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Physiotherapy interventions for shoulder pain

  1. Sally Green1,*,
  2. Rachelle Buchbinder2,
  3. Sarah E Hetrick3

Editorial Group: Cochrane Musculoskeletal Group

Published Online: 16 JUL 2008

Assessed as up-to-date: 23 FEB 2003

DOI: 10.1002/14651858.CD004258

Database Title

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How to Cite

Green S, Buchbinder R, Hetrick SE. Physiotherapy interventions for shoulder pain. Cochrane Database of Systematic Reviews 2003, Issue 2. Art. No.: CD004258. DOI: 10.1002/14651858.CD004258.

Author Information

  1. 1

    Monash University, School of Public Health & Preventive Medicine, Melbourne, Victoria, Australia

  2. 2

    Department of Epidemiology and Preventive Medicine, Monash University, Monash Department of Clinical Epidemiology at Cabrini Hospital, Malvern, Victoria, Australia

  3. 3

    University of Melbourne, Centre of Excellence in Youth Mental Health, Orygen Youth Health Research Centre, Centre for Youth Mental Health, Melbourne, Victoria, Australia

*Sally Green, School of Public Health & Preventive Medicine, Monash University, Monash Medical Centre, Locked Bag 29, Clayton, Melbourne, Victoria, 3168, Australia. sally.green@monash.edu.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 16 JUL 2008

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Characteristics of included studies [ordered by study ID]
Bang 2000
MethodsRandom allocation: Yes;Concealed allocation: No;Baseline comparability: Yes;Blind assessors: Yes;Blind subjects: No;Blind therapists: No;Adequate follow-up: Yes;Intention-to-treat analysis: No;Between-group comparisons: Yes;Point estimates & variability: Yes;Eligibility criteria: Yes
Participants52 participants (mean age treatment group 42, range 27-65; mean age control group 45, range 24-60) diagnosed with impingement syndrome
InterventionsBoth groups attended for 6 physiotherapy sessions over 3 weeksGroup 1: supervised flexibility and strength exercisesGroup 2: exercises as above plus mobilisation
OutcomesAssessed at 3 weeks and 2 months1. Isometric strength2. Pain on movement and resistance3. Function (questionnaire)
Notes
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear




Berry 1980
MethodsRandom allocation: Yes; Concealed allocation: No; Baseline comparability: Yes; Blind assessors: Yes; Blind subjects: No; Blind therapists: No; Adequate follow-up: Yes; Intention-to-treat analysis: No; Between-group comparisons: Yes; Point estimates and variability: Yes; Eligibility criteria: Yes
Participants60 outpatients (mean age acupuncture group 52.3; mean age steroid plus placebo 54.1; mean age steroid plus tolmentin 51.2; mean age physiotherapy 55.1; mean age placebo 56.2) (with an uncomplicated rotator-cuff lesion defined as pain on resisted movements of the shoulder with or without some loss of passive movement, mainly abduction
InterventionsFour weeks of:
Group 1: Acupuncture for 20 minutes weekly, using classical Chinese acupuncture with moxibustion
Group 2: Steroid injection of 40 mg methylprednisolone with 2 ml 2% lignocaine using anterior appraoch to the shoulder joint plus placebo tolmentin (2 tablets 3 times daily)
Group 3: Steroid injection plus active tolmetin sodium (a non steroidal anti-inflamtory drug) (400 mg 3 times daily)
Group 4: Physiotherapy of standardised ultrasound for 10 minutes for eight sessions
Group 5: Placebo tolmetin plus placebo ultrasound
OutcomesAssessed at start of study and at 2 and 4 weeks on:
1. Pain measured by visual analogue scale and 4 point scale (none, mild, moderate, servere pain); 2. Active total shoulder abduction using a goniometer; 3. Comparative assessment by patient and assessor (much better, better, same, worse, much worse); 5. Success or failure of the treatment at the end of four weeks, defined as need for steroid injection; 6. Adverse outcomes
Notes
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?NoC - Inadequate




Binder 1984
MethodsRandom allocation: Yes; Concealed allocation: No; Baseline comparability: No; Blind assessors: Yes; Blind subjects: Yes; Blind therapists: No; Adequate follow-up: Yes; Intention-to-treat analysis: No; Between-group comparisons: Yes; Point estimates & variability: No; Eligibility criteria: No
Participants29 participants (mean age treatment group 54.4; mean age control group 53.2). Shoulder pain on resisted Abduction and ER, excluded "frozen shoulder" and cuff tears
InterventionsPhase 1. Active treatment vs. placebo for 4 weeks.Phase 2. Without unblinding, all participants received active treatment for 4 weeks.Phase 3. 8 weeks of no active treatment Group 1: Pulsed electromagnetic field 4 weeks daily treatment (self administered).Group 2: Placebo
OutcomesAssessed at 4, 8 and 16 weeks.1. Pain VAS.2. Total range of active movement.3. Pain of resisted abduction, internal and external rotation (VAS).4. Painful arc on abduction.
NotesMet inclusion criteria of the review but did not report means, standard deviations, nor the means from which to calculate it (data presented graphically), and hence not included in meta analysis. In addition, placebo group all given active intervention at 4 weeks therefore longer term outcomes are not between group comparisons.
The authors have been contacted in attempt to obtain 4 week data.
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear




Brox 1993/7
MethodsRandom allocation: Yes; Concealed allocation: No; Baseline comparability: Yes; Blind assessors: Yes; Blind subjects: No; Blind therapists: No; Adequate follow-up: No; Intention-to-treat analysis: Yes; Between-group comparisons: Yes; Point estimates & variability: Yes; Eligibility criteria: No
Participants125 patients with pain in shoulder for at least 3 months. Pain resistant to physiotherapy and NSAIDS. Positive impingement test.
InterventionsGroup 1: Arthroscopic subacromial decompression.Group 2: 3 to 6 months of supervised low resistance exercises repeated many times. Group 3: Detuned (i.e. Placebo) laser.
OutcomesAssessed at 3 months, 6 months and 2.5 years.Success defined as a Neer shoulder score of >80.
Notes3 and 6 month data given as medians with no ranges. Presented in additional tables. 2 and 1/2 year data as dicotomous data therefore in meta-analysis and additional tables
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear




Bulgen 1984
MethodsRandom allocation: Yes; Concealed allocation: No; Baseline comparability: No; Blind assessors: No;Blind subjects: No; Blind therapists: No; Adequate follow-up: Yes; Intention-to-treat analysis: No; Between-group comparisons: Yes; Point estimates & variability: No; Eligibility criteria: No
Participants42 participants (mean age 55.8, range 44-74) with "frozen shoulder"1.Pain in shoulder2.Night pain3.Inability to the affected side.4.Restriction of active and passive movements.5.Restriction of ER to at least 50%.
InterventionsGroup 1: intra-articular steroid injection Group 2: mobilisation Group 3: ice therapyGroup 4: no treatment
OutcomesAssessed immediately post treatment and 8 months1.Pain: night pain, pain on movement, rest pain during the day (10cm VAS, and verbally "better", "worse", "the same").2.Passive movements: ER, total rotation, flexion, abduction, HBB (measured to the nearest 5°).3.Number of analgesics
NotesMet inclusion criteria for review, however no data reported to enable inclusion in meta-analysis or additional tables. Authors contacted. Also authors noted that patients had difficulty using the visual analogue scales so relied on verbal reports of progress as they appeared more consistent and relaible.
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear




Conroy 1998
MethodsRandom allocation: Yes; Concealed allocation: No; Baseline comparability: Yes; Blind assessors: Yes; Blind subjects: No; Blind therapists: No; Adequate follow-up: Yes; Intention-to-treat analysis: No; Between-group comparisons: Yes; Point estimates & variability: Yes; Eligibility criteria: Yes
Participants14 participants with primary shoulder impingement syndrome.
InterventionsThree treatments a week for 3 weeks.Group 1: Shoulder joint mobilisation and comprehensive treatment (hot packs, Active ROM, stretching, strengthening, soft tissue mobilisation, education). 3 times per week for 3 weeks.Group 2: Comprehensive treatment alone
OutcomesMeasured at end of treatment course (3 weeks)1. 24 hour pain2. Pain on subacromial compression (VAS), 3. Mobility4. Function.
NotesHeat (hot packs) constant across both groups therefore analysed with studies of mobilisation plus exercise versus exercise alone
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear




Dacre1989
MethodsRandom allocation: Yes; Concealed allocation: No; Baseline comparability: Yes; Blind assessors: Yes; Blind subjects: No; Blind therapists: No; Adequate follow-up: Yes; Intention-to-treat analysis: No; Between-group comparisons: No; Point estimates & variability: No; Eligibility criteria: Yes
Participants62 participants (mean age treatment group 58.8) 1.Pain and stiffness2.Restriction of movement3.Loss of full function4.Pain at night with inability to lie on the affected side.
InterventionsGroup 1: Four to six weeks of "physiotherapy thought most appropriate", performed by one therapist and mainly comprised of mobilisation.Group 2: Local steroid injections of 20,g triamcinolone with 1ml 2% lidocaine injected anteriorly around the shoulder joint by 1 physician.Group 3: Both physiotherapy and injection, as above.
OutcomesAssessed at baseline, 6 weeks & 6 months1.Day pain, night pain, pain on active movement and pain on passive movement (all assessed on individual 10cm visual analogue scales).2.Range of passive movement of abduction, external rotation and hand behind back.3.Treatment costs.
NotesWhile included in the review, data presented with no quantitative between group comparisons, and no measure of variance, hence not included in meta-analysis. The authors have been contacted in an attempt to access their data.
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear




Dal Conte 1990
MethodsRandom allocation: Yes; Concealed allocation: No; Baseline comparability: Yes; Blind assessors: No; Blind subjects: Yes; Blind therapists: Yes; Adequate follow-up: Yes; Intention-to-treat analysis: No; Between-group comparisons: Yes; Point estimates & variability: No; Eligibility criteria: Yes
Participants60 participants with symptomatic unilateral calcific tendinitis of at least 3 months duration
InterventionsGroup 1: pulsed magnetic field 30 minutes a day for 6 consecutive daysGroup 2: sham PMF of the same time and number of treatments
OutcomesAssessed at 3 and 6 days, and 6 weeks.1. Pain (spontaneous and provoked)2. Range of motion
Notes
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear




Downing 1986
MethodsRandom allocation: Yes; Concealed allocation: Yes; Baseline comparability: Yes; Blind assessors: No; Blind subjects: Yes; Blind therapists: Yes; Adequate follow-up: No; Intention-to-treat analysis: No; Between-group comparisons: Yes; Point estimates & variability: Yes; Eligibility criteria: No
Participants20 participants (mean age 53, range 28-75) with shoulder pain and limitation of movement for > 1 month and < 1 year.Pain on at least 1 activity and at end of range of at least one movement. Loss of range > 10° in at least 1 movement.
InterventionsGroup 1: Maximum tolerated dosage of ultrasound (mean 1.3 watts/cm squared 6 minutes, 3 times a week for 3 weeks.Group 2: Sham ultrasound at same frequency for three weeks
OutcomesAssessed at 0 and 3 weeks.1.Active and passive flexion, abduction and external rotation. 2.Pain on a descriptive scale3. Function4. Overall improvement (patient reported)
Notes
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?YesA - Adequate




Ebenbichler 1999
MethodsRandom allocation: Yes; Concealed allocation: Yes; Baseline comparability: Yes; Blind assessors: Yes; Blind subjects: Yes; Blind therapists: Yes; Adequate follow-up: Yes; Intention-to-treat analysis: No; Between-group comparisons: Yes; Point estimates & variability: Yes; Eligibility criteria: Yes
Participants54 participants (mean age treatment group 49; mean age control group 54) (61 shoulders) Radiographically verified calcific tendinitis.Mild-mod pain for >4 weeks or restricted ROM
Interventions24 treatment sessions (first 15 were daily then last 9 were 5 times weekly)Group 1: Ultrasound therapy (15 mins, .89MHz, 2.5w cm², pulsed 1:4, transducer size 5 cm²Group 2: Sham ultrasound
OutcomesAssessed following treatment course and at 9 months1. Assessment of change from baseline in calcium deposits on radiography2. 100 point Constant score (pain, AROM, strength, ADL's), 3. Pain (pain score and VAS and on abduction (4 point scale)4. QOL 10cm VAS
Notes
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?YesA - Adequate




England 1989
MethodsRandom allocation: Yes; Concealed allocation: No; Baseline comparability: No; Blind assessors: Yes; Blind subjects: Yes; Blind therapists: No; Adequate follow-up: Yes; Intention-to-treat analysis: No; Between-group comparisons: Yes; Point estimates & variability: Yes; Eligibility criteria: Yes
Participants20 participants (mean age 48) with supraspinatus and biceps tendonitis, full range of passive movement with pain on resisted abduction and pain on resisted elbow flexion and supination.
InterventionsGroup 1:Active infrared laser therapy at 904nm 3 times a week for 2 weeks.Group 2: Placebo laser therapy at same frequency.Group 3: Naproxen sodium 550mg 2 times a day for 2 weeks.
OutcomesOutcomes (0 and 2 weeks)1.Active range of shoulder flexion, abduction and extension 2.Subjective rating of benefit with respect to pain, stiffness and function as measured on a 10cm VAS
NotesResults presented as difference between medians. Refer additional table
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear




Ginn 1997
MethodsRandom allocation: Yes; Concealed allocation: Yes; Baseline comparability: Yes; Blind assessors: Yes; Blind subjects: No; Blind therapists: No; Adequate follow-up: Yes; Intention-to-treat analysis: No; Between-group comparisons: Yes; Point estimates & variability: Yes; Eligibility criteria: Yes
Participants66 participants over the age of 18 (mean age 56.4; mean age control group 62.7) with unilateral shoulder pain of no specific diagnosis (i.e. mixed population).
InterventionsGroup 1: 1 month of physiotherapy, 4-10 times, aimed at restoring function of shoulder muscles with a daily home exercise programme. Treatment individually determined by treating physiotherapist within the constraints of strengthening and stretching exercises as outlined on a training video.
Group 2: No treatment (waiting list)
OutcomesAssessment at baseline & 1 month:1.Standardised interview and musculoskeletal assessment.2.Isometric muscle force: dynamometry.3.Pain intensity: visual analogue scale.4.ROM: measured from photographs.5.Functional impairment: 57-point scale - modified from Oswestry.6.Self-perception of improvement: 5-point scale.
NotesData obtained from trial authors.
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?YesA - Adequate




Herrera-Lasso 1993
MethodsRandom allocation: Yes; Concealed allocation: No; Baseline comparability: Yes; Blind assessors: No; Blind subjects: No; Blind therapists: No; Adequate follow-up: Yes; Intention-to-treat analysis: No; Between-group comparisons: Yes; Point estimates and variability: No; Eligibility criteria: Yes
Participants30 participants (mean age US 56; mean age TENS 62) with bicipital or supraspinatus tendinitis, subdeltoid bursitis or periarthritis of the shoulder assessed clinically and radiologically
InterventionsGroup 1: Ultrasound to the glenohumeral joint for 10 minutes, 2-5 times per week for 13 sessions, starting with 0.5W/cm squared and increasing by 0.1 W/cm squared each session to 1 W/cm squared for all subsequent sessions
Group 2: Transcutaneous electrical nerve stimulation on the anterior and posterior aspects of the joint for 20 minutes for 2-5 times per week for 13 sessions, with a mean frequency of 50Hz.
All patients performed Codman (pendular) and stetching exercises and recieved superficial heat treatment
OutcomesAssessed before and after episode of treatment for: 1. range of movement (flexion and abduction) measured by standard goniomter; 2. pain on visual analogue scale
NotesAble to impute pain data from graph, but not range of motion. Authors contacted in attempt to retrieve range of motion data, awaiting response.
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?NoC - Inadequate




Leclaire 1991
MethodsRandom allocation: Yes; Concealed allocation: No; Baseline comparability: Yes; Blind assessors: Yes; Blind subjects: Yes; Blind therapists: Yes; Adequate follow-up: Yes; Intention-to-treat analysis: No; Between-group comparisons: Yes; Point estimates & variability: Yes; Eligibility criteria: No
Participants47 participants: 1.Pain 2.Limited active and passive movement >20%3.Pain on resisted abduction or rotation.4.Impaired glenohumeral joint motion.
InterventionsGroup 1: Electromagnetic therapy 3 times a week for 12 weeks or until complete resolution of symptoms (whichever was sooner).Group 2: Sham therapy.
OutcomesAssessed at 12 weeks1.Pain at rest, on motion and lying 2. Range of flexion, extension, abduction, adduction, ER, IR.3.Interference with daily activities.4.Adverse effects.
Notes
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear




Lee 1973
MethodsRandom allocation: Yes; Concealed allocation: Yes; Baseline comparability: No; Blind assessors: No; Blind subjects: No; Blind therapists: No; Adequate follow-up: No; Intention-to-treat analysis: No; Between-group comparisons: Yes; Point estimates and variability: No; Eligibility criteria: Yes
Participants80 participants (mean age 58)with periarthritis of the shoulder with pain associated with limitation of passive movement of the shoulder joint
InterventionsTreatment in each group lasted six weeks. Group 1: infra-red irradiation to both anterior and posterior aspects of the shoulder region. Each exposure lasted 10 minutes. Together with a scheme of graduated active exercises according to patient's tolerance
Group 2: intro-articular injection of hydrocortisone acetate, 25 mg (anterior approach, below the coracoid process) followed by the same scheme of graduated exercises
Group 3: injection of hydrocortisone acetate, 25 mg into the synovial sheath surrounding the bicipital tendon in the bicipital groove of the humerus, followed by the same scheme of graduated exercises
Group 4: analgesics only
OutcomesGroups 1, 2 and 3 assessed at beginning of treatment and at weekly intervals throughout the six weeks. Group 4 was assessed at the beginning and end of the trial period. ROM only outcome assessed
NotesComposite score for range of motion graphed but no numerical data. Reported no significant differences between heat/exercise group and injection/exercise groups, all groups better than analgesia alone.
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearD - Not used




Nicholson 1985
MethodsRandom allocation: Yes; Concealed allocation: No; Baseline comparability: Yes; Blind assessors: Yes; Blind subjects: No;Blind therapists: No; Adequate follow-up: No; Intention-to-treat analysis: No; Between-group comparisons: Yes; Point estimates & variability: Yes; Eligibility criteria: Yes
Participants20 participants (mean age treatment group 51, range 31-70; mean age control group 55, range 20-77) with shoulder pain plus limited passive motion of the glenohumeral joint.
InterventionsGroup 1:Mobilisation and active exercise 2-3 times a week for 4 weeks.Group 2: Active exercise only.
OutcomesAssessed at 4 weeks.Outcomes:1.Range of active internal rotation.2.Range of active abduction.3.Range of passive abduction4.Pain score
Notes
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?NoC - Inadequate




Nykanen 1995
MethodsRandom allocation: Yes; Concealed allocation: No; Baseline comparability: Yes; Blind assessors: Yes; Blind subjects: Yes; Blind therapists: Yes; Adequate follow-up: Yes; Intention-to-treat analysis: No; Between-group comparisons: Yes; Point estimates & variability: Yes; Eligibility criteria: Yes
Participants61 participants (aged 31 - 81; mean age treatment group 66; mean age control group 67) with rotator cuff disease without tear for at least 2 months
InterventionsGroup 1: Pulsed ultrasound (frequency 1.0mHz, on: off ratio 1:4 & intensity 1.0w/cm², 10 minutes), 10-12 treatments over 3-4 weeks.Group 2: Placebo ultrasound as above.
OutcomesAssessment at baseline, completion & 4-12 months follow-up.1.Clinical assessment: active ROM abduction, pain (supraspinatus test - 4 point scale)2.Questionaires answered re: pain, ADL's, medication, other treatment received.
Notes
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear




Perron 1997
MethodsRandom allocation: Yes; Concealed allocation: No; Baseline comparability: Yes; Blind assessors: Yes; Blind subjects: No; Blind therapists: No; Adequate follow-up: Yes; Intention-to-treat analysis: No; Between-group comparisons: Yes; Point estimates & variability: Yes; Eligibility criteria: Yes
Participants22 participants (mean age treatment group 43; mean age control group 40) with a confirmed diagnosis of symptomatic calcifying tendonitis of the shoulder, the area of the calcium deposit was to be 50mm or greater
InterventionsGroup 1: No treatment
Group 2: 9 treatments including acetic acid iontophoresis (5% acetic acid solution via the negative electrode, 5mA galvanic current, 20 minutes) followed by continuous ultrasound (0.8w/cm², 1MHz, 5 minutes)
OutcomesAssessment at baseline, and after the 3rd, 6th, and 9th treatments.Outcomes: X-ray of area (density of calcium deposit) and functional outcomes including passive shoulder abduction, ROM, pain intensity (present pain index scale - 6pt scale).
Notes
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear




Reid 1996
MethodsRandom allocation: Yes;Concealed allocation: No;Baseline comparability: Yes;Blind assessors: No;Blind subjects: No;Blind therapists: No;Adequate follow-up: No;Intention-to-treat analysis: No;Between-group comparisons: No;Point estimates & variability: Yes;Eligibility criteria: Yes
Participants20 male (mean age 22) university students with diagnosis of anterior instability (clinical history and positive apprehension test). Excluded if had history of voluntary or traumatic dislocation.
InterventionsGroup 1: Isokinetic resistance exercises, 2 times per week.Group 2: Electromyographic Biofeedback Re-education Program, 2 times per week. Biofeedback provided to instruct dynamic control of humeral head in functional activity.
OutcomesAssessed at 8, 26 and 52 weeks1. Function (modified Constant score)2. Pain at rest and on activity (3 point scale)3. Isokinetic strength
Notes
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear




Saunders 1995
MethodsRandom allocation: Yes, stratified by gender; Concealed allocation: Unclear; Baseline comparability: Yes;Blind assessors: Yes; Blind subjects: Yes; Blind therapists: Yes; Adequate follow-up: No;Intention-to-treat analysis: Yes;Between-group comparisons: Yes;Point estimates & variability: Yes;Eligibility criteria: Yes
Participants24 participants (mean age treatment group 49.8; mean age control group 50.7) with supraspinatus tendinitis of > 4 weeks duration.
InterventionsAll participants advised to rest arm from aggravating activity
Group 1: 9 x 3 minute treatments with active laser over three weeks.
Group 2: Identical regime with placebo laser
OutcomesPain on VAS over 24 hours.
Maximum voluntary contraction of abduction in internal rotation
Tenderness.
All assessed at end of intervention period. No long term follow up.
NotesOnly general improvement in pain data presented in a format suitable for inclusion in the review
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear




Shehab 2000
MethodsRandom allocation: Yes;Concealed allocation: No;Baseline comparability: Yes;Blind assessors: Yes;Blind subjects: No;Blind therapists: No;Adequate follow-up: No;Intention-to-treat analysis: Yes;Between-group comparisons: Yes;Point estimates & variability: Yes;Eligibility criteria: Yes
Participants50 female participants with painful shoulder movement of at least 1 month's duration. Diagnosis confirmed with provocative testing
InterventionsBoth groups treated 3-5 times a week for 13 sessionsGroup 1: TNS 30 mins 50Hz to anterior and posterior shoulderGroup 2: US 0.5W for 10 mins, increased by 0.1W for each sessionBoth groups had ice and stretching
OutcomesAssessed after 13 visits 1. Pain on VAS2. Flexion and Abduction ROM
NotesPresented medians and ranges hence not included in meta-analysis but in additional tables
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear




Taverna 1990
MethodsRandom allocation: Yes; Concealed allocation: No; Baseline comparability: No; Blind assessors: Yes; Blind subjects: Yes; Blind therapists: No; Adequate follow-up: Yes; Intention-to-treat analysis: Yes; Between-group comparisons: No; Point estimates & variability: No; Eligibility criteria: Yes
Participants40 participants (age range 23 - 79) with shoulder peri-arthritis (trial also includes 40 participants with cervical osteoarthritis but results presented separately)
InterventionsGroup 1: Treated with Laser therapy (1000Hz, 24mWatt for 15 to 20 minutes) over 15 treatments. Group 2: Control group (sham laser therapy)
OutcomesPatient reported success or failure
Notes
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear




van der Heijden 1999
MethodsRandom allocation: Yes; Concealed allocation: Yes; Baseline comparability: Yes; Blind assessors: Yes; Blind subjects: No; Blind therapists: No; Adequate follow-up: Yes; Intention-to-treat analysis: Yes; Between-group comparisons: Yes; Point estimates & variability: Yes; Eligibility criteria: Yes
Participants180 participants aged over 18 years (mean age active ET 51; mean age placebo ET 50; mean age no ET and no US 54; mean age active US 50; mean age placebo US 51) with pain over deltoid on movement OR reduced GH ROM OR both and a standardised clinical assessment revealing soft tissue injury.
Interventions5 groups who received 12 exercise therapy classes in 6 weeks as well as: Group 1: Active ET (Interferential electrotherapy) and US (Ultrasound)Group 2: Active ET and dummy USGroup 3: Dummy ET and active USGroup 4: Dummy ET and dummy USGroup 5: no additional adjuncts.ET: Bipolar interferential current (45Hz sinusoidal biphasis, amp module 60-100Hz rampt fall 1 see each and constant phase 2 sec in between.US: 0.8MHz 4cm², pulsed 2:8.
OutcomesAssessed at 6 weeks and 3, 6, 9 and 12 months.1. Recovery (7 point Likert scale) 2. Functional status (shoulder disability questionnaire) 3. Chief complaint 4. Pain 5. Clinical status6. ROM.
Notes
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?YesA - Adequate




van der Windt 1998
MethodsRandom allocation: Yes; Concealed allocation: Yes; Baseline comparability: Yes; Blind assessors: Yes; Blind subjects: No; Blind therapists: No; Adequate follow-up: Yes; Intention-to-treat analysis: Yes; Between-group comparisons: Yes; Point estimates & variability: Yes; Eligibility criteria: Yes
Participants108 participants (mean age corticosteroid 57.3; mean age physiotherapy 60.2). Painful restriction of GH joint and subjects 18 years and older
InterventionsGroup 1:Intraarticular corticosteroid injection (40mg triamcinolone acetonide 3 or less over 6 weeks, posterior route).Group 2: Physiotherapy (12 x 30 minute sessions of passive mobilisation, exercise and pain modalities).
OutcomesAssessed at 3, 7, 13, 26 and 52 weeks.Outcomes: 1. Improvement in main complaint and pain (6 point Likert scale, VAS scale), 2. Improvement in shoulder disability (shoulder disability questionnaire) 3. Adverse reactions, 4. Overall clinical severity (VAS), 5. Shoulder ROM.
Notes
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?YesA - Adequate




Vecchio 1993
MethodsRandom allocation: Yes; Concealed allocation: No; Baseline comparability: Yes; Blind assessors: Yes; Blind subjects: Yes; Blind therapists: Yes; Adequate follow-up: Yes; Intention-to-treat analysis: No; Between-group comparisons: Yes; Point estimates and variability: Yes; Eligibility criteria: Yes
Participants35 participants (mean age 54.4, range 17-77). Typical rotator cuff tendinitis with painful arc of abuction between 40-120 degrees and painful restricted movement in at least oneof abduction external or internal rotation. NSAID therapy ceased with a one week washout before baseline assessment. Exclusion: participants with frozen shoulder, acromioclavicular arthritis or clinical rotator cuff tears; patients who were pregnant or breast feeding or who had received ultra-articular or subacromial steroids in the three months prior to treatment; patients who had systemic disease or who had recieved physiotherapy for shoulder lesion
InterventionsGroup 1: Twice weekly low level laser treatment for eight weeks. EAch treatment 10 minutes consisting of three pulses (3J) to each of a maximum of five tender points with a wavelength of 830mn operated at 0 power.
Group 2: same regimen but dummy laser operated at 0 power.
Both groups performed exercises.
OutcomesAssessed at 2, 4 and 8 weeks. Outcomes: 1.Range of movement; 2. Painful arc score; 3. Resisted movement score; 4. Night, rest and movement pain (VAS); 5. Functional limitation (VAS)
Notes
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear




Winters 1997/9
MethodsRandom allocation: Yes; Concealed allocation: No; Baseline comparability: No; Blind assessors: No; \Blind subjects: No; Blind therapists: No; Adequate follow-up: No; Intention-to-treat analysis: No; Between-group comparisons: Yes; Point estimates & variability: Yes; Eligibility criteria: No
Participants178 participants (mean age shoulder girdle manipulation group 43.9; mean age shoulder girdle physiotherapy group 46.4; mean age synovial corticosteroid group 53.5; mean age synovial manipulation group 46.7; mean age synovial physiotherapy group 53.1) with shoulder complaints presenting to general practice. Two populations reported in this trial, a "shoulder girdle group" where pain originated from the cervical and thoracic spine, and a "synovial group" where pain originated from shoulder joint (n=114). Shoulder joint population only reported in this statement.
InterventionsFirst week: All received 50mg diclofenac sodium three times daily.Then, on the basis of reassessment they were divided into two groups: Group 1: Synovial group: Group 1: corticosteroid injection (1-3 injections as needed at baseline, 1 week and after 2 weeks of 1 ml of 40 mg/ml triamcinolone acctonide with 9ml of 10mg.ml lidocaine), Group 2: "manipulation" (mobilisation/manipulation of cervical upper spine, upper thoracic spine, upper ribs, AC joint, GH joint once weekly with a maximum of 6 treatments), Group 3 "physiotherapy" (no mobes or manips, exercise and electrotherapy 2 times weekly).
OutcomesAssessment at baseline and 1, 2, 6 and 11 weeks.1. Pain level: Shoulder pain score, 6-question scale and 101-point numerical pain scale. . Weekly pain score 2. Active and passive ROM 3. Asked if they felt "cured" of if treatment had failed. 4. Duration of shoulder complaints analysed by survival analysis.
NotesTwo groups of subjects reported in this trial, a "shoulder girdle group" where pain originated from cervical and thoracic spine, and a "synovial group" where pain originated from shoulder joint. Only data from "synovial group" included in this review.
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear


 
Characteristics of excluded studies [ordered by study ID]
StudyReason for exclusion
Anderson 1996Population not included in this review: post-operative shoulder surgery
Arciero 1994Population not included in this review: all patients had sustained trauma.
Arslan 2001Randomised controlled trial of corticosteroid injection versus combined physiotherapy and non-steroiodal anti-inflammatory. Not able to seperate out the effect of physiotherapy. Included in Cochrane Review of cortico-steroid injection for shoulder disorders
Biswas 1979Not clear if randomised, 2/3 of participants lost to follow up and no between group comparisons
Chee 1986Population not included in this review: was neck and shoulder pain with no separately reported data.
Curtis 1999Population not included in this review: wheelchair users not necessarily with shoulder pain. Intervention was unsupervised exercise as prevention of pain and disability
Echternach 1966Intervention not included in this review: assessed the intervention of audioanalgesia as a way to better tolerate mobilisation, not whether mobilisation, nor audioanalgesia, was effective treatment
Gam 1998Population not included in this review: myofascial neck and shoulder region pain
Grossi 1986Population not included in this review: 73 patients with either lateral epicondylitis or adhesive capsulitis (numbers of each individual diagnosis not given). Not possible to seperate lateral epicondylitis and adhesive capsulitis data.
Hagberg 2000Population not included in this review: myofascial neck and shoulder region pain
Inaba 1972Population not included in this review: hemiplegia
Lastayo 1998Population not included in this review: post-operative shoulder surgery
Leandri 1990Population not included in this review: hemiplegia
Leboeuf 1987Population not included in this review: repetitive strain injury of entire upper limb
Livesley 1992Population not included in this review: trauma
Lloyd-Roberts 1959Not randomised.
Lundberg 1979Population not included in this review: humeral head fractures). Subjects sustained trauma and therefore excluded
Lundblad 1999Population not included in this review: included participants with neck and shoulder complaints with data from participants with shoulder complaints not presented seperately
Melzer 1995Not randomised
Meyer 1997Not randomised
Morgan 1995Is a randomised controlled trial of the use of TNS to control pain during a painful intervention for shoulder disorder, not of an intervention for the disorder.
Nash 1990Trail of high intensity TENS compared to low intensity TENS for analgesia during hydrodilatation (distension arthrography), not as a treatment for shoulder disorder
Partridge 1990Population not included in this review: hemiplegia
Philipson 1983Population not included in this review: chronic myofascial syndrome
Quin 1965Not randomised
Raab 1996Population not included in this review: post-operative shoulder surgery
Rahme 1998Intervention is of surgery
Randlov 1998Population not included in this review: myofascial neck and shoulder region pain
Ritchie 1997Intervention is for post shoulder surgery pain relief, not treatment of shoulder disorder.
Rizk 1983Not randomised
Speer 1996Intervention is for post shoulder surgery pain relief, not treatment of shoulder disorder.
Spence 1995Population not included in this review: myofascial neck and shoulder region pain
Vasseljen 1998Population not included in this review: myofascial neck and shoulder region pain
Vecchini 1984Capsulitis data not presented seperately. Twelve of the 24 subjects in the study suffered adhesive capsulitis, the remaining 12 with lateral epicondylitis of the elbow.
Waldburger 1992Population not included in this review: post-traumatic
Waling 2000Population not included in this review: myofascial neck and shoulder region pain
Williams 1986Population not included in this review: rheumatoid arthritis
Wolf 1996Population not included in this review: post-operative shoulder surgery


 
Comparison 1. BIPOLAR INTERFERENTIAL CURRENT VERSUS PLACEBO
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
 1 Recovery or substantial improvement at 6 weeks1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    1.1 General shoulder pain (mixed diagnoses)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 2 Recovery or substantial improvement (participant rated) at 3 months1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    2.1 General shoulder pain (mixed diagnoses)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 3 Recovery or substantial improvement (participant rated) at 6 months1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    3.1 General shoulder pain (mixed diagnoses)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 4 Recovery or substantial improvement (participant rated) at 9 months1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    4.1 General shoulder pain (mixed diagnoses)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 5 Recovery or substantial improvement (participant rated) at 12 months1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    5.1 General shoulder pain (mixed diagnoses)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 
Comparison 2. ULTRASOUND VERSUS PLACEBO
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
 1 Recovery or substantial improvement (participant rated) - short term3229Risk Ratio (M-H, Fixed, 95% CI)1.41 [1.04, 1.90]
    1.1 General shoulder pain (combined diagnoses)
1145Risk Ratio (M-H, Fixed, 95% CI)1.44 [0.77, 2.70]
    1.2 Calcific tendinitis
160Risk Ratio (M-H, Fixed, 95% CI)1.81 [1.26, 2.60]
    1.3 Rotator cuff disease
124Risk Ratio (M-H, Fixed, 95% CI)0.67 [0.35, 1.28]
 2 Recovery or substantial improvement (participant rated) at 3 months1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    2.1 General shoulder pain (combined diagnoses)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 3 Recovery or substantial improvement (participant rated) at 6 months1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    3.1 General shoulder pain (combined diagnoses)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 4 Recovery or substantial improvement (participant rated) at 9 months2206Risk Ratio (M-H, Fixed, 95% CI)1.01 [0.78, 1.30]
    4.1 General shoulder pain (mixed diagnoses)
1145Risk Ratio (M-H, Fixed, 95% CI)0.87 [0.60, 1.26]
    4.2 Calcific tendinitis
161Risk Ratio (M-H, Fixed, 95% CI)1.26 [0.90, 1.77]
 5 Recovery or substantial improvement (participant rated) at 12 months1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    5.1 General shoulder pain (mixed diagnoses)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 6 Resolution or improvement of radiological finding at end of treatment (6 weeks)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    6.1 Calcific tendinitis
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 7 Resolution or improvement of radiological finding at 9 months1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    7.1 Calcific tendinitis
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 8 Normal function at end of treatment (6 weeks)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    8.1 Calcific tendinitis
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 9 Normal function at 9 months1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    9.1 Calcific tendinitis
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 10 Change in range of flexion1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    10.1 General shoulder pain (mixed diagnoses)
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 11 Range of abduction3116Mean Difference (IV, Fixed, 95% CI)-2.89 [-10.43, 4.66]
    11.1 General shoulder pain (combined diagnoses)
120Mean Difference (IV, Fixed, 95% CI)-1.0 [-10.80, 8.80]
    11.2 Rotator cuff disease
296Mean Difference (IV, Fixed, 95% CI)-5.64 [-17.48, 6.20]
 12 Change in internal rotation1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    12.1 General shoulder pain (combined diagnoses)
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 13 Change in external rotation1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    13.1 General shoulder pain (combined diagnoses)
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 14 Pain (100mmVAS) at 4 weeks1Std. Mean Difference (IV, Fixed, 95% CI)Totals not selected
    14.1 Rotator Cuff Disease
1Std. Mean Difference (IV, Fixed, 95% CI)Not estimable
 15 Painfree at 4 weeks1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    15.1 General shoulder pain (mixed diagnoses)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 16 Pain (out of 20) at 4 months1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    16.1 Rotator cuff disease
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 17 Pain (out of 20) at 12 months1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    17.1 Rotator cuff disease
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 18 Function (out of 14) at 4 months1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    18.1 Rotator cuff disease
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 19 Function (out of 14) at 12 months1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    19.1 Rotator cuff disease
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 
Comparison 3. SUPERVISED EXERCISES VERSUS PLACEBO OR NO TREATMENT
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
 1 Good or excellent function (Neer score) at 2 and a half years1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    1.1 Rotator cuff disease
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 2 No pain on activity at 2 and a half years1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    2.1 rotator cuff disease
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 3 No pain at rest at 2 and a half years1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    3.1 rotator cuff disease
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 4 No pain at night at two and a half years1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    4.1 rotator cuff disease
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 5 Substantial improvement or recovered post treatment (1 month). Participant rated1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    5.1 General shoulder pain (mixed diagnoses)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 6 No pain post treatment (1 month)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    6.1 General shoulder pain (mixed diagnoses)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 7 Good or excellent function post treatment (1 month)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    7.1 General shoulder pain (mixed diagnoses)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 8 Worsened range of abduction post treatment (1 month)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    8.1 General shoulder pain (mixed diagnoses)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 
Comparison 4. LASER VERSUS PLACEBO
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
 1 Excellent or good result264Risk Ratio (M-H, Fixed, 95% CI)3.71 [1.89, 7.28]
    1.1 Periarthritis (adhesive capsulitis)
140Risk Ratio (M-H, Fixed, 95% CI)8.0 [2.11, 30.34]
    1.2 Supraspinatus tendinitis
124Risk Ratio (M-H, Fixed, 95% CI)2.0 [0.98, 4.09]
 2 Change in Range of Movement at four weeks135Mean Difference (IV, Fixed, 95% CI)-10.8 [-40.76, 19.16]
    2.1 Supraspinatus tendinitis
135Mean Difference (IV, Fixed, 95% CI)-10.8 [-40.76, 19.16]
 3 Change in night pain at four weeks135Mean Difference (IV, Fixed, 95% CI)1.30 [-1.06, 3.66]
    3.1 Supraspinatus tendinitis
135Mean Difference (IV, Fixed, 95% CI)1.30 [-1.06, 3.66]
 4 Change in pain at rest at four weeks135Mean Difference (IV, Fixed, 95% CI)0.80 [-0.86, 2.46]
    4.1 Supraspinatus tendinitis
135Mean Difference (IV, Fixed, 95% CI)0.80 [-0.86, 2.46]
 5 Change in pain on movement at four weeks135Mean Difference (IV, Fixed, 95% CI)1.50 [-1.01, 4.01]
    5.1 Supraspinatus tendinitis
135Mean Difference (IV, Fixed, 95% CI)1.50 [-1.01, 4.01]
 6 Change in function at four weeks135Mean Difference (IV, Fixed, 95% CI)0.90 [-1.06, 2.86]
    6.1 Supraspinatus tendinitis
135Mean Difference (IV, Fixed, 95% CI)0.90 [-1.06, 2.86]
 7 Change in range of movement at 8 weeks135Mean Difference (IV, Fixed, 95% CI)-25.2 [-66.36, 15.96]
    7.1 Supraspinatus tendinitis
135Mean Difference (IV, Fixed, 95% CI)-25.2 [-66.36, 15.96]
 8 Change in night pain at 8 weeks135Mean Difference (IV, Fixed, 95% CI)1.20 [-1.74, 4.14]
    8.1 Supraspinatus tendinitis
135Mean Difference (IV, Fixed, 95% CI)1.20 [-1.74, 4.14]
 9 Change in pain at rest at 8 weeks135Mean Difference (IV, Fixed, 95% CI)1.7 [-0.69, 4.09]
    9.1 Supraspinatus tendinitis
135Mean Difference (IV, Fixed, 95% CI)1.7 [-0.69, 4.09]
 10 Change in pain on movement at 8 weeks135Mean Difference (IV, Fixed, 95% CI)1.8 [-1.14, 4.74]
    10.1 Supraspinatus tendinitis
135Mean Difference (IV, Fixed, 95% CI)1.8 [-1.14, 4.74]
 11 Change in function at 8 weeks135Mean Difference (IV, Fixed, 95% CI)0.70 [-2.08, 3.48]
    11.1 Supraspinatus tendinitis
135Mean Difference (IV, Fixed, 95% CI)0.70 [-2.08, 3.48]
 
Comparison 5. PULSED ELECTROMAGNETIC FIELD VERSUS PLACEBO
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
 1 No pain at end of treatment (6 days)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    1.1 Calcific tendinitis
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 2 No pain at 4-6 Weeks1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    2.1 Calcific tendinitis
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 3 Adverse effects1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    3.1 Post treatment pain
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
    3.2 Anxiety/ claustrophobia
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
    3.3 Headache
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
    3.4 Insomnia
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 
Comparison 6. IONTOPHORESIS WITH ACETIC ACID PLUS ULTRASOUND VERSUS NO TREATMENT
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
 1 Percent change in size of calcium deposit1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    1.1 Calcific tendinitis
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 2 Percent improvement in abduction1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    2.1 Calcific tendinitis
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 
Comparison 7. BIPOLAR INTERFERENTIAL CURRENT VERSUS ULTRASOUND
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
 1 Recovery or substantial improvement (participant rated) at 6 weeks1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    1.1 General shoulder pain (mixed diagnoses)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 2 Recovery or substantial improvement (participant rated) at 3 months1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    2.1 General shoulder pain (mixed diagnoses)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 3 Recovery or substantial improvement (participant rated) at 6 months1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    3.1 General shoulder pain (mixed diagnoses)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 4 Recovery or substantial improvement (participant rated) at 9 months1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    4.1 General shoulder pain (mixed diagnoses)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 5 Recovery or substantial improvement (participant rated) at 12 months1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    5.1 General shoulder pain (mixed diagnoses)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 
Comparison 8. TENS VERSUS ULTRASOUND
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
 1 Pain on VAS1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    1.1 General shoulder pain (mixed diagnoses)
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 
Comparison 9. MOBILISATION PLUS EXERCISE VERSUS EXERCISE ALONE
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
 1 Range of internal rotation at 3 to 4 weeks234Mean Difference (IV, Fixed, 95% CI)4.61 [-0.99, 10.21]
    1.1 adhesive capsulitis
120Mean Difference (IV, Fixed, 95% CI)6.08 [0.06, 12.10]
    1.2 rotator cuff impingement
114Mean Difference (IV, Fixed, 95% CI)-4.71 [-19.89, 10.47]
 2 Range of abduction at 3 to 4 weeks234Mean Difference (IV, Fixed, 95% CI)2.10 [-10.03, 14.22]
    2.1 adhesive capsulitis
120Mean Difference (IV, Fixed, 95% CI)4.4 [-9.02, 17.82]
    2.2 rotator cuff impingement
114Mean Difference (IV, Fixed, 95% CI)-8.15 [-36.46, 20.16]
 3 Pain at 3 to 4 weeks3Mean Difference (IV, Fixed, 95% CI)Subtotals only
    3.1 adhesive capsulitis (pain 10 cm VAS)
120Mean Difference (IV, Fixed, 95% CI)-2.20 [-6.13, 1.73]
    3.2 rotator cuff impingement (pain composite several 100 mm scales)
149Mean Difference (IV, Fixed, 95% CI)-186.23 [-319.33, -53.13]
    3.3 rotator cuff impingement (mm on VAS)
114Mean Difference (IV, Fixed, 95% CI)-32.07 [-58.04, -6.10]
 4 Range of passive abduction at 4 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    4.1 adhesive capsulitis
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 5 Composite strength score at 3 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    5.1 rotator cuff impingement
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 6 Function at 3 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    6.1 rotator cuff impingement
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 7 Pain on subacromial compression (mm on VAS) at 3 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    7.1 rotator cuff impingement
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 8 Range of elevation (degrees) at 3 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    8.1 rotator cuff impingement
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 9 Range of external rotation (degrees) at 3 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    9.1 rotator cuff impingement
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 
Comparison 10. MOBLISATION/ MANIPULATION VERSUS EXERCISES AND ELECTROTHERAPY
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
 1 Pain at end of intervention period1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    1.1 General shoulder pain (mixed diagnoses or no diagnosis given)
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 2 "Cured" at 5 weeks (participant rated)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    2.1 General shoulder pain (mixed diagnoses)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 3 "Not cured" (participant rated) at 2 and a half years (in those followed up)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    3.1 General shoulder pain (mixed diagnoses)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 
Comparison 11. ISOKINETIC RESISTANCE EXERCISES VERSUS ELECTROMYOGRAPHIC BIOFEEDBACK
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
 1 No functional limitation at work at 8 weeks1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    1.1 Anterior instability
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 2 No functional limitation at work at 26 weeks1Odds Ratio (M-H, Fixed, 95% CI)Totals not selected
    2.1 Anterior instability
1Odds Ratio (M-H, Fixed, 95% CI)Not estimable
 3 No functional limitation at work at 1 year1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    3.1 Anterior instability
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 4 No functional limitation at in sport at 8 weeks1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    4.1 Anterior instability
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 5 No functional limitation in sport at 26 weeks1Odds Ratio (M-H, Fixed, 95% CI)Totals not selected
    5.1 Anterior instability
1Odds Ratio (M-H, Fixed, 95% CI)Not estimable
 6 No functional limitation in sport at 1 year1Odds Ratio (M-H, Fixed, 95% CI)Totals not selected
    6.1 Anterior instability
1Odds Ratio (M-H, Fixed, 95% CI)Not estimable
 
Comparison 12. PHYSIOTHERAPY WITH ELECTRO MAGNETIC THERAPY VERSUS PHYSIOTHERAPY WITH NO ELECTRO MAGNETIC THERAPY
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
 1 Range of shoulder flexion at 12 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    1.1 adhesive capsulitis
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 2 Range of shoulder abduction at 12 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    2.1 adhesive capsulitis
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 3 Range of shoulder external rotation at 12 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    3.1 adhesive capsulitis
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 4 Range of shoulder internal rotation at 12 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    4.1 adhesive capsulitis
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 5 Pain at rest at 12 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    5.1 adhesive capsulitis
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 6 Pain on movement at 6 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    6.1 adhesive capsulitis
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 7 Pain on lying at 6 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    7.1 adhesive capsulitis
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 
Comparison 13. INTRA-ARTICULAR STEROID INJECTION VERSUS PHYSIOTHERAPY (MOBILISATION, EXERCISE AND ELECTROTHERAPY)
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
 1 Improvement in severity of main complaint at 3 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    1.1 Adhesive capsulitis
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 2 Improvement in severity of main complaint at 7 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    2.1 Adhesive capsulitis
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 3 Improvement in severity of main complaint at 13 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    3.1 Adhesive capsulitis
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 4 Improvement in severity of main complaint at 26 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    4.1 Adhesive capsulitis
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 5 Improvement in severity of main complaint at 52 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    5.1 Adhesive capsulitis
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 6 Pain at 2-3 weeks (100cm VAS)2133Mean Difference (IV, Fixed, 95% CI)-12.18 [-18.61, -5.75]
    6.1 Adhesive capsulitis
1109Mean Difference (IV, Fixed, 95% CI)-10.00 [-18.67, -5.33]
    6.2 Rotator cuff disease
124Mean Difference (IV, Fixed, 95% CI)-14.60 [-38.91, 9.71]
 7 Improvement in severity of day pain at 7 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    7.1 Adhesive capsulitis
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 8 Improvement in severity of day pain at 13 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    8.1 Adhesive capsulitis
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 9 Improvement in severity of day pain at 26 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    9.1 Adhesive capsulitis
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 10 Improvement in severity of day pain at 52 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    10.1 Adhesive capsulitis
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 11 Improvement in severity of night pain at 3 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    11.1 Adhesive capsulitis
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 12 Improvement in severity of night pain at 7 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    12.1 Adhesive capsulitis
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 13 Improvement in severity of night pain at 13 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    13.1 Adhesive capsulitis
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 14 Improvement in severity of night pain at 26 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    14.1 Adhesive capsulitis
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 15 Improvement in severity of night pain at 52 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    15.1 Adhesive capsulitis
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 16 Improvement in severity as rated by observer at 3 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    16.1 Adhesive capsulitis
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 17 Improvement in severity as rated by observer at 7 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    17.1 Adhesive capsulitis
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 18 Improvement in severity as rated by observer at 26 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    18.1 Adhesive capsulitis
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 19 Improvement in rating of shoulder disability at 3 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    19.1 Adhesive capsulitis
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 20 Improvement in rating of shoulder disability at 7 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    20.1 Adhesive capsulitis
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 21 Improvement in rating of shoulder disability at 13 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    21.1 Adhesive capsulitis
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 22 Improvement in rating of shoulder disability at 26 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    22.1 Adhesive capsulitis
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 23 Improvement in rating of shoulder disability at 52 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    23.1 Adhesive capsulitis
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 24 Range of abduction (degrees) at 2-3 weeks2133Mean Difference (IV, Fixed, 95% CI)5.0 [0.36, 9.64]
    24.1 Adhesive capsulitis
1109Mean Difference (IV, Fixed, 95% CI)5.0 [0.31, 9.69]
    24.2 Rotator cuff disease
124Mean Difference (IV, Fixed, 95% CI)5.0 [-24.93, 34.93]
 25 Improvement in degree of restriction of ROM of abduction at 7 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    25.1 Adhesive capsulitis
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 26 Improvement in degree of restriction of ROM of abduction at 26 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    26.1 Adhesive capsulitis
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 27 Improvement in degree of restriction of ROM of ER at 3 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    27.1 Adhesive capsulitis
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 28 Improvement in degree of restriction of ROM of ER at 7 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    28.2 Adhesive capsulitis
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 29 Improvement in degree of restriction of ROM of ER at 26 weeks1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    29.1 Adhesive capsulitis
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 30 Number needing additional treatment at 7 weeks1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    30.1 Adhesive capsulitis
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 31 Frequency of adverse reactions1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    31.1 pain after treatment > 2 days
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
    31.2 facial flushing
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
    31.3 irregular menstrual bleeding
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
    31.4 fever
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
    31.5 skin irritation
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
    31.6 overall
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 32 Short term treatment success1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    32.1 Rotator cuff disease
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 
Comparison 14. INTRA-ARTICULAR AND SUBACROMIAL STEROID INJECTION VERSUS PHYSIOTHERAPY (EXERCISES AND ELECTROTHERAPY)
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
 1 Pain at end of intervention period1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    1.1 General shoulder pain (mixed diagnoses)
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 2 "Cured" at 5 weeks (participant rated)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    2.1 General shoulder pain (mixed diagnoses)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 3 "Not cured" (participant rated) at 2 and a half years (in those followed up)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    3.1 General shoulder pain (mixed diagnoses)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 
Comparison 15. INTRA-ARTICULAR AND SUBACROMIAL STEROID INJECTION VERSUS PHYSIOTHERAPY (MOBILISATION AND MANIPULATION)
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
 1 Pain at end of intervention period1Mean Difference (IV, Fixed, 95% CI)Totals not selected
    1.1 General shoulder pain (mixed diagnoses)
1Mean Difference (IV, Fixed, 95% CI)Not estimable
 2 "Cured" at 5 weeks (participant rated)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    2.1 General shoulder pain (mixed diagnoses)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 3 "Not cured" (participant rated) at 2 and a half years (in those followed up)1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
    3.1 General shoulder pain (mixed diagnoses)
1Risk Ratio (M-H, Fixed, 95% CI)Not estimable
 
Table 1. Results of included studies with data not appropriate for metaview
Study IDInterventionsOutcomeResults
Shehab, 2000TENS VERSUS USPain post interventionMedian (Range) TENS 0(0-.65) US 0.5(0-2.75) Significantly better in US group
Flexion score post interventionMedian (Range) TENS 140 (120-160) US 175 (115-180) Significantly better in US group
Abduction score post interventionMedian (Range) TENS 130 (116.7-156.5) US 180 (101.2-180) Significantly better in US group
Brox, 1993ARTHROSCOPIC DECOPRESSION VERSUS EXERCISEPain at 3 monthsMedian Arthroscope 25 Median exercise 15
Pain at 6 monthsMedian Arthroscope 25 Median exercise 25
Pain at 2.5 yearsMean (SD) Arthroscope 24 (22) Mean (SD) exercise 22 (21)
Function at 3 monthsMedian Arthroscope 28 Median exercise 24
Function at 6 monthsMedian Arthroscope 28 Median exercise 25
Function at 2.5 yearsMean (SD) arthroscope 23 (20) Mean (SD) exercise 20 (19)
Overall change at 3 monthsMedian Arthroscope 84 Median exercise 74
Overall change at 6 monthsMedian Arthroscope 87 Median exercise 86
England 1989LASER VERSUS PLACEBOPain (10 cm VAS) at 2 weeksDifference between medians (95% CI) 2.5cm (2,3)
Function (10cm VAS) at 2 weeksDifference between medians (95%CI) 1.5cm (-0.1,3.99)
Range of abduction (degrees)Difference between medians (95% CI) 20 (10,40)
Range of flexion (degrees)Difference between medians (95% CI) 15 (5,29)
LASER VERSUS NSAIDPain (10 cm VAS) at 2 weeksDifference between medians (95% CI) 2cm (1,3.5)
Function (10cm VAS) at 2 weeksNo difference in medians
Range of abduction (degrees)Difference between medians (95% CI) 20 (10,40)
Range of flexion (degrees)Difference between medians (95% CI) 20 (10,40)
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