Exercise for rotator cuff-related shoulder pain is ubiquitous: 'how and why' is it beneficial?

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DOCTORAL THESIS

Exercise for rotator cuff-related shoulder pain is ubiquitous: 'how and why' is it beneficial? Exercise for rotator cuff-related shoulder pain is ubiquitous: 'How and why' is it beneficial?

ABSTRACT

Rotator cuff-related shoulder pain is the most common musculoskeletal condition of the shoulder joint and can cause profound disruption to activities of daily living and participation in valued activity. The negative sequelae of rotator cuff-related shoulder pain continues to fuel the ongoing pursuit of effective treatments to help manage pain and disability. Exercise therapy is the most recommended treatment for rotator cuff-related shoulder pain, because it out-performs no treatment and usual care comparators and is generally well received by patients. However, while exercise therapy for rotator cuff-related shoulder pain has a rich literature investigating its effectiveness, much less research has explored how and why it causes an effect. In other words, the causal mechanisms underpinning a reduction in shoulder pain or an improvement in shoulder function through engaging with an exercise program for individuals with rotator cuff-related shoulder pain is currently obstruse. At the commencement of this research program this was a substantial knowledge gap. The studies in the thesis are an attempt to contribute to the diminution of this knowledge gap and provide a foundation for future research.

Chapters one and two introduce rotator cuff-related shoulder pain and its history, briefly describe common treatment options for rotator cuff-related shoulder pain and outlines the importance of causal explanation in health science. The philosophical foundation that guides this research program is introduced and explained, as well as the research gaps, questions, and aims this thesis intends to explore.

Chapter three is an editorial that pithily summarises the current evidence-base concerning possible mechanisms of clinical improvement through engaging with a resistance exercise program for rotator cuff-related shoulder pain. The editorial of Chapter three supports a more comprehensive analysis of causal mechanisms in the following chapters and functions as a philosophical entrée for the remainder of the thesis. It outlines the uncertainty surrounding how and why exercise may help an individual with rotator cuff-related shoulder pain, and specifically challenges the prevailing view that 'getting stronger' or 'optimising scapular position or motion' is what's responsible for a positive clinical outcome with exercise therapy.

Chapters four to six explore the views of clinical researchers, clinicians, and patients about how and why they believe exercise to be beneficial for rotator cuff-related shoulder pain. The outcomes of these chapters and their corresponding studies reveal commonalities and discrepancies among the different stakeholders. The major through-line connecting the stakeholders is that exercise was hypothesised to work predominately via neuromuscular mechanisms (changes to muscle strength and motor control for example). Differences existed at the level of importance attached to psychosocial mechanisms, with patients and clinicians more likely to invoke these mechanisms to explain the effect of exercise compared to clinical researchers. Chapter six is a qualitative study that identified a positive experience with exercise therapy is context dependent, most prominently on the relationship between clinician and patient and the perceived individualisation of the exercise program.

Chapter seven critically discusses the current uncertainty and limitations of the evidence-base regarding exercise therapy for rotator cuff-related shoulder pain, the problems this may present for clinicians prescribing exercise in clinical practice and offers considerations and strategies to help navigate identified uncertainty. Chapter eight explores whether the best way to judge the efficacy and effectiveness of exercise therapy for rotator cuff-related shoulder pain is strictly through randomised controlled trials and their associated effect sizes. It was decided the Bradford Hill viewpoints of causality could be usefully applied to the exercise for rotator cuff-related shoulder pain literature to evaluate its causal claim. The findings of this review could not refute or corroborate the causal claim of exercise therapy but does highlight modifiable limitations in the literature that may warrant consideration and rectification.

Chapter nine is the concluding chapter of this thesis. It contextualises the findings of this research program with the wider evidence base, acknowledges the strengths and limitations of conducted research and provides recommendations for future research. This research program maps and critically discusses the causal mechanisms that may underpin the effectiveness of an exercise program for an individual with rotator cuff-related shoulder pain from a variety of perspectives. However, it must be acknowledged, there is still considerable research to undertake and progress to be made in order for a satisfactory explanation of the effect of exercise to be formulated. In the spirit of collaborative and iterative science, it is hoped this thesis may serve as a stepping stone on a continued pathway of discovery.

DECLARATION BY AUTHOR

RESEARCH OUTPUTS

CONFERENCE PROCEEDINGS (PRESENTATION)

ETHICS DECLARATION

COPYRIGHT DECLARATION

ONE point ONE. PREFACE

ONE point TWO. ROTATOR CUFF-RELATED SHOULDER PAIN: FROM PAST TO PRESENT

One point three Treating Rotator Cuff-Related Shoulder Pain

One point three point one Surgery

One point three point two Injection therapy

One point three point three Physical therapies

One point three point four Exercise therapy

One point four The Importance of Causal Explanation

One point four point one Mechanisms

One point four point two Doctor James Lind and Scurvy

One point four point three Doctor Ignaz Semmelweis and handwashing

One point four point four Treatment mechanisms in physiotherapy

One point four point five Mediators and mediation analysis

One point four point six Evidence-based medicine plus and the Bradford Hill viewpoints of causality

One point five. Philosophical foundation

One point five point two. Ontology and epistemology

One point five point three. The intersection between critical realism and complexity science

CHAPTER TWO: Research objective, questions, gaps, and methods

Two point two. Research Questions

Two point three. Research Gaps

Two point four. Research Methods

Two point five. Outline of Thesis Chapters

Three point two. SYNOPSIS

Three point three. BACKGROUND

Three point four. WHY DO CLINICIANS USE RESISTANCE EXERCISE FOR RCRSP?

Three point five. MOVEMENT AND STRENGTH DEFICITS CHARACTERISE RCRSP - CAN EXERCISE HELP?

3.6 WHY THE LIMITED INCREASES IN STRENGTH? UNDERLOADED EXERCISE AND EXCESSIVELY CAUTIOUS THERAPISTS?

Three point seven. Have clinicians been seduced by the hype of strengthening?

Three point eight. Is there more to resistance exercise than meets the eye for rotator cuff related shoulder pain?

Three point nine. Integrating resistance exercise into a modern understanding of rotator cuff related shoulder pain

Three point ten. Summary

Three point eleven. Key points

Four point two. Abstract

Objective

Design

Methods

Results

Conclusions

Highlights

Four point three INTRODUCTION

Four point four METHODS

Four point four point two Study selection

Four point four point three Data extraction

Four point four point four Data analysis

Four point five RESULTS

Four point five point two Tissue factors

Four point five point three Neuro-endocrine-immune

Four point five point four Psychological

Four point six DISCUSSION

Five point two. ABSTRACT

Materials and Methods

Five point two point one. Keywords

Five point four. METHODS

Five point four point two Ethics

Five point four point three Survey development

Five point four point four Sampling and recruitment

Five point four point five Statistical analysis

Five point five RESULTS

Five point five point one Would you prescribe exercise for this clinical presentation?

Five point five point two Exercise type

Five point five point three Exercise mechanisms

Five point five point four Scapular dyskinesis

Five point five point five Shoulder weakness

Five point five point six Posture

Five point five point seven Shoulder strength measurement

Five point five point eight Diagnostic label

Five point five point nine Knowledge of exercise mechanisms

Five point six DISCUSSION

Five point seven. CONCLUSION

Six point two. ABSTRACT

Methods

Results

Conclusions

Key words

Six point three. INTRODUCTION

Six point four. METHODS

Six point four point two. Qualitative approach and research paradigm

Six point four point three Researcher characteristics and reflexivity

Six point four point four Data collection methods

Six point four point five Sampling strategy

Six point four point six Ethics

Six point four point seven Pilot interview

Six point four point eight Data processing and analysis

Six point four point nine Techniques to enhance trustworthiness

Six point five RESULTS

Six point five point one Condition one: A strong therapeutic relationship is the foundation for a clinical improvement with exercise therapy

Condition Three: Timely clinical progress with exercise therapy matters

Six point five point two Condition Two: The exercise program should be structured and tailored to the individual clinical presentation

Six point five point three Condition Three: Timely clinical progress with exercise therapy matters

Six point five point four Causal explanation One: Shoulder strength influences clinical outcomes

Causal explanation One: Shoulder strength influences clinical outcomes

Causal explanation two: Exercise therapy influences psycho-emotional status

Causal explanation three: Exercise therapy has widespread positive health effects

Six point five point four Causal explanation two: Exercise therapy influences psycho-emotional status

Six point five point four Causal explanation three: Exercise therapy has widespread positive health effects

Six point six DISCUSSION

Six point seven LIMITATIONS

Six point eight CONCLUSION

Seven point two ABSTRACT

Aims

Results and discussion

Conclusion

Key words

Seven point four. Efficacy and Effectiveness

Seven point five. Should Exercise Be Delivered in Isolation or Combined with Manual Therapy?

Seven point six. Is There an Optimal Exercise Approach?

Seven point six point two Does the exercise dose make the poison?

Seven point six point three Does the muscle contraction type matter?

Seven point six point four Should exercise be supervised?

Seven point six point five Should pain be permitted during exercise?

Seven point seven WHAT CAN WE LEARN FROM THE LIVED EXPERIENCE OF INDIVIDUALS WHEN IT COMES TO EXERCISE FOR RCRSP?

Seven point eight. HOW DOES EXERCISE HELP INDIVIDUALS WITH RCRSP?

Seven point nine. NAVIGATING UNCERTAINTY: THEORETICAL CONSIDERATIONS FOR USING EXERCISE THERAPY

Seven point ten. Navigating Uncertainty: Practical Considerations for Using Exercise Therapy

Seven point eleven. Conclusion

Eight point two. Abstract

Methods

Results and discussion

Eight point three. Introduction

Eight point four. Strength of association

Eight point five. Consistency

Eight point six. Specificity

Eight point seven. Temporality

Eight point eight. Biological Gradient

Eight point nine. Plausibility

Eight point ten COHERENCE

Eight point eleven EXPERIMENT

Eight point twelve ANALOGY

Bradford Hill Viewpoint

Consistency

Temporality

Plausibility

Experiment

Verdict

Eight point thirteen CONCLUSION

CHAPTER Nine: Discussion, implications for clinical practice and directions for future research.

Nine point two. SUMMARY

Nine point four. Strengths and Limitations

Nine point five. Clinical Implications

Nine point six. Future Research Directions

Nine point six point two Considering context

Nine point six point three Placebo controlled trial

Nine point six point four Standardising diagnostic labels and selection criteria

Nine point six point five Better reporting of exercise parameters

Nine point seven THESIS CONTRIBUTIONS

Two point three - Survey development

Three point one | Would you prescribe exercise for this clinical presentation?

Three point three Exercise mechanisms

Three point nine | Knowledge of exercise mechanisms

Clinical scenario

Introduction

Sampling Strategy

Condition one: A Strong Therapeutic Relationship Is the Foundation for a Clinical Improvement With Exercise Therapy

Causal Explanation one: Shoulder Strength Influences Clinical Outcomes

Limitations

Ethics Approval

Disclosures

Is exercise therapy the right treatment for rotator cuff-related shoulder pain? Uncertainties, theory, and practice

Three | SHOULD EXERCISE BE DELIVERED IN ISOLATION OR COMBINED WITH MANUAL THERAPY?

Four point one Is there a superior exercise type?

Eight | NAVIGATING UNCERTAINTY: PRACTICAL CONSIDERATIONS FOR USING EXERCISE THERAPY

Overview

This thesis provides a comprehensive analysis of exercise therapy for rotator cuff-related shoulder pain, emphasizing the need to understand its underlying mechanisms. It captures the views of various stakeholders, including clinicians and patients, to illuminate how exercise is perceived to help alleviate pain and improve function.

Key Points

1Exercise therapy is the most recommended treatment for rotator cuff-related shoulder pain due to its effectiveness
2The thesis identifies a significant knowledge gap regarding the causal mechanisms of exercise therapy
3Stakeholders have differing views on the importance of psychosocial mechanisms in exercise therapy outcomes
4Qualitative research highlights that positive experiences with exercise therapy are dependent on clinician-patient relationships
5The findings suggest a need for reevaluation of how exercise therapy outcomes are judged, beyond traditional clinical trials

Details

Authors: Jared Powell
Category: Health and Medicine

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