Article Review: A Small Expert Consensus for Physiotherapy for Shoulder Pain; An Algorithm Based on Physical Assessment for the Treatment of Shoulder Pain

A new treatment algorithm for physiotherapy treatment of shoulder pain was published in International Orthopedics in April 2015. The paper forms the consensus of 9 European and Australian Shoulder Physiotherapy experts. The goal of this paper was to help less experienced physiotherapists in determining treatments for patients, and to spur on discussion of an international best practice guideline for shoulder rehabilitation. Unique to this article is the use of physical assessment findings to determine treatment instead of the results of imaging tests such as MRI. While there was no consensus among the authors on the specific exercise regimen that should be used, they emphasized two points in regard to exercises, that some form of active exercise therapy causing little to no patient pain should be used, and limiting the number of exercises prescribed to 4 or less to ensure patient compliance.

General guidelines for the type of patient the algorithm should be used to treat include shoulder pain with activity, but minimal pain at rest, no significant passive range of motion reduction when accounting for patient age, and no evidence of shoulder instability. The algorithm is for active exercises, but clinicians may also use other modalities, such as Passive Range of Motion exercise, in conjunction with those listed on the algorithm chart. The algorithm is meant to be used considering only physical assessment, not imaging findings. Reassessment should occur on a frequent basis, and treatment should change with improvement in reducing movement or strength deficits. Noticeable improvement is expected in 3 months of physiotherapy treatment appointments once a week and home exercise. Failure to meet this standard requires further investigation for the correct course of action to relieve shoulder pain. 

In prescribing exercise, the expert panel agreed that presenting symptom pain should not be felt while doing exercises, while non-presenting pain or discomfort due to exertion is tolerable if pain subsides within 12 hours of completing the exercise. Exercises should emphasize quality movement with optimal positioning and movement in the scapulohumeral joint to ensure a progression to subconscious motion. There should be no abnormal trunk muscle substitution during movement. Exercises should be simple, targeting one muscle at first, and limited to four in number, but should be progressed slowly from simple and unloaded to loaded and complex, as well as slow to fast depending on patient shoulder performance.

An emphasis on physical assessment was agreed upon due to little evidence of a link between imaging results and pain experienced by patients, as well as a general lack of consensus in classification systems for shoulder pathologies. Several studies have found little correlation between the degree of deficit or tear in the shoulder tendons shown by imaging and the level of pain experienced by patients. Therefore; the authors reasoned that the best test for shoulder pathology and finding treatment was physical assessment.

For further reading, and to see the algorithm, see the full-text post-print from Linköping University (link below) or the original publication at Springer Link.

References
Klintberg IH, Cools AM, Holmgren TM, Holzhausen AC, Johansson K, Maenhout AG, Moser JS, Spunton V, Ginn K. Consensus for physiotherapy for shoulder pain. Int Orthop. 2015 Apr;39(4):715-20. doi: 10.1007/s00264-014-2639-9. Epub 2014 Dec 31. PubMed PMID: 25548127. Full text post print available here.

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