Background: Shoulder pain (SP) represents a common musculoskeletal condition that requires physical therapy care. Along the years, the usual evaluation strategies based on clinical tests and diagnostic imaging has been challenged. Clinical tests appear unable to clearly identify the structures that generated pain and interpretation of diagnostic imaging is still controversial. The current patho-anatomical diagnostic categories have demonstrated poor reliability and seem inadequate for the SP treatment. Objectives: The present paper aims to (1) describe the different proposals of clinical approach to SP currently available in the literature; to (2) integrate these proposals in a single framework in order to help the management of SP. Conclusion: The proposed clinical framework, based on a bio-psychosocial vision of health, integrates symptoms characteristics, pain mechanisms and expectations, preferences and psychosocial factors of patients that may guide physiotherapist to make a diagnostic triage and to choose the right treatment for the individual patient. Keywords: Shoulder pain, Diagnosis, Rehabilitation treatment, Clinical framework Background Schellingerhout  defined the shoulder classification Shoulder pain (SP) is a common musculoskeletal condi- process as “a Babylonian confusion of tongues and seem tion that can influence negatively the function of the en- to be of little benefit for those with SP”. This conclusion tire upper limb . The prevalence of SP ranged is in line with Buchbinder : analyzing 5 classification between 7 and 26% within the general population, in- systems based on patho-anatomical way of soft tissue creasing with age . Most of the patients affected by SP disorders, she argued that they may not be acceptable describe the symptoms as “troublesome pain” . When for lack of validity and reliability of the inclusion criteria these symptoms become persistent and recurrent, the that create an overlapping of categories. demand for medical consulting increases . As consequence, we have thought it would be clinic- A large number of diagnostic categories have been de- ally useful to overcome the diagnostic difficulties by pro- veloped: they are based on patho-anatomical classifica- posing a new pragmatic and symptoms-based model, tions, such as tendinopathies, bursitis, labral tears, coherent with a bio-psychosocial approach and closer to tendon tears, impingement, etc. . However, there is patient’s needs. Moving from this vision, this debate considerable uncertainty regarding these diagnostic cri- aims to: 1) describe the reasons for this diagnostic in- teria , and the basis for them has been repeatedly consistency; 2) present the different alternative proposals challenged [7, 8]. Clinically, it may not be possible to existing in the literature; 3) integrate the different pro- distinguish between these patho-anatomical diagnostic posals in a single framework, in order to provide physio- categories with certainty . therapists with a helpful tool to deal with SP patients. Is the usual diagnostic process of SP valid and helpful? * Correspondence: firstname.lastname@example.org Via Magliotto, 2 17100, Savona, Italy In clinical practice, the assessment of a patient with SP is Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, based upon an in-depth conversation (relevant history tak- Maternal and Child Health, University of Genova, Campus of Savona, Savona, ing, understanding the patient’s complaints, and defining Italy Full list of author information is available at the end of the article his/her psychosocial status) and a clinical assessment, © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Ristori et al. Archives of Physiotherapy (2018) 8:7 Page 2 of 11 which, in some cases, may be supported by imaging (e.g. concluding that there was a need of a new system of as- magnetic resonance imaging [MRI] or ultrasound [US]). sessment in order to classify patients with SP . This approach is designed to enable a clinical diagnosis use- ful to guide the subsequent physiotherapy treatment . Importance of diagnostic imaging in SP In clinical practice, diagnostic imaging (e.g. MRI, mag- Importance of clinical physical tests in SP netic resonance arthrography [MRA], US and radio- Physical tests are tools commonly used in clinical practice, graphs [X-RAY]) is considered to play an essential role created to help the physiotherapist to identify which ana- during the assessment of patients with musculoskeletal tomical structures are involved with the patient’s symp- disorders . They are used both in specialist consult- toms. They are non-invasive, quick, convenient, and ation (e.g. MRI and X-RAY to quantify the lesions and provide immediate results . However, their interpret- to support surgical planning) and in general practitioner ation may differ with the examiners’ clinical expertise . (GP) consultation of primary care (e.g.US). Morpho- logical and degenerative alterations are commonly con- Anatomical basis sidered relevant and together with patient’s history and Green et al. state that only few studies give information examinations findings could support the choice of treat- concerning the anatomical basis of the proposed tests ment . . Only four tests among those included in their re- view present a clear anatomical base. For these reasons, the author suggests a lack of assumptions in order to Diagnostic accuracy know what is happening in the shoulder during these as- Lenza et al. , stated that MRI, MRA and US, are use- sessment procedures . ful tools to identify massive rotator cuff tears in a popu- The Hawkins-Kennedy represents a well-fitting ex- lation of patients included in a waiting list for surgery. ample of the confusion surrounding the anatomical con- Diagnostic performance of imaging decreases in line struct of these tests. It has been developed to identify with the reduction of size the lesion. Moreover, the avail- the presence of sub-acromial impingement . During able studies generally present weak methodological qual- years, many hypotheses have been suggested: compres- ity and heterogeneity of the included populations. sion of supraspinatus tendon under the coraco-acromial Indeed, the diagnostic accuracy of these tools dramatic- ligament , compression of the structures of the ally decreases when applied in populations with poorly sub-acromial space between the head of the humerus defined clinical features of association between struc- and the acromion , contact between acromion and tural lesions and symptoms . coraco-acromial ligament , compression of the long biceps head tendon . Clinical usefulness and relevance In 2013 a Cochrane editorial debated the diagnostic ac- Clinical usefulness curacy of imaging ; it was argued that the presence Others researchers have questioned the clinical useful- of asymptomatic rotator cuff tears  represents the ness of the physical tests in SP. Hegedus et al. have pub- “elephant in the room” responsible to challenge the rele- lished three literature reviews discussing this topic [17– vance of diagnostic imaging. Some observational studies 19]. They concluded that clinicians cannot confirm a confirm this perspective: Girish stated that up to 2/3 of diagnosis of the different shoulder problems neither with people with a rotator cuff lesion are asymptomatic  individual tests nor with cluster tests [18, 19]. They de- and rotator cuff tears are common in symptomatic and fined impingement as an “all-encompassing term” often asymptomatic populations . meaningless with respect to the treatment . There- Usually, in patients with SP, there is uncertainty con- fore, the clinical history collected from the patient and cerning the cause of pain and which risk factors are rele- expert clinical reasoning seems to be crucial in the diag- vant to the onset of symptoms. Some authors suggest nostic process . Hanchard et al. investigated physical that the possibility of symptoms increases with the size test for impingement and associated lesions. Authors of rotator cuff tear , while other authors proposed concluded that the body of evidence is extremely hetero- that the development of symptoms is mostly correlated geneous both in terms of performance (e.g. reliability, to other non-structural factors, such as gender, age and specificity and sensitivity) and relative interpretation psychosocial factors [29, 30]. Thus, clinical interpret- thus making impossible to perform a synthesis of avail- ation of diagnostic imaging in patients with SP remains able data and to draw conclusions about their clinical controversial, suggesting that the biomechanical classifi- application . Furthermore, the reliability of these cation system is unsuitable (Fig. 1). procedures was also found to be poor, with the authors Ristori et al. Archives of Physiotherapy (2018) 8:7 Page 3 of 11 still present some limitations that reduce their ability to interpret comprehensively all the features of SP. The STAR-shoulder classification and SSMP do not assess the contribution of central sensitization (CS) [31, 32]. Klintberg et al., propose a pure mechanist approach based on a diagnostic algorithm for the assessment of movement patterns . Moreover, excluding SSMP , the reliability of the existing proposals is still lacking. Moving from the existing proposals, we have tried to Fig. 1 Inconsistency of diagnostic labels in SP. The weak correlation overcome the limits of exclusively mechanistic classifica- between structural factors and shoulder pain, together with the limited diagnostic value of bio-imaging and clinical tests, caused a tion and to create a framework for assessment and treat- lack of uniformity in diagnostic labelling ment of SP that integrates and includes them in a bio-psychosocial perspective (Fig. 2). Anamnesis, phys- Are integrative procedures of assessment ical assessment, triage and treatment are the four clinical available? procedures mainly affected by the implementation of The lack of reliability of clinical tests and limited useful- our clinical perspective. ness of diagnostic imaging led some authors to suggest the integration of different assessment strategies, more Anamnesis pragmatic and focused on the results of functional as- The anamnesis is a milestone in the assessment of pa- sessment [31–33]. The existing proposals include: the tients with musculoskeletal dysfunction . Different shoulder symptom modification procedure (SSMP) , anamnestic elements must be collected (e.g. characteris- the staged approach for rehabilitation classification: tics of symptoms, mechanisms of pain, expectations, shoulder disorders (STAR-shoulder)  and the Klint- preferences and psychosocial factors of patients), berg proposal  that synthesize a consensus statement weighted and included in the clinical reasoning process of several shoulder rehabilitation experts (see Table 1). to guide the subsequent physical examination [11, 21]. Is it the time to move towards an integrated Characteristics of symptoms clinical framework for the assessment and Specific information regarding impairments and symp- treatment of SP? toms of SP must be investigated during the colloquium These current approaches have evolved as a conse- with the patient, including; onset, quality, 24 h behavior, quence of the uncertainty in biomedical model, but they localization, alleviating and aggravating factors . Table 1 Characteristics of existingproposals of assessment strategies Existing proposals of assessment strategies SSMP Star-shoulder Klintberg’s clinical algorithm The SSMP is a series of clinical The authors created a model The algorithm encompasses procedures aimed to reduce the providing a sub-classification the functional assessment patient’s symptoms. A procedure of patients on the basis of of a range of motion (ROM) able to eliminate/reduce the patho-anatomical features, and the evaluation of symptoms is adopted as a tissue irritability and individual presence/absence of abnormal treatment technique. If following impairments. Three steps are scapulohumeral the application of the SSMP, proposed: 1) screening, 2) motion pattern in order to symptoms have not completely patho-anatomical diagnosis identify patients with limited disappeared an exercise program (e.g. sub-acromial syndrome, passive ROM or with reduced is required; the SSMP is typically frozen shoulder, glenohumeral muscle performance that can embedded within a graduated instability) and 3) a be treated with specific exercises shoulder exercise program. rehabilitative step, based on or manual therapy. The algorithm Lewis suggests to apply the different the level of irritability. helps clinicians to choose techniques of the SSMP after the the adequate therapeutic approach. conduction of a preliminary assessment Moreover, it allows flexibility during (composed by detailed history, screening the assessment process. for potential red-flag, functional/disability Algorithm-based re-assessment questionnaires administration, evaluation of the patients allows monitoring of impairments and if necessary whether the proposed exercises orthopaedic tests and imaging). are correctly targeted towards the prevalent impairment or is necessary to test other clinical adjunctive problems. Ristori et al. Archives of Physiotherapy (2018) 8:7 Page 4 of 11 Fig. 2 The integrated clinical model for the assessment and treatment of SP. By history taking, the physiotherapist investigates pain characteristics, its prevalent mechanisms and patient’s beliefs and expectations. Integrating this information with the results of the physical assessment, the physiotherapist classifies the shoulder pain condition with three diagnostic labels: Red Flags and Specific SP which require a referral to a specialist consultation and Non-specific SP which falls within the competence of the physiotherapist Moreover, there is a need to consider symptoms in other non-coherence of any referred pain and the widespread body segments reported by patients correlated with the irritability. Moreover, other elements are disturbed sleep, main problem (e.g. cervical or thoracic spine), the co- areas of numbness, misperception of the affected seg- morbidities, the previous consultancy with other health- ment, the feeling of swelling in absence of evident edema care professions (e.g. orthopaedic), the previous positive/ which may increase with closed eyes [39, 42]. negative experiences with a specific therapeutic ap- In addition to the anamnestic elements, physical signs proach, the patient’s life context (e.g. family or work of CS must be investigated during physical examination problems) and the screening of red flags . Physio- (e.g. swelling, weakness or stiffness of the affected seg- therapists should also investigate the limitation of activ- ment, lack of correspondence between specific move- ities and restriction of participation associated with SP ments and pain) . During the assessment process, impairments with specific questionnaires (e.g. the dis- the identification of pain mechanism on the basis of pa- abilities of the arm, shoulder and hand questionnaire tient’s dysfunction could help physiotherapists to better [DASH], shoulder pain and disability index [SPADI], the manage the SP and to target more adequately the treat- pain self-efficacy questionnaire [PSEQ]) [36–38]. ment . Unfortunately, there is only preliminary discriminative Mechanisms of pain validity of mechanism-based classification of musculo- The features of symptom help physiotherapists to under- skeletal pain . The use of some self-reported tool stand the underpinning mechanism behind patient’s pain (e.g. central sensitization inventory [CSI]) could be use- presentation, such as nociceptive pain (NP) or CS. Po- ful for physiotherapists to quantify symptoms severity of tential indicators of NP are: the localization of pain in CS, thus guiding the clinical reasoning process . the area of injury/dysfunction, the description as intermittent and sharp during movement or constant Expectations, preferences and psychosocial factors of dull or throbbing ache at rest, as well as a clear re- patients sponse consistent with aggravating and easing mech- During the anamnesis, it is essential to investigate the anical factors . patient’s expectation, preferences and the presence of Evidence suggests that CS phenomena are present in psychosocial factors (yellow flags) in order to guide the patients with SP [40, 41]. Potential indicators of CS are: subsequent best treatment decisions and to reduce the the absence of correlation or inconsistency between pro- patient’s risk for developing long-term disability . vocative stimulus and response, the discontinuity of Recent evidence suggests that expectations and prefer- pain, its unpredictability and increase with non-specific ences about the physiotherapy treatment play an import- movements, the variable anatomical distribution, the ant role as influencers of musculoskeletal outcomes [46, Ristori et al. Archives of Physiotherapy (2018) 8:7 Page 5 of 11 47] also in patients with SP . It is useful to ask the non-specific pain. Firstly, the physiotherapist should ex- patients what he expects from physiotherapy to under- clude Red Flags, then distinguish patients, classifiable as stand if the achievement of the desired outcomes is pos- specific shoulder pain, with signs and symptoms of mus- sible or not. The physiotherapists should also investigate culoskeletal dysfunction for which is necessary the refer- the patient’s preferences towards a specific treatment ral to an orthopaedic evaluation before establishing a (e.g. manual therapy or exercises) [46, 47]. physiotherapy treatment [57, 58]. Finally, the physiother- Moreover, the predominance of specific psychological apist can classify as non-specific shoulder pain  the factors such as personal and environmental elements patients presenting clinical features that do not belong must be analysed. The physiotherapist should screen for to the two categories described above. older age (more of 50 years), higher perceived pain in- tensity, longer duration of symptoms, previous injury, Red flags and specific shoulder pain extensive sick leave, unemployment, co-morbidities, pre- Red flags are sign and symptoms alerting the physiother- vious SP, poor perceived general health, avoidance of ac- apist on a possible presence of a non-musculoskeletal, tivity for fear of pain and harm, perceived high job life-threatening pathology, fracture, infection, tumor and demands and low job satisfaction, higher body mass inflammatory rheumatic conditions . However, phys- index, poor social support, personal problems (alcohol, iotherapists must be careful in the evaluation of signs financial, marital) [49, 50]. and symptoms of patients . The prevalence and inci- dence of red flags in shoulder disorders are unknown [59, 61], thus limiting the identification of serious Physical assessment non-musculoskeletal pathology at the first consultation The evaluation of the quality of active and passive shoul- . Specific shoulder pain indicates that symptoms der and cervical spine movements , the range of mo- could refer to a pathology that has a clear structural, tion (ROM) and the shoulder muscles strength are the patho-anatomic or pathophysiologic origin (e.g. symptom- priority of the assessment . Physical assessment atic rotator cuff tears, superior labral tear from anterior to should explore the provocative movements of the pa- posterior [SLAP] or instability). It requires referral to an tient’s pain. It can be an active or passive movement of orthopaedic specialist to clarify diagnostic aspects or sur- the shoulder  or a movement of the neck region (in gical needs [63, 64]. Signs and symptoms characteristic of this case a comprehensive clinical assessment of this re- these two categories are listed in Table 2. It is not neces- gion should be considered) . sary that all symptoms have to be present at the same time Physical assessment is also aimed to confirm the pres- to guide physiotherapists during their clinical reasoning ence of CS signs suspected during anamnesis, such as process [65–68]. When a conservative approach has been swelling, weakness or stiffness of the affected segment, chosen for specific shoulder pain,physiotherapists may lack of correspondence between specific movements and refer to specific options for treatment available in litera- pain [39, 42], while the clinical utility of quantitative ture (e.g. for conservative treatment of patients with sensory testing (QST) for the detection of CS is ques- massive rotator cuff tears, we could propose stretching, tionable and still a source of debate . proprioceptive and active exercises towards functional Table 2 Red Flags and symptoms of specific shoulder pain Triage and treatment From a clinical-pragmatic perspective, there is the need Anamnestic and clinical Sign and symptoms of Features of red flags Specific shoulder pain to modify the diagnostic labeling used for patients with Fever, shivering, changes in body Recent trauma of the shoulder SP [6, 17, 20]. As proposed for other body regions (e.g. temperature overnight, diaphoresis, complex, high reactivity of lumbar spine, cervical spine), also in the shoulder com- nausea, unexplainable sweating symptoms, pain during the night, plex, there is a growing awareness of the very limited overnight, vomiting, sphincteric limitation of flexion (< 90° both complaints, diarrhoea, paleness, passive and active), apprehension, ability to identify a specific structure responsible for the fatigue, lurching, fainting, fear of movement and/or patient’s symptoms . Therefore, a transition of the exhaustion, excessive and weakness during humeral SP assessment from a strictly mechanistic to a more unexplainable weakness, not linked external rotation. to any physical effort, unexplainable bio-psychosocial oriented approach seems necessary. loss of weight, skin rash, The analysis of the patient’s history, beliefs, preferences unexplainable multiple hematoma, and functional movements, have recently assumed a key lumps over the body, deformities, inability to lay supine in bed, role . marked muscle weakness, marked In our clinical framework, we propose a process of restriction of movement, limb diagnostic triage that adopts a classification system simi- atrophy, local pain and pain during load when age is less than 20 years lar to the one already adopted for other regions (e.g. old and more than 50. lumbar spine [55, 56]): red flags, specific pain, Ristori et al. Archives of Physiotherapy (2018) 8:7 Page 6 of 11 movements, increasing progressively the position of exe- through exercise, thus playing an important role for this cution and the resistance) (see Table 4)[57, 58]. category of patients with SP . Indeed exercises have both the capacity of re-conditioning the anatomical Non-specific shoulder pain structures, with an effect on NP mechanisms [57, 80, 81] Once the patient is categorized as non-specific shoulder and the capacity of modulating the patient’s pain with an pain , the physiotherapist should recognize what is action on CS mechanisms . This effect of movement the prevalent mechanism of pain elaboration of the pa- and exercises have been demonstrated also in other body tient, and identify what are the functional movements regions [81, 83]. Various load strategies will be described that provoke symptoms. If the patient does not in the section below. recognize precisely the pain provocative shoulder move- ments, physiotherapists can use shoulder orthopaedic Algorithm of treatment To organize the treatment of tests to provoke pain . Three strategies, overlaid and patients with non-specific shoulder pain provoked by fused in every intervention of our clinical practice, shoulder movements, is advisable to adopt the same should be adopted to treat non-specific shoulder pain pa- functional approach proposed by Klintberg et al., that tients: education, de-sensitization and load management. seems to be flexible and easy to perform  (Fig. 3). Overall, in the choice of treatment, the physiotherapist Once the painful movement is identified, the patient must integrate, as much as possible, expectations and rates his/her pain on a numeric rating scale and then the preferences of patients thus adopting any previous posi- physiotherapist attempts to modify it applying specific tive physiotherapy solutions and avoiding the past nega- procedures [31, 57, 84–89] (see Table 3). tive experiences [46, 47]. Different procedures are administered to the patient until he/she reports a satisfying improvement occurring Education It is important to inform patients about their during or after the intervention . Some authors clinical condition, avoiding an excessive biomedical ter- stated that inter and intra-treatment changes may be minology (e.g. “shoulder impingement”), explaining the predictive of improvement of the specific symptom as pain mechanisms underpinning their symptoms, their fa- well as of the general condition of the patient: this vorable prognosis, the strategies of treatment that are phenomenon can be of support for the clinical intended to use proprioand the value of self-management decision-making [90, 91]. If the procedures of symptoms and home exercise [48, 70, 71]. This education process modification result effective, manual treatment in associ- should be promoted throughout the whole treatment, thus ation with exercises (with a progressive amount of load enhancing the patient’s engagement and empowerment based upon the clinical evolution of the patient) are [70, 72]. In presence of high predominance of yellow flags, adopted [51, 57, 85]. The pain-free therapeutic window the patient should be monitored and educated, thus modi- identified by the positive response of symptoms modifi- fying any dysfunctional beliefs and overestimated expecta- cation procedures can be used to propose pain-free exer- tions about SP and reconceptualising on a cognitive level cises (adopting positive procedures as exercises), any fear, harm and avoidance about shoulder activity . regardless of the presence of CS component of the clin- ical scenario (see Table 4). De-sensitization Manual therapy is one of the possible Regarding load management, the physiotherapist interventions to reduce SP. Mechanical stimuli applied should play with an accurate tuning of the posology, in to the skin of the patients by manual therapy, determine terms of specific target and modalities of execution (see several neurophysiological mechanisms (e.g. peripheral, Table 4)[32, 33, 43, 57, 79, 92, 93]. spinal and supra-spinal) that improve pain. Because of Even if some authors choose the structure(s) to which this variety of effects sources, we can assume that man- target the exercises on the base of the effect of the previ- ual therapy can be considered as a therapeutic interven- ously performed procedure (e.g. gleno-humeral muscles tion able to de-sensitize the neurologic system that if humeral head and muscular conditioning procedures supports pain perception [74–77]. Manual therapy could were positive; or thoracic spine muscles if modification play an important role to decrease fear of movement of thoracic kyphosis resulted positive) [33, 57, 87, 93], and catastrophization . The physiotherapists should according with Littlewood et al.  we suggest as pref- consider also the adoption of drugs (e.g. pain killers) or erable to rely on the dysfunctional pattern of movement exercises to reduce pain and to desensitize the patient of the patient in order to restore the activities of daily [51, 57], thus reducing the possibility of CS . life (e.g. respecting the tolerance of movement in terms of pain/fatigue, if abduction is the painful/lim- Load management We considered as load every move- ited movement, the physiotherapist will increase and ment that could increase the ability to perform a lim- modulate number of repetition and resistance in ab- ited/painful movement. The load is usually administered duction exercises). Ristori et al. Archives of Physiotherapy (2018) 8:7 Page 7 of 11 Fig. 3 Non-specific SP: the algorithm of treatment. De-sensitization procedures should be adopted first. If an improvement of pain and/or patient’s satisfaction is obtained, the treatment load should be increased by using the positive procedures and specific exercises. If this first approach does not reach its goal, then therapeutic strategies based on the prevalent pain mechanism should be implemented. Symptom-contingent strategy or manual techniques (in cases of joint stiffness) and time-contingent strategy have to be used in patients respectively with prevalent NP or CS mechanisms. In case of lack of improvement, the patient should be re-assessed or referred to the specialist If symptoms reduction procedures resulted negative Patients with CS mechanisms: de-sensitization and without influence patient’s SP, the load will be managed load management are coupled with the therapeutic by exercise, according with prevalent mechanisms of approach. The clinical conditions with prevalent CS pain elaboration showed by the patient: features are managed by patient’s education and “time-contingent” exercise (exercises have to be per- Patients with NP mechanisms: if the clinical formed for a certain time, agreed with the patient, condition is characterized by high level of reactivity, despite the presence of symptoms) in order to the therapeutic approach will be based on patient education , de-sensitization with rest, drugs Table 3 Examples of diagnostic/therapeutic procedures to (refer to medical management) or graded motor im- reduce the patient’s symptoms agery (GMI) . In the more active treatment Example of procedures for symptoms reduction phase, once the reactivity is reduced, load man- SSMP (thoracic kyphosis, humeral head procedures, scapular position) agement is predominant and exercises are pro- posed with the adoption of a “symptoms- Mulligan’s techniques of mobilization with movement contingent” strategy (the presence of symptoms limits the performance of exercises), targeting the Scapular assisted test and scapular repositioning test dysfunctional motor task (e.g. a program of exer- Manual or dry needling treatment cises that aim to load the impaired movement, of myofascial trigger points (mTrPs) starting from pain-free, simple, with low resist- Manual treatment of cervical and ance exercises toward more complex functional- thoracic joints (mobilization/manipulation) tasks) (see Table 4)[32, 33, 57, 80, 93, 95]; Ristori et al. Archives of Physiotherapy (2018) 8:7 Page 8 of 11 Table 4 Load strategies for specific and non-specific shoulder pain Load strategies Specific shoulder pain Non-specific shoulder pain Responsive Non responsive Non responsive (NP or CS) NP CS Aim: Increase movement/strength Aim: reduce pain, fear, increase Aim: reduce pain, increase Aim: reduce pain, fear, increase and flexibility. movement/strength. movement/strength. movement/strength. What to do: symptoms-contingent What to do: symptoms-contingent What to do: symptoms-contingent What to do: strategies; stretch, proprioceptive strategies; commute positive strategies; stretch and active exercises time-contingent strategies; graded and active exercises progressively procedures in exercises plus load progressively changing the position exposure/activity starting from the changing the position of execution the dysfunctional pattern of of execution and increasing number identification of painful tolerated and increasing number of patient’s movement increasing of repetition and the resistance exercise in terms of number of repetition and the resistance and modulating number according with patient’s pain. repetitions and pain granted during according with patient’s pain. of repetition and resistance the execution. according with patient’s pain. restructure the patient belief of association between our best efforts, several limitations affected the sug- pain-danger-harm (e.g. graded exposure/activity gested framework: 1) it is based on a discretionary ex- starting from the identification of painful tolerated pert opinion; 2) it is created without an international exercise in terms of number of repetitions and pain expert consensus methodology (e.g. Delphi study); 3) the granted during the execution) [42, 43, 70, 73, 82, 96– selection of relevant articles was based on narrative review 98]. Communication with patients (including informa- instead of a declared approach (e.g. systematic review); 4) tion, reassurance and education) could also help exer- its applicability, efficacy, validity and reliability has not cises and it plays an important role in the achievement been tested. Moreover, we actually could not classify dif- of this aim . GMI and low intensity, aerobic/non- ferent profile of patients under the label of non-specific specific exercise also seems to be particularly useful in shoulder pain . When it will be possible, as previ- this category of patients (see Table 4). ously happened for low back pain, it could permit us to optimize diagnostic and therapeutic proposals. Concerning the prognosis, when a positive progressive improvement is obtained, an exercise training of Conclusions 12 weeks duration is recommended [33, 92]. Moreover, Existing literature underlines the limits of a strictly ana- the presence of a lower baseline pain and disability, a pa- tomical model for the evaluation of patients with SP. tient expectation of a ‘complete recovery’ as ‘a result of The integration of the alternative purposes in that clin- physiotherapy treatment’ in comparison to ‘slight im- ical framework could help to orientate physiotherapists provement’, a higher pain self-efficacy and lower pain se- towards a more bio-psychosocial and pragmatic ap- verity at rest enhances the likelihood to reduce pain and proach. In the future, the category of non-specific shoul- improve disability in SP . Opposite, when capsular der pain and its peculiarities should be taken into stiffness is a predominant feature of the clinical scenario, account in diagnostic and prognostic research studies. a longer time is needed to fully restore functional move- Abbreviations ment . The concomitance of higher level of depres- CS: Central sensitization; CSI: Central sensitization inventory; DASH: The sion symptoms, catastrophizing thoughts, fear of disabilities of the arm, shoulder and hand questionnaire; GMI: Graded motor imagery; GP: General practitioner; MRA: Magnetic resonance arthrography; movement, fear of pain and anxiety were related to MRI: Magnetic resonance imaging; NP: Nociceptive pain; PSEQ: Pain self- higher disability, greater pain severity, lowest perceptions efficacy questionnaire; QST: Quantitative sensory testing; ROM: Range of of clinical improvement and increased possibility of de- motion; SLAP: Superior labral tear from anterior to posterior; SP: Shoulder pain; SPADI: Shoulder pain and disability index; SSMP: Shoulder symptom veloping a pattern of CS in patients with SP [102–105]. modification procedure; STAR-shoulder: Staged approach for rehabilitation Finally, in the short/medium term, the expected results classification: shoulder disorders; US: Ultrasound; X-RAY: Radiographs are not reached, the patient should be re-evaluated Acknowledgements re-exploring the different steps of the framework or re- The authors want to thank Samuele Graffiedi for his valuable advice during ferred to other specialists (e.g. orthopaedic) . the advancement of this manuscript. Authors’ contributions Study limitations All authors conceived, designed, drafted and approved the final manuscript. In this paper, we adopted an evidence-based approach to guide physiotherapists in the management of SP, thus Ethics approval and consent to participate Not applicable. proposing a framework inspired by the bio-psychosocial model  and aligned to the International Classifica- Competing interests tion of Functioning, Disability and Health . Despite The authors declare that they have no competing interests. Ristori et al. Archives of Physiotherapy (2018) 8:7 Page 9 of 11 Publisher’sNote 21. Lenza M, Buchbinder R, Takwoingi Y, Johnston RV, Hanchard NC, Faloppa F. Springer Nature remains neutral with regard to jurisdictional claims in Magnetic resonance imaging, magnetic resonance arthrography and published maps and institutional affiliations. ultrasonography for assessing rotator cuff tears in people with shoulder pain for whom surgery is being considered. 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Published: May 30, 2018
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