​Shoulder complaints are common in physiotherapy practice and consist of pain and functional limitations. Current research suggests that physical therapy is a reasonable and effective treatment option although effect sizes are small and recurrent rates are high. Most often, physical therapy consists of a combination of a) explanations of the signs and symptoms to patients, b) the use of passive musculoskeletal techniques and c) exercise. The majority of the shoulder literature suggests that a biological framework – in which signs and symptoms are explained as the consequence of specific, tissue-based, pathological processes and/or concrete biomechanical/kinesiological disturbances – is the dominant lens through which we should look at shoulder pain and limitation. However, the validity of this model has become under pressure as we have learned that the associations between tissue abnormalities or disturbances in movement parameters and pain or functional limitations are not straightforward. This means that researchers and clinicians are searching for new treatment avenues in order to find solutions for patients with this delimitating condition.

The indistinct role of ‘biological’ factors in shoulder pain problems also comes forward in a recent study of Rachel Chester and colleagues, in which they focus on factors that are associated with positive clinical outcomes in patients with shoulder pain (Chester et al. 2016). Surprisingly (or not), they conclude that psychological factors play an important role in the course of shoulder pain and should therefore be considered in physical therapy practice. They also conclude that clinical examination factors associated with a specific structural diagnosis are not associated with a positive treatment outcome.

To reach this important conclusion, Chester and colleagues conducted a cohort-study in which they followed 1030 patients with shoulder pain who were referred to physical therapy. All participants suffered from shoulder pain and associated functional limitations and were older than 18 years. Participating physical therapists delivered usual care for these patients. Outcome measures of interest were the Shoulder Pain and Disability Index (SPADI) and Quick Disability of the Arm, Shoulder and Hand Questionnaire (QuickDASH). A predefined list of 71 putative factors that could be associated with a positive outcome was selected from literature. SPADI and QuickDASH were filled in at the start of the treatment series, at six weeks and at six months (via email). Multivariate linear regression was used to analyse prognostic factors associated with outcome.

The results of this study show that four factors were associated with better outcomes for both SPADI and QuickDASH on both time points: 1) positive patient expectations regarding treatment outcome, 2) higher pain self-efficacy, 3) lower baseline disability and 4) lower pain severity at rest.

Based on these results the authors conclude that psychological factors play an important role in the clinical course of shoulder complaints and should be taken into account within the practice of shoulder rehabilitation. Physical therapists should invest time and energy in psychosocial factors and reinforce positive expectations of recovery. 

Dr. Lennard Voogt

Lennard currently works on a research-project called ‘pain-motor interactions and shoulder pain’.

2016  Pain in Motion

References and further reading:

Chester R, Jerosch-Herold C, Lewis J, et al. Br. J. Sports Med 2016;0-:1-8. Doi:10.1136/bjsports-2016-096084. http://www.ncbi.nlm.nih.gov/pubmed/27445360