Best Treatment for Shoulder Pain?

Pauline Anderson

August 06, 2014

Both manual physical therapy (MPT) and corticosteroid injections (CSI) significantly improve symptoms in patients with shoulder impingement syndrome (SIS), but physical therapy may be less costly to the healthcare system, according to a new study.

Physicians might consider physical therapy for patients with SIS — a sort of "catch all" diagnosis encompassing shoulder pain resulting from rotator cuff tendinosis and bursitis in the shoulder area — who don't want injections, said lead study author, Daniel Rhon, PT, DPT, DSc, who at the time of the study was director, research, Department of Physical Medicine, Madigan Army Medical Center, Tacoma, Washington.

"The number one reason patients didn't want to participate in this study was that they didn't want to get an injection, indicating that there is clearly a subset of patents who are averse to injections." For these patients, said Dr. Rhon, physical therapy "would be a great thing to keep top of mind in terms of other treatment options."

The study, which Dr. Rhon believes is the first to compare MPT with CSI "head to head" long term, was published online August 5 in Annals of Internal Medicine.

Dr. Daniel Rhon

Pain and Disability

Researchers randomly assigned consecutive patients aged 18 to 65 years with unilateral shoulder pain to receive CSI or MPT. Patients were referred from family practice and orthopedic clinics. None had had physical therapy or corticosteroid injections within the previous 3 months.

The CSI group received up to 3 injections of 40 mg triamcinolone acetonide 1 month apart. The injections were administered by a family practice physician with sports medicine fellowship training.

Matched to individual impairment, the MPT intervention consisted of a combination of joint and soft-tissue mobilizations, manual stretches, contract-relax techniques, and reinforcing exercises directed to the shoulder girdle or thoracic or cervical spine. Patients were treated twice weekly over a 3-week period and prescribed home exercises.

Ten CSI patients crossed over to receive physical therapy, and 9 in the MPT group crossed over to receive injections.

After 1 year, both the CSI group (n = 52) and the MPT group (n = 46) had a greater than 50% improvement in the Shoulder Pain and Disability Index (SPADI), with neither group being superior. The between-group difference in the SPADI, a 13-item, self-administered questionnaire that includes pain and disability subscales, was 1.55% (95% confidence interval [CI], –6.3% to 9.4%; P = .70). The minimal clinically important difference for the SPADI is a change between 8 and 13 points (6% to 10%).

Ratings on the Global Rating of Change (GRC) scale improved by 3 points (95% CI, 2 - 4) for each group. The GRC measures overall perceived changes in quality of life, with a score of 3 or more points being clinically meaningful.

Self-reported pain intensity as measured by the 11-point Numeric Pain Rating Scale significantly improved from baseline (P < .05) in both groups, but neither intervention was superior (between-group difference 0.4 (95% CI, –0.5 to 1.2; P = .42).

More Smokers

The researchers also looked at related healthcare use. The study showed that 37% of the MPT and 60% of the CSI groups had at least 1 additional healthcare visit to their primary care physician for shoulder pain.

MPT patients had fewer corticosteroid injections than the CSI group (20% vs 38%) after the end of the treatment portion of the study. Even though physical therapy can be costly, Dr. Rhon wondered whether starting patients on injections is "putting them on a path" to needing additional healthcare.

"Is this going to end up taking more time and costing more money in the long run than maybe starting with something like physical therapy at the beginning," said Dr. Rhon.

He said he hopes to compare the costs of the 2 interventions in the future.

As for adverse effects, 10.7% of the CSI group experienced transient pain and 4%, skin pigmentation. There were no reports of adverse effects of MPT.

Sleep quality and obesity can affect shoulder pain prognosis. However, in this study, both groups reported similar effects of pain on their sleep quality, and their baseline weight was similar (mean body mass index, 28.65 kg/m2 for CSI and 28.34 kg/m2 for MPT).

There were, however, twice as many smokers in the MPT group. It's possible, said Dr. Rhon, that the therapy group would have done even better had there been fewer smokers. He and his fellow researchers are now doing a secondary analysis looking at the effect of smoking.

On the other hand, the CSI group had more than twice the number of retired military personnel. However, Dr. Rhon doesn't believe this affected the outcome because the mean age of the 2 groups was almost identical (42 years for CSI and 40 years for MPT).

He pointed out that someone can enter the military at age 18 years and retire before age 40.

Patients and clinicians weren't blinded to the intervention, and the study included only patients referred for physical therapy. Other limitations were lack of standardized diagnostic criteria for SIS and of patients with a full-thickness rotator cuff tear.

Interpret With Caution

Commenting on the study for Medscape Medical News, Richard Radnovich, DO, Injury Care Medical Center, Boise, Idaho, and clinical instructor, University of Washington School of Medicine, Seattle, said that the study was "well thought out and executed" and had "appropriately limited focus" and that the results suggest certain types of manipulation are as effective as injections in treating SIS.

However, said Dr. Radnovich, the study had some drawbacks. For one thing, it looked at MPT techniques provided at a single military hospital with no copayments or other financial impediments to care and didn't compare the cost of this treatment to injections.

"It remains to be seen if patients would get similar results in a fee-for-service environment, or if access was an issue," said Dr. Radnovich.

He pointed out that the therapists in the study may have been "particularly skilled or even gifted" in this area of physical therapy and that physicians providing injections "may not have been particularly skilled."

The data may also have been "skewed" by the fact that the injection group had more than twice the number of retired military than the manipulation group. Military personnel, said Dr. Radnovich, may acquire more "wear and tear" injuries than, for example, dependents.

"Because of these and other limitations, we cannot overly generalize or extrapolate," said Dr. Radnovich. "However, if a patient prefers to avoid injections, and has the time, resources and a skilled manual therapist, trying a course of manipulation for SIS may be a reasonable option."

Dr. Rhon and Dr. Radnovich have disclosed no relevant financial relationships.

Ann Intern Med. 2014;161:161-169. Abstract

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