Effectiveness of Passive Physical Modalities for Hainan Yu ......! 4! Background: Shoulder pain is a common musculoskeletal condition in the general population. Passive physical modalities

doi: 10.2522/ptj.20140361 Published online November 13, 2014PHYS THER.

Taylor-Vaisey, Sean Abdulla and Yaadwinder Shergillder Velde, Linda Carroll, Craig L. Jacobs, Anne L. Ameis, Maja Stupar, Margareta Nordin, Gabreille M. vanVaratharajan, Danielle Southerst, Silvano A. Mior, Arthur

SharanyaWong, Deborah A. Sutton, Kristi A. Randhawa, Hainan Yu, Pierre Côté, Heather M. Shearer, Jessica J.Protocol for Traffic Injury Management CollaborationShoulder Pain: A Systematic Review by the Ontario Effectiveness of Passive Physical Modalities for

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Running head: Passive Physical Modalities for Shoulder Pain

Research Report

Effectiveness of Passive Physical Modalities for Shoulder Pain: A Systematic Review by the

Ontario Protocol for Traffic Injury Management Collaboration

Hainan Yu, Pierre Côté, Heather M. Shearer, Jessica J. Wong, Deborah A. Sutton, Kristi A.

Randhawa, Sharanya Varatharajan, Danielle Southerst, Silvano A. Mior, Arthur Ameis, Maja

Stupar, Margareta Nordin, Gabreille M. van der Velde, Linda Carroll, Craig L. Jacobs, Anne L.

Taylor-Vaisey, Sean Abdulla, Yaadwinder Shergill

H. Yu, MBBS, MSc, UOIT-CMCC Centre for the Study of Disability Prevention and

Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial

Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario, Canada, M2H 3 J1. Address all

correspondence to Dr Yu at: [email protected]

P. Côté, PhD, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation,

UOIT and CMCC.

H.M. Shearer, DC, MSc, FCCS(C), UOIT-CMCC Centre for the Study of Disability Prevention

and Rehabilitation, UOIT and CMCC.

J.J. Wong, BSc, DC, FCCS(C), UOIT-CMCC Centre for the Study of Disability Prevention and

Rehabilitation, UOIT and CMCC.

by Louis Houle on November 21, 2014http://ptjournal.apta.org/Downloaded from


2

D.A. Sutton, MEd, MSc, UOIT-CMCC Centre for the Study of Disability Prevention and


K.A. Randhawa, MPH, UOIT-CMCC Centre for the Study of Disability Prevention and


S. Varatharajan, MSc, UOIT-CMCC Centre for the Study of Disability Prevention and


D. Southerst, BScH, DC, FCCS(C), UOIT-CMCC Centre for the Study of Disability Prevention

and Rehabilitation, UOIT and CMCC.

S.A. Mior, DC, PhD, Division of Graduate Education and Research, CMCC.

A. Ameis, MD, FRCPC, DESS, DABPM&R, University of Montreal, Quebec, Canada.

M. Stupar, DC, PhD, UOIT-CMCC Centre for the Study of Disability Prevention and


M. Nordin, DrMedSci, Department of Orthopedic Surgery, New York University, New York,

New York.

G.M. van der Velde, DC, PhD, Toronto Health Economics and Technology Assessment

(THETA) Collaborative, University of Toronto, Toronto, Ontario, Canada, and Institute for

Work and Health, Toronto, Ontario, Canada.

L. Carroll, PhD, School of Public Health, University of Alberta, Alberta, Canada.

C.L. Jacobs, BFA, DC, MSc, FCCS(C), UOIT-CMCC Centre for the Study of Disability

Prevention and Rehabilitation, UOIT and CMCC.



3

A.L. Taylor-Vaisey, MLS, UOIT-CMCC Centre for the Study of Disability Prevention and


S. Abdulla, BA, MSc, DC, Department of Graduate Studies, CMCC.

Y. Shergill, BSc, DC, Department of Graduate Studies, CMCC, and Department of Anesthesia,

the Ottawa Hospital, Ottawa, Canada.

[Yu H, Côté P, Shearer H, et al. Effectiveness of passive physical modalities for shoulder pain: a

systematic review by the Ontario Protocol for Traffic Injury Management Collaboration. Phys

Ther. 2015;95:xxx–xxx.]

© 2014 American Physical Therapy Association

Published Ahead of Print: xxxx

Accepted: November 3, 2014

Submitted: August 25, 2014



4

Background: Shoulder pain is a common musculoskeletal condition in the general population.

Passive physical modalities are commonly used to treat shoulder pain. However, previous

systematic reviews report conflicting results.

Purpose: To evaluate the effectiveness of passive physical modalities for the management of

soft tissue injuries of the shoulder.

Data Sources: MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Central Register

of Controlled Trials from January 1st, 1990 to April 18th, 2013.

Study Selection: Randomized controlled trials (RCTs), cohort and case-control studies were

eligible. Random pairs of independent reviewers screened 1470 of 1760 retrieved articles after

removing 290 duplicates. Twenty-two articles were eligible for critical appraisal. We critically

appraised the eligible studies using the Scottish Intercollegiate Guidelines Network criteria. Of

those, 11 studies had a low risk of bias.

Data Extraction: The lead author extracted data from low risk of bias studies and built evidence

tables. A second reviewer independently checked the extracted data.

Data Synthesis: We synthesized the findings of low risk of bias studies according to principles

of best evidence synthesis. We found that pre-tensioned tape, ultrasound and interferential

current are not effective to manage shoulder pain. However, diathermy and corticosteroid

injections lead to similar outcomes. Low-level laser therapy provides short-term pain reduction



5

for subacromial impingement syndrome. Extracorporeal shock-wave therapy is not effective for

subacromial impingement syndrome but it provides benefits for persistent shoulder calcific

tendonitis.

Limitations: Non-English studies excluded.

Conclusions: Most passive physical modalities do not benefit patients with subacromial

impingement syndrome. However, low-level laser therapy is more effective than placebo or

ultrasound for subacromial impingement syndrome. Similarly, shock-wave therapy is more

effective than sham for persistent shoulder calcific tendinitis.



6

INTRODUCTION

Shoulder pain is common in the general population, ranking fourth behind low back pain, knee

pain and neck pain as the most prevalent musculoskeletal conditions.1-3 One third of adults

experience shoulder pain every year.2 Shoulder complaints place a significant burden upon the

health care system.4, 5 In the United Kingdom, 2.4% of the population consult general

practitioners for shoulder pain each year.6 In the United States, more than 500,000 rotator cuff

surgical repairs and shoulder arthroscopies are performed annually.7 Moreover, shoulder injuries

are associated with a substantial economic burden costing an average of €326 per patient during

six months in Sweden.8

Musculoskeletal conditions are commonly managed with passive physical modalities.9, 10

Despite being commonly used, large insurers such as the Ontario Workplace Safety and

Insurance Board (WSIB) do not recommend passive physical modalities for the management of

shoulder pain.11 Such recommendation is consistent with the results of several systematic

reviews suggesting that ultrasound, interferential current therapy and kinesiotaping are equal to

placebo or other interventions for the management of shoulder disorders.12-15 In addition,

evidence on the effectiveness of electromagnetic field therapy, low-level laser therapy and

shock-wave therapy is conflicting.14, 16-18 However, these reviews suffer from methodological

limitations that may have biased their conclusions. Specifically, the reviews pooled quantitative

results from heterogeneous studies13, 14, 16, 17 and synthesized the evidence from studies with

small sample sizes and/or a high risk of bias.12-18



7

Therefore, an up-to-date systematic review is needed to evaluate the effectiveness of passive

physical modalities for soft tissue shoulder injuries. We aim to address the limitations of

previous reviews by assessing the homogeneity of samples across studies. Moreover, our review

aims to minimize bias by restricting our synthesis to high-quality evidence. The purpose of our

review is to determine the effectiveness of passive physical modalities on self-rated recovery,

functional recovery, pain intensity, health-related quality of life, psychological outcomes, and

adverse events in patients with soft tissue injuries of the shoulder.

METHODS

Registration

We registered this review with the International Prospective Register of Systematic Reviews

(PROSPERO) on April 18th, 2013 (CRD42013004854).

Eligibility Criteria

Population: Our review targeted studies of adults and children with soft tissue injuries of the

shoulder. We included grade I-II sprains/strains, nonspecific diffuse shoulder pain, shoulder

tendinitis, impingement syndromes, bursitis, and other soft tissue injuries of the shoulder.19-22 We

excluded studies of shoulder pain due to pathology (e.g., fractures, dislocations, infections,

neoplasms, frozen shoulder or systemic disease). The principles outlined in the Declaration of

Helsinki were followed.

Interventions: We restricted our review to studies on the effectiveness of passive physical

modalities. Passive physical modalities include physical modalities or devices that do not require



8

the active participation of patients (including rest). We divided passive physical modalities into

two categories: physico-chemical and structural.9, 10 Physico-chemical modalities use thermal or

electromagnetic effect, such as cold, heat or light application at the skin level, or light, ultrasonic

or electromagnetic radiation affecting structures beneath the skin. Structural modalities include

non-functional assistive devices that encourage rest in anatomic positions (e.g., pillows, seat

cushions) or actively inhibit or prevent movement (e.g., collars, corsets, casts, slings, and rest

splints); and functional assistive devices that align, support or indirectly facilitate function in the

affected region (e.g., tenodesis splints, taping, and assistive braces).

Comparison groups: We included studies that compared passive physical modalities to other

types of conservative care, waiting list, sham/placebo or no intervention.

Outcomes: We aimed to capture both specific and generic health outcomes. Eligible studies had

to include one of the following outcomes: 1) self-rated recovery (e.g., self-reported on Likert

Scale); 2) functional recovery (e.g., range of motion measured with a goniometer; function

measured with the Constant-Murley Scale; disability measured with the Shoulder Pain and

Disability Index; self-reported return to activities, work or school); 3) pain intensity (e.g.,

measured with the Visual Analog Scale or Numerical Rating Scale); 4) health-related quality of

life (e.g., measured with EuroQol EQ-5D or the SF-36); 5) psychological outcomes (e.g.,

depression measured with the CES-D or Beck Depression Inventory); or 6) adverse events.

Study characteristics: Eligible studies met the following criteria: 1) English language; 2)

published between January 1st, 1990 to April 18th, 2013; 3) randomized controlled trials (RCTs),



9

cohort studies, or case-control studies; and 4) included an inception cohort of a minimum of 30

participants per treatment arm with a soft tissue shoulder injury in RCTs or 100 subjects per

group with the specified condition in cohort studies or case-control studies. We excluded studies

with the following characteristics: 1) letters, editorials, commentaries, unpublished manuscripts,

dissertations, government reports, books and book chapters, conference proceedings, meeting

abstracts, lectures and addresses, consensus development statements, or guideline statements; 2)

pilot studies, cross-sectional studies, case reports, case series, qualitative studies, narrative

reviews, systematic reviews, clinical practice guidelines, biomechanical studies, or laboratory

studies; or 3) cadaveric or animal studies.

Data Sources and Searches

We developed our search strategy with a health sciences librarian (Appendix I). A second

librarian reviewed the search strategy for completeness and accuracy using the Peer Review of

Electronic Search Strategies (PRESS) Checklist.23, 24 We searched MEDLINE, EMBASE,

CINAHL, PsycINFO, and the Cochrane Central Register of Controlled Trials from January 1st,

1990 to April 18th, 2013.

We developed the search strategy in MEDLINE, which was subsequently adapted to the other

bibliographic databases. The search terms included subject headings specific to each database

(e.g., MeSH in MEDLINE) and free text words relevant to passive physical modalities and soft

tissue injuries of the shoulder. We downloaded the search results into a database created using

EndNote X6 (http://endnote.com/if/online-user-manual).



10

Study Selection

We used a two-phase screening process. In phase one, random pairs of independent trained

reviewers (from a pool of eight reviewers) screened citation titles and abstracts to determine

eligibility and classified citations as relevant, possibly relevant or irrelevant. In phase two, the

same pairs of reviewers independently reviewed possibly relevant manuscripts to make a final

determination. Reviewers met to resolve disagreements. If consensus could not be reached, a

third reviewer was used.

Quality Assessment and Data Extraction

Eligible studies were critically appraised by random pairs of independent reviewers (from a pool

of ten reviewers). We assessed the internal validity of studies using the Scottish Intercollegiate

Guidelines Network (SIGN) criteria (Table 1).25 The SIGN criteria were used to qualitatively

evaluate the impact of selection bias, information bias, and confounding on study results. We did

not use a quantitative score or a cutoff point to determine the internal validity of studies.26

Rather, the SIGN criteria were used to assist reviewers in making an informed judgment on the

internal validity of studies.

Specifically, we critically appraised the following methodological aspects: 1) clarity of the

research question; 2) randomization method; 3) concealment of treatment allocation; 4) blinding

of treatment and outcomes; 5) similarity of baseline characteristics between/among treatment

arms; 6) co-intervention contamination; 7) validity and reliability of outcome measures; 8)

follow-up rates; 9) analysis according to intention to treat principles; and 10) comparability of

results across study sites (where applicable). All reviewers were trained to critically appraise



11

studies using the SIGN criteria. Consensus between two reviewers in each pair was reached

through discussion with the involvement of an independent third reviewer where necessary. We

contacted authors when we needed additional information for the critical appraisal to be accurate

and valid. After critical appraisal, studies with a low risk of bias were included in our synthesis.27

The lead author extracted data from studies with a low risk of bias and built evidence tables

(Table 2). A second reviewer independently checked the extracted data. Edits were made using

“Track Changes” in Microsoft Word by the second reviewer and incorporated by the lead author.

Disagreements were resolved through discussion.

Data Synthesis and Analysis

We assessed the clinical homogeneity of studies by comparing the diagnoses, characteristics of

the study samples and the parameters of the interventions. We considered conducting a meta-

analysis if the studies were homogeneous. However, a qualitative best evidence synthesis was

performed if the studies were clinically heterogeneous.27 We used minimal clinically important

differences (MCIDs) to determine the clinical significance of outcome measures. These include a

between-group difference of 1.4/10 cm on the Visual Analog Scale (VAS),28 18/100 on the

Shoulder Pain and Disability Index (SPADI),29 and 8/100 on the short form of the Disabilities of

the Arm, Shoulder, and Hand questionnaire (QuickDASH).30 The MCIDs for range of motion

(ROM), the Simple Shoulder Test (SST), the Constant-Murley Score (CMS) and the University

of California/Los Angeles (UCLA) scales have not been defined in the literature. We synthesized

the evidence according to the outcome measures. Specifically, we report the effectiveness of

interventions according to their impact on specific (e.g., shoulder function) or generic (e.g.,



12

health-related quality of life) outcomes. We stratified our results by shoulder diagnosis and

duration [i.e., recent (< 3 months), persistent (≥ 3 months) or variable (all durations included)].

We computed reviewer agreement for the screening of titles and abstracts and reported kappa

statistics (k) with 95% confidence interval (CI).31 The percentage agreement for critical appraisal

of articles was calculated for the studies with high and low risk of bias. We calculated

differences in mean change from baseline between groups with 95% CI where data were

available to quantify the effectiveness of interventions. We based the computation of the 95% CI

on the assumption that the pre- and post-intervention outcomes were highly correlated (r= 0.8).32,

33

Reporting

This systematic review complies with the Preferred Reporting Items for Systematic Reviews and

Meta-Analyses (PRISMA) statement.34

RESULTS

Study Selection

We retrieved 1760 articles, removed 290 duplicates and screened 1470 articles for eligibility

(Figure 1). Twenty-two articles were eligible for critical appraisal.35-56 Of those, 11 studies

(reported in 12 articles) had a low risk of bias and were included in our synthesis.35-46 Two of the

articles with a low risk of bias (Engebretsen et al., 2009/2011) reported outcomes from different

follow-ups from one study.39, 40 The inter-rater agreement for the screening of articles was

k=0.94 (95% CI 0.88, 1.00). The percentage agreement for the critical appraisal of studies was



13

81.0% (17/21 studies). For the four studies where reviewers disagreed, consensus was reached

through discussion.

Study Characteristics

All 11 low risk of bias studies were RCTs conducted in adults.35-46 Of these, six RCTs addressed

subacromial impingement syndrome,35, 39, 40, 42-45 two investigated nonspecific shoulder pain,36, 46

and three addressed shoulder calcific tendinitis.37, 38, 41 Of the 11 RCTs, five investigated the

effectiveness of shock-wave therapy,37-41, 45 three evaluated the effectiveness of ultrasound,36, 44,

46 and two examined the effectiveness of low-level laser therapy.35, 44 The remaining studies

compared the effectiveness of bipolar interferential current therapy,46 local microwave

diathermy43 and tape.42 The parameters of the passive physical modalities are described in Table

3. The studies were clinically heterogeneous and could not be pooled in a meta-analysis.

Risk of Bias

We critically appraised 21 studies reported in 22 articles. Of these, 11 studies (52%)35-46 had a

low risk of bias and 10 were judged to have a high risk of bias.47-56 All 11 studies with a low risk

of bias blinded data collection, used valid and reliable outcome measures and performed an

intention-to-treat analysis (Table 1).35-46 Eighty-two percent (9/11) of studies with a low risk of

bias used appropriate randomization 35, 36, 38-44, 46 and allocation concealment procedures.35-41, 43,

44, 46 Balance in baseline characteristics was reported in 10/11 studies.35-45 The remaining study

statistically controlled for differences in baseline characteristics.46 The follow-up rate was greater

than 70% in all studies with most (8/11) achieving a follow-up rate of at least 80%.35, 37-40, 42-44, 46



14

Of the 21 studies critically appraised, 10 studies had a high risk of bias and important

limitations.47-56 These limitations related to the methods of randomization (6/10),47-50, 52, 53, 55

concealment of treatment allocation (9/10),47-56 or blinding where possible (4/10).48, 50, 53, 55

Baseline characteristics were not reported in 5/10 studies48, 49, 53, 54, 56 and 3/10 trials reported

clinically important differences between groups at baseline.50, 51, 55 Co-interventions were not

described or accounted for in 8/10 studies.48-51, 53-56 Outcomes were not measured by using a

valid and reliable instrument in one study.47 Most studies (7/10) reported high attrition or

differential attrition between treatment arms, or did not report attrition by groups.48-50, 52, 53, 55, 56

Intention to treat analyses were not conducted or could not be confirmed in all but one study

(9/10).47

Summary of Evidence for Soft Tissue Injuries of the Shoulder

1. Subacromial Impingement Syndrome57 of Variable Duration

Low-level Laser Therapy

Consistent evidence from two RCTs suggests that low-level laser therapy (LLLT) is effective in

providing short-term pain reduction for subacromial impingement syndrome of variable duration.

However, the long-term benefits of LLLT are unknown. Abrisham et al. randomized participants

with subacromial impingement syndrome (rotator cuff and biceps tendinitis) to 10 sessions over

two weeks of: 1) LLLT (wavelength of 890 nm, pulsed mode) and exercise (strengthening,

stretching and mobilization exercises), or 2) placebo laser and the same exercise (Table 2).35

Participants in the LLLT group reported a clinically important reduction in shoulder pain

immediately post-intervention [between group mean change from baseline: VAS 1.6 (95% CI

1.27; 1.93)]. The LLLT group also showed greater improvement in active shoulder flexion



15

(17.8°) and abduction (17.9°) immediately post-intervention. However, the improvements of

shoulder range of motion (ROM) are within the standard error of the measurement (flexion: 25°;

abduction: 21°; as measured by goniometer).58 Similarly, Santamato et al. randomized

participants with subacromial impingement syndrome (≥ 4 weeks duration) to 10 sessions over

two weeks of: 1) high-intensity laser over the upper trapezius, deltoid, and pectoralis minor

muscles; or 2) continuous ultrasound over the superior and anterior peri-articular regions of the

glenohumeral joint and trigger points (Table 2).44 They reported a clinically important difference

in shoulder pain favouring LLLT immediately post-intervention [difference between group mean

change from baseline: VAS 1.69 (95% CI 1.12, 2.27)]. They also reported significant differences

in shoulder function (CMS) favouring LLLT, however the clinical importance of these

differences is unclear because there is no known MCID.

Scapular and Thoracic Pre-tensioned Taping

Evidence from one placebo-controlled crossover RCT suggests that one application of pre-

tensioned tape does not improve pain over placebo tape immediately post-intervention in patients

with subacromial impingement syndrome of variable duration. Lewis et al. randomized

participants with subacromial impingement syndrome (≥1 week duration) to one session of 20-30

minutes: 1) pre-tensioned tape (3.8 cm wide) or 2) placebo (not pre-tensioned) tape (5 cm wide).

A one-hour washout period occurred between interventions (Table 2).42 Both interventions were

applied bilaterally from T1 to T12 and from the center of the spine of the scapula to the T12

spinous process. No differences in pain between the two groups were reported immediately post-

intervention. Although the difference in ROM (measured by inclinometer) was statistically



16

significant, we cannot comment on the clinical importance of these differences because there is

no known MCID.

2. Persistent Subacromial Impingement Syndrome

Shock-Wave Therapy

Evidence from two RCTs suggests that shock-wave therapy is not effective for the management

of persistent subacromial impingement syndrome. Speed et al. randomized participants with

shoulder pain (≥ 3 months) to three sessions (1 session per month over 3 months) of: 1)

extracorporeal shock-wave therapy (dose of 1500 pulses/session, energy of 0.12mJ/mm2) at the

site of maximal tenderness or 2) placebo shock-wave therapy (Table 2).45 No differences in

shoulder pain and disability were found between groups at three months. In a second RCT,

Engebretsen et al. randomized patients with subacromial shoulder pain (≥ 3 months) to: 1) radial

extracorporeal shock-wave therapy (1 session per week / 4-6 weeks), or 2) a multimodal program

of care (supervised clinic and home based posture and endurance exercises and soft tissue

therapy) (2 sessions per week / 12 weeks) (Table 2).39, 40 No differences were found between

groups in shoulder pain (at rest or during activity), function or range of motion. However,

participants receiving a multimodal program of care were more likely than participants receiving

radial extracorporeal shock-wave therapy to report improvement in shoulder pain and disability

(≥19.6 on SPADI) [odds ratio (OR) 3.2 (95% CI 1.3, 7.8)] and to return to work [relative risk

(RR) 1.46 (95% CI 1.06, 2.00)] at 18 weeks.

Diathermy



17

Evidence from one RCT suggests that local microwave diathermy and subacromial corticosteroid

injections lead to similar outcomes in shoulder disability, pain, and function in adults with

persistent subacromial impingement syndrome. Rabini et al. randomized participants to: 1) local

microwave diathermy (3 sessions per week over 4 weeks); or 2) three local posterolateral

subacromial corticosteroid injections (1 injection every 2 weeks at baseline, 2 and 4 weeks)

(Table 2).43 They reported no differences between groups for shoulder disability, pain, and

function at 4, 12, or 24 weeks post-intervention.

3. Nonspecific Shoulder Pain of Variable Duration

Ultrasound

Evidence from two RCTs suggests that ultrasound is not effective for the management of

nonspecific shoulder pain of variable duration. Ainsworth et al., compared: 1) ultrasound

combined with education, exercises and manual therapy to 2) placebo ultrasound, education,

exercises and manual therapy for the management of unilateral nonspecific shoulder pain

(including upper arm pain) aggravated by movement (Table 2).36 Education, exercises and

manual therapy were identical in both groups. There were no differences between groups for

shoulder disability, average pain, global improvement or quality of life up to six months follow-

up. van der Heijen et al. randomized participants with pain in the deltoid region or restricted

glenohumeral range of motion to a six weeks program of: 1) ultrasound plus exercise; 2) placebo

ultrasound plus exercise; or 3) exercise alone (Table 2).46 The exercise program (active and

passive shoulder range of motion) was identical in all groups. There were no differences between

groups in self-perceived recovery, pain or functional capacity at short- and long-term follow-up.



18

Bipolar Interferential Current Therapy

Evidence from one RCT suggests that bipolar interferential current is not effective for the

management of nonspecific shoulder pain of variable duration. van der Heijen et al. randomized

participants with pain in the deltoid region or restricted glenohumeral range of motion to a six-

week program of: 1) bipolar interferential current plus exercise (active and passive shoulder

range of motion); 2) placebo bipolar interferential current plus exercise; or 3) exercise alone

(Table 2).46 The exercise program was standardized across treatment groups. There were no

differences between groups in self-perceived recovery, pain or functional capacity at short- and

long-term follow-up.

4. Persistent Shoulder Pain with Calcific Tendinitis

Shock-wave Therapy

Evidence from three RCTs suggests that shock-wave therapy is effective for improving shoulder

pain and disability in adults with persistent calcific tendinitis. Cacchio et al. randomized

participants with calcific tendinitis and shoulder pain lasting at least six months to four sessions

over four weeks of: 1) radial shock-wave therapy or 2) sham shock-wave therapy (Table 2).38

Clinically important differences in shoulder pain favoured the radial shock-wave therapy

[between group mean change from baseline post-intervention: VAS 5.19 (95% CI 4.7, 5.68) and

at six months: VAS 6.13 (95% CI 5.60, 6.66)]. Participants in the radial shock-wave therapy

group showed larger reductions in calcification size post-intervention. The authors reported



19

statistically significant differences in shoulder function (UCLA) favouring the radial shock-wave

therapy, but their clinical importance is unclear because there is no known MCID.

Two other trials support the results of Cacchio et al. In the first study, Albert et al. evaluated the

effectiveness of varied energy levels of shock-wave therapy for the management of calcific

tendinitis with shoulder discomfort (≥3 months) (Table 2).37 Participants were randomized to two

sessions with a 14 days interval of: 1) high-energy extracorporeal shock-wave therapy; or 2) low-

energy extracorporeal shock-wave therapy. Participants receiving high-energy shock-wave were

more likely to report improvement in shoulder pain and function (≥15 points on CMS) [RR 2.5

(95%CI 1.3, 5.0)] and to perceive treatment efficacy [RR 2.45 (95%CI 1.42, 4.24)] three months

post-intervention. There was no difference between groups for shoulder pain three months post-

intervention. In the second study, Gerdesmeyer et al. evaluated the effectiveness of high-energy,

low-energy and sham extracorporeal shock-wave therapy for the management of calcific

tendinitis with shoulder pain (≥ 6 months).41 Participants were randomized to two 1-hour

sessions with a 12-16 days interval of: 1) high-energy, 2) low-energy, or 3) sham extracorporeal

shock-wave therapy. All groups received ten sessions of physiotherapy following the

interventions (active and passive exercise, mobilization, massage and manual therapy) and pain

medication as needed. Clinically important differences in pain reduction favoured high-energy

over low-energy shock-wave therapy in the short and long-term [between group mean change

from baseline in VAS: 2.3 (95% CI 0.5, 1.3) at three months, 3.1 (95% CI 2.5, 4.3) at six

months, and 3.0 (95% CI 2.3, 3.7) at 12 months]. There were also reductions in the size of

calcifications favoring high-energy over low-energy shock-wave therapy in the short and long-

term. There is no difference in shoulder pain between low-energy and sham extracorporeal



20

shock-wave therapy. There were statistically significant differences in shoulder function (CMS)

among three groups, however the clinical importance of these differences is unclear because

there is no known MCID

5. Adverse Events

Eight of the 11 RCTs with a low risk of bias reported adverse events.35, 37-41, 43, 45, 46 The rate of

non-serious adverse events ranged from 3% for extracorporeal shock-wave therapy (energy=0.12

mJ/mm2)45 to 75% for high-energy extracorporeal shock-wave (energy=0.32 mJ/mm2).41 Non-

serious events included pain, erythema or bleeding (petechiae), hematoma, and aggravation of

presenting pain. No studies reported serious adverse events.

DISCUSSION

Summary of Evidence

We examined the effectiveness of passive physical modalities for the management of soft tissue

injuries of the shoulder. We found that pre-tensioned tape and shock-wave therapy are not more

effective than placebo for the management of subacromial impingement syndrome. Local

microwave diathermy and subacromial corticosteroid injections lead to similar outcomes for the

management of persistent subacromial impingement syndrome. Moreover, ultrasound and

interferential current therapy are not more effective than placebo for nonspecific shoulder pain of

variable duration. However, we found that LLLT is more effective than placebo or ultrasound in

providing short-term (two weeks) pain reduction for subacromial impingement syndrome of



21

variable duration. The long-term benefits of LLLT have not been investigated. Finally, we found

that shock-wave therapy is more effective than sham in improving short- and long-term (over

one year period) shoulder pain and disability for the treatment of persistent calcific tendinitis.

Furthermore, individuals receiving high-energy shock wave therapy reported more adverse

events.

Our review provides insight into the effective range of parameters of passive physical modalities

(Table 3). For laser, the reported parameters include wavelengths of 890nm and 1064nm, power

of 2-4J/cm2 and 0.76J/cm2 and irradiation time of 120s/point.35, 44 These parameters overlap with

the effective range of 820-830nm, 0.8-9.0J/ cm2 and 15-180s; or 904nm, 0.8-4.2J/ cm2 and 100-

600s, proposed by Chow et al.59 For shock-wave therapy, the range for radial medium-energy is

0.08mJ/mm2-0.28mJ/mm2 60 and for focused high-energy is 0.28mJ/mm2-0.60mJ/mm2 60 for the

effective management of persistent calcific tendonitis.37, 38, 41 For ultrasound, diathermy and tape,

we cannot comment on their effective parameters based on the comparison interventions used,

limited information of parameters and the study designs. More research is needed to validate the

effective range of parameters.

Previous Systematic Reviews

We did not identify systematic reviews that comprehensively investigated the effectiveness of

passive physical modalities for soft tissue injuries of the shoulder. However, many systematic

reviews focused on individual passive physical modalities.12-18, 61-65



22

Our results agree with two reviews that ultrasound is not effective for the management of soft

tissue shoulder injuries.12, 14 Our review strengthens these conclusions with the inclusion of a

recent RCT.44 Our conclusion that LLLT is effective for short-term relief of subacromial

impingement syndrome is consistent with von der Heyde et al. but not with Kromer et al.14, 18

This may be explained by the methodology used by Kromer et al. who performed a meta-

analysis of heterogeneous studies.14 We found that extracorporeal shock-wave therapy is

effective for the management of persistent calcific shoulder tendinitis. Our conclusion supports

the review by Ioppolo et al. but contradicts the findings of Lee et al. which was based on a meta-

analysis of outdated heterogeneous studies.16, 17 Our conclusion agrees with Fuentes et al. that

interferential current alone is not better than placebo or other therapies.13 Our review supports

the conclusions of Morris et al. who reported that taping is not more effective than sham or usual

care.15

Generalizability of Passive Physical Modalities in Body Regions

Our review highlights that the effectiveness of passive physical modalities may be modality and

condition specific. For example, previous reviews suggest that LLLT may be effective for the

management of neck pain, but not for persistent low back pain.59, 66-69 In our reviews, we found

evidence that LLLT is effective for the management of subacromial impingement syndrome.

Furthermore, one review found that shock-wave therapy is not effective for treating low back

pain.70 This conclusion agrees with our finding that it is not effective for the management of

subacromial impingement syndrome. However, we found that shock-wave therapy is effective



23

for shoulder calcific tendinitis. Therefore, broad generalizations about the effectiveness of

passive physical modalities cannot be made.

Strengths and Limitations

Our review has several strengths. First, we developed a comprehensive search strategy that was

reviewed by a second independent librarian to minimize errors. Second, we defined an explicit

set of inclusion and exclusion criteria to identify all possibly relevant literature. Third, we used

two independent reviewers for screening and critical appraisal in order to minimize error and

bias. Our methodology was standardized and all reviewers were trained in critical appraisal prior

to commencing the systematic review. Fourth, we used a well-accepted and valid set of criteria

(SIGN) for critical appraisal. Fifth, we performed a best evidence synthesis by including low risk

of bias studies to minimize bias. Finally, we assessed the clinical homogeneity of included

studies.

Our review has limitations. First, we restricted our search to studies published in the English

language. However, this is an unlikely source of bias because most large RCT’s are published in

English.71 Also, previous reviews reported that the restriction of systematic reviews to English

language studies does not lead to bias.72-75 Second, our search may have missed potentially

relevant studies. This may be due to inconsistently indexed terms of passive physical modalities.

Third, critical appraisal requires scientific judgment. However, we trained reviewers to use a

standardized critical appraisal tool and used a consensus to reach decisions regarding the quality



24

of studies. Finally, we did not include qualitative studies that explored the lived experience of

patients treated with passive physical modalities.

CONCLUSIONS

We found evidence that low-level laser therapy is more effective than placebo or ultrasound for

subacromial impingement syndrome at two weeks follow-up. We also found that shock-wave

therapy is more effective than sham for persistent calcific tendinitis over one year follow-up.

However, pre-tensioned tape and shock-wave therapy are not more effective than placebo for

subacromial impingement syndrome. Similarly, ultrasound and interferential current therapy are

not more effective than placebo for nonspecific shoulder pain. Our review challenges the role of

several passive physical modalities for the management of shoulder pain. Clinicians should

select interventions with demonstrated effectiveness.



25

Dr Yu, Dr Côté, Dr Shearer, Dr Wong, Ms Sutton, Ms Randhawa, Ms Varatharajan, Dr

Southerst, Dr Mior, Dr Ameis, Dr Stupar, Dr Nordin, Dr van der Velde, Dr Carroll, and Dr

Jacobs provided concept/idea/research design. Dr Yu, Dr Côté, Dr Wong, and Ms Sutton

provided writing. Dr Yu, Dr Côté, Dr Shearer, Dr Wong, Ms Sutton, Ms Randhawa, Ms

Varatharajan, Dr Southerst, Dr Mior, Dr van der Velde, Ms Taylor-Vaisey, Dr Abdulla, and Dr

Shergill provided data collection. Dr Yu, Dr Côté, and Dr Stupar provided data analysis. Dr Yu,

Dr Côté, Dr Shearer, and Dr Jacobs provided project management. Dr Côté provided fund

procurement, facilities/equipment, and institutional liaisons. Dr Yu provided administrative

support. Dr Côté, Dr Shearer, Dr Wong, Ms Sutton, Ms Randhawa, Ms Varatharajan, Dr

Southerst, Dr Mior, Dr Ameis, Dr Stupar, Dr Nordin, Dr van der Velde, Dr Carroll, Dr Jacobs,

Ms Taylor-Vaisey, Dr Abdulla, and Dr Shergill provided consultation (including review of

manuscript before submission).

This study was funded by the Ontario Ministry of Finance and the Financial Services

Commission of Ontario (RFP# No.: OSS_00267175). This research was undertaken, in part,

thanks to funding from the Canada Research Chairs program (#950-228941). The funding

agency was not involved in the collection of data, data analysis, interpretation of data, or drafting

of the manuscript.

Systematic Review Registration Number: CRD42013004854.



26

DOI: 10.2522/ptj.20140361



27

References

1. Hill CL, Gill TK, Shanahan EM and Taylor AW. Prevalence and correlates of shoulder

pain and stiffness in a population-based study: the North West Adelaide Health Study. Int J

Rheum Dis. 2010; 13: 215-22.

2. Picavet HS and Schouten JS. Musculoskeletal pain in the Netherlands: prevalences,

consequences and risk groups, the DMC(3)-study. Pain. 2003; 102: 167-78.

3. CDC and NCHS (National Center for Health Statistics). 2010. Health, United States,

2010. Chart-book, Special feature on death and dying. Hyattsville, MD: CDC and NCHS.

4. Ostor AJ, Richards CA, Prevost AT, Speed CA and Hazleman BL. Diagnosis and relation

to general health of shoulder disorders presenting to primary care. Rheumatology (Oxford). 2005;

44: 800-5.

5. van der Heijden GJ. Shoulder disorders: a state-of-the-art review. Baillieres Best Pract

Res Clin Rheumatol. 1999; 13: 287-309.

6. Linsell L, Dawson J, Zondervan K, et al. Prevalence and incidence of adults consulting

for shoulder conditions in UK primary care; patterns of diagnosis and referral. Rheumatology

(Oxford). 2006; 45: 215-21.

7. Jain NB, Higgins LD, Losina E, Collins J, Blazar PE and Katz JN. Epidemiology of

musculoskeletal upper extremity ambulatory surgery in the United States. BMC Musculoskelet

Disord. 2014; 15: 4.

8. Virta L, Joranger P, Brox JI and Eriksson R. Costs of shoulder pain and resource use in

primary health care: a cost-of-illness study in Sweden. BMC Musculoskelet Disord. 2012; 13: 17.



28

9. Lindsay DM, Dearness J and McGinley CC. Electrotherapy usage trends in private

physiotherapy practice in Alberta. Physiother Can. 1995; 47: 30-4.

10. Chipchase LS, Williams MT and Robertson VJ. A national study of the availability and

use of electrophysical agents by Australian physiotherapists. Physiother Theory Pract. 2009; 25:

279-96.

11. The Ontario Workplace Safety and Insurance Board. The Shoulder Program of Care

(Shoulder POC). Toronto, Ontario: WSIB, 2012. Available at:

http://www.wsib.on.ca/en/community/WSIB/ArticleDetail?vgnextoid=9bcdb0f3c956a310VgnV

CM100000469c710aRCRD, Accessed: May 02, 2014.

12. Alexander LD, Gilman DR, Brown DR, Brown JL and Houghton PE. Exposure to low

amounts of ultrasound energy does not improve soft tissue shoulder pathology: a systematic

review. Phys Ther. 2010; 90: 14-25.

13. Fuentes JP, Armijo Olivo S, Magee DJ and Gross DP. Effectiveness of interferential

current therapy in the management of musculoskeletal pain: a systematic review and meta-

analysis. Phys Ther. 2010; 90: 1219-38.

14. Kromer TO, Tautenhahn UG, de Bie RA, Staal JB and Bastiaenen CH. Effects of

physiotherapy in patients with shoulder impingement syndrome: a systematic review of the

literature. J Rehabil Med. 2009; 41: 870-80.

15. Morris D, Jones D, Ryan H and Ryan CG. The clinical effects of Kinesio(R) Tex taping:

A systematic review. Physiother Theory Pract. 2013; 29: 259-70.

16. Ioppolo F, Tattoli M, Di Sante L, et al. Clinical improvement and resorption of

calcifications in calcific tendinitis of the shoulder after shock wave therapy at 6 months' follow-

up: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2013; 94: 1699-706.



29

17. Lee SY, Cheng B and Grimmer-Somers K. The midterm effectiveness of extracorporeal

shockwave therapy in the management of chronic calcific shoulder tendinitis. J Shoulder Elbow

Surg. 2011; 20: 845-54.

18. von der Heyde RL. Occupational therapy interventions for shoulder conditions: a

systematic review. Am J Occup Ther. 2011; 65: 16-23.

19. AAOS. http://orthoinfo.aaos.org/topic.cfm?topic=A00551 2014. Available from:

http://orthoinfo.aaos.org/topic.cfm?topic=A00551.

20. Chan O, Del Buono A, Best TM and Maffulli N. Acute muscle strain injuries: a proposed

new classification system. Knee Surg Sports Traumatol Arthrosc. 2012; 20: 2356-62.

21. Noonan TJ and Garrett WE, Jr. Muscle strain injury: diagnosis and treatment. J Am Acad

Orthop Surg. 1999; 7: 262-9.

22. Woodward TW and Best TM. The painful shoulder: part II. Acute and chronic disorders.

Am Fam Physician. 2000; 61: 3291-300.

23. McGowan J, Sampson M and Lefebvre C. An Evidence Based Checklist for the Peer

Review of Electronic Search Strategies (PRESS EBC). 2010.

24. Sampson M, McGowan J, Cogo E, Grimshaw J, Moher D and Lefebvre C. An evidence-

based practice guideline for the peer review of electronic search strategies. J Clin Epidemiol.

2009; 62: 944-52.

25. Harbour R and Miller J. A new system for grading recommendations in evidence based

guidelines. BMJ. 2001; 323: 334-6.

26. van der Velde G, van Tulder M, Cote P, et al. The sensitivity of review results to methods

used to appraise and incorporate trial quality into data synthesis. Spine (Phila Pa 1976). 2007;

32: 796-806.



30

27. Slavin RE. Best evidence synthesis: an intelligent alternative to meta-analysis. J Clin

Epidemiol. 1995; 48: 9-18.

28. Tashjian RZ, Deloach J, Porucznik CA and Powell AP. Minimal clinically important

differences (MCID) and patient acceptable symptomatic state (PASS) for visual analog scales

(VAS) measuring pain in patients treated for rotator cuff disease. J Shoulder Elbow Surg. 2009;

18: 927-32.

29. Breckenridge JD and McAuley JH. Shoulder Pain and Disability Index (SPADI). J

Physiother. 2011; 57: 197.

30. Mintken PE, Glynn P and Cleland JA. Psychometric properties of the shortened

disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) and Numeric Pain

Rating Scale in patients with shoulder pain. J Shoulder Elbow Surg. 2009; 18: 920-6.

31. Cohen J. A coefficient of agreement for nominal scales. Educational and pscyhological

measurement. 1960; 20: 37-46.

32. Abrams KR, Gillies CL and Lambert PC. Meta-analysis of heterogeneously reported

trials assessing change from baseline. Stat Med. 2005; 24: 3823-44.

33. Follmann D, Elliott P, Suh I and Cutler J. Variance imputation for overviews of clinical

trials with continuous response. J Clin Epidemiol. 1992; 45: 769-73.

34. Moher D, Liberati A, Tetzlaff J, Altman DG and Group P. Preferred reporting items for

systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009; 339: b2535.

35. Abrisham SMK-A, M.; Ghahramani, R.; Jabbari, L.; Jomeh, H.; Zare, M. Additive effects

of low-level laser therapy with exercise on subacromial syndrome: a randomised, double-blind,

controlled trial. Clinical Rheumatology. 2011; 30: 1341-6.



31

36. Ainsworth RD, K.; Hiller, L.; Daniels, J.; Bruton, A.; Broadfield, J. A prospective double

blind placebo-controlled randomized trial of ultrasound in the physiotherapy treatment of

shoulder pain. Rheumatology. 2007; 46: 815-20.

37. Albert JDM, J.; Guggenbuhl, P.; Marin, F.; Benkalfate, T.; Thomazeau, H.; Chalès, G.

High-energy extracorporeal shock-wave therapy for calcifying tendinitis of the rotator cuff: a

randomised trial. The Journal of bone and joint surgery British volume 89: 335-41 (2007).

38. Cacchio AP, M.; Barile, A.; Don, R.; de Paulis, F.; Calvisi, V.; Ranavolo, A.; Frascarelli,

M.; Santilli, V.; Spacca, G. Effectiveness of radial shock-wave therapy for calcific tendinitis of

the shoulder: single-blind, randomized clinical study. Physical Therapy. 2006; 86: 672-82.

39. Engebretsen KG, M.; Bautz-Holter, E.; Sandvik, L.; Juel, N. G.; Ekeberg, O. M.; Brox, J.

I. Radial extracorporeal shockwave treatment compared with supervised exercises in patients

with subacromial pain syndrome: single blind randomised study. BMJ (Clinical research ed).

2009; 339: b3360.

40. Engebretsen KG, M.; Bautz-Holter, E.; Ekeberg, O. M.; Juel, N. G.; Brox, J. I.

Supervised exercises compared with radial extracorporeal shock-wave therapy for subacromial

shoulder pain: 1-year results of a single-blind randomized controlled trial. Physical Therapy.

2011; 91: 37-47.

41. Gerdesmeyer LW, S.; Haake, M.; Maier, M.; Loew, M.; Wörtler, K.; Lampe, R.; Seil, R.;

Handle, G.; Gassel, S.; Rompe, J. D. Extracorporeal shock wave therapy for the treatment of

chronic calcifying tendonitis of the rotator cuff: a randomized controlled trial. JAMA : the

journal of the American Medical Association 290: 2573-80 (2003).



32

42. Lewis JSW, C.; Green, A. Subacromial impingement syndrome: the effect of changing

posture on shoulder range of movement. The Journal of orthopaedic and sports physical therapy.

2005; 35: 72-87.

43. Rabini AP, D. B.; Bertolini, C.; Deriu, L.; Saccomanno, M. F.; Santagada, D. A.; Sgadari,

A.; Bernabei, R.; Fabbriciani, C.; Marzetti, E.; Milano, G. Effects of local microwave diathermy

on shoulder pain and function in patients with rotator cuff tendinopathy in comparison to

subacromial corticosteroid injections: a single-blind randomized trial. Journal of Orthopaedic &

Sports Physical Therapy. 2012; 42: 363-70.

44. Santamato AS, V.; Panza, F.; Tondi, G.; Frisardi, V.; Leggin, B. G.; Ranieri, M.; Fiore, P.

Short-term effects of high-intensity laser therapy versus ultrasound therapy in the treatment of

people with subacromial impingement syndrome: a randomized clinical trial.[Erratum appears in

Phys Ther. 2009 Sep;89(9):999]. Physical Therapy. 2009; 89: 643-52.

45. Speed CAR, C.; Nichols, D.; Burnet, S.; Wies, J. T.; Humphreys, H.; Hazleman, B. L.

Extracorporeal shock-wave therapy for tendonitis of the rotator cuff. A double-blind,

randomised, controlled trial. Journal of Bone & Joint Surgery - British Volume. 2002; 84: 509-

12.

46. Van Der Heijden GJL, P.; Wolters, P. J.; Verheijden, J. J.; van Mameren, H.; Houben, J.

P.; Bouter, L. M.; Knipschild, P. G. No effect of bipolar interferential electrotherapy and pulsed

ultrasound for soft tissue shoulder disorders: a randomised controlled trial. Annals of the

Rheumatic Diseases. 1999; 58: 530-40.

47. Johansson KMA, L. E.; Foldevi, M. O. Effects of acupuncture versus ultrasound in

patients with impingement syndrome: randomized clinical trial. Physical Therapy. 2005; 85:

490-501.



33

48. Baskurt ZB, F.; Ozcan, A.; Yilmaz, O. The immediate effects of heat and TENS on

pressure pain threshold and pain intensity in patients with Stage I shoulder impingement

syndrome. Pain Clinic 18: 81-5 (2006).

49. Cosentino RDS, R.; Selvi, E.; Frati, E.; Manca, S.; Frediani, B.; Marcolongo, R.

Extracorporeal shock wave therapy for chronic calcific tendinitis of the shoulder: single blind

study. Annals of the Rheumatic Diseases. 2003; 62: 248-50.

50. Melegati GT, D.; Bandi, M. Effectiveness of extracorporeal shock wave therapy

associated with kinesitherapy in the treatment of subacromial impingement: A randomised,

controlled study; Efficacia della terapia con onde d'urto extracorporee associata a chinesiterapia

nel trattamento della sindrome da conflitto subacromiale: Studio randomizzato controllato.

Journal of Sports Traumatology and Related Research. 2000; 22: 58-64.

51. Montes-Molina RP-B, A.; Martinez-Rodriguez, M. E.; Romojaro-Rodriguez, A. B.;

Gallego-Mendez, V.; Martinez-Ruiz, F. Interferential laser therapy in the treatment of shoulder

pain and disability from musculoskeletal pathologies: a randomised comparative study.

Physiotherapy. 2012; 98: 143-50.

52. Nykanen M. Pulsed ultrasound treatment of the painful shoulder a randomized, double-

blind, placebo-controlled study. Scandinavian Journal of Rehabilitation Medicine. 1995; 27:

105-8.

53. Perlick LL, C.; Bathis, H.; Perlick, C.; Kraft, C.; Diedrich, O. Efficacy of extracorporal

shock-wave treatment for calcific tendinitis of the shoulder: experimental and clinical results.

Journal of Orthopaedic Science. 2003; 8: 777-83.

54. Peters JL, W.; Schwarz, W.; Jacobi, V.; Herzog, C.; Vogl, T. J. Extracorporeal shock

wave therapy in calcific tendinitis of the shoulder. Skeletal Radiology 33: 712-8 (2004).



34

55. Rompe JDB, R.; Hopf, C.; Eysel, P. Shoulder function after extracorporal shock wave

therapy for calcific tendinitis. Journal of Shoulder & Elbow Surgery. 1998; 7: 505-9.

56. Yeldan IC, E.; Razak Ozdincler, A. The effectiveness of low-level laser therapy on

shoulder function in subacromial impingement syndrome. Disability and Rehabilitation. 2009;

31: 935-40.

57. Umer M, Qadir I and Azam M. Subacromial impingement syndrome. Orthop Rev

(Pavia). 2012; 4: e18.

58. Hayes K, Walton JR, Szomor ZR and Murrell GA. Reliability of five methods for

assessing shoulder range of motion. Aust J Physiother. 2001; 47: 289-94.

59. Chow RT, Johnson MI, Lopes-Martins RA and Bjordal JM. Efficacy of low-level laser

therapy in the management of neck pain: a systematic review and meta-analysis of randomised

placebo or active-treatment controlled trials. Lancet. 2009; 374: 1897-908.

60. Harniman E, Carette S, Kennedy C and Beaton D. Extracorporeal shock wave therapy for

calcific and noncalcific tendonitis of the rotator cuff: a systematic review. J Hand Ther. 2004;

17: 132-51.

61. Grant HJ, Arthur A and Pichora DR. Evaluation of interventions for rotator cuff

pathology: a systematic review. J Hand Ther. 2004; 17: 274-99.

62. Green S, Buchbinder R and Hetrick S. Physiotherapy interventions for shoulder pain.

Cochrane Database Syst Rev. 2003: CD004258.

63. Michener LA, Walsworth MK and Burnet EN. Effectiveness of rehabilitation for patients

with subacromial impingement syndrome: a systematic review. J Hand Ther. 2004; 17: 152-64.

64. Robertson VJ and Baker KG. A review of therapeutic ultrasound: effectiveness studies.

Phys Ther. 2001; 81: 1339-50.



35

65. van der Windt DA, van der Heijden GJ, van den Berg SG, ter Riet G, de Winter AF and

Bouter LM. Ultrasound therapy for musculoskeletal disorders: a systematic review. Pain. 1999;

81: 257-71.

66. Yousefi-Nooraie R, Schonstein E, Heidari K, et al. Low level laser therapy for

nonspecific low-back pain. Cochrane Database Syst Rev. 2008: CD005107.

67. Low Back Pain: Early Management of Persistent Non-specific Low Back Pain. London:

Royal College of General Practitioners, 2009.

68. Hurwitz EL, Carragee EJ, van der Velde G, et al. Treatment of neck pain: noninvasive

interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its

Associated Disorders. Spine (Phila Pa 1976). 2008; 33: S123-52.

69. Airaksinen O, Brox JI, Cedraschi C, et al. Chapter 4. European guidelines for the

management of chronic nonspecific low back pain. Eur Spine J. 2006; 15 Suppl 2: S192-300.

70. Seco J, Kovacs FM and Urrutia G. The efficacy, safety, effectiveness, and cost-

effectiveness of ultrasound and shock wave therapies for low back pain: a systematic review.

Spine J. 2011; 11: 966-77.

71. Juni P, Holenstein F, Sterne J, Bartlett C and Egger M. Direction and impact of language

bias in meta-analyses of controlled trials: empirical study. Int J Epidemiol. 2002; 31: 115-23.

72. Moher D, Fortin P, Jadad AR, et al. Completeness of reporting of trials published in

languages other than English: implications for conduct and reporting of systematic reviews.

Lancet. 1996; 347: 363-6.

73. Moher D, Pham B, Lawson ML and Klassen TP. The inclusion of reports of randomised

trials published in languages other than English in systematic reviews. Health Technol Assess.

2003; 7: 1-90.



36

74. Morrison A, Polisena J, Husereau D, et al. The effect of English-language restriction on

systematic review-based meta-analyses: a systematic review of empirical studies. Int J Technol

Assess Health Care. 2012; 28: 138-44.

75. Sutton AJ, Duval SJ, Tweedie RL, Abrams KR and Jones DR. Empirical assessment of

effect of publication bias on meta-analyses. BMJ. 2000; 320: 1574-7.



38

Table 1: Risk of Bias for Accepted Randomized Controlled Trials based on Scottish Intercollegiate Guidelines Network (SIGN) Criteria 25

Author, Year

Research

Question

Randomi-zation

Conceal-ment

Blinding Similarity at

baseline

Similarity between

arms

Outcome measure-

ment

Percent drop-out†

Intention to treat

Comparable results between

sites

Abrisham et al., 201135

Y Y Y Y Y Y Y 0% for both group

Y NA

Ainsworth et al., 200736

Y Y Y Y Y Y Y U/S: 26.5% Placebo: 31.5%

Y CS

Albert et al., 200737

Y CS Y Y Y CS Y High-energy ESWT:2.5% Low-energy ESWT:2.5%

Y NA

Cacchio et al., 200638

Y Y Y Y Y Y Y RSWT: 0%; Sham RSWT:

13.3%

Y NA

Engebretsen et al., 2009 and 201139, 40

Y Y Y Y Y Y Y Radial ESWT:11.5%

SE:7.7%

Y NA

Gerdesmeyer et al., 200341

Y Y Y Y Y Y Y High ESWT:27.1%

Low ESWT:8.3%

Sham ESWT:33.3%

Y Y

Lewis et al., 200542

Y Y CS Y Y CS Y 0% for both group

Y NA

Rabini et al, 201243

Y Y Y Y Y CS Y LMD:17.4% SCI:15.2%

Y NA

Santamato et Y Y Y Y Y Y Y 0% drop out Y NA



39

Author, Year

Research

Question

Randomi-zation

Conceal-ment

Blinding Similarity at

baseline

Similarity between

arms

Outcome measure-

ment

Percent drop-out†

Intention to treat

Comparable results between

sites

al, 200944 in each arm Speed et al., 200245

Y CS CS Y Y CS Y ESWT:20.6% Placebo

ESWT:20.0%

Y NA

van der Heijden et al, 199946

Y Y Y Y N Y Y Overall: 1.7% (3/180)

Y CS

Acronyms: CS: can’t say (insufficient detail to allow an assessment to be made); ESWT: extracorporeal shock-wave therapy; ET: electrotherapy; LMD: local microwave diathermy; N: no; N/A: not applicable; RSWT: radial shock-wave therapy; SCI: subacromial corticosteroid injection; SE: supervised exercise; U/S: ultrasound; Y: yes.

†percent drop-out is the overall dropout rate at the end of the follow-up.



40

Table 2: Evidence table for accepted randomized controlled trials on passive modalities for shoulder soft tissue injuries

Author(s), Year

Subjects and Setting; Number

(n) Enrolled

Interventions; Number (n) of

Subjects

Comparisons; Number (n) of

Subjects Follow-up Outcomes Key Findings

Abrisham et al., 201135

Participants (≥18 y.o.) presenting toa clinic in Yazd, Iran.

Case definition: subacromial impingement syndrome (rotator cuff and biceps tendinitis). (n=80)

Low-level laser therapy (LLLT) by a physiotherapist (10 sessions/ 2 weeks): pulsed infrared laser radiation (wavelength=890nm, time= 2 min/point, power 2-4 j/cm2 at coracoid, glenohumeral joint, rotator cuff tendon and biceps tendon); exercise program (strengthening, stretching and mobilization exercises in clinic and at home). (n=40)

Placebo by same physiotherapist (10 sessions/2 weeks): placebo laser therapy (inactivated radiation); same exercise program. (n=40)

Immediately post-intervention (2 weeks following the start of treatment)

Shoulder pain (VAS, 0-10); active and passive shoulder ROM (goniometer, °).

Adverse events

Difference in mean change (LLLT - placebo)*

Shoulder pain (VAS, 0-10): 1.6 (95% CI 1.27, 1.93) Active shoulder flexion: 17.8 (95% CI16.08, 19.52) Passive shoulder flexion: 21 (95% CI 18.98, 23.02) Active shoulder abduction: 17.9 (95% CI 15.83, 19.97) Passive shoulder abduction: 14.1 (95% CI 12.08, 16.12) Active shoulder external rotation: 3.7 (95% CI 2.39, 5.01) Passive shoulder external rotation: 7.2 (95% CI 5.74, 8.66)

No adverse events reported.

Ainsworth et al., 200736

Participants (≥ 18 y.o.) referred tophysiotherapy in Birmingham, UK between January

Ultrasound therapy (US) by physiotherapists (maximum 8 20-min sessions):

Placebo by physiotherapist (maximum 8 20-min sessions): placebo ultrasound

2 and 6 weeks, 6 months

Primary outcome: disability (SDQ-UK, 0-100);

No statistically significant difference between groups at any of the follow-up points.



41

Author(s), Year


(n) Enrolled


Subjects



1999 and September 2001.

Case definition: unilateral shoulder pain exacerbated by active or passive shoulder movement. (n=221)

varied dose of pulsed ultrasound, exercise, manual therapy (no acupuncture and other electrotherapy modalities), and education (advice sheet). (n=113)

(inactivated), exercise, manual therapy (no acupuncture and other electrotherapy modalities), and education (advice sheet). (n=108)

Secondary outcome: global assessment of improvement (5-point scale); average pain during previous 24h (VAS 0-10); global perception of shoulder problem affection (VAS 0-10); global HRQoL (EuroQol EQ-5D and EuroQol health thermometer); range of movement.

Albert et al., 200737

Participants (18-75 y.o.) referred byrheumatologists

High-energy extracorporeal shock-wave

Low-energy extracorporeal shock-wave

3 months post-interventio

Primary outcome: shoulder pain

Difference in mean change (hESWT – lESWT)

Shoulder pain and function (CMS, 0-100): 8.0



42

Author(s), Year


(n) Enrolled


Subjects



and orthopaedic surgeons, France.

Case definition: shoulder discomfort (≥3 months) with radiological evidence of calcification (≤10 mm in largest diameter) type I (homogenous structure and sharp contours) or type II (non-homogenous structure and sharp contours). (n=80)

therapy (hESWT) (2 sessions with 14 days interval): dose=2500 impulses/session, frequency = 1Hz for the first 200 impulses and 2Hz thereafter, energy= maximum tolerated energy but <0.45 mJ/mm2 per impulse. (n=40)

therapy (lESWT) (2 sessions with 14 days interval): dose=2500 impulses/session, frequency = 1Hz for the first 200 impulses and 2Hz thereafter, energy gradually increased from 0.02 mJ/mm2

to 0.06 mJ/mm2 per impulse (145 mJ/mm2 per session). (n=40)

n and function (CMS, 0-100);

Secondary outcome: shoulder pain during previous 48h (VAS, 0-10), global assessment of treatment efficacy (5-level verbal scale).

Adverse events

(95% CI 0.9-15.1) Activities of daily living (subscale of CMS, 0-20): 2.1 (95%CI 0.1, 4.1)

Improvement (≥15 points on CMS, 0-100) favoring hESWT: RR 2.5 (95%CI 1.3, 5.0)* Treatment efficacy favoring hESWT: RR 2.45 (95%CI 1.42, 4.24)*

No statistically significant difference between groups in other subscales of CMS and shoulder pain.

No serious events reported. In the active group 14 and 15 patients developed superficial skin lesions (petechiae or small bruises) during the first and second treatment sessions respectively. All the lesions disappeared within 48h. No skin lesions occurred in the control group.


Participants (≥18y.o.) recruited between November 2002 and December 2003, Italy.

Radial shock-wave therapy (RSWT) by a physician (4 sessions with 1 week interval): dose=2500 impulses/session,

Sham RSWT by same physician (4 sessions with 1 week interval): same treatment procedure as RSWT group

Immediately post-intervention, 6 months

Primary outcomes: shoulder pain and function (UCLA, 0-35), shoulder pain (VAS,

Post-intervention Difference in mean change (RSWT – Sham RSWT)* Shoulder pain and function (UCLA, 0-35): 21.73 (95%CI 21.00, 22.46) Shoulder pain (subscale of UCLA, 0-10): 4.7 (95%CI 4.25, 5.15)



43

Author(s), Year


(n) Enrolled


Subjects



Case definition: shoulder pain (≥6 months and ≥4 on VAS at baseline) and radiographically verified shoulder calcific tendinitis with type I (homogenous structure and sharp contours) or type II (non-homogenous structure and sharp contours) calcification. (n=90)

pressure=1.5 bar for first 500 impulses and 2.5 bar thereafter, frequency= 4.5Hz for the first 500 impulses and 10Hz thereafter, energy flux density= 0.10mJ/mm2, time/impulse=2ms. (n=45)

except dose=25 impulses/session, pressure=1.5 bar for first 5 impulses and 2.5 bar thereafter, frequency= 4.5Hz for the first 5 impulses and 10Hz thereafter

0-10);

Secondary outcome: decrease of calcifications post-intervention (radiography, using Gartner and Simons Classification and calipers).

Adverse events

Active range of forward flexion (subscale of UCLA): 50.74 (95%CI 43.04, 58.44) Strength of forward flexion (subscale of UCLA, 0-5): 0.99 (95%CI 0.73, 1.25) Patient satisfaction (subscale of UCLA, 0-5): 3.14 (95%CI2.63, 3.65) Shoulder pain (VAS, 0-10): 5.19 (95%CI 4.7, 5.68) Decrease of calcification (radiography): 19.6mm (95%CI 17.15, 22.05)

No statistically significant difference between groups in function (subscale of UCLA)

6 months Difference in mean change (RSWT – Sham RSWT)* Shoulder pain and function (UCLA, 0-35): 22.44 (95%CI 21.48, 23.40) Shoulder pain (subscale of UCLA, 0-10): 4.96 (95%CI 4.69, 5.23) Active range of forward flexion (subscale of UCLA): 63.39 (95%CI 56.05, 70.73) Strength of forward flexion (subscale of UCLA, 0-5): 1.1 (95%CI 0.85, 1.35) Function (subscale of UCLA): 2.13 (95%CI 1.71, 2.55) Patient satisfaction (subscale of UCLA, 0-5): 3.59 (95%CI 3.31, 3.87) Shoulder pain (VAS, 0-10): 6.13 (95%CI 5.60,



44

Author(s), Year


(n) Enrolled


Subjects



6.66)

No serious adverse events reported in both groups. Hematoma (lasting 4-6 days) was reported by 3 (6.7%) participants in RSWT group but did not cause discomfort, pain or withdrawal from the study.

Engebretsen et al., 2009 and 201139,

40

Participants (18-70 y.o.) in anoutpatient clinic in Ullevaal, Norway between 2006 and 2008.

Case definition: subacromial shoulder pain (≥3 months). (n=104)

Radial extracorporeal shock-wave therapy (rESWT) by a physiotherapist (1 session per week/4-6 weeks): low-to medium energy, frequency = 8-12 Hz, pressure = 2.5 to 4.0 bar, dose≥2000 pulses/session at insertion of supraspinatus tendon, dorsolaterally below acromion and maximum of 3 trigger points in rotator cuff

Multimodal program of care (MPC) by 2 physical therapists (2 45-min sessions per week /maximal 12 weeks): supervised posture and endurance exercise of rotator cuff and subacromial structures, soft tissue therapy to loosen tense muscles and adjusted home-based exercise (correction of alignment and simple low-load exercises). (n=52)

12 and 18 weeks, and 1 year

Primary outcome: shoulder pain and disability (SPADI, 0-100);

Secondary outcomes: pain intensity during rest and activity (9-point Likert scale, 0(no pain) to 9 (sever pain)), specific shoulder functioning (7-point Likert scale,

Difference in mean change (rESWT – MPC)

12 weeks Shoulder pain and disability (SPADI 0-100): -10.3 (95%CI -19.8, -0.8)

No statistically significant differences between the two groups in other outcome measures at 12 weeks.

18 weeks Shoulder pain and disability (SPADI 0-100): -8.4 (95%CI -16.5, -0.6)

Improvement (≥19.6 on SPADI) of shoulder pain and disability favoring MPC group: OR 3.2 (95%CI 1.3, 7.8)

Returned to work favoring MPC group: RR 1.46 (95%CI 1.06, 2.00)*

No statistically significant differences between



45

Author(s), Year


(n) Enrolled


Subjects



muscles. (n=52) 1 (easy) to 7 (impossible)), active ROM, returned to work, daily and weekly medication used.

Adverse events

the two groups in pain during rest and activity, function, active ROM, and medication use.

1 year: Returned to work favoring MPC group: OR 1.1 (95%CI 1.0, 1.2)

No statistically significant differences between the two groups in the shoulder pain and disability (SPADI), pain intensity during rest and activity, function and medication use.

Adverse events: 2 participants reported aggravation of pain in rESWT group.


Participants (≥18 y.o.) referred byprimary care physicians, orthopedic surgeons and sports physicians from 7 orthopedic departments in Germany and Austria between February 1997 and March 2001.

Case definition: shoulder symptoms

High-energy extracorporeal shock-wave therapy (hESWT) (2 1-hour sessions with 12 to16 days interval followed by 10 physiotherapy sessions): dose=1500 impulses/session, energy=0.32mJ/mm2, frequency=120 impulses/minute, total energy

Low-energy extracorporeal shock-wave therapy (lESWT) (2 1-hour sessions with 12 to 16 days interval followed by 10 physiotherapy sessions): Dose=6000 impulses/session, energy=0.08mJ/mm2, frequency=120 impulses/minute, total energy

3, 6 and 12 months post-intervention

Primary outcome: shoulder pain and function (CMS, 0-100) at 6 months post-intervention;

Secondary outcomes: shoulder pain and function (CMS, 0-100) at 3 and 12 months

3 months Difference in mean change (hESWT – sESWT) Shoulder pain and function (CMS, 0-100): 16.4 (95%CI 10.3, 22.5) Proportion of patients with 30% improvement on CMS: 0.56 (95%CI 0.36, 0.71) Pain (VAS, 0-10): 3.2 (95%CI 2.2, 4.2) Decrease of calcific deposit (mm2): 98.6 (95%CI 51.8, 145.4)

Difference in mean change (lESWT – sESWT) Pain and function (CMS, 0-100): 6.6 (95%CI 0.1, 13.1) Shoulder ADL (subscale of CMS, 0-20): 2.0 (95%CI 0.2, 3.7)



46

Author(s), Year


(n) Enrolled


Subjects



(≥6 months), radiographically diagnosed type I (homogenous structure and sharp contours) or type II (non-homogenous structure and sharp contours) calcific deposits (≥5mm diameter), and resistant to conservative care (physiotherapy and local anesthetic or corticosteroid injections and NSAIDs). (n=144)

received/2 sessions=0.960 J/mm2; physiotherapy (10 sessions after hESWT: active and passive exercise mobilization techniques, massage, and manual therapy); pain medication as needed. (n=48)

received/2 sessions=0.960 j/mm2; same physiotherapy and pain medication as hESWT group. (n=48)

Sham extracorporeal shock-wave therapy (sESWT) (2 1-hour sessions with 12 to 16 days interval followed by 10 physiotherapy sessions): the same setting as hESWT group and air-chambered polyethylene foil used to block shock wave; same physiotherapy and pain mediation as hESWT group. (n=48)

post-intervention, shoulder pain (VAS, 0-10), presence and size of calcified deposits (radiography).

Adverse events

No statistically significant difference in shoulder pain (CMS), range of motion, power, proportion of patients with 30% improvement, shoulder pain (VAS) and calcific deposit size between the two groups.

Difference in mean change (hESWT – lESWT) Pain and function (CMS, 0-100): 9.6 (95%CI 3.4, 15.8) Proportion of patients with 30% improvement on CMS: 0.37 (95%CI 0.18, 0.55) Pain (VAS, 0-10): 2.3 (95%CI 1.37, 3.23)* Decrease of calcific deposit (mm2): 72.6 (95%CI 8.2, 141.1)

No statistically significant difference in shoulder range of motion between the two groups.

6 months Difference in mean change (hESWT – sESWT) Pain and function (CMS, 0-100): 24.4 (95%CI 17.8, 31.0) Proportion of patients with 30% improvement on CMS: 0.72 (95%CI 0.55, 0.84) Pain (VAS, 0-10): 3.7 (95%CI 2.7, 4.7) Decrease of calcific deposit (mm2): 111.8 (95%CI 63.2, 160.5)

Difference in mean change (lESWT – sESWT)



47

Author(s), Year


(n) Enrolled


Subjects



Pain and function (CMS, 0-100): 8.4 (95%CI 1.4, 15.4) Proportion of patients with 30% improvement on CMS: 0.24 (95%CI 0.05, 0.42) Pain (VAS, 0-10): 1.3 (95%CI 0.4, 2.2)

No statistically significant difference in decrease of calcific deposits between the two groups.

Difference in mean change (hESWT – lESWT) Pain and function (CMS, 0-100): 16.0 (95%CI 10.8, 22.9) Proportion of patients with 30% improvement on CMS: 0.48 (95%CI 0.30, 0.63) Pain (VAS, 0-10): 3.1 (95%CI 2.5, 4.3) Decrease of calcific deposit (mm2): 75.1 (95%CI 9.0, 144.3)

12 months Difference in mean changes (hESWT – sESWT) Pain and function (CMS, 0-100): 17.9 (95%CI 11.1, 24.7) Proportion of patients with 30% improvement on CMS: 0.72 (95%CI 0.53, 0.85) Pain (VAS, 0-10): 3.7 (95%CI 2.7, 4.7) Decrease of calcific deposit (mm2): 115.4 (95%CI 65.4, 165.4)



48

Author(s), Year


(n) Enrolled


Subjects



Difference in mean change (lESWT – sESWT) Proportion of patients with 30% improvement on CMS: 0.23 (95%CI 0.01, 0.43)

No statistically significant difference in shoulder pain and function, shoulder pain (CMS), activities of daily living, range of motion, power, shoulder pain (VAS) and calcific deposit size between the two groups.

Difference in mean change (hESWT – lESWT) Pain and function (CMS, 0-100): 13.9 (95%CI 8.3, 19.7) Proportion of patients with 30% improvement on CMS: 0.49 (95%CI 0.31, 0.64) Pain (VAS, 0-10): 3.0 (95%CI 2.3, 3.7) Decrease of calcific deposit (mm2): 70.7 (95%CI 1.9, 139.5)

No serious adverse events except severe pain. 20 participants reported moderate pain and 16 reported severe pain in the hESWT group. 22 participants reported moderate pain and 5 reported severe pain in the lESWT group. 25 participants reported some sensation of pain in the sESWT group.

Petechiae, bleeding, hematoma, or erythema were found in three groups (36 in hESWT, 32 in lESWT and 8 in sESWT).



49

Author(s), Year


(n) Enrolled


Subjects



Lewis et al., 200542

Participants (18-75 y.o.) in Coventry, the UK. Case definition: unilateral shoulder pain (>1 week) localized to acromion and produced/increased during shoulder flexion/adduction with positive impingement signs. (n=60)

Cross-over study: each participant treated by treatment tape and placebo tape with 1 hour wash-out period. Treatment tape: pre-tensioned tape (3.8-cm-wide Leukotape) applied bilaterally from T1 to T12 while participants fully retracted and depressed scapula and extended their thoracic spine. (n=60)

Placebo tape: tape (5-cm-wide Fixomull Tape) not pre-tensioned and applied over same locations as treatment group while participants remained their natural postures. (n=60)

Immediately post-intervention

Pain-free range of shoulder flexion (inclinometer, °), pain-free range of scapular plane abduction (inclinometer, °), pain during shoulder flexion (VAS, 0-10), pain during shoulder scapular plane abduction (VAS, 0-10)

Difference in mean change (pre-tensioned tape – placebo tape) Pain-free range of shoulder flexion: 16.2 (99%CI 7.9, 24.4) Pain-free range of scapular abduction: 14.7 (99%CI 5.7, 23.6) No statistically significant difference in pain between groups.

Rabini et al., 201243

Participants (≥18 y.o.) recruited from a hospital outpatient clinic in Rome, Italy. Case definition: rotator cuff

Local microwave diathermy (LMD) by a physiotherapist (3 30-min sessions/week for 4 weeks): power=40w,

Subacromial corticosteroid injections (SCI) by a physician (3 local injections, 1 injection/ 2 weeks): 1 mL 40 mg methylprednisolon

4, 12, 24 weeks post-intervention

Primary outcome: disability (QuickDASH, 0-100); Secondary outcomes:

No statistically significant difference between groups at any of the follow-up points. No adverse events reported in both groups.



50

Author(s), Year


(n) Enrolled


Subjects



tendinopathy (including degenerative rotator cuff tendinopathy with or without partial-thickness tendon tears) diagnosed clinically with imaging and shoulder pain (≥3 months). (n=92)

silicone pad water temperature= 38°C, silicone pad located between the glenoid and the humeral head, participants lying supine with the arm at 60° of abduction and externally rotated. (n=46)

e acetate containing 10 mg lidocaine chlorhydrate injected, using a 21-gauge needle, through a posterolateral access. (n=46)

shoulder pain and function (CMS, 0-100), shoulder pain (VAS, 0-100)

Adverse events

Santamato et al., 200944

Participants attending a university hospital in Foggia, Italy between September 2006 and July 2007.

Case definition: shoulder pain (≥4 weeks) and diagnosis of subcaromial impingement syndrome (shoulder pain, pain on abduction with a painful arc,

High-intensity laser therapy (HILT) by a physiatrist (10 10-min sessions/2 weeks): pulsed laser, peak power=1kW, average power=6W, maximum energy of single impulse=150mJ, duration of single impulse<150milliseconds, fluency=760mJ/cm2, wavelength=1064n

Ultrasound therapy (US) provided by a physical therapist (10 10-min sessions/2 weeks): continuous ultrasound (frequency=1MHz, intensity=2W/cm2, duty cycle=100%), slow circular movement of transducer head over the superior and anterior periarticular regions of glenohumeral joint

Immediately post-intervention (2 weeks following the start of treatment)

Shoulder pain (VAS, 0-10), shoulder pain and function (CMS, 0-100), pain and function (SST, 0-100)

Difference in mean change ( HILT – US)

Shoulder pain (VAS, 0-10): 1.69 (95% CI 1.12, 2.27) Shoulder pain and function (CMS, 0-100): 3.66 (95% CI 2.13, 5.19) Pain and function (SST, 0-100): 0.63 (95% CI 0.18, 1.08)



51

Author(s), Year


(n) Enrolled


Subjects



positive impingement sign, relief of pain within 15 minutes of anesthestic injection into subacromial space, and confirmation of stage I or II by diagnostic ultrasound/MRI).. (n=70)

m. Three phasesper session: 1) fast manual scanning of upper trapezius, deltoid, and pectoralis minor in transverse and longitudinal directions (total energy 1000J), 2) handpiece fixed vertically over trigger points until 70 to 80% pain reduction (total energy 50J), 3) slow manual scanning of upper trapezius, deltoid, and pectoralis minor in transverse and longitudinal directions (total energy 1000J) (n=35)

and trigger points. (n=35)

Speed et al., 200245

Participants (>18 y.o.), UK.

Case definition: shoulder pain (≥3

Extracorporeal shock-wave therapy (ESWT) (1 session per month/3 months):

Placebo ESWT (1 session per month/3 months): treatment head deflated, no gel

1 and 3 months post-intervention

Shoulder pain and disability (SPADI, 0-100), night

No statistically significant difference between two groups at any of the follow-up points.

No serious adverse events reported. One participant in ESWT group cannot tolerate



52

Author(s), Year


(n) Enrolled


Subjects



months) and clinical signs of a unilateral non-calcific tendonitis of the rotator cuff. (n=74)

dose=1500 pulses/session, energy= 0.12 mJ/mm2 at site of maximal tenderness. (n=34)

applied, standard contact avoided, minimal energy (0.04 mJ/mm2) pulses generated/session at site of maximal tenderness. (n=40)

pain (VAS, 0-100).

Adverse events

the treatment and withdrew.

van der Heijden et al., 199946

Participants (≥18 y.o.) referred tophysiotherapy in the Netherlands.

Case definition: pain of deltoid region elicited or aggravated by movement or a restricted range of glenohumeral motion, or both. (n=180)

Bipolar interferential electrotherapy (ET) by therapists (12 maximum 15-min or 3 habituations reached sessions/6 weeks): two electrodes palced in deltoid region and over homolateral erector trunci, frequency=4KHz sinusoidal biphasic electric current, amplitude=60-100 Hz with a ramp and fall of one second each and constant phase of two seconds in

Placebo ET by therapists (12 15-min sessions/6 weeks): similar procedure as ET group except no electric output; same exercise as exercise group. (n=72)

Placebo U/S by therapists (12 15-min sessions/6 weeks): same procedure as U/S group except inactivated ultrasound output; same exercise as exercise group. (n=72)

6 weeks, 3, 6, 9 and 12 months

Primary outcome: improvement (defined as very much improvement in a 7 point Likert scale);

Secondary outcomes: chief complaint (VAS, 0-100), disability (SDQ, 0-100), pain after assessment, yesterday and last night

Comparison among ET, placebo ET and exercise 6 months (ET - placebo ET) Difference in improvement rates: -20% (95% CI -35%, -4%)

No statistically significant difference in the rest of the outcomes between ET group and placebo ET group at all follow-up points.

No statistically significant difference in all outcomes between placebo group and exercise group at all follow-up points.

Comparison among U/S, placebo U/S and exercise

No statistically significant difference in all outcomes between placebo U/S group and exercise group at all follow-up points.

No statistically significant difference in all



53

Author(s), Year


(n) Enrolled


Subjects



between; same exercise as exercise group. (n=73)

Ultrasound (U/S) by therapists (12 sessions/6 weeks): pulsed ultrasound with a 20% duty cycle (on-off ratio of 2:8), slow circular transducer movements, frequency=0.8MHz, effective radiating transducer area=4cm2, beam non-uniformaty ration=4 to 6, sonation time=2 minutes, maximum esposure= 50J/cm2; same exercise as exercise group. (n=73)

Exercise therapy by therapists (12 sessions/6 weeks): active and passive abduction, flexion, internal and external rotation, extension, adduction, and optional exercise for pain reduction and mobility improvement. (n=35)

(VAS, 0-100), physical impairment (VAS, 0-100), symptom score (VAS, 0-100), mobility (VAS, 0-100)

Adverse events

outcomes between U/S group and placebo U/S group at all follow-up points.

No adverse events reported in all groups.

*Calculated by the OPTIMa CollaborationAcronyms: AL Score: the Adolfsson-Lysholm Shoulder Score; ADL: activities of daily living; CMS: Constant-Murley Scale; HRQoL: the health-related quality of life; LLLT: low-level laser therapy; MIN: minutes; ROM: range of motion; MRI: magnetic resonance imaging; OR: odds ratio; QuickDASH: the short form of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire; RR: relative risk; SDQ: the Shoulder Disability Questionnaire; SPADI: the Shoulder Pain and Disability Index; SST:



54

the Simple Shoulder Test; UCLA: the University of California-Los Angeles shoulder Rating Scale; VAS: Visual Analogue Scale; y.o.: years old.



56

Table 3: Parameters of passive physical modalities in accepted randomized controlled trials

Author(s), Year Diagnoses Interventions Comparisons

Calcific shoulder pain Albert et al., 200737

Persistent shoulder calcific tendonitis

High-energy extracorporeal shock-wave therapy (hESWT); • Focused• dose=2500 impulses/session, frequency = 1Hz for the

first 200 impulses and 2Hz thereafter, energy= maximumtolerated energy but <0.45 mJ/mm2 per impulse

Low-energy extracorporeal shock-wave therapy (lESWT):

• Pulsed• dose=2500 impulses/session,

frequency = 1Hz for the first 200impulses and 2Hz thereafter,energy gradually increased from0.02 mJ/mm2 to 0.06 mJ/mm2 perimpulse (145 mJ/mm2 per session)



Radial shock-wave therapy (RSWT) : • Radial• dose=2500 impulses/session, pressure=1.5 bar for first

500 impulses and 2.5 bar thereafter, frequency= 4.5Hzfor the first 500 impulses and 10Hz thereafter, energyflux density= 0.10mJ/mm2, time/impulse=2ms

Sham RSWT: same treatment procedure as RSWT group except dose=25 impulses/session, pressure=1.5 bar for first 5 impulses and 2.5 bar thereafter, frequency= 4.5Hz for the first 5 impulses and 10Hz thereafter



High-energy extracorporeal shock-wave therapy (hESWT) : • Focused• dose=1500 impulses/session, energy=0.32mJ/mm2,

frequency=120 impulses/minute, total energy received/2sessions=0.960 J/mm2

Low-energy extracorporeal shock-wave therapy (lESWT):

• Pulsed• Dose=6000 impulses/session,

energy=0.08mJ/mm2,frequency=120 impulses/minute,total energy received/2sessions=0.960 j/mm2

Sham extracorporeal shock-wave therapy (sESWT); the same setting as hESWT group and air-chambered polyethylene foil used to block



57


shock wave; same physiotherapy and pain mediation as hESWT group

Non-calcific shoulder pain Laser therapy Abrisham et al., 201135

Subacromial impingement syndrome

Low-level laser therapy (LLLT) : • Pulsed• wavelength=890nm, time= 2 min/point, power 2-4 j/cm2

in each 3 points

Placebo : • Inactivated

Santamato et al., 200944


High-intensity laser therapy (HILT) : • Pulsed• peak power=1kW, average power=6W, maximum energy

of single impulse=150mJ, duration of singleimpulse=150milliseconds, fluency=760mJ/cm2,wavelength=1064nm

Ultrasound therapy (US) : • Continuous U/S• frequency=1MHz,

intensity=2W/cm2, dutycycle=100%

Ultrasound Ainsworth et al., 200736

Nonspecific shoulder pain

Ultrasound therapy: • Pulsed• No details of parameters

Placebo: • Inactivated

van der Heijden et al., 199946

Nonspecific shoulder pain

Bipolar interferential electrotherapy (ET)

Ultrasound (U/S): • Pulsed• 20% duty cycle (on-off ratio of 2:8)• frequency=0.8MHz, effective radiating transducer

area=4cm2, beam non-uniformaty ration=4 to 6, sonationtime=2 minutes, maximum exposure= 50J/cm2

• Intensity increased as electric paraesthesia diminished

Placebo ET

Placebo U/S: • Inactivated U/S

Exercise therapy

Shock-wave therapy Engebretsen et al., 2009

Subacromial impingement

Radial extracorporeal shock-wave therapy (rESWT): • Radial

Supervised exercise (SE)



58


and 201139,

40syndrome • frequency = 8-12 Hz, pressure = 2.5 to 4.0 bar,

dose≥2000 pulses/session• Low to medium energy shock-wave (no number

provided)Speed et al., 200245


Extracorporeal shock-wave therapy (ESWT): • Focused• dose=1500 pulses/session, energy= 0.12 mJ/mm2 at site

of maximal tenderness

Placebo ESWT: treatment head deflated, no gel applied, standard contact avoided, minimal energy (0.04 mJ/mm2) pulses generated/session at site of maximal tenderness

Diathermy Rabini et al., 201243


Local microwave diathermy (LMD): power=40w, silicone pad water temperature= 38°C

Subacromial corticosteroid injections (SCI)

Efficacy study Lewis et al., 200542


Pre-tensioned tape Placebo tape



60

Figure Legends

Figure 1: Identification and Selection of Articles



61

Figure 1: Identification and Selection of Articles

Citations identified through database searching: 1760

Duplicates removed: 290

Citations screened: 1470

(Title/abstracts screening)

Citations excluded due to ineligibility: 1427

Eligible for critical appraisal in full text: 22

Articles with a high risk of bias: 10

Articles with a low risk of bias: 12 (reporting 11 randomized

controlled trials)

Citations screened: 43

(Full-text screening) Full-text articles excluded: 20

Primary reasons for exclusion: - Small sample size = 9 - Ineligible design = 5 - Shoulder specific results not reported = 3 - Ineligible intervention of interest = 2 - Non-English article = 1

Article could not be retrieved: 1



62

Appendix I: MEDLINE through OVID search Strategy

1. exp Hydrotherapy/

2. Laser Therapy, Low-Level/

3. Cryotherapy/

4. Magnetic Field Therapy/

5. exp Electric Stimulation Therapy/

6. exp Orthotic Devices/

7. exp Diathermy/

8. Hot Temperature/tu [Therapeutic Use]

9. Casts, Surgical/

10. Fluid Therapy/

11. Magnetics/tu [Therapeutic Use]

12. "Bedding and Linens"/

13. High-Energy Shock Waves/tu [Therapeutic Use]

14. Bed Rest/

15. Rest/

16. Self-Help Devices/

17. Restraint, Physical/

18. or/1-17

19. (cold and (therap* or pack* or compress or massage or immersion or soak or treatment or

therap*)).ab,ti.

20. (ice and (therap* or pack* or compress or massage or immersion or soak or treatment or

therap*)).ab,ti.

21. (heat* and (therap* or pack* or compress or massage or lamp or pad or bath or soak or tub or

bottle or superficial or therapeutic)).ab,ti.

22. (hot and (therap* or pack* or compress or massage or lamp or pad or bath or soak or tub or

bottle or superficial or therapeutic)).ab,ti.

23. ((shockwave* or shock wave* or shock-wave*) and (ultrasonic or therap* or radiation)).ab,ti.



63

24. "assistive device*".ab,ti.

25. (athletic and (tape or taping)).ab,ti.

26. "back belt*".ab,ti.

27. (braces or brace or bracing).ab,ti.

28. (cast or casts).ab,ti.

29. (collar or collars).ab,ti.

30. (corset or corsets).ab,ti.

31. "cryotherap*".ab,ti.

32. diathermy.ab,ti.

33. (electric* and (stimulation or EMS or heating pad*)).ab,ti.

34. electroanalgesia.ab,ti.

35. (electrogalvanic stimulation or EGS).ab,ti.

36. (electromagnet* and (radiation or therap*)).ab,ti.

37. "electromodalit*".ab,ti.

38. electrotherapy.ab,ti.

39. "fluidotherap*".ab,ti.

40. galvanic stimulation.ab,ti.

41. (guard* and (teeth or night or mouth or wrist or knee)).ab,ti.

42. (high energy shock wave* or high-energy shock wave* or HESW).ab,ti.

43. (H-Wave Device Stimulation or HWDS).ab,ti.

44. "hydrocollar*".ab,ti.

45. "hydrotherap*".ab,ti.

46. infrared.ab,ti.

47. (interferential current* or ICS or IFC).ab,ti.

48. iontophoresis.ab,ti.

49. "kinesiotap*".ab,ti.

50. (laser* and (phototherapy or irradiation or biostimulation or light or therap*)).ab,ti.

51. "low level laser*".ab,ti.

52. "lumbar support*".ab,ti.

53. (magnetic and (necklace* or therap* or bracelet*)).ab,ti.

54. Microcurrent Electrical Neuromuscular Stimulation.ab,ti.



64

55. "microwave*".ab,ti.

56. "moist air bath*".ab,ti.

57. muscle activation.ab,ti.

58. myofascial release.ab,ti.

59. (Neuromuscular Electrical Stimulation or NMES).ab,ti.

60. "orthotic*".ab,ti.

61. (paraffin and (treatment* or therap*)).ab,ti.

62. "passive modalit*".ab,ti.

63. "Percutaneous Electric* Nerve Stimulation".ab,ti.

64. "pillow*".ab,ti.

65. (pulsed and (electromagnetic or magnetic or radio frequency or energy)).ab,ti.

66. radiant light.ab,ti.

67. Russian stimulation.ab,ti.

68. "seat cushion*".ab,ti.

69. (short wave* or short-wave*).ab,ti.

70. (sling or slings).ab,ti.

71. (splint or splinting or splints).ab,ti.

72. "spray and stretch".ab,ti.

73. (tape or taping).ab,ti.

74. (transcutaneous electrical stimulation or TENS).ab,ti.

75. ultrasound.ab,ti.

76. vapocoolant spray.ab,ti.

77. "vibration therap*".ab,ti.

78. "warm compress*".ab,ti.

79. "wax treatment*".ab,ti.

80. whirlpool.ab,ti.

81. or/19-80

82. 18 or 81

83. Shoulder Pain/

84. Shoulder Impingement Syndrome/

85. exp Shoulder Joint/in [Injuries]



65

86. Rotator Cuff/

87. Shoulder/in [Injuries]

88. "Sprains and Strains"/

89. "shoulder*".ab,ti.

90. 88 and 89

91. (shoulder* and (pain or sprain* or strain* or injur* or impair* or impingement)).ab,ti.

92. (shoulder* and (tendinopathy or tendinitis or tendonitis or capsulitis)).ab,ti.

93. ((glenohumeral or scapul* or acromioclavicular) and (pain or sprain* or strain* or

injur*)).ab,ti.

94. (rotator cuff* and (sprain* or strain* or tear* or bursitis tendinitis or impingement)).ab,ti.

95. ((supraspinatus or infraspinatus or subscapularis or teres minor or teres major or trapezius or

deltoid or bicep* or bicipital) and (impingement or strain* or tear*)).ab,ti.

96. biceps tendinitis.ab,ti.

97. painful arc.ab,ti.

98. (shoulder and capsul* and (sprain* or tear*)).ab,ti.

99. 83 or 84 or 85 or 86 or 87 or 90 or 91 or 92 or 93 or 94 or 95 or 96 or 97 or 98

100. Randomized Controlled Trials as Topic/

101. exp Controlled Clinical Trials as Topic/

102. exp Case-Control Studies/

103. exp Cohort Studies/

104. exp Double-Blind Method/

105. exp Single-Blind Method/

106. Placebos/

107. randomized controlled trial.pt.

108. controlled clinical trial.pt.

109. (meta analys* or meta-analys* or metaanalys*).ab,ti.

110. (cohort adj4 (study or studies or analys*)).ab,ti.

111. (random* adj4 (control* or clinical or allocat*)).ab,ti.

112. (case adj control*).ab,ti.

113. ((double or single) adj4 blind*).ab,ti.

114. "placebo*".ab,ti.



66

115. or/100-114

116. 82 and 99 and 115

117. 82 and 99 and 115

118. limit 117 to (english language and humans and yr="2000 – April 15, 2013")



doi: 10.2522/ptj.20140361 Published online November 13, 2014PHYS THER.

Taylor-Vaisey, Sean Abdulla and Yaadwinder Shergillder Velde, Linda Carroll, Craig L. Jacobs, Anne L. Ameis, Maja Stupar, Margareta Nordin, Gabreille M. vanVaratharajan, Danielle Southerst, Silvano A. Mior, Arthur

SharanyaWong, Deborah A. Sutton, Kristi A. Randhawa, Hainan Yu, Pierre Côté, Heather M. Shearer, Jessica J.Protocol for Traffic Injury Management CollaborationShoulder Pain: A Systematic Review by the Ontario Effectiveness of Passive Physical Modalities for

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Effectiveness of Passive Physical Modalities for Hainan Yu ......! 4! Background: Shoulder pain is a common musculoskeletal condition in the general population. Passive physical modalities