Physiotherapy interventions for shoulder pain

 

Abstract

Background

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.

Objectives

To determine the efficacy of physiotherapy interventions for disorders resulting in pain, stiffness and/or disability of the shoulder.

Search methods

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.

Selection criteria

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.

Main results

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 (RR 3.71 (1.89, 7.28) for adhesive capsulitis but not for rotator cuff tendinitis. 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

Authors' conclusions

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.

 

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.

 

摘要

背景

物理治療治療肩部疼痛

肩部疼痛盛行率約為7 – 36% ，並造成失能和罹病。許多治療包括物理治療用於治療肩部疼痛，但少有被隨機對照試驗證實。本文為更新系列回顧治療肩部疼痛方法之一。

目標

研究物理治療治療肩部疼痛、僵硬及失能的效果。

搜尋策略

搜尋MEDLINE, EMBASE, the Cochrane Clinical Trials Regiter and CINAHL (直到2002年6月)。

選擇標準

物理治療師執行治療肩痛的隨機分配對照試驗。排除受傷及全身發炎疾病如類風濕性關節造炎成者。

資料收集與分析

兩位作者使用預定條件﹝根據專門評估物理治療可信度之PEDro scale﹞獨立進行資料摘錄，並對每篇試驗研究的品質進行評估。儘量聯絡作者取得資料，如可能則進行統合分析。結果分別呈現旋轉肌疾病、沾黏性肩關節囊炎、肱盂關節的前向不穩定等。

主要結論

26個研究包含於分析中。研究方法品質不一，參與人數介於14到180 (中位數48人)。 物理治療訓練在旋轉肌疾病短期回復相對風險7.74 (95% CI 1.97, 30.32)，長期功能受益相對風險2.45 (95% CI 1.24, 4.86)。旋轉肌疾病之運動加訓練﹝mobilisation with exercis﹞比只訓練好。雷射治療在沾黏性肩關節囊炎方面比安慰劑好，相對風險3.71 (1.89, 7.28)，但在旋轉肌疾病無顯著差異。超音波與電磁場治療在鈣化性肌腱炎比安慰劑好，相對風險分別是1.81 (1.26, 2.60) 及1 1.16, 12.43)。超音波在肩痛﹝混合診斷﹞、沾黏性肩關節囊炎、旋轉肌肌腱炎無證據顯示療效，超音波加上訓練運動與單獨訓練運動並無差異。注射類固醇對旋轉肌疾病有效，但單純物理治療沾黏性肩關節囊炎未顯示有效。

作者結論

參與研究人數少及研究方法品質不一、及研究人群異質性，物理治療方式，追蹤時間等不同，而無法得到整體結論。本文反應目前臨床治療現況。臨床試驗應有足夠檢定力及研究品質，如分配隱密性及盲性評估。

翻譯人

本摘要由林口長庚醫院余光輝翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

某些個案當中，物理治療對於肩部疼痛具有療效。肩部疼痛社區盛行率非常高，並且可能造成劇烈疼痛與失能。物理治療通常為肩部疼痛第一線療法。 共計有26個試驗，並且有足夠的數據納入統合分析(metaanalysis)當中。某些證據(來自方法學品質較弱的試驗)顯示物理治療對於特定的肩部疼痛有療效。其結果整體而言僅能提供少許建議治療的證據。顯然需要更高品質的物理治療研究，其中包括結合各種物理治療處置肩部疼痛的研究。