Shoulder Pain Treatment Strategies E-Book

Treatment Strategies for Shoulder Pain A multimodal approach to managing shoulder conditions

TABLE OF CONTENTS

Introduction to shoulder injuries

3 Common Causes of Shoulder Pain

Rotator Cuff Calcification

10 The role of Photobiomodulation in relieving pain and improving mobility 14 ESWT (Extracorporeal shockwave therapy) 16 Strategies for shoulder impingement and tendon pathology 19 The Multimodal Playbook for Shoulder Tendinopathy/Impingement 22 Treatments for frozen shoulder 25 Treatment tools for shoulder pain 26 About Enovis™

INTRODUCTION TO SHOULDER INJURIES

Shoulder pain is reported to be the third most prevalent orthopedic condition. 1 Due to the complexity of the shoulder girdle, it is usually a problem that requires some level of professional intervention to restore function. Clinics can impact new patient traffic and overall revenue by creating specialized programs to address common shoulder conditions like chronic impingement, thrower’s shoulder, cuff pathology, and frozen shoulder.

Shoulder pain is unique because…

It’s Complex The shoulder is the most mobile joint in the body. 2 It requires multiple muscles and joints to work in harmony to allow normal function. Most patients presenting with shoulder pain have problem lists that require skilled intervention. Restoring glenohumeral rhythm is not an intuitive process for most patients and usually requires treatment components that cannot be addressed independently. These problems rarely fix themselves.

It Impacts Daily Function Patients use their arms a lot. Having a painful shoulder can impact everything from sleeping to any activity that requires overhead motion. Shoulder pain is a commonly reported reason for having to miss work. 1 Abnormal mechanics tend to worsen with time which frustrates most patients. This makes them a highly motivated patient population and places a premium on having treatment options that impact pain quickly, as it is paramount to improving shoulder function.

It Takes Time Shoulder problems often require longer plans of care due to a variety of factors that include: poor blood flow to tendinous structures, time required to build strength of the cuff musculature, time required to re-educate scapular muscles, and the challenges restoring motion at the glenohumeral and scapulothoracic complexes. These extended plans of care are highly desirable for most clinics but, if not managed well, can lead to higher rates of patient self-discharge.

Its Prognosis Several studies have reported that only 50% of patients presenting with shoulder pain achieve complete recovery after six months and only 60% after 12 months. 3 Given the challenges these patients represent, plans of care need to be optimized and evidence-based whenever possible.

There is growing support for the use of passive modalities to help impact pain and clear the way for more active therapies. 4 Passive modalities, such as laser therapy and extracorporeal shock wave therapy, combined with exercise have outperformed placebo devices and standard plans of care when treating conditions like frozen shoulder, cuff tendinopathy, calcification and impingement. 5,6, 7 Laser therapy has actually been shown to be as effective as cortisone injection when addressing pain associated with shoulder impingement. 8

This guide will include an evidence-based review of laser, extracorporeal shock wave, electrical stimulation, and hot and cold therapy modalities and explain how these technologies can be incorporated into the treatment plans for common shoulder injuries. Treatment recommendations are applicable to rehab professionals who commonly work with shoulder patients which includes but is not limited to: osteopaths, physical therapists, athletic trainers, and chiropractors.

The treatment concepts outlined in this e-book are intended to improve the conservative management of different shoulder conditions. The significance of conservative approaches has been supported by the findings of the prospective 2013 MOON (Multicenter Orthopaedic Outcomes Network) shoulder study that showed conservative therapy helped 75% of non-surgical patients suffering from atraumatic, full-thickness cuff tears for a period of at least seven years. 9

Intelect® Mobile 2

3 COMMON CAUSES OF SHOULDER PAIN

Before diving into treatment recommendations, let’s review 3 common shoulder categories.

#1 Impingement

Arguably the most common shoulder presentation in the clinic, research shows that shoulder impingement syndrome is believed to account for 44-65% of all shoulder complaints. 4 Shoulder impingement occurs as a result of the structural narrowing of the subacromial space causing the tendons of the rotator cuff muscle to become irritated and inflamed as they pass through the subacromial space of the shoulder joint. 10 This can lead to rotator cuff tendinitis with pain and limited range of motion in the shoulder. Symptoms of shoulder impingements can be similar to rotator cuff tears and should be thoroughly evaluated before prescribing a plan of care. Shoulder impingements are typically diagnosed by physical examination.

Common causes of shoulder impingement include

Overuse or repetitive overhead movements, such as throwing, swimming, or painting. Improper scapular mobility and/ or muscle imbalances make impingement common in athletes and individuals with physically demanding occupations where repetitive overhead motions are common. Bone spurs in the shoulder joint that narrow the subacromial space. A recent study showed that 68% of adults in their late 50’s, with or without cuff tears, had acromial spurs and the incidence increased with age. 11 It also highlighted that individuals with spurs were more at risk for full thickness cuff tears.

Poor posture can contribute to poor scapular mechanics and anterior soft tissue restrictions that predispose individuals for shoulder impingement. This is a common driver for individuals that have desk jobs, especially with prolonged keyboard use.

Muscle weakness, poor endurance, or strength

imbalances at the rotator cuff and/or scapular muscles can lead to poor positioning of the glenohumeral joint under load or with overhead activities. This can lead to irritation of multiple tissues that reside below the acromion.

SHOULDER IMPINGEMENT SYMPTOMS • Pain in the top and outer side of the shoulder 12 • Point tenderness over the distal attachments of infra and supraspinatus muscles • Discomfort with overhead movement 12 • Aching or pain in the night that impacts sleep 12 • Arm weakness 12

Trauma or injury to the shoulder, such as a fall or sudden impact.

#2 Frozen Shoulder

Frozen shoulder is also known as adhesive capsulitis and is characterized by stiffness, pain, and limited range of motion in the shoulder joint. This condition typically develops gradually over time and takes one to three years for symptom improvement. The “freezing” of the shoulder results from the thickening of the shoulder joint capsule of connective tissue, causing it to tighten and restrict the shoulder joint. 13

Risk factors associated with frozen shoulder include 13

Reduced mobility from injury, surgery, or stroke.

Individuals over the age of 40 with women being more likely to be affected by the condition.

Diseases such as diabetes, hyperthyroidism, hypothyroidism, cardiovascular disease, and Parkinson’s.

40+

FROZEN SHOULDER SYMPTOMS Unlike other forms of shoulder pain, frozen shoulder symptoms typically present in a four-stage process. 14 Most therapy is supported during the early and thawing stages.

Stage One Early Stage (1 to 3 months)

Stage Three Frozen (9 to 15 months)

During this stage of the condition, range of motion is typically unaffected often resulting in the condition being misdiagnosed as shoulder impingement. Patients experience pain in the shoulder when at rest and at the end range of motion. Patients also tend to report difficulty sleeping. 14, 15

As the name of this stage suggests, range of motion is severely limited in all directions. Pain continues and can be a throbbing sensation for patients even at rest. The synovium becomes less inflamed, but it is replaced with capsuloligamentous fibrosis. 14,15

Stage Four Thawing (15 to 24 months)

Stage Two Freezing/ Painful Stage (3 to 9 months)

During this stage, symptoms begin to resolve. Both the synovitis and capsular fibrosis are diminished and patient pain improves. Mild pain and mobility deficits may persist for several years, but patients still tend to report improvement in function and are able to return to routine activities. 14,15 Physical therapy programs focused on joint mobility and restoring functional strength to the shoulder can be helpful during this stage.

By this stage, the synovium has become inflamed. Pain continues to increase and patients gradually lose range of motion in all directions. 14,15 Home exercise programs can be prescribed to help patients retain range of motion and reduce pain.

#3 Rotator Cuff

The rotator cuff is a group of muscles and tendons around the shoulder joint that keep the upper arm bone in the shoulder socket. 16 Various levels of injury can occur to the rotator cuff, including tendonitis, chronic tendinopathy, partial tears, and full-thickness tears. Tendonitis commonly occurs due to trauma or overuse and can progress to a chronic state of tendinopathy. Once in this chronic stage, the rotator cuff may become weak and can lead to further tearing. 17 Rotator cuff tears are extremely common, affecting at least 10% of those over the age of 60 in the United States, which equates to over six million cases per year. 9 It has been shown that 23% of asymptomatic shoulders have tears with the percentages increasing each decade after 50 years of age. 18 Cuff pathology is considered a progressive disorder. Twenty percent of asymptomatic tears are progressive, and do not get smaller with time. 9 Industry estimates suggest rotator cuff surgeries are performed in the US on 75,000–250,000 patients per year and the failure rate for surgical repair of rotator cuff tears is between 25 and 90%. 9 Fortunately, patients with failed repairs report satisfaction levels and outcome scores that are nearly indistinguishable from those whose repairs are intact. 9 A number of retrospective case series and one randomized controlled trial have suggested that nonoperative treatment of full thickness rotator cuff tears may be successful in some patients. 9

COMMON CAUSES OF ROTATOR CUFF INJURIES INCLUDE

Rotator cuff injury symptoms

A dull deep shoulder ache

• Repetitive overhead movements making rotator cuff injuries common across a diverse patient population. 16 • Trauma such as falls, rapid humeral deceleration with throwers, or high resistive forces applied through the shoulder. 16 • Individuals over the age of 60 are more prone to rotator cuff injury. 16 • Subacromial bone spurs can contribute to impingement, leading to an increased likelihood of rotator cuff pathology. 11 • Weakness or imbalance of muscles surrounding the shoulder joint. 16

Pain that disturbs sleep

Discomfort with overhead movement and with moving the arm behind the back

Arm weakness

ROTATOR CUFF CALCIFICATION

Rotator cuff calcification, also known as calcific tendonitis, occurs when calcium deposits build up in the tendons of the rotator cuff. These deposits can cause inflammation and severe pain, especially when they grow or become irritated.

Symptoms

Causes

• • •

Sudden shoulder pain and stiffness Intense pain with shoulder movement

The exact cause isn’t fully understood, but it’s more common in people between the ages of 40 and 60, and slightly more prevalent in women.

Pain that disrupts sleep

• Reduced range of motion in the shoulder

Diagnosis

Diagnosis typically involves imaging tests like X-rays or ultrasound scans to identify the calcium deposits.

Treatment

Treatment options include:

• Pain relief medications like paracetamol or ibuprofen • Physiotherapy to strengthen and maintain shoulder flexibility • Corticosteroid injections to reduce inflammation • Ultrasound-guided barbotage, a procedure to remove calcium deposits • Shockwave therapy, a non-invasive procedure to remove calcium deposits • Surgery in severe cases to remove the deposits and create more space in the shoulder joint

Studies to support the use of shockwave therapy in the treatment of calcific tendonitis

Focused, radial and combined shock wave therapy in treatment of calcific shoulder tendinopathy. pubmed.ncbi.nlm.nih.gov/33283581/

The effects of shockwave therapy on musculoskeletal conditions based on changes in imaging: a systematic review and meta-analysis with meta-regression. pubmed.ncbi.nlm.nih.gov/32345281/

Comparison of Radial Extracorporeal Shock Wave Therapy and Traditional Physiotherapy in Rotator Cuff Calcific Tendinitis Treatment. pubmed.ncbi.nlm.nih.gov/31598593/

Prognostic factors for the outcome of extracorporeal shockwave therapy for calcific tendinitis of the shoulder. pubmed.ncbi.nlm.nih.gov/29212688/

Individualised radial extracorporeal shock wave therapy (rESWT) for symptomatic calcific shoulder tendinopathy: a retrospective clinical study. pubmed.ncbi.nlm.nih.gov/29207984/

THE ROLE OF PHOTOBIOMODULATION IN RELIEVING PAIN AND IMPROVING MOBILITY

Energy modalities are becoming more popular in the physical therapy, osteopath, chiropractic, and athletic training fields as research continues to support the benefit they provide when added to treatment protocols. The complexity of shoulder pain necessitates a multimodal approach to care, and incorporating modalities such as photobiomodulation therapy (PBMT), also known as laser therapy, and extracorporeal shock wave therapy, can help optimize patient outcomes. PBMT can result in beneficial therapeutic outcomes such as the alleviation of pain, increased blood flow, muscle relaxation, and relief from joint stiffness. 19-21 Relieving pain and increasing muscle relaxation allows patients suffering from shoulder conditions to get more out of their therapy program which can lead to improved outcomes and an accelerated recovery. Photobiomodulation therapy (PBMT) is a form of light therapy based on the photochemical process called photobiomodulation (PBM). In photobiomodulation therapy, a light source is placed near or in contact with the skin, the light energy penetrates the skin reaching the mitochondria of damaged or diseased tissue leading to photobiomodulation. This process can result in beneficial therapeutic outcomes such as the alleviation of pain, increased blood flow, muscle relaxation, and relief from joint stiffness. 25-27 PBMT is a form of light therapy based on the photochemical process called photobiomodulation (PBM). In photobiomodulation therapy, a light source is placed near or in contact with the skin; the light energy penetrates the skin, reaching the mitochondria of damaged or diseased tissue, leading to photobiomodulation. PBM mechanisms of action The application of a therapeutic dose of light to impaired or dysfunctional tissue leads to a cellular response mediated by mitochondrial mechanisms involved in pain relief and tissue repair processes . 26 PHOTOBIOMODULATION (PBM) THERAPY A proven way to impact tissue at the cellular level The primary target (chromophore) for the process is the cytochrome c complex which is found in the inner membrane of the cell mitochondria. Cytochrome c is a vital component of the electron transport chain that drives cellular metabolism. As light is absorbed, cytochrome c is stimulated, leading to increased production of adenosine triphosphate (ATP), the molecule that facilitates energy transfer within the cell. 26-28 In addition to ATP, laser stimulation also produces free nitric oxide and reactive oxygen species. Nitric oxide is a powerful vasodilator and an important cellular signaling molecule involved in many physiological processes. Reactive oxygen species have been shown to affect many important physiological signaling pathways including the inflammatory response. In concert, these molecules have been shown to increase growth factor production and promote extracellular matrix deposition. The resultant increase in cell proliferation and motility leads to pro-survival pathways for the cell . 26-28 PBM mechanisms of action The application of a therapeutic dose of light to impaired or dysfunctional tissue leads to a cellular response mediated by mitochondrial mechanisms involved in pain relief and tissue repair processes. 20

Physiological effects • A nalgesic • Increased tissue oxygenation and nutrition • Increased synthesis of ATP • Impacts the biochemical pathways involved in tissue repair • Increased microcirculation The primary target (chromophore) for the process is the cytochrome c complex which is found in the inner membrane of the cell mitochondria. Cytochrome c is a vital component of the electron transport chain that drives cellular metabolism. As light is absorbed, cytochrome c is stimulated, leading to increased production of adenosine triphosphate (ATP), the molecule that facilitates energy transfer within the cell. 20-22 In addition to ATP, laser stimulation also produces free nitric oxide and reactive oxygen species. Nitric oxide is a powerful vasodilator and an important cellular signaling molecule involved in many physiological processes. Reactive oxygen species have been shown to affect many important physiological signaling pathways including the inflammatory response. In concert, these molecules have been shown to increase growth factor production and promote extracellular matrix deposition.

Jun/Fos

AP-1

Mitochondria

ATP

Gene Transcription

lkB

NO ROS-

NF-kB

HIF-1 α

NF-kB

CA 2+ /NA + Antiporter NA + /H + Antiporter NA + , K + -ATPase CA 2+ Pump ∆CA 2+ , K + ∆cAMP, ∆pH

Physiological effects

A significant reduction in inflammatory markers and neurotransmitters 67

Increased synthesis of ATP 67

Impacts the biochemical pathways involved in tissue repair 67

Increased microcirculation 67

Analgesic Long lasting pain relief by having a direct influence on nocioceptive activation 67

DELIVERY AND DOSAGE

A drug-free, surgery-free, non-invasive pain treatment alternative

PBMT offers versatile treatment applications for the shoulder 23,24 , neck 25 , and back 26 , making it an appropriate tool in the multimodal toolbox for the treatment of shoulder pain and these common referring sites.

PBM dosing - the key to results

Dosimetry in photobiomodulation (PBM) therapy is highly complicated - no single “dose” will work for all possible PBM therapies, and in some cases, different dosimetries can be equally effective. Safe and effective PBM dosimetry must consider multiple treatment parameters including: wavelength, irradiance (often called power density or brightness), and irradiation time. 22 Furthermore, it is important to recognize that PBM is challenged by energy loss that occurs as light enters the skin and travels from superficial to deeper tissues. At the skin’s surface this is primarily due to reflection and below the surface by absorption from different tissues competing for different wavelengths of light. Proper configuration of the laser is a key factor in getting sufficient energy to target tissues.

The massage ball treatment applicator can help maximize clinical results for deep muscle conditions such as those present in the shoulder and back with the benefits of LightForce’s patented, on-contact PBMT treatment application.

REFLECTION Contact application of delivery to tissue minimizes energy loss due to reflection PHOTOBIOM DOSING A drug-free, surgery-free, non-invasive PBM dosing - the k ey to results Dosimetry in photobiomodulation (PBM) therapy is highly therapies, and in some cases, different dosimetries can be consider multiple treatment parameters including: wavele and irradiation time . 28

COMPRESSION Gets you closer to target tissue. Blanching reduces obstacles of superficial absorbers

SOFT TISSUE WORK Allows you to do manual soft tissue work with the massage ball applicator while delivering energy PHOTOBIOMODULAT DOSING A drug-free, surgery-free, non-invasive pain treatment alternati Furthermore, it is important to recognize that PBM is chal travels from superficial to deeper tissues. At the skin’s su by absorption from different tissues competing for differe key factor in getting sufficient energy to target tissues. PBM dosing - the k ey to results Dosimetry in photobiomodulation (PBM) therapy is highly complicated - no single “dose” will w therapies, and in some cases, different dosimetries can be equally effective. Safe and effective consider multiple treatment parameters including: wavelength, irradiance (often called power and irradiation time . 28 Furthermore, it is important to recognize that PBM is challenged by energy loss that occurs as travels from superficial to deeper tissues. At the skin’s surface this is primarily due to reflectio by absorption from different tissues competing for different wavelengths of light. Proper confi key factor in getting sufficient energy to target tissues. Lase Laser In the laser

COLLIMATION The massage ball acts to collimate the delivery of light to tissue reducing energy loss

REFRACTIVE INDEX The fused silica composition of the massage ball minimizes light losses as it passes from the massage ball into the skin due to similar refractive indices

Factors that impact dose delivery at depth • Wavelength • Irradiance (power & beam area)

• Cl • Cl

• Mechanism of delivery (contact vs. non-contact) • Treatment time • Size of treatment area • Type of tissue

Factors that impact dose delivery at depth

• • Factors that impact dose delivery at depth • Wavelength • Irradiance (power & beam area) Treatment time • Type of tissue

Both C be wo Laser classes - what do they Lasers are classified by the FDA according In the field of photobiomodulation therapy laser classifications:

• •

Wavelength

Irradiance (power & beam area)

Size of treatment area

•

Mechanism of delivery (contact vs. non-contact)

• Class IIIb, Maximum power output of 0. • Class IV, Maximum power output of ove

• Mechanism of delivery (contact vs. non-contact) • Treatment time • Size of treatment area • Type of tissue

The impact of power on treatment time Power is a key factor when delivering a therapeutic dose higher output powers, but they also have larger beam are to larger treatment areas. For example, to effectively treat a 300 cm 2 thoracic spine of the skin to deliver a therapeutic dose at depth. How lon IV laser? Both Class IIIb and Class IV lasers require be worn during emission.

Class IIIb 3,000 J at 0.5 W = 100 min For example, to effectively treat a 300 cm 2 thoracic spine at 10 J/cm 2 , 3,000 joules of energy a of the skin to deliver a therapeutic dose at depth. How long would that treatment take with a Cl IV laser? Class IV 3,000 J at 15 W = 3.3 The impact of power on treatment time Power is a key factor when delivering a therapeutic dose to deep target tissues. Not only do Lig higher output powers, but they also have larger beam areas, making them more capable of del to larger treatment areas.

The impact of power on treatment time Power is a key factor when delivering a therapeutic dose to deep target tissues. Not only do LightForce® lasers have higher output powers, but they also have larger beam areas, making them more capable of delivering a therapeutic dose to larger treatment areas. For example, to effectively treat a 300 cm 2 thoracic spine at 10 J/cm 2 , 3,000 joules of energy are required at the surface of the skin to deliver a therapeutic dose at depth. How long would that treatment take with a Class IIIb laser vs. a Class IV laser?

Class IIIb 3,000 J at 0.5 W = 100 min

Class IV 3,000 J at 15 W = 3.3 min

PBMT provides a drug-free, surgery-free, non-invasive pain treatment alternative that many patients with shoulder pain are searching for. A conservative first-line treatment for shoulder pain

Research supports the use of laser therapy for shoulder pain.

• Elsodany and colleagues demonstrated that laser therapy combined with exercise therapy is more effective at improving pain and function in patients with rotator cuff tendinopathy when compared to sham laser and exercise. 28 • Kelle and Kozanoglu compared laser therapy to corticosteroid injection in patients with shoulder impingement and concluded that both treatments were more effective than sham laser in improving patient pain. 8 • The Cochrane Review, Electrotherapy modalities for rotator cuff disease, concludes that laser therapy when compared to placebo may offer short-term benefits to patients with rotator cuff disease. 29 • A review by Haslerud et al. reported that laser therapy, whether used alone or in conjunction with other physiotherapy treatments, can provide shoulder tendinopathy patients clinically significant pain relief. 30 • A recent meta-analysis of clinical trials using laser therapy to treat musculoskeletal conditions demonstrated that laser therapy had the greatest functional impact on the shoulder (and knee) compared to other anatomical locations treated. 31

Clinical data collected on LightForce lasers

374 Patient cases were analyzed, inclusive of all anatomy 32

SECOND Shoulders were the most common anatomical location treated with laser therapy

Patients had a minimum of

4 weeks of treatment with a LightForce® high power laser

84% of shoulder cases had a clinically significant reduction in pain

Data was collected from healthcare providers through a third-party administered survey as part of routine post- market clinical follow-up on the safety and performance of the LightForce® Therapy Laser devices.

ESWT (EXTRACORPOREAL SHOCKWAVE THERAPY)

ESWT (Extracorporeal Shockwave Therapy), which encompasses both Radial Shockwave (RSW) and Focus Shockwave (FSW) therapy, is a non-invasive treatment option that has support in the literature for helping address muscle aches and pains associated with shoulder dysfunction. 33 During treatment with ESWT, high-energy sound waves are transmitted into the tissue propagating radially and creating a therapeutic effect on the impacted areas. 34

Listed below are conditions that can be treated with Chattanooga® Radial Shockwave (RSW) devices. 33

• • • • •

Plantar Fasciitis and Heel Pain

Achilles Tendinopathy

Disorders of Tendon Insertions

Myofascial Trigger Points

Muscle Pain & Aches

How does ESWT help tissue? High energy waves, called shockwaves, which can be created via different mechanisms, create a phenomenon called mechanotransduction. Simply put, it is the process of imparting brief, physical deformation to cells that leads to biochemical changes. These changes have the potential to positively impact pain and tissue repair. 35

In some instances, the negative pressure created during the tensile phase of a shockwave creates cavitation bubbles within cells. 36 If intense enough, it can lead to disruption of damaged cells which is why ESWT can be classified as a proinflammatory modality. Disruption of cells can lead to cell death (apoptosis) which triggers a low-level inflammatory response that benefits the process of removal and replacement of damaged tissue. This is another way that RSW therapy can uniquely assist in treating chronic soft tissue problems.

Radial shockwave energy delivery is dependent on the following:

• The volume of shocks provided. Most studies, and Enovis TM , recommend 2000 pulses per location when treating tendon dysfunction. Trigger points may require fewer shocks. Patient feedback will dictate length and intensity of treatment over an area. • The rate at which the shocks are provided (Hz). Some patients will subjectively prefer higher frequency treatments. Treating at higher rates will also shorten treatment times. • The bar pressure of the machine which dictates the intensity of the radial pressure wave. Deeper tissue dysfunction requires higher bar settings in most cases.

• The applicator used. Softer materials transmit less energy and are useful for superficial tissues/ sensitive areas. Harder metals (steel and titanium) are used to treat deeper tissues as they transmit more energy into the tissue. Examples of different applicators are listed below:

F15 White soft transmitter 15mm for superficial pain regions, muscles of mastication, cervical spine Penetration depth 0-30mm Intensity level: Very Low Ro40 15mm Energy beam transmitter with concave coupling surface, best for pain zones near the skin surface Penetration depth 0-35mm Intensity level: Medium DI15 Golden Depth 15mm Deep Impact ® transmitter for deep target areas, chronic disorder, local trigger points Penetration depth 0-60mm Intensity level: High

D20-S Standard Oscillator, 20mm transmitter for muscle and connective tissue Penetration depth 0-50mm Intensity level: Medium

C15 CERAma-x ® Ceramic Energy 15mm transmitter for any type of tendinopathy Penetration depth 0-35mm Intensity level: High

Atlas Soft flexible tipped transmitter 15mm for highly sensitive regions and trigger points in the cervical spine

The divergent wave of the RSW makes it easier to locate painful tissue when scanning for painful areas. This is a key factor in why RSW has been shown to be statistically more effective in 88.5% of studies that compared RSW to either placebo or alternative treatment modalities when treating different types of tendinopathies. 37

STRATEGIES FOR SHOULDER IMPINGEMENT AND TENDON PATHOLOGY

Plans of care for patients dealing with shoulder pain can vary from weeks to months depending on the specific pathology and stage of the condition (pain acuity). Additional factors that can impact outcomes and length of care can include the patient’s age and general health, mental status, and level of desired functional return. 38 Thoughtful consideration should be given to these factors when making a prognostic plan of care for any shoulder patient. Pain reduction and restoring range of motion (ROM) are usually the top priorities for most shoulder conditions requiring clinical care. Getting pain under control is paramount to improving ROM and function and is also a critical component of gaining patient trust and improving patient compliance.

How important is it? In today’s climate of high deductibles/ co-pays, approximately 20% of tendinopathy patients self-discharge within the first three visits, while 70% of patients fail to complete their full plan of care. A white paper from Marquette University states that a lack of immediate results is one of the leading causes of high attrition rates. Data suggest that high symptom severity and low functional ability increase the rate of self-discharge. 63 Educating patients that conservative care can help most shoulder problems is as important as proving it. Clinicians’ choices to address problems with pain, ROM, and functional deficits are based on various factors, including the specifics of the patient profile and diagnosis, as well as the technology they have at their disposal. When addressing shoulder impingement and tendinitis, clinicians should be mindful of 5 basic components. 39

#1 Identify and remove any external factors

• Ensure there are no external, anatomical causes for the impingement. This could include surgical considerations regarding bone spurs and soft tissue abnormalities. • Address functional components that may create impingement due to poor posture, i.e., poor scapular position and/ or glenohumeral positioning.

Strategies for Shoulder Impingement and Tendon Pathology

An accurate description of early tendon pain is important. Acute injuries can be framed in one of three phases. #2 Estimate phase of the tendinitis/ tendinosis

Early phase involves pain only after activity without significant loss of range. Pain usually resolves when activity stops. If mechanics and or tendon loading activities are not corrected, tendon irritation can progress.

Moderate pathology presents with extreme exertion and lasts 1-2 hours after activity. As it progresses, pain may be present with moderate activity and last four-six hours after exercise.

Severe pathology will present with pain during any activity that rapidly increases with continued activity. Pain can last 8-24 hours after exercise. Eventually all daily activities become painful.

Chronic tendon pain lasting > six months falls into the tendinosis category. This is a state where a tendon physically starts to change. These changes may include hypoechoic areas as well as general thickening of the tendon evident on ultrasound. 40 • This pathology requires a careful loading program that focuses on high load, long duration resistive activities. • The Physical Therapy Program at The University of Delaware has done extensive research on tendinosis. Click here to see an example of this type of rehabilitation program for achilles tendinopathy. 41

#3 Determine appropriate focus of treatment This will be based on how the patient is presenting. Acute pain will require rest, education, and treatments to address inflammation. More chronic conditions will require progressive loading programs.

#4 Institute appropriate tensile loading program based on the stage of tendon pathology.

Strategies for Shoulder Impingement and Tendon Pathology

#5 Control pain and inflammation Any number of modalities could be used to help in this area. A recent meta analysis of 177 trials that reviewed twenty treatment options for addressing subacromial dysfunction concluded that six modalities/ treatments had a high probability of being most effective, in the short term, for pain and function. These included: 42

• • •

Acupuncture

• • •

Exercise plus manual therapy

Manual therapy

PBMT (laser therapy)

Exercise

Microcurrent (MENS) (TENS) 42

Intelect® RPW2

High power laser and radial shockwave technologies both have the ability to change pain quickly and restore ROM, albeit via different mechanisms. 28,43 These devices should help restore ROM and reduce pain more effectively than exercise alone. A meta-analysis by Steuri et al. concluded that shoulder exercises should be part of the treatment program but that adding laser or shockwave therapy can provide an additional benefit to patients. 64

Yilmaz et al. recommends a multimodal approach to control pain that can include treatments like TENS and superficial hot and cold applications. 44

THE MULTIMODAL PLAYBOOK FOR SHOULDER TENDINOPATHY/ IMPINGEMENT

Neck pathology All shoulder patients should be screened for neck pain or nerve involvement to rule out other conditions or nerve involvement that may be contributing to shoulder dysfunction. Traction, transcutaneous electrical nerve stimulation (TENS), and high-power lasers may be beneficial in relieving pain from nerve impingement and cervical conditions.

TRITON DTS™ 6E

Traction Patients suffering from nerve

impingement and disc related radicular complaints can benefit from traction to help normalize intradiscal pressures, improve space in the foramina, and improve blood flow and EMG activity in affected muscles. 45-47 Both mechanically driven traction and home cervical traction units have been shown to benefit patients with radicular complaints.

SAUNDERS NECK TRACTION

Adding mechanical or home traction to an exercise program compared to exercise alone, has been shown to significantly impact NDI (Neck Disability Index) scores and reduce neck and arm pain, especially at long term follow up. 48 Two traction devices that can help are the Triton DTS™ system for clinic use and the Saunders cervical and lumbar home traction unit for remote applications. The Triton system is highly customizable and can provide cervical traction in a variety of intermittent and static pull patterns. The Saunders Cervical unit is a pneumatic device that is easy to use at home and can provide up to 50 lbs of pull in a comfortable supine position. Adjusting tension on the device is done via a simple hand pump to create desired levels of traction as compared to over the door units that often require adding or subtracting water to a bag to adjust traction levels.

LIGHTFORCE® THERAPY LASER

Thoracic Pain/ Hypomobility Poor posture has the potential to negatively impact scapular mechanics. 49 Pain and stiffness in the thoracic spine and/ or muscles around the scapula can be components of postural dysfunction. Therefore, modalites that help address pain in this area may help improve underlying components of non- traumatic shoulder pain. The Intelect® RPW 2 has Spine Actor attachments that are specially designed to address painful muscles around the spine. For those muscles around the scapula, the Periactors are ideal for treating hard to reach soft tissue interfaces around the edges of the scapula.

Both groups of these attachments can have the frequency and intensity of the treatment adjusted to meet individual patient needs.

High power laser is useful in helping to relieve pain in this area as well. Use of high power lasers has ability to impact pain quickly which may be beneficial when addressing pain in the thoracic spine area. 50 Since most LightForce treatments only require a few minutes, it is an ideal adjunct to most manual therapies.

While not new, TENS and interferential treatments have a proven track record for reducing musculoskeletal pain during and immediately after treatment. 51 Since TENS acts via non-specific therapeutic neuromodulation, it can address pain that is generated from different tissues, making it a useful preparatory treatment before exercise or manual therapies in the mid-back and shoulder. TENS and IFC only provide short term pain relief (20 minutes - 2 hours), whereas Lightforce therapy can provide long-term pain relief. Ucurum and colleagues demonstrated that ultrasound, interferential current, and TENS when used in addition to exercise therapy all similarly improved pain, function, and quality of life for patients with shoulder impingement syndrome. 52

Use the treatment protocols in the Intelect® Mobile 2 Combo to reduce musculoskeletal pain associated with the mid-back and shoulder.

Pro Tip In cases where there is significant weakness in the cuff muscles or weakness in the lower trapezius, consider using neuromuscular electrical stimulation (NMES) to help promote contraction in these muscle groups.

A prospective clinical trial by Moroder et al concluded the shoulder-pacemaker therapy concept, using the Chattanooga Wireless Pro muscle stimulator, is an effective treatment with rapid improvement and sustained outcome over the course of 2 years in patients with noncontrollable PP-FSI (positional functional shoulder instability) with previously failed conventional treatment. Young and more athletic patients with lower weight and unilateral pathology respond best to the treatment. 66

Research supporting use of different modalities to address pain and function for shoulder tendinopathy. • A clinical practice guide by Yu et al. recommends using laser therapy for short-term pain relief in patients with subacromial impingement syndrome as studies demonstrated laser was more effective than placebo or ultrasound. 53 • A clinical study conducted by Yilmaz and colleagues demonstrated that combining high intensity laser therapy with exercise gave patients better pain relief, quality of life, function, and ROM than patients receiving exercise and sham laser. 54 • A retrospective study by Karaca concluded that high-power laser therapy was effective at reducing pain and disability in patients with subacromial impingement syndrome out to 8 weeks post-treatment. 55 • Elsodany and colleagues demonstrated that laser therapy combined with exercise therapy is more effective at improving pain and function in patients with rotator cuff tendinopathy when compared to sham laser and exercise. 28 • The Cochrane Review by Page et al concludes that both ultrasound and laser therapy may have short-term benefits in patients with rotator cuff disease compared to placebo. 29 • A study by Dedes and colleagues showed that using RPW to treat rotator cuff tendinopathy resulted in improved pain, function, and quality of life when compared to control groups. 7 • A review by Haslerud et al. reported that laser therapy, whether used alone or in conjunction with other physiotherapy treatments, can provide shoulder tendinopathy patients clinically significant pain relief. 30

White Paper Download Take a deep dive on the treatment of tendinopathy, including rotator cuff tendinopathy with this new white paper.

TREATMENTS FOR FROZEN SHOULDER

As discussed earlier, the course of frozen shoulder is broken down into four different stages, each characterized by levels of pain and pathological changes. Therefore, it is important to cater treatment strategies to address the specific stage of the condition. Pain begins to build during the early stage and continues to increase until it peaks at the frozen stage. Providing patients with pain relief during these stages is a top priority. 56 Specifically, the CPG (Clinical Practice Guideline) from the American Physical Therapy Association recommends therapy during the early inflammatory stages (six-eight weeks) to help manage pain and provide patient education. 14 Addressing pain will

enable patients to continue to do their daily activities while at the same time allowing for exercise and some mobilization techniques. As the condition progresses to the frozen stage and the range of motion is lost, the treatment strategy should be adjusted to focus on regaining function and increasing the range of motion. By the thawing stage, pain is minimal so therapy can continue to focus on functional improvements. 56 Pain relief in frozen shoulder can be managed by various mechanisms including nonsteroidal anti-inflammatories, corticosteroids (oral and injectable), short wave diathermy, ultrasound, heat therapy, electrotherapy, and shockwave and laser therapy. 14, 56,61

Corticosteroid injection 57 • Superior to placebo and physiotherapy in the short-term (up to 12 weeks). • There was no difference in outcomes between corticosteroid injection and oral nonsteroidal anti-inflammatory drugs at 24 weeks. • Generally safe, with infrequent and minor side effects. • Usually performed during early stages when pain is the predominant presentation.

Arthrographic joint distension 58 • Joint distention, also referred to as guided hydrodilatation, is a treatment performed by injecting mixed, diluted corticosteroid and local anesthetic into the contracted glenohumeral joint space. • This is performed under ultrasound guidance to achieve hydraulic capsular distension (or rupture) and reduce inflammation and pain. • Commonly followed by physiotherapy for continued joint mobilization and ROM work.

As noted in the Cochrane review by Page et al., laser therapy when added to exercise provided frozen shoulder patients with more pain relief than patients that received exercise therapy alone. 29 Ordahan et al. compared treating frozen shoulder with low level laser therapy versus treating with high power laser therapy. Shoulder pain was significantly improved in both groups demonstrating the effectiveness of laser therapy in helping to manage the symptoms of frozen shoulder. It is important to note, however, that the patients treated with high power laser therapy had better outcomes than those treated with low level laser therapy. 65 When it comes to improving shoulder function and range of motion, Pandy and Madi suggest a therapy program focused on mobilization of the shoulder including range of motion exercises as well as muscle strengthening exercises. 56 Jain and colleagues recommend adding heat therapy as it can help improve range of motion, shoulder function, and decrease pain. 59 Steroid injections and capsular distension are also common treatments for helping patients to regain function. However, a recent meta-analysis by Zhang and colleagues stated that “ESWT and laser therapy are the preferred new treatments” as both modalities have demonstrated benefits to patient recovery. 60 A clinical study by Naggar et al. demonstrated that treatment with radial shockwave therapy gave frozen shoulder patients more pain relief and better functional outcomes than those treated with an intra-articular steroid injection. 61 • In the Page et al. Cochrane review, patients treated with laser therapy and exercise had more functional improvement and better range of motion than those only completing exercises. 29 • The Ordahan et al clinical trial demonstrated that patients treated with laser therapy had significant functional improvement after three weeks. 65 Research supports this statement: •

In about 90% of patients, conservative treatment can provide patients pain relief and help them to regain their shoulder function. For those that need additional treatment, surgical procedures, such as glenohumeral manipulation or arthroscopic capsular release may be required. 56

Recommended modalities include

Electrical Stimulation 14

Shortwave Diathermy 14

Laser Therapy 29

Ultrasound 14

Stretching Exercises 14,29

RSW (Shockwave) 61

Suggested studies to review for impingement/tendinitis:

Comparison of Radial Extracorporeal Shock Wave Therapy and Traditional Physiotherapy in Rotator Cuff Calcific Tendinitis Treatment 62 pubmed.ncbi.nlm.nih.gov/31598593/

Focused, radial and combined shock wave therapy in treatment of calcific shoulder tendinopathy. https://pubmed.ncbi.nlm.nih.gov/33283581/

Effects of high-intensity laser therapy on subacromial impingement syndrome: a systematic review and meta-analysis. https://pubmed.ncbi.nlm.nih.gov/39317844/

Suggested studies to review for frozen shoulder:

Ordahan article and article summary: Efficacy of Low-level Laser Versus High-intensity Laser Therapy in the Management of Adhesive Capsulitis: A Randomized Clinical Trial 65 pubmed.ncbi.nlm.nih.gov/37533657/

TREATMENT TOOLS FOR SHOULDER PAIN

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