Physiotherapy Treatment for Shoulder Pain – Research Evidence

Another Research Evidence post! This time the shoulder…..What is the research evidence in regards to Physiotherapy Treatment for Shoulder Pain?

Diagnostic Tests

Hughes et al (2008)

  • A systematic review of investigations into the diagnostic accuracy of clinical tests for rotator cuff pathology.
  • Conclusions:
    • Overall, most tests for rotator cuff pathology were inaccurate and cannot be recommended for clinical use.
    • At best, suspicion of a rotator cuff tear may be heightened by a positive palpation, combined Hawkins/painful arc/infraspinatus test, Napoleon test, lift-off test, belly-press test, or drop-arm test, and it may be reduced by a negative palpation, empty can test or Hawkins-Kennedy test.

 Hegedus et al (2012)

  • Systematic Review
  • Based on data from the original 2008 review and this update, the use of any single shoulder physical exam test (ShPE) to make a pathoanatomic diagnosis cannot be unequivocally recommended. There exist some promising tests but their properties must be confirmed in more than one study. Combinations of ShPE tests provide better accuracy, but marginally so. These findings seem to provide support for stressing a comprehensive clinical examination including history and physical examination.
  • However, there is a great need for large, prospective, well-designed studies that examine the diagnostic accuracy of the many aspects of the clinical examination and what combinations of these aspects are useful in differentially diagnosing pathologies of the shoulder.

Wright et al (2012)

  • Systematic Review regarding the diagnostic accuracy of physical examination tests for the scapula in patients with shoulder disorders.
  • Overall, no physical examination test of the scapula was found to be useful in differentially diagnosing pathologies of the shoulder.

Braman et al (2013)

  • “Impingement syndrome” is a common diagnostic label for patients presenting with shoulder pain. Historically, it was believed to be due to compression of the rotator cuff tendons beneath the acromion.
  • It has become evident that “impingement syndrome” is not likely an isolated condition that can be easily diagnosed with clinical tests or most successfully treated surgically. Rather, it is likely a complex of conditions involving a combination of intrinsic and extrinsic factors.
  • Therefore, it is advocated that the clinical diagnosis of “impingement syndrome” be eliminated as it is no more informative than the diagnosis of “anterior shoulder pain”. While both terms are ambiguous, the latter is less likely to presume an anatomical tissue pathology that may be difficult to isolate either with a clinical examination or with diagnostic imaging and may prevent potentially inappropriate surgical interventions.
  • For shoulder researchers, we recommend investigations of homogenous patient groups with accurately defined specific pathologies, or with subgrouping or classification based on specific movement deviations.

Manual Therapy and Exercise

Lewis et al (2005)

  • Conducted a study to investigate the effect of changing thoracic and scapular posture on shoulder flexion and scapular plane abduction range of motion in asymptomatic subjects, and in subjects with subacromial impingement syndrome.
  • Results:
    • Changing posture:
      • Had an effect on all components of posture measured and these changes were associated with a significant increase  in the range of motion in shoulder flexion and abduction in the plane of the scapula.
      • Was not found to have a significant effect on the intensity of pain experienced by the symptomatic subjects, although the point in the range of shoulder elevation at which they experienced their pain was significantly higher.
  • Conclusion:
    • The findings of this investigation suggest that changing 1 or more of the components of posture may have a positive effect on shoulder range of movement and the point at which pain is experienced.

Braun et al (2010)

  • Systematic review
  • Aim:
    • To assess the effectiveness of manual therapy and exercises to improve pain, disability and function in people with shoulder impingement.
  • Results/Conclusions:
    • Manual therapy and exercise seem effective for shoulder impingement, but varying methodological quality and risk of bias in reviews and trials warrant caution in the interpretation of the results. There is a need for further good-quality primary research.

Brantingham et al (2011)

  • Systematic Review
  • Aim:
    • To conduct a systematic review on manual and manipulative therapy (MMT) for common shoulder pain and disorders.
  • Conclusions:
    • This study found a level of B or fair evidence for MMT of the shoulder, shoulder girdle, and/or the FKC combined with multimodal or exercise therapy for rotator cuff injuries/disorders, disease, or dysfunction.
    • There is a fair or B level of evidence for MMT of the shoulder/shoulder girdle and FKC combined with a multimodal treatment approach for shouldercomplaints, dysfunction, disorders, and/or pain.

Kromer et al (2009)

  • Systematic Review
  • Aim:
    • To critically summarize the effectiveness of physiotherapy in patients presenting with clinical signs of shoulder impingement syndrome.
  • Conclusions:
    • This review shows an equal effectiveness of physiotherapist-led exercises compared with surgery in the long term and of home-based exercises compared with combined physiotherapy interventions in patients with shoulder impingement syndrome in the short and long term; passive treatments cannot be recommended for shoulder impingement syndrome.
    • However, in general, the samples were small, and different diagnostic criteria were applied, which makes a firm conclusion difficult. More high-quality trials with longer follow-ups are recommended.

Hanratty et al (2012)

  • Systematic Review
  • Aim:
    • To evaluate the effectiveness of exercise in the treatment of people with subacromial impingement syndrome (SAIS).
  • Conclusions:
    • Physiotherapy exercises are effective in the management of SAIS. However, heterogeneity of the exercise interventions, coupled with poor reporting of exercise protocols, prevented conclusions being drawn about which specific components of the exercise protocols (ie, type, intensity, frequency and duration) are associated with best outcomes.

 Frozen Shoulder

Maund et al (2012)

  • Systematic Review
  • Aim:
    • To evaluate the clinical effectiveness and cost-effectiveness of treatments for primary frozen shoulder, identify the most appropriate intervention by stage of condition and highlight any gaps in the evidence.
  • Limitations:
    • The key limitation was the lack of data available.
    • It was not possible to undertake the planned synthesis exploring the influence of stage of frozen shoulder or the presence of diabetes on treatment effect.
    • The lack of available data made the development of a decision-analytic model implausible.
    • We found little evidence on treatment related to stage of condition, treatment pathways, the impact on quality of life, associated resource use and no information on utilities. Without making a number of questionable assumptions modelling was not possible.
  • Conclusions:
    • There was limited clinical evidence on the effectiveness of treatments for primary frozen shoulder.
    • The economic evidence was so limited that no conclusions can be made about the cost-effectiveness of the different treatments.
    • High-quality primary research is required.

References:

Braman JP, Zhao KD, Lawrence RL, Harrison AK, Ludewig PM. Shoulder impingement revisited: evolution of diagnostic understanding in orthopedic surgeryand physical therapy. Med Biol Eng Comput. 2013 Apr 10. [Epub ahead of print]

Brantingham JW, Cassa TK, Bonnefin D, Jensen M, Globe G, Hicks M, Korporaal C. Manipulative therapy for shoulder pain and disorders: expansion of a systematic review. J Manipulative Physiol Ther. 2011 Jun;34(5):314-46.

Braun C, Hanchard NCA. Manual therapy and exercise for impingement related shoulder pain. Physical Therapy Reviews 2010 Apr;15(2):62-83.

Hanratty CE, McVeigh JG, Kerr DP, Basford JR, Finch MB, Pendleton A, Sim J. The effectiveness of physiotherapy exercises in subacromial impingement syndrome: a systematic review and meta-analysis. Semin Arthritis Rheum. 2012 Dec;42(3):297-316.

Hegedus EJ, Goode AP, Cook CE, Michener L, Myer CA, Myer DM, Wright AA. Which physical examination tests provide clinicians with the most value when examining theshoulder? Update of a systematic review with meta-analysis of individual tests. Br J Sports Med. 2012 Nov;46(14):964-78.

Hughes PC, Taylor NF, Green RA. Most clinical tests cannot accurately diagnose rotator cuff pathology: a systematic review. Aust J Physiother. 2008;54(3):159-70.

Kromer TO, Tautenhahn UG, de Bie RA, Staal JB, Bastiaenen CH. Effects of physiotherapy in patients with shoulder impingement syndrome: a systematic review of the literature. J Rehabil Med. 2009 Nov;41(11):870-80.

Lewis JS, Wright C, Green A. Subacromial impingement syndrome: the effect of changing posture on shoulder range of movement. J Orthop Sports Phys Ther. 2005 Feb;35(2):72-87.

Maund E, Craig D, Suekarran S, Neilson A, Wright K, Brealey S, Dennis L, Goodchild L, Hanchard N, Rangan A, Richardson G,Robertson J, McDaid C. Management of frozen shoulder: a systematic review and cost-effectiveness analysis. Health Technol Assess. 2012;16(11):1-264.

Wright AA, Wassinger CA, Frank M, Michener LA, Hegedus EJ. Diagnostic accuracy of scapular physical examination tests for shoulder disorders: a systematic review. Br J Sports Med. 2012 Oct 18. [Epub ahead of print].

About the Author:

Mark is a Specialist Musculoskeletal Physiotherapist who consults at both Insight Physiotherapy and Pain Options, in Perth, Western Australia. He specialises in the assessment and management of persistent/chronic musculoskeletal pain. In addition to his clinical role he maintains regular involvement in education of the profession having held a Teaching Fellow position at the University of Western Australia for 10 years and regularly presenting at courses and seminars through the Australian Physiotherapy Association and private education sector. Mark is also a Facilitator for the Australian College of Physiotherapists Specialisation Training Program and a Branch Councillor on the Western Australian Branch of the Australian Physiotherapy Association.

4 Comments on "Physiotherapy Treatment for Shoulder Pain – Research Evidence"

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  1. Harrison Vaughan says:

    Great stuff Mark! Lookin forward to reading more from you. My interns will definitely benefit from you research reviews.

    Best,
    Harrison

  2. The treatment is entirely based on the cause(s). General treatment methods involve rest and altering activities by limiting those, which can aggravate the condition. Physiotherapy and massage therapy are the most effective methods to improve the strength and flexibility of the affected part.
    adhesive capsulitis treatment

    • Thanks for the comment.
      Would you care to elaborate on the cause(s) of this condition and provide some evidence regarding the treatment methods you have mentioned?
      Thanks for participating.

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