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.
BACKGROUND:Patient-reported outcome measures have increasingly accompanied objective examination findings in the evaluation of orthopaedic interventions. Our objective was to determine whether a ...validated measure of mental health (Short Form-36 Mental Component Summary SF-36 MCS) or measures of tear severity on magnetic resonance imaging were more strongly associated with self-assessed shoulder pain and function in patients with symptomatic full-thickness rotator cuff tears.
METHODS:One hundred and sixty-nine patients with full-thickness rotator cuff tears were prospectively enrolled. Patients completed the Short Form-36, visual analog scales for shoulder pain and function, the Simple Shoulder Test (SST), and the American Shoulder and Elbow Surgeons (ASES) instrument at the time of diagnosis. Shoulder magnetic resonance imaging examinations were reviewed to document the number of tendons involved, tear size, tendon retraction, and tear surface area. Age, sex, body mass index, number of medical comorbidities, smoking status, and Workers’ Compensation status were recorded. Bivariate correlations and multivariate regression models were calculated to identify associations with baseline shoulder scores.
RESULTS:The SF-36 MCS had the strongest correlation with the visual analog scale for shoulder pain (Pearson correlation coefficient, −0.48; p < 0.001), the visual analog scale for shoulder function (Pearson correlation coefficient, −0.33; p < 0.001), the SST (Pearson correlation coefficient, 0.37; p < 0.001), and the ASES score (Pearson correlation coefficient, 0.51; p < 0.001). Tear severity only correlated with the visual analog scale for shoulder function; the Pearson correlation coefficient was 0.19 for tear size (p = 0.018), 0.18 for tendon retraction (p = 0.025), 0.18 for tear area (p = 0.022), and 0.20 for the number of tendons involved (p = 0.011). Tear severity did not correlate with other scores in bivariate correlations (all p > 0.05). In all multivariate models, the SF-36 MCS had the strongest association with the visual analog scale for shoulder pain, the visual analog scale for shoulder function, the SST, and the ASES score (all p < 0.001).
CONCLUSIONS:Patient mental health may play an influential role in patient-reported pain and function in patients with full-thickness rotator cuff tears. Further studies are needed to determine its effect on the outcome of the treatment of rotator cuff disease.
LEVEL OF EVIDENCE:Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
Prior cohort studies validated that a subgroup defined by a specific COMT genotype and pain catastrophizing is at increased risk for heightened responses to exercise-induced or surgically induced ...shoulder pain. In this clinical trial, we used our preclinical model of exercise-induced muscle injury and pain to test the efficacy of interventions matched to characteristics of this high-risk subgroup (ie, personalized medicine approach). Potential participants provided informed consent to be screened for eligibility based on subgroup membership and then, as appropriate, were enrolled into the trial. Participants (n = 261) were randomized to 1 of 4 intervention groups comprised of pharmaceutical (propranolol or placebo) and informational (general education or psychologic intervention) combinations. After muscle injury was induced, participants received randomly assigned treatment and were followed for the primary outcome of shoulder pain intensity recovery over 4 consecutive days. Recovery rates were 56.4% (placebo and psychologic intervention), 55.4% (placebo and general education), 62.9% (propranolol and psychologic intervention), and 56.1% (propranolol and general education). No statistical differences were found between intervention groups in the primary analyses. Additional analyses found no differences between these intervention groups when shoulder pain duration was an outcome, and no differential treatment responses were detected based on sex, race, or level of pain catastrophizing. This trial indicates that these treatments were not efficacious for this high-risk subgroup when shoulder pain was induced by exercise-induced muscle injury. Accordingly, this phenotype should only be used for prognostic purposes until additional trials are completed in clinical populations.
Introduction
Shoulder pain is one of the most common complications after laparoscopy. Previous studies have found a number of methods to reduce shoulder pain after laparoscopic surgery, but these ...methods have not been targeted to specific populations. The purpose of this study was to identify people who are more likely to develop shoulder pain.
Material and methods
A total of 203 patients underwent laparoscopy for benign gynecological diseases between July 2020 and February 2021. Patients were divided into two groups according to the Chinese overweight standard, body mass index less than 24 kg/m2 group and 24 kg/m2 or more group. The baseline characteristics and intraoperative data between the two groups were compared. The intensity of the shoulder pain was quantified using a visual analog scale (VAS).
Results
The incidence and the VAS scores of shoulder pain were significantly higher in the less than 24 kg/m2 group (63.64% vs 38.03%, p < 0.001 in incidence; median 5 (interquartile range IQR 3–7) vs 3 (IQR 2–5), p < 0.001 in VAS scores), and the chance of shoulder pain within 24 hours after laparoscopy was higher in the less than 24 kg/m2 group (89.29% vs 66.67%, p = 0.013). In univariate and multivariate logistic regression analysis, BMI less than 24 kg/m2 was an independent risk factor of shoulder pain after laparoscopic surgery (p = 0.001, p = 0.031, respectively). Shoulder pain scores were inversely correlated with BMI (r = −0.300, p = 0.001).
Conclusions
Patients with low body mass index are more likely to develop shoulder pain after laparoscopy, with earlier onset and higher pain scores.
Patients with low BMI are more likely to develop shoulder pain after laparoscopy, with earlier onset and higher pain scores.
Psychologic factors are associated with pain and disability in patients with chronic shoulder pain. Recent research regarding the association of affective psychologic factors (emotions) with ...patients' pain and disability outcome after surgery disagrees; and the relationship between cognitive psychologic factors (thoughts and beliefs) and outcome after surgery is unknown.
(1) Are there identifiable clusters (based on psychologic functioning measures) in patients undergoing shoulder surgery? (2) Is poorer psychologic functioning associated with worse outcome (American Shoulder and Elbow Surgeons ASES score) after shoulder surgery?
This prospective cohort study investigated patients undergoing shoulder surgery for rotator cuff-related shoulder pain or rotator cuff tear by one of six surgeons between January 2014 and July 2015. Inclusion criteria were patients undergoing surgery for rotator cuff repair with or without subacromial decompression and arthroscopic subacromial decompression only. Of 153 patients who were recruited and consented to participate in the study, 16 withdrew before data collection, leaving 137 who underwent surgery and were included in analyses. Of these, 124 (46 of 124 37% female; median age, 54 years range, 21-79 years) had a complete set of four psychologic measures before surgery: Depression, Anxiety and Stress Scale; Pain Catastrophizing Scale; Pain Self-Efficacy Questionnaire; and Tampa Scale for Kinesiophobia. The existence of clusters of people with different profiles of affective and cognitive factors was investigated using latent class analysis, which grouped people according to their pattern of scores on the four psychologic measures. Resultant clusters were profiled on potential confounding variables. The ASES score was measured before surgery and 3 and 12 months after surgery. Linear mixed models assessed the association between psychologic cluster membership before surgery and trajectories of ASES score over time adjusting for potential confounding variables.
Two clusters were identified: one cluster (84 of 124 68%) had lower scores indicating better psychologic functioning and a second cluster (40 of 124 32%) had higher scores indicating poorer psychologic functioning. Accounting for all variables, the cluster with poorer psychologic functioning was found to be independently associated with worse ASES score at all time points (regression coefficient for ASES: before surgery -9 95% confidence interval {CI}, -16 to -2, p = 0.011); 3 months after surgery -15 95% CI, -23 to -8, p < 0.001); and 12 months after surgery -9 95% CI, -17 to -1, p = 0.023). However, both clusters showed improvement in ASES score from before to 12 months after surgery, and there was no difference in the amount of improvement between clusters (regression coefficient for ASES: cluster with poorer psychologic function 31 95% CI, 26-36, p < 0.001); cluster with better psychologic function 31 95% CI, 23-39, p < 0.001).
Patients who scored poorly on a range of psychologic measures before shoulder surgery displayed worse ASES scores at 3 and 12 months after surgery. Screening of psychologic factors before surgery is recommended to identify patients with poor psychologic function. Such patients may warrant additional behavioral or psychologic management before proceeding to surgery. However, further research is needed to determine the optimal management for patients with poorer psychologic function to improve pain and disability levels before and after surgery.
Level II, therapeutic study.
Objective:
To determine the effectiveness of neck and shoulder stretching exercises for relief neck pain among office workers.
Design:
Randomized controlled trial.
Setting:
An outpatient setting.
...Participants:
A total of 96 subjects with moderate-to-severe neck pain (visual analogue score ⩾5/10) for ⩾3 months.
Interventions:
All participants received an informative brochure indicating the proper position and ergonomics to be applied during daily work. The treatment group received the additional instruction to perform neck and around shoulder stretching exercises two times/day, five days/week during four weeks.
Main outcomes:
Pain, neck functions, and quality of life were evaluated at baseline and week 4 using pain visual analogue scale, Northwick Park Neck Pain Questionnaire, and Short Form-36, respectively.
Results:
Both groups had comparable baseline data. All outcomes were improved significantly from baseline. When compared between groups, the magnitude of improvement was significantly greater in the treatment group than in the control group (–1.4; 95% CI: –2.2, –0.7 for visual analogue scale; –4.8; 95% CI: –9.3, –0.4 for Northwick Park Neck Pain Questionnaire; and 14.0; 95% CI: 7.1, 20.9 for physical dimension of the Short Form-36). Compared with the patients who performed exercises <3 times/week, those who exercised ⩾3 times/week yielded significantly greater improvement in neck function and physical dimension of quality of life scores (p = 0.005 and p = 0.018, respectively).
Conclusion:
A regular stretching exercise program performed for four weeks can decrease neck and shoulder pain and improve neck function and quality of life for office workers who have chronic moderate-to-severe neck or shoulder pain.
To evaluate the 3-month effects of pulsed electromagnetic field therapy (PEMF) in the treatment of subacromial impingement syndrome (SIS).
Planned analysis of a randomized controlled trial with 4- ...and 12-week follow-ups.
Physical medicine and rehabilitation clinic, treatment unit.
Of the 250 individuals screened for eligibility, participants with a diagnosis of SIS (N=80) were randomized to intervention or control groups.
The first group received PEMF + exercise and the second group received sham PEMF + exercise 5 days a week for a total of 20 sessions.
Visual Analog Scale (VAS), Constant Murley Score (CMS), Shoulder Pain and Disability Index (SPADI), Short Form-36 (SF-36) Quality of Life Questionnaire, and shoulder muscle strength measurement with an isokinetic dynamometer. Evaluations were performed before treatment (T0), after treatment (T1), and 12th week (T2).
Evaluation at T1 and T2 showed improvement in most parameters in both groups compared with baseline. In the comparison between the 2 groups at T1 and T2, more improvement was found in the PEMF group in most parameters.
In our study, PEMF was found to be superior to sham PEMF in terms of pain, ROM, functionality, and quality of life at the first and third months.
After the COVID-19 outbreak, many Chinese high school students have increased their dependence on electronic devices for studying and life, which may affect the incidence of neck and shoulder pain ...(NSP) in Chinese adolescents.
To evaluate the prevalence of NSP in high school students and its associated risk factors during COVID-19, a survey was conducted among 5,046 high school students in Shanghai, Qinghai, Henan and Macao during the second semester and summer vacation of the 2019-2020 academic year. The questionnaire included questions regarding demographic characteristics, the prevalence of NSP and lifestyle factors such as sedentary behavior, poor posture and electronic device usage. Univariable and multivariable logistic regression was used to analyze the possible influencing factors for neck and shoulder pain.
A total of 4793 valid questionnaires (95.0%) were collected. The results indicated that the prevalence of NSP was 23.7% among high school students. Binary logistic regression analysis revealed that female gender (P < 0.05, OR = 1.82), grade (P < 0.05, range OR 1.40-1.51) and subject selection (P < 0.05, range OR 0.49-0.68) were risk factors for NSP in high school students. Sedentary behavior (P < 0.05, range OR 1.74-2.36), poor posture (P < 0.05, range OR 1.19-2.56), backpack weight (P < 0.05, range OR 1.17-1.88), exercise style and frequency (P < 0.05, range OR 1.18-1.31; P < 0.05, range OR 0.76-0.79, respectively), and the time spent using electronic devices (P < 0.05, range OR 1.23-1.38)had a significant correlation with NSP in high school students.
NSP is currently very common among high school students during the outbreak of COVID-19. Sedentary behavior, poor posture and other factors have a great impact on the occurrence of NSP in high school students. Education regarding healthy lifestyle choices should be advocated for to decrease NSP among high school students, such as more physical activity, changing poor postures and reducing the amount of time spent using electronic devices.
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