Physiotherapy interventions for shoulder pain

Sally Green; Rachelle Buchbinder; Sarah E Hetrick

doi:10.1002/14651858.CD004258

. 2003 Apr 22;2003(2):CD004258. doi: 10.1002/14651858.CD004258

Physiotherapy interventions for shoulder pain

Sally Green ^1,^✉, Rachelle Buchbinder ², Sarah E Hetrick ³

Editor: Cochrane Musculoskeletal Group

PMCID: PMC8769566 PMID: 12804509

Abstract

Background

The prevalence of shoulder disorders has been reported to range from seven to 36% of the population (Lundberg 1969) accounting for 1.2% of all General Practitioner encounters in Australia (Bridges Webb 1992). Substantial disability and significant morbidity can result from shoulder disorders. While many treatments have been employed in the treatment of shoulder disorders, few have been proven in randomised controlled trials. Physiotherapy is often the first line of management for shoulder pain and to date its efficacy has not been established. This review is one in a series of reviews of varying interventions for shoulder disorders, updated from an earlier Cochrane review of all interventions for shoulder disorder.

Objectives

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

Search methods

MEDLINE, EMBASE, the Cochrane Clinical Trials Regiter and CINAHL were searched 1966 to June 2002. The Cochrane Musculoskeletal Review Group's search strategy was used and key words gained from previous reviews and all relevant articles were used as text terms in the search.

Selection criteria

Each identified study was assessed for possible inclusion by two independent reviewers. The determinants for inclusion were that the trial be of an intervention generally delivered by a physiotherapist, that treatment allocation was randomised; and that the study population be suffering from a shoulder disorder, excluding trauma and systemic inflammatory diseases such as rheumatoid arthritis.

Data collection and analysis

The methodological quality of the included trials was assessed by two independent reviewers according to a list of predetermined criteria, which were based on the PEDro scale specifically designed for the assessment of validity of trials of physiotherapy interventions. Outcome data was extracted and entered into Revman 4.1. Means and standard deviations for continuous outcomes and number of events for binary outcomes were extracted where available from the published reports. All standard errors of the mean were converted to standard deviation. For trials where the required data was not reported or not able to be calculated, further details were requested from first authors. If no further details were provided, the trial was included in the review and fully described, but not included in the meta‐analysis. Results were presented for each diagnostic sub group (rotator cuff disease, adhesive capsulitis, anterior instability etc) and, where possible, combined in meta‐analysis to give a treatment effect across all trials.

Main results

Twenty six trials met inclusion criteria. Methodological quality was variable and trial populations were generally small (median sample size = 48, range 14 to 180). Exercise was demonstrated to be effective in terms of short term recovery in rotator cuff disease (RR 7.74 (1.97, 30.32), and longer term benefit with respect to function (RR 2.45 (1.24, 4.86). Combining mobilisation with exercise resulted in additional benefit when compared to exercise alone for rotator cuff disease. Laser therapy was demonstrated to be more effective than placebo for adhesive capsulitis (RR 8, 95%CI 2.11 to 30.34) but not for supraspinatus tendinitis (RR 2, 95%CI 0.98 to 4.09). Both ultrasound and pulsed electromagnetic field therapy resulted in improvement compared to placebo in pain in calcific tendinitis (RR 1.81 (1.26, 2.60) and RR 19 (1.16, 12.43) respectively). There is no evidence of the effect of ultrasound in shoulder pain (mixed diagnosis), adhesive capsulitis or rotator cuff tendinitis. When compared to exercises, ultrasound is of no additional benefit over and above exercise alone. There is some evidence that for rotator cuff disease, corticosteroid injections are superior to physiotherapy and no evidence that physiotherapy alone is of benefit for adhesive capsulitis

Authors' conclusions

The small sample sizes, variable methodological quality and heterogeneity in terms of population studied, physiotherapy intervention employed and length of follow up of randomised controlled trials of physiotherapy interventions results in little overall evidence to guide treatment. There is evidence to support the use of some interventions in specific and circumscribed cases. There is a need for trials of physiotherapy interventions for specific clinical conditions associated with shoulder pain, for shoulder pain where combinations of physiotherapy interventions, as well as, physiotherapy interventions as an adjunct to other, non physiotherapy interventions are compared. This is more reflective of current clinical practice. Trials should be adequately powered and address key methodological criteria such as allocation concealment and blinding of outcome assessor.

Plain language summary

Some physiotherapy interventions are effective for shoulder pain in some cases.

There is a high prevalence of shoulder disorders in the community. Shoulder disorders can result in considerable pain and disability. Physiotherapy is often the first line of treatment for shoulder disorder. Twenty‐six trials presented sufficient data to be included in meta‐analysis. There is some evidence from methodologically weak trials to indicate that some physiotherapy interventions are effective for some specific shoulder disorders. The results overall provide little evidence to guide treatment. There is a clear need for further high quality trials of physiotherapy interventions, including trials using combinations of modalities, in the treatment of shoulder disorders.

Background

Conditions causing shoulder pain are common and contribute substantially to the musculoskeletal morbidity of the community (Bjelle 1989). The prevalence of shoulder disorders has been reported to range from seven to 36% of the general population (Lundberg 1969). Shoulder disorders account for 1.2% of all general practice encounters in Australia, being third only to back and neck complaints as musculoskeletal reasons for primary care consultation (Bridges Webb 1992). In Dutch general practice the incidence of shoulder disorders has been estimated to be 11.2 per 1000 registered patients per year (van der Windt 1995). The shoulder is frequently injured, particularly in competitive sports. Eight to 13% of athletic injuries involve the shoulder (Hill 1983).

Prevalence of shoulder disorders has been shown to increase with age (Badley 1992). This finding has implications for the provision of health care in view of the aging of the population as a whole. In contrast, others (Allander 1974, Ingemar 1993) have demonstrated a decline in both the prevalence and incidence of shoulder pain with age, the peak prevalence occurring in the 56 ‐ 60 year age group.

Substantial disability may result from shoulder disorders. Moving the shoulder allows placement of the hand, hence compromised shoulder mobility impacts substantially on the performance of tasks essential to daily living (e.g. dressing, personal hygiene, eating and work). In addition, shoulder pain is often associated with impaired ability to sleep, so affecting mood and concentration. People with shoulder pain have been shown to score substantially less than normal values on the SF‐36 (a standardised measure of general health) for physical function, social function, physical role function, emotional role function and pain (Beaton 1996;Gartsman 1998). Shoulder disorders are often recalcitrant with some studies demonstrating persisting pain and disability from 12 months (van der Windt 1995) to 18 months (Chard 1991) in up to 50% of cases.

There are many commonly employed forms of treatment for shoulder disorders, including, non‐steroidal anti‐inflammatory drugs, glucocorticosteroid injections, oral glucocorticosteroid medication, manipulation under anaesthesia, physical therapy, hydrodilatation (distension arthrography) and surgery. A previous version of this systematic review of randomised controlled trials investigated all these treatments and concluded that there was very little evidence to either support or refute the efficacy of interventions commonly used to treat shoulder pain. Furthermore, the interpretation of results of studies that have been performed is hampered by the fact that these disorders are labelled and defined in diverse and often conflicting ways. (Green 1998) In a review of the diagnostic labels and/or definitions of the study populations, we concluded that most trials can be broadly categorised as studying adhesive capsulitis (specific diagnoses also including periarthritis and frozen shoulder) and/or rotator cuff tendonitis disease Green 1998. Shoulder pain and disorder may be caused by varying underlying pathologies, and the diagnostic criteria for defining these disorders are not consistently nor reliably applied. No standardised definitions are used and often there are conflicting criteria defining the same condition in different trials.

Since our original review (Green 1999), many new clinical trials, studying a diverse range of interventions, have been performed. In order to update and simplify the review, it has been subdivided into a series of reviews investigating the evidence for efficacy of single interventions. The review has also been broadened by including all randomised or pseudo‐randomised clinical trials regardless of whether outcome assessment was blinded.

This review examines the evidence for efficacy and safety of physiotherapy for the treatment of adults with shoulder pain. Physiotherapy encompasses a broad range of interventions. This group of interventions are often the first line of management for shoulder pain. The aim is to relieve pain, promote healing, reduce muscle spasms, increase joint range and strengthen weakened muscles and ultimately to prevent and treat functional impairment (Lee 1973). Physiotherapy interventions include manual physical therapy where passive joint mobilisation is employed to mobilise and stretch the soft tissue. Supervised and prescribed exercises aim to improve range of movement and muscle function by restoring shoulder mobility and stability. Physiotherapy interventions also include a number of electrotherapeutic modalities including Laser Therapy, Ultrasound, Bipolar Interferential Current, Transcutaneous Electromagnetic Stimulation, and Pulsed Electromagnetic Field Therapy. Laser therapy is light amplification by stimulated emission of radiation. This results in a beam of light of a single frequency with little divergence, thought to reduce inflammation and improve circulation (England 1989). Ultrasound is used as a physiotheray intervention for its physiological effects which include argumentation of blood flow, increased capillary permeability and tissue metabolism, enhancement of tissue extensibility, elevation of pain threshold, and alteration of neuromuscular activity leading to muscle relaxation (Downing 1986). Bipolar Interferential Current is believed to promote recovery by elevation of the pain threshold and promotion of muscle relaxation (van der Heijden 1996).Transcutaneous Electromagnetic Stimulation (TENS) uses analgesic currents and while its mechanism of action is not completely understood it is thought that it serves to release endogenous opiates in specific areas of the Central Nervous System (Herrera‐Lasso 1993). Pulsed Electromagnetic Field Therapy is thought to improve vascularisation, so promoting healing (Binder 1984). In practice, patients with shoulder pain seldom receive a single treatment intervention in isolation.

This review will specifically address the effectiveness of physiotherapy interventions alone or in combination for relief of pain and dysfunction of the shoulder.

Objectives

To determine the efficacy of physiotherapy interventions for shoulder pain and dysfunction.

Methods

Criteria for considering studies for this review

Types of studies

a) Randomised or pseudo‐randomised controlled trials. Studies where participants were not randomised into intervention groups were excluded from the review.   b) Trials in which allocation to treatment or control group was not concealed from the outcome assessor were included but recorded as such in the table of included studies.   c) Studies in all languages were translated into English and considered for inclusion in the review.

Types of participants

Inclusion in this review was restricted to trials with participants meeting the following criteria:

a) Adults >16 years of age.   b) Shoulder pain or disorder for greater than 3 weeks. Studies that included various soft tissue disorders were considered if the results for shoulder pain were presented separately or if 90% or more of participants in the study had shoulder pain.   c) Studies of participants suffering a history of significant trauma or systemic inflammatory conditions such as rheumatoid arthritis, hemiplegic shoulders, post‐operative and peri‐operative shoulder pain and pain in the shoulder region as part of a complex myofacial neck/shoulder arm pain were excluded.

Trials were sub grouped into type of shoulder disorder for analysis (see methods section).

Types of interventions

All randomised controlled comparisons of a physiotherapist delivered intervention versus placebo, no treatment, another intervention, or of varying physiotherapy interventions compared to each other were included.

Types of outcome measures

No studies were excluded on the basis of outcome measure used. The clinically relevant outcomes of interest in shoulder disorder are pain, range of motion (active and passive), function/ disability and quality of life, strength, return to work, participants' perception of overall effect, global preference, physicians' preference and adverse effects.

Search methods for identification of studies

MEDLINE, EMBASE, CINAHL (includes all major physiotherapy and occupational therapy journals from U.S.A., Canada, England, Australia and New Zealand), and Science Citation Index (SCISEARCH) were searched 1966 to June 2002 .

1 Shoulder Pain/   2 Shoulder Impingement Syndrome/   3 Rotator Cuff/   4 exp Bursitis/   5 ((shoulder$ or rotator cuff) adj5 (bursitis or frozen or impinge$ or tendinitis or tendonitis or pain$)).mp.   6 rotator cuff.mp.   7 adhesive capulitis.mp.   8 or/1‐7   9 exp Rehabilitation/   10 exp Physical Therapy Techniques/   11 exp Musculoskeletal Manipulations/   12 exp Exercise Movement Techniques/   13 exp Ultrasonography, Interventional/   14 (rehabilitat$ or physiotherap$ or physical therap$ or manual therap$ or exercis$ or ultrasound or ultrasonograph$ or TNS or TENS or shockwave or electrotherap$ or mobili$). mp.   15 or/9‐14   16 Clinical trial.pt   17 random$.mp.   18 ((single or double) adj (blind$ or mask$)).mp.   19 placebo$.mp.   20 or/16‐19   21 8 and 15 an 20

In addition, the Cochrane Controlled Trials Register (CCTR) Issue 2, 2002 was searched.

Data collection and analysis

Following identification of potential trials for inclusion by the previously outlined search strategy, the methods sections of all identified trials were reviewed independently according to predetermined criteria (see selection criteria), by two reviewers. All articles were coded and details of source, intervention, population and funding recorded. Where the two reviewers disagreed, discussion was facilitated in order to reach consensus. If this was to fail, the trial was sent to a third reviewer for arbitration.

Trials meeting inclusion criteria were collated, and the methods and results sections re‐sent to the same two reviewers for assessment of trial validity and data extraction.

ASSESSMENT OF VALIDITY   Validity of included trials was assessed by comment on whether they met key criteria (including appropriate randomisation, allocation concealment, blinding, number lost to follow up and intention to treat analysis). These criteria were based on the PEDro scale specifically designed and validated for the assessment of validity for trials of physiotherapy interventions (http://ptwww.cchs.usyd.edu.au/pedro/). Trials were not scored numerically. The only quantitative scoring was given for allocation concealment, ranked as:

A: adequate   B: unclear, or   C: inadequate.

Whether or not trials met the key methodological criteria was recorded on a pre‐piloted data extraction sheet and later transposed into the "Characteristics of Included Studies" table.   Validity of trials was assessed in this qualitative way as opposed to using a numerical or summary scale. There are concerns regarding the validity of such scales and a lack of information about whether all the criteria included in such scales impact on the overall outcome of the trial (Juni 1999).

DATA EXTRACTION AND ANALYSIS   In order to assess efficacy, raw data for outcomes of interest, specifically means and standard deviations for continuous outcomes and number of events for binary outcomes were extracted where available from the published reports. All standard errors of the mean were converted to standard deviation. Wherever reported data was converted or imputed, this was recorded in the notes section of the included studies table. For trials where the required data was not reported or not able to be calculated, further details were requested from first authors. If no further details were provided, the trial was included in the review and fully described, but not included in the meta‐analysis. An entry to that effect was made in the notes section of the included studies table.

When trial results were not normally distributed and so reported as median and range, the trial was not included in the meta‐analysis but results presented in Additional Tables.   Meta‐analysis was facilitated by RevMan 4.1. The following choices of statistic and 95% confidence intervals were presented for all outcomes.     CONTINUOUS OUTCOMES:   Weighted mean difference using a fixed effect model was selected when outcomes were measured on standard scales. When outcomes were reported on non standard scales, using differing units and methods of assessment (for example disability scales), a standardised mean difference was selected. Possible clinical reasons for heterogeneity were explored, and in the presence of significant heterogeneity, trial results were not combined.

DICHOTOMOUS OUTCOMES:   Relative risk using a fixed effects model was selected for interpretation of dichotomous outcome measures in this review as we believe that this is the most appropriate statistic for interpretation when the event is common . Reasons for heterogeneity were evaluated and in the event of significant heterogeneity trial results were not pooled.

SUBGROUP ANALYSIS   Shoulder pain and disorder may be caused by varying underlying pathologies, and the diagnostic criteria for defining these disorders are not consistent nor reliably applied. In general, adhesive capsulitis was defined as the presence of pain with restriction of active and passive glenohumeral joint movements, and rotator cuff tendonitis was defined by the presence of painful arc and pain with resisted movements, and/or normal passive range of motion. However there were no standardised definitions used in the included trials and often there were conflicting criteria defining the same condition in different trials. For example, "pain with resisted movements of the shoulder and loss of passive abduction" was used to define rotator cuff tendonitis in one trial, whereas another trial used "pain on resisted abduction and full passive range of motion". Based upon review of the diagnostic labels and/or definitions of the study populations (Green 1998), most trials could be broadly categorised as studying adhesive capsulitis (specific diagnoses also including periarthritis and frozen shoulder) and/or rotator cuff tendonitis disease. For the purposes of subgroup analysis rotator cuff disease was categorised as tendinitis (specific diagnoses also including supraspinatus, infraspinatus and subscapularis tendonitis) or full rotator cuff tear. Results for each intervention were analysed within each diagnostic subgroup where described. If not described by the trialist, the population was labelled as general shoulder pain. This was planned a priori.

Results

Description of studies

Individual studies are fully described in the table of included studies. Sixty seven potentially eligible trials were identified by the search strategy. There was agreement in all cases between reviewers on inclusion of studies. A total of twenty‐six trials fulfilled the inclusion criteria. The reasons for exclusion of the other 41 trials are listed in the table of excluded studies. The 26 included studies are described below.

PHYSIOTHERAPY MODALITIES COMPARED WITH PLACEBO OR NO TREATMENT   Fourteen studies compared a physiotherapy modality to placebo (one study included two different modalities and placebo). The physiotherapy modalities studied were bipolar interferential current (one trial) (van der Heijden 1999), ultrasound (five trials) (van der Heijden 1999; Ebenbichler 1999; Berry 1980; Downing 1986; Nykanen 1995), laser (three trials) (Taverna 1990; Saunders 1995; England 1989) pulsed electromagnetic field (two trials) (Dal Conte 1990; Binder 1984), combined iontophoresis of acetic acid plus ultrasound (one trial) (Perron 1997), supervised exercises (two trials) (Brox 1993/7; Ginn 1997) and mobilisation (one trial) (Bulgen 1984).

COMPARISONS OF ONE TYPE OF PHYSIOTHERAPY MODALITY TO ANOTHER   Eight trials compared one type of physiotherapy modality to another.

Electrotherapeutic agents compared to non electrotherapeutic interventions:   One trial compared electrotherapy plus exercise to mobilisation and manipulation (Winters 1997/9) and one trial compared physiotherapy including electromagnetic therapy to an identical intervention without electromagnetic therapy (Leclaire 1991).   One type of electrotherapeutical agent to another:   One trial compared bipolar interferential current to ultrasound (van der Heijden 1999) and two compared transcutaneous nerve stimulation (TENS) to ultrasound (Herrera‐Lasso 1993; Shehab 2000)

Manual interventions:   Three trials compared mobilisation plus exercise to exercise alone (Nicholson 1985; Conroy 1998; Bang 2000)

Exercise interventions:   One trial investigated the effect of isokinetic resisted exercise compared to biofeedback (Reid 1996).

PHYSIOTHERAPY MODALITIES COMPARED TO OTHER, NON PHYSIOTHERAPY TREATMENT INTERVENTIONS   Seven trials compared injection to physiotherapy. These comprised two trials comparing intra‐articular corticosteroid injection with a combined physiotherapy intervention (van der Windt 1998; Berry 1980), two trials comparing intra‐articular and subacromial corticosteroid injection to electrotherapy and exercises (Winters 1997/9; Lee 1973), and three comparing injections to mobilisation and manipulation (Winters 1997/9; Bulgen 1984; Dacre1989).

One trial compared laser to non‐steroidal anti‐inflammatory medication (England 1989).

Risk of bias in included studies

Included studies were of varying methodological quality. A full description of whether or not the methods of each trial met the predetermined quality assessment criteria can be found in the table of included studies. Trial populations were generally small (median sample size = 48, range 14 to 180) with many trials underpowered to demonstrate a difference between groups if one was present. Six of the 26 trials (23%) had adequate allocation concealment (Downing 1986; Ebenbichler 1999; Ginn 1997; Lee 1973; van der Heijden 1999; van der Windt 1998) (1 unclear and 19 inadequate), 19/26 (73%) trials had a blinded outcome assessor (Bang 2000; Berry 1980; Binder 1984; Brox 1993/7; Conroy 1998; Dacre1989; Ebenbichler 1999; England 1989; Ginn 1997; Leclaire 1991; Nicholson 1985; Nykanen 1995; Perron 1997; Saunders 1995; Shehab 2000; Taverna 1990; van der Heijden 1999; van der Windt 1998; Vecchio 1993) and 10/26 (38%) trials blinded the participants ( Binder 1984; Dal Conte 1990; Downing 1986; Ebenbichler 1999; England 1989; Leclaire 1991; Nykanen 1995; Saunders 1995; Taverna 1990; Vecchio 1993). In eight trials (8/26; 31%) there was greater than 20% loss to follow‐up (Brox 1993/7; Downing 1986; Lee 1973; Nicholson 1985; Reid 1996; Saunders 1995; Shehab 2000; Winters 1997/9) and in 6/26 (23%) the trialists described intention to treat analysis (Brox 1993/7; Saunders 1995; Shehab 2000; Taverna 1990; van der Heijden 1999; van der Windt 1998).

Twenty trials (20/26; 77%) presented sufficient data to be included in meta‐analysis, two presented data in a form which could not be included in meta‐analysis so these results are included as additional tables, and four trials did not present any data that could be included in the review.

Effects of interventions

PHYSIOTHERAPY MODALITIES COMPARED WITH PLACEBO OR NO TREATMENT

ELECTROTHERAPY INTERVENTIONS

One trial of 145 participants demonstrated bipolar interferential current to be no more beneficial than placebo in general (mixed population) shoulder disorders for the recovery or substantial improvement in pain in the short or long term (6 weeks to 12 month follow‐up) (van der Heijden 1999).

Based on the results of one trial (Ebenbichler 1999), ultrasound appears to have some significant benefit over placebo in calcific tendinitis (RR for recovery or substantial improvement in the short term (end of treatment) 1.81 (1.26, 2.60). In addition, the same trial demonstrated a significant effect in terms of improvement in radiological appearance of calcific tendinitis in the short term (end of treatment) (RR 4.53 (1.46, 14.07)) and long term (nine month follow‐up) (RR 3.74 (1.62, 8.66)). However, an additional trial investigating the effect of iontophoresis of acetic acid plus ultrasound (Perron 1997) found no significant benefit in calcific tendinitis. There is no evidence of effect of ultrasound in general shoulder pain or rotator cuff tendinitis. A pooled analysis of three trials assessing the effect of ultrasound on short term recovery or substantial improvement in three varying clinical conditions (van der Heijden 1999; Ebenbichler 1999; Berry 1980) demonstrated a very small but significant benefit over placebo (RR 1.41 (1.04,1.90)). This benefit was attributable to the trial in calcific tendinitis and was not supported by two additional trials, not included in the meta‐analysis, measuring the effect of ultrasound on pain (as opposed to recovery/ improvement). These trials demonstrated no benefit of ultrasound over placebo (Downing 1986; Nykanen 1995). Ultrasound had no significant effect demonstrated from pooled analysis of three trials on range of motion (WMD ‐2.89 (‐10.43, 4.66) (Downing 1986; Berry 1980; Nykanen 1995). No trial included in this review assessed adverse effects of ultrasound.

The effect of laser compared to placebo has been assessed by four trials, two included in meta‐analysis (Taverna 1990; Saunders 1995), one with results presented as single‐study forest plots (Vecchio 1993) and one with results presented as an additional table (England 1989). The pooled analysis demonstrates laser to be significantly more effective than placebo in bringing about a good or excellent result in the short term (RR 3.71, 95% CI 1.89 to 7.28). This analysis included a trial including participants with adhesive capsulitis (Taverna 1990) and a trial including participants with supraspinatus tendinitis (Saunders 1995). When looking at the results of each trial individually, the beneficial effect of laser therapy was only found for adhesive capsulitis. The trial including participants with rotator cuff tendinitis (Vecchio 1993) did not demonstrate statistically significant differences in outcomes between laser therapy and placebo. Finally, the fourth trial (England 1989), which included participants with supraspinatus or bicipital tendinitis, demonstrated a difference in medians of pain measured on a 10 cm VAS at 2 weeks to be 2.5cm (95% CI 2 to 3) (Table 1), however, the statistical significance of this difference could not be determined.

1. Results of included studies with data not appropriate for metaview.

Study ID	Interventions	Outcome	Results
Shehab, 2000	TENS VERSUS US	Pain post intervention	Median (Range) TENS 0(0‐.65) US 0.5(0‐2.75) Significantly better in US group
		Flexion score post intervention	Median (Range) TENS 140 (120‐160) US 175 (115‐180) Significantly better in US group
		Abduction score post intervention	Median (Range) TENS 130 (116.7‐156.5) US 180 (101.2‐180) Significantly better in US group
Brox, 1993	ARTHROSCOPIC DECOPRESSION VERSUS EXERCISE	Pain at 3 months	Median Arthroscope 25 Median exercise 15
		Pain at 6 months	Median Arthroscope 25 Median exercise 25
		Pain at 2.5 years	Mean (SD) Arthroscope 24 (22) Mean (SD) exercise 22 (21)
		Function at 3 months	Median Arthroscope 28 Median exercise 24
		Function at 6 months	Median Arthroscope 28 Median exercise 25
		Function at 2.5 years	Mean (SD) arthroscope 23 (20) Mean (SD) exercise 20 (19)
		Overall change at 3 months	Median Arthroscope 84 Median exercise 74
		Overall change at 6 months	Median Arthroscope 87 Median exercise 86
England 1989	LASER VERSUS PLACEBO	Pain (10 cm VAS) at 2 weeks	Difference between medians (95% CI) 2.5cm (2,3)
		Function (10cm VAS) at 2 weeks	Difference 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 NSAID	Pain (10 cm VAS) at 2 weeks	Difference between medians (95% CI) 2cm (1,3.5)
		Function (10cm VAS) at 2 weeks	No 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)

Date	Event	Description
1 May 2008	Amended	Converted to RM5. CMSG ID C067‐R
24 February 2003	New citation required and conclusions have changed	Substantive amendment
24 February 2003	Amended	This review is based on the original review of 'Interventions for shoulder pain'. Please see published notes for further details.

Outcome or subgroup title	No. of studies	Statistical method	Effect size
1 Recovery or substantial improvement at 6 weeks	1	Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.1 General shoulder pain (mixed diagnoses)	1	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2 Recovery or substantial improvement (participant rated) at 3 months	1	Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
2.1 General shoulder pain (mixed diagnoses)	1	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3 Recovery or substantial improvement (participant rated) at 6 months	1	Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
3.1 General shoulder pain (mixed diagnoses)	1	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4 Recovery or substantial improvement (participant rated) at 9 months	1	Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
4.1 General shoulder pain (mixed diagnoses)	1	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5 Recovery or substantial improvement (participant rated) at 12 months	1	Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
5.1 General shoulder pain (mixed diagnoses)	1	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Recovery or substantial improvement (participant rated) ‐ short term	3	229	Risk Ratio (M‐H, Fixed, 95% CI)	1.41 [1.04, 1.90]
1.1 General shoulder pain (combined diagnoses)	1	145	Risk Ratio (M‐H, Fixed, 95% CI)	1.44 [0.77, 2.70]
1.2 Calcific tendinitis	1	60	Risk Ratio (M‐H, Fixed, 95% CI)	1.81 [1.26, 2.60]
1.3 Rotator cuff disease	1	24	Risk Ratio (M‐H, Fixed, 95% CI)	0.67 [0.35, 1.28]
2 Recovery or substantial improvement (participant rated) at 3 months	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
2.1 General shoulder pain (combined diagnoses)	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3 Recovery or substantial improvement (participant rated) at 6 months	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
3.1 General shoulder pain (combined diagnoses)	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4 Recovery or substantial improvement (participant rated) at 9 months	2	206	Risk Ratio (M‐H, Fixed, 95% CI)	1.01 [0.78, 1.30]
4.1 General shoulder pain (mixed diagnoses)	1	145	Risk Ratio (M‐H, Fixed, 95% CI)	0.87 [0.60, 1.26]
4.2 Calcific tendinitis	1	61	Risk Ratio (M‐H, Fixed, 95% CI)	1.26 [0.90, 1.77]
5 Recovery or substantial improvement (participant rated) at 12 months	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
5.1 General shoulder pain (mixed diagnoses)	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6 Resolution or improvement of radiological finding at end of treatment (6 weeks)	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
6.1 Calcific tendinitis	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7 Resolution or improvement of radiological finding at 9 months	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
7.1 Calcific tendinitis	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
8 Normal function at end of treatment (6 weeks)	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
8.1 Calcific tendinitis	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
9 Normal function at 9 months	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
9.1 Calcific tendinitis	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
10 Change in range of flexion	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
10.1 General shoulder pain (mixed diagnoses)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
11 Range of abduction	3	116	Mean Difference (IV, Fixed, 95% CI)	‐2.89 [‐10.43, 4.66]
11.1 General shoulder pain (combined diagnoses)	1	20	Mean Difference (IV, Fixed, 95% CI)	‐1.0 [‐10.80, 8.80]
11.2 Rotator cuff disease	2	96	Mean Difference (IV, Fixed, 95% CI)	‐5.64 [‐17.48, 6.20]
12 Change in internal rotation	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
12.1 General shoulder pain (combined diagnoses)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
13 Change in external rotation	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
13.1 General shoulder pain (combined diagnoses)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
14 Pain (100mmVAS) at 4 weeks	1		Std. Mean Difference (IV, Fixed, 95% CI)	Totals not selected
14.1 Rotator Cuff Disease	1		Std. Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
15 Painfree at 4 weeks	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
15.1 General shoulder pain (mixed diagnoses)	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
16 Pain (out of 20) at 4 months	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
16.1 Rotator cuff disease	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
17 Pain (out of 20) at 12 months	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
17.1 Rotator cuff disease	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
18 Function (out of 14) at 4 months	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
18.1 Rotator cuff disease	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
19 Function (out of 14) at 12 months	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
19.1 Rotator cuff disease	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]

Outcome or subgroup title	No. of studies	Statistical method	Effect size
1 Good or excellent function (Neer score) at 2 and a half years	1	Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.1 Rotator cuff disease	1	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2 No pain on activity at 2 and a half years	1	Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
2.1 rotator cuff disease	1	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3 No pain at rest at 2 and a half years	1	Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
3.1 rotator cuff disease	1	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4 No pain at night at two and a half years	1	Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
4.1 rotator cuff disease	1	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5 Substantial improvement or recovered post treatment (1 month). Participant rated	1	Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
5.1 General shoulder pain (mixed diagnoses)	1	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6 No pain post treatment (1 month)	1	Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
6.1 General shoulder pain (mixed diagnoses)	1	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7 Good or excellent function post treatment (1 month)	1	Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
7.1 General shoulder pain (mixed diagnoses)	1	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
8 Worsened range of abduction post treatment (1 month)	1	Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
8.1 General shoulder pain (mixed diagnoses)	1	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Excellent or good result	2	64	Risk Ratio (M‐H, Fixed, 95% CI)	3.71 [1.89, 7.28]
1.1 Periarthritis (adhesive capsulitis)	1	40	Risk Ratio (M‐H, Fixed, 95% CI)	8.0 [2.11, 30.34]
1.2 Supraspinatus tendinitis	1	24	Risk Ratio (M‐H, Fixed, 95% CI)	2.0 [0.98, 4.09]
2 Change in Range of Movement at four weeks	1	35	Mean Difference (IV, Fixed, 95% CI)	‐10.8 [‐40.76, 19.16]
2.1 Supraspinatus tendinitis	1	35	Mean Difference (IV, Fixed, 95% CI)	‐10.8 [‐40.76, 19.16]
3 Change in night pain at four weeks	1	35	Mean Difference (IV, Fixed, 95% CI)	1.30 [‐1.06, 3.66]
3.1 Supraspinatus tendinitis	1	35	Mean Difference (IV, Fixed, 95% CI)	1.30 [‐1.06, 3.66]
4 Change in pain at rest at four weeks	1	35	Mean Difference (IV, Fixed, 95% CI)	0.80 [‐0.86, 2.46]
4.1 Supraspinatus tendinitis	1	35	Mean Difference (IV, Fixed, 95% CI)	0.80 [‐0.86, 2.46]
5 Change in pain on movement at four weeks	1	35	Mean Difference (IV, Fixed, 95% CI)	1.50 [‐1.01, 4.01]
5.1 Supraspinatus tendinitis	1	35	Mean Difference (IV, Fixed, 95% CI)	1.50 [‐1.01, 4.01]
6 Change in function at four weeks	1	35	Mean Difference (IV, Fixed, 95% CI)	0.90 [‐1.06, 2.86]
6.1 Supraspinatus tendinitis	1	35	Mean Difference (IV, Fixed, 95% CI)	0.90 [‐1.06, 2.86]
7 Change in range of movement at 8 weeks	1	35	Mean Difference (IV, Fixed, 95% CI)	‐25.2 [‐66.36, 15.96]
7.1 Supraspinatus tendinitis	1	35	Mean Difference (IV, Fixed, 95% CI)	‐25.2 [‐66.36, 15.96]
8 Change in night pain at 8 weeks	1	35	Mean Difference (IV, Fixed, 95% CI)	1.20 [‐1.74, 4.14]
8.1 Supraspinatus tendinitis	1	35	Mean Difference (IV, Fixed, 95% CI)	1.20 [‐1.74, 4.14]
9 Change in pain at rest at 8 weeks	1	35	Mean Difference (IV, Fixed, 95% CI)	1.7 [‐0.69, 4.09]
9.1 Supraspinatus tendinitis	1	35	Mean Difference (IV, Fixed, 95% CI)	1.7 [‐0.69, 4.09]
10 Change in pain on movement at 8 weeks	1	35	Mean Difference (IV, Fixed, 95% CI)	1.8 [‐1.14, 4.74]
10.1 Supraspinatus tendinitis	1	35	Mean Difference (IV, Fixed, 95% CI)	1.8 [‐1.14, 4.74]
11 Change in function at 8 weeks	1	35	Mean Difference (IV, Fixed, 95% CI)	0.70 [‐2.08, 3.48]
11.1 Supraspinatus tendinitis	1	35	Mean Difference (IV, Fixed, 95% CI)	0.70 [‐2.08, 3.48]

Outcome or subgroup title	No. of studies	Statistical method	Effect size
1 No pain at end of treatment (6 days)	1	Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.1 Calcific tendinitis	1	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2 No pain at 4‐6 Weeks	1	Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
2.1 Calcific tendinitis	1	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3 Adverse effects	1	Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
3.1 Post treatment pain	1	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3.2 Anxiety/ claustrophobia	1	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3.3 Headache	1	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3.4 Insomnia	1	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Outcome or subgroup title	No. of studies	Statistical method	Effect size
1 Percent change in size of calcium deposit	1	Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.1 Calcific tendinitis	1	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
2 Percent improvement in abduction	1	Mean Difference (IV, Fixed, 95% CI)	Totals not selected
2.1 Calcific tendinitis	1	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain on VAS	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.1 General shoulder pain (mixed diagnoses)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Range of internal rotation at 3 to 4 weeks	2	34	Mean Difference (IV, Fixed, 95% CI)	4.61 [‐0.99, 10.21]
1.1 adhesive capsulitis	1	20	Mean Difference (IV, Fixed, 95% CI)	6.08 [0.06, 12.10]
1.2 rotator cuff impingement	1	14	Mean Difference (IV, Fixed, 95% CI)	‐4.71 [‐19.89, 10.47]
2 Range of abduction at 3 to 4 weeks	2	34	Mean Difference (IV, Fixed, 95% CI)	2.10 [‐10.03, 14.22]
2.1 adhesive capsulitis	1	20	Mean Difference (IV, Fixed, 95% CI)	4.4 [‐9.02, 17.82]
2.2 rotator cuff impingement	1	14	Mean Difference (IV, Fixed, 95% CI)	‐8.15 [‐36.46, 20.16]
3 Pain at 3 to 4 weeks	3		Mean Difference (IV, Fixed, 95% CI)	Subtotals only
3.1 adhesive capsulitis (pain 10 cm VAS)	1	20	Mean Difference (IV, Fixed, 95% CI)	‐2.20 [‐6.13, 1.73]
3.2 rotator cuff impingement (pain composite several 100 mm scales)	1	49	Mean Difference (IV, Fixed, 95% CI)	‐186.23 [‐319.33, ‐53.13]
3.3 rotator cuff impingement (mm on VAS)	1	14	Mean Difference (IV, Fixed, 95% CI)	‐32.07 [‐58.04, ‐6.10]
4 Range of passive abduction at 4 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
4.1 adhesive capsulitis	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
5 Composite strength score at 3 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
5.1 rotator cuff impingement	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
6 Function at 3 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
6.1 rotator cuff impingement	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
7 Pain on subacromial compression (mm on VAS) at 3 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
7.1 rotator cuff impingement	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
8 Range of elevation (degrees) at 3 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
8.1 rotator cuff impingement	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
9 Range of external rotation (degrees) at 3 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
9.1 rotator cuff impingement	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]

Outcome or subgroup title	No. of studies	Statistical method	Effect size
1 Pain at end of intervention period	1	Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.1 General shoulder pain (mixed diagnoses or no diagnosis given)	1	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
2 "Cured" at 5 weeks (participant rated)	1	Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
2.1 General shoulder pain (mixed diagnoses)	1	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3 "Not cured" (participant rated) at 2 and a half years (in those followed up)	1	Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
3.1 General shoulder pain (mixed diagnoses)	1	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Methods	Random 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
Participants	52 participants (mean age treatment group 42, range 27‐65; mean age control group 45, range 24‐60) diagnosed with impingement syndrome
Interventions	Both groups attended for 6 physiotherapy sessions over 3 weeksGroup 1: supervised flexibility and strength exercisesGroup 2: exercises as above plus mobilisation
Outcomes	Assessed at 3 weeks and 2 months1. Isometric strength2. Pain on movement and resistance3. Function (questionnaire)
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment (selection bias)	Unclear risk	B ‐ Unclear

Methods	Random 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
Participants	60 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
Interventions	Four 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
Outcomes	Assessed 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*
Bias	Authors' judgement	Support for judgement
Allocation concealment (selection bias)	High risk	C ‐ Inadequate

Methods	Random 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
Participants	29 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
Interventions	Phase 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
Outcomes	Assessed 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.
Notes	Met 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*
Bias	Authors' judgement	Support for judgement
Allocation concealment (selection bias)	Unclear risk	B ‐ Unclear

Methods	Random 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
Participants	125 patients with pain in shoulder for at least 3 months. Pain resistant to physiotherapy and NSAIDS. Positive impingement test.
Interventions	Group 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.
Outcomes	Assessed at 3 months, 6 months and 2.5 years.Success defined as a Neer shoulder score of >80.
Notes	3 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*
Bias	Authors' judgement	Support for judgement
Allocation concealment (selection bias)	Unclear risk	B ‐ Unclear

Outcome or subgroup title	No. of studies	Statistical method	Effect size
1 No functional limitation at work at 8 weeks	1	Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
1.1 Anterior instability	1	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2 No functional limitation at work at 26 weeks	1	Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected
2.1 Anterior instability	1	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3 No functional limitation at work at 1 year	1	Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
3.1 Anterior instability	1	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4 No functional limitation at in sport at 8 weeks	1	Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
4.1 Anterior instability	1	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5 No functional limitation in sport at 26 weeks	1	Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected
5.1 Anterior instability	1	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6 No functional limitation in sport at 1 year	1	Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected
6.1 Anterior instability	1	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Outcome or subgroup title	No. of studies	Statistical method	Effect size
1 Range of shoulder flexion at 12 weeks	1	Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.1 adhesive capsulitis	1	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
2 Range of shoulder abduction at 12 weeks	1	Mean Difference (IV, Fixed, 95% CI)	Totals not selected
2.1 adhesive capsulitis	1	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
3 Range of shoulder external rotation at 12 weeks	1	Mean Difference (IV, Fixed, 95% CI)	Totals not selected
3.1 adhesive capsulitis	1	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
4 Range of shoulder internal rotation at 12 weeks	1	Mean Difference (IV, Fixed, 95% CI)	Totals not selected
4.1 adhesive capsulitis	1	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
5 Pain at rest at 12 weeks	1	Mean Difference (IV, Fixed, 95% CI)	Totals not selected
5.1 adhesive capsulitis	1	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
6 Pain on movement at 6 weeks	1	Mean Difference (IV, Fixed, 95% CI)	Totals not selected
6.1 adhesive capsulitis	1	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
7 Pain on lying at 6 weeks	1	Mean Difference (IV, Fixed, 95% CI)	Totals not selected
7.1 adhesive capsulitis	1	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Improvement in severity of main complaint at 3 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
1.1 Adhesive capsulitis	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
2 Improvement in severity of main complaint at 7 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
2.1 Adhesive capsulitis	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
3 Improvement in severity of main complaint at 13 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
3.1 Adhesive capsulitis	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
4 Improvement in severity of main complaint at 26 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
4.1 Adhesive capsulitis	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
5 Improvement in severity of main complaint at 52 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
5.1 Adhesive capsulitis	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
6 Pain at 2‐3 weeks (100cm VAS)	2	133	Mean Difference (IV, Fixed, 95% CI)	‐12.18 [‐18.61, ‐5.75]
6.1 Adhesive capsulitis	1	109	Mean Difference (IV, Fixed, 95% CI)	‐10.00 [‐18.67, ‐5.33]
6.2 Rotator cuff disease	1	24	Mean Difference (IV, Fixed, 95% CI)	‐14.60 [‐38.91, 9.71]
7 Improvement in severity of day pain at 7 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
7.1 Adhesive capsulitis	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
8 Improvement in severity of day pain at 13 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
8.1 Adhesive capsulitis	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
9 Improvement in severity of day pain at 26 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
9.1 Adhesive capsulitis	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
10 Improvement in severity of day pain at 52 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
10.1 Adhesive capsulitis	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
11 Improvement in severity of night pain at 3 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
11.1 Adhesive capsulitis	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
12 Improvement in severity of night pain at 7 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
12.1 Adhesive capsulitis	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
13 Improvement in severity of night pain at 13 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
13.1 Adhesive capsulitis	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
14 Improvement in severity of night pain at 26 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
14.1 Adhesive capsulitis	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
15 Improvement in severity of night pain at 52 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
15.1 Adhesive capsulitis	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
16 Improvement in severity as rated by observer at 3 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
16.1 Adhesive capsulitis	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
17 Improvement in severity as rated by observer at 7 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
17.1 Adhesive capsulitis	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
18 Improvement in severity as rated by observer at 26 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
18.1 Adhesive capsulitis	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
19 Improvement in rating of shoulder disability at 3 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
19.1 Adhesive capsulitis	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
20 Improvement in rating of shoulder disability at 7 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
20.1 Adhesive capsulitis	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
21 Improvement in rating of shoulder disability at 13 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
21.1 Adhesive capsulitis	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
22 Improvement in rating of shoulder disability at 26 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
22.1 Adhesive capsulitis	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
23 Improvement in rating of shoulder disability at 52 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
23.1 Adhesive capsulitis	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
24 Range of abduction (degrees) at 2‐3 weeks	2	133	Mean Difference (IV, Fixed, 95% CI)	5.0 [0.36, 9.64]
24.1 Adhesive capsulitis	1	109	Mean Difference (IV, Fixed, 95% CI)	5.0 [0.31, 9.69]
24.2 Rotator cuff disease	1	24	Mean Difference (IV, Fixed, 95% CI)	5.0 [‐24.93, 34.93]
25 Improvement in degree of restriction of ROM of abduction at 7 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
25.1 Adhesive capsulitis	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
26 Improvement in degree of restriction of ROM of abduction at 26 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
26.1 Adhesive capsulitis	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
27 Improvement in degree of restriction of ROM of ER at 3 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
27.1 Adhesive capsulitis	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
28 Improvement in degree of restriction of ROM of ER at 7 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
28.1 Adhesive capsulitis	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
29 Improvement in degree of restriction of ROM of ER at 26 weeks	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
29.1 Adhesive capsulitis	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
30 Number needing additional treatment at 7 weeks	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
30.1 Adhesive capsulitis	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
31 Frequency of adverse reactions	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
31.1 pain after treatment > 2 days	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
31.2 facial flushing	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
31.3 irregular menstrual bleeding	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
31.4 fever	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
31.5 skin irritation	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
31.6 overall	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
32 Short term treatment success	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
32.1 Rotator cuff disease	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Methods	Random 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
Participants	24 participants (mean age treatment group 49.8; mean age control group 50.7) with supraspinatus tendinitis of > 4 weeks duration.
Interventions	All 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
Outcomes	Pain 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.
Notes	Only general improvement in pain data presented in a format suitable for inclusion in the review
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Allocation concealment (selection bias)	Unclear risk	B ‐ Unclear

Study	Reason for exclusion
Anderson 1996	Population not included in this review: post‐operative shoulder surgery
Arciero 1994	Population not included in this review: all patients had sustained trauma.
Arslan 2001	Randomised 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 1979	Not clear if randomised, 2/3 of participants lost to follow up and no between group comparisons
Chee 1986	Population not included in this review: was neck and shoulder pain with no separately reported data.
Curtis 1999	Population not included in this review: wheelchair users not necessarily with shoulder pain. Intervention was unsupervised exercise as prevention of pain and disability
Echternach 1966	Intervention 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 1998	Population not included in this review: myofascial neck and shoulder region pain
Grossi 1986	Population 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 2000	Population not included in this review: myofascial neck and shoulder region pain
Inaba 1972	Population not included in this review: hemiplegia
Lastayo 1998	Population not included in this review: post‐operative shoulder surgery
Leandri 1990	Population not included in this review: hemiplegia
Leboeuf 1987	Population not included in this review: repetitive strain injury of entire upper limb
Livesley 1992	Population not included in this review: trauma
Lloyd‐Roberts 1959	Not randomised.
Lundberg 1979	Population not included in this review: humeral head fractures). Subjects sustained trauma and therefore excluded
Lundblad 1999	Population not included in this review: included participants with neck and shoulder complaints with data from participants with shoulder complaints not presented seperately
Melzer 1995	Not randomised
Meyer 1997	Not randomised
Morgan 1995	Is 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 1990	Trail of high intensity TENS compared to low intensity TENS for analgesia during hydrodilatation (distension arthrography), not as a treatment for shoulder disorder
Partridge 1990	Population not included in this review: hemiplegia
Philipson 1983	Population not included in this review: chronic myofascial syndrome
Quin 1965	Not randomised
Raab 1996	Population not included in this review: post‐operative shoulder surgery
Rahme 1998	Intervention is of surgery
Randlov 1998	Population not included in this review: myofascial neck and shoulder region pain
Ritchie 1997	Intervention is for post shoulder surgery pain relief, not treatment of shoulder disorder.
Rizk 1983	Not randomised
Speer 1996	Intervention is for post shoulder surgery pain relief, not treatment of shoulder disorder.
Spence 1995	Population not included in this review: myofascial neck and shoulder region pain
Vasseljen 1998	Population not included in this review: myofascial neck and shoulder region pain
Vecchini 1984	Capsulitis 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 1992	Population not included in this review: post‐traumatic
Waling 2000	Population not included in this review: myofascial neck and shoulder region pain
Williams 1986	Population not included in this review: rheumatoid arthritis
Wolf 1996	Population not included in this review: post‐operative shoulder surgery

PERMALINK

Physiotherapy interventions for shoulder pain

Sally Green

Rachelle Buchbinder

Sarah E Hetrick

Abstract

Background

Objectives

Search methods

Selection criteria

Data collection and analysis

Main results

Authors' conclusions

Plain language summary

Background

Objectives

Methods

Criteria for considering studies for this review

Types of studies

Types of participants

Types of interventions

Types of outcome measures

Search methods for identification of studies

Data collection and analysis

Results

Description of studies

Risk of bias in included studies

Effects of interventions

1. Results of included studies with data not appropriate for metaview.

Discussion

Authors' conclusions

Implications for practice.

Implications for research.

What's new

History

Notes

Acknowledgements

Data and analyses

Comparison 1. BIPOLAR INTERFERENTIAL CURRENT VERSUS PLACEBO.

1.1. Analysis.

1.2. Analysis.

1.3. Analysis.

1.4. Analysis.

1.5. Analysis.

Comparison 2. ULTRASOUND VERSUS PLACEBO.

2.1. Analysis.

2.2. Analysis.

2.3. Analysis.

2.4. Analysis.

2.5. Analysis.

2.6. Analysis.

2.7. Analysis.

2.8. Analysis.

2.9. Analysis.

2.10. Analysis.

2.11. Analysis.

2.12. Analysis.

2.13. Analysis.

2.14. Analysis.

2.15. Analysis.

2.16. Analysis.

2.17. Analysis.

2.18. Analysis.

2.19. Analysis.

Comparison 3. SUPERVISED EXERCISES VERSUS PLACEBO OR NO TREATMENT.

3.1. Analysis.

3.2. Analysis.

3.3. Analysis.

3.4. Analysis.

3.5. Analysis.

3.6. Analysis.

3.7. Analysis.

3.8. Analysis.

Comparison 4. LASER VERSUS PLACEBO.

4.1. Analysis.

4.2. Analysis.

4.3. Analysis.

4.4. Analysis.

4.5. Analysis.

4.6. Analysis.