Return to work is a challenge in shoulder rehabilitation for patients participating in jobs with high requirements for the shoulder like for example construction workers, dentists or domestic helpers.
From working with these patients I recognize three pitfalls related to exercise therapy, that might contribute (among other factors) to early failure of return to work :
- The gap between the load of an exercise program and the load during occupational activities is too large. Load progression should continue up to the level that is needed in the job activities. Moreover partial start to work for half days of few days a week is excellent to allow the shoulder to adapt again to the load at work.
- Not addressing motor control / ergonomics during work specific tasks or activities. We should observe and analyze the tasks they need to perform at work. Give advice how tasks can be adapted to decrease load on the shoulder.
- The exercises of the program are too analytical/underloaded and not meeting the needs of the shoulder during the occupational activities. Analyzing job activities allows us to create exercises resembling (parts of) the tasks to train the shoulder in an activity oriented way.
Delayed or failed return to work largely impacts the patient, the employer and society (think workers compensation, depression,…). Striving to increase ultimate success of a happy patient participating fully at home and at work is what drives us.
Obviously return to work is more complex and a multidimensional approach is needed but let’s focus on exercise therapy for a moment. Curious for what the evidence can tell us, I guided our students ( Eline Rycx, Margeaux Legein, Lisa Lernout) during master thesis in performing a systematic review on evidence for exercise therapy in overhead workers together with my colleague and occupational therapist Dr. Stijn De Baets.
The aim of this systematic review was to assess the effect and evidence on exercise therapy within adults who suffered work-related complaints of the shoulder and we were interested in the exercise programs they used.
Five studies were included in this systematic review. Out of these five studies, only one study got a level of evidence A2 (Sundstrup et al., 2014) and 4 were judged as level of evidence B. One study had a high risk of bias, two a moderate risk of bias, and two a low risk of bias. The higher risk of bias was mainly caused by selection bias, performance bias, and detection bias.
Frequently used outcome measurements were pain, questionnaires on shoulder functionality, maximal voluntary isometric contractions (MVIC), muscular endurance, muscular coordination, and aerobic power.
Sundelin et al. (2001) divided the population into an endurance-, a strength-, a coordination-training group and a control group with no training. All training sessions included 40 minutes of specific group exercises.
- The endurance training group consisted of cycling on an arm ergometer in combination with exercises using elastic bands.
- The strength group performed exercises such as rowing, triceps press, and shoulder press.
- The coordination group received body awareness training.
- The non-training group got stress handling once a week.
There were differences between these training groups, but in general, all three training groups showed improvements in pain, aerobic power, static strength, endurance, and coordination. They concluded that a ten-week training program (strength, endurance, or coordination) had a positive effect on pain, aerobic power, static strength, endurance and coordination.
Ager et al. (2018) randomly assigned participants to two intervention groups.
- The first group got a 6 week multi-station, group supervised upper extremity neuromuscular training program. The eleven stations contained different types of exercises, e.g. postural and scapulothoracic control exercises.
- The second group got one-on-one usual physiotherapy care (UPC). This UPC group got a combination of an individualized home exercise program and 12physiotherapy sessions.
The authors could find a statistically significant time effect for both training groups regarding pain, the DASH and WORC questionnaire. No training program was superior to the other.
Lowe et al. (2017) compared 2 groups:
- Exercise group with strength training of the serratus anterior and rotator cuff muscles combined with stretching (pectoralis minor and posterior capsule) and scapulohumeral rythm exercises to decrease upper trap activation
- Non-training group
They demonstrated no significant differences for the training group regarding the SRQ and DASH. However, the item ‘troubles in the last seven days’, as part of the NORDIC questionnaire, decreased significantly in both training and non-training groups.
Ludewig et al. (2003) compared
- Home exercise program: consisted of a combination of strengthening and stretching of specific muscles (pectoralis minor and the posterior shoulder region)
- Non-training group.
The training group achieved a better score than the non-training group. However, the symptomatic training group could not show better results than the asymptomatic nontraining group.
Finally, a study by Sundstrup et al. (2014) compared between:
- Strength training of the shoulder, arm, and hand
- Ergonomic advice
In general, the Work Ability Index scores increased in both the training and ergonomic group. The items ‘mental resources’ and ‘work ability in relation to the demands of the job’ showed significantly more improvement for the training group in comparison with the ergonomic advice-group.
Conclusions: Results suggest that an exercise program is superior to no exercise therapy. There is no evidence in favour of a specific type of exercise therapy for work-related shoulder complaints among overhead workers. It is worth mentioning that 4 out of 5 studies gave their participants an intervention with analytic function based (strength, coordination or enduranc) exercise program but measured the progression with functional outcome measurements.
Together with the physiotherapy students we recently performed a study to investigate which tasks overhead workers experience difficulties with. This could give us more insight in the challenging aspects of occupational activities and give direction to exerise selection for return to work exercise programs in this group. The results will be shared in a next post in 6 weeks so stay tuned!
Ager, A. L., Roy, J. S., Gamache, F., & Hébert, L. J. (2019). The Effectiveness of an Upper Extremity Neuromuscular Training Program on the Shoulder Function of Military Members With a Rotator Cuff Tendinopathy: A Pilot Randomized Controlled Trial. Military medicine, 184(5-6), e385-e393.
Lowe, B. D., Shaw, P. B., Wilson, S. R., Whitaker, J. R., Witherspoon, G. J., Hudock, S. D., … & Wurzelbacher, S. J. (2017). Evaluation of a workplace exercise program for control of shoulder disorders in overhead assembly work. Journal of occupational and environmental medicine, 59(6), 563.
Ludewig, P. M., & Borstad, J. D. (2003). Effects of a home exercise programme on shoulder pain and functional status in construction workers. Occupational and environmental medicine, 60(11), 841-849.
Sundelin, G. (2001). Effects on physical performance and pain from three dynamic training programs for women with work-related trapezius myalgia. J Rehabil Med, 33, 162-169.
Sundstrup, E., Jakobsen, M. D., Brandt, M., Jay, K., Persson, R., Aagaard, P., & Andersen, L. L. (2014). Workplace strength training prevents deterioration of work ability among workers with chronic pain and work disability: a randomized controlled trial. Scandinavian journal of work, environment & health, 244-251.