Injections and Physical Therapy Equal for Treating Shoulder Pain

By Kathryn Doyle

NEW YORK - Physical therapy and corticosteroid injections work equally well for shoulder impingement syndrome, according to a new study.

"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 rheumatologists," he noted.

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 corticosteroid group were offered up to three injections 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 during a year of follow-up, the research team reported online August 4 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% of the steroid injection group had returned to their primary care doctor for shoulder pain again, compared to 37% 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."

"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 of the University of Queensland in Brisbane, Australia, who coauthored an editorial accompanying the study.

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 self-management approaches."

Injections are less costly than therapy because they only involve one visit, but if they also result in more 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.

SOURCE: https://bit.ly/1mgAgYL

Ann Intern Med 2014.

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