The influence of exercise therapy dosing on pain and functional outcomes in patients with subacromial pain syndrome: A systematic review

Is exercise therapy the right treatment for rotator cuff-related shoulder pain? Uncertainties, theory, and practice

BACKGROUND

Exercise therapy is a popular non-surgical treatment to help manage individuals with rotator cuff-related shoulder pain (RCRSP) and is recommended in all clinical practice guidelines. Due to modest effect sizes, low quality evidence, uncertainty relating to efficacy, and mechanism(s) of benefit, exercise as a therapeutic intervention has been the subject of increasing scrutiny.

AIMS

The aim of this critical review is to lay out where the purported uncertainties of exercise for RCRSP exist by exploring the relevant quantitative and qualitative literature. We conclude by offering theoretical and practical considerations to help reduce the uncertainty of delivering exercise therapy in a clinical environment.

RESULTS AND DISCUSSION

Uncertainty underpins much of the theory and practice of delivering exercise therapy for individuals with RCRSP. Nonetheless, exercise is an often-valued treatment by individuals with RCRSP, when provided within an appropriate clinical context. We encourage clinicians to use a shared decision-making paradigm and embrace a pluralistic model when prescribing therapeutic exercise. This may take the form of using exercise experiments to trial different exercise approaches, adjusting, and adapting the exercise type, load, and context based on the individual's symptom irritability, preferences, and goals.

CONCLUSION

We contend that providing exercise therapy should remain a principal treatment option for helping individuals with RCRSP. Limitations notwithstanding, exercise therapy is relatively low cost, accessible, and often valued by individuals with RCRSP. The uncertainty surrounding exercise therapy requires ongoing research and emphasis could be directed towards investigating causal mechanisms to better understand how exercise may benefit an individual with RCRSP.

Reproducibility of Exercise Interventions in Randomized Controlled Trials for the Treatment of Rotator Cuff-Related Shoulder Pain: A Systematic Review

OBJECTIVE

To determine the reproducibility of exercise therapy interventions in randomized controlled trials for rotator cuff-related shoulder pain (RCRSP).

DATA SOURCES

Data sources included Medline, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, and SPORTDiscus from studies published from database inception to April 23, 2022.

STUDY SELECTION

Randomized controlled trials studying the use of exercise therapy for RCRSP.

DATA EXTRACTION

Two reviewers extracted exercise reporting details from all studies using the Template for Intervention Description and Replication (TIDieR) and the modified Consensus on Exercise Reporting Template (CERT). The same 2 reviewers assessed risk of bias of all studies using Cochrane Risk of Bias Tool version 2.0.

DATA SYNTHESIS

For 104 studies meeting inclusion criteria, the average number of items reported on the TIDieR was 5.27 (SD 2.50, range 1-12 out of 12) and 5.09 (SD 4.01, range 0-16 out of 16) on the CERT. Improved reporting over time was seen on both the TIDieR and CERT dating back to 1993 and through April 23, 2022. When comparing groups of studies published before and after the TIDieR (2014) and CERT (2016) were established, a statistically significant increase in median scores was noted on the TIDieR (P=.02) but not the CERT (P=.31). Quality of exercise therapy reporting was highest in studies with "low risk" of bias, and lowest in studies with "high risk" of bias on the RoB-2.

CONCLUSION

Overall exercise reporting in trials for RCRSP is incomplete despite the development of the TIDieR and CERT checklists. This has implications for translating evidence into practice.

Manual Therapy and Exercise Have Similar Outcomes to Corticosteroid Injections in the Management of Patients With Subacromial Pain Syndrome: A Systematic Review and Meta-Analysis

Subacromial pain syndrome (SAPS) is the most frequent diagnosis in patients with shoulder pain presenting with persistent pain and significant functional decline. Although exercise and manual therapy (EMT) and corticosteroid injections provide first-line treatment options, evidence for the best management of SAPS remains inconclusive. We aimed to evaluate the effectiveness of EMT compared with corticosteroid injections on disability, recovery rates, and pain in patients with SAPS through a systematic review and meta-analysis approach. PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Physiotherapy Evidence Database (PEDro), ScienceDirect, the Cochrane Library, and grey literature databases were searched. Only randomized controlled trials evaluating the effectiveness of EMT alone or as an additive intervention compared to corticosteroid injections were included. Methodological quality was evaluated with the PEDro score and certainty of evidence with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. In total, 8 trials with 946 patients were included. EMT presented no difference in disability compared with corticosteroid injections at very short- (standardized mean difference {SMD}: 0.19; 95%CI: -0.20, 0.58), short- (SMD: -0.16; 95%CI: -0.58, 0.25), mid- (SMD: -0.14; 95%CI: -0.44, 0.16), and long-term (SMD: 0.00; 95%CI: -0.25, 0.25) follow-up. No difference was found between the comparators in self-perceived recovery at very short- (risk ratio: 0.93; 95%CI: 0.71, 1.21) and mid- (risk ratio: 0.98; 95%CI: 0.90, 1.07) follow-up and in pain rating at very short- (SMD: -0.18; 95%CI: -0.73, 0.38), short- (SMD: 0.05; 95%CI: -0.26, 0.37), and long-term (SMD: 0.04; 95%CI: -0.26, 0.34) follow-ups. The addition of corticosteroid injections to EMT provided no better results in shoulder disability compared with EMT (SMD: 0.45; 95%CI: -0.47, 1.37) or corticosteroid injections alone (MD: 2.70; 95%CI: -7.70, 13.10) in the mid-term. Based on very low to moderate certainty of evidence, EMT has similar effects to corticosteroid injections on improving all outcomes in patients with SAPS at all follow-up periods. Based on low certainty of evidence the combination of both interventions does not change the treatment outcome compared with each intervention alone.