Relationship Between Intensity of Neck Pain and Disability and Shoulder Pain and Disability in Individuals With Subacromial Impingement Symptoms: A Cross-Sectional Study.

OBJECTIVE: This study aimed to verify a possible relationship between shoulder disability and shoulder pain intensity and the variables related to cervical-spine dysfunction, and determine which of these can differentiate moderate to severe shoulder pain (>4 on a numerical rating scale [NRS]) from mild shoulder pain (≤4 on the NRS) in individuals with subacromial impingement symptoms. METHODS: One hundred and forty volunteers with shoulder pain were evaluated. Demographic information and variables related to the shoulder and neck were collected. Self-reported pain and disability of the shoulder and cervical spine were measured using the Shoulder Pain and Disability Index (SPADI) and Neck Disability Index (NDI) questionnaires, respectively. An NRS was used to measure pain in the shoulder and cervical spine. A purposeful modeling strategy was used to determine the best model to predict shoulder disability and shoulder pain (dependent variables). Multiple logistic regression analysis followed by receiver operating curve analysis was used to determine which variables better differentiated moderate to severe shoulder pain from mild shoulder pain. RESULTS: Variables such as Neck Disability Index (NDI) score (ß = 1.09, P = .00) and age (ß = -0.19, P = .03) were associated with the total SPADI score. Neck pain was significantly associated with shoulder pain (ß = 0.40, P = .00). The combination of variables predicting moderate to severe shoulder pain was total SPADI score (odds ratio [OR] = 1.15, P = .003), neck pain (OR = 3.20, P = .04), and age (OR = 1.01, P = .05). CONCLUSION: Our results demonstrate the important connection between shoulder- and neck-related symptoms in individuals with subacromial impingement symptoms.

The protocol for a multisite, double blind, randomized, placebo-controlled trial of axillary nerve stimulation for chronic shoulder pain.

BACKGROUND: Shoulder impingement syndrome is one of the most common causes of shoulder pain, accounting for approximately 30% of all shoulder pain. Approximately 35% of patients with shoulder impingement syndrome are refractory to conservative treatment. For patients who fail conservative treatment, there is no established treatment to successfully treat their chronic pain. Prior randomized control trials have demonstrated efficacy for the use of a single lead intramuscular peripheral nerve stimulation of the axillary nerve at the motor points of the deltoid muscle for treatment of hemiplegic shoulder pain. This is the first controlled trial to utilize the same novel technology to treat shoulder impingement syndrome outside of the stroke population. METHODS: This is a dual-site, placebo-controlled, double-blinded, randomized control trial. Participants will be randomized to two treatment groups. The intervention group will be treated with active peripheral nerve stimulation of the axillary nerve of the affected shoulder and the control group will be treated with sham peripheral nerve stimulation of the axillary nerve of the affected shoulder. Both groups will receive a standardized exercise therapy program directed by a licensed therapist. DISCUSSION: This study protocol will allow the investigators to determine if this novel, non-pharmacologic treatment of shoulder pain can demonstrate the same benefit in musculoskeletal patients which has been previously demonstrated in the stroke population. TRIAL REGISTRATION: Clinicaltrials.gov, NCT03752619. Registered on 26 November 2018.

Comparison of different electrotherapy methods and exercise therapy in shoulder impingement syndrome: A prospective randomized controlled trial.

OBJECTIVE: The aim of this study was to assess and compare the effects of different electrotherapy methods and exercise therapy on pain, function and quality of life in shoulder impingement syndrome. METHODS: Eighty-three patients (66 females, 17 males; mean age: 48.2 ± 7.33 years) with shoulder impingement syndrome were selected and 79 of them were randomly allocated into four groups. Group 1 (n = 19, mean age: 47.89 ± 7.12 years) was given hot pack and exercises, Group 2 (n = 20, mean age: 47.70 ± 6.51 years) was given hot packs, exercises and interferential current, Group 3 (n = 20, mean age: 48.50 ± 8.34 years) was given hot packs, exercises and TENS and Group 4 (n = 20, mean age: 48.55 ± 7.89 years) was given hot packs, exercises and ultrasound three times a week for four weeks. Assessments were made before treatment, right after it and three months after that using the visual analog scale (VAS), Short Form-36 (SF-36) and the Disabilities of the Arm, Shoulder and Hand (DASH) outcome measures. RESULTS: At the fourth week and third month assessments, all groups showed significant improvements in terms of pain, DASH and SF-36 physical component scores (p < 0.05). In intragroup comparisons, a significant difference between pre- and post-treatment results was found only in SF-36 mental component scores of Group 2. No significant difference was observed between the groups in any stage of the study period (p > 0.05). CONCLUSION: Application of ultrasound, interferential current and TENS in addition to exercise therapy in shoulder impingement syndrome treatment had similar improvements in terms of pain, function and physical component of quality of life. However, interferential current treatment showed significantly better outcomes for the mental component of quality of life. LEVEL OF EVIDENCE: Level I, Therapeutic study.

Short-Term Effectiveness of Precut Kinesiology Tape Versus an NSAID as Adjuvant Treatment to Exercise for Subacromial Impingement: A Randomized Controlled Trial.

OBJECTIVE: To compare the short-term effectiveness of precut kinesiology tape (PCT) to a nonsteroidal anti-inflammatory drug (NSAID) as adjuvant treatment to exercise physiotherapy in improving pain and function in patients with shoulder impingement. DESIGN: Randomized, controlled assessor-blind parallel-design trial with 3 groups. SETTING: Academic-community hospital. PATIENTS: One hundred patients (mean age: 48 ± 12.3, 61 men, 39 women) with a diagnosis of subacromial impingement (SAI) syndrome were randomized to a treatment group from October 2009 to June 2012. Eighty-one patients completed the study. INTERVENTIONS: Patients were randomized to one of the 3 treatment groups: PCT and Exercise (n = 33), NSAID and Exercise (n = 29), or Exercise only (n = 38) for a 4 session 2-week intervention with a registered physiotherapist. MAIN OUTCOME MEASURES: Numeric pain rating scales for pain at rest and pain with arm elevation, the Simple Shoulder Test (SST), and the Constant Score were assessed pretreatment and post-treatment. RESULTS: A statistically significant reduction in pain at rest and pain with arm elevation, as well as improvement in SST and Constant Score were observed in all 3 treatment groups, with minimal clinically important differences shown on pain with elevation and SST scores. Between-group differences on all outcome measures were not statistically significant or clinically meaningful. CONCLUSIONS: The improvements in pain and function observed with an NSAID or PCT as adjuvant treatments were no greater than with rehabilitation exercise alone. If adjuvant treatment is desired, PCT seems to be better tolerated than an NSAID, although the difference did not reach significance. CLINICAL RELEVANCE: The routine addition of adjuvant treatment is not supported by the results of this study. As adjuvant therapy, PCT seems to be better tolerated than an NSAID. If desired, clinicians may consider incorporating PCT along with an exercise component in the conservative treatment of SAI syndrome.

Efficacy of dynamic humeral centering according to Neer test results: a stratified analysis of a randomized-controlled trial.

The aim of this study was to assess the efficacy of dynamic humeral centering (DHC) according to Neer test results. The study was a stratified analysis of a previously reported randomized trial. The patients included had shoulder pain with impingement syndrome. Interventions were DHC or nonspecific mobilization for control. The primary outcome was the Constant score including subscores for pain, activity, mobility, and strength at 3 months. All patients improved at follow-up, with better results after DHC. There was no interaction between Neer test results, treatments, and time. However, a trend toward higher effect sizes was observed after DHC in patients with a positive Neer test in comparison with negative patients. Patients with a positive Neer test showed improvement after DHC for rotator cuff disease compared with nonspecific mobilization.

Intervención grupal del síndrome subacromial en atención primaria / A group intervention for shoulder impingement syndrome in primary care

Introducción. El aumento de consultas por dolor de hombro en los servicios de rehabilitación impone buscar alternativas eficientes para mejorar su manejo. Objetivos. Evaluar la efectividad de un programa de rehabilitación grupal para mejorar la funcionalidad y el dolor en pacientes afectos de síndrome subacromial y ver qué variables se asocian a un mejor resultado funcional final. Métodos. Estudio longitudinal prospectivo de intervención antes/después. Muestra: 211 pacientes. La intervención consistió en 10 sesiones de electroterapia analgésica individual, 5 sesiones de cinesiterapia grupal y una sesión informativa: «escuela de hombro». El seguimiento fue de un año. Medimos la funcionalidad con el test de Constant y el dolor con la escala visual analógica. Pruebas estadísticas: chi cuadrado, T-test, ANOVA y regresión lineal múltiple (p < 0,05). Resultados. La funcionalidad mejoró significativamente en los 4 períodos estudiados respecto al valor inicial y se estabilizó a los 6 meses. El perfil de paciente que obtuvo mayor funcionalidad fue: mujer, mayor de 60 años, sin dolor en reposo inicial y laboralmente no activa. La mejora del dolor observada a largo plazo no fue significativa. El consumo de analgésicos se redujo significativamente a los 3 meses. La adherencia al tratamiento domiciliario de ejercicios fue del 81% a los 3 y 6 meses y del 70,6% al año. Conclusiones. La aplicación de un programa de rehabilitación grupal en pacientes afectos de síndrome subacromial se ha mostrado efectivo para mejorar la funcionalidad a largo plazo. Sin embargo, el dolor no ha mostrado mejoría significativa a lo largo del estudio (AU)

Introduction. Due to the increase in consultations for shoulder pain in rehabilitation services, there is a need for efficient alternatives to improve the management of this disorder. Objectives. To evaluate the effectiveness of a supervised group exercise program to improve functionality and pain in patients with shoulder impingement syndrome and to identify the variables that are associated with a better functional outcome. Methods. A prospective longitudinal, pre and post intervention study was carried out in a sample of 211 patients. The treatment consisted of 10 individual sessions of analgesic electrotherapy, 5 sessions of group exercise therapy and an educational session: «shoulder school». One year follow-up was performed. Shoulder function and pain were assessed using Constant's test and the visual analogue scale. The statistical analysis was carried out with the chi-square test, T-test, ANOVA and multiple linear regression (P < .05). Results. Functionality improved significantly in all periods studied compared with baseline and stabilized at 6 months. The profile of patients who achieved greater functionality was female, older than 60 years, with no initial rest pain and occupationally inactive. Long-term pain improvement was not significant. Analgesic use was significantly reduced at 3 months. Adherence to home exercise treatment was 81% at 3 and 6 months and 70.6% at one year. Conclusions. The application of a group rehabilitation program in patients with shoulder impingement syndrome was effective in improving long-term functionality. However, there was no significant pain improvement during the study (AU)

Percutaneous peripheral nerve stimulation for chronic pain in subacromial impingement syndrome: a case series.

OBJECTIVE: The objective of this study was to determine the effect of peripheral nerve stimulation (PNS) on pain reduction for those with refractory subacromial impingement syndrome (SIS) and to evaluate the association with reduced disability, impairment, and safety. Our hypotheses are that PNS will be associated with a reduction in pain, impairment and disability, and improvement in quality of life while demonstrating safety. MATERIAL AND METHODS: Adults with shoulder pain of at least six months duration were recruited for a three-week treatment of percutaneous PNS applied through a percutaneous electrode to the axillary motor points of the deltoid muscle. Subjects were followed for 12 weeks after treatment. The primary outcome was the worst pain in the last week, and secondary outcomes included pain interference, the Disabilities of the Arm, Shoulder, and Hand questionnaire, shoulder abduction range of motion, and safety. Analysis was with a linear mixed model. RESULTS: Ten subjects were recruited. Longitudinal analysis demonstrated significant reduction in pain relative to baseline (F(1, 66) = 12.9, p < 0.01). After correcting for multiple comparisons, there were significant reductions at explantation and all follow-up time points when compared with baseline. There were also significant improvements in pain interference (F(1,65) = 15.0, p < 0.01), the Disabilities of the Arm, Shoulder, and Hand questionnaire (F(1,35) = 7.0, p = 0.01), and shoulder abduction range of motion (F(1,35) = 6.3, p = 0.02). CONCLUSION: Intramuscular PNS for chronic shoulder pain due to SIS is a safe treatment associated with pain reduction, lower pain interference with activities of daily living, reduced disability, and improved shoulder abduction. Pain reduction is maintained for at least 12 weeks after treatment.

Single-lead percutaneous peripheral nerve stimulation for the treatment of shoulder pain from subacromial impingement syndrome.

This case report demonstrates the feasibility of a single-lead peripheral nerve stimulation system for the treatment of pain secondary to chronic subacromial impingement syndrome. The participant was a 57-year-old man who experienced persistent pain from subacromial impingement syndrome for 20 months despite having undergone conservative therapy of steroid injection and physical therapy. After study enrollment, a single intramuscular lead was placed percutaneously into the deltoid muscle of the affected shoulder. He was treated 6 hours per day for 3 weeks and the lead was removed. The primary outcome measure was the Brief Pain Inventory (Short-form) Question 3 (BPI 3), which queries the worst pain in the last week on a 0-10 numerical rating scale. At baseline, BPI 3 was an 8. At the end of treatment and at 4 and 12 weeks after treatment, BPI 3 scores were 2, 0, and 0, respectively. Substantial improvements in shoulder impairment, quality of life, and shoulder disability measures were also observed. Additional studies are needed to further demonstrate safety and efficacy, determine optimal dose, define optimal prescriptive parameters, expand clinical indications, and demonstrate long-term effect.

Mobilization with movement and kinesiotaping compared with a supervised exercise program for painful shoulder: results of a clinical trial.

OBJECTIVE: The purpose of this study was to compare the efficacy of Mobilization with Movement (MWM) and kinesiotaping (KT) techniques with a supervised exercise program in participants with patients with shoulder pain. METHODS: Twenty subjects with shoulder pain were included if subjects were diagnosed by the referring physician with either rotator cuff lesion with impingement syndrome or impingement shoulder syndrome. Participants were randomly assigned to 1 of 2 groups after clinical and radiologic assessment: group 1 was treated with MWM and KT techniques, whereas group 2 was treated with a supervised exercise program. The main outcome measures were active pain-free shoulder abduction and flexion tested on days 0, 5, and 10. RESULTS: Improvement in active pain-free shoulder range of motion was significantly higher in the group treated with MWM and KT. Repeated-measures analysis of variance indicated significant effects of treatment, time, and treatment×time interaction. CONCLUSION: This study suggests that MWM and KT may be an effective and useful treatment in range of motion augmentation of subjects with rotator cuff lesion and impingement syndrome or impingement shoulder syndrome.

Changes in pain and pressure pain sensitivity after manual treatment of active trigger points in patients with unilateral shoulder impingement: a case series.

The aim of this case series was to investigate changes in pain and pressure pain sensitivity after manual treatment of active trigger points (TrPs) in the shoulder muscles in individuals with unilateral shoulder impingement. Twelve patients (7 men, 5 women, age: 25 ± 9 years) diagnosed with unilateral shoulder impingement attended 4 sessions for 2 weeks (2 sessions/week). They received TrP pressure release and neuromuscular interventions over each active TrP that was found. The outcome measures were pain during arm elevation (visual analogue scale, VAS) and pressure pain thresholds (PPT) over levator scapulae, supraspinatus infraspinatus, pectoralis major, and tibialis anterior muscles. Pain was captured pre-intervention and at a 1-month follow-up, whereas PPT were assessed pre- and post-treatment, and at a 1-month follow-up. Patients experienced a significant (P < 0.001) reduction in pain after treatment (mean ± SD: 1.3 ± 0.5) with a large effect size (d > 1). In addition, patients also experienced a significant increase in PPT immediate after the treatment (P < 0.05) and one month after discharge (P < 0.01), with effect sizes ranging from moderate (d = 0.4) to large (d > 1).A significant negative association (r(s) = -0.525; P = 0.049) between the increase in PPT over the supraspinatus muscle and the decrease in pain was found: the greater the decrease in pain, the greater the increase in PPT. This case series has shown that manual treatment of active muscle TrPs can help to reduce shoulder pain and pressure sensitivity in shoulder impingement. Current findings suggest that active TrPs in the shoulder musculature may contribute directly to shoulder complaint and sensitization in patients with shoulder impingement syndrome, although future randomized controlled trials are required.

The effectiveness of manual therapy in supraspinatus tendinopathy.

OBJECTIVES: The aim of this randomized controlled study was to assess the efficacy of manual therapy in the treatment of patients with symptomatic supraspinatus tendinopathy. METHODS: Seventy-seven patients (age range, 30 to 55 years) with supraspinatus tendinopathy, were randomly assigned to one of the three treatment groups: a supervised exercise program (Group 1), a supervised exercise program combined with joint and soft tissue mobilization (Group 2), or a home-based rehabilitation program (Group 3). All patients had rehabilitation for 12 weeks. Pain level was evaluated with a visual analogue scale (VAS) and the range of motion (ROM) was measured with a goniometer. The Modified American Shoulder and Elbow Surgery (MASES) score was used in functional assessment. Flexion, abduction, internal and external rotation strengths were measured with a manual muscle test. All patients were evaluated before, and at the 4th and 12th week of the rehabilitation. RESULTS: All groups experienced significant decrease in pain and an increase in shoulder muscle strength and function by both the 4th and 12th weeks of treatment (p<0.05). There was no significant difference between the groups in terms of function (p>0.05). However, the greatest improvement in functionality was found in Group 2. CONCLUSION: Supervised exercise, supervised and manual therapy, and home-based exercise are all effective and promising methods in the rehabilitation of the patients with subacromial impingement syndrome. The addition of an initial manual therapy may improve the results of the rehabilitation with exercise.

Additive effects of low-level laser therapy with exercise on subacromial syndrome: a randomised, double-blind, controlled trial.

The subacromial syndrome is the most common source of shoulder pain. The mainstays of conservative treatment are non-steroidal anti-inflammatory drugs and exercise therapy. Recently, low-level laser therapy (LLLT) has been popularized in the treatment of various musculoskeletal disorders. The aim of this study is to evaluate the additive effects of LLLT with exercise in comparison with exercise therapy alone in treatment of the subacromial syndrome. We conducted a randomised clinical study of 80 patients who presented to clinic with subacromial syndrome (rotator cuff and biceps tendinitis). Patients were randomly allocated into two groups. In group I (n = 40), patients were given laser treatment (pulsed infrared laser) and exercise therapy for ten sessions during a period of 2 weeks. In group II (n = 40), placebo laser and the same exercise therapy were given for the same period. Patients were evaluated for the pain with visual analogue scale (VAS) and shoulder range of motion (ROM) in an active and passive movement of flexion, abduction and external rotation before and after treatment. In both groups, significant post-treatment improvements were achieved in all parameters (P = 0.00). In comparison between the two groups, a significant improvement was noted in all movements in group I (P = 0.00). Also, there was a substantial difference between the groups in VAS scores (P = 0.00) which showed significant pain reduction in group I. This study indicates that LLLT combined exercise is more effective than exercise therapy alone in relieving pain and in improving the shoulder ROM in patients with subacromial syndrome.

Assessment of dynamic humeral centering in shoulder pain with impingement syndrome: a randomised clinical trial.

OBJECTIVES: Treatment for degenerative rotator cuff disease of the shoulder includes physiotherapy. Dynamic humeral centering (DHC) aims at preventing subacromial impingement, which contributes to the disease. The goal of this study was to assess the effectiveness of DHC. METHOD: 69 patients with shoulder pain and impingement syndrome were prospectively included in a single-centre randomised trial with a 12-month follow-up. Patients and assessor were blinded to the study hypothesis and treatment, respectively. DHC and non-specific mobilisation as control were performed for 6 weeks, in 15 supervised individual outpatient sessions, and patients performed daily home exercises. The planned primary outcome was the Constant score including subscores for pain, activity, mobility and strength at 3 months. Secondary outcomes were the Constant score and subscores at 12 months, and medication use for pain at 3 and 12 months. RESULTS: The DHC group did not differ from the control group in the total Constant score at 3 months. However, the DHC group showed a higher Constant subscore for pain (12.2 (SD 2.8) vs 9.9 (2.9), least square means difference 2.1, 95% CI 0.7 to 3.5, p=0.004). At 3 months, the DHC group also showed a higher rate of no medication use (96.7% vs 71%, proportional difference 25.7, 95% CI 3.7 to 51.9, p=0.012). There was no other intergroup difference. CONCLUSIONS: There was no difference in the total Constant score between DHC and controls. However, pain was improved at 3 months after DHC. The differences found in subscores for pain should be explored in future studies. Trial registration clinicaltrials.gov Identifier: NCT 01022775.

Clinical and MRI findings after high dosage medical exercise therapy in patients with long lasting subacromial pain syndrome: a case series on six patients.

UNLABELLED: SUMMARY BACKGROUND AND PURPOSE: The primary aim of this case series was to investigate the effect of a high dosage medical exercise therapy program on shoulder pain in patients with subacromial pain syndrome. SUBJECTS: Six subjects were assigned to a medical exercise therapy group. METHODS: They received three treatments a week over three months. Outcome measures were descriptions of the subacromial space including supraspinatus tendon diameter, function, pain, and active range of motion in the shoulder girdle. RESULTS: The subjects showed improvement posttest compared to pretest with respect to pain, function, range of motion, and isometric strength. An MRI demonstrated no change in tendon thickness after the treatment. Inflammatory signs such as fluid in the subacromial bursa decreased in some patients. DISCUSSION AND CONCLUSION: In patients with uncomplicated subacromial pain syndrome, high dosage medical exercise therapy might be an efficient treatment approach. The clinical effects might be explained by morphological changes in the subacromial space.

Contributions of myofascial pain in diagnosis and treatment of shoulder pain. A randomized control trial.

BACKGROUND: Rotator cuff tendinopathy and subacromial impingement syndrome present complex patomechanical situations, frequent difficulties in clinical diagnosis and lack of effectiveness in treatment. Based on clinical experience, we have therefore considered the existence of another pathological entity as the possible origin of pain and dysfunction. The hypothesis of this study is to relate subacromial impingement syndrome (SIS) with myofascial pain syndrome (MPS), since myofascial trigger points (MTrPs) cause pain, functional limitation, lack of coordination and alterations in quality of movement, even prior to a tendinopathy. MTrPs can coexist with any degenerative subacromial condition. If they are not taken into consideration, they could perpetuate and aggravate the problem, hindering diagnosis and making the applied treatments ineffective.The aims and methods of this study are related with providing evidence of the relationship that may exist between this condition and MPS in the diagnosis and treatment of rotator cuff tendonitis and/or SIS. METHOD/DESIGN: A descriptive transversal study will be made to find the correlation between the diagnosis of SIS and rotator cuff tendonitis, positive provocation test responses, the existence of active MTrPs and the results obtained with ultrasonography (US) and Magnetic Renonance Imaging (MRI). A randomized double blinded clinical trial will be carried out in experimental conditions: A Protocolized treatment based on active and passive joint repositioning, stabilization exercises, stretching of the periarticular shoulder muscles and postural reeducation. B. The previously described protocolized treatment, with the addition of dry needling applied to active MTrPs with the purpose of isolating the efficacy of dry needling in treatment. DISCUSSION: This study aims to provide a new vision of shoulder pain, from the perspective of MPS. This syndrome can, by itself, account for shoulder pain and dysfunction, although it can coexist with real conditions involving the tendons. TRIAL REGISTRATION: ISRCTN Number: 30907460.

The effect of local injections in hemiplegic shoulder pain: a prospective, randomized, controlled study.

OBJECTIVE: The aim of this study was to evaluate the effects of corticosteroid injections on hemiplegic shoulder pain and range of motion. DESIGN: Fifty-two stroke patients with shoulder pain were evaluated. Thirty-eight patients who fulfilled the criteria were assigned randomly into either injection or control groups. Transcutaneous electrical nerve stimulation and therapeutic exercise program were applied to both groups for 15 sessions. The patients in the injection group were administered either intra-articular or subacromial injections of corticosteroid and local anesthetic according to their pathology. The evaluations were performed before treatment and at the first and fourth weeks of treatment. Primary follow-up parameters were passive shoulder range of motion and verbal analog scale for shoulder pain; secondary follow-up parameters were modified Barthel index, Brunnstrom upper-extremity score, and modified Ashworth scale. RESULTS: In both groups, shoulder range of motion and shoulder pain scores showed significant improvement. When the two groups were compared, the improvement was more significant in the injection group. Barthel scores improved in both groups, and no difference was found between the groups. Brunnstrom upper-extremity and modified Ashworth scores revealed nonsignificant changes in both groups. CONCLUSIONS: Adding corticosteroid injection to conventional treatment in hemiplegic shoulder pain improved shoulder range of motion and decreased pain scores before treatment to the first and fourth weeks of treatment. Injection in hemiplegic shoulder pain is recommended in appropriate patients.

Treatment of myofascial trigger points in common shoulder disorders by physical therapy: a randomized controlled trial [ISRCTN75722066].

BACKGROUND: Shoulder disorders are a common health problem in western societies. Several treatment protocols have been developed for the clinical management of persons with shoulder pain. However available evidence does not support any protocol as being superior over others. Systematic reviews provide some evidence that certain physical therapy interventions (i.e. supervised exercises and mobilisation) are effective in particular shoulder disorders (i.e. rotator cuff disorders, mixed shoulder disorders and adhesive capsulitis), but there is an ongoing need for high quality trials of physical therapy interventions. Usually, physical therapy consists of active exercises intended to strengthen the shoulder muscles as stabilizers of the glenohumeral joint or perform mobilisations to improve restricted mobility of the glenohumeral or adjacent joints (shoulder girdle). It is generally accepted that a-traumatic shoulder problems are the result of impingement of the subacromial structures, such as the bursa or rotator cuff tendons. Myofascial trigger points (MTrPs) in shoulder muscles may also lead to a complex of symptoms that are often seen in patients diagnosed with subacromial impingement or rotator cuff tendinopathy. Little is known about the treatment of MTrPs in patients with shoulder disorders.The primary aim of this study is to investigate whether physical therapy modalities to inactivate MTrPs can reduce symptoms and improve shoulder function in daily activities in a population of chronic a-traumatic shoulder patients when compared to a wait-and-see strategy. In addition we investigate the recurrence rate during a one-year-follow-up period. METHODS/DESIGN: This paper presents the design for a randomized controlled trial to be conducted between September 2007 - September 2008, evaluating the effectiveness of a physical therapy treatment for non-traumatic shoulder complaints. One hundred subjects are included in this study. All subjects have unilateral shoulder pain for at least six months and are referred to a physical therapy practice specialized in musculoskeletal disorders of the neck-, shoulder-, and arm. After the initial assessment patients are randomly assigned to either an intervention group or a control-group (wait and see). The primary outcome measure is the overall score of the Dutch language version of the DASH (Disabilities of Arm, Shoulder and Hand) questionnaire. DISCUSSION: Since there is only little evidence for the efficacy of physical therapy interventions in certain shoulder disorders, there is a need for further research. We found only a few studies examining the efficacy of MTrP therapy for shoulder disorders. Therefore we will perform a randomised clinical trial of the effect of physical therapy interventions aimed to inactivate MTrPs, on pain and impairment in shoulder function in a population of chronic a-traumatic shoulder patients. We opted for an intervention strategy that best reflects daily practice. Manual high velocity thrust techniques and dry-needling are excluded. Because in most physical therapy interventions, blinding of the patient and the therapist is not possible, we will perform a randomised, controlled and observer-blinded study. TRIAL REGISTRATION: This randomized clinical trial is registered at current controlled trials ISRCTN75722066.

Acupuncture and rehabilitation of the painful shoulder: study protocol of an ongoing multicentre randomised controlled clinical trial [ISRCTN28687220].

BACKGROUND: Although the painful shoulder is one of the most common dysfunctions of the locomotor apparatus, and is frequently treated both at primary healthcare centres and by specialists, little evidence has been reported to support or refute the effectiveness of the treatments most commonly applied. According to the bibliography reviewed, physiotherapy, which is the most common action taken to alleviate this problem, has not yet been proven to be effective, because of the small size of sample groups and the lack of methodological rigor in the papers published on the subject. No reviews have been made to assess the effectiveness of acupuncture in treating this complaint, but in recent years controlled randomised studies have been made and these demonstrate an increasing use of acupuncture to treat pathologies of the soft tissues of the shoulder. In this study, we seek to evaluate the effectiveness of physiotherapy applied jointly with acupuncture, compared with physiotherapy applied with a TENS-placebo, in the treatment of painful shoulder caused by subacromial syndrome (rotator cuff tendinitis and subacromial bursitis). METHODS/DESIGN: Randomised controlled multicentre study with blind evaluation by an independent observer and blind, independent analysis. A study will be made of 465 patients referred to the rehabilitation services at participating healthcare centres, belonging to the regional public health systems of Andalusia and Murcia, these patients presenting symptoms of painful shoulder and a diagnosis of subacromial syndrome (rotator cuff tendinitis and subacromial bursitis). The patients will be randomised into two groups: 1) experimental (acupuncture + physiotherapy); 2) control (TENS-placebo + physiotherapy); the administration of rescue medication will also be allowed. The treatment period will have a duration of three weeks. The main result variable will be the change produced on Constant's Shoulder Function Assessment (SFA) Scale; as secondary variables, we will record the changes in diurnal pain intensity on a visual analogue scale (VAS), nocturnal pain intensity on the VAS, doses of non-steroid anti-inflammatory drugs (NSAIDs) taken during the study period, credibility scale for the treatment, degree of improvement perceived by the patient and degree of improvement perceived by the evaluator. A follow up examination will be made at 3, 6 and 12 months after the study period has ended. Two types of population will be considered for analysis: per protocol and per intention to treat. DISCUSSION: The discussion will take into account the limitations of the study, together with considerations such as the choice of a simple, safe method to treat this shoulder complaint, the choice of the control group, and the blinding of the patients, evaluators and those responsible for carrying out the final analysis.

Scapular muscle tests in subjects with shoulder pain and functional loss: reliability and construct validity.

BACKGROUND AND PURPOSE: Scapular muscle performance evaluated with a handheld dynamometer (HHD) has been investigated only in people without shoulder dysfunction for test-retest reliability of data obtained with a single scapular muscle test. The purpose of this study was to assess the reliability, error, and validity of data obtained with an HHD for 4 scapular muscle tests in subjects with shoulder pain and functional loss. SUBJECTS AND METHODS: Subjects (N=40) with shoulder pain and functional loss were tested by measuring the kilograms applied with an HHD during 3 trials for muscle tests for the lower trapezius, upper trapezius, middle trapezius, and serratus anterior muscles. Concurrently, surface electromyography (sEMG) data were collected for the 4 muscles. The same procedures were performed 24 to 72 hours after the initial testing by the same tester. Muscle tests were performed 3 times, and the results were averaged for data analysis. RESULTS: Intraclass correlation coefficients for intratester reliability of measurements of isometric force obtained using an HHD ranged from .89 to .96. The standard error of the measure (90% confidence interval [CI]) ranged from 1.3 to 2.7 kg; the minimal detectable change (90% CI) ranged from 1.8 to 3.6 kg. Construct validity assessment, done by comparing the amounts of isometric muscle activity (sEMG) for each muscle across the 4 muscle tests, revealed that the muscle activity of the upper trapezius and lower trapezius muscles was highest during their respective tests. Conversely, the isometric muscle activity of the middle trapezius and serratus anterior muscles was not highest during their respective tests. DISCUSSION AND CONCLUSION: In people with shoulder pain and functional loss, the intrarater reliability and error over 1 to 3 days were established using an HHD for measurement of isometric force for the assessment of scapular muscle performance. Error values can be used to make decisions regarding individual patients. Construct validity was established for the lower and upper trapezius muscle tests; therefore, these tests are advocated for use. However, construct validity was not demonstrated for the serratus anterior and middle trapezius muscle tests as performed in this study. Further investigation of these muscle tests is warranted.