Anna Kuryliszyn-Moskal1, Joanna Zablocka2, Andrzej Julian Niewinski1, *Anna Hryniewicz1
Role of physiotherapy in the treatment of shoulder pain in rheumatic diseases – the state of actual knowledge
Rola fizjoterapii w leczeniu zespołu bolesnego barku w chorobach reumatycznych – aktualny stan wiedzy
1Department of Rehabilitation, Faculty of Health Sciences, University of Bialystok, Poland
2Doctoral Studies, Department of Rehabilitation, Faculty of Health Sciences, University of Bialystok, Poland
W pracy przedstawiono aktualną problematykę dotyczącą zasad leczenia fizjoterapeutycznego zespołów bólowych kompleksu barkowego w przebiegu chorób reumatycznych. Szczegółowo omówiono postępowanie w najczęstszych chorobach reumatycznych, takich jak: RA, OA i SpA. Zwrócono szczególną uwagę na znaczenie postępowania kinezyterapeutycznego, wskazując jednocześnie na rolę leczenia metodami fizykalnymi z zakresu termoterapii, elektrolecznictwa, laseroterapii, zastosowania ultradźwięków i pola magnetycznego. Uzupełniające znaczenie pełni leczenie balneologiczne o działaniu miorelaksującym, przeciwbólowym i przeciwzapalnym.
W podsumowaniu podkreślono, iż celem postępowania rehabilitacyjnego w zespołach bolesnego barku w przebiegu chorób reumatycznych jest nie tylko uzyskanie efektu przeciwbólowego i poprawa stanu funkcjonalnego, lecz przede wszystkim indywidualna i kompleksowa terapia, zmierzająca do osiągnięcia poprawy sprawności chorych, umożliwiającej powrót do codziennej aktywności.
Realizacja skutecznego i kompleksowego programu terapeutycznego wymaga jednoczesnego podjęcia wszechstronnych działań: edukacyjnych, opracowania indywidualnej strategii postępowania fizjoterapeutycznego, psychoterapeutycznego, zastosowania indywidualnie dobranego zaopatrzenia ortopedycznego, a także zaoferowania pomocy socjalnej. W celu realizacji tych zadań niezbędna jest współpraca zespołu specjalistów z wielu dziedzin. Jedynie jak najwcześniejsze wdrożenie interdyscyplinarnego i kompleksowego postępowania stwarza możliwość powrotu chorych do pełnej aktywności rodzinnej, społecznej i zawodowej.
The study presents the current problems concerning the principles of physiotherapeutic treatment of shoulder pain syndromes in the course of rheumatic diseases. The principles of the treatment in the most common rheumatic diseases such as RA, OA and SpA are discussed. Particular attention has been paid to the importance of kinesitherapeutic treatment, while indicating the role of treatment with physical methods in the field of thermotherapy, electrotherapy, laser therapy, the use of ultrasounds and magnetic field. Balneological treatment with myorelaxing, analgesic and anti-inflammatory effects is of complementary importance.
The summary emphasizes that the goal of rehabilitation in shoulder pain syndromes in the course of rheumatic diseases is not only to achieve analgesic effect and improve the functional status, but, above all, an individual and comprehensive therapy aimed at improving the efficiency of the patients, enabling return to daily activities.
The implementation of an effective and complex therapeutic program requires the simultaneous undertaking of comprehensive activities: educational, developing an individual strategy of physiotherapeutic and psychotherapeutic treatment, the use of individually selected orthopedic supplies, as well as offering social assistance.
In order to perform above procedures, a multidisciplinary team is necessary. Only the most immediate possible implementation of interdisciplinary and complex procedures makes enables patients to return to full family, social and professional activity.
Pain syndrome of the shoulder and cervical spine is the second most frequent complaint of the musculoskeletal system, following back pain in the lumbosacral segment. The term “shoulder” is a colloquial term for pectoral girdle, which includes bones (collarbone, scapula, humerus), their connections to the axial skeleton, as well as the connection of the shoulder and chest wall and joints: shoulder, acromioclavicular and sternoclavicular. Ligaments and muscles, forming, along with the ligatures, myofascial meridians, are also important elements, acting as the transmission of tensions caused by muscles (1).
Pain may be the result of structural or functional damage. Structural changes usually appear as a result of an injury or inflammatory process, while functional damage consists of disorders of the nervous system, muscle synergy and shoulder arthroplasty. Both, internal and external factors affect the above dysfunctions. Internal factors include: impaired vascularization, inflammatory and degenerative changes in the course of rheumatic diseases, high intramuscular pressure. The external factors are mechanical loads (1-3). Risk factors for shoulder pain syndrome include: excessive physical effort during work, older age, smoking, long-term immobilization of the limb, muscle weakness of the upper limb, postural defects, abdominal obesity, diabetes, and low physical activity (4). Often, one patient reveal several causes of pain (3, 4).
The fact that the upper limb is an open biokinematic chain means that even a small degree of dysfunctions in the shoulder area cause significant pain (5).
The most common symptom that hinders daily functioning of the patient is the pain that occurs soon after the limb activity begins. Occasionally, it is accompanied by swelling that indicates the development of inflammation in the tissues (5).
In the acute phase, lasting approximately six weeks, pain and increased muscle tension lead to a reduction in mobility in the joint. In the chronic phase, pain is reduced, while muscle tone, causing the appearance of contracture – increases, leading to further limitation of motion (5). Shoulder pain may also radiate to nearby structures. As a result of the progressive functional destabilization process, the pectoral girdle elevation is observed, slightly above the level of a healthy shoulder. Change in skin temperature around the affected shoulder joint and increased sensitivity to touch as well as crepitations in the joint are further symptoms of joint dysfunction (6).
Shoulder pain is a common complaint in the course of rheumatic diseases such as: rheumatoid arthritis (RA), ankylosing spondylitis (SpA) or osteoarthritis (OA). Although the mechanism of pain formation is better understood, a considerable variety of the clinical picture requires individual programming of the rehabilitation procedure, depending on the degree of damage and the nature of dysfunction. The issue of current knowledge about physiotherapy in patients with shoulder pain syndrome in the course of rheumatic diseases is the subject of further considerations.
General principles of physiotherapeutic treatment in shoulder pain syndromes in the course of rheumatic diseases
Physiotherapeutic treatment should be preceded by a detailed clinical examination, necessary to identify damage of particular structures of the shoulder complex, assess the degree of damage and the nature of dysfunction.
Diagnostic procedure consists of three elements: case history, physical examination and additional tests. The subjective examination includes a detailed interview concerning not only the nature, severity and location of pain, but also the circumstances in which pain appeared, the current treatment and the patient expectations towards the rehabilitation process. Objective examination includes observation of the shoulder area, posture, palpation, assessment of muscle strength, joint stability and measurement of limb length and circumferences. The next step is to conduct functional tests, active and passive, to assess the mobility of the shoulder joint and the location of dysfunction. Additional tests, such as radiological investigation, computer tomography, magnetic resonance imaging, ultrasound, computer arthrography or electromyographic examinations are performed to determine the cause of dysfunction and detailed assessment of pathological changes.
The choice of method depends on the degree of damage and the type of dysfunction. In the acute phase, conservative treatment is recommended, combining pharmacotherapy (analgesics, non-steroidal anti-inflammatory drugs, muscle relaxants, glucocorticosteroids – locally) with rehabilitation. Initially, in the period of significant pain intensity, in addition to pharmacological treatment, it is recommended to reduce the load and immobilize the joint in abduction using a properly selected orthotic stabilizing of the shoulder joint (stabilization by orthotic devices).
In further stages, in order to achieve the desired range of movement and its maintenance, as well as reduce pain, individual kinesitherapy and physical procedures are applied. Maintained limitation of mobility is an indication to use manual therapy techniques under anesthesia, increasing the range of motion in the joint. Occasionally, surgical treatment is necessary (7).
It should be emphasized that the aim of rehabilitation treatment of patients with shoulder pain syndrome in the course of rheumatic diseases is not only to achieve analgesic, anti-inflammatory and functional improvement, but, above all, versatile effect, aiming at achieving general fitness, enabling return to previous life activity (7).
Physiotherapy of shoulder pain in the course of rheumatoid arthritis
Rheumatoid arthritis is a chronic, inflammatory autoimmune disease characterized by a broad spectrum of clinical manifestations. Inflammation includes all joint structures, leading to their irreversible damage. As a consequence, there is a limitation of motion, contractures, subluxation, deformations and muscle atrophies (8).
The development of the inflammatory process in the course of RA leads to the rotator cuff tear, whose tendons intertwine with the fibers of the joint capsule. Limitations in the mobility of shoulder and acromioclavicular joints lead to disturbance of the motor pattern. The situation is aggravated by muscular dystrophies caused by immobility (escape from pain) and inflammatory reaction. Calcium deposits appear on the supraspinatus muscle, leading to its disruption in the late period of the disease, which may result in an axillary dislocation of the head of humerus.
What is more, disturbed balance of the supraspinous muscle and the long head of biceps muscle with deltoid muscle may lead to the subacromial impingement syndrome (3). Inflammation also includes structures of adjacent muscles and tendons (e.g. tendon of the biceps muscle), a rotator cuff and bursae (especially subacromial bursa). Pain in the shoulder area may also be the result of changes in the cervical spine (3).
Rehabilitation of a rheumatoid patient with shoulder pain syndrome requires comprehensive management. The early implementation of treatment is of particular importance, in the reversible phase of the development of the inflammatory process, when distortions in the musculoskeletal system are not yet fixed. The essence of the procedure is to break the vicious circle of pain, which determines the simultaneous analgesic, relaxing and relieving effects. In addition to pain management, an important goal of physiotherapeutic activities is to increase muscle strength and the range of motion in the joints and restore proper movement patterns (7).
The analgesic effect of cryotherapy has been demonstrated, especially during the period of intensified inflammatory changes in joints of the shoulder complex (9). In studies conducted by Piechura et al., an air stream at a temperature of -65°C to -75°C has been used, resulting in a reduction of pain and increase of muscle strength (10).
A valuable complement to therapy is a procedure in a cryochamber, which beneficial effects on the body is not only systemic, but also due to the lowering of the pain threshold, after a few minutes in the cryochamber a decrease in muscle tone and the severity of pain is observed (11). This allows to improve the range of movement, which is used during kinesitherapy.
The results of recent reports also indicate the analgesic and anti-inflammatory effects of laser biostimulation. Reduction of morning stiffness in patients with RA by 95% and reduction in pain by 70% has been demonstrated (12). It is also recommended local laser therapy (with synovium regeneration effect) on the periarticular area, ultrasounds and iontophoresis (with hydrocortisone, non-steroidal analgesics, lignocaine) (11).
In the field of electrotherapy, it is recommended to use transcutaneous electrical nerve stimulation (TENS) with a strong analgesic effect, lasting up to several hours after the procedure (1).
Recent observations indicate the beneficial effects of Extracorporeal Shock Wave Therapy (EWST), which not only has analgesic effects, but also improves microcirculation and stimulates the repair (regeneration) processes of tissues. It is recommended to perform the procedure several times (3-5 times) with weekly breaks (13, 14). Very good treatment results are also noted during the use of magnetotherapy, which improves microcirculation and improves nutritional processes in the diseased area (15).
In the remission period, infrared radiation and compresses are also used before the exercises, however, deeply overheating treatments, such as mud compresses, should be avoided.
In order to obtain the desired range of movement and its maintenance, relaxation, stretching, active-passive, relieving exercises are performed (very carefully, taking into account the contraindications). At the beginning of therapy it is important to implement exercises that relax the increased muscle tone. For patients with rheumatoid arthritis, first of all, exercises with low dynamics are recommended, which contribute to the increase of the range of motion in the joints of the shoulder complex, e.g. isometric exercises, in order to increase the strength of the muscles driving the work in the discussed area. If during the exercise session following ailments are observed: pain during or after exercise, long-term fatigue, increase of edema – intensity of exercise should be reduced (11).
The results of studies by Rotter et al. (16) suggest that better treatment results are achieved by improving the patient using the PNF (Proprioceptive Neuromuscular Facilitation) method than traditional kinesitherapy. In the case of unilateral, non-traumatic pain of the shoulder area, the therapy of dorsal muscle trigger points is used, and to reduce pain – manual therapy and eccentric exercises of upper limbs, which in addition to pain reduction contribute to the improvement of strength (17-19). Research carried out by Henning et al. (20) in the group of athletes performing throws from the level of the head confirms the importance of the stabilization exercises of the scapula and the trapezius muscle and serratus anterior muscle strengthening.
The importance of the Brian Mulligan’s Mobilization with Movement (MWM) technique is also emphasized, especially in shoulder joint dysfunctions in the elderly patients (21).
During the remission phase, the use of deep tissue massage, which forms the upper limb meridian, should be considered. The aim of the treatment is not only to reduce pain, by restoring the balance of tension between individual muscle groups, but also to induce local hyperemia and improve the metabolism of soft tissues around the shoulder joint. In addition, it has been proved that massage reduces the level of stress hormones, which contributes to improving patient mood (22).
An important element of the rehabilitation process in the course of RA is learning to compensate, consisting in adjusting everyday objects to the functional capabilities of the limb and orthopedic supply, which allows reducing the daily overload of the joints (7).
Surgical intervention is indicated in the case of damage that significantly impairs the function of the limb, such as the muscle tendon rupture, the presence of large size rheumatoid nodules or nerve compression (23).
It should be emphasized that the implementation of an effective and complex therapeutic program requires the simultaneous undertaking of comprehensive activities not only in the field of physiotherapy but also psychotherapeutic treatment, which condition the return of patients to professional and social activity (7).
Physiotherapy of shoulder pain in the course of osteoarthritis
Osteoarthritis (OA) is a progressive disease of the synovial joints that causes joint pain, stiffness, and limitation of function. As a result of the pain and functional impairment, it may severely affect quality of life. OA is characterized by an imbalance between anabolic and catabolic pathways, in which articular cartilage, synovium and chondrocytes are critical to the disease process. Radiographic OA changes may affect more than 80% of individuals aged 55 years and over (24). Its prevalence dramatically increases with age.
Shoulder OA is a result of progressive changes in the subchondral bone, the joint capsule, and the synovial membrane, causing pain and significant functional impairment. Current treatment recommendations include a combination of non-pharmacological and pharmacological treatments. The main objectives of using physical therapy in the treatment of shoulder pain in OA patients include: education, pain relief and improvement in function.
It is important to avoid physical activity leading to overload in the joints forming the shoulder complex. It is recommended to perform off-load exercises, which aim is to protect the joint during movement and to gradually increase the range of mobility of the shoulder girdle to the extent enabling the patient to perform daily activities. After reducing pain, therapy should include off-load exercises, but with dosed resistance (pulley and weight system). Increasing the load has a beneficial effect on improving muscle strength, while protecting the joint. Exercises that increase the strength and strength of the rotator cuff muscles as well as stretching exercises of contorted structures that surround the altered joint are also widely recommended as modern physiotherapeutic methods. Based on data review, Leininger and Kamper (19) stated that the addition of shoulder joint mobilization to the daily exercise program has no significant effect on the improvement of functions in the area of the shoulder complex. In young active patients, the short-term mobilization, obtained through the use of appropriate exercises in combination with manual therapy, is of basic importance (25). A beneficial therapeutic effect may be obtained by postisometric muscle relaxation and fascial techniques that reduce soft tissue pain (7). In order to improve muscle function, therapeutic exercises are recommended for stretching (for postural muscles) and strengthening (for phase muscles) of particular muscle groups and preventive exercises – aerobic exercises that help improve the body’s efficiency and monitor body weight (23).
According to Chinese scientists, moderately beneficial results of physiotherapeutic treatment of degenerative disease of the shoulder complex are noted during treatment with magnetic field (26, 27). In order to reduce pain and stimulate repair of damaged structures, laser therapy and medium frequency currents DD are applied (2, 28). To reduce muscle tone, TENS transdermal stimulation in combination with various forms of thermotherapy is recommended. With co-existing edema, only cryotherapy or ultrasound is recommended. In the advanced stage of degenerative disease there may be a reduction in the effectiveness of physiotherapeutic procedures, due to the degree of destruction of articular cartilage and the appearance of intra-articular pain (7, 13, 14, 24).
Physiotherapy of shoulder pain in the course of ankylosing spondylitis
The symptoms of arthritis of the shoulder complex in the course of Bechterew’s disease are pain, swelling and exudation. Pain complaints associated with inflammatory changes aggravate at night, in the mornings patients experience stiffness, which decreases in the course of physical activity (28). Treatment of ankylosing spondylitis is based on pharmacotherapy and non-pharmacological treatment, where physiotherapy and kinesitherapy play particularly important role.
The basis for the rehabilitation treatment of patients with SpA is kinesitherapy, which increases the effectiveness of therapy by nearly 50% (28). Exercises should be applied systematically and individually, depending on the severity of the changes and the clinical condition. The scope of rehabilitation should be modified depending on the severity of the changes (7).
In the early phase of the disease, the main goal of physiotherapeutic intervention is to alleviate the pain and prevent the functional disorders occurring in patients. The most important goal of physical rehabilitation during the entire duration of the disease is to maintain the optimal range of mobility of joints of the upper limb. It is confirmed by the research, which indicate that the combination of water exercises with muscle relaxation, performed three times a week, have a positive effect on the physical fitness of patients with SpA (29). The use of breathing exercises reduces the pain in the chest, and thus improve the respiratory efficiency of patients with SpA (29). Some sources indicate the effect of increased intensity of exercise on delaying the development of changes in the spine. The comprehensive therapy program should also include the education of patients regarding the correct posture, as well as exercises recommended to patients to perform systematically at home (29).
In phases of disease exacerbation, physical therapy based mainly on analgesic therapy should be used. The recommended treatments include TENS currents, interference currents, and iontophoresis using non-steroidal anti-inflammatory drugs. Of particular importance are procedures of thermotherapy, such as irradiation with a Sollux lamp, mud or fango wraps, which lead to muscle relaxation and prepare them for exercise. Similar effect is obtained by means of systemic cryotherapy (29).
In addition to the standard proceedings, balneological treatments with the use of curative waters (including: brine baths, sulphidic and hydrosulphuric bath and peloids (muds) with anti-inflammatory and analgesic effects are suggested. There are many scientific reports about the beneficial effect of radon on the course of SpA (30). Cryotherapy in combination with the ultrasound or laser treatment is recommended for the treatment of inflammatory changes of entheses (31). The remaining methods of physical treatment in patients with Bechterew’s disease do not show significant efficacy and are rarely used (30, 31).
The aim of rehabilitation process in shoulder pain syndromes in the course of rheumatic diseases is not only to achieve an analgesic effect and improve the functional status, but, above all, an individual and comprehensive therapy aimed at improving the fitness of the patients, enabling their return to daily activities. The implementation of an effective and complex therapeutic program requires the simultaneous undertaking of comprehensive activities: educational, developing an individual strategy of physiotherapeutic and psychotherapeutic treatment, the use of individually selected orthopedic supplies, as well as offering social assistance. In order to perform above procedures, a multidisciplinary team is necessary. Only the earliest possible implementation of interdisciplinary and comprehensive procedures enable patients return to full family, social and professional activity.
1. Lemański JB: Zespół bolesnego barku. Medycyna Sportowa 2006; 13: 22-23.
2. Page P: Shoulder muscle imbalance and subacromial impingement syndrome in overhead athletes. Int J Sports Phys Ther 2011; 6: 51-58.
3. Lesiak A: Zespół bolesnego barku – patofizjologia i patobiomechanika. Rehabilitacja Medyczna 2002; 6: 7-19.
4. Rechardt M, Shiri R, Karppinen J et al.: Lifestyle and metabolic factors in relation to shoulder pain and rotator cuff tendinitis: a population-based study. BMC Musculoskelet Disord 2010; 1: 1-11.
5. Lesiak A: Zespół bolesnego barku – patogeneza, obraz kliniczny i leczenie. Rehabilitacja Medyczna 2002; 6: 26-44.
6. Lisiński P, Samborski W: Czynniki warunkujące powstawanie i rozwój zespołu bolesnego barku. Nowiny Lekarskie 2007; 76: 99-102.
7. Kuryliszyn-Moskal A, Kita J, Chwieśko-Minarowska S: Rehabilitacja w chorobach reumatycznych. [W:] Zimmerman-Górska I (red.): Terapia w chorobach reumatycznych. PZWL, Warszawa 2018: 595-624.
8. Filipowicz-Sosnowska A: Reumatoidalne zapalenie stawów. [W:] Zimmerman-Górska I (red.): Terapia w chorobach reumatycznych. PZWL, Warszawa 2018: 1-42.
9. Boerner E, Brzyk R, Bienias-Jędrzejewska M: Ocena skuteczności krioterapii miejscowej w leczeniu zespołu bolesnego barku. Acta Bio-Opt Inf Med Biomed Eng 2007; 13: 54-56.
10. Piechura J, Skrzek A, Rożek K: Zastosowanie zabiegów krioterapii miejscowej w terapii osób z zespołem bolesnego barku. Fizjoterapia 2010; 18: 19-25.
11. Park Y, Chang M: Effects of rehabilitation for pain relief in patients with rheumatoid arthritis: a systematic review. J Phys Ther Sci 2016; 28: 304-308.
12. Karaca B: Effectiveness of High-Intensity Laser Therapy in Subacromial Impingement Syndrome. Photomed Laser Surg 2016; 34: 223-228.
13. Lubkowska A, Dobek A, Garczynski W: Evaluation of the functional status of patients with diagnosis of painful soulder before and after a series of 3 radial shock wave treatments. J Health Sci 2014; 4: 89-101.
14. Nawrocka-Bogusz H, Majchrzycki M, Łańczak-Trzaskowska M: Ocena skuteczności terapii ESWT w wybranych jednostkach chorobowych – opis przypadków. Nowiny Lekarskie 2010; 79: 228-234.
15. Zwolinska J, Gasior M, Sniezek E: The use of magnetic fields in treatment of patients with rheumatoid arthritis. Review of the literature. Reumatologia 2016; 54: 201-206.
16. Rotter I, Mosiejczuk H, Zugaj J: Assessment of the influence of selected kinesitherapeutic methods on the function of the shoulder girdle in patients with the shoulder impingement syndrome. J Public Health Nurs Med Rescue 2015; 1: 65-72.
17. Bron C, Dommerholt J, Stegenga B: High prevalence of shoulder girdle muscles with myofascial trigger points in patients with shoulder pain. Musculoskelet Disord 2011; 12: 139.
18. Desjardins-Charbonneau A, Roy JS, Dionne CE: The efficacy of manual therapy for rotator cuff tendinopathy: a systematic review and meta-analysis. J Orthop Sports Phys Ther 2015; 45: 330-350.
19. Leininger BD, Kamper SJ: No strong evidence that the addition of joint mobilisation to an exercise programme improves outcomes for shoulder dysfunction. Br J Sports Med 2013; 48: 1196-1197.
20. Henning L, Plummer H, Oliver GD: Comparison of scapular muscle activation during three overhead throwing exercises. Int JS Sports Phys Ther 2016; 11: 108-114.
21. Lirio Romero C, Torres Lacomba M, Castilla Montoro Y: Mobilization With Movement for Shoulder Dysfunction in Older Adults: A Pilot Trial. J Chiropr Med 2015; 14: 249-258.
22. Romanowski M, Barańska E, Klimorowski M: Masaż głęboki taśmy głębokiej przedniej kończyny górnej w zespole ,,bolesnego barku” u chorych z reumatoidalnym zapaleniem stawów. [W:] Majchrzycki M (red.): Dysfunkcje narządów ruchu. Różne oblicza fizjoterapii. Wydawnictwo Naukowe Uniwersytetu Medycznego im. Karola Marcinkowskiego w Poznaniu 2014: 83-94.
23. Małdyk P: Leczenie operacyjne chorych reumatycznych – wskazania i p/wskazania. [W:] Księżopolska-Orłowska K (red.): Fizjoterapia w reumatologii. Wydawnictwo Lekarskie PZWL, Warszawa 2013: 185-211.
24. Szczepański L: Choroba zwyrodnieniowa stawów. [W:] Zimmerman-Górska I (red.): Terapia w chorobach reumatycznych. PZWL, Warszawa 2018: 373-392.
25. Crowell MS, Tragord BS: Orthopaedic manual physical therapy for shoulder pain and impaired movement in a patient with glenohumeral joint osteoarthritis: a case report. J Orthop Sports Phys Ther 2015; 45: 453-461.
26. Li S, Yu B, Zhou D: Electromagnetic fields for treating osteoarthritis. Cochrane Database Syst Rev 2013; 12: 1-48.
27. Zimmerman-Górska I: Spondyloartropatie. [W:] Zimmerman-Górska I (red.): Terapia w chorobach reumatycznych. PZWL, Warszawa 2018: 329-348.
28. Elyan M, Khan MA: Does physical therapy still have a place in the treatment of ankylosing spondylitis? Curr Opin Rheumatol 2008; 20: 282-286.
29. Mur E: Physikalische Therapie in der Frühphase des M. Bechterew. Wiener Medizinische Wochenschrift 2008; 158: 206-208.
30. Gyurcsik Z, Bodnár N, Szekanecz Z: Treatment of ankylosing spondylitis with biologics and targeted physical therapy: positive effect on chest pain, diminished chest mobility, and respiratory function. Z Rheumatol 2013; 72: 997-1004.
31. Wylie JD, Suter T, Potter MQ: Mental Health Has a Stronger Association with Patient-Reported Shoulder Pain and Function Than Tear Size in Patients with Full-Thickness Rotator Cuff Tears. J Bone Joint Surg Am 2016; 98: 251-256.
32. Żuk B, Księżopolska-Orłowska K: Ochrona stawów w reumatoidalnym zapaleniu stawów. Czynności dnia codziennego. Reumatologia 2009; 47: 193-201.
33. Page P: Shoulder muscle imbalance and subacromial impingement syndrome in overhead athletes. Int J Sports Phys Ther 2011; 6: 51-58.
34. Virta L, Joranger P, Brox JI: Costs of shoulder pain and resource use in primary health care: a cost-of-illness study in Sweden. BMC Musculoskelet Disord 2012; 13: 1-11.
35. Brzeziński K, Jarosz MJ, Kondracki B: Ocena długoterminowej skuteczności blokady nerwu nadłopatkowego w leczeniu zespołu bolesnego barku- doniesienie wstępne. Pol Med Paliatywna 2005; 4: 101-106.