The influence of home exercise programs for patients with non-specific or specific neck pain: a systematic review of the literature

Abstract

Study design: Systematic review of randomized controlled trials (RCT).

Objectives: To examine the effects of a therapeutic home exercise program (HEP) for patients with neck pain (associated with whiplash, non-specific, or specific neck pain, with or without radiculopathy, or cervicogenic headache) on pain, function, and disability. Our secondary aim was to describe the design, dosage, and adherence of the prescribed HEPs.

Background: Neck pain is a leading cause of disability that affects 22–70% of the population. Different techniques have been found effective for the treatment of neck pain. However, there is conflicting evidence to support the role of a therapeutic HEP to reduce pain, disability, and improve function and quality of life (QOL).

Methods: A systematic review in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement for reporting systematic reviews. The full-text review utilized the Maastricht–Amsterdam assessment tool to assess quality among RCTs.

Results: A total of 1927 subjects included within seven full-text articles met our specific search strategy. It was found that HEPs with a focus on strength and endurance-training exercises, as well as self- mobilization, have a positive effect when used in combination with other conservative treatments or alone.

Conclusions: Home exercise programs that utilize either self-mobilizations within an augmented HEP to address specific spinal levels, or strengthening, and/or endurance exercise are effective at reducing neck pain, function, and disability and improving QOL. The benefit of HEPs in combination with other conservative interventions yields some benefit with a range of effect sizes.     

Exercise Therapy Is Effective for Improvement in Range of Motion,Function, and Pain in Patients With Frozen Shoulder: A Systematic Review and Meta-analysis

Objective(s)To determine (1) the effect of exercise therapy alone or in combination with other interventions compared with solely exercises and programs with or without exercises and (2) what kind of exercise therapy or combination with other interventions is most effective.Data SourcesPubMed, Web of Science and Cochrane Central Register of Controlled Trials.Study SelectionStudies were screened in a 2-phase approach by 2 independent reviewers (M.M. and L.M.). Reference lists of included studies and interesting systematic reviews were hand searched.Data ExtractionTwo independent reviewers (M.M. and L.M.) extracted information about origin, characteristics of study participants, eligibility criteria, characteristics of interventions, outcome measures and main results in a pre-defined template.Data SynthesisThirty-three studies were included in the qualitative and 19 in the meta-analysis. Preliminary evidence was found for supervised exercises to be more beneficial than home exercises for ROM and function. Multimodal programs comprising exercises may result in little to no difference in ROM compared to solely exercises. Programs comprising muscle energy techniques show little to no difference in ROM when compared with programs with other exercises. Adding stretches to a multimodal program with exercises may increase ROM. There is uncertain evidence that there is a difference between those programs regarding function and pain. Preliminary evidence was found for several treatment programs including exercises to be beneficial for improvement in both passive and active ROM, function, pain, and muscle strength. No studies used patient satisfaction as an outcome measure.ConclusionsROM, function, and pain improve with both solely exercises and programs with exercises, but for ROM and pain there was little to no difference between programs and for function the evidence was uncertain. Adding exercises improve active ROM compared with a program without exercises, whereas adding physical modalities has no beneficial effect. Muscle energy techniques are a beneficial type of exercise therapy for improving function compared with other types of exercise. Unfortunately, no conclusion can be drawn about the results in the long-term and most effective dose of exercise therapy.     

Investigation of the effect of conservative interventions in thumb carpometacarpal osteoarthritis: systematic review and meta-analysis

Abstract

Purpose: The purpose of this study was to conduct a current review of randomized controlled trials regarding the effect of conservative interventions on pain and function in people with thumb carpometacarpal (CMC) osteoarthritis (OA), perform a meta-analysis of the findings and summarize current knowledge. Method: Data were obtained from MEDLINE, CINAHL, Embase, PEDro and CENTRAL databases from their inception to May 2014. Reference lists of relevant literature reviews were also searched. All published randomized trials without restrictions to time of publication or language were considered for inclusion. Study subjects were symptomatic adults with thumb CMC OA. Two reviewers independently selected studies, conducted quality assessment and extracted results. Data were pooled in a meta-analysis, when possible, using a random-effects model. Quality of the body evidence was assessed using GRADE approach. Results: Sixteen RCTs involving 1145 participants met the inclusion criteria. Twelve were of high quality (PEDro score?>?6). We found moderate quality evidence that manual therapy and therapeutic exercise combined with manual therapy improve pain in thumb CMC OA at short- and intermediate-term follow-up, and from low to moderate quality evidences that magneto therapy improves pain and function at short-term follow-up. Orthoses (splints) were found to improve function at long-term follow-up and pinch strength at short-term follow-up. Finally, we found from very low to low-quality evidence that other conservative interventions provide no significant improvement in pain and in function at short- and long-term follow-up. Conclusions: Some of the commonly performed conservative interventions performed in therapy have evidence to support their use to improve hand function and decrease hand pain. Additional research is required to determine the efficacy of other therapeutic interventions that are performed with patients with thumb CMC OA.

• Implications for Rehabilitation

• Manual therapy and exercise are an effective means of improving pain and function at short-term follow-up by patients with thumb CMC OA.

• Magneto therapy, manual therapy, manual therapy and exercise and Orthoses (splints) were found to have clinically significant results.

• Very few of the included studies showed a clinically significant effect size in favor of treatment.

     

The effectiveness of conservative management for disabled throwing shoulder in baseball: a systematic review of Japanese-language primary studies

Background: Conservative management is often the first-choice treatment for baseball players with disabled throwing shoulder (DTS). Considering the high popularity of baseball in Japan, we suspected that there might be some evidence regarding this topic in the Japanese-language literature.

Objective: This study aimed to systematically review Japanese-language primary studies investigating the effectiveness of conservative management for DTS in baseball.

Methods: Eight databases were systematically searched from inception to 7 April 2016. Data on authors, publication years, sample characteristics, types of interventions, outcome measures and results were extracted. Data were synthesised qualitatively.

Results: Seven studies with low evidence level and low-to-moderate study quality were included. Interventions examined in the included studies were downward throwing, combined physiotherapy interventions and joint distension. Forming correction, stretching for posterior shoulder muscles and strengthening exercises to improve scapular/trunk stability were commonly used in combined physiotherapy interventions. Downward throwing and combined physiotherapy interventions corresponded with expert opinions described in the English-language literature. Due to the lack of studies with high level of evidence, however, it was difficult to determine the genuine effects of these interventions.

Conclusion: Our systematic review found limited evidence about the effectiveness of any conservative management for baseball players with DTS. Although downward throwing and combined physiotherapy interventions might be appropriate management in some cases, further studies of higher level of evidence and greater methodological rigour are required.     

A systematic review of the effectiveness of physical therapy interventions for temporomandibular disorders

BACKGROUND AND PURPOSE: The purpose of this qualitative systematic review was to assess the evidence concerning the effectiveness of physical therapy interventions in the management of temporomandibular disorders. METHODS: A literature search of published and unpublished articles resulted in the retrieval of 36 potential articles. RESULTS: Twelve studies met all selection criteria for inclusion in the review: 4 studies addressed the use of therapeutic exercise interventions, 2 studies examined the use of acupuncture, and 6 studies examined electrophysical modalities. Two studies provided evidence in support of postural exercises to reduce pain and to improve function and oral opening. One study provided evidence for the use of manual therapy in combination with active exercises to reduce pain and to improve oral opening. One study provided evidence in support of acupuncture to reduce pain when compared with no treatment; however, in another study no significant differences in pain outcomes were found between acupuncture and sham acupuncture. Significant improvements in oral opening were found with muscular awareness relaxation therapy, biofeedback training, and low-level laser therapy treatment. DISCUSSION AND CONCLUSION: Most of the studies included in this review were of very poor methodological quality; therefore, the findings should be interpreted with caution.     

Outcomes of strengthening approaches in the treatment of low-grade spondylolisthesis

Abstract

Background: Historically, spondylolisthesis has been treated by a wide variety of techniques such as flexion exercises, bracing, abdominal stabilizing programs, general strengthening, stretching, and in some cases, motor control exercises. Although surgical treatment of spondylolisthesis has been outlined in current literature, strengthening programs have not been well defined for this population.

Objective: To describe the outcomes in randomized clinical or controlled trials (RCTs) in which either a global or local strengthening approach was assessed against another comparator in conservative treatment of patients with a low-grade spondylolisthesis.

Methods: A systematic review of the literature. This review was formatted using the PRISMA guidelines, a 27-item checklist and four-phase flow diagram. An electronic search strategy targeting randomized controlled and clinical trials that compared conservative treatments for low-grade (I and II) spondylolisthesis that used a local stabilization approach, motor control, and/or a general strengthening program versus a surgical intervention or a control group was used. Physiotherapy Evidence Database (PEDro) was used to critically appraise each study for quality. Outcome measures included changes in pain measured by the visual analog scale (VAS) along with secondary measures of functional disability, working status, and lumbar range of motion.

Results: Although 28 studies went through full text review, only three studies met inclusion criteria. Within the studies, global strengthening exercise programs significantly decreased subjects’ pain as measured using the VAS but did not significantly improve the level of disability. In contrast, local stabilization or motor control exercises demonstrated improvements in both pain and disability. No studies directly compared a global strengthening approach versus a stabilization approach.

Conclusion: Our findings indicate that both exercise training programs of local strengthening/stabilization interventions, as well as general strengthening programs may be beneficial as conservative strengthening management to patients with a low-grade spondylolisthesis. A direct comparison of these approaches is needed for the spondylolisthesis population.     

Benefits and harms of non-surgical and non-pharmacological management of osteoporotic vertebral fractures: A systematic review and meta-analysis

BackgroundOsteoporotic vertebral fractures affect a large number of older adultsObjectivesSystematically review evidence of the benefits and harms of non-surgical and non-pharmacological management of people with osteoporotic vertebral fractures compared with standard care (control); and evaluate the benefits and harms of non-surgical and non-pharmacological management of people with osteoporotic vertebral fractures compared with an alternative non-pharmacological, non-invasive intervention.DesignSystematic review and meta-analysis of randomized controlled trials. Five electronic databases (CINAHL, EMBASE, MEDLINE, PUBMED, and COCHRANE) were searched. Eligible trials included participants with primary osteoporosis and at least one vertebral fracture diagnosed on radiographs, with treatment that was non-surgical and non-pharmacological involving more than one session.ResultsTwenty randomized controlled trials were included with 2083 participants with osteoporotic vertebral fractures. Exercise, bracing, multimodal therapy, electrotherapy, and taping were investigated interventions. Meta-analyses provided low certainty evidence that exercise interventions compared to no exercise were effective in reducing pain in patients with osteoporotic vertebral fractures (mean difference (MD)= 1.01; 95% confidence interval (CI): 0.08, 1.93), and low certainty evidence that rigid bracing intervention compared with no bracing was effective in reducing pain in patients with osteoporotic vertebral fractures (MD= 2.61; 95%CI: 0.95, 4.27). Meta-analyses showed no differences in harms between exercise and no exercise groups. No health-related quality of life or activity improvements were demonstrated for exercise interventions, bracing, electrotherapy, or multimodal interventions.ConclusionsExercise and rigid bracing as management for patients with osteoporotic vertebral fractures may have a small benefit for pain without increasing risk of harm.Trial registrationPROSPERO registration number CRD42012002936     

Manual therapy and exercise for impingementrelated shoulder pain

Abstract

Background: Shoulder complaints are among the commonest causes of musculoskeletal pain. They are potentially disabling and frequently cause absenteeism from work and claims for sickness benefits. One of the most prevalent subtypes of shoulder pain is impingement. This is often managed physiotherapeutically, with 'hands-on' manual therapy and exercises being mainstays.

Objectives: To assess the effectiveness of manual therapy and exercises to improve pain, disability and function in people with shoulder impingement.

Methods: A systematic review was conducted including systematic reviews, quasi-randomized trials and randomized controlled trials published up to October 2008. Searches included the Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Medline, Embase, Cinahl and PEDro. Methodological quality and risk of bias were assessed with appropriate instruments. All findings were critically analysed and discussed, and summary conclusions formulated.

Results: Eight systematic reviews and six randomized controlled trials were included. Methodological quality and risk of bias as well as population and treatment parameters varied. Clinical heterogeneity prevented meta-analysis, thus all findings were synthesized narratively. The included research provides limited evidence to support the use of manual therapy and exercise interventions for shoulder impingement. This primarily relates to subacute and chronic conditions and short to medium-term effectiveness.

Conclusions: Manual therapy and exercise seem effective for shoulder impingement, but varying methodological quality and risk of bias in reviews and trials warrant caution in the interpretation of the results. There is a need for further good-quality primary research.     

Exercises for hand osteoarthritis: a systematic review of clinical practice guidelines and consensus recommendations

Background: Individuals with hand osteoarthritis (OA) often experience hand pain, joint stiffness and reduced grip strength, which affect performance of everyday functional tasks. There is a need to evaluate evidence-based rehabilitation strategies that aim to lessen the burden and improve the quality of life of people living with hand OA.

Objectives: Our objectives were to (1) identify guidelines and consensus recommendations on hand OA management to ascertain whether hand exercises are recommended as part of best practice; (2) identify the type and dosage of exercises recommended regarding frequency, intensity and duration and (3) provide a summary of exercise recommendations for the management of hand OA.

Methods: This systematic review followed the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines and was registered on Prospero (CRD42018086440). Seven published databases and 20 grey literature sources were searched (January 1997–January2019). Quality assessment was conducted with the Appraisal of Guidelines, Research and Evaluation (AGREE) II instrument and, using a narrative approach, evidence was synthesized based on the levels of evidence and strength of recommendations.

Results: Eight guidelines and consensus recommendations were identified and included. Evidence from seven guidelines was rated between fair to high quality. Five out of seven guidelines recommended exercises for the management of hand OA. Limited information on exercise dosage (frequency, intensity and duration) was reported. Three strong and two weak recommendations for using different hand exercises were proposed in this systematic review.

Conclusion: Available guidelines and consensus recommendations on hand OA recommend exercises as part of current best practice for hand OA management. There is strong evidence to support the recommendation of strengthening, stretching and joint mobility exercises for the management of the hand OA. These recommended exercises, however, lacked specific details regarding the type and dosage (frequency, intensity and time) for optimal uptake, which therefore need to be established through research.     

The potential role of upper extremity muscle fatigue in the generation of extrinsic subacromial impingement syndrome: a kinematic perspective

Abstract

Background:

Subacromial impingement syndrome (SAIS) of the shoulder has a multi-factorial aetiology which includes both intrinsic and extrinsic mechanisms. Upper extremity muscle fatigue has been proposed as a potential causative factor in extrinsic SAIS development.

Objectives:

This review summarises the current state of knowledge regarding fatigue-induced glenohumeral (GH) and scapulothoracic (ST) kinematic changes as they relate to subacromial space reduction and subsequent SAIS. It specifically addresses evidence for mechanisms including superior humeral head translation and scapular reorientation.

Major findings:

Global upper extremity muscle fatigue elicits GH kinematic changes that increase SAIS risk. Concurrent compensatory ST kinematic alterations, primarily scapular upward rotation (UR), lessen this risk. Additionally, fatiguing protocols aimed to selectively exhaust certain muscles or muscle groups without fatiguing the rotator cuff were unsuccessful, suggesting that rotator cuff fatigue is likely for a wide range of fatiguing upper extremity tasks.

Conclusions:

Despite the compensatory response of scapular reorientation in fatigued conditions, the dimensions of the subacromial space still pose increased risk for SAIS development, and the variability in kinematic responses produces highly differential risk, particularly for those exposed to tasks requiring increased rotator cuff muscle demand.     

Efficacy of strengthening exercises for osteoarthritis (Part I): A meta-analysis

Abstract

Objective: Osteoarthritis (OA) is highly prevalent among older adults and is associated with increased pain, loss of strength and joint range of motion (ROM), as well as to an overall decrease in functional status. Therapeutic strength exercises are recommended as part of the standard intervention programme for the patient with OA in an effort to control pain and improve functional and health status. The purpose of this meta-analysis is to review the strength and quality of evidence supporting the effectiveness of therapeutic strengthening exercises for improving a variety of measured outcomes relevant for OA.

Methods: A systematic review was conducted, following a protocol of methods recommended by the Cochrane Collaboration. Trials were identified by a literature search of Medline, EMBASE, and the Cochrane Controlled Trials Register. Only randomised controlled trials using strengthening exercises as an intervention and treating clients with OA were eligible. Twenty-two trials were included with 2325 patients undergoing various forms strengthening exercises (e.g. isometric, isotonic, isokinetic, concentric, concentric/eccentric, dynamic). The exercises were implemented either in stand-alone format or in combination with other exercises, such as stretching and ROM. Interventions were either facility-based, home-based or a combination of the two.

Results: Evidence is provided for the inclusion of strengthening exercises in the rehabilitation programme for the patient with OA. Improvements were found for strength, pain, function and quality of life (QOL). Important components of the exercise programme that influence outcome include: (i) the combination of joint-specific strengthening with general strength, flexibility and functional exercises; (ii) progression of the exercise programme; and (iii) level of client self-reliance to sustain the programme. There is no evidence that the type of strengthening (i.e. isometric, isotonic or isokinetic) has an important impact on programme outcome. However, evidence is provided that the control of pain may be a dominant mechanism by which strengthening exercise produces beneficial effects for the patient with OA.

Conclusion: Strengthening exercises alone have some effects on improving pain and functional outcomes in clients with OA. However, in order to maximise the effectiveness of strengthening exercise for these clients, it is necessary to combine strengthening exercises with a more complete exercise programme including ROM, stretching, functional balance and aerobic exercises.     

Spinal manipulative therapy for low back pain: A systematic review

Abstract

Objectives: Gather and analyse relevant literature on spinal manipulative therapy for low back pain through systematic review to present a balanced and impartial summary of the findings. The aim of this systematic review was to investigate the efficacy of spinal manipulative therapy in patients with low back pain.

Methods: Databases searched included COCHRANE, MEDLINE, EMBASE, PEDro, PUBMED, WEB OF KNOWLEDGE, INGENTA CONNECT and GOOGLE SCHOLAR between January 2000 and January 2008. Sixteen articles were retrieved. Standardised inclusion and exclusion criteria were applied to select articles relevant to the review question. Seven studies were excluded and nine studies were included. In the next step, the methodological quality of the included studies was assessed with the PEDro scale, which rated the studies from 0 to 10.

Results: Methodological quality scores ranged from 4 to 8 out of a possible 10. Spinal manipulative therapy can be preferred for short-term relief of low back pain when compared with general exercise and dynamic strengthening exercises, which is revealed by a high quality study, moderate quality studies and a low quality study. Spinal manipulative therapy combined with exercise is more effective than exercise alone, which is revealed by a high quality study.

Conclusions: Further studies are needed to improve the quality of the evidence. There is evidence that spinal manipulative therapy combined with exercise is more effective than other procedures like spinal manipulative therapy, exercise or physician consultation alone.     

Does the dose of Traditional Chinese Medicine acupuncture in addition to usual care affect outcomes for adults with chronic low back pain? Protocol for a randomized controlled feasibility study

Background: Acupuncture is considered a clinically effective and cost-effective treatment option for chronic low back pain. However, few clinical trials have evaluated the dose dependence of acupuncture for chronic low back pain based on the number of sessions. Conclusions are conflicting and there is little high-quality evidence to support the cumulative effects of repeated interventions. A randomized controlled trial to investigate the optimal number of sessions of acupuncture in addition to usual care for adults with chronic low back pain is required; a feasibility study to test the rationale and method for the full-scale trial is the first step in that process.

Design: A pragmatic parallel three-armed randomized, controlled feasibility study.

Methods: Forty-five participants with chronic low back pain will be recruited locally and randomized on a 1:1:1 basis to receive usual care plus 4 (n = 15), 7 (n = 15) or 10 sessions (n = 15) of semi-standardized acupuncture. Primary outcomes are acceptability of and adherence to different numbers of sessions of acupuncture, as well as the feasibility of the recruitment approach and completion of the specific outcome measures. Secondary outcomes include pain intensity and patient satisfaction. Follow-up questionnaires will be collected at discharge, 6, and 12 weeks after randomization.

Discussion: Outcomes will inform the decision to conduct a full-scale trial to definitively test the dose dependence of acupuncture. Findings will add to the limited evidence available regarding the optimal number of sessions of acupuncture in the management of chronic low back pain, as well as being clinically relevant to clinicians, researchers and policy makers.     

Efficacy of pulsed high-intensity laser therapy on pain,functional capacity,and gait in children with haemophilic arthropathy

Aim: The aim of this study was to evaluate the effects of pulsed high-intensity laser therapy (HILT) on pain, functional capacity, and gait in children with haemophilia.

Methods: Thirty children with haemophilia type A with ages ranging from 9 to 13 years were selected for this study. They were assigned randomly, into two equal treatment groups. The laser group received the traditional physical therapy programme plus active laser (total energy of 1500 J through three phases/3 sessions/week), whereas the placebo group received the same physical therapy programme plus placebo laser over three consecutive months. Baseline and post-treatment assessments used the visual analogue scale (VAS) to evaluate pain, a 6-min walk test (6MWT) to evaluate functional capacity, and the GAITRite^® system to evaluate gait parameters.

Results: Children in the laser group showed significant improvement in pain, functional capacity, and gait parameters compared to those in the placebo group (p?Conclusions: HILT is an effective modality in reducing pain, increasing functional capacity, and improving gait performance in children with haemophilic arthropathy.

• Implications for Rehabilitation

• Haemophilic arthropathy due to recurrent joint bleeding leads to physical, psychological, and socioeconomic problems in children with haemophilia and reduces their quality of life.

• Early physiotherapeutic interventions help to prevent and treat the sequelae of recurrent haemarthrosis.

• High-intensity laser therapy has been introduced as non-invasive and an effective physiotherapy modality for rapid pain control, with consequent improvement in children’s quality of life.

• High-intensity laser therapy should be used as an adjunct to exercise programme in the rehabilitation of children with haemophilic arthropathy.

     

Activation levels of gluteus medius during therapeutic exercise as measured with electromyography: a structured review

Abstract

Background: Strengthening exercise for gluteus medius (GMed) is an important management strategy for lower limb disorders such as osteoarthritis and patello-femoral syndrome, and exercises in functional positions are commonly prescribed. Electromyography (EMG) can be used to measure muscle activation to ascertain the extent of muscle recruitment during exercise.

Objectives: To review the available evidence on the magnitude of GMed activation measured with EMG during therapeutic exercise.

Methods: A structured review of studies which measured EMG magnitude of GMed during a range of therapeutic exercises was undertaken. Amplitude levels of GMed were reported as a percentage of maximum voluntary isometric contraction.

Results: Fifteen studies were included. Most of these were conducted on asymptomatic volunteers, with three studies investigating individuals with knee or hip pathology. A wide range of exercises was investigated in both weightbearing (WB) and nonweightbearing (NWB) positions. In general, EMG activation was greater in WB positions but variation occurred across studies. Many exercises were below levels considered necessary for strength gains. Generally, methodological quality was good but there was variation in the reporting of technical aspects of the study. Many of the studies did not acknowledge the range of limitations of EMG in measuring muscle activation in therapeutic exercise.

Conclusions: The results provide some information regarding GMed recruitment during exercise, although there were some discrepancies in results between studies which may be due to factors related to EMG measurement and recording as well as the execution of the exercise. Extrapolation of results to symptomatic populations in a clinical setting islimited.     

Shoulder tendinopathy

Abstract

Background: Shoulder tendinopathy is a common condition in physical therapy, and the term tendinopathy covers a broad spectrum of pathology. Additionally, there is a lack of consensus on proper terminology for shoulder disorders. Nomenclature for shoulder disorders includes such terms as impingement, tendinitis, tendinosis, and tendinopathy. The continuum of physiologic changes with tendinopathy, as well as the various causes of tendinopathy are complex and require a detailed physical examination to discover the source of pain and extent of pathology to determine appropriate course of treatment.

Objectives: The purpose of this review is three fold. First, the physiology of shoulder tendinopathy will be discussed. Second, the various mechanisms for shoulder tendinopathy will be explored. Finally, a review of the proposed interventions for shoulder tendinopathy will be highlighted, citing the best available evidence for each intervention.

Major findings: Both the causes and the physiology of shoulder tendinopathy require a multi-faceted approach to maximize outcomes. There is a paucity of data supporting modalities in the management of shoulder tendinopathy, but high-energy extracorporeal shock wave therapy has shown some effectiveness in calcifying tendinitis. Therapeutic exercise is generally accepted as a beneficial intervention, but definitive conclusions cannot be made at this time. Furthermore, eccentric training for management of tendinopathies in general is gaining more support in the literature, but evidence for its utilization in shoulder tendinopathy is scarce.

Conclusions: A host of causes and physiologic changes exist for shoulder tendinopathy, in addition to multiple treatment options. However, no definitive conclusions can be made regarding the best treatment for shoulder tendinopathy. Current evidence is largely anecdotal and speculative. More randomized, controlled trials are needed that compare modalities, manual therapy, and therapeutic exercise.     

The Effect of 2 Different Exercise Programs on Pain Intensity and Muscle Dimensions in Patients With Chronic Low Back Pain: A Randomized Controlled Trial

Objectives

The purpose of this study was to compare the effect of 2 exercise programs combined with electrotherapy on pain intensity and lumbar stabilizer muscles dimensions in patients with nonspecific chronic low back pain.

Nonpharmacological treatments for musculoskeletal pain

BACKGROUND: Several types of physical therapy are used in the management of painful musculoskeletal disorders. These treatment modalities can be broadly categorized as electrotherapy modalities (e.g., transcutaneous electrical nerve stimulation), acupuncture, thermal modalities (e.g., moist heat, ultrasound), manual therapies (e.g., manipulation or massage), or exercise. Within each of these broad categories significant variations in treatment parameters are possible. OBJECTIVE: To consider the evidence base for each of these main categories of physical therapy in the management of musculoskeletal pain. METHOD: To consider the available evidence related to clinical effectiveness and then to review evidence from basic science studies evaluating potentially therapeutic effects of the various therapies. RESULTS: There seems to be evidence from basic science research to suggest that many of the therapies could have potentially therapeutic effects. However, there appears to be limited high-quality evidence from randomized clinical trials to support the therapeutic effectiveness of several of the therapies. CONCLUSIONS: There is some preliminary evidence to support the use of manual therapies, exercise, and acupuncture in the management of some categories of musculoskeletal pain. Limitations of the existing research base are discussed and recommendations for areas of future research are provided.