Physiotherapy or corticosteroid injection for shoulder pain?

In their introduction the authors describe shoulder pain to be a common complaint, with an estimated annual incidence in general practice of 6.6 to 25 cases per 1000 patients. They comment that most patients are treated in primary care, initially with analgesics or non-steroidal anti-inflammatory drugs escalating to physiotherapy or local infiltration of a corticosteroid for those not responding. The review identifies that until recently there has been little data on the effectiveness of these interventions. The authors cite a current study 1 by Hay et al and two previous Dutch general practice investigations 2,3 that have directly compared the effects of physiotherapy with corticosteroid injections.When examining the results of these three primary care trials, the reviewers consider three points for discussion. Firstly, the short term findings are rather different, with the Dutch trials clearly showing better effects of corticosteroid injections, whereas the Hay et al trial reports similar outcomes for the two interventions. Secondly, all three trials show minor and non-significant differences at long term follow up. Thirdly, the 'somewhat ambiguous' overall evidence may leave substantial room for considering patient preferences and expectations when applying the results in clinical practice. In their summary the authors call for a consensus on a core set of outcome measures for the assessment of shoulder pain. They comment that such a consensus would enable comparison of results across studies, enhance the analysis of pooled data and facilitate the development of clinical practice guidelines. van der Windt et al 4 propose that the long-term effectiveness of both interventions requires further investigation with a particular emphasis on evaluating the influence of patient expectations and preferences on treatment outcome.References:1. Hay, E. Thomas, E. Paterson, S. et al. 2003. 'A pragmatic randomised controlled trial of local corticosteroid injection and physiotherapy for the treatment of new episodes of unilateral shoulder pain in primary care', Annals of the Rheumatic Diseases, vol. 62, pp. 394-399. 2. Winters, J. Sobel. J. Groenier, K. et al. 1997. 'Comparison of physiotherapy, manipulation, and corticosteroid injection for treating shoulder complaints in general practice: randomised, single blind study', British Medical Journal, vol. 314, pp. 1320-5. 3. van der Windt, D. Koes, B. Boeke, A. et al. 1998. 'Corticosteroid injections versus physiotherapy for painful stiff shoulder in primary care: randomised trial', British Medical Journal, vol. 317, pp. 1292-1296.4. van der Windt, D. Bouter, L. 2003. 'Physiotherapy or corticosteroid injection for shoulder pain?' Annals of the Rheumatic Diseases, vol. 62, pp. 385-387....