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E. VARELA 1, R. VALERO 1, A. A. KÜÇÜKDEVECI 2, A. ORAL 3, E. ILIEVA 4, M. BERTEANU 5, N. CHRISTODOULOU 6
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One of the objectives of the Professional Practice 1Member, Professional Practice Committee
Committee (PPC) of the Physical and Rehabilitation UEMS Section of PRM
Medicine (PRM) Section of the Union of European Departamento de Medicina Física y Rehabilitación
Medical Specialists (UEMS) is the development of the Facultad de Medicina UCM
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field of competence of PRM physicians in Europe. To
achieve this objective, UEMS PRM Section PPC has
Ciudad Universitaria, Madrid, Spain
2Member, Professional Practice Committee
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adopted a systematic action plan of preparing a series UEMS Section of PRM,
of papers describing the role of PRM physicians in a Department of Physical Medicine and Rehabilitation
number of disabling health conditions, based on the Faculty of Medicine, Ankara University, Ankara, Turkey
3Member, Board Committee, UEMS Board of PRM
evidence of effectiveness of the physical and rehabili- Department of Physical Medicine and Rehabilitation
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Table I.—Musculoskeletal disturbances that can cause shoulder Table II.—Some clinical assessment maneuvers for SP.
pain.
Neer test Sub-acromial impingement
Subacromial syndrome Sprinter test Sub-acromial impingement
Frozen shoulder Palm-up-test Bicipital tendinitis
Rotator cuff tendonitis and tear Jobe test Supraspinatus tendinitis
Calcifying tendonitis Dropping-sign test Infraspinatus tendinitis
Biceps large portion tendonitis and tear Lift-of test Subscapularis tendinitis
Gleno-humeral instability
Patte test External rotators test
Press belly test Internal rotators test
Anterior apprehension test Anterior capsular instability
Positive re-centration test Anterior capsular instability
activities and participation in different areas of life. Sulcus test Inferior capsular instability
Almost 50% of the population suffers from SP at Posterior apprehension test Posterior capsular instability
least once a year.1 The prevalence of SP accompa-
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nied by disability is approximately 20% in the gen-
eral population over 70 years of age 2 about 1.2%
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ening are the most common symptoms of shoulder
of all patients who visit their doctor. Prospective problems. However, the manifestation of this health
studies in Europe have shown that approximately condition, and its associated functional limitation,
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11 out of every 1000 patients seen by a general may vary from patient to patient. Different patholo-
practitioner (GP) have SP.1, 2 Over 50% of patients gies may also coexist, further compounding the dif-
diagnosed by a GP to have shoulder tendinitis are ficulty of coming to a diagnosis. It is therefore im-
referred for physical therapy.3 After low-back and
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neck pain, SP is the third cause of disability of mus-
culoskeletal origin.4 Musculoskeletal disorders such
portant to independently quantify the consequences
that a patient’s symptoms may have on his or her
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activities and participation in normal life.9
as subacromial syndrome (SS), frozen shoulder A range of clinical tests should be performed by
(FS) and gleno-humeral instability (GHI), etc., can the physician to better identify the exact cause of
all cause SP (Table I).5, 6 The physical and rehabili- SP,10 including the palm-up, Jobe, Patte, dropping
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tation medicine (PRM) specialist/physician is well sign, lift-off, belly press, apprehension, recentration,
placed to prevent, assess, treat and follow-up many and sulcus tests, etc. (Table II). Shoulder assess-
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of the problems in the acute, post-acute or chronic ment scales are normally used to describe the “total
phase, and thus help the affected patient be more shoulder disturbance” independent of the diagno-
socially active.7
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ist, an orthopaedic surgeon or a rheumatologist, Pain is a subjective symptom that has to be objec-
etc., might be the first to examine a patient suffer- tively quantified during patient assessment. Differ-
ing from SP. However, the PRM specialist should be- ent factors should be assessed, including dosage of
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come involved as soon as possible, even when the medication needs, the presence of nocturnal pain,
process is in the acute phase,8 and should continue and interferences in sport, work or daily life activi-
to provide care during the post-acute and long-term ties (DLA).
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all disabilities is well documented by the White Book the trunk and then with 90º of shoulder abduc-
of Physical and Rehabilitation Medicine in Europe, tion).14
published by the UEMS-PRM Section and Board, and The most common method for strength assess-
the European Academy of PRM.7 ment is the manual muscle testing (which provides
Pain, reduced range of motion (ROM) and weak- a score of 0 to 5); the patient’s age, gender and mor-
photype should, of course, be taken into considera- Table III.—Some shoulder functional assessment scales.
tion in such testing.15 Simple shoulder test General scale
Shoulder-Rating Questionnaire General scale
Shoulder Pain and Disability Index General Scale
Shoulder functional assessment scales Constant-Murley Scale Shoulder specific scale
American Shoulder and Elbow Index Shoulder specific scale
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Functional restoration
nations are more general, others are more specific
(Table III). Some can easily be completed by the
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patient alone.
has been reported as low.27 The CSA shows a high
The Simple Shoulder Test correlation (R2>90) with the Shoulder Severity Index
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(SSI) of Patte.28
This involves asking the patient 12 questions con-
cerning performance in DLA.18, 19 Some researches The American Shoulder and Elbow Surgeons’ Shoul-
suggest that the Simple Shoulder Test (SST) may be der Assessment Form
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too imprecise for following the evolution of some
patients with very low or very high scores.20, 21
This involves a self-evaluation and a clinical ex-
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amination. The clinical examination assesses shoul-
der motion (active and passive), signs, strength and
The Shoulder Rating Questionnaire instability.29
This includes 6 separately scored domains: glo-
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which he believes improvement is most significant. complete the assessment of the patient, including X-
rays, ultrasound imaging, magnetic resonance imag-
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The Shoulder Pain and Disability Index ing or CT scans. In some cases, scintillation scanning
might be necessary, as well as an EMG to check for
This is a self-administered questionnaire that anal-
any cervical or local neuropathy.30-33
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nents. The former include the assessment of pain otherapists and occupational therapists is often
and the ability to perform DLA or gestures. A modi- needed, which the PRM specialist is well placed to
fied version of the The Constant-Murley Shoulder lead.7, 34 Sports exercise, under medical supervision,
Assessment Scale (CSA) has recently been pro- may be needed to increase strength and endurance.
posed.26 However, the overall reliability of the score Some basic goals should be considered (Table IV).
Pain relief and reduction of inflammation cated due to the broad inclusion criteria followed in
many studies, which allow for mixed samples of SP
Pain relief is one of the most important goals of of different aetiology.39
the PRM specialist in shoulder disturbances. Upper
limb rest, modifications to DLA, oral medication, lo-
cal injections, iontophoresis, and physical therapy Oral medication
modalities of pain reduction, etc., should be pre- The short-term effectiveness of non-steroidal in-
scribed as soon as possible. Cryotherapy, massage, flammatory drugs (NSAIDs) over placebo has been
infrared, ultrasound or transcutaneous electrical reported.3, 40, 41 Side effects of NSAID administration
nerve stimulation (TENS) are the most commonly can be taken into account.42 Systemic corticosteroids
used physical modalities for reducing pain and in- can only be used in the early phase of SP, for short
flammation.35 periods.43
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Movement preservation and restoration of the pos- Local injections
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tural trunk muscle to restore scapulo-humeral
rhythm Subacromial infiltrations are reported to be effec-
tive in the treatment of SS and rotator cuff distur-
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Once the inflammation has been reduced, the bances, but no more so than oral NSAIDs. Intra-joint
PRM specialist should prescribe therapeutic exer- infiltrations plus physiotherapy have been found
cise to stretch the soft tissues. Such exercises should more effective in the treatment of SP than physi-
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include passive and assisted shoulder movements,
plus joint capsule stretching if needed. Shoulder
mobilization should always be performed within the
otherapy alone.44, 45
Suprascapular nerve block (SSNB) has been
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shown effective as an analgesic for FS.46, 47 It is
painless ROM.36 more effective when performed in conjunction with
a rehabilitation program.48 It provides an attractive
Muscular strengthening and endurance choice for pain relief and allows physiotherapy to
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This is the final objective of the rehabilitation pro- the short-term, as well as for SS. However, no differ-
cess. The goal of the PRM specialist is, through the ences were seen between laser+physiotherapy and
use of a variety of interventions, to enable the pa- placebo+physiotherapy.43
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tient’s DLA and social participation without restric- In terms of pain relief and ROM recovery, ultra-
tion.37 sound therapy has not been shown more effective
than placebo treatment in patients with subacromial
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pain relief and deposit resorption, are associated with can lead to improvements similar to those achieved
the use of high energy levels.53 A more recent review, with surgery in SS.
based on 54 randomized clinical trials, found that both Another study 66 showed it is better to have pa-
high-energy ESWT and radial SWT to be effective in tients perform simple exercises at home, with peri-
treating chronic rotator cuff syndrome with calcium de- odic medical checks, than to have patients follow a
posits.54 The duration of effectiveness is some 2-3 years, course of intensive physiotherapy.
with a better response seen in patients with grade II dis-
ease according to the Gartner classification (inhomoge-
neous calcification with a sharp outline or homogene- Choosing the right PRM program
ous with no defined borders), in whom the results are
comparable to those achieved by surgery.55 Radial SWT Subacromial impingement
is also effective: in one study, calcification disappeared
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completely in 86.6% of patients thus treated, compared Studies have documented the universal presence
to just 8.8% (who showed only partial resorption) in the of degenerative changes and conditions, including
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control group.56 In a recent study, Galasso 57 reported full avulsions without symptoms.6 During the acute
good results with low intensity SWT. phase of the associated SP, relative rest is necessary
Iontophoresis with acetic acid for the treatment of to avoid damage to healthy anatomical structures.
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calcifying tendonitis has been reported not to be su- Rest has to include restriction of all damaging activ-
perior to control group.51 ity, such as avoidance of all arm elevation above
TENS, superficial local heat, or deep local heat, head level. Slings are not recommended since they
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as well as local cold, may be beneficial for pain re-
lief and muscle relaxation before and after exercise,
could encourage FS. Medication can be prescribed
for short periods of time. In some cases, local injec-
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however ultrasound, laser and interferential therapy tions can be administered if pain is severe and not
have not proved to be effective as adjuvants to exer- relieved by pain-killers or NSAIDs after several days
cise therapy in SP.1-3, 59, 60 or weeks.39 Self-passive exercises, such as Codman
No significant differences between acupuncture exercises, should be prescribed soon after injury in
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and placebo,61 in the treatment of rotator cuff distur- order to maintain ROM.67 Once the acute pain has
bances, have been reported; although in some trials been relieved or diminished, specific exercise pro-
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very small short-term improvements were seen with grams are recommended with passive and assisted
this technique.62 physiotherapy to maintain or improve the ROM. Lat-
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only demonstrated effective treatment for improve- be controlled, surgery may have to be considered.
ments, in this disease process.61 Another SR,63 con- Younger patients with rotator cuff tear respond bet-
cluded that physical exercise improves many symp- ter to surgery than older patients.59
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with exercise programs in patients who had suffered Physiotherapy with the aim of maintaining shoulder
SS for more than six months. Both groups improved ROM is important, as is muscle strengthening. The
significantly, with no significant differences ob- injection of corticosteroids into the acromio-clavicu-
served between them over the 12 month follow-up lar joint can be of great help. If PRM treatment fails,
period. Thus, exercise programs, if well designed, surgery should be considered.67
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used with good effect in pain relief and the reduc- Gleno-humeral instability
tion of calcification.52-58
Muscle strengthening prevents gleno-humeral
dislocations during DLA. This can be useful in pa-
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Frozen shoulder tients with lax joints. The aim of PRM treatment is
PRM treatment depends on the stage of the dis- to strengthen the stabilizing muscles. When there is
ease. Pain should be relieved by medication. Intra- anterior instability, the specific muscles for strength-
articular cortisone up to three or four times, with ening include the internal rotator and adductors
10-14 day intervals between injections, can be (pectoralis major, subscapularis, latissimus dorsi and
very effective in pain relief, if no contraindication teres major); when there is posterior instability, the
or other proprietary information of the Publisher.
is present. Local injections may allow physiothera- external rotators, i.e., the posterior deltoideum, in-
py to be started early. A specific exercise program fraspinatus, and teres minor, are the main muscles
should be prescribed as soon as possible, starting to be exercised. Results depend on patient age as
by stretching of the joint capsule, joint mobilization well as the type of instability. In some cases, surgery
and active movement within the ROM. Later, muscle should be considered.70-73
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the Country and medical centre. According to some tis,50, 51 but others have not 3
authors,74 several intervention stages need to be — ESWT is effective in patients with calcifying tendinopathy
passed through for the best results to be achieved of the rotator cuff,54, 55 especially when performed using
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(Figure 1). After patient assessment, the first stage fluoroscopic guidance 53
— Both, high-energy ESWT and radial SWT are effective for
is the provision of information to the patient, the
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chronic rotator cuff syndrome with calcium deposits 54
prescription of medications and/or local injections, — Therapeutic exercise improves many symptoms: pain, func-
the recommendation of activity modifications, and tional limitation, lack of strength and ROM 59, 61
the performance of simple home exercises. Should — Therapeutic exercise programs, if well designed, can lead to
improvements similar to those achieved with surgery in SS 65
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disability diminishes, the patient can be referred to
a GP or even completely discharged. If symptoms
do not improve, or worsen, evidence-based physical
— Simple home exercises performance with periodical medi-
cal checks could be more effective than intensive physio-
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therapy 66
therapy (therapeutic exercises and/or physical mo-
dalities) should be prescribed for a period of some
weeks. Should the patient improves, physical treat- simple home exercises, DLA modifications, etc have
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ment can be continued for some further weeks, de- to be prescribed and supervised when necessary.
pending on syptoms, after which the patient could If symptoms do not improve or worsen, then ap-
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be discharged to a GP follow-up or even to home. plications of physical modalities and therapeutic ex-
If symptoms do not regress and disability persists or ercises have to be considered, followed by patient
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sidered (X-rays, ultrasound-imaging, magnetic reso- care of patients suffering from any kind of disability
nance imaging, CT Scan, EMG, etc.). In such cases, caused by SP. His job is to identify the best medical
surgery should be considered.75 evidence to guide, assess, treat and rehabilitate the
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