Daniel Major is working as a PhD-student at the Oslo and Akershus University College. His main area of research is self-managed exercise interventions for shoulder pain. Daniel is also an experienced clinician and has been a leader of the outpatient clinic at the Institute of Physiotherapy. Finally, Daniel is running the Facebook group Major Fysioterapi and writes a blog at www.bevegdegmer.no
In this post, I will try to provide brief answers to some questions I often get and I believe are important related to treatment of patients with chronic shoulder pain. I will try to elaborate with some of my thoughts regarding possibilities of the enhancement of physiotherapy treatment for people with chronic shoulder pain. These thoughts are based on my experience as a physiotherapist and the massive amount of research I have been reading the past year when preparing for the start of my PhD journey.
How common is shoulder pain and what is the cost-of-illness?
Shoulder pain is common, with a point prevalence ranging from 7 to 26% in the general population. A Swedish cost-of-illness study revealed that the mean healthcare cost per patient was €326 (SD 389) during six months, where physiotherapy treatments accounted for 60%. The mean annual total cost was €4139 per patient and the costs for sick leave contributed to 84% of the total costs.
What is the most effective treatment intervention for patients with chronic shoulder pain? Physiotherapy (active exercises) or surgery (arthroscopy)?
To answer big questions like this one, I prefer reading systematic reviews with a meta-analysis. Different studies often reach different conclusions, which could be caused by methodological weaknesses. Saltychev et al., published a systematic review and meta-analysis in 2015, where active exercises and arthroscopy was compared for patients with “shoulder impingement” (also known as subacromial pain, rotator cuff tendinopathy, rotator cuff related shoulder pain, non-specific shoulder pain). Based on seven randomised controlled trials (RCTs) there is moderate evidence that surgery and active exercises are equally as effective in reducing pain intensity among patients with subacromial pain. This was also the conclusion from Brox et al’s RCT, published in BMJ already in 1993. Saltychev et al., conclude that because surgery is associated with higher cost and a higher risk for complications, physiotherapy should be the first choice for patients with “shoulder impingement”. About 2 ½ years ago, Professor Jens Ivar Brox told the Norwegian media (tv2) that about 90 percent too many patients with shoulder pain are undergoing surgery. He also said that for 90 percent of the patients active exercises might be sufficient. Despite the evidence, the number of shoulder surgeries are increasing.
For how long should patients do active exercises before surgery is considered?
I often hear that patients with shoulder pain should try physiotherapy for 3 months before they get surgery. This wording is a little provocative to me as a physiotherapist, because some patients interpret this into that physiotherapy is something they try, before they get the “gold standard”/surgery. As previously described, surgery is not the gold standard. I also think we should question whether 3 months is enough to reduce pain and increase function. When reading studies I often see that there is a further positive change in function and pain measures from 3-6 months. In both Ketola et al., and Bennell et al., the results show this trend, and when looking at Ketola et al’s two year follow-up the change in the outcome measures continues to improve. Therefore, I think we should consider extending the period with active exercises to a minimum of 6 months. However, this does not imply that the patients will have to do supervised physiotherapy for 6 months, but I believe that they should do exercises up to 6 months and preferably continue doing some exercises or general movement, which includes their upper extremities.
If physiotherapy does not work, does surgery work?
Ketola et al., published a subanalysis in 2015, which provided many interesting findings. In this study the authors questions whether surgery will work, if physiotherapy does not. Eighteen patients in the active exercise group were not satisfied with the results and crossed over to surgery. These patients, did however sadly not improve with this intervention either. The authors state that it seems that 1/3 of the patients does not improve with any form of treatment. So, which factors appears to increase the risk of persistent pain? In this study the duration of symptoms, marital status (single), and lack of professional education appeared to increase this risk. There was also a negative correlation between satisfaction at work and the perception of pain.
Which role does expectations have regarding the patient’s “choice of treatment” and the benefit of treatment?
In a study from Dunn et al., it is shown that within patients with full thickness rotator cuff tears, the decision to undergo surgery is more influenced by low expectations regarding physiotherapy than anatomical features of the of the rotator cuff tear. A large multicentre cohort study (n = 1030) from the UK has also shown that positive expectations regarding the physiotherapy treatment is significantly and positively associated with the outcome. It is therefore important to address the patient’s expectations and it must be our job to clarify their expectations and to assist them in having appropriate expectations of recovery. In my opinion, we need to build a strong patient-therapist relationship as a fundament for this journey, which might also increase the patients’ expectations, and has been shown to have a positive effect on treatment outcome.
Is there an optimal exercise program for patients with chronic shoulder pain?
There is to my knowledge, no consensus regarding this question in the literature and no optimal dose to apply to all patients, but it seems that exercises that includes resistance might be an important component. To me this is not shocking, even though it used to annoy me when I was a student and had very little experience treating patients. One-size-fits-all models rarely works, when treating people with multidimensional problems like chronic shoulder pain. There are also some results that show that the amount of exercises influences the patients’ adherence. Maybe we should start with 2-3 meaningful exercises, and gradually progress, change and add on to the exercise program based on the patients’ response. The best exercise is often the exercise that you do. If a patient with chronic shoulder pain presents with fear-avoidance behaviour, maybe we should start with providing pain neuroscience education and graded exposure to these exact movements and make use of cognition-targeted exercise therapy as described by Nijs et al. Based on self-management literature it is important to make a detailed action plan, which the patient believe they will be able to do and provide active follow-up. If the patients does not believe they will be able to adhere to the action plan and/or are having problems adhering to the action plan, it is wisely to do some problem solving with the patient and provide a revised action plan.
Which modifiable factors are associated with a positive outcome?
Higher pain self-efficacy has been shown to be associated with a positive outcome for patients with shoulder pain. In my opinion, we should therefore focus on knowledge translation and effective reassurance to build resilience and provide the patient with active coping strategies, using self-management strategies. Self-efficacy has also been shown to be an important predictor for the patients’ adherence to home based exercises. Findings from chronic low back pain research suggests that pain management and rehabilitation programs should specifically target pain self-efficacy as a key aspect of treatment.
It has been shown that active exercises (physiotherapy) has a similar effect to surgery to a fraction of the cost for patients with subacromial pain. It will be very interesting to see the results from the placebo controlled “The CSAW Study” (Can Shoulder Arthroscopy Work). If surgery ends up being as “effective” as sham surgery, it is my opinion that we as physiotherapist, who provide exercise treatment will also need to consider a change in our management, considering that active exercises is equally as effective as surgery.
Professor Peter O’Sullivan wrote the brilliant editorial; “It’s time for a change in management of non-specific chronic low back pain” in 2011. I believe it’s time for a change in management of non-specific chronic shoulder pain. It is time to move away from the purely pathoanatomical treatment, which in my opinion has been dominant in management of chronic shoulder pain. In a high quality RCT, a standardised manual therapy and home exercise program has not been shown to provide clinical important differences in comparison with a placebo intervention (inactive ultrasound therapy and application of an inert gel). If it is the psychological factors that are most strongly associated with a positive/negative outcome, maybe we should try modifying these factors? I do not believe these are targeted with an approach that solely focuses on force couples, scapula dyskinesis and posture, which according to the literature is less important than many seems to believe. A Norwegian RCT by Fersum et al., has shown superior outcomes of a classification-based cognitive functional therapy for non-specific low back pain when compared with traditional manual therapy and exercise. Is it time to try something similar when treating patients with chronic shoulder pain? I think shoulder researchers and clinicians should get inspired by the work of international leading low back pain researchers, who have acknowledged that the patients often present with a complex interaction of biopsychosocial factors and suggests that our treatment needs to reflect this?
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