Shoulder pain? Exercise is the main treatment backed by research

✅ Key Content

Objective: This review aimed to determine whether adding other physical therapy interventions (multimodal therapy) to an exercise-alone program provides superior benefits for patients with shoulder pain, compared to exercise alone. The included studies were Randomized Controlled Trials (RCTs) published between 2018 and 2023.
Registration: The review was registered under PROSPERO CRD42023417709.
Inclusion: The review included 20 studies with a total of approximately 2,385 patients.
Primary Outcomes: The main outcome measures used were the SPADI (Shoulder Pain and Disability Index) and the DASH (Disability of Arm, Shoulder & Hand).

The combination of Exercise + Manual Therapy was the most common pairing, but it was not statistically significantly better than exercise alone. (Exercise only vs. Exercise + Manual Therapy)
The combination of Exercise + Low-Level Laser Therapy (LLLT) showed the largest reduction in SPADI scores, with a mean difference of approximately −1.06 (95% CI: −1.51 to −0.60).
The mean difference for Exercise + High-Intensity Laser Therapy (HILT) was −0.53 (95% CI: −1.12 to 0.06), which was close to the boundary of statistical significance.
The Exercise + Manual Therapy combination had a mean difference of −0.24 (95% CI: −0.74 to 0.27), suggesting minimal significant additional benefit.
The overall meta-analysis for all Multimodal Therapy (various treatment combinations) versus exercise alone showed a non-statistically significant average effect of −0.12 (95% CI: −0.36 to 0.11). The heterogeneity across studies was also high .

Main Conclusion: The core takeaway is that therapeutic exercise remains the primary intervention for treating patients with shoulder pain, and laser therapy appears to be the most promising additional option.
Implication: Adding interventions such as manual therapy or education/advice (like telerehab/self-management) to exercise did not consistently show significant additional benefits, which highlights limitations due to variations in research protocol and study quality.
Practical Tip: Clinical practice should prioritize "designing and executing a high-quality exercise program." When choosing additional interventions, clinicians must consider evidence-based options, patient characteristics, cost, and feasibility.
Future Research: The paper emphasizes the need for higher quality RCTs, standardized treatment protocols, long-term follow-up studies, and cost-effectiveness analyses.

Generalizability: The ability to generalize to "all shoulder pain" is limited because the included studies varied greatly in their treatment modalities, patient characteristics, and diagnostic labels (e.g., subacromial pain, rotator cuff related pain, etc.).
Laser Therapy Interpretation: While laser therapy showed positive results, this should be viewed as a "potential" rather than a "certainty." This is due to the small number of included studies and high heterogeneity.
Overall Effect: Since the meta-analysis for all multimodal therapy combinations versus exercise alone did not show a statistically significant average effect, it is difficult to generalize that 'exercise + any additional treatment is always better.

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