The effects of telemedicine on Rotator cuff-related shoulder function and pain symptoms: a meta-analysis of randomized clinical trials.

BACKGROUND: The effectiveness of telemedicine in aiding rehabilitation exercises among patients with rotator cuff (RC) disorders remains unknown. Therefore, this meta-analysis aimed to assess the effectiveness of telemedicine in patients with RC disorders. METHODS: Randomized clinical trials (RCTs) on the effectiveness of telemedicine in patients with RC disorders were summarized through a meta-analysis. A systematic search for these RCTs was conducted in PubMed, Cochrane, Embase, and Web of Science databases up to July 2024. Statistical analysis was performed using Stata 16. Publication bias was estimated with the funnel plot and Egger's test. RESULTS: Ten studies involving 497 participants (telemedicine group = 248 and conventional group = 249) were enrolled, with follow-up durations ranging from 8 weeks to 48 weeks. Functional outcomes measured by the Constant-Murley score were markedly improved after treatment in the telemedicine group compared to the conventional group. Moreover, compared to conventional treatment, telemedicine significantly improved shoulder function evaluated by Quick Disabilities of the Arm, Shoulder, and Hand Score, relieved pain assessed by visual analog scale pain score, and improved range of motion after treatment and in the final follow-up period. CONCLUSION: Telemedicine has demonstrated potential in alleviating pain and enhancing shoulder function and motion in patients with RC injuries. It may be a feasible intervention for rehabilitation exercises. Further research with a large sample size and standardized treatment is warranted to validate these findings.

Pain, function and peritendinous effusion improvement after dry needling in patients with long head of biceps brachii tendinopathy: a single-blind randomized clinical trial.

INTRODUCTION: Long head of biceps brachii tendinopathy, a frequent source of anterior shoulder pain, may lead to discomfort and diminished function. The objective of this study is to assess the efficacy of dry needling and transcutaneous electrical nerve stimulation in these patients. PATIENTS AND METHODS: Thirty patients were randomized into dry needling and transcutaneous electrical nerve stimulation groups and assessed before treatment, 8 and 15 days after treatment using a visual analogue scale, shoulder pain and disability index, pressure pain threshold, tissue hardness, and biceps peritendinous effusion. RESULTS: Both treatments significantly reduced the visual analogue scale in immediate (p < 0.001), short-term (p < 0.01), and medium-term effects (p < 0.01). Dry needling outperformed transcutaneous electrical nerve stimulation for the pain (p < 0.01) and disability (p < 0.03) subscales of the shoulder pain and disability index in the short-term and medium-term effects, respectively. Pressure pain threshold increased after both treatments but didn't last beyond 8 days. Neither treatment showed any improvements in tissue hardness of the long head of biceps brachii muscle. Notably, only the dry needling group significantly reduced biceps peritendinous effusion in both short-term and medium-term effects (p < 0.01). CONCLUSIONS: Dry needling showed non-inferior results to transcutaneous electrical nerve stimulation in reducing pain and disability and demonstrated even superior results in reducing biceps peritendinous effusion (see Graphical Abstract). TRIAL REGISTRATION: The Institutional Review Board of the China Medical University Hospital (CMUH107-REC2-101) approved this study, and it was registered with Identifier NCT03639454 on ClinicalTrials.gov.

Both dry needling and transcutaneous electrical nerve stimulation effectively reduced pain in the long head of biceps brachii tendinopathy.Dry needling outperformed transcutaneous electrical nerve stimulation in short-term and medium-term pain and disability relief, respectively.Dry needling demonstrated superior results in reducing biceps peritendinous effusion compared to transcutaneous electrical nerve stimulation.

[Long head of the biceps pathologies : diagnosis and treatments]. / Diagnostics et traitements des pathologies du long chef du biceps.

The long head of the biceps (LHB) tendon is a common source of shoulder pain. Often associated with other injuries, the tendon can alone be responsible of the symptoms. Spontaneous rupture has been observed to allow for pain relief. The spectrum of LHB lesions is broad. Repetitive motion, carrying heavy loads, have been associated with diagnosis. Specific tests have been described to diagnose biceps injuries, their implementation can remain difficult in the presence of associated pathologies. The combination of a history and clinical examination with the use of targeted imaging is required to establish the diagnosis. The management of bicipital pathologies is frequently carried out following main surgical procedures. Isolated management of biceps lesions can provide a satisfactory result when a comprehensive procedure cannot be performed.

Le tendon du long chef du biceps (LCB) est une source fréquente de douleurs à l'épaule. Souvent associé à d'autres atteintes, il peut être seul responsable de la symptomatologie et sa rupture peut apporter un soulagement « salvateur ¼. Le spectre des lésions du LCB est large. Les mouvements répétés de lancer, tirer ou le port de charges ont été associés à une atteinte du LCB. De nombreux examens spécifiques ont été développés afin de diagnostiquer ces lésions. Leur réalisation peut rester un défi clinique en cas de pathologies associées. Une anamnèse, un examen clinique ainsi qu'une imagerie ciblée sont requis pour établir le diagnostic. La prise en charge de ces lésions est souvent réalisée durant des procédures chirurgicales principales. Leur prise en charge isolée permet un résultat fonctionnel satisfaisant lorsqu'un geste exhaustif ne peut être réalisé.

Combined Prolotherapy and Physical Therapy in a 60-Year-Old Man with Left Shoulder Pain and Limited Range of Motion (Frozen Shoulder) Following a Hemiplegic Stroke: A Case Report.

BACKGROUND Frozen shoulder with limited range of motion is a common and debilitating condition that occurs on the affected side following a stroke. The effectiveness of therapy was reported to be negatively correlated with the complexity of pathogenesis. Prolotherapy involves injection into the joint of a small amount of irritant, such as dextrose, which enhances tissue strength and facilitates healing by targeting joint spaces. The treatment is used to relieve pain. This report describes the effects of combined prolotherapy and physical therapy in a 60-year-old man with left shoulder pain and limited range of motion (frozen shoulder) following a hemiplegic stroke. CASE REPORT A 60-year-old man had left shoulder pain and limited ROM for 9 months, which disrupted daily life, with a NRS of 7 and a DASH score of 58.3%. The patient had an ischemic stroke 1 year ago, with left extremity weakness. On physical examination, joint active ROM was significantly restricted and the joint was tender upon palpation. Therapy is carried out using prolotherapy combined with exercise and physical therapy for 6 weeks. At the 6-week follow-up, he had good outcomes for pain relief, increasing ROM, and quality of life. CONCLUSIONS The use of prolotherapy with physical therapy may be an effective treatment for painful frozen shoulder following a hemiplegic stroke.

Effects of a web application based on multimedia animations to support therapeutic exercise for rotator cuff-related shoulder pain: protocol for an open-label randomised controlled trial.

INTRODUCTION: Rotator cuff-related shoulder pain (RCRSP) is the most common cause of shoulder pain. Currently, exercise is proposed as the first-line treatment for patients suffering from RCRSP. However, adherence to therapeutic exercise programmes can be poor in the long term in a home setting. The aim of this study is to evaluate the effects of adding video animations to a traditional paper-based exercise programme. METHODS AND ANALYSIS: A single-centre, randomised, open-labelled clinical trial will be conducted in a hospital in Spain. Adults aged between 18 and 80 years diagnosed with RCRSP who meet the eligibility criteria will be included. Patients (n=132) will be randomised into two groups, with both receiving paper-based exercises, and the experimental group will also be provided with video animations. The participants will receive seven face-to-face physical therapy sessions and will be asked to perform the exercises at home for 6 months. The primary outcome measure will be the Shoulder Pain and Disability Index, measured at baseline, 3 weeks, 3 months (primary analysis) and 6 months. Secondary outcomes will be the patient's pain intensity during the last week (rest, during movement and at night); expectations of improvement; satisfaction with treatment; impression of improvement; perceived usability, usefulness and satisfaction of multimedia animations; and adherence to exercises. Generalised least squares regression models with an autoregressive-moving average lag one correlation structure will be implemented, with an intention-to-treat analysis. ETHICS AND DISSEMINATION: This study has been approved by the ethics committee of Hospital Universitario Fundación Alcorcón (Madrid, Spain), reference number CI18/16. All participants will sign an informed consent. The results will be published in a peer-reviewed scientific journal. TRIAL REGISTRATION: ClinicalTrials.gov, NCT05770908.

Factors predicting long-term outcomes following physiotherapy in patients with subacromial pain syndrome: a secondary analysis.

BACKGROUND: Although patients with shoulder complaints are frequently referred to physiotherapy, putative predictive factors for outcomes are still unclear. In this regard, only a limited amount of scientific data for patients with subacromial pain syndrome exist, with inconsistent results. An improved knowledge about the ability of baseline variables to predict outcomes could help patients make informed treatment decisions, prevent them from receiving ineffective treatments, and minimize the risk of developing chronic pain. AIM: The aims of this secondary longitudinal analysis are threefold: First, to investigate baseline differences between patients with and without successful long-term outcomes following physiotherapy. Second, to compare the predictive ability of two sets of putative predictive variables on outcomes, one based on the literature and one based on the data of the original trial. Third, to explore the contribution of short-term follow-up data to predictive models. METHODS: Differences between responders and nonresponders were calculated. The predictive ability of variables defined through literature and of variables based on the Akaike Information Criterion (AIC) from the original trial dataset on the Shoulder Pain and Disability Index and the Patients' Global Impression of Change at the one-year follow-up were analyzed. To test the robustness of the results, different statistical models were used. To investigate the contribution of follow-up data to prediction, short-term data were included in the analyses. RESULTS: A sample of 87 patients with subacromial pain syndrome was analyzed. 77% (n = 67) of these participants were classified as responders. Higher expectations and short-term change scores were positive, and higher fear avoidance beliefs, greater baseline disability and pain levels were negative predictors of long-term outcomes in patients with subacromial pain syndrome. CONCLUSIONS: Although our results are in line with previous research and support the use of clinical factors for prediction, our findings suggest that psychological factors, especially patient expectations and fear avoidance beliefs, also contribute to long-term outcomes and should therefore be considered in the clinical context and further research. However, the hypotheses and recommendations generated from our results need to be confirmed in further studies due to their explorative nature. TRIAL REGISTRATION: The original trial was registered at Current Controlled Trials under the trial registration number ISRCTN86900354 on March 17, 2010.

Radiofrequency ablation for shoulder pain: an updated systematic review.

BACKGROUND: Radiofrequency ablation (RFA) is a treatment modality that has been increasingly used for the management of chronic shoulder pain. Serious conditions that can identified as the cause of chronic shoulder pain include rotator cuff disorders, adhesive capsulitis, osteoarthritis, glenohumeral instability, and acromioclavicular joint disorders. Treatment of chronic shoulder pain typically consists of physical therapy, oral and topical medications, intra-articular corticosteroid injections, and even surgery. The aim of this study was to examine the most recent primary and secondary outcomes of RFA for chronic shoulder pain. METHODS: A systematic review was conducted using three different databases including PubMed, MEDLINE, and the Cochrane Database. The key concepts of "radiofrequency ablation" and "shoulder pain" were used. The search took place in June 2023, and it included articles from the past 20 years. RESULTS: Of the 396 articles found, 29 were included in the review. Most studies focused on reduction in pain scores, duration of relief, function, and patient satisfaction. In several studies, RFA was compared to conservative options such as physical therapy or corticosteroid injections. CONCLUSIONS: Overall, RFA shows positive outcomes in terms of the management of chronic shoulder pain. Therefore, RFA can serve as another treatment option for patients who fail conservative management or are not strong surgical candidates. Understanding the outcomes of RFA for chronic shoulder pain can provide patients and clinicians with evidence for the most appropriate treatment.

Arthro-distension with early and intensive mobilization for shoulder adhesive capsulitis: A randomized controlled trial.

BACKGROUND: There are several therapeutic options for the management of shoulder adhesive capsulitis (AC). The superiority of arthro-distension over intra-articular steroid injection (ISI) for AC remains controversial. OBJECTIVES: To evaluate the efficacy of a single arthro-distension procedure combined with early and intensive mobilization (ADM) and physiotherapy, versus ISI and physiotherapy, in people with AC lasting ≥3 months. METHODS: This was a prospective, 2 parallel-group, 2-center, observer-blind randomized controlled trial conducted in tertiary care settings. Adults with AC were randomly assigned to the treatment or control group. Efficacy was assessed using the self-administered Shoulder Pain and Disability Index (SPADI). Total, pain and disability SPADI scores 15 days, 6 weeks, and 3, 6 and 12 months after the procedure (total SPADI at 15 days: primary outcome; other outcomes were secondary) were compared between groups using analysis of covariance (ANCOVA). A post hoc analysis stratified on the initial range of passive glenohumeral abduction, which had not been pre-specified, was conducted. RESULTS: There were 33 participants in each group. Both groups improved over time. Mean (SD) total SPADI score at 15 days was 33.8 (19.6) in the treatment group and 32.8 (17.5) in the control group, p = 0.393. There were no significant differences for any variables in the overall sample. The post hoc analysis found ADM to be associated with a significant decrease in total SPADI score at 15 days compared with ISI (p = 0.049) in individuals with initial passive glenohumeral abduction >45°. CONCLUSIONS: The effects of ADM on pain and function were not statistically different from those of ISI. However, ADM may be useful in individuals with initial passive glenohumeral abduction >45°. DATABASE REGISTRATION: NCT00724113.

Patient experiences of hydrodistension as a treatment for frozen shoulder: A longitudinal qualitative study.

BACKGROUND: Frozen shoulder is a condition associated with severe shoulder pain and loss of function impacting on a persons' physical and mental health. Hydrodistension treatment that has been widely adopted within the UK National Health Service for the condition. However, evidence of clinical effectiveness and understanding of the patient experiences of this treatment are lacking. This study explored the experiences of people with a frozen shoulder who received hydrodistension treatment. METHODS: A qualitative design with repeat semi-structured interviews was used to explore participants' experiences of hydrodistension treatment. Participants were interviewed 2-4 weeks and again at 8-10 weeks after treatment. Interviews were audio-recorded and transcribed verbatim. Findings were analysed using an inductive thematic analysis framework. The study is reported in accordance with the consolidated criteria for reporting qualitative (COREQ) research. RESULTS: 15 participants were interviewed online or over the phone. Three themes were identified: 'Preparing for and having a hydrodistension', 'Physiotherapy after hydrodistension', and 'Outcome of hydrodistension '. Participants believed hydrodistension would benefit them, was well tolerated by many, and the effects were apparent to most within the first week. Physiotherapy still seemed to be valued to support recovery beyond this timepoint, despite these early effects. Some participant's experienced harms including severe procedural pain and blood sugar dysregulation. CONCLUSION: This is the first study to investigate the experiences of people who undergo hydrodistension for frozen shoulder. Hydrodistension appears an acceptable treatment to participants with a frozen shoulder, acceptability is enhanced through adequate shared decision making. Further high-quality research is required to understand the comparative effectiveness of hydrodistension as a treatment for frozen shoulder, including adverse events, and the benefit of treatment by a physiotherapist after hydrodistension.

FITT Odyssey: A Scoping Review of Exercise Programs for Managing Rotator Cuff-Related Shoulder Pain.

OBJECTIVE: To summarize the FITT (frequency, intensity, time, type), components of exercise programs included in randomized controlled trials (RCTs) that compared 2 or more programs for managing rotator cuff-related shoulder pain (RCRSP). DESIGN: Scoping review. LITERATURE SEARCH: Electronic searches were conducted up to May 2023. STUDY SELECTION CRITERIA: RCTs comparing the effects of 2 or more types of exercise programs, differing in prescription according to the FITT principle, in people with RCRSP. DATA SYNTHESIS: We extracted data from each trial report so that we could answer items 1 to 10 and 13 to 15 from the Consensus on Exercise Reporting Template (CERT). Descriptive analysis of the exercise programs was performed by summarizing and presenting the FITT characteristics, and other relevant CERT characteristics (material, provider, delivery, tailoring). RESULTS: FITT characteristics from 46 exercise programs included in 22 trials were extracted. The exercise programs were divided into 4 categories (defined in accordance to the original authors' description and proposed rationale): motor control (n = 8), scapula-focused (n = 7), eccentric (n = 8), and nonspecific exercise programs (n = 28). Five programs were allocated to 2 different categories. The different program types had similar parameters. Exercise programs frequency ranged from 2 to 7 times per week, dose ranged from 1 to 3 sets and 4 to 30 repetitions per sets, and exercise program duration ranged from 4 to 16 weeks. CONCLUSION: There was considerable variability in the parameters used to prescribe exercises for RCRSP. Clinicians seeking guidance on FITT parameters derived from trials should do so cautiously because there was no one-size-fits-all approach. J Orthop Sports Phys Ther 2024;54(8):513-529. Epub 4 June 2024. doi:10.2519/jospt.2024.12452.

The Efficacy of Exercise Therapy for Rotator Cuff-Related Shoulder Pain According to the FITT Principle: A Systematic Review With Meta-analyses.

OBJECTIVE: To evaluate the efficacy of exercise interventions with differing frequency, intensity, type, and time (FITT) on shoulder pain and disability in people with rotator cuff-related shoulder pain (RCRSP). DESIGN: Intervention systematic review with meta-analyses. LITERATURE SEARCH: Electronic searches were conducted up to May 2023. STUDY SELECTION CRITERIA: Randomized controlled trials (RCTs) comparing the effects of exercise interventions differing in prescription according to the FITT principle, in people with RCRSP. DATA SYNTHESIS: Separate meta-analyses comparing exercise type (specific versus nonspecific exercise) and intensity (high versus low) were conducted. Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) was used to evaluate the certainty of evidence. RESULTS: Twenty-two RCTs (n = 1281) were included. There was moderate-certainty evidence that motor control exercise programs, when compared to nonspecific exercise programs, significantly reduced disability in the short (SMD: -0.29; 95% CI: -0.51, -0.07; n = 323; 7 RCTs) and medium terms (SMD: -0.33; 95% CI: -0.57, -0.09; n = 286; 5 RCTs), but not pain in the short term (SMD: -0.19; 95% CI: -0.41, 0.03; n = 323; 7 RCTs). Uncertainties remained regarding other exercise types (eccentric and scapula-focused exercise programs) versus nonspecific exercise programs, and exercise intensity due to low- to very low-certainty evidence. No trials were identified that compared different frequencies or times. CONCLUSION: For adults with RCRSP, motor control exercise programs were probably slightly superior to nonspecific exercise programs. However, it is unclear if the effects were due to motor control exercise or to other program characteristics such as progression and tailoring. J Orthop Sports Phys Ther 2024;54(8):499-512. Epub 7 June 2024. doi:10.2519/jospt.2024.12453.

Effectiveness of a joint mobilizations protocol for shoulder subacromial pain syndrome: A pilot study.

BACKGROUND: Subacromial pain syndrome (SPS) is the most frequent shoulder pathology. The aims of this prospective randomized study were to evaluate the effects of some specific shoulder joint mobilizations ("spin correction"), and the effectiveness of a rehabilitation program, named Shoulder Global Concept, in SPS patients. METHODS: 45 patients with SPS were randomly assigned to two groups, to benefit from a different first session of mobilizations: the experimental group received all specific mobilizations, while the control group received the same program but without the spin correction mobilizations. The second session was identical for both groups, with all specific mobilizations. Before and after the first two sessions, range of motion (ROM) in flexion, abduction, external and internal rotations, pain and functional status with Constant score and Quick Dash were evaluated. Evaluation was repeated with 24 patients after 11 rehabilitation sessions. Rehabilitation with Shoulder Global Concept included 13 mobilizations aiming at improving the ROM with passive and active-assisted mobilizations, static stretching, and muscle strengthening. RESULTS: All ROM were improved at the end of the first session for both groups, but significantly more in the experimental group for glenohumeral (GH) abduction and external rotation (p < 0.05). Functional scores, pain and strength were significantly improved after 11 rehabilitation sessions with the Shoulder Global Concept. CONCLUSION: This manual therapy method was able to improve shoulder mobility in one session. The additional joint mobilizations (spin correction) specifically increased GH abduction and external rotation. Rehabilitation of SPS with Shoulder Global Concept allowed to improve functional capacity and decrease pain.

Effect of extracorporeal shockwave therapy for rotator cuff tendinopathy: a systematic review and meta-analysis.

BACKGROUND: Rotator cuff tendinopathy (RCT) is a widespread musculoskeletal disorder and a primary cause of shoulder pain and limited function. The resulting pain and limited functionality have a detrimental impact on the overall quality of life. The purpose of this study was to perform a systematic review of the effects of extracorporeal shock wave therapy (ESWT) for RCT. METHODS: The literature search was conducted on the following databases from inception to February 20, 2024: PubMed, Web of Science, the Cochrane Library, Scopus, MEDLINE, EMBASE, EBSCO, and China National Knowledge Infrastructure (CNKI) were checked to identify the potential studies exploring the effect of ESWT for the treatment of Rotator cuff tendinopathy (Calcification or non-calcification), control group for sham, other treatments (including placebo), without restriction of date, language. Two researchers independently screened literature, extracted data, evaluated the risk of bias in the included studies, and performed meta-analysis using RevMan 5.3 software. RESULTS: A total of 16 RCTs with 1093 patients were included. The results showed that compared with the control group, ESWT for pain score Visual Analogue Scale/Score (VAS) (SMD = -1.95, 95% CI -2.47, -1.41, P < 0.00001), function score Constant-Murley score (CMS) (SMD = 1.30, 95% CI 0.67, 1.92, P < 0.00001), University of California Los Angeles score (UCLA) (SMD = 2.69, 95% CI 1.64, 3.74, P < 0.00001), American Shoulder and Elbow Surgeons form (ASES) (SMD = 1.29, 95% CI 0.93, 1.65, P < 0.00001), Range of motion (ROM) External rotation (SMD = 1.00, 95% CI 0.29, 1.72, P = 0.02), Total effective rate (TER) (OR = 3.64, 95% CI 1.85, 7.14, P = 0.0002), the differences in the above results were statistically significant. But ROM-Abduction (SMD = 0.72, 95% CI -0.22, 1.66, P = 0.13), the difference was not statistically significant. CONCLUSION: Currently limited evidence suggests that, compared with the control group, ESWT can provide better pain relief, functional recovery, and maintenance of function in patients with RCT.

Adherence of individuals with shoulder pain to home exercise booklets: Barriers, facilitators, and the impact of disability, self-efficacy, and treatment expectations.

BACKGROUND: home exercise booklets offer several benefits to individuals with shoulder pain. However, it is necessary to investigate the factors that determine adherence to home exercises. OBJECTIVES: 1) To investigate the level of adherence of individuals with chronic shoulder pain to a home exercise booklet conducted without the mediation of a healthcare professional, 2) To describe the barriers and facilitators to adherence, and 3) to determine if shoulder disability, self-efficacy, and treatment expectations are predictors of the level of adherence. DESIGN: prospective longitudinal study. METHODS: A total of 47 individuals with chronic shoulder pain were recruited. The Numeric Pain Rating Scale (NPRS) was used to assess pain intensity, the Shoulder Pain and Disability Index (SPADI) to measure shoulder disability, the Pain Self-Efficacy Questionnaire (PSEQ-10) for self-efficacy, and a likert scale to measure treatment expectations. Adherence was measured by Exercise Adherence Assessment Scale (EAAE-Br). RESULTS: A total of 23 individuals (48.93%) adhered to the home exercise program. The most commonly cited barriers were pain and health-related issues, while the most cited facilitators were pain improvement and symptom relief. Barriers associated with adherence were time constraints and other commitments, while the facilitator associated with adherence was enjoying the exercises. Binary logistic regression analysis revealed that shoulder disability, self-efficacy, and treatment expectations were unable to predict adherence to home exercises in individuals with shoulder pain [F (1,47) = 2.384; p = 0.130; R2 = 0.056]. CONCLUSION: The study revealed barriers and facilitators to home exercise in individuals with shoulder pain. Disability, self-efficacy, and treatment expectations were not able to predict adherence.

Do therapeutic exercises impact supraspinatus tendon thickness? Secondary analyses of the combined dataset from two randomized controlled trials in patients with rotator cuff-related shoulder pain.

BACKGROUND: The mechanistic response of rotator cuff tendons to exercises within the context of rotator cuff-related shoulder pain (RCRSP) remains a significant gap in current research. A greater understanding of this response can shed light on why individuals exhibit varying responses to exercise interventions. It can also provide information on the influence of certain types of exercise on tendons. The primary aim of this article is to explore if changes in supraspinatus tendon thickness (SSTT) ratio differ between exercise interventions (high load vs. low load). The secondary aims are to explore if changes in SSTT ratio differ between ultrasonographic tendinopathy subgroups (reactive vs. degenerative) and if there are associations between tendinopathy subgroups, changes in tendon thickness ratio, and clinical outcomes (disability). METHODS: This study comprises secondary analyses of the combined dataset from two randomized controlled trials that compared high and low-load exercises in patients with RCRSP. In those trials, different exercise interventions were compared: 1) progressive high-load strengthening exercises and 2) low-load strengthening with or without motor control exercises. In 1 trial, there was also a third group that was not allocated to exercises (education only). Ultrasound-assessed SSTT ratio, derived from comparing symptomatic and asymptomatic sides, served as the primary measure in categorizing participants into tendinopathy subgroups (reactive, normal and degenerative) at baseline. RESULTS: Data from 159 participants were analyzed. Two-way repeated measures ANOVAs revealed significant Group (P < .001) and Group × Time interaction (P < .001) effects for the SSTT ratio in different tendinopathy subgroups, but no Time effect (P = .63). Following the interventions, SSTT ratio increased in the "Degenerative" subgroup (0.14 [95% confidence interval {CI}: 0.09-0.19]), decreased in the "Reactive" subgroup (-0.11 [95% CI: -0.16 to -0.06]), and remained unchanged in the "Normal" subgroup (-0.01 [95% CI: -0.04 to 0.02]). There was no Time (P = .21), Group (P = .61), or Group × Time interaction (P = .66) effect for the SSTT ratio based on intervention allocation. Results of the linear regression did not highlight any significant association between the tendinopathy subgroup (P = .25) or change in SSTT ratio (P = .40) and change in disability score. CONCLUSION: Findings from this study suggest that, over time, SSTT in individuals with RCRSP tends to normalize, compared to the contralateral side, regardless of the exercise intervention. Different subgroups of symptomatic tendons behave differently, emphasizing the need to potentially consider tendinopathy subtypes in RCRSP research. Future adequately powered studies should investigate how those different tendinopathy subgroups may predict long-term clinical outcomes.

Ultrasound definition of subacromial chronic "fibro-adhesive" bursitis and its treatment via ultrasound guided hydrodilation: a prospective pilot study.

PURPOSE: The shoulder pain is one of the main causes that lead the patient to medical evaluation. Today, the ultrasound (US) represents an essential tool in the orthopaedical, rheumatological and rehabilitative setting to address the musculoskeletal causes of pain. Amongst the commonest causes of shoulder complains lay the frequent subacromial chronic bursitis (SACB). In this condition, the thickening of the bursal walls and subsequent fusion of the two synovial sheets leads to the reciprocal loss of bursal walls gliding under the subacromial space and consequently pain. This condition represents a common cause of shoulder pain and may be easily addressed by musculoskeletal sonographers. The purpose of this paper will be to describe the US appearance of SACB and to evaluate the efficacy of US-guided hydrodilation in its treatment. METHODS: We included patients with painful shoulder attending our outpatient clinic for shoulder complains with the diagnosis of SACB with a bursal wall > 1.5 mm. A group was treated via US-guided hydrodilation, while the control group was treated via a classical blind approach using triamcinolone acetonide. Both groups underwent the same rehabilitation program following the injections. The shoulder functionality was assessed via qDASH questionnaire at baseline, days 3, 7, 14, 30, 60, and 90. A p <0.05 was considered significant. RESULTS: Both groups displayed a significant reduction of pain; nevertheless, in the group treated with US-hydrodilation, there was no need for re-treatment. CONCLUSIONS: The US-guided hydrodilation for SACB should be the preferred technique to detach bursal walls and improve patient symptoms, since it requires fewer invasive maneuvers.

Is exercise therapy the right treatment for rotator cuff-related shoulder pain? Uncertainties, theory, and practice.

BACKGROUND: Exercise therapy is a popular non-surgical treatment to help manage individuals with rotator cuff-related shoulder pain (RCRSP) and is recommended in all clinical practice guidelines. Due to modest effect sizes, low quality evidence, uncertainty relating to efficacy, and mechanism(s) of benefit, exercise as a therapeutic intervention has been the subject of increasing scrutiny. AIMS: The aim of this critical review is to lay out where the purported uncertainties of exercise for RCRSP exist by exploring the relevant quantitative and qualitative literature. We conclude by offering theoretical and practical considerations to help reduce the uncertainty of delivering exercise therapy in a clinical environment. RESULTS AND DISCUSSION: Uncertainty underpins much of the theory and practice of delivering exercise therapy for individuals with RCRSP. Nonetheless, exercise is an often-valued treatment by individuals with RCRSP, when provided within an appropriate clinical context. We encourage clinicians to use a shared decision-making paradigm and embrace a pluralistic model when prescribing therapeutic exercise. This may take the form of using exercise experiments to trial different exercise approaches, adjusting, and adapting the exercise type, load, and context based on the individual's symptom irritability, preferences, and goals. CONCLUSION: We contend that providing exercise therapy should remain a principal treatment option for helping individuals with RCRSP. Limitations notwithstanding, exercise therapy is relatively low cost, accessible, and often valued by individuals with RCRSP. The uncertainty surrounding exercise therapy requires ongoing research and emphasis could be directed towards investigating causal mechanisms to better understand how exercise may benefit an individual with RCRSP.

Shoulder specific exercise therapy is effective in reducing chronic shoulder pain: A network meta-analysis.

BACKGROUND: Exercise therapy (ET) is frequently an early treatment of choice when managing shoulder pain, yet evidence on its efficacy to expedite recovery is inconsistent. Moreover, the value of adding adjunct therapies (i.e. injections, manual therapy, electrotherapy) to ET is currently unclear. This study combined both direct and indirect evidence across studies on the effectiveness of ET with/without adjunct therapies compared to usual medical care for adults with chronic shoulder pain. METHODS AND FINDINGS: Using a network meta-analysis, randomized control trials comparing ET along with adjunct therapies were identified in MEDLINE, Embase, CINAHL, Sportdiscus, CENTRAL, Conference Proceedings Citation Index-Science, clinicaltrials.gov, and association websites. Outcomes included pain, range of motion (ROM), and health-related quality of life (HRQL) measures in adult patients with chronic shoulder pain. Data analysis used a Frequentist hierarchical model. CINeMA tool assessed the confidence in the results and Cochrane Risk of Bias tool assessed quality of studies. 54 studies primarily from Europe (40.38%) included 3,893 participants who were followed up to 52 weeks. Shoulder-specific ET (Mean difference (MD) = -2.1; 95% confidence interval (CI) = -3.5 to -0.7) or in combination with electro-physical agents (MD = -2.5; 95% CI = -4.2 to -0.7), injections (MD = -2.4; 95% CI = -3.9 to-1.04) or manual therapy (MD = -2.3; 95% CI = -3.7 to -0.8) decreased pain compared to usual medical care. Trends with ROM and HRQL scores were seen; however, only Manual Therapy (MD = -12.7 and 95% CI = -24.4 to -1.0) achieved meaningfully important changes. Sensitivity analysis excluding studies with high risk of bias showed similar results, with exception of injections that did not reach significance (MD = -1.3; 95% CI = -4.3 to 1.7). CONCLUSION(S): Shoulder-specific ET provided pain relief up to 52 weeks. Adjunct therapies to shoulder-specific ET added little value in reducing pain. The quality of evidence varied between moderate and very low.

The effect of joint position sense therapy on chronic shoulder pain with central sensitization.

BACKGROUND: Chronic shoulder pain is a common musculoskeletal problem associated with unreleased pain and functional dysfunction that can evolve into central sensitization. Some forms of manual therapy may exacerbate pain and central sensitization. This study investigated the impact of joint position sense therapy (JPST), a moderate joint proprioception training technique, on central sensitization, shoulder functional dysfunction, and pain in patients with chronic shoulder pain compared with more intense exercises or aggressive manual therapies. METHODS: We assessed the pressure pain threshold (PPT) in 30 patients with and 30 patients without chronic shoulder pain. The assessment focused on 4 muscle sites: deltoid, upper trapezius, brachioradialis, and tibialis anterior. Thirty patients with chronic shoulder pain were randomly divided into the JPST and control groups. The JPST group underwent additional shoulder joint position-sense training. The efficiency outcomes were the disabilities of the arm, shoulder, and hand questionnaire, visual analog scale (VAS), and PPT, evaluated at baseline and after the intervention. RESULTS: Significant differences were observed in the PPT values at the brachioradialis (P < .05), deltoid (P < .01), and trapezius (P < .001) among the non-chronic and chronic groups, but not in the tibialis anterior muscle (P > .05). Although both control and JPST interventions effectively improved the disabilities of the arm, shoulder, and hand questionnaire score, pain intensity, and PPT values in the upper limb, the outcomes in the JPST group were significantly different from those in the control group. CONCLUSIONS: Generalized hyperalgesia changes limited to the upper limbs were observed in patients with chronic shoulder pain. JPST has beneficial effects on pain control and functional dysfunction in patients with chronic shoulder pain.