Researchers compared the treatments for people with shoulder
impingement syndrome, a common type of persistent pain that can be
caused by tendonitis, bursitis or other inflammation in the shoulder
“Interestingly, there is not standardized treatment for this and it
can vary,” said lead author Daniel I. Rhon, a physical therapist at
the Center for the Intrepid at Brooke Army Medical Center in Fort
Sam Houston, Texas.
“I think there is a strong consensus that exercises can help, and
patients may also get a referral to physical therapy for this
condition,” Rhon told Reuters Health in an email. “Because of the
pain and inflammation that is sometimes present with shoulder
impingement, corticosteroid injections are also a very common
treatment used by general practitioners, orthopedists, and
Some doctors send patients to physical therapy and others don’t,
while still others will give a shot and also recommend physical
therapy, he said. Patients have some say in which treatment they
get, but doctors usually influence the choice.
Rhon and his team randomly divided 104 patients with this kind of
pain into two groups. One group received physical therapy twice a
week for three weeks. The therapists evaluated weakness, mobility
and pain and performed stretches, contract-relax techniques and
reinforcing exercises on the shoulder or upper spine area. They also
prescribed at-home exercises for the patients.
Patients in the other group were offered up to three injections of
corticosteroids over the course of a year. They also received
printed instructions for gentle exercises to do at home.
Both groups had significant improvement in symptoms after one month,
which continued over the one-year period of the study, the research
team reported in the Annals of Internal Medicine. Patients’ scores
on pain and disability were reduced by half with either treatment.
By the end of the year, 60 percent of the steroid injection group
had returned to their primary care doctor for shoulder pain again,
compared to 37 percent of the physical therapy group. The injection
group was also more likely to end up having more injections or
additional physical therapy.
The research was supported by funding from the American Academy of
Orthopaedic Manual Therapists.
“In the clinic I often see patients that have had multiple
injections and continue to have persistent pain - thus their
referral to physical therapy,” Rhon said. “I was curious to
understand a little more about this.”
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“Only half of all new episodes (of shoulder impingement) end in
complete recovery after six months, indicating it is a serious
health problem,” said Brooke K. Coombes, who coauthored an editorial
accompanying the study.
Coombes studies rehabilitation medicine in the physiotherapy
department of the University of Queensland in Brisbane, Australia.
She was not surprised that steroid injections and physical therapy
worked about equally well. The relief from an injection may not last
as long, leading to more treatments, or the physical therapy
appointments may give doctors more time to educate patients about
dealing with shoulder pain, Coombes told Reuters Health by email.
“Physical therapy involves more patient-clinician contact than a
single consultation at which an injection is given,” she said. “This
may allow for advice or reassurance about the condition and
Injections are less costly than therapy because they only involve
one visit to the doctor rather than several therapy sessions, but if
they also result in more doctor visits down the line, that may end
up balancing out costs, she said.
Certain people may benefit more from steroid injections than
physical therapy, or vice versa, but that will need to be researched
more, she said.
“One thing to point out is that the number one reason that patients
turned down participation in this study was because they did not
want to be randomized into a group that might receive an injection,”
Rhon said. “This suggests that there is a number of patients that
really don't want to get an injection.”
Physical therapy is an excellent treatment option to consider for
these patients, he said.
Annals of Internal Medicine, online August 4, 2014.
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