (2011): 49-56.
  16. Brantingham, James W., et al. "Manipulative therapy for shoulder pain and disorders: expansion of a systematic review." Journal of manipulative and physiological therapeutics 34.5 (2011): 314- 346.
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  18. Macdonald R. Taping Techniques: Principles and Practice. Oxford, UK: Butterworth-Heinemann Ltd; 1994.
  19. Mulligan B. Manual Therapy ’Nags’, ’Snags’, ’PRP’s etc. Wellington, New Zealand: Plane View Services; 1995.
  20. Schmitt L, Snyder-Mackler L. Role of scapular stabilizers in aetiology and treatment of impingement syndrome. J Orthop Sports Phys Ther. 1999;29:31-38.
  21. 21.0 21.1 Lewis JS, Wright C, Green A. Subacromial impingement syndrome: the effect of changing posture on shoulder range of movement. Journal of Orthopaedic & Sports Physical Therapy. 2005 Feb;35(2):72-87.
  22. Thelen, Mark D., James A. Dauber, and Paul D. Stoneman. "The clinical efficacy of kinesio tape for shoulder pain: a randomized, double-blinded, clinical trial." journal of orthopaedic & sports physical therapy 38.7 (2008): 389-395.
  23. Hsu, Yin-Hsin, et al. "The effects of taping on scapular kinematics and muscle performance in baseball players with shoulder impingement syndrome." Journal of electromyography and kinesiology 19.6 (2009): 1092-1099.
  24. 24.0 24.1 24.2 Littlewood C, May S, Walters S. A review of systematic reviews of the effectiveness of conservative interventions for rotator cuff tendinopathy. Shoulder & Elbow. 2013 Jul 1;5(3):151-67.
  25. 25.0 25.1 25.2 25.3 Haslerud S, Magnussen LH, Joensen J, Lopes‐Martins RA, Bjordal JM. The efficacy of low‐level laser therapy for shoulder tendinopathy: a systematic review and meta‐analysis of randomized controlled trials. Physiotherapy Research International. 2015 Jun 1;20(2):108-25.
  26. Avancini-Dobrović V, Frlan-Vrgoč L, Stamenković D, Pavlović I, Schnurrer-Luke Vrbanić T. Radial extracorporeal shock wave therapy in the treatment of shoulder calcific tendinitis. Collegium antropologicum. 2011 Sep 25;35(2):221-5.
  27. Mangone G, Veliaj A, Postiglione M, Viliani T, Pasquetti P. Radial extracorporeal shock-wave therapy in rotator cuff calcific tendinosis. Clinical cases in mineral and bone metabolism. 2010 May;7(2):91.
  28. Magosch P, Lichtenberg S, Habermeyer P, Ellenbogenchirurgie SU. Radial shock wave therapy in calcifying tendinitis of the rotator cuff-a prospective study. Zeitschrift fur Orthopadie und ihre Grenzgebiete. 2003 Nov 1;141(6):629-36.
  29. Kachewar SG, Kulkarni DS. Calcific tendinitis of the rotator cuff: a review. Journal of clinical and diagnostic research: JCDR. 2013 Jul;7(7):1482.
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