Physiotherapy for patients with soft tissue shoulder disorders: a systematic review of randomised clinical trials

Abstract

Objective: To assess the effectiveness of physiotherapy for patients with soft tissue shoulder disorders. Design: A systematic computerised literature search of Medline and Embase, supplemented with citation tracking, for relevant trials with random allocation published before 1996. Subjects: Patients treated with physiotherapy for disorders of soft tissue of the shoulder. Main outcome measures: Success rates, mobility, pain, functional status. Results: Six of the 20 assessed trials satisfied at least five of eight validity criteria. Assessment of methods was often hampered by insufficient information on various validity criteria, and trials were often flawed by lack of blinding, high proportions of withdrawals from treatment, and high proportions of missing values. Trial sizes were small: only six trials included intervention groups of more than 25 patients. Ultrasound therapy, evaluated in six trials, was not shown to be effective. Four other trials favoured physiotherapy (laser therapy or manipulation), but the validity of their methods was unsatisfactory. Conclusions: There is evidence that ultrasound therapy is ineffective in the treatment of soft tissue shoulder disorders. Due to small trial sizes and unsatisfactory methods, evidence for the effectiveness of other methods of physiotherapy is inconclusive. For all methods of treatment, trials were too heterogeneous with respect to included patients, index and reference treatments, and follow up to merit valid statistical pooling. Future studies should show whether physiotherapy is superior to treatment with drugs, steroid injections, or a wait and see policy. Because of the small sample sizes and unsatisfactory methods of most trials, only a few randomised clinical trials of methods of physiotherapy in patients with soft tissue shoulder disorders allow firm conclusions on effectiveness of treatment When compared with placebo or another treatment, ultrasound therapy seems ineffective in patients with shoulder disorders Evidence is insufficient to support the effectiveness of low level laser therapy, heat treatment, cold therapy, electrotherapy, exercise, and mobilisation in such patients Future trials should focus on the effectiveness of exercise and mobilisation in comparison to analgesics, non-steroidal drugs, steroid injections, and advice and a wait and see policy Special attention should also be given to the principles of adequate design and conduct of trials and the standards of reporting