Seven Key Themes in Physical Therapy Advice For Patients Living With Subacromial Shoulder Pain: A Scoping Review

[ literature review ]
KAREN MEEHAN, PT, BPhty(Hons)1 • CRAIG WASSINGER, PT, PhD2

JEAN-SÉBASTIEN ROY, PT, PhD3,4 • GISELA SOLE, PT, PhD5
Downloaded from www.jospt.org at Asociación de Kinesiología del Deporte (AKD) on April 27, 2021. For personal use only. No other uses without permission.
Seven Key Themes in Physical

Therapy Advice for Patients Living
With Subacromial Shoulder
Pain: A Scoping Review
P
atient education is an important component of managing to provide applicable advice and educa-
persistent musculoskeletal pain.38,79,90 The health literacy, tion may facilitate dependence on the cli-
expectations of treatment, and personal attributes (such as nician, reduce self-efficacy or compliance
Copyright © 2020 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
with rehabilitation, and increase fear and

self-efficacy) of patients may have an important influence
anxiety.
on treatment outcomes.19,94 Patients who understand their health Shoulder pain is the third most com-
condition are empowered to share in the decision-making process mon musculoskeletal disorder seen in
and take greater responsibility for the understanding of their condition and primary care physical therapy.59 Subacro-
self-management of their condition,87 how to self-manage it (poor health lit- mial shoulder pain, the largest contribu-
and show improvements in health status, eracy) may have poorer health outcomes, tor to cases of shoulder pain, encompasses
well-being, quality of life, and satisfaction increased emergency care use, and lower a variety of conditions and symptoms, in-
with health care.88,93,94 Patients with poor use of preventive health care.6,13,94 Failing cluding partial and full rotator cuff tears,
Journal of Orthopaedic & Sports Physical Therapy®
inflammation of the rotator cuff tendons

U OBJECTIVE: To systematically scope the reported studies; 16 nonrandomized observational interven- and bursa, and subacromial impinge-
advice and education in physical therapy manage- tion studies or case series; and 7 surveys, audits ment syndrome.22 Subacromial shoulder
ment of patients with subacromial shoulder pain, and of physical therapy patient records, and focus
pain can affect sleep, movement, partici-
to define key themes of the advice and education. groups with physical therapists. We identified 7 key
pation in activities of daily living, and em-
U DESIGN: Scoping review. themes for advice and education: exercise intensity
ployment.32,62 The person-related burden
and pain response, activity modification advice,
U LITERATURE SEARCH: We searched MEDLINE, posture advice, pain self-management advice, of potentially decreased quality of life and
Scopus, Web of Science, and CINAHL, with publi- pathoanatomical and diagnosis information, increased suffering adds to the overall
cation dates from 2007 to September 2019. behavioral approaches, and pain biology advice. costs of subacromial shoulder pain.92
U STUDY SELECTION CRITERIA: We included U CONCLUSION: While advice focused pre- To address central mechanisms and
quantitative and qualitative research that reported dominantly on the local tissue pathology model, psychosocial influences that may be as-
on physical therapy interventions for subacromial 10% of studies included information about pain
shoulder pain.
sociated with persistent shoulder pain, a
neuroscience education, psychosocial factors, mo-
management approach with a wider fo-
U DATA SYNTHESIS: We performed a qualitative tor imagery, or behavior change. J Orthop Sports
cus than physical symptom modification
synthesis that identified items included in patient Phys Ther 2020;50(6):285-293. doi:10.2519/
advice and education. jospt.2020.9152 is indicated. This wider approach may
U RESULTS: Of 89 original studies included, there U KEY WORDS: advice, patient education, rotator
include techniques to boost patient un-
were 61 randomized controlled trials; 5 prospective cuff, shoulder pain derstanding and beliefs about persistent
shoulder pain, or “cognitive training.”
1
Sportsmed Mosgiel, Mosgiel, New Zealand. 2Department of Physical Therapy, East Tennessee State University, Johnson City, TN. 3Department of Rehabilitation, Faculty of
Medicine, Laval University, Quebec City, Canada. 4Centre for Interdisciplinary Research in Rehabilitation and Social Integration, Quebec Rehabilitation Institute, Quebec City,
Canada. 5Centre for Health, Activity, and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand. This study was internally funded. The
authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed
in the article. Address correspondence to Dr Gisela Sole, Centre for Health, Activity, and Rehabilitation Research, School of Physiotherapy, University of Otago, Box 56, Dunedin
9054 New Zealand. E-mail: [email protected] t Copyright ©2020 Journal of Orthopaedic & Sports Physical Therapy®
journal of orthopaedic & sports physical therapy | volume 50 | number 6 | june 2020 | 285

Such techniques may be part of an overall identified and combined using Bool- Selection Criteria Studies that met the
approach that includes pain education; ean operators. We searched 4 databases following criteria were included:
self-management strategies to improve (MEDLINE, Scopus, Web of Science, • Patients of any age diagnosed with
self-efficacy, coping, and resilience; and and CINAHL). Prior to defining the fi- subacromial shoulder pain or unspeci-
exercises and physical activity to decrease nal search strategy, pilot searches were fied shoulder pain
nervous system sensitivity.51,52,67,68,88 conducted independently by 2 review- • Treatment delivered by a physical
Effective self-management strategies ers. We used an iterative process with therapist
may help reverse the escalating health- several amendments until we agreed on • Published in the English language
and person-related costs of subacromial the final search strategy (TABLE 1). Publi- from January 2007 to September 2019
shoulder pain. Advice and education cation dates were limited from 2007 to • Research designs: quantitative re-
as part of a biopsychosocial approach 2019. We hand searched reference lists search studies—randomized clini-
may contribute to effective self-man- of appropriate primary articles that did cal trials, prospective cohort studies,
agement.50,51 Advice and education may not appear in the original search results. pre-post study designs (including
overlap with the behavioral or psychoso- The first and final searches were under- case series), and surveys—and quali-
cial approach of physical therapy and en- taken on March 14, 2017 and September tative studies with focus groups or
hance the patient’s understanding of pain 19, 2019, respectively. interviews
neurophysiology, address potential fear- We focused on studies published be-
avoidance behavior, and modify general Screening tween 2007 and 2019, as the role of pa-
health behavior. Although patient educa- The results from the search strategy tient education in the physical therapy
tion is widely accepted as part of man- were imported into EndNote X8 (Clari- management of persistent pain has ad-
agement of persistent musculoskeletal vate Analytics, Philadelphia, PA) and vanced during this period.
pain,51 the content and mode of delivery duplicates were removed. One reviewer Studies that met the following criteria
of such patient education for subacromial screened all titles of the initial search. A were excluded:
shoulder pain, as reported in clinical re- second reviewer independently screened • A diagnosis of adhesive capsulitis
search studies, are unclear. 25% of excluded articles to verify judg- (frozen shoulder), fracture, disloca-
We aimed (1) to systematically scope ment of the first assessor, and verified tion, rheumatoid arthritis, or primary
the reported content of advice and educa- all included articles. The titles of 32 osteoarthritis
tion in physical therapy management for articles were discussed by the 2 review- • Treatment, surgery, or postsurgery
patients with subacromial shoulder pain ers, who decided by consensus whether follow-up that was only medical
and (2) to define key themes of the advice to review the article abstracts. The 2 • Study of the immediate effects of in-
and education. reviewers independently reviewed the terventions on biomechanical vari-
abstracts of the included titles, applying ables (such as advanced kinematic
METHODS selection criteria. Articles that could not analysis or muscle activity)
be included or excluded based on their • Shoulder pain associated with cere-
Design abstract and methods were assessed in bral vascular accident or other neuro-
W
e used the Preferred Report- full text. logical disorders
ing Items for Systematic Reviews
and Meta-Analyses (PRISMA)
extension for Scoping Reviews89 for the TABLE 1 Search Parameters a
design and reporting of the review. A
scoping review explores available evi-
dence, allows a broad search and map- Concept 1 Concept 2 Concept 3 Concept 4
ping of the literature, and clarifies • Rotator cuff injuries • Physical therapy • Advice • Adhesive capsulitis
• Rotator cuff modalities • Education (health) • Fracture dislocation
working definitions of concepts.89 Due to
• Shoulder impinge- • Education/patient education • Fracture
their exploratory nature, scoping reviews ment syndrome • Handout/patient education • Shoulder dislocation
generally do not include a quality assess- • Shoulder pain • Pain education • Dislocation
ment of included studies.33 • Exercise • Rheumatoid arthritis
• Motivation • General surgery
• Mindfulness • Postsurgical
Search
• Relax* • Postoperative pain
The systematic search strategy was de- • Musculoskeletal manipulations
veloped and refined by the research a
OR within each concept; AND concepts 1, 2, and 3; NOT concept 4.
team. Appropriate search terms were
286 | june 2020 | volume 50 | number 6 | journal of orthopaedic & sports physical therapy

• Shoulder pain associated with diabetes evidence was undertaken. Items included and included surveys, audits, guide-
or nonspecific neck/shoulder pain that in patient advice and education were cat- line implementation studies, and focus
could not be differentiated from neck egorized into key themes via consensus. groups with physical therapists. Stud-
pain ies reported using advice and education

• Review article, expert opinion, clinical RESULTS in combination with exercise, manual
commentary, or case report therapy, acupuncture, electrotherapies,
O
ur search identified 1193 stud- and taping.
Data Extraction ies, of which 104 met the inclu-
Data were extracted in Microsoft Word sion criteria (FIGURE). Fifteen of Key Themes for Advice and Education in
(Microsoft Corporation, Redmond, WA), the 104 included studies were pilot the Patient-Focused Studies
using an iterative process between K.M. studies, protocols, or follow-up stud- Of the 82 intervention/prospective stud-
and G.S., and exported to Microsoft Ex- ies4,5,7,9,20,41-43,46-48,53,54,61,83 of published ies, 52 (63%) specified that participants
cel (Microsoft Corporation) for analysis. main studies. Finally, out of 89 inde- were provided with advice or education, 7
The author, title, year of publication and pendent, original studies (APPENDIX, (9%) indicated that advice was provided
geographical area, inclusion criteria, available at www.jospt.org) identified, but did not specify that advice, and 171
whether patient advice or education was 82 were classified as “patient-focused” stated that advice was not provided.
given, and type of advice or education studies (61 randomized clinical trials; We categorized the items included
were extracted from each article. When a 5 prospective cohort studies; and 16 in education and advice into 7 themes
pilot study, protocol, or follow-up study nonrandomized or retrospective stud- (TABLE 2): exercise intensity and pain re-
was published in addition to a main ar- ies, case series, or qualitative inter- sponse (n = 32, 39%); activity modifica-
ticle, the details of all publications were views). The remaining 7 were classified tion advice (n = 17, 21%); posture advice
combined. A qualitative synthesis of the as “physical therapist–focused” studies (n = 15, 18%); pain self-management
advice; pathoanatomical and diagnosis
information; behavioral approaches;
Identification
Records identified through Additional records identified

database search, through other sources, and pain biology advice. Of 82 studies,
n = 1183 n = 10 9 (11%) provided written instructions or
booklets. One protocol paper37 reported
the use of multimedia to cater to patient
health literacy and preferences.

Records after duplicates Exercise Intensity and Pain Response In
removed, n = 672 nearly 40% of studies, exercise-relat-
ed advice supplemented prescribed
shoulder exercises (stretching and/or
Screening
Records screened by title, strengthening for the rotator cuff, gle-

n = 672 nohumeral joint, or scapular thoracic
Records excluded, n = 447 muscle groups). Specific guidelines for
progression of exercises were outlined
Records screened by abstract in 3 studies.1,8,37 A protocol provided a
and methods, n = 225 detailed outline for patients regarding
Eligibility
Records excluded, n = 96 acceptable pain levels during and follow-

ing exercises, without focusing on specific
Full-text articles assessed for Articles excluded, n = 25 intensity of pain.37 One study21 provided
eligibility, n = 129 • Pain not isolated to the shoulder, n = 3
information that pain levels should drop
• Intervention not physical therapy
based, n = 5 to the pre-exercise level after 30 minutes
• Presurgical and postsurgical physical of rest. Two studies specified that pain
Included
Studies included, n = 104 therapy, n = 3 during exercises should not exceed the
• Advice of general practitioners, n = 1
numeric pain-rating scale level of 3/10,
• Consensus statement, n = 1
• Unable to locate full text, n = 7 or should not last longer than 30 seconds
• Not available in English, n = 4 after exercise.1,47
• Economic analysis, n = 1 Activity Modification Advice Patients
were advised to avoid painful move-
FIGURE. PRISMA diagram of the search process.
ments,16,24,27,31,40,85,97,98 overhead sports- or

work-related movements,81 or all sporting of the study methods.39 Analay Akbaba In the United Kingdom, 20 physical
activities during the course of treatment et al2 explored whether patients’ expec- therapists used education about the eti-
or the clinical trial.82 Yiasemides et al97 tations of treatment outcomes (of Kinesio ology of shoulder impingement, the im-
included a focus on scapular movement Taping) influenced outcomes. portance of posture to minimize risk of
within the pain-free range of motion, also Pain Biology Advice Two studies provid- impingement, and strategies to minimize
encouraging preferential use of the unaf- ed information about the neuroscience or pain to promote self-management.34 Of
fected arm. One study specified encourag- biology of pain.8,27 Detail of such informa- 505 physical therapists in Belgium and
ing return to “normal” activity following tion was not provided. the Netherlands, three quarters pro-
cessation of the program.81 vided advice based on self-management,
Posture Advice Some studies included Advice and Education Reported posture, activity modification, work, and
detailed instructions regarding move- by Physical Therapists: Surveys home exercises for rotator cuff disor-
ments and postures at work17 and pos- and Focus Groups ders.74 Approximately 70% of the physical
tures associated with lower loads on the Of 5 surveys of physical therapists, 184 did therapists advised patients to undertake
rotator cuff or decreased compression on not include patient education/advice and exercises with levels of pain “acceptable
the shoulder80 (referred to as “proper” 142 did not specify the advice provided. Of to the patient.” Instructions regarding the
posture40 or “postural hygiene”3), and 271 Swedish physical therapists in prima- behavior of pain during and following ex-
other studies did not specify the type of ry care, 85% provided advice about pos- ercise varied.74
advice.24,35,72,76 Specific advice regarding ture to patients with subacromial pain,
“centering of the humerus” and scapular 50% provided advice about staying ac- DISCUSSION
position was defined by Vas et al.91 Four tive, and 10% provided advice regarding
W
studies provided advice regarding sleep- bed rest.11 The most common modalities e reviewed the content of pa-
ing positions.1,8,27,37 used by 13 physical therapists when man- tient advice and education includ-
Pain Self-management Advice Pain aging shoulder pain in the United King- ed in published physical therapy
management included advice regarding dom were education (85/98 patients) interventions for subacromial shoulder
use of analgesia,55 nonsteroidal anti- and exercise prescription (87/98 pa- pain. The physical therapy–focused sur-
inflammatory drugs, taping,28 heat,14 tients).29 Education focused on anatomi- veys and focus groups indicate that ad-
or ice15; accessing treatment from other cal structure of the shoulder, describing vice and education comprise a modality
health care professionals, if needed37; or why pain occurred, and encouragement that, similar to exercise prescription, is
was not further specified.8,27 Littlewood to return to usual activity.29 In the SUP- frequently reported in the management
et al53 also included lifestyle changes in PORT trial,76 88% of treatment sessions of such patients. We identified 7 cat-
addition to self-management of shoul- included advice/education of unspecified egories from the patient-focused studies
der symptoms. content.83 that may provide a clinical structure for
Pathoanatomical and Diagnosis Infor-
mation Information about the etiology
Key Themes for Advice and Education Specified
and pathology of the underlying sources TABLE 2
in the Patient-Focused Studies (n = 82)
of symptoms was based on anatomy and
biomechanics of the shoulder complex
Theme Advice Mentioned by Studies Studiesa
and on “impingement.”15,21,27,40,46,76 Kromer
Exercise intensity and Home exercise program prescription: instruction about dosage, progression, 32 (39)
et al46 provided information about possi- pain response and pain response to the exercises
ble contributing factors to shoulder pain. Activity modification Activity modification, rest, activity avoidance, advice to work within pain 17 (21)
Specific information about “contributing advice limits, guidelines for activities of daily living, encouraging physical activity
factors” was not provided. Posture advice Posture, biomechanics, ergonomics, shoulder positioning, instruction to 15 (18)
Behavioral Approaches Behavioral ap- decrease load on the shoulder
proaches or psychologically informed Pain self-management Use of nonsteroidal anti-inflammatory drugs or analgesics, application of 10 (12)
components were wide ranging and advice heat/cold, application and use of taping
might have overlapped the nonphysical Pathoanatomical and Information about etiology of diagnosis; anatomy and biomechanics of the 7 (9)
diagnosis information shoulder complex
or cognitive treatment approaches specif-
Behavioral approaches Empowerment, goal setting, motor imagery, cognitive behavioral techniques, 6 (7)
ically explored in the studies. This cate-
self-efficacy and self-management, reassurance, level of research
gory included specifying goal setting,9,46,54 evidence for the intervention used in the study
motivation and positive reinforcement,9 Pain biology advice Information about the neuroscience or physiology of pain 2 (2)
reassurance,37 and the use of mental im- a
Values are n (percent).
agery while performing exercises as part

individual-specific and tailored education of information that is provided to patients with self-reported shoulder pain and
for patients with subacromial shoulder with subacromial shoulder pain may also disability.18,60 Psychologically informed
pain. These categories address potential be important.44,87 For example, the word- treatment approaches, such as cognitive
sources and mechanisms of pain; advice ing used by the clinician to the patient behavioral therapy, motor imagery, em-
related to exercise, ergonomics, and gen- regarding imaging findings and implica- powerment, and other behavioral tech-
eral physical activity; and psychosocial tions for treatment and outcomes should niques, are being explored and applied
factors. be characterized by reassurance and avoid for the management of persistent mus-
unnecessary cause for fear and anxiety.44,87 culoskeletal pain,58 shoulder pain,56 and
Mechanisms of Pain lower back pain.65,66,70 Such approaches
Reported advice and education were most- Advice Related to Exercise, Ergonomics, include a substantial element of patient
ly based on anatomical and biomechani- and Physical Activity education and are reported in our scop-
cal factors related to the shoulder girdle. Evidence for exercise therapy for sub- ing review. Psychologically informed
A mechanistic approach that focused on acromial pain syndromes appears to be approaches, particularly cognitive behav-
shoulder symptoms was thus most com- increasing,73 and advice as an adjunct to ioral therapy, may be crucial for success-
monly included. This approach may apply, exercise was the most frequent category ful physical therapy management of pain
in particular, to patients with acute-onset (39%). Besides describing the exercises, conditions.30,45,77
pain, such as those with an acute injury, few studies outlined guidelines for pro- Two surveys of Swedish physical thera-
sudden onset after unaccustomed activity, gression1,8,37 or recommended pain re- pists10,11 found that 5% to 8% of the respon-
or repetitive loading activities. sponse to the exercise.1,21,47 Future studies dents reported using behavioral therapy.
Patients with shoulder pain expect to should provide such details to allow rep- Furthermore, the low number of inter-
be provided with a pathoanatomic diag- lication of methods, comparison between vention studies8,27 that explicitly reported
nosis when seeking health care advice,23 exercise programs, and application to inclusion of behavioral approaches (n = 6)
and providing pathoanatomic informa- clinical practice. Other reported factors to the management of subacromial shoul-
tion may meet this expectation. Howev- included postural or ergonomic advice der pain indicates that this area should be
er, the relationship between anatomical and avoiding positions of potential im- explored more thoroughly. It is currently
lesions or pathology and the presence of pingement and/or pain. unknown whether such approaches are
shoulder-related symptoms is unclear, Progressive return to activity and life- more effective than those focused on “lo-
especially in chronic pain states.12,49 Fur- style factors are important considerations cal structures” specific to patients with
ther, peripheral influences and changes for patients with persistent musculoskele- persistent subacromial shoulder pain.
in central pathways, such as central sensi- tal pain.26 Shoulder-specific health-related The increasing health costs that appear to
tization or central motor reorganization, quality of life measures are influenced by be associated with subacromial shoulder
may also contribute to the experience of comorbidities.95 There is increased aware- pain, in addition to personal costs, suggest
shoulder pain.25,53,64,78 Such information ness that chronic metabolic disorders, that further investigations are warranted
should, therefore, aim to enhance pa- as well as increased body mass index,75,96 to determine whether the cost trajectory
tients’ understanding of the multiple fac- may be associated with rotator cuff–re- can be reversed.
tors that can influence their pain.57 Two lated conditions. Only 1 protocol included
intervention studies8,27 explicitly reported in this review explicitly stated considering Recommendations for Future Directions
education about the mechanisms of pain lifestyle factors as part of self-management None of the included studies compared
(neurophysiology/pain biology), indicat- for patients with subacromial shoulder different modes of advice/education or
ing a potential new trend to include such pain.53 While the factors were not further the effect of education versus that of
information. defined,53 they may include considerations other interventions. Physical therapists
Given the individual and societal bur- for sleep patterns, stress management, nu- used a range of modes to deliver educa-
den of shoulder pain,63,86 management trition, and general physical activity. Life- tion, the content and delivery of which
must focus on decreasing risk for chronic- style factors, as well as behavior change, may change with increased clinical expe-
ity. Patients who understand their condi- may need to be considered in future stud- rience.34 Future research is warranted to
tion and related pain often have enhanced ies as part of holistic management for pa- explore the content of advice and educa-
clinical outcomes.67,69 Treatment involving tients with persistent shoulder pain. tion as part of physical therapy manage-
education and advice surrounding pain ment of persistent subacromial shoulder
physiology/neuroscience can improve Behavioral and Psychologically pain. Such advice may need to expand
outcomes, supporting the inclusion of Informed Advice beyond the local tissue pathology model
these “nonphysical” interventions in re- There is growing evidence that psycho- to include the neurosciences, physical ac-
habilitation.57 The impact of the content logical responses may be associated tivity, and lifestyle factors. As indicated

for all patients, the advice needs to be sponse, activity modification advice, 2019;184:e385-e393. https://doi.org/10.1093/
patient centered, considering their level posture advice, pain self-management milmed/usy294
of health literacy, goals, concerns, beliefs, advice, pathoanatomical and diagnosis 2. Analay Akbaba Y, Kaya Mutlu E, Altun S, Celik D.
Does the patients’ expectations on kinesiotape

social support, and other factors.37,38,90 information, behavioral approaches, and
affect the outcomes of patients with a rotator
pain biology advice. While advice fo- cuff tear? A randomized controlled clinical trial.
Strengths and Limitations cused predominantly on the local tissue Clin Rehabil. 2018;32:1509-1519. https://doi.
We followed best-practice guidelines, pathology model, 10% of studies includ- org/10.1177/0269215518779645
3. Asensio-García MDR, Bernabeú-Casas RC,
with clearly reported and well-defined ed information about pain neuroscience
Palazón-Bru A, Tomás-Rodríguez MI, Nouni-
methods. Advice and education may be education, psychosocial factors, motor García R. Effectiveness of a group physiotherapy
difficult to clearly differentiate from other imagery, or behavior change. t intervention in nontraumatic, inoperable pain-
modalities, as they are often interlinked, ful shoulder: a randomized clinical trial. Am J
Phys Med Rehabil. 2018;97:110-115. https://doi.
such as in the prescription of home-based KEY POINTS
org/10.1097/PHM.0000000000000817
exercises and self-management of pain.34 FINDINGS: This scoping review provides a 4. Barra ME, López C, Fernández G, Murillo E,
The challenge of defining advice and edu- structured approach of themes for ad- Villar E, Raya L. The immediate effects of
cation as an explicit modality of rehabili- vice and education provided for patients diacutaneous fibrolysis on pain and mobility
in patients suffering from painful shoulder: a
tation may help to explain why at least with subacromial shoulder pain. Advice
randomized placebo-controlled pilot study.
one third of the articles included in our and education reported in included Clin Rehabil. 2011;25:339-348. https://doi.
scoping review did not specifically report studies focused mainly on pathoana- org/10.1177/0269215510385480
providing advice. The authors may not tomical and biomechanical factors. 5. Barrett E, Hayes A, Kelleher M, et al. Exploring
patient experiences of participating in a group

have considered providing advice and IMPLICATIONS: Clinicians may need to con-
exercise class for the management of nonspe-
education as an explicit modality, but sider integrating education about pain cific shoulder pain. Physiother Theory Pract.
rather as part of the conversation with mechanisms and psychological factors 2018;34:464-471. https://doi.org/10.1080/09593
the patient about the treatment inter- into their management of patients with 985.2017.1422208
6. Batterham RW, Hawkins M, Collins PA,
vention. Due to manuscript word count subacromial shoulder pain, tailoring
Buchbinder R, Osborne RH. Health literacy:
limits, authors may have prioritized in- these to patient-specific health literacy, applying current concepts to improve health
formation directly aligned with the aims goals, beliefs, and support systems. services and reduce health inequalities. Public
of the individual study. Using reporting CAUTION: A scoping review does not de- Health. 2016;132:3-12. https://doi.org/10.1016/j.
puhe.2016.01.001
guidelines, for example, the Template for fine the most effective patient education
7. Beaudreuil J, Lasbleiz S, Aout M, et al. Effect

Intervention Description and Replica- that should be provided to patients with of dynamic humeral centring (DHC) treatment
tion checklist,36 would assist researchers subacromial shoulder pain. on painful active elevation of the arm in sub-
to clearly define interventions in future acromial impingement syndrome. Secondary
analysis of data from an RCT. Br J Sports Med.
trials. STUDY DETAILS
2015;49:343-346. https://doi.org/10.1136/
Due to the scoping review design, we AUTHOR CONTRIBUTIONS: Dr Sole and Kar- bjsports-2012-091996
do not provide evidence for effectiveness en Meehan conceived of and designed 8. Belley AF, Mercier C, Bastien M, Léonard G,
of various items of advice/education for the study and collected the data. All au- Gaudreault N, Roy JS. Anodal transcranial direct-
current stimulation to enhance rehabilitation
patients with subacromial shoulder pain. thors analyzed and interpreted the data,
in individuals with rotator cuff tendinopathy: a
We used an iterative process to categorize drafted and revised the manuscript, and triple-blind randomized controlled trial. J Orthop
patient education reported in studies of gave final approval of the manuscript. Sports Phys Ther. 2018;48:541-551. https://doi.
physical therapy management of sub- DATA SHARING: Data are available on org/10.2519/jospt.2018.7871
9. Bennell K, Coburn S, Wee E, et al. Efficacy and
acromial shoulder pain. There may be request.
cost-effectiveness of a physiotherapy program
other topics that physical therapists cover PATIENT AND PUBLIC INVOLVEMENT: Patient for chronic rotator cuff pathology: a protocol for
in clinical practice that are not reported and public partners were not involved in a randomised, double-blind, placebo-controlled
in published research. Our results may the design, conduct, interpretation, and/ trial. BMC Musculoskelet Disord. 2007;8:86.
https://doi.org/10.1186/1471-2474-8-86
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10. Bernhardsson S, Larsson MEH. Does a tailored
management contexts. guideline implementation strategy have an
impact on clinical physiotherapy practice? A
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APPENDIX
STUDIES INCLUDED IN THE REVIEW

Patient-Focused Studies
Randomized Clinical Trials
Study Country Participant Inclusion Criteria Advice and Education
Ager et al1 Canada Military personnel with clinical diagnosis of rotator cuff tendi- Posture, relative rest, sleeping position, physical training; guidance
nopathy; DASH score >15%; reported shoulder pain; painful for intensity of exercise and pain levels during exercise (3/10 on
arc during flexion or abduction; positive Neer or Hawkins NPRS)
test; pain on resisted external rotation, abduction, or the
empty-can test
Age, 18-60 y
Imaging: to exclude other conditions
Ainsworth et al2 United Kingdom Unilateral shoulder pain exacerbated by active or passive Advice sheet about shoulder pain and home exercise program
shoulder movement
Age, ≥18 y
Imaging: none
Al Dajah3 Saudi Arabia Clear diagnosis of SIS; VAS, ≥5 No advice mentioned

Age, 40-60 y
Imaging: none
Analay Akbaba et al4 Turkey MRI-verified partial rotator cuff tear, shoulder pain for ≥3 mo, Patients informed of effectiveness of Kinesio Taping. Group 1: there
insufficient response to nonoperative management (local is no evidence that Kinesio Taping is effective; group 2: there is
corticosteroid injection, NSAID, rest, and physical therapy) limited evidence that Kinesio Taping is effective; group 3: there is
Imaging: MRI evidence that Kinesio Taping is effective
Apeldoorn et al,6 the Netherlands Two positive impingement tests indicating subacromial impinge- No advice mentioned
Kalter et al56 ment
Age, 18-65 y
Imaging: X-ray, ultrasound

Asensio-García et al7 Spain Patients with nontraumatic shoulder pain referred to physical Group information sessions about “recommendations” and postural
therapy: nontraumatic rotator cuff tear, supraspinatus or “hygiene,” with description of exercises
infraspinatus tendinitis, SIS, partial or complete tendon tear,
or capsulitis
VAS, ≤8/10
Younger than 80 y of age
Barra et al,8 Barra Spain Referred to physical therapy if diagnosed with chronic (>3 mo) No advice mentioned
López et al9 painful shoulder of peri-articular origin; some degree of pain
and restricted movement in at least 1 of the shoulder move-
ments analyzed in this study
Age, ≥18 y
Imaging: none
Beaudreuil et al13,14 France SIS, pain duration >1 mo No advice mentioned
Total Constant score, <80
Age, ≥30 y
At least 2 positive tests: Neer, Yocum, Hawkins-Kennedy
Imaging: none
Belley et al15 Canada Unilateral rotator cuff tendinopathy: a positive finding for 1 of Pain neuroscience, pain management, structures affected, rehabili-
the following: (1) painful arc movement, (2) positive Neer test tation stages, graded exposure to exercise, shoulder and body
or Hawkins-Kennedy test, and (3) pain on resisted isometric mechanics and posture, sleeping, activities, work, and sports
lateral rotation, abduction, or Jobe test
Age, 18-65 y
Imaging: none
Table continues on page A2.
journal of orthopaedic & sports physical therapy | volume 50 | number 6 | june 2020 | a1

APPENDIX

Bennell et al16,17 Australia Shoulder pain for ≥3 mo; pain severity, at least 4/10 on move- Unspecified “education”; cognitive behavioral strategies for the
ment; pain on active abduction or external rotation; positive intervention group: education, goal setting, motivation, positive
shoulder impingement quick test reinforcement; home exercise
Age, ≥18 y Placebo group: no advice/education
Imaging: X-ray
Bron et al21 the Netherlands Unilateral nontraumatic shoulder pain for ≥6 mo Advice on the application of heat, advice on pain relief, ergonomic
Age, 18-65 y advice and instructions to assume and maintain good posture,
Imaging: none relaxation exercises
Calis et al22 Turkey SIS No advice mentioned
Age, 18-65 y
Imaging: MRI
Chaconas et al24 United States Shoulder pain for ≥3 mo; positive result on all of the following: Home exercises
Neer test, Hawkins-Kennedy test, empty-can test; pain with
resisted external rotation; palpable tenderness at insertion of
supraspinatus or infraspinatus; or painful arc from 60° to 120°
of abduction
Mean ± SD age, 46.9 ± 17.3 y

Imaging: none
Chen et al25 Australia Pain over the glenohumeral joint or in the proximal upper limb Advice to avoid painful activity, advice to use pain-free methods
and reproduced with shoulder movement; duration, >1 mo; to perform everyday activities, instruction to perform provided
shoulder range of motion, ≤140° of flexion and abduction exercises in a pain-free manner
Imaging: none
Cheng and Hung26 China Work-related rotator cuff tendinitis, clinically diagnosed by a Ergonomic education: keeping the load close to the body, resting
medical doctor arm on support during extended reach, leaning forward or to the
Imaging: none side to reduce arm extension, turning the upper body to bring in
more shoulder muscles when making lateral movements, holding
on to overhead support with one hand to reduce fatigue during
overhead work, alternating hands for 1-handed tasks where arm

is extended, holding on to vertical supports in front of a load
when pushing it forward so the shoulders are stabilized
Cloke et al31 United Kingdom Pain originating from the subacromial region during active arm No advice mentioned
abduction against gravity without added resistance (painful
arc)
Age, ≥18 y
Imaging: none
de Oliveira et al35 Canada Diagnosed with a rotator cuff tear: painful arc on movement dur- Guidance to improve patients’ understanding of shoulder overload,
ing flexion or abduction; positive Neer or Hawkins-Kennedy pain neuroscience, pain management, posture, rehabilita-
impingement sign; pain during resisted external rotation, tion stages, graded exposure to exercise, shoulder and body
abduction, or empty-can test mechanics and movements that provoke impingement, and
Age, 18-65 y preferred shoulder positioning during sleep, work, and daily
Imaging: none specified sports activities
Dejaco et al34 the Netherlands Unilateral subacromial pain for >3 mo; 2 of 3 positive impinge- Home exercises
ment tests: empty-can test, Hawkins-Kennedy test, modified
Neer test
Age, 18-65 y
Imaging: X-ray and ultrasound for exclusion criteria
Devereaux et al38 Canada Primary complaint of anterolateral shoulder pain, subacute pain Exercise instruction and home exercise program, use of diary,
onset (<12 mo), painful arc (60°-120°), positive Hawkins- instruction about use of tape and NSAIDs
Kennedy test
Age, ≥18 y
Imaging: yes, but not specified
a2 | june 2020 | volume 50 | number 6 | journal of orthopaedic & sports physical therapy

APPENDIX

Elsodany et al42 Saudi Arabia Rotator cuff tendinopathy diagnosed clinically with shoulder pain Home exercises
for >3 mo; limited shoulder abduction range and external
and internal rotation range; positive diagnostic tests of Neer,
Hawkins, Jobe, and external rotation lag sign
Engebretsen et al43 Norway Subacromial shoulder pain (or rotator cuff rupture) lasting >3 mo, Postural awareness, avoid activities that elicit pain
dysfunction/pain on abduction, normal passive glenohumeral
range of motion, pain on 2 of 3 isometric tests (abduction,
internal rotation, and external rotation), positive Hawkins-
Kennedy test
Age, 18-70 y
Imaging: none
Eslamian et al44 Iran Rotator cuff tendinitis defined by 2 of the following tests: painful No advice reported
arc syndrome, positive impingement test, positive Hawkins-
Kennedy test, sensitivity on palpation, positive supraspinatus
test
Inclusion age range not defined
Imaging: none
de Paula Gomes Brazil Patients on a waiting list for physical therapy with SIS and No advice reported
et al37 anterolateral and unilateral shoulder pain for >3 mo
Orthopaedic doctor confirmed diagnosis with minimum score of
4/10 on the NPRS at rest and during shoulder movement and
2 of 3 positive tests: Neer, Hawkins, and Jobe
Age, 18-60 y
Imaging: none
de Paula Gomes Brazil SIS and anterolateral and unilateral shoulder pain for >3 mo No advice reported
et al36 Orthopaedic doctor confirmed diagnosis with minimum score of
4/10 on the NPRS at rest and during shoulder movement and
2 of 3 positive tests: Neer, Hawkins, and Jobe

Age, 18-60 y
Imaging: none
Gutiérrez-Espinoza Chile SIS with poor response to initial conservative treatment, under No advice reported
et al46 evaluation for surgery
Orthopaedic surgeon to conduct assessment: pain located on the
anterolateral side of the shoulder for >6 mo; painful arc during
elevation; positive Neer or Hawkins-Kennedy test; pain with
resisted external rotation, abduction, or empty-can test
Age, >18 y
Imaging: MRI
Haider et al47 Pakistan SIS with pain for 2-3 mo; NPRS, ≥3/10 No advice reported
Age, 25-60 y
Haik et al48 Spain Shoulder pain in the C5-6 dermatome region and 3 of the fol- No advice reported
lowing tests positive for SIS: Neer, Hawkins, Jobe, pain during
active elevation in the scapular or sagittal plane, and pain or
weakness with resisted shoulder external rotation
Age, 18-60 y
Imaging: none
Hando et al49 United States New episode of shoulder pain with at least 2 of the following posi- No advice reported
tive signs: impingement tests, painful arc, pain with isometric
resistance, rotator cuff weakness compared to opposite side
Imaging: none

APPENDIX

Heredia-Rizo et al51 Spain Impingement defined with positive results in at least 2 of 3 Postural advice
specific tests: Neer test, Jobe test, Yergason test; negative
response to cervical compression test
Age, ≥18 y
Imaging: none
Heron et al52 United Kingdom Shoulder pain for ≥3 mo Home exercises
No passive limitation of range-of-motion testing
Pain on Hawkins-Kennedy or empty-can test
Imaging: none
Hopewell et al53 United Kingdom A new episode of shoulder pain (within last 6 mo) attributable Assessment and advice: self-management leaflets, tailored educa-
to rotator cuff disorder using diagnostic criteria of the British tion, reassurance and advice on pain management and activity
Elbow and Shoulder Society guidelines modification
Imaging: none Home exercises
Behavioral change strategies
Hoyek et al54 France Identified as stage II of SIS Motor imagery: requested to imagine the exercise/movement
Age, 35-65 y performed before performing it
Imaging: none
Kachingwe et al55 United States Superolateral shoulder pain with 2 of 4 tests: positive Neer test, Instruction for home exercises
positive Hawkins-Kennedy test, painful limitation of active Education on the etiology of SIS and the importance of proper
shoulder elevation, pain or limitation with the functional move- posture
ment patterns of hand behind back or hand behind head Instructed to modify overhead activity
Imaging: X-ray to exclude calcific tendinitis
Kamali et al57 Iran Overhead athletes with unilateral SIS: positive Neer and Hawkins No advice reported
tests, active muscle trigger points identified by palpation (taut
band, tenderness that reproduced patient’s familiar pain, pain
intensity of at least 3/10 on a VAS)
Age, 18-60 y
Imaging: none
Kaya et al62 Turkey Shoulder pain reproduced with empty-can test and Hawkins- No advice reported
Kennedy test, subjective complaint of difficulty performing
ADL, pain before 150° of active shoulder elevation in any plane
Age, 18-70 y
Imaging: none
Kinsella et al63 Australia Pain localized to the proximal anterolateral shoulder No advice reported, but exercise booklet will be provided
Positive for pain on at least 1 of the following: Hawkins-Kennedy,
Neer, and Jobe impingement tests
Positive for pain on at least 1 of the following: painful arc, drop-
arm test, lift-off test, and resisted external rotation
Age, 18-80 y
Kromer et al64-67 Germany Main complaints in the glenohumeral joint region or the proximal Information booklet: anatomy and biomechanics of the shoulder
arm for >4 wk; positive Neer or Hawkins-Kennedy test or complex, etiology of SIS, pathology, brief overview about possible
painful arc with active abduction or flexion; pain with resisted contributing factors, goals for treatment, general guidelines for
external rotation, internal rotation, abduction, or flexion behavior through daily living
Age, 18-75 y
Imaging: none
Kukkonen et al69 Finland Atraumatic supraspinatus tendon tear comprising <75% of the Written information for home exercises
tendon insertion and documented with MRI, full range of
motion in the shoulder
Age, ≥55 y
Imaging: MRI, X-ray

APPENDIX

Kvalvaag et al70 Norway Shoulder pain for ≥3 mo Home exercises
Pain on 1 of the following tests: isometric abduction in 45° or
external rotation with arm at side, positive Hawkins-Kennedy
impingement sign
Normal passive glenohumeral range of motion
Age, 25-70 y
Imaging: none
Lewis et al72 United Kingdom Unilateral shoulder pain in C5-6 dermatome Shoulder advice and exercise class
Age, ≥18 y
Imaging: none
Littlewood et al73-75 United Kingdom Primary complaint of shoulder pain with or without referral into Pain education, explanation of the cause of the problem, enhance-
the upper limb for >3 mo, no or minimal resting shoulder pain, ment of self-efficacy, encouragement of self-management
range of motion largely preserved (>50% external rotation),
shoulder pain provoked consistently with resisted muscle
tests (abduction or external rotation)
Age, ≥18 y
Imaging: none
Lombardi et al76 Brazil Shoulder pain, positive Neer and Hawkins-Kennedy tests, pain Advice regarding analgesic usage
between 3 and 8 on the NPRS in the arc of movement that
produced the greatest pain
Imaging: none
Mintken et al,78 United States Shoulder pain (between neck and elbow at rest or during arm Advised to maintain usual activities that did not increase symptoms
McDevitt et al77 movements), baseline SPADI ≥20% and avoid exacerbating activities
Age, 18-65 y
Moosmayer et al79 Norway Lateral shoulder pain at rest or with exercise, painful arc, positive No advice mentioned
impingement signs, passive range of motion of at least 140°
for abduction and flexion
Imaging: MRI; ultrasound finding of full-thickness tear, tear of <3

cm on the short and long axes; muscle atrophy on MRI not
exceeding stage 2
Østerås and Norway Shoulder pain duration of >3 mo; positive subacromial impinge- Education surrounding muscle fatigue resulting from exercise
Torstensen80 ment test
Age, 18-60 y
Imaging: none
Pekyavas and Turkey Diagnosis of SIS by a physical medicine and rehabilitation doctor, Written instruction for exercises provided
Baltaci81 symptoms for >3 mo
Imaging: none
Pérez-Merino et al82 Spain SIS diagnosed by ultrasound, with rotator cuff tendinitis or tendi- No advice given
nosis, or partial tear of the cuff and/or brachial biceps
Age, 36-70 y
Imaging: ultrasound
Perez-Palomares Spain Diagnosis of rotator cuff tendinitis and/or SIS by general Postural re-education
et al83 practitioner
Functional limitation and pain above 50% of flexion, abduction,
and elevation in the scapular plane
Imaging: MRI, ultrasound
Rhon et al85 United States Primary symptom of unilateral shoulder pain No advice mentioned
Age, 18-65 y
Imaging: none
Roddy et al86 United Kingdom Clinical diagnosis of SIS, pain in deltoid insertion, positive Neer Information leaflet: shoulder anatomy and SIS, simple messages
and Hawkins-Kennedy tests, pain on shoulder abduction about pain relief and activities
Age, ≥18 y
Imaging: none

APPENDIX

Stevenson et al92 United Kingdom Audit of treatment report form of physical therapists for patients 88% of sessions included education and advice, but not further
with shoulder pain (661 treatments) specified
Salom-Moreno et al87 Spain Unilateral shoulder pain for ≥6 mo, pain intensity >3 points on No advice mentioned
11-point NPRS, positive painful arc test during abduction,
at least 2 positive tests: Hawkins-Kennedy test, Neer sign,
empty-can test, drop-arm test, or lift-off test
Imaging: none
Santamato et al88 Italy Subacromial impingement confirmed using ultrasound or MRI No advice mentioned
Shoulder pain for ≥4 wk, painful abduction of the shoulder with
a painful arc, positive Hawkins-Kennedy test, pain relief within
15 min of injection of local anesthetic into the subacromial
space
Imaging: MRI, ultrasound
Senbursa et al90 Turkey Shoulder pain, painful range of motion, no marked loss of active Advice to avoid overhead work and overhead sports, encouraged to
or passive range of motion use shoulder “normally without any limitation” after completion
Imaging: MRI of the treatment
Shoulder exercise brochures were provided

Senbursa et al91 Turkey Presence of SIS or stage 1 rotator cuff tear diagnosed by clinical Leaflet with instructions for exercises, avoidance of sports activities
examination and MRI for 12 wk
Imaging: MRI
Ucurum et al97 Turkey SIS, unilateral shoulder pain for ≥4 wk, passive range of motion No advice reported
of the shoulder: restriction of <30% compared to opposite
side
Vas et al99 Spain Chronic symptoms of unilateral subacromial syndrome; duration, A series of postural and ergonomic instructions (eg, centering the
≥3 mo humeral head and scapula during movement)
Imaging: X-ray to exclude other conditions
Vallés-Carrascosa Spain Diagnosis of subacromial syndrome by physician No advice reported

et al98 Painful arc between 60° and 120° of abduction
Age, 25-70 y
Imaging: none
Vinuesa-Montoya Spain Unilateral shoulder pain compatible with medical diagnosis of Home exercises
et al100 SIS; duration, ≤12 mo; baseline pain, ≥2/10 on the VAS; pain
or dysfunction with overhead activities; pain during active
shoulder movements; positive Neer or Hawkins-Kennedy test
Included age range not reported
Imaging: none
Wright et al101 United States Shoulder pain with 3 positive tests for the diagnosis of SIS: Home exercise
Hawkins-Kennedy test, painful arc sign, weakness in external
rotation with arm at the side
Age, ≤18 y
Imaging: none
Yiasemides et al102 Australia Painful active flexion or abduction for >1 mo; minimal shoulder Advice on how to avoid/minimize painful movement during ADL:
movement restrictions; pain/tenderness or restriction during limiting movement to pain-free range of motion, maintaining
passive accessory movements at the glenohumeral joint, normal scapulohumeral rhythm within pain-free range of motion,
acromioclavicular joint, or sternoclavicular joint, or during using the affected upper limb in a slow/careful manner, using
passive scapular movements techniques to minimize pain during activity, preferential use of
Included age range not reported nonaffected upper limb
Imaging: none
Yildirim et al103 Turkey Shoulder symptoms with findings compatible with shoulder Advice not to use affected arm for ADL or overhead activity
impingement for >6 mo, passive range of motion less than
30% compared to the unaffected side
Age, >40 y
Imaging: MRI, X-ray

APPENDIX
Prospective Cohort Studies

Braun et al20 Germany Shoulder pain associated with nontraumatic partial-thickness No advice mentioned
rotator cuff tear
Clinical signs of shoulder impingement
Age, ≥18 y
Imaging: ultrasound
Chester et al27,28 United Kingdom Musculoskeletal shoulder pain of any duration, score of ≤8 on the Advice and exercise
SPADI or QuickDASH, reproduction of pain and/or restriction
on active or passive movement in at least 1 direction
Age, ≥18 y
Imaging: none
Christiansen et al30 Denmark Diagnosis of rotator cuff syndrome, bicipital tendinitis, calcific Advice on self-training
tendinitis, impingement syndrome, bursitis, other shoulder
lesions, or unspecified shoulder lesions
Age, 18-65 y
Imaging: none
Cummins et al33 United States Diagnosis of impingement syndrome using diagnostic subacro- Work within pain, only progress exercise as tolerated, posture
mial injection
Age, 35-65 y
Imaging: none
Karel et al58 the Netherlands Shoulder pain (not further defined) Informing, advising, counseling, and coaching were documented for
Imaging: ultrasound imaging in 31% of 389 included patients 86% of patients
Nonrandomized or Retrospective Studies, Case Series, or Qualitative Interviews

Andrews et al5 United States Overhead athletes (water polo, baseball, basketball, volleyball) No advice mentioned
with complaints of SIS

Imaging: none
Barrett et al10,11 Ireland Minimum 6-wk history of shoulder pain; aggravated by resisted Encouraged to perform home exercises
shoulder flexion, abduction, or external rotation
Age, ≥18 y
Baydar et al12 Turkey MRI-confirmed full-thickness rotator cuff tears Activity modification
Camargo et al23 Brazil Clinical diagnosis of SIS Basic instruction about the anatomy and biomechanical factors
No evidence of rotator cuff or long head biceps tendon tear related to SIS; advice surrounding arm and trunk positions that
Imaging: ultrasound may lead to impingement; strategies to reduce load on the shoul-
der; instructions to use cryotherapy at home, as in sessions, if
pain is present
Christensen et al29 Denmark Experienced symptoms of rotator cuff rupture for ≥3 mo; rupture Information on the diagnosis and rationale for exercise protocol,
of at least the supraspinatus and infraspinatus, visualized by advice on how to manage pain related to exercise
ultrasound or arthroscopy
Imaging: ultrasound, MRI, or arthroscopy
Collin et al32 France Full-thickness tears of at least 2 rotator cuff tendons, stage 3 or 4 No advice mentioned
fatty muscle degeneration in the affected muscles, pain score
of ≤4 on the VAS, shoulder pseudo-paralysis: less than 90° of
active elevation with full passive range of motion
Imaging: none defined
Dickinson et al39 United States Symptomatic rotator cuff tears, pain and decreased function for No advice reported
≤4 wk
Age, ≤45 y
Imaging: MRI

APPENDIX

Elkhadir et al41 Saudi Arabia Rotator cuff tear, subacromial bursitis, subdeltoid bursitis, labral Advice not specified
tears
Imaging: MRI
Garrison et al45 United States Medically diagnosed with impingement syndrome with 1 or more No advice mentioned
of the following: dull ache at the anterolateral aspect of the
shoulder, pain with overhead activity, pain with resisted ab-
duction/external rotation, and pain with overhead positioning
or direct pressure against the shoulder
Imaging: none
Kuhn et al68 United States MRI-documented atraumatic full-thickness rotator cuff tears Instructive rehabilitative booklets
Age, 18-100 y
Imaging: MRI
Leffa et al71 Brazil Clinical diagnosis of rotator cuff injury, pain for ≥3 mo No advice reported
Age, 18-70 y
Savoie et al89 Canada Shoulder pain with painful arc of movement during flexion or Education regarding posture and body mechanics; instructions
abduction; positive Neer or Hawkins-Kennedy test; pain on around preferred shoulder positioning during sleep, activities,
resisted lateral rotation, abduction, or the empty-can test work, and sports
Age, 18-65 y
Imaging: none
Su et al94 China Pain or dysfunction for the shoulder for >3 mo No advice reported
Age, ≥18 y
Imaging: MRI indicating rotator cuff tendinopathy
Tate et al95 United States Shoulder pain: VAS, ≤7/10 at rest, positive Hawkins-Kennedy or Patient education: posture and body mechanics, avoidance of posi-
Neer test, positive painful arc, pain or weakness with either tions likely to provoke impingement
the Jobe empty-can test or resisted shoulder external rotation
Age, 14-80 y
Imaging: none
Tyler et al96 United States Shoulder pain with posterior glenohumeral joint line tenderness, No advice mentioned
posterosuperior glenoid labral lesion on MRI, positive reloca-
tion test, positive posterior impingement sign
Imaging: MRI
Yılmaz and Tuncer104 Turkey Subacromial bursa and supraspinatus tendon pathology with or Home exercise program
without restricted shoulder movement
Imaging: X-ray
Physical Therapist–Focused Studies

Surveys/Audits, Guidelines Implementation Studies, and Focus Groups With Physical Therapists
Bernhardsson et al19 Sweden 271 physical therapists in primary care (survey) Advice on posture, 85%; advice to stay active, 50%; advice on bed
rest, 10%; behavioral therapy, 5%
Bernhardsson and Sweden Total of 256 physical therapists surveyed in primary care as part Advice on posture: intervention group, 95%; control group, 92%
Larsson18 of an implementation study Advice to stay active: intervention group, 89%; control group, 87%
Intervention group: 168 physical therapists included in a program Advice on bed rest: intervention group, 10%; control group, 10%
to implement clinical guidelines for subacromial pain Behavioral therapy: intervention group, 8%; control group, 5%
Control group: 88 physical therapists
Dziedzic et al40 United Kingdom Audit of physical therapy patient notes Basic description of shoulder complex, what makes the shoulder
painful, why movements may be stiff, how to ease discomfort,
advice on when to move, encouragement to get back to daily
routine
Hanratty et al50 United Kingdom Physical therapists with ≥5 y of postgraduate experience working Patient education to improve “buy-in”: SIS etiology, self-manage-
with musculoskeletal conditions, working on a daily basis in a ment through exercise, postural advice, pain management
musculoskeletal role (survey)

APPENDIX

Karel et al59-61 the Netherlands 125 physical therapists participating in a prospective study, Information/advice: 92% of patients with SIS, but not defined
reporting their treatment interventions for patients with
shoulder pain; 112 (48%) of the patients were diagnosed as
having a subacromial impingement (survey)
Pieters et al84 Belgium and the 505 physical therapists, comparing those who were members Self-management of pain, posture, activity modification, work-
Netherlands of a professional shoulder network group to those who were related advice, options for exercise
not members
Struyf et al93 Belgium Dutch-speaking members of the Belgian physical therapist soci- Patient education/advice was not included
ety who had the possibility of treating patients with shoulder
pain (183 respondents) (survey)
Abbreviations: ADL, activities of daily living; DASH, Disabilities of the Arm, Shoulder and Hand questionnaire; MRI, magnetic resonance imaging; NPRS, nu-
meric pain-rating scale; NSAID, nonsteroidal anti-inflammatory drug; QuickDASH, shortened version of the Disabilities of the Arm, Shoulder and Hand ques-
tionnaire; SIS, subacromial impingement syndrome/shoulder impingement syndrome; SPADI, Shoulder Pain and Disability Index; VAS, visual analog scale.
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APPENDIX
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APPENDIX
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Seven Key Themes in Physical Therapy Advice For Patients Living With Subacromial Shoulder Pain: A Scoping Review

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[ literature review ]

KAREN MEEHAN, PT, BPhty(Hons)1 • CRAIG WASSINGER, PT, PhD2

Seven Key Themes in Physical

with rehabilitation, and increase fear and

inflammation of the rotator cuff tendons

journal of orthopaedic & sports physical therapy | volume 50 | number 6 | june 2020 | 285

286 | june 2020 | volume 50 | number 6 | journal of orthopaedic & sports physical therapy

pain ies reported using advice and education

Records identified through Additional records identified

health literacy and preferences.

Records screened by title, strengthening for the rotator cuff, gle-

Records excluded, n = 96 acceptable pain levels during and follow-

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288 | june 2020 | volume 50 | number 6 | journal of orthopaedic & sports physical therapy

journal of orthopaedic & sports physical therapy | volume 50 | number 6 | june 2020 | 289

Does the patients’ expectations on kinesiotape

patient experiences of participating in a group

7. Beaudreuil J, Lasbleiz S, Aout M, et al. Effect

290 | june 2020 | volume 50 | number 6 | journal of orthopaedic & sports physical therapy

journal of orthopaedic & sports physical therapy | volume 50 | number 6 | june 2020 | 291

292 | june 2020 | volume 50 | number 6 | journal of orthopaedic & sports physical therapy

CHECK Your References With the JOSPT Reference Library

This resource is updated twice a year on JOSPT’s website.

The JOSPT Reference Library can be found at: http://www.jospt.org/page/

journal of orthopaedic & sports physical therapy | volume 50 | number 6 | june 2020 | 293

STUDIES INCLUDED IN THE REVIEW

Al Dajah3 Saudi Arabia Clear diagnosis of SIS; VAS, ≥5 No advice mentioned

Imaging: X-ray, ultrasound

journal of orthopaedic & sports physical therapy | volume 50 | number 6 | june 2020 | a1

Study Country Participant Inclusion Criteria Advice and Education

Mean ± SD age, 46.9 ± 17.3 y

overhead work, alternating hands for 1-handed tasks where arm

a2 | june 2020 | volume 50 | number 6 | journal of orthopaedic & sports physical therapy

Study Country Participant Inclusion Criteria Advice and Education

2 of 3 positive tests: Neer, Hawkins, and Jobe

journal of orthopaedic & sports physical therapy | volume 50 | number 6 | june 2020 | a3

Study Country Participant Inclusion Criteria Advice and Education

a4 | june 2020 | volume 50 | number 6 | journal of orthopaedic & sports physical therapy

Study Country Participant Inclusion Criteria Advice and Education

Imaging: MRI; ultrasound finding of full-thickness tear, tear of <3

journal of orthopaedic & sports physical therapy | volume 50 | number 6 | june 2020 | a5

Study Country Participant Inclusion Criteria Advice and Education

Shoulder exercise brochures were provided

Vallés-Carrascosa Spain Diagnosis of subacromial syndrome by physician No advice reported

a6 | june 2020 | volume 50 | number 6 | journal of orthopaedic & sports physical therapy

Prospective Cohort Studies

Nonrandomized or Retrospective Studies, Case Series, or Qualitative Interviews

with complaints of SIS

journal of orthopaedic & sports physical therapy | volume 50 | number 6 | june 2020 | a7

Study Country Participant Inclusion Criteria Advice and Education

Physical Therapist–Focused Studies

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Study Country Participant Inclusion Criteria Advice and Education

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a10 | june 2020 | volume 50 | number 6 | journal of orthopaedic & sports physical therapy

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a12 | june 2020 | volume 50 | number 6 | journal of orthopaedic & sports physical therapy

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