Screening of the cervical spine in subacromial shoulder pain: a systematic review

The takeaway

When research studies treat people for subacromial shoulder pain, how often and how well do they check whether the neck is part of the problem?

Across 102 randomized trials of physiotherapy for subacromial shoulder pain, the way the neck (cervical spine) was checked varied widely, and most studies either did not screen the neck at all or relied only on the location of symptoms. There is no agreed best method for screening the neck in this setting.

DescriptiveRead paper

Systematic review102 TrialsLimited evidence

Key points

This review looked only at how trials screened the cervical spine, not at which shoulder treatment works best.
Of 102 trials, 26 (25.5%) reported no method of neck screening and 49 (48.0%) relied only on localized neck symptoms or radicular pain.
Only 14 trials (13.7%) used a combined approach mixing symptoms with physical examination.
Missing or minimal neck screening risks mixed patient groups in research and misdirected treatment in clinic.
The authors conclude the optimal way to screen the cervical spine in shoulder pain remains unknown and needs more research.

How it was conducted

Design: Systematic review of randomized controlled trials
Data sources: PEDro and MEDLINE searched from 2000 to December 2016
Participants: Adults (over 18) with subacromial shoulder pain (impingement, rotator cuff tendinopathy, subacromial pain syndrome)
What was extracted: Method of cervical spine screening, PEDro quality score, and shoulder diagnosis method (no clinical outcome data)
Synthesis: Screening methods sorted into six categories, with a sensitivity analysis of higher-quality trials

What they found

102 trials were included after 55 were excluded at full text.
Neck screening categories across all 102 trials: No method reported 26 (25.5%), Localized cervical symptoms and/or radiculopathy 49 (48.0%), Cervical examination 9 (8.8%), Manual testing 2 (2.0%), History of cervical surgery 2 (2.0%), Combined approaches 14 (13.7%).
Within the 9 cervical examination trials: unspecified examination n=4, AROM and/or PROM n=4, neurological testing n=1.
75 of 102 trials (73.5%) either did not screen or relied on symptom location only.
Median PEDro quality score was 6 (range 2 to 10).
In the sensitivity analysis of 68 higher-quality trials (PEDro 6 or above): No method reported 12 (17.8%), Localized cervical symptoms 34 (50.0%), Cervical examination 8 (11.7%), Manual testing 2 (2.9%), History of cervical surgery 1 (1.5%), Combined approaches 11 (16%).

Limitations

Only two databases (PEDro and MEDLINE) were searched, a pragmatic choice that may have missed relevant trials.
The search was limited to a 10-year window (2000 to December 2016), so older studies were not included.
Language restrictions were applied, excluding at least one non-English trial.
It is unknown how these trial screening practices relate to real-world clinical practice.

Why it matters

For patients: If you have shoulder pain, your neck can sometimes be part of the cause, and this review shows even research studies often do not check it carefully.
For clinicians: There is no validated standard for cervical screening in subacromial shoulder pain, so combining symptoms with examination is reasonable but not yet evidence-backed.
For readers: This is a methods review highlighting a gap, not a comparison of treatments, so it tells you how inconsistently the neck is assessed rather than which therapy works.

Source

doi:10.1177/1758573218798023

Read the original paper

Clinically assessing this area? See the shoulder special tests.