Rotator Cuff Disease: An Osteopathic Approach to Treatment

Rotator Cuff Disease

Rotator cuff disease is a common case of shoulder pain. Shoulder pain is common, with a point prevalence ranging from 7% to 26% in the general population. Although not life-threatening, it impacts on the performance of tasks essential to daily living (such as dressing, personal hygiene, eating and work), and often results in substantial utilisation of healthcare resources (Page et al. 2016).

What is the most common cause of shoulder pain?

The most common cause of shoulder pain in primary care is disorders of the rotator cuff, which comprises the supraspinatus, infraspinatus, subscapularis and teres minor muscles. These muscles facilitate both movement and dynamic stabilisation of the shoulder joint (Page et al. 2016)

Definition of Rotator Cuff Disease

Numerous diagnostic labels have been used in the literature to describe disorders of the rotator cuff (for example, subacromial impingement syndrome, rotator cuff tendinopathy or tendinitis, partial or full rotator cuff tear, calcific tendinitis and subacromial bursitis) but the terms are not standardised (Page et al. 2016)

Typical Presentation of Rotator Cuff Disease

People with rotator cuff disease often describe their shoulder pain as being worse at night and exacerbated by overhead activity, and some describe weakness or loss of function; however, there are few data regarding the diagnostic accuracy of individual symptoms in rotator cuff disease without tears (Page et al. 2016).

What is the Purpose of Manual Therapy and Exercise on Rotator Cuff Disease

Manual therapy and exercise, usually delivered together as components of a physical therapy intervention, are commonly used in the management of rotator cuff disease. Manual therapy includes any clinician-applied movement of the joints and other structures, for example mobilisation or manipulation. Exercise includes any purposeful movement of a joint, muscle contraction or prescribed activity, which may be performed under the supervision of a clinician or unsupervised at home. Commonly prescribe d exercises include range of motion (ROM), stretching, stabilising and strengthening (Page et al. 2016).

Who Can Perform Manual Therapy for Rotator Cuff Disease

Manual therapy and exercise are delivered by various clinicians, including physiotherapists, physical therapists, chiropractors, and osteopaths. The aims of both types of interventions are to improve function, promote healing, increase joint range, strengthen weakened muscles and correct imbalance in the stabilising function of the rotator cuff (Page et al. 2016).

Other Therapeutic Interventions

Often, electrotherapy modalities (e.g. therapeutic ultrasound, laser therapy) are also delivered as part of a multimodal physical therapy intervention and manual therapy and exercise may also be used in conjunction with other interventions such as non-steroidal anti-inflammatory drugs (NSAIDs) or glucocorticoid injection, or both (Page et al. 2016).

Spinal Manipulation of the Upper Rib Cage

There are two studies that explore the effects of thoracic spine (mid-back) manipulation and rib manipulation on rotator cuff disease.

Subjects with subacromial impingement syndrome who received thoracic spine manipulation demonstrated statistically significant changes in pain and disability scores at 48 hours post treatment (Boyles et al. 2009). Where thoracic spine and upper rib manipulative therapy is associated with improvement in shoulder pain and ROM immediately following intervention in patients with a primary complaint of shoulder pain. No patients reported adverse effects or a worsening of shoulder symptoms following treatment with thoracic spine or upper rib manipulations (Strunce et al. 2009).

How the intervention might work

Manual therapy and exercise interventions are hypothesised to produce a number of beneficial physiological and biomechanical
effects. Manual therapy is employed to reduce pain by stimulating peripheral mechanoreceptors and inhibiting nociceptors, and to
increase joint mobility by enhancing exchange between synovial fluid and cartilage matrix. Exercise aims to improve muscle function and range of motion by restoring shoulder mobility, proprioception and stability (Page et al. 2016).

When delivered together, it is unclear whether the effects of manual therapy with exercise represent the effects of manual therapy, the
effects of exercise, or an interaction between the two. It has been suggested that the short-term analgesic effects of manual therapy may allow people with other musculoskeletal conditions (e.g. neck pain) to perform exercises designed to produce long-term changes in muscle function and range of motion. A similar mechanism of action may occur in people with rotator cuff disease (Page et al. 2016).

Evidence Base for Manual Therapy for Rotator Cuff Disease

Page et al. (2016) reviewed 60 eligible trials, only one trial compared a combination of manual therapy and exercise reflective of common current practice to placebo. We judged it to be of high quality and found no clinically important differences between groups in any outcome. Effects of manual therapy and exercise may be similar to those of glucocorticoid injection and arthroscopic subacromial decompression, but this is based on low quality evidence. Adverse events associated with manual therapy and exercise are relatively more frequent than placebo but mild in nature. Novel combinations of manual therapy and exercise should be compared with a realistic placebo in future trials. Further trials of manual therapy alone or exercise alone for rotator cuff disease should be based upon a strong rationale and consideration of whether or not they would alter the conclusions of this review.

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Reference List

Boyles RE, Ritland BM, Miracle BM, Barclay DM, Faul MS, Moore JH, Koppenhaver SL, Wainner RS (2009). The short-term effects of thoracic spine thrust manipulation on patients with shoulderimpingement syndromeMan Ther. Aug;14(4):375-80.

Page MJ, Green S, McBain B, Surace SJ, Deitch J, Lyttle N, Mrocki MA, Buchbinder R (2016). Manual therapy and exercise for rotator cuff disease. Cochrane Database Syst Rev. Jun 10;(6)

Strunce JB, Walker MJ, Boyles RE, Young BA (2009). The immediate effects of thoracic spine and rib manipulation on subjects with primary complaints of shoulder pain. J Man Manip Ther. 17(4):230-6.

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