Effectiveness of exercise therapy versus passive conservative treatments for rotator cuff-related shoulder pain: a systematic review and meta-analysis of randomized controlled trials.

BackgroundGroin pain is a common pathology among athletes, presenting pain and a reduced range of motion (ROM) as clinical characteristics. Passive physical therapy (PPT) and exercise therapy (ET) interventions are chosen firstly before surgery. The aim of this systematic review and meta-analysis was: (i) to qualitative review the effects of each non-surgical intervention; (ii) to quantitative compare the effects of PPTs plus ET intervention to ET in isolation in pain intensity, and hip ROM in athletes with groin pain.MethodsA systematic review and meta-analysis was conducted. Pubmed, PEDro, Web of science, Scopus and Cochrane library were searched. Randomized controlled trials comparing PPT plus ET to ET interventions were included. The methodological quality and risk of bias of the included studies, were assessed with the PEDro scale and the Cochrane risk-of-bias tool. To assess the certainty of evidence the GRADEpro GDT was used. Meta-analyses were conducted using RevMan 5.4 using mean difference analysis to assess the variables pain intensity and hip ROM.ResultsA total of 175 studies was identified from the consulted databases. Five studies were included for systematic- review, from which three studies were meta-analyzed. The methodological quality of the included studies ranged from poor to high. ET compared to PPT plus ET provided statistically significant improvements in pain intensity in the short-term (MD = 2.45; 95% CI 1.11, 3.79; I2 :65%). No statistically significant differences between interventions were obtained for hip ROM in the short-term.ConclusionsThe qualitative review showed that PPTs plus ET and ET seem to have positive effects on pain intensity and hip ROM. The quantitative analysis found very low certainty of evidence proposing a positive effect in pain intensity for ET interventions based on hip muscles stretching, compared to PPT combined with ET, in the short-term.

Background/Objective: The objective of this study is to compare the relative effectiveness of combination therapy (exercise plus manual therapy) versus single-modality physiotherapy interventions for improving pain and function in patients with rotator cuff-related shoulder pain (RCRSP), using a network meta-analysis (NMA) approach. Methods: We systematically searched five electronic databases from inception to October 2023 for randomized controlled trials (RCTs) evaluating non-invasive physiotherapy interventions in adults with RCRSP. Primary outcomes included pain intensity and shoulder function, assessed at 12 weeks. A frequentist NMA was conducted to estimate standardized mean differences (SMDs) with 95% confidence intervals (CIs). Risk of bias was assessed using the Cochrane RoB 2.0 tool. Results: Eleven RCTs (n = 548) were included. Combination therapy demonstrated the greatest improvement in function (SMD = -1.02; 95% CI: -2.59 to 0.56) and pain (SMD = -1.05; 95% CI: -2.41 to 0.30), although the wide confidence intervals crossing the null suggests statistical uncertainty. Exercise therapy alone showed moderate functional improvement (SMD = -0.41; 95% CI: -1.64 to 0.82), and Kinesio taping (KT) provided moderate pain relief (SMD = -0.53; 95% CI: -1.81 to 0.75). While these effects approached known minimal clinically important difference (MCID) thresholds (e.g., DASH: 10-15; VAS: 1.4-2.0), they did not reach statistical significance. Conclusions: Based on 11 RCTs, combination therapy (exercise plus manual therapy) appears to be the most effective non-invasive approach for improving pain and function in patients with RCRSP. However, the wide confidence intervals highlight uncertainty. Further large-scale and long-term trials are warranted to confirm its clinical utility and sustainability.

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. 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. 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. 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.

Purpose To evaluate the effectiveness of trigger point manual therapy (TPMT) in treating rotator cuff related shoulder pain (RCRSP). Methods Randomized controlled trials that compared the effects of TPMT with no or other conservative treatments in patients with RCRSP were included. Primary outcomes were shoulder pain intensity and function. Secondary outcomes were pressure pain threshold (PPT) and number of myofascial trigger points (MTrPs). The Cochrane Risk of Bias 2.0 tool, PEDro scale and GRADE approach were employed. Results Ten studies were included in this systematic review and seven in the meta-analysis. Very low to low quality of evidence showed no statistically significant difference between TPMT and other conservative treatments in rest and activity pain reduction in the short term (3 days to 12 weeks), and the difference in shoulder function was statistically significant in favor of TPMT. Furthermore, TPMT was found to be effective in the improvement of PPT and the inactivation of active MTrPs in the short term. Conclusion TPMT may be equally effective as other passive treatments for the pain reduction in patients with RCRSP in the short term, and slightly more effective for functional improvement. TPMT seems to be effective to treat the active MTrPs in RCRSP. Registration number CRD42023409101

Due to the low- to very low-quality of the evidence for all treatment comparisons, outcomes, and follow-up periods investigated, it is uncertain if Back School is effective for chronic low back pain. Although the quality of the evidence was mostly very low, the results showed no difference or a trivial effect in favour of Back School. There are myriad potential variants on the Back School approach regarding the employment of different exercises and educational methods. While current evidence does not warrant their use, future variants on Back School may have different effects and will need to be studied in future RCTs and reviews.

Rotator cuff-related shoulder pain (RCRSP) is the most common form of shoulder pain. Exercise therapy is a first-line recommended treatment for RCRSP. However, the causal mechanisms underpinning the benefits of exercise for RCRSP are not well understood. Moreover, how individuals with lived experience of RCRSP believe exercise helped or did not help them is unknown. This study aimed to gain insights into how individuals with RCRSP believe exercise influenced their shoulder pain and identify the clinical conditions that promoted or inhibited their beliefs. This qualitative study was underpinned by a critical realist approach to thematic analysis. Participants were recruited using hybrid purposive and convenience sampling techniques. Each participant attended an online semi-structured interview. The data were coded by 2 members of the research team (J.K.P. and N.C.) and verified by a third (B.S.). Recruitment continued until theoretical sufficiency was achieved. Participants reviewed and validated preliminary causal explanations. Three causal explanations were consistently expressed by 11 participants to explain the benefits of exercise therapy: (1) shoulder strength; (2) changes to psychoemotional status; and (3) exercise has widespread health effects. However, the activation of these causal mechanisms depended on (1) the presence of a strong therapeutic relationship; (2) the provision of a structured and tailored exercise program; and (3) experiencing timely clinical progress. Participants believed exercise improved their shoulder pain through associated health benefits, improved shoulder strength, and psychoemotional variables. Whether an exercise program was able to cause a clinical improvement for an individual with RCRSP was contingent on clinical contextual features. Thus, the clinical context that an exercise program is delivered within may be just as important as the exercise program itself. Exercise is a recommended first-line intervention to manage RCRSP. The results of this study suggest that a positive experience and outcome with exercise for RCRSP is contingent on several clinical contextual features, such as a strong therapeutic relationship. The clinical context that an exercise program is prescribed and delivered within should be considered by clinicians.

“You have (rotator cuff related) shoulder pain, and to treat it, I recommend exercise.” A scoping review of the possible mechanisms underpinning exercise therapy

Exercise therapy for chronic fatigue syndrome.

Non-operative management of patients with rotator cuff related shoulder pain (RCRSP) has been shown to be effective with outcomes similar to operative interventions. Exercise therapy and education are recommended as first-line treatments; however, program content, progression and referral criteria are typically inadequately detailed to be easily reproduced by clinicians. This study evaluated the effectiveness of a well-defined, criteria-based progressive exercise physical therapy (PT) program in patients with rotator cuff related shoulder pain (RCRSP) over a 26-week evaluation period. A longitudinal, prospective cohort study evaluated 143 patients aged 30-65 years with RCRSP. Participants participated in a 12-week in-person and home-exercise shoulder program and were assessed at baseline, 6-weeks, 12-weeks and 26-weeks. Primary outcome measures were pain at rest, at night and with activity. Secondary measures were active range of motion (ROM), strength, and health related quality of life (HRQL) using the Western Ontario Rotator Cuff (WORC) score. Significant reductions in pain at rest, at night and with activity (p < 0.001) occurred within six weeks and continued to 26-weeks. Active range of motion (ROM), particularly abduction and external rotation in 90 degrees of abduction, significantly improved between 0- and 6-weeks (p < 0.001) as well as at 12-weeks (p < 0.001) and 26-weeks (p < 0.001). Strength similarly improved, especially between 6- and 12-weeks (p < 0.001). Ongoing improvements were reported at 26-weeks. Finally, the WORC score improved over time, with significant improvements at each measurement point, and clinically important improvements occurring within 12 weeks. Utilizing a criteria-based progressive PT program that provided detailed information, including progression criteria and a proven algorithm for referring non-responsive patients for an orthopedic surgical consult was effective in significantly reducing pain, improving active ROM, strength and HRQL in those living with RCRSP.

BackgroundScapular stabilization exercises (SSE) are often included in the treatment of individuals with rotator cuff-related shoulder pain (RCRSP) to decrease pain and improve function. These SSE typically aim to strengthen the scapular muscles and optimize dynamic neuromuscular control of the scapula, which may improve overall shoulder stability and movement quality. No consensus of the recommended SSE for the management of RCRSP is available. Hence, this study aimed to consult physiotherapists to co-create an inventory of recommended SSE based on the exercise’s relevance and frequency of prescriptions for the rehabilitation of individuals with RCRSP.MethodsA group of 16 physiotherapists with experience in treating shoulder pain participated in a sequential consultation incorporating two distinct rounds of consultation focusing on SSE (modified Delphi design). In round 1, physiotherapists identified and demonstrated up to 10 SSE that they commonly recommend or use among individuals with RCRSP. The description and performance of all SSE were audio and video recorded. All SSE suggested by more than one participant in round 1 advanced to round 2. In round 2, physiotherapists rated these SSE on a 4-point Likert scale according to their perceived relevance and frequency of prescription for this population.ResultsIn round 1, out of the 25 SSE recommended by participants, 19 SSE (76.0%) were recommended by more than one physiotherapist and advanced to round 2. In round 2, 13 SSE were consensually classified (agreement ≥75%) as being relevant for the rehabilitation of individuals with RCRSP. SSE targeting the recruitment of the serratus anterior and lower trapezius muscles were considered the most relevant for the management of RCRSP, whereas SSE targeting neuromuscular scapular control were the most prescribed SSE for the management of RCRSP.ConclusionsAn inventory composed of 13 SSE was co-created by physiotherapists based on their relevance and frequency of prescription for the rehabilitation of individuals with RCRSP. When designing an exercise program, physiotherapists can use this SSE inventory to inform their exercise selection, in combination with their current knowledge on shoulder rehabilitation, as well as patients’ preferences.

The case reported herein consists of nodular pulmonary amyloidosis presenting with unusual cystic radiological features which reveal a pulmonary localisation of an extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma). The present case is the first to report a radiological presentation of nodular pulmonary amyloidosis in the absence of Sjögren's syndrome. Although transthoracic fine-needle biopsy was helpful for the diagnostic of amyloidosis, final diagnosis of associated MALT-type lymphoma required an open lung biopsy. This emphasises the importance of performing surgical investigations in pulmonary nodular amyloidosis in order to depict the presence of underlying lung tumours or lymphoproliferative disorders.

Tendinopathy is a common, painful and functionally limiting condition, primarily managed conservatively using exercise therapy. (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? 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. 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. Despite a large body of literature on exercise for tendinopathy, there are methodological and reporting limitations that influenced the recommendations that could be made. 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. 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. 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). 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.

(i) Optimizing non-operative care

Objective To analyze the effectiveness of manual therapy and exercise therapy on otological symptoms in individuals with temporomandibular disorders. Methods A systematic review of clinical trials compared exercise and manual therapy with standard care or placebo/control for individuals with temporomandibular disorders. Otological-related symptoms (tinnitus, earache, ear fullness, vertigo, dizziness, and hypo/hyperacusis) were assessed. The Cochrane risk of bias tool was used to assess the risk of bias, and the certainty of evidence was rated using the GRADE approach. Qualitative data synthesis was performed through evidence tables and graphs. Results A total of 4,356 articles were screened, and six studies reported in nine manuscripts were included. Manual therapy combined with exercises targeted to the neck and jaw reduced tinnitus severity and tinnitus-related quality of life after treatment, and at three- and six-month follow-up when compared to exercises alone. Earache and ear fullness improved after orofacial myofunctional therapy and oral motor exercises compared to no treatment. The overall certainty of the evidence was rated as very low. Conclusions The combination of neck and jaw exercises with manual therapy potentially reduce otological symptoms in individuals with temporomandibular disorders. Studies with higher methodological quality are needed, due to a very low certainty of evidence. Implications for rehabilitation Exercises and manual therapy techniques aimed at the jaw and neck potentially improve otological symptoms related to TMD; Clinicians and researchers should design TMD interventions considering otological symptoms as an important complaint while planning the protocols, A standardization of the tools used to assess otological symptoms is needed.

Exercise therapy is the first-line treatment in rotator cuff-related shoulder pain (RCRSP), and diverse types of exercise seem effective. However, it is not still clear if painful exercise should be allowed or avoided during exercises. The objective of this study was to investigate if exercise into pain is more effective than no pain in RCRSP. A randomized controlled trial was conducted in a physiotherapy clinic in Belgium. Forty-three participants with chronic RCRSP were randomly allocated to G1 (exercising into pain) or G2 (exercising without pain) in a 12-week intervention with 6-month follow-up. Primary outcome was the Shoulder Pain and Disability Index (SPADI); secondary outcomes were pain intensity, fear-avoidance beliefs, fear of pain, quality of life, strength, and range of motion. Outcomes were measured at baseline (T0), after 9weeks (T1), 12weeks (T2), and 6 months (T3) from the first session and analysed with linear mixed models. No between-group difference in SPADI (time-by-group interaction, p = 0.25) up to 6 months was found, with mean difference (G1-G2) at T1 = 5.78 (CI95%: -3.43,14.59; p = 0.33), at T2 = 0.93 (CI95%: -7.20,9.05; p = 0.82), at T3 = 4.15 (CI95%: -2.61,10.92; p = 0.33). No between-group differences were found for any other outcomes. Pain provocation seems not to be necessary in RCRSP for achieving successful treatment effect in pain and disability reduction, fear-related beliefs, and quality of life up to 6 months. ClinicalTrials.gov NCT04553289.