Evidence Based Interventions for Shoulder Pain

Introduction

Several different techniques are now used to treat shoulder pain. Shoulder pain results from many MSK conditions e.g. Shoulder Osteoarthritis Rotator cuff tendinopathy. Surgery gives better results than non-surgical treatment in some cases, according to a study conditions [1]; while others have argued that nonsurgical interventions produce results equivalent to surgery [2][3][4]. Several systematic reviews of the effectiveness of conservative interventions for shoulder pain have been published although evidence is currently insufficient to allows definitive conclusions about treatment of abuse [3][5][6][7]. The primary goal of conservative management of shoulder pain is to reduce pain and improve function by correcting modifiable physical deformity [8].

Education

Education plays a large role in managing individuals with shoulder pain. The physical therapist should provide a careful explanation to reassure the patient that no serious illness or injury has been diagnosed. Great care is needed to choose appropriate non-threatening words that will not do so misinterpreted by the patient and providing biomechanical information about the shoulder that is not based on evidence can compound their discomfort. It is important to avoid reinforcing individual fears about dangerous processes that may be occurring because these fears or concerns can act as a a barrier to recovery and must be effectively addressed. The key to treating individuals with shoulder pain is to encourage active movement. The ultimate goal is to help patients resume their usual activities as soon as possible. Counseling can be effective supported by the provision of simple evidence-based educational materials.

Exercise Therapy

Exercise has a beneficial role to play and the inclusion of loaded exercise is safe and does not compromise outcome [3]. In rotator cuff tendinopathy, both home-based and supervised exercise programs have been found to be more effective than no intervention or medication and as effective as minimal comparisons s.e., s.e. functional brace or active comparators e.g. multimodal gynecological surgery. [3][9] .

Recently, there has been an increased interest in physical rehabilitation as a means of managing partial and thick rotator cuff tears by specifically addressing weakness and functional deficits. Recent studies have shown that patients who choose therapeutic exercise have shown high satisfaction improvement in function and success in avoiding surgery[5][10].

However, optimal indices of exercise and loading such as the mechanism of response to treatment have not yet been established [3]. The intent of the dosage frequency approach to reproduce acceptable pain tolerance inter-exercise activity levels and specific exercise inclusion is not they were able to do so.[11][12][13][14] Further well-designed randomized studies investigating the therapeutic efficacy of exercises for specific shoulder conditions are really needed if criteria for therapeutic exercises are to be determined it is the best. Read more about Therapeutic Exercises for the Shoulder…

Level 2 – Confidence A

• It is effective in terms of short-term relief in rotator cuff disease and long-term functional benefits [6].
• It is effective for reducing pain and restoring function in impingement (11 trials) [7].

Passive Treatments

Evidence suggests that conservative treatment modalities such as manual therapy electrotherapy taping should be avoided as mono-therapy but in some cases may provide some additional benefit when combined with therapeutic exercise programs. The effectiveness of passive treatment modalities can be both a modality and a specific situation. [15] .

Manual Therapy

Evidence suggests that manual therapy broadly defined as ..the healing and curative use of hands or the therapeutic use of hands… is beneficial for at least some patients if they have shoulder pain is greatly improved with inclusion exercise but limited evidence as a stand-alone treatment. Manual therapy refers to the use of manipulation (high velocity limiting the range of motion of the joint that moves the joint beyond a passive range) with mobilization (movement of the joint in the appropriate range with movement ) and massage (hand massage soft tissue manipulation or mobilization).

Several reports in the recent peer-reviewed literature indicate that management strategies targeting the cervical and thoracic spine in combination with physical activity provide superior gains in in patients with subacromial[16] and/or rotator cuff related shoulder pain. Positive evidence in this area is limited and further research is needed to determine the extent and nature of the relationship between diaphragm changes and shoulder pain. See your Manual Therapy Techniques for the Shoulder…

Level 2 – Confidence B

• Benefits appear to be mostly short-term, about the same as with injections [6]
• In the long-term terminal range, high-end is better than low-range, and MWM is better than mid-range [17]
• Mobilization plus exercise was better than exercise alone, but only during the shortest follow-up period [17]
• For manual therapy in general with common shoulder diseases excluding arthritis [18].

The following Case Study examines the role of Manual Therapy for Shoulder Pain;

• How Thoracic Manipulations Help With Shoulder Pain
• Cervicothaoracic Manipulation for Shoulder Pain

Taping

The use of taping has been recommended for many therapeutic reasons including modifying joint stability and controlling posture in a joint causing weakness or inhibition of muscle activity improved muscular effort sensorimotor control cutaneous stimulation pain modulation via altered sensory input that increases motoneurone excitability resulting in increased joint torque. and enhance proprioception [19][20][21][22][23].

** The use of KT tape with physical therapy has shown some benefit[24].

Postural Taping

Increased thoracic kyphotic forward shoulder posture and chronically elevated scapular forward tilt and downward rotation are associated with forward head tilt or “slack” posture and are thought to result in decreased glenohumeral motion, and Associated with many shoulder disorders. Studies have shown that postural taping produces significantly less forward head posture, less forward shoulder posture, less kyphosis, less scapular lateral displacement, less elevated scapular position, and increased anterior sagittal position Increased pain-free range of shoulder flexion and pain-free range of scapular abduction compared with placebo taping in symptomatic and asymptomatic subjects may contribute to short-term improvement in shoulder flexion and out-of-scapular plane scope of exhibition. [23]

Level 2 – Confidence D

• Kinesio Tape vs. Kinesio Tape Sham in 42 subjects – Did not help impingement pain [25].
• 17 baseballers with impingement pain – Increased post scap tilt @ 30 & 60 elevation AND increased from low activity at 60-30 floor [26].

Electrotherapy Modalities

Electrical stimulants and thermal agents are most commonly used in physical therapy for pain management. However, non-thermal agents such as pulsed ultrasound have been reported to have analgesic effects. Evidence of efficacy of most electrotherapy modalities is limited Management of shoulder pain.

Laser

Systematic reviews have consistently concluded that the evidence does not support the effectiveness of laser therapy compared with other interventions. [27] [28] While low-level laser light (LLL) does not appear to have strong evidence as a stand-alone treatment, there is limited evidence that LLL Reduces pain, is a viable pain-relieving treatment, and therefore may accelerate improvements in physical function by controlling inflammation or stimulating tendon repair, with the end result being less pain and faster improvement when added to exercise-based therapy program. It has also been suggested that LLL may have a more pronounced effect on shoulder function if the pain-relieving benefit is dedicated to optimizing motion parameters. [29] The study also showed that LLL treatment was a safe and effective pain management option compared to Corticosteroid injections, especially for rotator cuff tendinopathy, should therefore be offered prior to injection therapy. [27] [29] Further high-quality trials are needed to determine the effects of lasers, especially direct comparisons with drugs. [6][29]

Level 2 – Confidence B

• LLL showed significantly better shoulder function at the end of treatment compared to placebo (p < 0.0001) [29]
• LLL superior to sham LLL
• Short-term (2-week gain) vs. placebo RR 3.71 (1.89-7.28) [6]

Ultrasound

Several current systematic reviews do not support the efficacy of ultrasound when used for shoulder pain (mixed review) adhesive capsulitis subacromial or rotator cuff related shoulder pain. There is some evidence that ultrasound improves compared to placebo when it is primarily used for painful calcific lesions of the rotator cuff.[6]

Shockwave Therapy

There is some evidence of pain reduction and functional improvement with shockwave therapy in calcific tendonitis and it has been suggested as an alternative to surgery if it occurs as a management therapy strict controls are ineffective in relieving pain and other symptoms if. [31] [32] [33] . Another study has shown the benefit of shockwave therapy over conservative physiotherapy for adhesive capsulitis to reduce pain[34] but the results of this study should be interpreted with caution as the conservative physiotherapy intervention was not defined.