The addition of cervical unilateral posterior–anterior mobilisation in the treatment of patients with shoulder impingement syndrome: A randomised clinical trial

Association between kinetic chain factors and the presence of shoulder pain in the non-athletic population

Background

The proximal-distal energy transfer between body segments occurs through the kinetic chain. Although some kinetic chain aspects have been investigated in individuals not engaged in sports, their relationship with shoulder pain in this population remains unclear. This cross-sectional study aimed to verify associations between kinetic chain factors and the presence of shoulder pain in adults.

Methods

Lumbopelvic stability (single-leg bridge test); active range of motion of the shoulder, trunk, and hip; and isometric peak strength of shoulder, trunk, hip, and knee muscles were assessed. A multivariate binary logistic regression analyzed the likelihood of shoulder pain based on these clinical results.

Results

Forty individuals (26.3 ± 10.4 years, 19 with shoulder pain) were assessed. The isometric strength of trunk extensor muscles significantly influenced the regression model (odds ratio = 0.99 [0.98-1.00]; p = 0.027), indicating that each 1 N increase in strength reduced the likelihood of shoulder pain by about 1%. No significant relationships were observed between other outcomes and shoulder pain.

Discussion

Isometric strength of trunk extensor muscles may be associated with shoulder pain. No associations were observed between shoulder pain and stability, mobility, and strength of other kinetic chain segments.

Cervical Spine Screening Based on Movement Strategies Improves Shoulder Physical Variables in Neck-Related Shoulder Pain Patients: A Secondary Analysis from an Observational Study

Background: It is important to consider the cervical spine as a potential contributor to shoulder pain, indicating the paramount importance of screening the cervical spine in patients with shoulder pain. Objectives: To study the immediate effects of cervical spine screening (CSS) on the shoulder active range of motion, isometric strength and self-reported function in patients with neck-related shoulder pain. Methods: A secondary analysis was conducted on data from a previous study. A cervical contribution was considered if a ≥30% shoulder symptom modification of pain intensity (Numeric Pain Rating Scales) was recorded during the most painful shoulder movement after CSS. Pre-post measurements of the shoulder active range of motion (inclinometer) and shoulder isometric strength (dynamometer) were recorded in a single session. Self-reported shoulder function (Shoulder Pain and Disability Index) was assessed at a 1-week follow-up. Results: Among 60 participants, statistically significant changes were found for those with a cervical contribution (n = 30) for shoulder flexion and the abduction range of motion (p < 0.001), with a medium size effect (r = 0.55), and in internal rotation (p = 0.02) and external rotation at 0° abduction (p = 0.008), with a small size effect (r = 0.3 and 0.34, respectively). The self-reported shoulder function in those without a cervical contribution significantly declined from the pre to post measurements (p = 0.002), with a small size effect (r = 0.4). No statistically significant changes were found for the isometric strength in either group. Conclusions: In patients with shoulder pain classified as having a cervical contribution, CSS produces intrasession improvements in the active shoulder range of motion but not in the shoulder isometric strength or self-reported shoulder function.

Thinking outside the shoulder: A systematic review and metanalysis of kinetic chain characteristics in non-athletes with shoulder pain

INTRODUCTION

The kinetic chain is important in the proximal-distal energy transfer along body segments. Although biomechanical impairments in components of the kinetic chain have already been reported in athletes with shoulder pain, such investigations in non-athlete individuals have not yet been synthesized.

OBJECTIVE

To systematically review the literature and analyze the quality of evidence on the characteristics of the kinetic chain of non-athletes with shoulder pain compared to asymptomatic individuals.

METHODS

Studies published until February 2024 (without language restrictions) that quantitatively assessed outcomes related to the kinetic chain of non-athlete individuals were searched in five databases (MEDLINE, CINAHL, Web of Science, EMBASE, and SCOPUS). The risk of bias and quality of evidence were analyzed using the Joanna Briggs Institute Critical Appraisal Tool for Analytical Cross-Sectional Studies and the Grading of Recommendations, Assessment, Development, and Evaluation approach, respectively. To summarize the findings, meta-analyses with random-effects models were performed.

RESULTS

Six cross-sectional studies (n = 562 [282 with shoulder pain], mean age = 48.7 ± 8.1 years) with low risk of bias were included in this review. Very low-quality evidence suggests that individuals with shoulder pain may present a lower active range of motion and muscular endurance/strength in the cervical spine, thoracolumbar region, and hip, as well as deficits in neuromuscular control of the lower extremities. Findings related to thoracic spine posture were conflicting and no differences were found in cervical spine isometric muscular strength between individuals with and without shoulder pain.

CONCLUSION

Individuals with shoulder pain may present alterations in active mobility, muscular endurance, and neuromuscular control in kinetic chain segments. These findings suggest that broader physical assessments considering components of the kinetic chain may be clinically relevant in this population. However, based on the very low quality of evidence, the findings of this review should be interpreted with caution.

Efficacy of Transcutaneous Pulsed Radiofrequency Treatment in Subacromial Impingement Syndrome: A Randomized Controlled Study

Background: This study assessed Transcutaneous Pulse Radiofrequency Therapy's (TCPRF) effectiveness in reducing shoulder pain and improving shoulder function. Methods: A double-blind randomized controlled trial involved 50 SAIS patients with chronic shoulder pain. Participants were randomized into two groups: the study group (n = 27) received TCPRF, while the control (n = 23) received sham treatment. The primary outcome was shoulder pain, secondary outcomes, including shoulder function, quality of life, and range of motion, were assessed at baseline, and at 1, 4, and 12 weeks using the Visual Analog Scale (VAS), Shoulder Pain and Disability Index (SPADI), and the SF-36 questionnaire. Supraspinatus tendon thickness (SSPT) and acromiohumeral distance (AHD) were measured by ultrasound. Results: Both groups showed reductions in activity and resting pain over 12 weeks. In the control, activity pain dropped from a median (IQR) of 8 (7-8) to 6 (3-7), and in TCPRF from 8 (7-10) to 3.5 (2-6.3), with no significant difference at 12 weeks (p = 0.192). Resting pain decreased from 3 (1-6) to 1 (1-3) in the control, and from 3 (2-4) to 0 (0-2) in TCPRF, showing a lower resting pain at 12 weeks (p = 0.041). SPADI-Total scores decreased from 87 (54-105) to 50 (29-82) in the control and from 84 (69-107) to 21 (9-66.3) in TCPRF, favoring TCPRF at 12 weeks (p = 0.017). SPADI-Disability scores reduced from 49 (30-63) to 30 (15-30) in control and from 47 (35-62) to 11 (5.8-38.8) in TCPRF, also favoring TCPRF (p = 0.008). Both groups showed similar improvements in other outcomes. Conclusions: TCPRF reduced resting pain and shoulder disability in SAIS over 12 weeks, though other outcomes showed similar improvement in both groups. Further studies are needed to determine long-term effects.

The prevalence of cervical contribution in patients reporting shoulder pain. An observational study

BACKGROUND

Shoulder pain is the third most common musculoskeletal disorder yet diagnosis remains challenging. In some cases, shoulder symptoms can be partially attributed to a cervical origin.

OBJECTIVES

To estimate the prevalence of cervical contribution in patients presenting with shoulder pain. To determine symptom reproduction and symptom modification (i.e., pain intensity and pain location) after cervical spine screening (CSS) and compare these changes between patients with and without cervical contribution.

DESIGN

Observational study.

METHOD

Sixty patients were included. Cervical contribution was present if a ≥30.0% change in shoulder pain intensity on active movement was recorded after CSS. The CSS consisted of several tests and shoulder symptom modification or reproduction was noted. The presence of a centralization phenomenon was also noted and was considered to be present if the location of pain diminished from more distal areas after the CSS.

RESULTS

A 50.0% prevalence of cervical contribution (CI95% 37,35-62,65) was found. Cervical contribution was more likely in those that demonstrated centralization of their pain after the CSS (p = 0.002) and those that had a history of previous neck pain (p = 0.007). Symptom reproduction occurred for 23 out of the 60 participants (38.3%), being present in 18 of those with cervical contribution (60.0%). After the CSS, a statistically significant decrease of shoulder pain intensity was found for those classified as having cervical contribution (p < 0.001).

CONCLUSIONS

Cervical contribution is prevalent in 50% of patients presenting with shoulder pain; this was evidenced as shoulder symptom modification and, to a lesser extent, symptom reproduction following a CSS.

Adverse Events Reported in Trials Assessing Manual Therapy to the Extremities: A Systematic Review

Objective: This review aimed to describe the quality and comprehensiveness of adverse event (AE) reporting in clinical trials incorporating manual therapy (MT) as an intervention for extremity conditions using the Consolidated Standards of Reporting Trials (CONSORT)-Harms extension as the benchmark. The secondary aim was to determine whether the quality of AE reporting improved after the availability of the CONSORT reporting checklist. Design: Systematic review. Methods: A literature search was conducted using multiple databases to identify trials where MT was used to treat extremity conditions. Studies that reported AEs were identified and evaluated using the CONSORT-Harms extension. The frequency of trials reporting study AEs before and after the publication of the updated 2010 CONSORT statement was calculated, along with the categorization of how study AEs were reported. Results: Of the 55,539 studies initially identified, 220 trials met all inclusion criteria. Eighty trials (36.4%) reported AE occurrence. None of the studies that reported AEs adhered to all 10 criteria proposed by the 2010 CONSORT-Harms extension. The most commonly reported criterion was number four, which clarified how AE-related information was collected (30% of trials). The least reported criterion was number six, which describes the participant withdrawals for each arm due to AEs and the experience with the allocated treatment (1.3% of trials). The nomenclature used to describe AEs varied substantially. Fifty-nine of 76 trials (33.3%) were published after the updated CONSORT Harms-checklist was available, compared to 21 of 44 trials (46.7%) published before it was available. Conclusion: Reporting of AEs in trials investigating MT for extremity conditions is poor. Every included trial lacked adherence to all 10 criteria proposed by the CONSORT-Harms Extension. The quality and comprehensiveness of AE reporting did not improve after the most recent CONSORT update recommending AE reporting. Clinicians must obtain informed consent before performing any intervention, including MT, which requires disclosing potential risks, which could be better known with improved tracking, analyzing, and reporting of AEs. The authors recommend improved adherence to best practices for adequately tracking and reporting AEs in future MT trials.

To allow or avoid pain during shoulder rehabilitation exercises for patients with chronic rotator cuff tendinopathy-Study protocol for a randomized controlled trial (the PASE trial)

BACKGROUND

Rotator cuff (RC) tendinopathy is the most reported shoulder disorder in the general population with highest prevalence in overhead athletes and adult working-age population. A growing body of evidence support exercise therapy as an effective intervention, but to date there are no prospective randomized controlled trials addressing pain as an intervention variable.

METHODS

A single-site, prospective, pragmatic, assessor-blinded randomized controlled superiority trial. Eighty-four patients aged 18-55 years with chronic (symptom duration over 3 months) RC tendinopathy are randomized 1:1 to receive shoulder exercise during which pain is either allowed or avoided. The intervention period lasts 26 weeks. During that period, participants in both groups are offered 8 individual on-site sessions with an assigned sports physiotherapist. Participants perform home exercises and are provided with a pain and exercise logbook and asked to report completed home-based exercise sessions and reasons for not completing sessions (pain or other reasons). Patients are also asked to report load and the number of sets and repetitions per sets for each exercise session. The logbooks are collected continuously throughout the intervention period. The primary and secondary outcomes are obtained at baseline, 6 weeks, 26 weeks, and 1 year after baseline. The primary outcome is patient-reported pain and disability using the Shoulder PAin and Disability Index (SPADI). Secondary outcomes are patient-reported pain and disability using Disability Arm Shoulder and Hand short-form (Quick DASH), and shoulder pain using Numeric Pain Rating Scale. Objective outcomes are shoulder range of motion, isometric shoulder muscle strength, pain sensitivity, working ability, and structural changes in the supraspinatus tendon and muscle using ultrasound.

DISCUSSION

The results of this study will contribute knowledge about the treatment strategies for patients with RC tendinopathy and help physiotherapists in clinical decision-making. This is the first randomized controlled trial comparing the effects of allowing pain versus avoiding pain during shoulder exercises in patients with chronic RC tendinopathy. If tolerating pain during and after exercise proves to be effective, it will potentially expand our understanding of "exercising into pain" for this patient group, as there is currently no consensus.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05124769. Registered on August 11, 2021.

Is there 'trustworthy' evidence for using manual therapy to treat patients with shoulder dysfunction?: A systematic review

The primary objective of this review was to create a 'trustworthy,' living systematic review and meta-analysis for the application of manual therapy interventions in treating patients with shoulder dysfunction. Included studies were English-language randomized controlled trials published between 1/1/2010 and 8/3/2023, with searches performed in: PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), CINHAL, ProQuest Nursing & Allied Health, EBSCO Medline, and PEDro. The population of focus included adults 18 years and older with musculoskeletal impairments related to shoulder dysfunction. Our primary outcomes included pain and region-specific outcome measures. We excluded trials, including participants having shoulder dysfunction resulting from surgery, radicular pain, instability/dislocation, fracture, lymphedema, and radiation. Our screening methodology was based upon a previously published 'trustworthy' systematic review protocol. This included the application of our PICOTS criteria in addition to screening for prospective clinical trial registration and following of prospective intent, as well as assessment of PEDro scores, risk-of-bias ratings, GRADE scoring, and examination of confidence in estimated effects. Twenty-six randomized controlled trials met our PICOTS criteria; however, only 15 of these were registered. Only three were registered prospectively. Two of these did not have discussions and conclusions that aligned with their primary outcome. The remaining single study was found to have a high risk-of-bias, meaning the remainder of the protocol could not be employed and that no randomized controlled trials could undergo further assessment or meta-analysis. The results of this systematic review indicate there are no 'trustworthy' randomized controlled trials examining the effectiveness of manual therapy interventions for the treatment of patients with shoulder dysfunction, as defined by the prospectively established methodology. Therefore, these findings signal that creating a 'trustworthy,' living systematic review on this clinically relevant topic is not yet possible due to a lack of 'trustworthy' randomized controlled trials.

Exercise therapy for tendinopathy: a mixed-methods evidence synthesis exploring feasibility, acceptability and effectiveness

Background

Tendinopathy is a common, painful and functionally limiting condition, primarily managed conservatively using exercise therapy.

Review questions

(i) What exercise interventions have been reported in the literature for which tendinopathies? (ii) What outcomes have been reported in studies investigating exercise interventions for tendinopathy? (iii) Which exercise interventions are most effective across all tendinopathies? (iv) Does type/location of tendinopathy or other specific covariates affect which are the most effective exercise therapies? (v) How feasible and acceptable are exercise interventions for tendinopathies?

Methods

A scoping review mapped exercise interventions for tendinopathies and outcomes reported to date (questions i and ii). Thereafter, two contingent systematic review workstreams were conducted. The first investigated a large number of studies and was split into three efficacy reviews that quantified and compared efficacy across different interventions (question iii), and investigated the influence of a range of potential moderators (question iv). The second was a convergent segregated mixed-method review (question v). Searches for studies published from 1998 were conducted in library databases (n = 9), trial registries (n = 6), grey literature databases (n = 5) and Google Scholar. Scoping review searches were completed on 28 April 2020 with efficacy and mixed-method search updates conducted on 19 January 2021 and 29 March 2021.

Results

Scoping review - 555 included studies identified a range of exercise interventions and outcomes across a range of tendinopathies, most commonly Achilles, patellar, lateral elbow and rotator cuff-related shoulder pain. Strengthening exercise was most common, with flexibility exercise used primarily in the upper limb. Disability was the most common outcome measured in Achilles, patellar and rotator cuff-related shoulder pain; physical function capacity was most common in lateral elbow tendinopathy. Efficacy reviews - 204 studies provided evidence that exercise therapy is safe and beneficial, and that patients are generally satisfied with treatment outcome and perceive the improvement to be substantial. In the context of generally low and very low-quality evidence, results identified that: (1) the shoulder may benefit more from flexibility (effect sizeResistance:Flexibility = 0.18 [95% CrI 0.07 to 0.29]) and proprioception (effect sizeResistance:Proprioception = 0.16 [95% CrI -1.8 to 0.32]); (2) when performing strengthening exercise it may be most beneficial to combine concentric and eccentric modes (effect sizeEccentricOnly:Concentric+Eccentric = 0.48 [95% CrI -0.13 to 1.1]; and (3) exercise may be most beneficial when combined with another conservative modality (e.g. injection or electro-therapy increasing effect size by ≈0.1 to 0.3). Mixed-method review - 94 studies (11 qualitative) provided evidence that exercise interventions for tendinopathy can largely be considered feasible and acceptable, and that several important factors should be considered when prescribing exercise for tendinopathy, including an awareness of potential barriers to and facilitators of engaging with exercise, patients' and providers' prior experience and beliefs, and the importance of patient education, self-management and the patient-healthcare professional relationship.

Limitations

Despite a large body of literature on exercise for tendinopathy, there are methodological and reporting limitations that influenced the recommendations that could be made.

Conclusion

The findings provide some support for the use of exercise combined with another conservative modality; flexibility and proprioception exercise for the shoulder; and a combination of eccentric and concentric strengthening exercise across tendinopathies. However, the findings must be interpreted within the context of the quality of the available evidence.

Future work

There is an urgent need for high-quality efficacy, effectiveness, cost-effectiveness and qualitative research that is adequately reported, using common terminology, definitions and outcomes.

Study registration

This project is registered as DOI: 10.11124/JBIES-20-00175 (scoping review); PROSPERO CRD 42020168187 (efficacy reviews); https://osf.io/preprints/sportrxiv/y7sk6/ (efficacy review 1); https://osf.io/preprints/sportrxiv/eyxgk/ (efficacy review 2); https://osf.io/preprints/sportrxiv/mx5pv/ (efficacy review 3); PROSPERO CRD42020164641 (mixed-method review).

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) HTA programme and will be published in full in HTA Journal; Vol. 27, No. 24. See the NIHR Journals Library website for further project information.

Immediate effects of thoracic manipulation on cervical joint position sense in individuals with mechanical neck pain: A randomized controlled trial

BACKGROUND

Performing thoracic manipulations for neck pain can result in immediate improvements in neck function.

OBJECTIVE

The aim of this study was to investigate the immediate effects of thoracic manipulation on cervical joint position sense and cervical range of motion in individuals with chronic mechanical neck pain.

METHODS

Eighty male volunteers between 18-25 years and having chronic or recurrent neck or shoulder pain of at least 3 months duration with or without arm pain were randomized into two groups: Thoracic Manipulation Group (TMG:50) and Control Group (CG:30), with a pretest-posttest experimental design. The TMG was treated with thoracic extension manipulation while the CG received no intervention. Cervical joint position error and cervical range of motion of the individuals were assessed at baseline and 5 minutes later.

RESULTS

There was no difference in demographic variables such as age (p= 0.764), Body Mass Index (p= 0.917) and Neck Pain Disability Scale (NPDS) scores (p= 0.436) at baseline outcomes between TMG and CGs. Joint position error outcomes between the two groups following intervention were similar in all directions at 30 and 50 degrees. Differences in range of motion following intervention in neck flexion (p< 0.001) and right rotation (p= 0.004) were higher in TMG compared to CG.

CONCLUSIONS

A single session of thoracic manipulation seems to be inefficient on joint position sense in individuals with mild mechanical neck pain. However, thoracic manipulation might be an effective option to increase flexion and rotation of the cervical region as an adjunctive to treatment.

Noninvasive management of soft tissue disorders of the shoulder: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration

OBJECTIVES

Objective of this study is to develop an evidence-based guideline for the noninvasive management of soft tissue disorders of the shoulder (shoulder pain), excluding major pathology.

METHODS

This guideline is based on high-quality evidence from seven systematic reviews. Multidisciplinary experts considered the evidence of effectiveness, safety, cost-effectiveness, societal and ethical values, and patient experiences when formulating recommendations. Target audience is clinicians; target population is adults with shoulder pain.

RESULTS

When managing patients with shoulder pain, clinicians should (a) rule out major structural or other pathologies as the cause of shoulder pain and reassure patients about the benign and self-limited nature of most soft tissue shoulder pain; (b) develop a care plan in partnership with the patient; (c) for shoulder pain of any duration, consider low-level laser therapy; multimodal care (heat/cold, joint mobilization, and range of motion exercise); cervicothoracic spine manipulation and mobilization for shoulder pain when associated pain or restricted movement of the cervicothoracic spine; or thoracic spine manipulation; (d) for shoulder pain >3-month duration, consider stretching and/or strengthening exercises; laser acupuncture; or general physician care (information, advice, and pharmacological pain management if necessary); (e) for shoulder pain with calcific tendinitis on imaging, consider shock-wave therapy; (f) for shoulder pain of any duration, do not offer ultrasound; taping; interferential current therapy; diacutaneous fibrolysis; soft tissue massage; or cervicothoracic spine manipulation and mobilization as an adjunct to exercise (i.e., range of motion, strengthening and stretching exercise) for pain between the neck and the elbow at rest or during movement of the arm; (g) for shoulder pain >3-month duration, do not offer shock-wave therapy; and (h) should reassess the patient's status at each visit for worsening of symptoms or new physical, mental, or psychological symptoms, or satisfactory recovery.

CONCLUSIONS

Our evidence-based guideline provides recommendations for non-invasive management of shoulder pain. The impact of the guideline in clinical practice requires further evaluation.

SIGNIFICANCE

Shoulder pain of any duration can be effectively treated with laser therapy, multimodal care (i.e., heat/cold, joint mobilization, range of motion exercise), or cervicothoracic manipulation and mobilization. Shoulder pain (>3 months) can be effectively treated with exercises, laser acupuncture, or general physician care (information, advice, and pharmacological pain management if necessary).

Comparison of low-level laser treatment and extracorporeal shock wave therapy in subacromial impingement syndrome: a randomized, prospective clinical study

The aim of this study was to compare the efficacy of low-level laser treatment (LLLT) and extracorporeal shock wave therapy (ESWT) in the treatment of subacromial impingement syndrome (SIS). Seventy-one patients with subacromial impingement were randomly assigned to LLLT (n = 37) and ESWT (n = 34) groups. The patients received a total of 15 sessions of LLLT or once a week for 3 sessions of ESWT. All patients, before treatment, at the end of treatment, and 3 months after treatment, were evaluated with range of motion (ROM), visual analogue pain scale (VAS pain), Shoulder Pain and Disability Index (SPADI), Beck Depression and Anxiety Inventories, the Short Form Health Survey (SF-36), and Pittsburgh Sleep Quality Index (PSQI). In both groups, there was a significant improvement in all outcome measures (p < 0.05) except the mental health score in the LLLT group. ESWT group showed more improvements in terms of SPADI disability and total scores, PSQI, and physical-mental health scores at the end of treatment (p < 0.05). The improvement in VAS pain day and SPADI scores at the third month was significantly more evident in the ESWT group (p < 0.05). Both LLLT and ESWT treatments are effective in the treatment of SIS in the short-medium term and can be used in clinical practice. Future larger prospective clinical trials are needed to investigate the long-term efficacy and optimal treatment protocol of LLLT and ESWT in SIS.

Screening of the cervical spine in subacromial shoulder pain: A systematic review

BACKGROUND

Subacromial shoulder pain is a common clinical presentation with much diagnostic uncertainty. Some of this uncertainty relates to the involvement of the cervical spine as a source or contribution to subacromial shoulder pain. Currently, there is no accepted method of screening of the cervical spine in the presence of subacromial shoulder pain, which risks patients receiving misguided and/or ineffective interventions.

OBJECTIVE

To evaluate approaches used to screen the cervical spine in patients with subacromial shoulder pain.

DESIGN

Systematic review of randomized controlled trials.

METHODS

Electronic searches of PEDro and MEDLINE to December 2016 were conducted. Randomized controlled trials evaluating the effectiveness of interventions within the current scope of physiotherapy comprising of adult patients complaining of subacromial shoulder pain were included. Data relating to the method of cervical spine screening were extracted and synthesized categorically.

RESULTS

One hundred and two studies were included. Twenty-six (25.5%) were categorized as "No method of screening undertaken or reported," 49 (48.0%) were categorized as "Localized cervical spine symptoms and/or radiculopathy/radicular pain," nine (8.8%) were categorized as "Cervical examination," two (2.0%) were categorized as "Manual testing," two (2.0%) were categorized as "History of cervical surgery," and 14 (13.7%) were categorized as using "Combined approaches."

CONCLUSION

Examination of the cervical spine in patients with subacromial shoulder pain is variable in randomized controlled trials. In many instances, no or minimal attempts to screen were undertaken or reported. This has potential research and management implications and further research is indicated to facilitate development of this aspect of examination.

Immediate effects of cervical unilateral anterior-posterior mobilisation on shoulder pain and impairment in post-operative arthroscopy patients

BACKGROUND

Lateral gliding cervical spine mobilisation is shown to improve shoulder pain, disability and function. However, despite common clinical-use, no study reports the effect of unilateral anterior-posterior (A-P) cervical mobilisation on shoulder pain and function, and particularly in patients after arthroscopic shoulder surgery.

OBJECTIVE

Examine the immediate effect of single-level Grade III cervical unilateral A-P mobilisation on shoulder pain, flexion and abduction range of motion (ROM) and external rotator strength compared to placebo cervical unilateral A-P light touch pressure.

METHODS

Single session intervention with a crossover design in 32 (15 women) postoperative arthroscopic shoulder patients.

RESULTS

Immediate and superior treatment effects were shown for A-P cervical mobilisation in improving flexion ROM, isometric strength of external rotation, and pain intensity during flexion (all p< 0.05) when compared to the placebo. However, effects may not be considered clinically meaningful.

CONCLUSION

Unilateral A-P mobilisation applied to the cervical spine shows a tendency toward positively influencing post-arthroscopy shoulder pain and function. Further study examining cervical mobilisations directed in different planes to influence shoulder motion appear warranted.

The Foot Orthoses versus Hip eXercises (FOHX) trial for patellofemoral pain: a protocol for a randomized clinical trial to determine if foot mobility is associated with better outcomes from foot orthoses

BACKGROUND

Patellofemoral pain (PFP) is a prevalent, often recalcitrant and multifactorial knee pain condition. One method to optimize treatment outcome is to tailor treatments to the patient's presenting characteristics. Foot orthoses and hip exercises are two such treatments for PFP with proven efficacy yet target different ends of the lower limb with different proposed mechanisms of effect. These treatments have not been compared head-to-head, so there is a dearth of evidence for which to use clinically. Only foot orthoses have been explored for identifying patient characteristics that might predict a beneficial effect with either of these two treatments. Preliminary evidence suggests patients will do well with foot orthoses if they have a midfoot width in weight bearing that is ≥ 11 mm more than in non-weight bearing, but this has yet to be verified in a study that includes a comparator treatment and an adequate sample size. This trial will determine if: (i) hip exercises are more efficacious than foot orthoses, and (ii) greater midfoot width mobility will be associated with success with foot orthoses, when compared to hip exercises.

METHODS

Two hundred and twenty participants, aged 18-40 years, with a clinical diagnosis of PFP will be randomly allocated with a 1:1 ratio to receive foot orthoses or progressive resisted hip exercises, and stratified into two subgroups based on their presenting midfoot width mobility (high mobility defined as ≥11 mm). The primary outcome will be a 7-point Likert scale for global rating of change. All analyses will be conducted on an intention-to-treat basis using regression models.

DISCUSSION

This trial is designed to compare the efficacy of foot orthoses versus hip exercise, as well as to determine if high midfoot width mobility is associated with better outcomes with foot orthoses when compared to hip exercises. Results of this trial will assist clinicians in optimising the management of those with PFP by testing whether a simple measure of midfoot width mobility can help to determine which patients are most likely to benefit from foot orthoses.

TRIAL REGISTRATION

This trial is registered on the Australian New Zealand Clinical Trials Register (ACTRN12614000260628).

Shoulder impingement syndrome: a systematic review of clinical trial participant selection criteria

BACKGROUND

Shoulder impingement syndrome (SIS) is a common diagnosis for patients with pain and dysfunction of the shoulder. Variations in the signs and symptoms might lead to uncertainty regarding the definition of SIS. The aim of this review is to explore the participant selection criteria used in the literature when investigating SIS and to assess differences in criteria among treating professions.

METHODS

This is a PRISMA systematic review of publications from 2009 to 2014 from MEDLINE, PubMed, The Cochrane Library, Embase, Scopus and CINAHL.

RESULTS

Ninety-seven articles met inclusion criteria for this review. Twenty-five different surgical and nonsurgical treatments were investigated. Impingement-specific index tests were used in all studies. Exclusion index tests were used in 62% of studies. Twenty index tests were identified. Radiological investigations were reported in 53% of all studies, of which a further 53% reported using two or more radiological investigations.

CONCLUSIONS

This systematic review has illustrated that studies investigating SIS test for various signs and symptoms, which is in keeping with describing the condition as a 'syndrome'. However, there are inconsistencies in participant selection criteria between health disciplines, highlighting a need for harmonization of the selection criteria in the form of an international editorial consensus.

Subacute effects of cervicothoracic spinal thrust/non-thrust in addition to shoulder manual therapy plus exercise intervention in individuals with subacromial impingement syndrome: a prospective, randomized controlled clinical trial pilot study

OBJECTIVES

To determine the subacute effects of cervicothoracic spinal thrust/non-thrust in addition to shoulder non-thrust plus exercise in patients with subacromial pathology.

METHODS

This was a randomized, single blinded controlled trial pilot study. This trial was registered at ClinicalTrials.gov (NCT01753271) and reported according to Consolidated Standards of Reporting Trials requirements. Patients were randomly assigned to either shoulder treatment plus cervicothoracic spinal thrust/non-thrust or shoulder treatment-only group. Primary outcomes were average pain intensity (Numeric Pain Rating Scale) and physical function (Shoulder Pain and Disability Index) at 2 weeks, 4 weeks, and patient discharge.

RESULTS

18 patients, mean age 43.1(15.8) years satisfied the eligibility criteria and were analyzed for follow-up data. Both groups showed statistically significant improvements in both pain and function at 2 weeks, 4 weeks, and discharge. The between-group differences for changes in pain or physical function were not significant at any time point.

DISCUSSION

The addition of cervicothoracic spinal thrust/non-thrust to the shoulder treatment-only group did not significantly alter improvement in pain or function in patients with subacromial pathology. Both approaches appeared to provide an equally notable benefit. Both groups improved on all outcomes and met the criteria for clinical relevance for both pain and function.

LEVEL OF EVIDENCE

2b.

Cervicothoracic Manual Therapy Plus Exercise Therapy Versus Exercise Therapy Alone in the Management of Individuals With Shoulder Pain: A Multicenter Randomized Controlled Trial

Study Design Multicenter randomized controlled trial. Background Cervicothoracic manual therapy has been shown to improve pain and disability in individuals with shoulder pain, but the incremental effects of manual therapy in addition to exercise therapy have not been investigated in a randomized controlled trial. Objectives To compare the effects of cervicothoracic manual therapy and exercise therapy to those of exercise therapy alone in individuals with shoulder pain. Methods Individuals (n = 140) with shoulder pain were randomly assigned to receive 2 sessions of cervicothoracic range-of-motion exercises plus 6 sessions of exercise therapy, or 2 sessions of high-dose cervicothoracic manual therapy and range-of-motion exercises plus 6 sessions of exercise therapy (manual therapy plus exercise). Pain and disability were assessed at baseline, 1 week, 4 weeks, and 6 months. The primary aim (treatment group by time) was examined using linear mixed-model analyses and the repeated measure of time for the Shoulder Pain and Disability Index (SPADI), the numeric pain-rating scale, and the shortened version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH). Patient-perceived success was assessed and analyzed using the global rating of change (GROC) and the Patient Acceptable Symptom State (PASS), using chi-square tests of independence. Results There were no significant 2-way interactions of group by time or main effects by group for pain or disability. Both groups improved significantly on the SPADI, numeric pain-rating scale, and QuickDASH. Secondary outcomes of success on the GROC and PASS significantly favored the manual therapy-plus-exercise group at 4 weeks (P = .03 and P<.01, respectively) and on the GROC at 6 months (P = .04). Conclusion Adding 2 sessions of high-dose cervicothoracic manual therapy to an exercise program did not improve pain or disability in patients with shoulder pain, but did improve patient-perceived success at 4 weeks and 6 months and acceptability of symptoms at 4 weeks. More research is needed on the use of cervicothoracic manual therapy for treating shoulder pain. Level of Evidence Therapy, level 1b. Prospectively registered March 30, 2012 at www.ClinicalTrials.gov (NCT01571674). J Orthop Sports Phys Ther 2016;46(8):617-628. doi:10.2519/jospt.2016.6319.

Manual therapy and exercise for rotator cuff disease

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.

The effectiveness of manual therapy for the management of musculoskeletal disorders of the upper and lower extremities: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

BACKGROUND

Musculoskeletal disorders (MSDs) of the upper and lower extremities are common in the general population and place a significant burden on the health care system. Manual therapy is recommended by clinical practice guidelines for the management of these injuries; however, there is limited evidence to support its effectiveness. The purpose of our review was to investigate the effectiveness of manual therapy in adults or children with MSDs of the upper or lower extremity.

METHODS

Randomized controlled trials (RCTs), cohort studies, and case-control studies evaluating the effectiveness of manual therapy were eligible. We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials from 1990 to 2015. Paired reviewers screened studies for relevance and critically appraised relevant studies using the Scottish Intercollegiate Guidelines Network criteria. Studies with low risk of bias were synthesized following best-evidence synthesis principles. Where available, we computed mean changes between groups, relative risks and 95 % CI.

RESULTS

We screened 6047 articles. Seven RCTs were critically appraised and three had low risk of bias. For adults with nonspecific shoulder pain of variable duration, cervicothoracic spinal manipulation and mobilization in addition to usual care may improve self-perceived recovery compared to usual care alone. For adults with subacromial impingement syndrome of variable duration, neck mobilization in addition to a multimodal shoulder program of care provides no added benefit. Finally, for adults with grade I-II ankle sprains of variable duration, lower extremity mobilization in addition to home exercise and advice provides greater short-term improvements in activities and function over home exercise and advice alone. No studies were included that evaluated the effectiveness of manual therapy in children or for the management of other extremity injuries in adults.

CONCLUSIONS

The current evidence on the effectiveness of manual therapy for MSDs of the upper and lower extremities is limited. The available evidence supports the use of manual therapy for non-specific shoulder pain and ankle sprains, but not for subacromial impingement syndrome in adults. Future research is needed to determine the effectiveness of manual therapy and guide clinical practice.

SYSTEMATIC REVIEW REGISTRATION NUMBER

CRD42014009899.

Can experienced physiotherapists identify which patients are likely to succeed with physical therapy treatment?

Background

The purpose of the study was to determine if clinician predicted prognosis is associated with patient outcomes.

Methods

The study was a secondary analysis of data that were collected in 8 physiotherapy outpatient clinics. Nine physiotherapists with post-graduate training in manual therapy (mean 20.3 years of experience) were asked at baseline to project the outcome of the patients evaluated. In total, 112 patients with low back (74 %) or neck (26 %) pain were treated pragmatically with interventions consisting of manual therapy, strengthening, and patient-specific education. Outcomes measures consisted of percent change in disability (Oswestry or Neck Disability Index), self-reported rate of recovery (0–100 %), and percent change in pain (numerical pain rating scale). Hierarchical logistic regression determined potential factors (clinician predicted prognosis score (1–10) at baseline, dichotomised as poor (1–6) and good (7–10); symptom duration categorised as acute, subacute or chronic; same previous injury (yes/no); baseline pain and disability scores; within-session improvement at initial visit (yes/no); and presence of ≥ one psychological factor) associated with meaningful changes in each of the three outcomes at discharge (disability and pain > 50 % improvement, rate of recovery ≥82.5 % improvement).

Results

Clinician predicted prognosis (OR 4.15, 95%CI = 1.31, 13.19, p = 0.02) and duration of symptoms (OR subacute 0.24, 95%CI = 0.07, 0.89, p = 0.03; chronic 0.21, 95%CI = 0.05, 0.90, p = 0.04) were associated with rate of recovery, whereas only clinician predicted prognosis was associated with disability improvement (OR 4.28, 95 % CI 1.37, 13.37, p = 0.01). No variables were associated with pain improvement.

Conclusions

Clinician predicted prognosis is potentially valuable for patients, as a good predicted prognosis is associated with improvements in disability and rate of recovery.

Treatments for shoulder impingement syndrome: a PRISMA systematic review and network meta-analysis

Many treatments for shoulder impingement syndrome (SIS) are available in clinical practice; some of which have already been compared with other treatments by various investigators. However, a comprehensive treatment comparison is lacking. Several widely used electronic databases were searched for eligible studies. The outcome measurements were the pain score and the Constant-Murley score (CMS). Direct comparisons were performed using the conventional pair-wise meta-analysis method, while a network meta-analysis based on the Bayesian model was used to calculate the results of all potentially possible comparisons and rank probabilities. Included in the meta-analysis procedure were 33 randomized controlled trials involving 2300 patients. Good agreement was demonstrated between the results of the pair-wise meta-analyses and the network meta-analyses. Regarding nonoperative treatments, with respect to the pain score, combined treatments composed of exercise and other therapies tended to yield better effects than single-intervention therapies. Localized drug injections that were combined with exercise showed better treatment effects than any other treatments, whereas worse effects were observed when such injections were used alone. Regarding the CMS, most combined treatments based on exercise also demonstrated better effects than exercise alone. Regarding surgical treatments, according to the pain score and the CMS, arthroscopic subacromial decompression (ASD) together with treatments derived from it, such as ASD combined with radiofrequency and arthroscopic bursectomy, showed better effects than open subacromial decompression (OSD) and OSD combined with the injection of platelet-leukocyte gel. Exercise therapy also demonstrated good performance. Results for inconsistency, sensitivity analysis, and meta-regression all supported the robustness and reliability of these network meta-analyses. Exercise and other exercise-based therapies, such as kinesio taping, specific exercises, and acupuncture, are ideal treatments for patients at an early stage of SIS. However, low-level laser therapy and the localized injection of nonsteroidal anti-inflammatory drugs are not recommended. For patients who have a long-term disease course, operative treatments may be considered, with standard ASD surgery preferred over arthroscopic bursectomy and the open surgical technique for subacromial decompression. Notwithstanding, the choice of surgery should be made cautiously because similar outcomes may also be achieved by the implementation of exercise therapy.