Physiotherapy interventions for shoulder pain
The prevalence of shoulder disorders has been reported to range from seven to 36% of the population (Lundberg 1969) accounting for 1.2% of all General Practitioner encounters in Australia (Bridges Webb 1992). Substantial disability and significant morbidity can result from shoulder disorders. While many treatments have been employed in the treatment of shoulder disorders, few have been proven in randomised controlled trials. Physiotherapy is often the first line of management for shoulder pain and to date its efficacy has not been established. This review is one in a series of reviews of varying interventions for shoulder disorders, updated from an earlier Cochrane review of all interventions for shoulder disorder.
To determine the efficacy of physiotherapy interventions for disorders resulting in pain, stiffness and/or disability of the shoulder.
MEDLINE, EMBASE, the Cochrane Clinical Trials Regiter and CINAHL were searched 1966 to June 2002. The Cochrane Musculoskeletal Review Group's search strategy was used and key words gained from previous reviews and all relevant articles were used as text terms in the search.
Each identified study was assessed for possible inclusion by two independent reviewers. The determinants for inclusion were that the trial be of an intervention generally delivered by a physiotherapist, that treatment allocation was randomised; and that the study population be suffering from a shoulder disorder, excluding trauma and systemic inflammatory diseases such as rheumatoid arthritis.
Data collection and analysis
The methodological quality of the included trials was assessed by two independent reviewers according to a list of predetermined criteria, which were based on the PEDro scale specifically designed for the assessment of validity of trials of physiotherapy interventions. Outcome data was extracted and entered into Revman 4.1. Means and standard deviations for continuous outcomes and number of events for binary outcomes were extracted where available from the published reports. All standard errors of the mean were converted to standard deviation. For trials where the required data was not reported or not able to be calculated, further details were requested from first authors. If no further details were provided, the trial was included in the review and fully described, but not included in the meta‐analysis. Results were presented for each diagnostic sub group (rotator cuff disease, adhesive capsulitis, anterior instability etc) and, where possible, combined in meta‐analysis to give a treatment effect across all trials.
Twenty six trials met inclusion criteria. Methodological quality was variable and trial populations were generally small (median sample size = 48, range 14 to 180). Exercise was demonstrated to be effective in terms of short term recovery in rotator cuff disease (RR 7.74 (1.97, 30.32), and longer term benefit with respect to function (RR 2.45 (1.24, 4.86). Combining mobilisation with exercise resulted in additional benefit when compared to exercise alone for rotator cuff disease. Laser therapy was demonstrated to be more effective than placebo for adhesive capsulitis (RR 8, 95%CI 2.11 to 30.34) but not for supraspinatus tendinitis (RR 2, 95%CI 0.98 to 4.09). Both ultrasound and pulsed electromagnetic field therapy resulted in improvement compared to placebo in pain in calcific tendinitis (RR 1.81 (1.26, 2.60) and RR 19 (1.16, 12.43) respectively). There is no evidence of the effect of ultrasound in shoulder pain (mixed diagnosis), adhesive capsulitis or rotator cuff tendinitis. When compared to exercises, ultrasound is of no additional benefit over and above exercise alone. There is some evidence that for rotator cuff disease, corticosteroid injections are superior to physiotherapy and no evidence that physiotherapy alone is of benefit for adhesive capsulitis
The small sample sizes, variable methodological quality and heterogeneity in terms of population studied, physiotherapy intervention employed and length of follow up of randomised controlled trials of physiotherapy interventions results in little overall evidence to guide treatment. There is evidence to support the use of some interventions in specific and circumscribed cases. There is a need for trials of physiotherapy interventions for specific clinical conditions associated with shoulder pain, for shoulder pain where combinations of physiotherapy interventions, as well as, physiotherapy interventions as an adjunct to other, non physiotherapy interventions are compared. This is more reflective of current clinical practice. Trials should be adequately powered and address key methodological criteria such as allocation concealment and blinding of outcome assessor.
Sally Green, Rachelle Buchbinder, Sarah E Hetrick
Plain language summary
Some physiotherapy interventions are effective for shoulder pain in some cases.
There is a high prevalence of shoulder disorders in the community. Shoulder disorders can result in considerable pain and disability. Physiotherapy is often the first line of treatment for shoulder disorder. Twenty‐six trials presented sufficient data to be included in meta‐analysis. There is some evidence from methodologically weak trials to indicate that some physiotherapy interventions are effective for some specific shoulder disorders. The results overall provide little evidence to guide treatment. There is a clear need for further high quality trials of physiotherapy interventions, including trials using combinations of modalities, in the treatment of shoulder disorders.
Sally Green, Rachelle Buchbinder, Sarah E Hetrick
Implications for practice
Further research, in particular larger trials of higher methodological quality, of well defined interventions and in specific populations need to be conducted. Furthermore, high quality trials more reflective of the current clinical practice of combined interventions using standardised methods of delivery need to be conducted before we can draw conclusions regarding the benefits and optimal use of physiotherapy interventions in the treatment of shoulder disorders. The evidence to date can be summarised as follows:
There is weak evidence from few, methodologically compromised trials to indicate:
- Exercise for rotator cuff disease with additional benefit from exercise plus mobilisation (2 trials, Bang 2000; Conroy 1998).
- Laser for adhesive capsulitis in the short term, but not for rotator cuff disease (4 trials, Taverna 1990; England 1989; Saunders 1995; Vecchio 1993)
- Pulsed Electromagnetic Field for rotator cuff disease in the short term (1 trial, Binder 1984)
- Ultrasound and Pulsed Electromagnetic Field for Calcific tendinitis. (2 trials Ebenbichler 1999; Dal Conte 1990)
- In general, ultrasound is of no additional benefit over and above exercise alone (1 trial Winters 1997/9)
- For rotator cuff disease, corticosteroid injections are superior to physiotherapy interventions (4 trials, van der Windt 1998; Berry 1980; Winters 1997/9; Bulgen 1984)
- No evidence that physiotherapy interventions alone is of benefit for Adhesive Capsulitis (1 trial Dacre1989)
- Supervised exercise regime is of benefit in the short and long term for mixed shoulder disorders and rotator cuff disease (Brox 1993/7; Ginn 1997)
Implications for research
There is a clear need for trials of physiotherapy interventions, including trials of combinations of modalities, in the treatment of shoulder disorders. There is a need for validation studies of the inclusion and exclusion criteria used to define specific conditions which result in painful shoulder and trials should aim to use properly defined interventions. Trials should be adequately powered and address key methodological criteria (allocation concealment, blinding of participants and outcome assessors, adequate follow up and appropriate statistical reporting). Specifically, further research is needed before we can draw conclusions about:
- Any physiotherapy intervention for Rotator Cuff tear
- Physiotherapy interventions as an adjunct to medical interventions in any shoulder disorder.
- Any physiotherapy intervention for instability or hypermobility of the glenohumeral joint.