Terry Buisman PT, Pres, OrthoRehab Specialists, Twin Cities Shoulder
Encompassing reviews of the scientific literature on a particular subject matter is an excellent way to appreciate the “state of the state” of a condition. One such review by Pieters et al examines the literature for the value of conservative physical therapy care for superior shoulder pain (SSP); that which is situated just below the bony point of the shoulder.
This current review updated a similar project published in 2013 that focused on evaluating the effectiveness of interventions within the scope of physical therapy, including exercise, manual therapy (hands on care), electrotherapy (utilization of different types of therapeutic electrical current), and combinations thereof to managing shoulder pain.
That study by Littlewood et al reviewed the scientific literature regarding management of rotator cuff tendinopathy (a common injury for many adults over 50, frequently accompanied by pain). Although the magnitude of the improvement was uncertain, the review reported that exercise and other types of physical therapy intervention might be effective in the management of rotator cuff tendinopathy.
This is of interest because the journal of which it appeared was surgically based. Yet, the trend to solve shoulder pain and dysfunction was changing rapidly at this time from one of that of surgery followed by rehabilitation to that of a rehabilitative focus which has proven to be quite successful and cost effective. The author estimates that 80-90% of shoulder pain is resolved via specialized physical therapy care.
The aim of this current review was to perform an updated review of systematic reviews to investigate the effectiveness of conservative physical therapy treatment for SSP. Littlewood et al suggested that exercise and multimodal physical therapy were promising interventions for SSP, but the extent of their effectiveness remains unclear. The conclusions of the current update were able to support and strengthen the recommendation regarding exercise therapy. Evidence for exercise as an intervention for SSP is increasing and strengthening, although the optimal type, dose, and load still remain unclear.
Conclusion
Evidence for exercise as the most important management strategy for SSP is increasing and strengthening. Ongoing research is necessary to identify whether there is an optimal dose and type of exercise. Currently, it is not possible to state that one exercise program is more appropriate than another. However, a strong recommendation may be made to include manual therapy as an adjunct intervention with exercise. Conflicting evidence surrounds the effectiveness of multimodal therapy and corticosteroid injection. Other commonly prescribed nonsurgical interventions, such as ultrasound, low-level laser, and extracorporeal shockwave therapy, lack evidence of effectiveness.
| What is known about this subject | Exercise and multimodal physical therapy might be effective in the management of rotator cuff tendinopathy Exercise therapy should be prioritized as the primary treatment option, due to its clinical effectiveness, cost-effectiveness, and other associated health benefits |
| What this study adds to existing knowledge | The evidence for the use of exercise therapy in the management of subacromial shoulder pain is consistent, and exercise should be considered as a principal intervention in the management of those with subacromial shoulder pain Manual therapy may provide further benefit if used in addition to exercise therapy Conflicting evidence surrounds the effectiveness of multimodal therapy and corticosteroid injection Ultrasound, low-level laser, and extracorporeal shockwave therapy lack evidence of effectiveness |
Over the course of the past 35 years, the author has evaluated nearly 10,000 shoulder cases with subsequent treatment and concurs with the conclusions of the current study. He teams with orthopedic shoulder surgeons who appreciate the same message, again noting that only a small percentage of people with shoulder pain actually need surgery. The mindset is that of resolving problems via the most conservative means possible.
This is a “WIN-WIN” scenario for the patient noting that there are commonly many mechanical corrections that need to be made about the shoulder girdle. As noted, a diligent effort with one’s prescribed exercises generally resolves the problem. In the few cases where it does not, the shoulder girdle returns to a maximally functional status more quickly following surgery because of the improved functionality already established.
L Pieters PT et al. An Update of Systematic Reviews Examining the Effectiveness of Conservative Physical Therapy Interventions for Subacromial Shoulder Pain. Journal of Orthopaedic & Sports Physical Therapy. Published Online: February 29, 2020 Volume 50, Issue3; Pages131-141.
Lewis JS, et al. Subacromial impingement syndrome: the role of posture and muscle imbalance. J Shoulder Elbow Surg. 2005; 14: 385– 392.
Twin Cities Shoulder is a specialty shoulder care practice under the umbrella of OrthoRehab Specialists Inc. ORSI is an outpatient orthopedic and neurologic private practice that has provided physical therapy care for over 30 years in the Twin Cities metro. Terry Buisman PT is the co-owner of ORSI and heads TCS. His specialty is adult shoulder (non/post-surgical/adhesive capsulitis) as well as combined shoulder and spinal based pathology. For more information see: tcshoulder.com. We greatly appreciate the opportunity to play a role in your patients return to health.
