Treatment for Rotator Cuff Related Shoulder Pain
In relation to shoulder pain, the rotator cuff is implicated in as many as 70-85% of cases (3, 4). As described by Jeremy Lewis, rotator cuff related shoulder pain (RCRSP) encompasses shoulder pathologies including subacromial pain syndrome, rotator cuff tendinoathy, and partial and full thickness rotator cuff tears (8). The prevalence of rotator cuff related pain significantly increases over the age of 40. Asymptomatic tears are twice as common as symptomatic rotator cuff tears, and it has been discussed that rotator cuff tears should be considered “normal” due to the high prevalence of asymptomatic tears and age related degenerative changes (10, 13). However, for those who have RCRSP, treatment methods differ, including: exercise therapy, manual therapy, electrotherapy, steroid injection, medication, and surgery (4). The purpose of this article is to discuss addition of dry needling and spinal manipulative therapy to a traditional conservative treatment approach for RCRSP.
While conservative management is the first method of treatment for RCRSP, this is unsuccessful in over one third of cases. Several reasons may be due to lack of education on the condition, kinesiophobia, pain catastrophizing, occupational factors, lifestyle factors, lack of adherence to the exercise program, low expectation of recovery, or only focusing on treatment of the shoulder complex alone (4, 12). While many physical therapists will manage RCRSP with exercise and manual therapy, few perform dry needling and spinal manipulation in combination.
There are a small number of studies that do not support the addition of dry needling to traditional physical therapy treatment for non-specific shoulder pain. Though, these studies fail to include patient’s timeline for improvement and involvement with other healthcare providers. A study that evaluated cost-effectiveness of dry needling with sub-acromial pain syndrome concluded that subjects that received dry needling in combination with exercise therapy, compared to exercise therapy alone, had less visits to medical doctors and a decreased amount of other healthcare costs (1). Dry needling for treatment of tendinopathies was shown to improve pain on the Visual Analog Scale (VAS) by up to 56.1%. (7). Dry needling in combination with strength training in patients with rotator cuff tendinopathy promoted a larger decrease in pain and improved quality of life. While an individualized exercise program is shown to improve pain in those with RCRSP, the inclusion of dry needling with exercise further decreased pain and improved function at up to one year follow-up (2). These results cannot be ignored, and dry needling should be used in combination with traditional conservative treatment methods to encourage quicker recovery and decreased costs.
Research has shown that with glenohumeral elevation, there is also movement of the thoracic spine into lateral flexion, rotation, and extension (14). Healthy shoulder patients have the highest amount of thoracic mobility, and shoulder impingement patients had the lowest amount of thoracic mobility (9). Consequently, limitations in movement of the thoracic spine will lead to reduced mobility of the glenohumeral joint. This makes treatment of the thoracic spine with RCRSP imperative in conservative management. With high-velocity low-amplitude thoracic spine manipulation in patients with RCRSP, there was significant improvements in shoulder flexion and abduction range of motion (12). Thoracic manipulation alone has also been shown to improve pain with shoulder flexion, and improved shoulder function on the Disabilities of the Arm, Shoulder, and Hand Questionnaire (11). The improvements in thoracic spine mobility after a high-velocity low-amplitude thrust manipulation is proven to improve shoulder range of motion and shoulder pain.
In combination, spinal thrust manipulation and electrical dry needling compared with non-thrust joint mobilization, exercise, and interferential current electrical stimulation significantly improved shoulder pain and disability at 3-month follow up. Spinal thrust manipulation and electrical dry needling groups also had a greater proportion of patients who ceased taking pain medication (5). The goal for clinicians is to combine therapeutic exercise, joint mobilization, soft tissue mobilization, spinal manipulation, and dry needling in order to have improved overall success in the management of RCRSP. These are treatments we offer at Dynamic Physio and we are skilled in helping you return to your goals pain free after developing shoulder pain of any kind.
Due to the high prevalence of asymptomatic rotator cuff tears, surgery consideration should be delayed until after conservative management. There are tremendous benefits with traditional physical therapy, and patients are sure to improve with traditional physical therapy as shown with innumerable studies. Nonetheless, to ensure full recovery, physical therapists should treat the shoulder complex with exercise and shoulder mobilizations, in combination with dry needling and thoracic spine manipulation.
References
1. Arias-Buría, José L, PT, MSc, PhD, Martín-Saborido, Carlos, PT, MSc, PhD, Cleland, Joshua, PT, PhD, Koppenhaver, Shane L, PT, PhD, Plaza-Manzano, Gustavo, PT, PhD, Fernández-de-las-Peñas, César, PT, PhD, DMSc, Cost-effectiveness Evaluation of the Inclusion of Dry Needling into an Exercise Program for Subacromial Pain Syndrome: Evidence from a Randomized Clinical Trial, Pain Medicine, Volume 19, Issue 12, December 2018, Pages 2336–2347, https://doi.org/10.1093/pm/pny021
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