[ literature review ]

EVA BARRETT, PT, PhD1 • LOUISE LARKIN, PT, PhD2,3 • SANDRA CAULFIELD, PT, MSc4  •  NEASA DE BURCA, PT, MSc5
AVRIL FLANAGAN, PT, MSc6 • CLARE GILSENAN, PT, MSc7 • MARGARET KELLEHER, PT, MSc8
EDWINA MCCARTHY, PT, MSc6 • RIONA MURTAGH, PT, MSc9 • KAREN MCCREESH, PT, PhD2,3
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Physical Therapy Management of

Nontraumatic Shoulder Problems Lacks
High-Quality Clinical Practice Guidelines:
A Systematic Review With Quality
Assessment Using the AGREE II Checklist

N
Copyright © 2021 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

onsurgical management (eg, exercise, manual therapy, often not implemented, as many patients
medication, and/or injections) is the first-line treatment for fail to undergo adequate nonsurgical
many nontraumatic sources of shoulder pain, including rotator management before surgical treatment.29
High-quality clinical practice guidelines
cuff disorders and frozen shoulder.21 Best evidence for managing
(CPGs) can help clinicians translate best
shoulder pain—a program of progressive exercise and education—is evidence into practice.
High-quality CPGs are systemati-
U OBJECTIVES: To appraise the quality of clinical U RESULTS: We included 9 CPGs. Five CPGs fo- cally developed18 and should describe the
practice guidelines (CPGs) for physical therapy man- cused on rotator cuff disorders, 2 focused on frozen best standard of care, reducing health
Journal of Orthopaedic & Sports Physical Therapy®

agement of nontraumatic shoulder pain disorders.
U DESIGN: Systematic review of CPGs.
U LITERATURE SEARCH: Two reviewers indepen-
dently conducted a search of 7 databases and 7
gray literature sources.
U STUDY SELECTION CRITERIA: We included
systematically developed CPGs for physical
therapy management of nontraumatic musculo-
skeletal conditions of the shoulder in adults that
were available in full text in the English language.
We excluded CPGs for physical therapy manage-
ment of surgically treated shoulder pain disorders.
U DATA SYNTHESIS: Three reviewers indepen-
dently rated the quality of included CPGs using the
Appraisal of Guidelines for Research and Evaluation
II (AGREE II) instrument. Data were compiled into
tables that displayed AGREE II domain scores for
each CPG and mean item scores across the CPGs.
shoulder, and 2 covered a range of soft tissue shoul-
der diagnoses. Three CPGs were judged as high
quality (all were 5 or more years old) and 6 were
judged as low quality. The quality domains in which
CPGs were rated highest were “scope and purpose”
(all CPGs scored greater than 50% and 4 scored
greater than 80%) and “clarity of presentation” (all
CPGs scored greater than 50% and 7 scored greater
than 80%). The domains in which CPGs were rated
most poorly were “applicability” (6 CPGs scored
40% or less) and “editorial independence” (4 CPGs
scored less than 40%).
U CONCLUSION: There were no high-quality,
contemporary CPGs to guide physical therapy
management of nontraumatic shoulder pain.
J Orthop Sports Phys Ther 2021;51(2):63-71.
Epub 25 Dec 2020. doi:10.2519/jospt.2021.9397
U KEY WORDS: clinical guideline, physical
therapy, shoulder
care variation and improving outcomes.
However, the quality of CPGs can vary
considerably, especially in the rigor of
their development and reporting.2 Clini-
cal practice guidelines for musculoskel-
etal problems often fail to address how
evidence was synthesized or how the
CPG should be implemented.28 A recent
review25 of CPGs for musculoskeletal pain
published in the last 5 years identified 34
different guidelines, of which only 8 were
judged to be of high quality. Key areas of
weakness were applicability to clinical
practice and editorial independence.25
A recent systematic review9 of CPGs
addressed the medical, radiographic, chi-
ropractic, surgical, and physical therapy

School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland. 2School of Allied Health, University of Limerick, Limerick, Ireland. 3Ageing Research
1

Centre, Health Research Institute, University of Limerick, Limerick, Ireland. 4University Hospital Limerick, Croom, Ireland. 5University Hospital Galway, Galway, Ireland. 6Primary,
Community and Continuing Care, Physiotherapy Department, University Hospital Limerick, Limerick, Ireland. 7Beaumont Hospital, Dublin, Ireland. 8Midland Regional Hospital,
Mullingar, Ireland. 9Carlow Physiotherapy, Carlow, Ireland. This review was registered with PROSPERO (CRD42015027307). Dr McCreesh was supported by a Knowledge Exchange
grant from the Health Research Board of Ireland when conducting this review. The authors certify that they have no affiliations with or financial involvement in any organization or
entity with a direct financial interest in the subject matter or materials discussed in the article. Address correspondence to Dr Karen McCreesh, School of Allied Health, University
of Limerick, Limerick, V94 T9PX Ireland. E-mail: karen.mccreesh@ul.ie t Copyright ©2021 JOSPT®, Inc

journal of orthopaedic & sports physical therapy | volume 51 | number 2 | february 2021 | 63

 [ literature review
management of rotator cuff disorders,
summarizing specific recommendations
for clinical practice and return to work.9
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There was limited information about CPG
quality. A thorough evaluation of CPG
quality, which includes detailed analysis
of strengths and weaknesses of currently
available CPGs, is required to identify the
best-quality CPGs for physical therapists
across the spectrum of nontraumatic
shoulder pain, and to identify missing
information for future CPG development.
Colleagues in our physical therapy
community of practice were searching
for quality guidance on how to manage
the broad range of shoulder conditions
they encountered in primary care. Our
systematic review was prompted by the
questions our colleagues asked. We aimed
Copyright © 2021 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
to systematically identify and appraise the
quality of CPGs for physical therapy man-
agement of nontraumatic shoulder pain
disorders. We employed the methods of
a previous25 review of clinical guideline
quality in musculoskeletal pain and tai-
lored our review to the most common
shoulder pain disorders encountered in
primary care practice.
Journal of Orthopaedic & Sports Physical Therapy®
METHODS
T
his systematic review was con-
ducted in accordance with the
Preferred Reporting Items for
Systematic reviews and Meta-Analyses
(PRISMA) statement23 and was pro-
spectively registered with PROSPERO
(CRD42015027307).
Search
Two reviewers independently searched
the following databases in November
2015: the Cumulative Index to Nursing
and Allied Health Literature (CINAHL),
MEDLINE, SPORTDiscus, Cochrane Li-
brary, Embase, Web of Science, and the
Physiotherapy Evidence Database (PE-
Dro). The search was limited to articles
published in the English language from
the year 2000 onward. In September
2018, an updated search was performed,
using an identical search strategy, to cap-
64 | february 2021 | volume 51 | number 2 | journal of orthopaedic & sports physical therapy
ture the articles published from Decem-
ber 2015 to September 2018. The search
was updated, using the same methods,
covering the period from October 2018
through the end of November 2019. The
following search terms were used on each
occasion: [Shoulder OR rotator cuff OR
glenohumeral OR scapula* OR acromio*
OR sternoclav* (abstract)] AND [‘Clini-
cal guideline’ OR standard OR recom-
mendation OR ‘practice guideline’ OR
consensus OR protocol (title)].
We searched gray literature using the
following guideline repositories: the US
National Guideline Clearinghouse, the
UK National Institute for Health and
Care Excellence (NICE), the Scottish In-
tercollegiate Guidelines Network (SIGN),
the Guidelines International Network,
the Australian National Health and Med-
ical Research Council, the New Zealand
Guidelines Group, the American Physical
Therapy Association, and the UK Char-
tered Society of Physiotherapy, using the
key words “shoulder” or “glenohumeral.”
Title and abstract screening, followed by
full-text screening where relevant, was
performed by 2 independent reviewers.
Inclusion of final articles was agreed on
by consensus.
Eligibility Criteria
We included articles that were (1) clearly
identified as a CPG, (2) relevant to non-
traumatic musculoskeletal conditions
of the shoulder in adults, (3) focused
on physical therapy or other nonsurgi-
cal management of shoulder pain (eg,
medication, injections), (4) systemati-
cally developed, involving a systematic
literature search and quality appraisal
of identified literature, (5) available in
full-text format, and (6) published in the
English language. We excluded articles
that (1) addressed shoulder pain in neu-
rological or rheumatological conditions
or pediatric populations (eg, shoulder
dystocia), (2) predominantly focused on
surgical or postoperative management of
the shoulder, or (3) were consensus pa-
pers, expert narrative reviews, or clinical
commentaries.
]
Quality Appraisal
We used the Appraisal of Guidelines for
Research and Evaluation II (AGREE II)
instrument to rate the quality of CPGs,
performed on the AGREE II online tool.
This instrument was designed to assess
the methodological rigor and the trans-
parency of CPG development.6 Each CPG
in our review was appraised by 3 inde-
pendent physical therapists (academics
and clinicians who were members of the
community of practice). Training was
undertaken by all appraisers, which in-
volved a face-to-face workshop on CPG
quality and the AGREE II tool and orien-
tation to the AGREE II online platform.
Pilot testing was undertaken using 2 un-
related CPGs. An experienced physical
therapy academic was a common rater
across all guidelines.
The quality appraisal involved scoring
23 items within the following 6 domains:
scope and purpose (3 items), stakeholder
involvement (3 items), rigor of develop-
ment (8 items), clarity of presentation (3
items), applicability (4 items), and edito-
rial independence (2 items). Each item
was rated on a 7-point Likert scale rang-
ing from “strongly disagree” (1 point) to
“strongly agree” (7 points).
The CPGs were closely examined for
evidence of features that aligned with
the AGREE II assessment items. The
AGREE II tool provides very clear de-
scriptions of what is required to award a
high score for each item, which directed
our scoring.6 For example, the editorial
independence domain required the CPG
to include a specific statement about
conflict of interest to receive a positive
rating.
After the 3 raters independently sub-
mitted their online appraisal, 1 member
of the group checked the agreement
between raters. A discrepancy of more
than 2 points on any item was resolved
by group discussion and given a consen-
sus score. When the discrepancy was less
than 2 points, we applied the mean score.
Percentage scores for each domain were
then automatically calculated by the on-
line tool.
 The AGREE II instrument does not
specify minimum domain scores to differ-
entiate between high-quality and poor-
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quality CPGs. Rather, it recommends that
guideline review teams identify the key
domains relevant to their purpose when
assessing overall quality.6 In a consensus
meeting before data analysis, we identi-
fied and prioritized 3 domains by their
importance to the quality of a CPG on
shoulder pain: (1) stakeholder involve-
ment, (2) rigor of development, and (3)
applicability. To be judged as a high-qual-
ity CPG, it was agreed in advance that a
CPG must have a percentage score of at
least 50% in all 3 domains. Previous re-
search examining the quality of CPGs in
musculoskeletal pain employed a similar
quality-assessment method.25
Copyright © 2021 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Data Extraction
Data were extracted by 1 reviewer (E.B.)
based on a prespecified data-extraction
form, which was then cross-checked
thoroughly by a second reviewer (L.L.).
The variables of interest were guideline
developer, year of publication, year of
completed literature search, the compo-
Journal of Orthopaedic & Sports Physical Therapy®
sition of the CPG development team, tar-
get condition, intended target users, and
anticipated year of updated CPG, which
were summarized in table format. Scores
for the AGREE II tool were compiled in
tables as percentages per domain for each
CPG, and also by mean score per AGREE
II item across all CPGs evaluated.
The key focus of our review was the
quality of the guidelines, similar to the
methods of Lin et al.25 Therefore, we did
not synthesize the recommendations of
the guidelines.
RESULTS
T
he database search identified
1788 records and additional sources
yielded an additional 2 records (n
= 1790), of which 1007 remained after
removing duplicates. Following title/ab-
stract screening, 984 records were exclud-
ed, leaving 23 articles for full-text review.
After full-text review, 14 CPGs were ex-
journal of orthopaedic & sports physical therapy | volume 51 | number 2 | february 2021 | 65
cluded for reasons outlined in the FIGURE
and 9 were included in this review. One
eligible CPG10 was included following the
first update (September 2018), and there
were no eligible CPGs identified in the
second update (November 2019).
Characteristics of Included Clinical
Practice Guidelines
Two CPGs focused on managing frozen
shoulder,15,19 2 covered a range of shoul-
der diagnoses,1,26 and 5 focused on man-
aging rotator cuff pain (TABLE 1).3,8,10,14,17
Three CPGs were produced in the United
States,1,3,19 1 in Canada,10 1 in Australia,17
1 in New Zealand,26 2 in the UK,14,15 and 1
in the Netherlands.8 Two CPGs were pub-
lished in or after 2014.8,10
Quality Appraisal of Clinical
Practice Guidelines
Overall, 3 of 9 CPGs were rated as high
quality (TABLE 2).14,15,17 Of the high-quality
CPGs, 214,17 scored greater than 70% in
the stakeholder involvement, rigor of
development, and applicability domains
and 1 CPG15 scored below 70% in the ap-
plicability domain.
Identification
Records identified through
database searching,
n = 1788
Records after duplicates removed, n = 1007
Screening
Title/abstract screened, n = 1007
Eligibility
Full-text articles assessed for eligibility, n = 23
Included
Studies included in review, n = 9
FIGURE. PRISMA flow diagram. Abbreviation: CPG, clinical practice guideline.
Overall, the domains in which CPGs
were rated highest were “scope and
purpose” (all CPGs scored greater than
50% and 4 scored greater than 80%)
and “clarity of presentation” (all CPGs
scored greater than 50% and 7 scored
greater than 80%). The domains that
were rated poorest were “applicability” (6
CPGs scored 40% or less) and “editorial
independence” (4 CPGs scored less than
40%). While the composite scores for the
domains “stakeholder involvement” and
“rigor of development” were moderate,
3 CPGs scored less than 50% for “stake-
holder involvement” and 2 CPGs scored
less than 50% for “rigor of development.”
Summary of AGREE II Results
TABLE 3 details the mean scores for each
of the 23 AGREE II items, rated on a
1-to-7 scale (higher score indicates bet-
ter quality). The items that were well ad-
dressed by CPGs (with a mean score of
6 or greater) included a clear statement
of the intended target users (mean ± SD,
6.0 ± 2.4), an explicit link between rec-
ommendations and evidence (mean ±
SD, 6.4 ± 1.4), and the provision of clearly
Additional records
identified through other
sources, n = 2
Records excluded, n = 984
• Not a CPG, n = 789
• Not musculoskeletal shoulder
pain, n = 12
• Not conservative shoulder pain
management, n = 183
Full-text articles excluded, n = 14
• Not a CPG, n = 6
• Unable to access full text, n = 3
• Not musculoskeletal shoulder
pain, n = 3
• Surgical guideline, n = 2
 [ literature review ]

TABLE 1 Characteristics of Included CPGs
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Search Anticipated
CPG/Country Target Condition Intended Target Users Published Completed CPG Development Team Update
Kelley et al19 Adhesive capsulitis (including Orthopaedic physical 2013 2011 Physical therapists, statisticians, sports medicine physicians 2017
United States primary and secondary) therapists External review: claims review, coding, epidemiology, medi-
cal practice guidelines, orthopaedic physical therapy
residency education, orthopaedic physical therapy clinical
practice, orthopaedic surgery, rheumatology, physical
therapy academic education, sports physical therapy and
rehabilitation clinical practice, sports physical therapy
residency education
AAOS3 Adults with a diagnosis of rotator Orthopaedic surgeons, 2010 2008 Orthopaedic surgeons, research and quality support, guide- Every 5 y
United States cuff tear or rotator cuff– other qualified line development support, research analysts, librarian
related symptoms clinicians External review: orthopaedic surgeons, physical therapists,
shoulder and elbow therapists
NZGG26 Soft tissue injuries of the shoul- Primary care practitio- 2004 2003 Orthopaedic surgeons, sports physicians, nurse, radiologist, Every 5 y
New Zealand der and related disorders, ners, physical thera- emergency medicine physician, osteopath, physical
categorized as rotator cuff pists, osteopaths, therapist, GP
Copyright © 2021 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

disorders, frozen shoulder,
glenohumeral instabilities,
and acromioclavicular and
sternoclavicular injuries
Albright et al1 Shoulder pain, defined as
United States nonspecific shoulder pain,
calcific tendinitis, bursitis, and
capsulitis
Hanchard et al14 Shoulder impingement
Journal of Orthopaedic & Sports Physical Therapy®
consumers External review: consumer groups, primary health care
organizations, expert clinicians, professional colleges
Physical therapists, 2001 2000 Orthopaedic surgeon, physician, rheumatologist, physical Not stated
physicians, therapist, GP, epidemiologist, biostatistician, kinesiologist,
orthopaedic surgeon, medical sociologist, librarian
rheumatologists, External review: physical therapists, orthopaedic specialists,
GPs, neurologists physicians, GPs, rheumatologists
Physical therapists, 2004 2003 Academic and clinical physical therapists with expertise in 2008

United King- syndrome GPs, orthopaedic the shoulder

dom surgeons, rheuma- External review: physical therapists, GP, rheumatologist,
tologists orthopaedic surgeon
Hanchard et al15 Contracted (frozen) shoulder in Physical therapists, 2011 2008 Physical therapists with expertise in the shoulder and a 2015
United King- people aged 18 y and older health care providers medical specialist
dom or commissioners, Delphi panel members: people with frozen shoulder, mem-
GPs, orthopaedic bers of the public, specialist physical therapists, shoulder
surgeons, radiolo- surgeons
gists, rheumatol-
ogists
Hopman et al17 Degenerative rotator cuff GPs, medical 2013 2012 Physical therapists, rheumatologist, occupational therapist, Every 5 y
Australia syndrome in adults, occurring specialists, health physicians, GPs, orthopaedic surgeon, intended consum-
following the performance of practitioners, ers
work tasks workplace-based External review: GP, physician, rehabilitation specialist,
employees, workers’ physical therapists, rheumatologist, radiologist, members
compensation insur- of the public
ers, ergonomists
Diercks et al8 Subacromial pain syndrome Health care providers 2014 Not stated Physical therapists, orthopaedists, GPs, rehabilitation Not stated
the Netherlands (eg, bursitis, supraspinatus specialists, occupational specialists, radiologists
tendinopathy, partial tear External review: not stated
of the rotator cuff, biceps
tendinitis)
Eubank et al10 Rotator cuff pathology (acute and Health care providers 2016 2015 Clinicians, sport scientists, orthopaedic surgeon, athletic Not stated
Canada chronic) therapists, physical therapists, sport medicine physicians,
and orthopaedic surgeons
External review: not stated
Abbreviations: AAOS, American Academy of Orthopaedic Surgeons; CPG, clinical practice guideline; GP, general practitioner; NZGG, New Zealand Guidelines Group.

66 | february 2021 | volume 51 | number 2 | journal of orthopaedic & sports physical therapy

 identifiable recommendations (mean ± shoulder pain were of high quality. Our ers have taken steps to facilitate imple-
SD, 6.3 ± 1.1) that were specific (mean ± results align with a recent broader re- mentation in clinical practice, potentially
SD, 6.2 ± 12.5). view of CPGs for musculoskeletal pain,25 increasing the readiness of clinicians to
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The 3 lowest item scores were all in
the “applicability” domain, with severe
shortcomings in consideration of barriers
and facilitators to guideline implemen-
tation (mean ± SD, 3.3 ± 8.8), potential
resource implications (mean ± SD, 2.8 ±
2.3), and provision of criteria for moni-
toring implementation (mean ± SD, 2.6
± 2.0). Consideration of the views of the
public and patients in CPG development
was another key weakness of the included
CPGs (mean ± SD, 3.5 ± 2.1).
DISCUSSION
Summary
Copyright © 2021 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
which found that just 8 of 34 identified
CPGs were of high quality, and a review
of CPGs for rotator cuff problems,9 where
one third of CPGs were of high quality.8,17
Key Domains for Quality Clinical
Practice Guidelines
We considered stakeholder involvement,
rigor of development, and applicability
to be the most relevant domains to as-
sessing the quality of CPGs for managing
shoulder pain. The rigor of development
domain has the greatest influence on
CPGs, and the applicability domain is the
second most important.16 A CPG with a
high rigor of development is at low risk
adopt the recommendations.12 Our team
identified stakeholder involvement as our
third most important domain, given that
effective management of shoulder pain
requires a multidisciplinary approach.
Rigor of Development
Just 2 CPGs failed to meet the AGREE II
rigor of development cutoff score (mean,
71%), suggesting that the majority of
the guidelines undertook a systematic
approach to searching for evidence and
formulating recommendations. For the
CPGs scoring under 50%, lack of clarity
on the links between the evidence and the
final recommendations was a key weak-

O
nly one third of the CPGs of bias and has a robust, evidence-based ness, along with a lack of external review
for physical therapy management approach to development.2 An applicable and a plan for guideline updating. While
of nontraumatic musculoskeletal CPG suggests that the guideline develop- 7 of the 9 guidelines in our review included

TABLE 2 CPG Domain Scores and Overall Quality Assessment a

Domain
Journal of Orthopaedic & Sports Physical Therapy®

Scope and Stakeholder Rigor of Clarity of Editorial

CPG/Condition Purpose Involvement Development Presentation Applicability Independence Overall Score Quality
Kelley et al19 56 76 67 96 40 6 56 Low
Adhesive capsulitis
AAOS3 83 46 83 94 14 92 83 Low
Rotator cuff
NZGG26 69 70 49 89 25 50 56 Low
Soft tissue injuries
Albright et al1 63 56 58 59 6 19 50 Low
Shoulder pain
Hanchard et al14 98 87 97 98 71 83 89 High
Shoulder impingement
syndrome
Hanchard et al15 96 87 83 87 57 78 89 High
Frozen shoulder
Hopman et al17 94 93 92 98 72 100 94 High
Rotator cuff
Diercks et al8 74 31 40 93 7 8 44 Low
Subacromial pain
syndrome
Eubank et al10 76 37 57 69 29 33 56 Low
Rotator cuff
Mean ± SD domain score 79.1 ± 16.0 68.3 ± 30.9 71.1 ± 31.0 89.3 ± 40.6 38.8 ± 23.8 57.3 ± 37.3 70.1 ± 32.7 ...
Abbreviations: AAOS, American Academy of Orthopaedic Surgeons; CPG, clinical practice guideline; NZGG, New Zealand Guidelines Group.
a
Values are percent.

journal of orthopaedic & sports physical therapy | volume 51 | number 2 | february 2021 | 67

 [ literature review
reference to a procedure for updating
the CPG, we could not identify any CPGs
where such work had been undertaken.
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This gap in CPG updating is a substantial
problem. The 3 high-quality CPGs were
out of date by the time of our review, with
no update currently under way.
We were not able to identify a specific
reason but speculate that lack of funding
for CPG development in musculoskel-
etal physical therapy contributes to the
production of CPGs that do not have a
sustainable quality process for updating.
Developing a CPG is expensive and la-
bor intensive. External funding is highly
valuable in supporting this process, as
long as potential conflicts of interest, for
example, where health care funders or
commercial interests are involved, are
Copyright © 2021 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
cautiously managed.7
Stakeholder Involvement
Three CPGs fell below the cutoff for
stakeholder involvement (mean, 68%).
There is a wide range of health profes-
sionals involved in the care of people with
shoulder pain, all of whom should be in-
cluded in guideline development teams.
Journal of Orthopaedic & Sports Physical Therapy®
The other key stakeholders include pa-
tients as well as health care funders and
other members of the public. Patient
involvement has a positive impact on
guideline development,4 and the Guide-
lines International Network provides an
extensive toolkit to support guideline
development teams in including patient
and public involvement (https://g-i-n.
net/working-groups/gin-public/toolkit).
Applicability
The applicability domain was the lowest
scoring across all domains (mean, 39%).
Only 3 CPGs met the high-quality cutoff
score of greater than 50%, and therefore
this domain provided a key differentiation
between high- and low-quality guidelines
in our review. Reasons for poor applica-
bility scores included a lack of attention
to barriers and facilitators to applying
the recommendations, and the absence
of tools for CPG implementation (eg, de-
cision aids, flow charts, or digital tools).
68 | february 2021 | volume 51 | number 2 | journal of orthopaedic & sports physical therapy
]
Guideline implementation tools have a useful implementation tools for clinicians
positive influence on clinician behaviors are likely to be those that can be integrated
and on patient outcomes.11 However, a re- directly in clinical care, such as point-of-
cent review22 of implementation tools in care checklists integrated into medical
CPGs found that only 2 of 3 CPGs pub- records, whereas for patients, self-man-
lished between 2010 and 2017 included agement resources and decision-making
any type of implementation tool. When tools should be foremost.22
included, implementation tools were es- Digital technologies offer opportuni-
sentially just summaries of the CPG rec- ties to assist with guideline implementa-
ommendations for clinicians.22 The most tion. We recommend that future CPGs
Overall Domain Scores and Item
TABLE 3
Scores From the AGREE II Tool
Domain/Item Scorea
Domain 1: scope and purpose 79.1 ± 16.0
1. The overall objective(s) of the guideline is (are) specifically described 5.9 ± 11.2
2. The health question(s) covered by the guideline is (are) specifically described 5.6 ± 1.3
3. The population (patients, public, etc) to whom the guideline is meant to apply is specifically 5.5 ± 1.6
described
Domain 2: stakeholder involvement 68.3 ± 30.9
4. The guideline development group includes individuals from all relevant professional groups 5.5 ± 10.3
5. The views and preferences of the target population (patients, public, etc) have been sought 3.5 ± 2.1
6. The target users of the guideline are clearly defined 6.0 ± 2.4
Domain 3: rigor of development 71.1 ± 31.0
7. Systematic methods were used to search for evidence 5.6 ± 10.5
8. The criteria for selecting the evidence are clearly described 5.0 ± 1.7
9. The strengths and limitations of the body of evidence are clearly described 4.6 ± 1.8
10. The methods for formulating the recommendations are clearly described 5.8 ± 1.5
11. The health benefits, side effects, and risks have been considered in formulating the recom- 4.8 ± 1.3
mendations
12. There is an explicit link between the recommendations and the supporting evidence 6.4 ± 1.4
13. The guideline has been externally reviewed by experts prior to its publication 5.1 ± 1.5
14. A procedure for updating the guideline is provided 4.3 ± 2.0
Domain 4: clarity of presentation 89.3 ± 40.6
15. The recommendations are specific and unambiguous 6.2 ± 12.5
16. The different options for management of the condition or health issue are clearly presented 5.8 ± 1.0
17. Key recommendations are easily identifiable 6.3 ± 1.1
Domain 5: applicability 38.8 ± 23.8
18. The guideline describes facilitators and barriers to its application 3.3 ± 8.8
19. The guideline provides advice and/or tools on how the recommendations can be put into 4.4 ± 2.2
practice
20. The potential resource implications of applying the recommendations have been considered 2.8 ± 2.3
21. The guideline presents monitoring and/or auditing criteria 2.6 ± 2.0
Domain 6: editorial independence 57.3 ± 37.3
22. The views of the funding body have not influenced the content of the guideline 4.3 ± 11.9
23. Competing interests of guideline development group members have been recorded and 4.6 ± 2.4
addressed
Overall score 70.1 ± 32.7
Abbreviation: AGREE, Appraisal of Guidelines for Research and Evaluation.
a
Values for domain and overall scores are mean ± SD percent. Items were answered on a 1-to-7 Likert
scale (1, strongly disagree; 7, strongly agree).
 exploit these technologies to enhance ap-
plicability. A shortage of tools for moni-
toring guideline implementation was
Downloaded from www.jospt.org at Asociación de Kinesiología del Deporte (AKD) on April 27, 2021. For personal use only. No other uses without permission.
also apparent in our review and should
be a relatively simple element to build
into CPG development. One shoulder
impingement guideline14 provided an ex-
ample of a simple audit tool in the form
of a checklist to evaluate adherence to
the guideline when reviewing physical
therapy clinical records.
Editorial Independence
The low scores on editorial indepen-
dence are similar to those found in other
reviews of CPG quality. Developers of-
ten fail to provide explicit information
about the influence from funding bod-
ies on the final recommendations, and
Copyright © 2021 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
about the competing interests of CPG
authors. Conflicts of interest affect CPG
quality.27 Guideline users must be con-
fident that the guideline development
process is independent from any indi-
vidual or body with potential conflicts
of interest.27
Clinical Implications
Journal of Orthopaedic & Sports Physical Therapy®
We aimed to assess the quality of CPGs
for physical therapy management of the
most common type of shoulder pain en-
countered in primary care practice. Five
CPGs focused on rotator cuff disorders,
2 were specific to frozen shoulder, and 2
covered a range of soft tissue shoulder
diagnoses. Given that shoulder pain is
the third most common musculoskel-
etal condition presenting in primary
care, with rotator cuff disorders making
up the majority of presentations, there
is a clear need for high-quality CPGs
to help guide practice for both general
practitioners and physical therapists
who encounter these patients on a daily
basis. It is concerning that no high-
quality CPG for nontraumatic shoulder
pain has been published since 2013, and
that there has been no update of existing
high-quality guidelines. On the basis of
these shortcomings, there is no CPG that
can be recommended for current use by
clinicians.5
journal of orthopaedic & sports physical therapy | volume 51 | number 2 | february 2021 | 69
The central focus on shoulder pain
CPG quality and how it can be improved
distinguishes our review from a recent re-
view9 focused on synthesizing published
recommendations from CPGs related to
rotator cuff disorders. Two CPGs were
common to both reviews. The reasons be-
hind the dearth of high-quality CPGs in
the area of physical therapy management
of shoulder pain are unclear, but it is like-
ly that funding and expertise in develop-
ing CPGs are relevant challenges. There
is a wide variety of best-practice guidance
on developing CPGs from organizations
such as the World Health Organization,
NICE, and SIGN, with which any future
shoulder pain CPGs should align. Kredo
et al20 describe a variety of high-quality
resources designed to support guideline
updating, dissemination, implementa-
tion, or adaptation to different contexts,
which should facilitate the production
of user-friendly CPGs that can positively
impact clinical practice and patient out-
comes. Those considering developing a
new shoulder pain guideline can learn
from our findings by doing the following:
• Securing sustainable funding to sup-
port high-quality CPG development
• Developing a long-term strategy for
updating the CPG
• Ensuring and declaring editorial
independence
• Including all end users, in particular
patient contributors, throughout the
process
• Developing clinician-friendly dis-
semination tools to promote uptake of
recommendations
In the meantime, while physical ther-
apists are left without high-quality CPGs
on nontraumatic shoulder pain to guide
clinical practice, the summary of recom-
mendations from a broad range of CPGs
for musculoskeletal pain24 may be of
value. Core recommendations are to (1)
screen for red flags and psychosocial fac-
tors, (2) limit use of imaging, (3) provide
patient education, (4) offer evidence-in-
formed nonsurgical care prior to consid-
ering surgery, and (5) evaluate patient
outcomes.
We encourage clinicians to be mindful
of the quality and timeliness of the CPGs
that they encounter in everyday practice.
While the AGREE II tool provides a robust
method of evaluating CPG quality, it is un-
wieldy for clinicians because it requires
multiple raters for its 23 items. A more re-
cently published checklist, the Internation-
al Centre for Allied Health Evidence CPG
quality checklist, is strongly recommended
for the individual clinician who wishes to
evaluate CPG quality. Its 14 items can be
rated by a single rater.13
Strengths and Limitations
Strengths of this review are its broad
search, which included multiple data-
bases and guideline registries; its use of
multiple raters to assess guideline quality;
and its use of the AGREE II tool and plat-
form to administer the quality-assessment
process. Limitations were the inclusion
of only English-language CPGs and the
subjective nature of the AGREE II tool in
evaluating guideline quality. The AGREE
II tool, while the recognized benchmark
for guideline quality, reflects an emphasis
on elements of guideline quality and does
not evaluate the content of the CPG rec-
ommendations. While reviewers received
training in the use of the AGREE II tool,
ratings remain subjective, as does the
consensus-based approach used to choose
quality domains of importance.
CONCLUSION
W
e identified 9 CPGs for the
nonsurgical management of
nontraumatic shoulder pain.
Three CPGs were of high quality. No
high-quality guideline has been pub-
lished since 2013. There is a clear need
for contemporary, high-quality CPGs for
the management of nontraumatic shoul-
der pain and for using the AGREE II
tool and other high-quality frameworks
to develop guidelines systematically, in-
dependent of conflicts of interest, so that
they are representative of the views of all
stakeholders and provide tools to support
clinicians in practice. t
 [ literature review ]
KEY POINTS Care. 2010;19:e58. https://doi.org/10.1136/ Shoulder Impingement Syndrome. London, UK:
FINDINGS: This systematic review of 9 clin- qshc.2010.042077 Chartered Society of Physiotherapy; 2004.
ical practice guidelines (CPGs) identified 3. American Academy of Orthopaedic Surgeons. 15. Hanchard N, Goodchild L, Thompson J, et al.
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no high-quality, contemporary guideline
to guide the physical therapy manage-
ment of musculoskeletal shoulder pain.
IMPLICATIONS: While a gap exists in specific
CPGs for shoulder pain, broad guidance
on managing musculoskeletal pain can
be applied, such as limiting the use of im-
aging, providing education, and ensuring
that optimal nonsurgical care is delivered
before surgical options are offered. Fu-
ture CPG development groups should en-
sure that best practices in developing and
updating the CPG are followed, through
use of quality-assessment frameworks.
CAUTION: This review included only Eng-
lish-language CPGs and focused on CPG
Copyright © 2021 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Optimizing the Management of Rotator Cuff
Problems: Guideline and Evidence Report.
Rosemont, IL: American Academy of Orthopaedic
Surgeons; 2010.
4. Armstrong MJ, Mullins CD, Gronseth GS,
Gagliardi AR. Impact of patient involvement on
clinical practice guideline development: a parallel
group study. Implement Sci. 2018;13:55. https://
doi.org/10.1186/s13012-018-0745-6
5. Boudoulas KD, Leier CV, Geleris P, Boudoulas H.
The shortcomings of clinical practice guidelines.
Cardiology. 2015;130:187-200. https://doi.
org/10.1159/000371572
6. Brouwers MC, Kho ME, Browman GP, et al.
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https://doi.org/10.1371/journal.pone.0174831
17. Hopman K, Krahe L, Lukersmith S, McColl AR,
Vine K. Clinical Practice Guidelines for the
Management of Rotator Cuff Syndrome in the
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18. Johnston A, Kelly SE, Hsieh SC, Skidmore
B, Wells GA. Systematic reviews of clinical
practice guidelines: a methodological guide.
J Clin Epidemiol. 2019;108:64-76. https://doi.

that produce clinical practice guidelines and the org/10.1016/j.jclinepi.2018.11.030

quality rather than content.
STUDY DETAILS
AUTHOR CONTRIBUTIONS: Dr Barrett was
involved in data collection, data analy-
sis, data interpretation, and drafting the
manuscript. Drs Larkin and McCreesh
were involved in concept development,
project planning, data collection, data
Journal of Orthopaedic & Sports Physical Therapy®
biomedical industry: a cross-sectional study.
PLoS Med. 2016;13:e1002029. https://doi.
org/10.1371/journal.pmed.1002029
8. Diercks R, Bron C, Dorrestijn O, et al. Guideline
for diagnosis and treatment of subacromial pain
syndrome: a multidisciplinary review by the
Dutch Orthopaedic Association. Acta Orthop.
2014;85:314-322. https://doi.org/10.3109/174536
74.2014.920991
9. Doiron-Cadrin P, Lafrance S, Saulnier M, et al.
19. Kelley MJ, Shaffer MA, Kuhn JE, et al. Shoulder
pain and mobility deficits: adhesive capsulitis.
J Orthop Sports Phys Ther. 2013;43:A1-A31.
https://doi.org/10.2519/jospt.2013.0302
20. Kredo T, Bernhardsson S, Machingaidze S, et al.
Guide to clinical practice guidelines: the current
state of play. Int J Qual Health Care. 2016;28:122-
128. https://doi.org/10.1093/intqhc/mzv115
21. Lewis J. Rotator cuff related shoulder pain: as-
sessment, management and uncertainties. Man

Shoulder rotator cuff disorders: a systematic Ther. 2016;23:57-68. https://doi.org/10.1016/j.

analysis, and drafting the manuscript.
Sandra Caulfield, Neasa de Burca, Avril
Flanagan, Clare Gilsenan, Margaret
Kelleher, Edwina McCarthy, and Riona
Murtagh were involved in project plan-
ning, data collection, and data analysis.
All authors critically revised the manu-
script and approved the final version.
DATA SHARING: All data relevant to the
study are included in the article.
PATIENT AND PUBLIC INVOLVEMENT: There
were no patients involved in this review.
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