All MSK Elves know that shoulder pain is one of the most common complaints referred for assessment and therapeutic intervention both in the acute and primary sectors. The reason for the development of the pain is often blamed on degenerative changes in the rotator cuff. Prescribing the most appropriate form of exercise based on evidence is still not very clear, so let’s take a look at a recent systematic review of the effects of exercise versus other interventions for signs and symptoms relating to rotator cuff tendinopathy referred to by the authors as a sub-group of ‘sub-acromial impingement’.
Here’s what they did
They searched electronic databases up to November 2010 for Randomised Controlled Trials (RCTs) that examined the effects of exercise on adult populations with signs and symptoms suggesting rotator cuff tendinopathy. They defined this as meeting combinations of the criteria below and 4 studies were included all of which had low risk of bias.
- Symptoms duration greater than 3 months
- Minimal resting pain
- Largely preserved range of shoulder motion
- Pain exacerbated consistently through resisted testing, usually abduction and/or lateral rotation
- No cervical spin involvement
Here’s what they found
- versus no intervention: Moderate evidence from 1 RCT (n = 60) to support effectiveness of exercise in terms of pain
- versus placebo: Moderate evidence from 1 RCT (n =125) to support effectiveness of exercise in terms of pain and function in short intermediate and long term. However outcome measure not validated.
- versus surgery: Moderate evidence from 1 RCT showing no difference between interventions in terms of pain or function in short intermediate or long term. Outcome measure not validated.
Home exercise programme
- versus no intervention: Moderate evidence from 1 RCT (n =92) to support effectiveness in terms of shoulder pain and disability in short term (2 month follow-up). May not be clinically significant.
- versus functional brace: Moderate evidence from 1 RCT (n=60) no difference between interventions in the short term (follow-up 6 to 12 weeks)
- versus multimodal physiotherapy: Moderate evidence from 1 RCT suggesting no difference between interventions in the short term (follow-up 6 to 12 weeks)
The authors concluded
“The role of exercise in the treatment of rotator cuff tendinopathy is promising.”
The Musculoskeletal Elf’s view
So are we really any further forward in determining the effectiveness of exercise to manage rotator cuff tendinopathy? A major issues for studies of this nature is the fact that the underlying pathology is poorly defined in the first instance i.e. sub-acromial impingement is a generic term used to encompass a variety of conditions. The focus of this review was rotator cuff tendinopathy referred to by the authors as a sub-group of sub-acromial impingement. Jeremy Lewis has previously discussed the dilemmas associated with the methods for the clinical examination of the shoulder for this group of patients and proposed an alternative method.
Further issues surround the the follow-up time for determining the effectiveness of exercise interventions. In this review with the exception of one study it was relatively short especially for the management of rotator cuff tendinopathy where clinical experience suggests that maximal improvement can take a relatively long period of time to achieve. Once again we note that outcome measures should also be standardised using validated tools.
This Elf is certainly going off to do more investigation with the first stop a look at the UK Chartered Society of Physiotherapy’s guidelines on Shoulder Impingement.
Do you think based on this review you would be able to make any changes to your practice? What would you consider a reasonable follow-up period for patient’s undertaking an exercise programme for rotator cuff tendinopathy? Do you recommend unloaded or loaded exercises for rotator cuff tendinopathy for your patients? What about dosage?
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- Chartered Society of Physiotherapy’s guidelines on Shoulder Impingement. [available for CSP members or £15]
- Littlewood C, Ashton J, Chance-Larsen K, May S, Sturrock B. 2012, Exercise for rotator cuff tendinopathy: A systematic review, Physiotherapy, Vol. 98, no. 2, pp. 101-109.
- Lweis J 2009 Rotator cuff tendinopathy/subacromial impingement syndrome: is it time for a new method of assessment? Br J Sports Med 2009;43:259–264. doi:10.1136/bjsm.2008.052183