Review of Conservative Care Options for Shoulder Pain

Along with back pain, shoulder pain is a major cause for patients to seek medical care.  In fact, shoulder issues are the 3^rd leading musculoskeletal complaint in primary care visits.  An estimated 67% of adults will experience shoulder pain at some point in life, with the most occurrences during the 40-65 years of age range.

The most frequently seen conditions are rotator cuff issues (such as shoulder impingement syndrome – SIS), adhesive capsulitis (AC) and unspecified shoulder pain.  Medical care typically begins with analgesics or exercises.  If that is unsuccessful, more invasive options include steroid injections and surgery.  Both of these options are more financially costly in addition to incurring additional risk factors.

There is evidence that steroid injections may have lasting effects on cellular characteristics and mechanical properties of tendons, especially when used for long-term treatment.  Even with these treatments, only half of the patients have their pain resolved within 6 months, leading to a large group of people suffering chronic shoulder pain.

Many patients have turned to conservative care in a search for relief while avoiding the risks of medications and more invasive procedures.  While reviews are largely positive, there had not been a succinct scientific report confirming this.  To attempt to provide such a report, in 2016, researchers conducted a review of available data to “evaluate the evidence for conservative nondrug, nonsurgical interventions, either alone or in combination, for conditions of the shoulder.”

They found 25 systemic reviews and 44 randomized controlled trials studying adults with a shoulder diagnosis.  While patients in comparison group(s) may have received prescription medication or surgical procedures, the subjects being studied received strictly conservative, non-pharmaceutical, non-surgical interventions.

Primary shoulder diagnosis were: shoulder impingement syndrome (SIS), rotator cuff-associated disorders (RCs), adhesive capsulitis (AC), and nonspecific shoulder pain.  Since studies evaluate various aspects of treatment and recovery, for this review, researchers only looked at pain and function/disability that had been “assessed by valid and reliable patient-based outcome measures.”  When the study included a report of adverse events, this was included for the review.

Below are a few notes regarding their findings:

Noncalcific Rotator Cuff-Associated Conditions:

• Manual therapy may have beneficial effects on pain.
• Combining manual therapy and exercise is effective treatment.
• Dietary advice coupled with acupuncture provided increases in patients’ perceived improvements and the results were maintained through the follow-up time period.

Rotator Cuff Calcific Tendinitis

• Extracorporeal shockwave therapy (ESWT) was shown to increase shoulder function, reduce pain and dissolve calcifications.
• Benefits of ESWT were sustained through the 6-month follow-up.
• While some studies reported a small number of adverse events with ESWT, they were all resolved within a few days.

Adhesive Capsulitis

• Low-level laser therapy (LLLT) may improve overall treatment success.
• LLLT combined with exercise for 8 weeks can lead to improvement in pain for up to 4 weeks and improvement in function for as long as 4 months.
• Mobilization techniques have beneficial effects for patients with primary AC.
• Therapeutic exercises and mobilization therapy are effective for both reducing pain and improving function for stages 2 and 3 AC.
• LLLT appears very effective for pain relief, and moderately effective for improving function, but does not seem to improve range of motion (ROM).
• Manipulative therapy along with exercise was found to be beneficial for treatment of AC.
• LLLT is effective in treatment of frozen shoulder in the short term.

Non-specific Shoulder Pain

• Thoracic Manual Therapy helps speed recovery, reduce pain and disability immediately. Improvements were sustained for up to a year.
• There is some evidence that mobilization and/or manipulation along with soft tissue and exercise may be beneficial for shoulder pain.
• Massage therapy had significant improvement in pain immediately and through the short-term.
• Spinal manipulative therapy of the thoracic spine may help reduce pain and speed recovery in both the short and long term.

Shoulder Impingement Syndrome

• Conservative methods may reduce pain intensity as well as surgery.
• Isokinetic training may help improve pain and disability.
• Manual therapy may significantly improve pain intensity.
• Kinesiotaping (KT) along with exercise may significantly reduce pain and improve function.
• KT may also improve night pain specifically.
• LLLT combined with exercise may improve pain.
• Therapeutic ultrasound combined with exercise may improve pain and function.
• Both supervised exercise and home exercise lead to significant improvements in pain and function that continue up to 26 weeks.

Adhesive Capsulitis

• Extracorporeal shockwave therapy (ESWT) was found to be more beneficial than oral prednisone at 4, 6 and 12 weeks.
• Acupuncture was found to improve pain immediately post-treatment.
• A home stretching program alone was as effective for improving function as the combination of arthroscopic capsular release, manipulation under anesthesia and a home stretching program.

Rotator Cuff-Associated Disorders

• LLLT added to physical therapy (heat, ultrasound, TENS and exercise in this study) produced greater improvements in pain and function.
• Diathermy was as effective as subacromial corticosteroid injection (CSI) for improving pain and function.

Studies Show Conservative Care for Shoulder Conditions Beneficial  

The studies compiled for this review addressed a variety of conditions and interventions.  This variation made it difficult to form solid generalizations.  Additionally, some of the studies were very small.  Some had conflicting findings or had other issues such that they cannot be considered conclusive.  The authors suggest more rigorous research studies to address the various treatment options, both single modalities and combinations, as well as frequency, intensity and duration of the interventions.

Despite these limitations, there is considerable evidence that conservative care may be as good as, and in some cases better for many patients.  Specifically, researchers offer these practical applications:

• Manual therapy is beneficial for common shoulder conditions.
• Low-level laser therapy is beneficial for common shoulder conditions.
• Exercise protocols are beneficial for both Shoulder Impingement Syndrome and Adhesive Capsulitis.

Relief may be closer than you think.  As experts in the musculoskeletal system, chiropractors are an excellent choice for conservative treatment of shoulder pain.  Talk to your chiropractor about your shoulder pain treatment options.

Contact your local chiropractor to schedule an exam, evaluation and discussion of how you may benefit from conservative treatment of shoulder pain.  If you have not previously seen a chiropractor, you may click here to find a TCA member doctor.

 

Reference: “Systematic Review of Nondrug, Nonsurgical Treatment of Shoulder Conditions” by:Cheryl Hawk, DC, PhD, Amy L. Minkalis, DC, MS, Raheleh Khorsan, MA, Clinton J. Daniels, DC, MS, Dennis Homack, DC, MS, Jordan A. Gliedt, DC, Julie A. Hartman, DC, MS, Shireesh Bhalerao, DC, MCR Published in Journal of Manipulative and Physiological Therapeutics, June 2017 Volume 40, Issue 5, Pages 293–319.