Seven key themes in physical therapy advice for patients living with subacromial shoulder pain: a scoping review

Key points

1. 01Exercise intensity and pain response guidance was the most commonly reported advice category, mentioned in 32 of 82 studies (39%)
2. 02Activity modification advice appeared in 17 studies (21%), and posture advice in 15 studies (18%)
3. 03Pain self-management advice (12%), patho-anatomical and diagnosis information (9%), behavioral approaches (7%), and pain biology advice (2%) were less frequently reported
4. 0485% of Swedish physiotherapists surveyed advised patients on posture, while 50% advised staying active and only 10% recommended bed rest
5. 05Pain biology and neuroscience education was rarely included (only 2 studies), despite growing evidence supporting its role in persistent pain management

How it was conducted

Design

Scoping review using PRISMA extension for Scoping Reviews

Databases searched

MEDLINE, Scopus, Web of Science, and CINAHL

Publication period

January 2007 to September 2019

Included studies

104 studies meeting inclusion criteria; 82 classified as patient-focused intervention or prospective studies

Study types included

Randomized clinical trials (61), prospective cohort studies (5), nonrandomized or retrospective studies, case series, qualitative interviews, surveys, audits, and focus groups

Primary aim

Systematically scope the reported content of advice and education in physical therapy for subacromial shoulder pain and define key themes

What they found

• Of 82 patient-focused intervention or prospective studies, 63% specified participants received advice or education, 9% indicated advice without specifying content, and the remainder stated advice was not provided
• Exercise intensity and pain response advice was reported in 32 studies (39%)
• Activity modification advice was reported in 17 studies (21%)
• Posture advice was reported in 15 studies (18%)
• Pain self-management advice was reported in 10 studies (12%)
• Patho-anatomical and diagnosis information was reported in 7 studies (9%)
• Behavioral approaches were reported in 6 studies (7%)
• Pain biology advice was reported in 2 studies (2%)
• 9 of 82 studies (11%) provided written instructions or booklets
• Two studies specified that pain during exercises should not exceed a numeric pain-rating scale level of 3/10
• Among Swedish physiotherapists, 85% provided posture advice, 50% advised staying active, and 10% recommended bed rest
• In the UK, education was used in 85 of 98 patient encounters and exercise prescription in 87 of 98
• Approximately 70% of physiotherapists in Belgium and the Netherlands advised patients to exercise within pain levels acceptable to the patient

Limitations

• Scoping reviews do not include quality assessment of individual studies, so the rigor of the included research is unknown
• The content of advice and education was frequently underreported in the primary studies, making synthesis incomplete
• No included study compared different types or modes of advice against each other, so the relative effectiveness of these themes is unknown
• The review was limited to English-language publications from 2007 to 2019, which may exclude relevant earlier or non-English evidence

Why it matters

For patients

Patients with subacromial shoulder pain can expect their physiotherapist to give advice mainly on exercise pacing and activity modification, but the specific content and quality of that advice varies considerably between clinicians and settings.

For clinicians

Clinicians should be aware that pain biology and neuroscience education, as well as behavioral approaches, are currently underused in practice despite growing evidence supporting their role, and that clear documentation of advice content would improve research replication and comparison.

For readers

This review maps the landscape of patient education in subacromial shoulder pain physiotherapy and highlights a substantial gap between the potential value of biopsychosocial advice and what is actually being delivered and reported in clinical trials.