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Matthew Moore
Matthew Moore

Physiotherapy Interventions For Shoulder Pain -...

A wide range of both conservative and surgical interventions are currently used to treat shoulder pain. Shoulder pain arises from many MSK conditions eg Shoulder Osteoarthritis, Rotator cuff tendinopathy. 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].

Physiotherapy interventions for shoulder pain -...

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.

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.[11][12][13][14] 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...

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[16] 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...

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.

Systematic reviews consistently conclude that the evidence does not support the effectiveness of laser therapy compared to other interventions.[27] [28] 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. [29] 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.[27][29] Further high-quality trials are required to determine the effect of laser, in particular directly compared with pharmaceuticals. [6][29]

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][27] 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]

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.[30][31][32][33] Another study has demonstrated the beneficial effect of shockwave therapy over conservative physiotherapy for adhesive capsulitis to reduce pain[34], however, the results of this study should be interpreted with caution as the "conservative physiotherapy" intervention was not described."

Background: The prevalence of shoulder disorders has been reported to range from seven to 36% of the population (Lundberg 1969) accounting for 1.2% of all General Practitioner encounters in Australia (Bridges Webb 1992). Substantial disability and significant morbidity can result from shoulder disorders. While many treatments have been employed in the treatment of shoulder disorders, few have been proven in randomised controlled trials. Physiotherapy is often the first line of management for shoulder pain and to date its efficacy has not been established. This review is one in a series of reviews of varying interventions for shoulder disorders, updated from an earlier Cochrane review of all interventions for shoulder disorder.

Data collection and analysis: The methodological quality of the included trials was assessed by two independent reviewers according to a list of predetermined criteria, which were based on the PEDro scale specifically designed for the assessment of validity of trials of physiotherapy interventions. Outcome data was extracted and entered into Revman 4.1. Means and standard deviations for continuous outcomes and number of events for binary outcomes were extracted where available from the published reports. All standard errors of the mean were converted to standard deviation. For trials where the required data was not reported or not able to be calculated, further details were requested from first authors. If no further details were provided, the trial was included in the review and fully described, but not included in the meta-analysis. Results were presented for each diagnostic sub group (rotator cuff disease, adhesive capsulitis, anterior instability etc) and, where possible, combined in meta-analysis to give a treatment effect across all trials.

Main results: Twenty six trials met inclusion criteria. Methodological quality was variable and trial populations were generally small (median sample size = 48, range 14 to 180). Exercise was demonstrated to be effective in terms of short term recovery in rotator cuff disease (RR 7.74 (1.97, 30.32), and longer term benefit with respect to function (RR 2.45 (1.24, 4.86). Combining mobilisation with exercise resulted in additional benefit when compared to exercise alone for rotator cuff disease. Laser therapy was demonstrated to be more effective than placebo (RR 3.71 (1.89, 7.28) for adhesive capsulitis but not for rotator cuff tendinitis. Both ultrasound and pulsed electromagnetic field therapy resulted in improvement compared to placebo in pain in calcific tendinitis (RR 1.81 (1.26, 2.60) and RR 19 (1.16, 12.43) respectively). There is no evidence of the effect of ultrasound in shoulder pain (mixed diagnosis), adhesive capsulitis or rotator cuff tendinitis. When compared to exercises, ultrasound is of no additional benefit over and above exercise alone. There is some evidence that for rotator cuff disease, corticosteroid injections are superior to physiotherapy and no evidence that physiotherapy alone is of benefit for Adhesive Capsulitis

Reviewer's conclusions: The small sample sizes, variable methodological quality and heterogeneity in terms of population studied, physiotherapy intervention employed and length of follow up of randomised controlled trials of physiotherapy interventions results in little overall evidence to guide treatment. There is evidence to support the use of some interventions in specific and circumscribed cases. There is a need for trials of physiotherapy interventions for specific clinical conditions associated with shoulder pain, for shoulder pain where combinations of physiotherapy interventions, as well as, physiotherapy interventions as an adjunct to other, non physiotherapy interventions are compared. This is more reflective of current clinical practice. Trials should be adequately powered and address key methodological criteria such as allocation concealment and blinding of outcome assessor. 041b061a72

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