Rotator Cuff-Related Shoulder Pain: Is It Time to Reframe the Advice, "You Need to Strengthen Your Shoulder"?

SYNOPSIS: Progressive resistance exercise, in isolation or in combination with other noninvasive therapies such as therapeutic touch, is the first-line approach to managing nontraumatic rotator cuff-related shoulder pain (RCRSP). Resistance exercise may be effective for people with RCRSP secondary to improving mechanical features of the shoulder, including strength, kinematics, and muscle timing and activation. However, strength gains are often small and clinically unimportant when measured during clinical trials. In this Viewpoint, we argue that clinicians should (1) continue to prescribe resistance exercise when managing RCRSP, and (2) embrace the broad biological mechanisms underpinning the efficacy of resistance exercise. Any benefit is governed by more than simple mechanical changes. The clinical message must go beyond the idea that the patient's weak, deconditioned, or frail shoulder is the basis of his or her pain, and all the patient needs to do is to get strong. J Orthop Sports Phys Ther 2021;51(4):156-158. doi:10.2519/jospt.2021.10199.

Decreased Synovial Fluid Biomarkers Levels Are Associated with Rehabilitation of Function and Pain in Rotator Cuff Tear Patients Following Electroacupuncture Therapy.

BACKGROUND The aim of this study was to assess inflammatory cytokines levels in synovial fluid (SF) before and after electroacupuncture (EA) treatment and to explore whether these biomarkers are associated with function of rotator cuff tear (RCT) patients. MATERIAL AND METHODS We recruited 54 patients with RCT and separated them into an EA group and a control group. The SF biomarker levels were detected at baseline and at 6-week and 6-month follow-up. The symptomatic severity was evaluated by visual analog scale (VAS), Constant-Murley score, and American Shoulder and Elbow Surgeons score (ASES). We also investigated the correlation between symptomatic severity and biomarker levels in SF of the shoulder joint. RESULTS The reductions in VAS and improved functional score (ASES and Constant-Murley score) were significantly different between the 2 groups, and SF biomarker concentrations were significantly lower in the EA group. IL-1ß levels were significantly negatively correlated with Constant-Murley score (r=-0.73, P=0.04) and ASES score (r=-0.59, P<0.001) and positively correlated with VAS scores (r=0.81, P=0.004). IL-6 levels were significantly negatively correlated with Constant-Murley score (r=-0.67, P=0.03) and positively correlated with VAS score (r=0.7, P=0.01). MMP-1 levels were significantly negatively correlated with ASES score (r=-0.57, P<0.001). CONCLUSIONS The biomarkers in SF were directly associated with shoulder pain and shoulder function in rotator cuff tear. EA, as a safe and effective conservative therapy, obviously decreased the level of inflammatory cytokines in RCT patients, accompanied by a reduction in shoulder pain and improved function.

Rotator CUFF disorders: A survey of current physiotherapy practice in Belgium and the Netherlands.

BACKGROUND: Disorders of the rotator cuff are a common musculoskeletal pain presentation in the general population, and treatment by a physiotherapist is often prescribed. In 2011, 2016, surveys of physiotherapy practice in the United Kingdom (UK) were performed, which reported that advice and exercise were the most common treatment strategies used. The aim of this current survey was to examine current physiotherapy practice in Belgium and The Netherlands, with consideration of differences between physiotherapists who were members of a shoulder network and physiotherapists who were not. METHODS: During February/March 2018, a cross-sectional online survey was conducted in Belgium and The Netherlands. RESULTS: 505 physiotherapists completed the survey. Advice (n = 362/505), isotonic exercises (n = 302/505) and scapular stabilisation exercises (n = 359/505) were the most common treatment modalities for patients with rotator cuff disorders. Physiotherapists not part of a shoulder network group more commonly integrated mobilization (n = 66/254 SN, n = 125/251 N-SN), electrotherapy (n = 1/254 SN, n = 19/251 N-SN) and massage (n = 48/254 SN, n = 89/251 N-SN) compared to those who were member of the group. CONCLUSION: Advice and exercise were the most common treatment prescriptions, which aligns with recommendations from current research evidence. Practice differs between physiotherapists involved with a shoulder network group compared to those who are not.

Terapia de juicio de lateralidad e imaginería de movimiento y ejercicios de activación muscular selectiva glenohumerales en sujetos con ruptura masiva del manguito rotador: serie de casos / Therapy of judgment of laterality and imagenery of movement and exercises of selective muscular activation glenohumeral in subjects with massive rupture of the rotating sleeve: case series

Introducción: El desgarro masivo del maguito rotador (DMMR) es una condición clínica degenerativa que corresponde a una ruptura de 5 cm, o una que compromete a dos o más tendones del manguito rotador (MR), generando pérdida de funcionalidad y dolor incapacitante. Objetivo: Describir los cambios en el dolor y función de hombro posterior a un programa de 6 semanas de terapia de juicio de lateralidad e imaginería de movimiento y ejercicios de activación selectiva glenohumerales en sujetos con rotura masiva del manguito rotador. Métodos: Este estudio es una investigación descriptiva y diseño serie de casos, con una muestra de 50 participantes con diagnóstico de ruptura masiva de manguito rotador. Los pacientes realizaron un programa de ejercicios selectivos glenohumerales más terapia de juicio de lateralidad e imaginería de movimiento durante 6 semanas. Se midieron las variables de función, dolor, ROM de abducción y flexión de hombro, a la sexta semana y al sexto mes de evolución. Resultados: Existen diferencias significativas en la intensidad del dolor, función de hombro, AROM de flexión y AROM de abducción de hombro, posterior a la intervención (p < 0,05). Existen diferencias estadísticamente significativas para todas las medidas de resultados entre la intervención y el sexto mes de seguimiento (p < 0,05). Solo el dolor presentó diferencias estadísticamente significativas entre la sexta semana y el sexto mes de seguimiento (p = 0,01). Conclusión: La aplicación de la terapia de juicio de lateralidad e imaginería de movimiento adicionada a un programa de ejercicios selectivos estabilizadores glenohumerales durante 6 semanas podría mejorar la función de hombro, disminuir el dolor y aumentar los AROM de flexión y abducción de hombro en pacientes con ruptura masiva del manguito rotador

Introduction: Massive tear of the rotator cuff (DMMR) is a degenerative clinical condition, which corresponds to a 5 cm rupture, or one that compromises two or more tendons of the rotator cuff (MR), generating loss of functionality and disabling pain. Objective: To describe changes in pain and shoulder function following a 6-week program of lateral-imaging and motion imaging therapy and selective glenohumeral activation exercises in subjects with massive rotator cuff tears. Methods: This study is a descriptive research and design of a series of cases, with a sample of 50 participants with diagnosis of rotator cuff mastication. Patients underwent a glenohumeral selective exercise program plus laterality and motion imaging therapy for 6 weeks. The variables of function, pain, abduction ROM and shoulder flexion were measured at sixth week and sixth month of evolution. Results: There were significant differences in pain intensity, shoulder function, AROM flexion and shoulder abduction AROM, after the intervention (p > 0.05). Statistically significant differences were found for all outcome measures between the intervention and the sixth follow-up month (p < 0.05). Only the pain of the statistically significant differences between the sixth week and the sixth month of follow-up (p = 0.01). Conclusion: The application of laterality trial therapy and motion imaging added to a program of selective exercises stabilizadores glenohumerales during 6 weeks, could improve shoulder function, decrease pain and increase AROM flexion and shoulder abduction in patients with massive rupture of the rotator cuff

The clinical effect of rehabilitation following arthroscopic rotator cuff repair: A meta-analysis of early versus delayed passive motion.

BACKGROUND: The argument on the recommended rehabilitation protocol following arthroscopic rotator cuff repair remains to be resolved. So this meta-analysis was presented to evaluate the differences of clinical effects between the 2 distinct rehabilitation protocols after arthroscopic rotator cuff repair. METHODS: The PubMed, Cochrane Library, Web of Science, and EMBASE were systematically searched. Only randomized controlled trials (RCTs) published up to July 25, 2017, comparing early passive motion (EPM) versus delayed passive motion (DPM) rehabilitation protocols following arthroscopic rotator cuff repair were identified. The primary outcomes included range of motion and healing rate, while the secondary outcomes were Constant score, American Shoulder and Elbow Society (ASES) score, and Simple Shoulder Test (SST) score. The exclusion criteria contained biochemical trials, reviews, case reports, retrospective studies, without mention about passive motion exercise, no assessment of outcomes mentioned above, and no comparison of EPM and DPM rehabilitation protocols. RESULTS: Eight RCTs with 671 patients were enrolled in this study. The EPM resulted in improved shoulder forward flexion at short term, mid-term, and long-term follow-ups. The EPM group was superior to the DPM group in terms of external rotation (ER) at short-term and mid-term follow-ups. However, the DPM performed better long-term ASES score. These 2 protocols were equivalent in terms of ER at long term, ASES score at mid-term, SST score, Constant score, and healing rate. After excluding 2 RCTs that examined only small- and medium-sized tears, the pooled results of healing rate decreased from 82.4% to 76.6% in the EPM and 86.9% to 85.9% in the DPM. CONCLUSION: The meta-analysis suggests that the EPM protocol results in superior ROM recovery after arthroscopic rotator cuff repair but may adversely affect the shoulder function, which should be supported by further research. The healing rate at long-term follow-up is not clearly affected by the type of rehabilitation, but the EPM protocol might result in lower rates of tendon healing in the shoulder with large-sized tendon tears.

Efficacy of transcutaneous electrical nerve stimulation for rotator cuff tendinopathy: a systematic review.

OBJECTIVE: To perform a systematic review on the efficacy of transcutaneous electrical nerve stimulation (TENS) for the treatment of rotator cuff tendinopathy in adults. METHODS: A literature search was conducted in four databases (CINAHL, Embase, PubMed and PeDRO) for randomised controlled trials published from date of inception until April 2015, comparing the efficacy of TENS for the treatment of rotator cuff tendinopathy with placebo or any other intervention. Risk of bias was evaluated using the Cochrane risk of bias tool. Results were summarised qualitatively. RESULTS: Six studies were included in this review. The mean methodological score was 49% (standard deviation 16%), indicating an overall high risk of bias. One placebo-controlled trial reported that a single TENS session provided immediate pain reduction for patients with rotator cuff tendinopathy, but did not follow the participants in the short, medium or long term. Two trials that compared ultrasound therapy with TENS reported discrepancy and contradictory results in terms of pain reduction and shoulder range of motion. Corticosteroid injections were found to be superior to TENS for pain reduction in the short term, but the differences were not clinically important. Other studies included in this review concluded that TENS was not superior to heat or pulsed radiofrequency. CONCLUSION: Due to the limited number of studies and the overall high risk of bias of the studies included in this review, no conclusions can be drawn on the efficacy of TENS for the treatment of rotator cuff tendinopathy. More methodologically sound studies are needed to document the efficacy of TENS. Until then, clinicians should prefer other evidence-based rehabilitation interventions proven to be efficacious to treat patients with rotator cuff tendinopathy.