Home Medicine Pain trajectories and exercise-induced pain during 16 weeks of high-load or low-load shoulder exercise in patients with hypermobile shoulders: A secondary analysis of a randomized controlled trial
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Pain trajectories and exercise-induced pain during 16 weeks of high-load or low-load shoulder exercise in patients with hypermobile shoulders: A secondary analysis of a randomized controlled trial

  • Behnam Liaghat EMAIL logo , Birgit Juul-Kristensen , Frederik Holsteen Christensen , Simon Enghuus Nissen , Søren T. Skou , Karen Søgaard , Jens Søndergaard and Jonas Bloch Thorlund
Published/Copyright: June 2, 2025
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Scandinavian Journal of Pain
From the journal Scandinavian Journal of Pain Volume 25 Issue 1

Abstract

Objectives

To compare pain trajectories and acute exercise-induced pain over a 16-week period in patients with hypermobility spectrum disorder (HSD) undergoing high-load (HEAVY) or low-load (LIGHT) shoulder exercise.

Methods

In this secondary analysis using data from a randomized controlled trial, we included men and women aged 18–65 with HSD and shoulder complaints >3 months. Participants were randomly allocated (1:1 ratio) to 16 weeks of HEAVY or LIGHT shoulder exercise program, performed three times weekly. The HEAVY program consisted of progressive strengthening and full range of motion exercises, while the LIGHT program included low-load exercises performed in neutral to mid-range. Pain was assessed using the numeric rating scale (NRS) before and after each exercise session. Pain trajectories were assessed using pre-exercise pain scores at the final session each week. Exercise-induced pain was evaluated as the change in pain before and after exercise, using the mean of the three sessions each week. Both outcomes were analyzed using linear mixed models.

Results

Data from 64 out of 100 patients (HEAVY 34, LIGHT 30) were analyzed (80% women, mean age 39.6, mean Beighton score of 5.8). Shoulder pain was reduced by 0.89 NRS in HEAVY (95% CI 0.4 to 1.4) and 0.33 NRS (95% CI −0.25 to 0.91) in LIGHT. The between-group difference in change in pain from baseline to week 16 was 0.56 (95% CI −0.20 to 1.33, p = 0.149). There was no between-group difference in pain trajectories (group × time interaction, p = 0.321). The mean exercise-induced pain over time was similar in both groups (group × time interaction, p = 0.614), with pain below 0.5 NRS throughout the 16 weeks.

Conclusions

Pain trajectories over 16 weeks were similar in patients with HSD and persistent shoulder complaints performing high-load or low-load shoulder exercises. There was minor to no exercise-induced pain during high-load strengthening exercise, challenging previous beliefs.

Keywords: joint instability; exercise therapy; shoulder; pain management

1 Introduction

Hypermobile spectrum disorder (HSD) is a group of conditions characterized by generalized joint hypermobility (GJH) and one or more secondary symptomatic musculoskeletal manifestations [1]. While HSD shares similarities with hypermobile Ehlers–Danlos syndrome (hEDS) in terms of symptoms, HSD does not have significant systemic manifestations [1]. In all, 80–85% of the people with GJH experience shoulder problems such as instability, functional impairments, deficits in strength, and persistent shoulder pain [2,3,4,5,6]. Shoulder complaints can have significant impact on an individual’s work capacity and socio-financial situation, severely affecting the ability to live a normal life [7].

Currently, there is no established standard treatment for patients with hEDS or HSD and shoulder complaints [8]. Studies comparing different exercise protocols in the population have found similar improvements in shoulder function [9,10], with some short-term advantages to increase shoulder function using high-load strengthening and potential long-term emotional benefits [11]. These trials primarily focus on end-of-treatment effects and mean changes from baseline to follow-up, with little focus on pain fluctuations during the treatment period and pain during exercise.

Previous studies on painful joints in the lower limbs have shown that joint pain can fluctuate during an exercise program, and patients with joint pain may avoid engaging in such exercises due to the fluctuations [12,13]. Patients may also experience exercise-induced pain, which can affect their self-efficacy and discourage them from exercising. It is plausible that this could also apply to shoulder pain [14,15]. Understanding pain trajectories and exercise-induced/related pain is important for educating patients and positively influencing their willingness to engage in exercise therapy, improving self-efficacy and compliance while reducing the risk of unfavorable coping strategies like fear avoidance [16,17]. Therefore, we aimed to investigate pain trajectories and exercise-induced pain during a 16-week period of high-load compared with low-load shoulder exercises in patients with HSD and persistent shoulder complaints.

2 Methods

2.1 Study design

This is a secondary analysis using data from a randomized controlled trial (RCT) (ClinicalTrials.gov NCT03869307, Registered on March 11, 2019) comparing a high-load strengthening exercise program with a low-load exercise program in patients with HSD and shoulder complaints [10]. The study was approved by The Regional Committees on Health Research Ethics of Southern Denmark (May 31, 2017, S-20170066) and followed the Declaration of Helsinki [18]. This study adhered to the Strengthening the Reporting of OBservational studies in Epidemiology guidelines [19].

2.2 Participants

Participants provided informed consent before participating in the trial. Men and women aged 18–65 years meeting the following inclusion criteria were included from Danish primary care: (1) generalized HSD (G-HSD) defined as a Beighton score ≥5/9 (higher is more hypermobile joints) for women up to 50 years of age, and ≥4/9 for women >50 years and all men [10], and (2) musculoskeletal pain in at least one shoulder for minimum 3 months and/or recurrent joint instability or dislocations [10]. For historical HSD, we accepted a 1-point lower Beighton score if the 5-part hypermobility questionnaire was positive with a cut-point of 2.

Exclusion criteria were referred pain from the cervical spine, diagnosis of rheumatic-, connective tissue-, and/or neurological diseases, pregnancy, childbirth within a year or planning to get pregnant during the study period (due to increased levels of relaxin), shoulder surgery within the past year, steroid injection in the affected shoulder in the past 3 months, and inability to speak or understand Danish, to comply with the study protocol or to provide informed consent.

2.3 Randomization

Participants were randomized in the original study using a 1:1 allocation ratio without the option to cross over. The allocation sequence was computer generated with balanced block randomization, set up by an external data manager. Everyone was blinded to block sizes and unaware of the following assignment in the allocation sequence to ensure allocation concealment [10]. The original group allocation was kept for this secondary analysis.

2.4 Intervention

All participants received education in scapular correction and joint protection adapted from the Danish Rheumatism Association [20]. For patients in both groups, pain below a threshold was accepted during exercise, and participants were monitored and guided during the 16-week exercise period in accordance with their self-reported pain. Pain from 0 to 2 was considered safe, 3–5 was acceptable, and pain above 5 was considered high risk, and exercise volume or level was reduced to fit the individual participant. If pain was above 5 at baseline, it was considered safe, but no further increase was allowed to occur. If any participants in either group experienced pain or symptoms that exceeded the acceptable threshold, certain modifications were implemented. These modifications included reducing the demands and number of exercise sessions, adjusting the load, range of motion, sets and repetitions, and excluding exercises that provoked pain. The complete descriptions of both interventions can be found in the published trial protocol [8].

2.4.1 High-load shoulder strengthening exercise (HEAVY, intervention)

Participants randomized to HEAVY performed 16 weeks of progressive strengthening full range of motion shoulder-specific exercises including side-lying external rotation (ER) in neutral, prone horizontal abduction, prone ER at 90° of shoulder abduction, supine scapular protraction, and seated shoulder elevation in the scapular plane. Twice per week, participants were individually supervised at a physiotherapy clinic (60 min for the first session, 30 min for the remaining sessions), and once per week, the participants performed an unsupervised session. The load was individualized for all participants. Starting at 50% 10RM (3 sets of 10 repetitions) at week 1, progressing through 70 and 90% 10RM in weeks 2 and 3, respectively, 10RM in weeks 4–9, and 8RM (4 sets of 8 repetitions) in weeks 10–15, concluding with 70% 8RM in week 16 for better recovery before the final testing. The exercise load was continuously adjusted to fit the capabilities of the participant; the load would increase when the participant could complete more than the predefined repetitions for all sets with acceptable pain (≤5/10 on the numerical pain scale [NRS]) and maintain correct form [8,10].

2.4.2 Standard care (LIGHT, comparator)

Participants randomized to LIGHT performed 16 weeks of low-load exercises performed at home, starting with isometric exercises and progressing to dynamic exercises. The participants were instructed to do three sessions per week. Exercises were introduced during an in-person consultation before initiating the program. Exercises were unsupervised except at the program initiation, and at weeks 5 and 11 where participants had 30 min of individual supervision to initiate a different phase of their exercise program. Week 1–4 focused on scapula setting 1 × 10 repetitions. Week 5–10 focused on static positions with four exercises including shoulder abduction, shoulder internal rotation and external rotation with 90° flexion at the elbow joint and standing weight-bearing in the shoulders against a table performed 2 × 10 repetitions. Week 11–13 focused on static contractions and dynamic movements performed 1 × 10 repetitions each. Week 14–16 focused on dynamic movement with 2 × 10 repetitions. Participants should adjust their exercise level to complete 10 repetitions without feeling fatigued [8,10].

2.5 Outcomes

2.5.1 Baseline characteristics

Baseline characteristics included age, sex, weight, height, symptom duration, self-reported previous shoulder dislocation shoulder pain (worst, least, and average) for the past week using an 11-point NRS ranging from 0 (no pain) to 10 (worst pain imaginable), [21] and shoulder function using the Western Ontario Shoulder Instability Index (range 0–2,100 points with 0 indicating maximal function). Information on pain medication use (i.e., paracetamol or NSAIDs) before exercise was collected.

2.5.2 Pain assessment

Various pain measurements were collected in the RCT. For this trial, we used data from exercise logbooks where participants reported their current shoulder pain intensity before and after each exercise session. Pain trajectories were assessed using pre-exercise pain scores at the final session each week. Exercise-induced pain was evaluated as the change in pain before and after exercise, using the mean of the three sessions each week.

2.6 Statistical methods

Baseline characteristics were summarized as mean (SD) for continuous data and number and proportions (%) for categorical data. Pain trajectories – changes in pain scores over time – were analyzed using a linear mixed model. The outcome variable was the pre-exercise pain level, measured at the last session of each week. Patient ID was included as a random effect, while group (HEAVY vs LIGHT), time (weeks 1–16), and the interaction term “group × time” were included as fixed effects. Model assumptions, including normal distribution and homoscedasticity (normality of residuals and distribution of standardized residuals), were checked. For exercise-induced pain, we used the same mixed model approach to compare between groups over time. In this model, the dependent variable was the change in pain scores before and after each exercise session using the mean of the three sessions each week; patient ID was included as a random effect, while group (HEAVY vs LIGHT), time (weeks 1–16), and the interaction term group × time were included as fixed effects. In a sensitivity analysis, we analyzed data from all 48 individual exercise sessions. In a second sensitivity analysis, we excluded sessions in which patients had taken pain medication before exercise. An alpha level of 0.05 (two-sided) was considered statistically significant. All statistical analyses were performed using Stata V.18.

3 Results

A total of 100 participants were included in the RCT [10]. Logbooks from 36 participants were lost to follow up (16 HEAVY, 20 LIGHT), resulting in 64 participants providing data for this study (34 in the HEAVY and 30 in the LIGHT groups). Participants were mainly women (77 and 83% in HEAVY and LIGHT, respectively), with a mean age of 39.6 and a mean Beighton score of 5.8 (Table 1). Participants in the HEAVY group exercised with higher loads, reaching a peak mean of 43% above their baseline 10RM over the 16-week period (Figure S1, Supplementary material).

Table 1

Baseline characteristics for the intervention (HEAVY) and comparator (LIGHT) in patients with HSD and shoulder complaints

Variables HEAVY (n = 34) LIGHT (n = 30)
Sex (female), n (%) 26 (77%) 25 (83%)
Age (years) 40.7 (13.2) 38.5 (12.4)
Weight (kg) 74.7 (14.9) 80.6 (16.0)
Height (cm) 171.9 (8.7) 172.5 (9.2)
Beighton score (scale 0–9) 5.6 (1.4) 5.9 (1.9)
Symptom duration (months) 77.5 (72) 70.5 (85)
Previous shoulder dislocation (yes), n (%) 8 (24%) 2 (7%)
WOSI total (scale 0–2,100) 1,011 (360) 1,043 (380)
Shoulder pain past week (scale 0–10)
 Lowest 2.1 (1.8), 2.2 (2.1)
 Average 3.4 (2.0) 3.7 (2.2)
 Highest 5.4 (2.2) 6.1 (2.6)
Pain medication before exercise
 (≥1 session), n (%) 13 (38%) 14 (47%)
 Total number of sessions, n (%) 30 of 1,231 (2%) 90 of 1,065 (8%)

Continuous data are presented as mean (SD), and categorical variables are presented as proportion n (%). HSD, Hypermobility Spectrum Disorder; WOSI, Western Ontario Shoulder Instability Index.

For the pain trajectory analysis, a decrease in shoulder pain over 16 weeks was observed in both groups (Figure 1). Shoulder pain was reduced by 0.89 NRS in HEAVY (95% CI 0.4 to 1.4) from 1.47 at baseline (95% CI 0.96 to 1.98) to 0.58 (95% CI 0.02 to 1.14) at 16-week follow-up. In LIGHT, shoulder pain was reduced by 0.33 NRS (95% CI −0.25 to 0.91) from 1.75 at baseline (95% CI 1.20 to 2.29) to 1.42 (95% CI 0.77 to 2.07) at 16-week follow-up. The between-group difference in change in pain from baseline to week 16 was 0.56 (95% CI −0.20 to 1.33, p = 0.149). There was no significant difference in the pain trajectories between the HEAVY and LIGHT groups (group × time, p = 0.321).

Figure 1 Pre-exercise pain level during the 16-week exercise period expressed as the estimated marginal pain ratings pre-session for the last exercise session of the week. Error bars show 95% confidence interval. n = number of participants with data for the given week. HEAVY: Intervention group receiving high-load shoulder exercise. LIGHT: Comparison group receiving low-load shoulder exercise.
Figure 1

Pre-exercise pain level during the 16-week exercise period expressed as the estimated marginal pain ratings pre-session for the last exercise session of the week. Error bars show 95% confidence interval. n = number of participants with data for the given week. HEAVY: Intervention group receiving high-load shoulder exercise. LIGHT: Comparison group receiving low-load shoulder exercise.

The mean exercise-induced pain over time was similar between HEAVY and LIGHT (group × time, p = 0.138) (Figure 2). Both groups experienced low levels of exercise-induced pain, with average exercise-induced pain ratings remaining below 0.5 NRS throughout the 16 weeks (Figure 2). A sensitivity analysis using exercise-induced pain data from all 48 individual exercise sessions yielded comparable results (p = 0.109) (Figure S2, Supplementary material). A sensitivity analysis excluding sessions where patients had used pain medication before exercise did not alter the findings (p = 0.123).

Figure 2 Exercise-induced shoulder pain between pre- and post-sessions using the mean of three sessions each week. Error bars show 95% confidence interval. n = number of participants contributing with data at each week. HEAVY: Intervention group receiving high-load shoulder exercise. LIGHT: Comparison group receiving low-load shoulder exercise.
Figure 2

Exercise-induced shoulder pain between pre- and post-sessions using the mean of three sessions each week. Error bars show 95% confidence interval. n = number of participants contributing with data at each week. HEAVY: Intervention group receiving high-load shoulder exercise. LIGHT: Comparison group receiving low-load shoulder exercise.

4 Discussion

In patients with HSD and shoulder complaints, treatment with high-load or low-load shoulder exercise programs resulted in similar pain trajectories during the 16-week treatment period. Both groups experienced low levels of exercise-induced pain, below 0.5 NRS throughout the 16 weeks. Contrary to previous beliefs, high-load strengthening did not result in larger exercise-induced pain compared with low-load exercises in this population.

We investigated pain trajectories and exercise-induced pain in patients with HSD and shoulder complaints undergoing high-load and low-load shoulder exercises. Our findings align with results from a similar study on a population with knee and hip pain during 8 weeks of neuromuscular exercise [12], where a decrease in joint pain of 1 point on the NRS was observed, from 3.6 at baseline to 2.6 at 8-week follow-up. Furthermore, that study further reported a reduction in exercise-induced pain over time, with a decrease of 0.08 points per week. Another study on patients with knee osteoarthritis participating in a 12-week neuromuscular exercise program found that pain-change decreased by 0.9 NRS (95% CI 0.4 to 1.3) and showed a decrease over time, plateauing around week 9 [13]. This is comparable with our findings. These consistent findings across different patient populations suggest that most often patients without previous experience with exercise can tolerate progressive exercise programs without exacerbating pain and can therefore be confident that they will experience a reduction in pain as the exercise program progresses.

Previous research has suggested that the smallest worthwhile effect is at least a 20% reduction in pain or improvement in the shoulder disability when compared to natural recovery in order to justify the costs, potential side effects, and inconveniences of the treatment [22]. Another study reported the minimal clinically important improvement to be 1 NRS point in a population with chronic musculoskeletal pain [23]. While the HEAVY group in our study showed a 0.89-point reduction in pain from baseline to the 16-week follow-up, this falls just short of the clinically meaningful threshold and cannot definitively be considered clinically relevant/satisfactory. The relatively small absolute decrease in shoulder pain observed in both groups (0.89 for HEAVY and 0.33 for LIGHT) from baseline to follow-up (Figure 1) should be interpreted in the context of the study’s inclusion criteria. Patients were eligible for inclusion if they had either pain or mechanical shoulder symptoms, meaning that some participants may not have experienced significant shoulder pain but instead reported discomfort or functional limitations due to mechanical symptoms when entering the RCT [24]. Additionally, there was no requirement for participants to have a minimum level of pain for inclusion, further contributing to the lower pain levels at baseline, limiting the potential for pain reductions. As a result, while some patients experienced noticeable pain improvements, the overall group effect sizes may appear smaller due to the diverse symptom profiles within the cohort. Therefore, the relatively small exercise-induced pain observed in our study may not fully represent patients with higher pain levels before starting a shoulder exercise program. Only approximately 17–18% of the participants in the RCT experienced a persistent worsening of their symptoms during the intervention, suggesting that a subgroup of patients does not have an immediate positive response to exercise or need other treatments [10]. Factors beyond physical pain, such as psychological aspects like self-efficacy and the duration of symptoms prior to beginning the exercise regimen, may also influence response to treatment [25].

Current guidelines advise against high-load, full range of motion strengthening exercises for patients with HSD due to concerns about increased pain and potential adverse events. Our findings demonstrate that pain levels during treatment were similar to those seen with standard care (low-load exercise), and excessive pain can be avoided if patients are carefully guided to follow the defined NRS pain intervals: safe (0–2), acceptable (2–5), and high risk that should be avoided (>5). For this approach to be effective, exercises in the HEAVY program were closely monitored during 2 of the 3 weekly sessions. The supervision ensured that strict rules for adjusting and modifying exercises were followed. These adjustments included modifying the range of motion, avoiding exercises that caused pain, reducing the number of sets and repetitions, and decreasing external load when necessary [8]. We developed 3D-printed dumbbells, which allowed for much smaller load increments (50 g), as opposed to traditional dumbbells, where increments are typically 500 g. This precision in load adjustment provided more flexibility in managing pain and avoiding aggravation. While we allowed pain levels up to 5/10 on the NRS during exercises, on average, this threshold was not reached, further supporting the safety of high-load training in this population when carefully supervised.

4.1 Clinical implications

Patients are often concerned about pain and potential pain flare during exercise. This study provides important information for clinicians to guide patients about what to expect, alleviating concerns and enhancing their confidence in engaging with shoulder rehabilitation programs, which in turn could improve patient adherence and overall treatment outcomes. Future research should explore how patients with more severe baseline symptoms respond to high-load strengthening exercises and investigate the importance of close supervision when introducing these exercises.

4.2 Limitations

This study has limitations. First, only participants who returned their exercise log after the 16-week intervention period were eligible for this study, excluding about one-third of the participants. The effect on estimates from this attrition bias is unknown. Similarly, the number of participants included in the regression analyses at the specific exercise sessions decreased over time (Figures 1 and 2).

Second, the study focused specifically on patients with HSD, so it is uncertain whether the results can be generalized to patients with hEDS, as they were not included, although both groups have similar clinical presentation [26,27,28]. Caution is also needed when interpreting these results for patients with other shoulder conditions. Third, recruitment took place in primary care, making it unclear whether the results would apply to patients in secondary care, where increased comorbidities might influence exercise-induced pain responses.

Finally, our analysis did not account for potential variations in pain fluctuations between subgroups or sex differences previously highlighted in the literature [29].

5 Conclusion

In this secondary analysis using data from an RCT, patients with HSD and persistent shoulder complaints experienced similar pain trajectories when performing high-load or low-load shoulder exercise programs. Both groups experienced low levels of exercise-induced pain, below 0.5 NRS throughout the 16 weeks. Contrary to previous beliefs, high-load strengthening did not result in more exercise-induced pain compared with low-load exercises in this population.

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Acknowledgments

We want to thank all the patients who agreed to be involved in this project. We also want to acknowledge Anne Marie Rosager for her role as the project manager, the Odense Patient data Explorative Network, Odense University Hospital, Odense, Denmark, for data management support and access to REDCap, and Andreas Drevsfeldt for data preparation for this secondary analysis. Lastly, we thank all the medical doctors and physiotherapists responsible for recruiting patients, and physiotherapists who delivered the interventions.

  1. Research ethics: The study was approved by the Regional Committees on Health Research Ethics of Southern Denmark (31 May 2017, S-20170066), the Danish Data Protection Agency (15 Feb 2018, 17/36907), and the Committee of Multipractice Studies in General Practice in Denmark (12 Feb 2018, MPU 15-2017).

  2. Informed consent: Informed consent has been obtained from all the participants in this study.

  3. Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

  4. Competing interests: The authors state no conflict of interest.

  5. Research funding: This work was supported by The Ehlers Danlos Society, the Region of Southern Denmark, Esbjerg municipality, The Danish-Rheumatism Association, Fund for Research, Quality and Education in Physiotherapy Practice, and the University of Southern Denmark. Dr. Skou is funded by a program grant from Region Zealand (Exercise First) and by two grants from the European Union’s Horizon 2020 research and innovation program (MOBILIZE, grant agreement No. 801790; and ESCAPE, grant agreement No. 945377).

  6. Data availability: The materials supporting the analysis and conclusions in this study can be obtained by contacting the corresponding author (provided reasonable request).

  7. Artificial intelligence/Machine learning tool: Not applicable.

  8. Supplementary material: This article contains supplementary material (followed by the link to the article online).

References

[1] Castori M, Tinkle B, Levy H, Grahame R, Malfait F, Hakim A. A framework for the classification of joint hypermobility and related conditions. Am J Med Genet C Semin Med Genet. 2017;175(1):148–57.10.1002/ajmg.c.31539Search in Google Scholar PubMed

[2] Mulvey MR, Macfarlane GJ, Beasley M, Symmons DP, Lovell K, Keeley P, et al. Modest association of joint hypermobility with disabling and limiting musculoskeletal pain: results from a large-scale general population-based survey. Arthritis Care Res (Hoboken). 2013;65(8):1325–33.10.1002/acr.21979Search in Google Scholar PubMed

[3] Johannessen EC, Reiten HS, Løvaas H, Maeland S, Juul-Kristensen B. Shoulder function, pain and health related quality of life in adults with joint hypermobility syndrome/Ehlers-Danlos syndrome-hypermobility type. Disabil Rehabil. 2016;38(14):1382–90.10.3109/09638288.2015.1102336Search in Google Scholar PubMed

[4] Rombaut L, Malfait F, Cools A, De Paepe A, Calders P. Musculoskeletal complaints, physical activity and health-related quality of life among patients with the Ehlers-Danlos syndrome hypermobility type. Disabil Rehabil. 2010;32(16):1339–45.10.3109/09638280903514739Search in Google Scholar PubMed

[5] Smith TO, Jerman E, Easton V, Bacon H, Armon K, Poland F, et al. Do people with benign joint hypermobility syndrome (BJHS) have reduced joint proprioception? A systematic review and meta-analysis. Rheumatol Int. 2013;33(11):2709–16.10.1007/s00296-013-2790-4Search in Google Scholar PubMed

[6] Scheper MC, Juul-Kristensen B, Rombaut L, Rameckers EA, Verbunt J, Engelbert RH. Disability in Adolescents and Adults Diagnosed With Hypermobility-Related Disorders: A Meta-Analysis. Arch Phys Med Rehabil. 2016;97(12):2174–87.10.1016/j.apmr.2016.02.015Search in Google Scholar PubMed

[7] Luime JJ, Koes BW, Hendriksen IJ, Burdorf A, Verhagen AP, Miedema HS, et al. Prevalence and incidence of shoulder pain in the general population; a systematic review. Scand J Rheumatol. 2004;33(2):73–81.10.1080/03009740310004667Search in Google Scholar PubMed

[8] Liaghat B, Skou ST, Søndergaard J, Boyle E, Søgaard K, Juul-Kristensen B. A randomised controlled trial of heavy shoulder strengthening exercise in patients with hypermobility spectrum disorder or hypermobile Ehlers-Danlos syndrome and long-lasting shoulder complaints: study protocol for the Shoulder-MOBILEX study. Trials. 2020;21(1):992.10.1186/s13063-020-04892-0Search in Google Scholar PubMed PubMed Central

[9] Spanhove V, De Wandele I, Malfait F, Calders P, Cools A. Home-based exercise therapy for treating shoulder instability in patients with hypermobile Ehlers-Danlos syndrome/hypermobility spectrum disorders. A randomized trial. Disabil Rehabil. 2023;45(11):1811–21.10.1080/09638288.2022.2076932Search in Google Scholar PubMed

[10] Liaghat B, Skou ST, Søndergaard J, Boyle E, Søgaard K, Juul-Kristensen B. Short-term effectiveness of high-load compared with low-load strengthening exercise on self-reported function in patients with hypermobile shoulders: a randomised controlled trial. Br J Sports Med. 2022;56(22):1269–76.10.1136/bjsports-2021-105223Search in Google Scholar PubMed PubMed Central

[11] Liaghat B, Juul-Kristensen B, Faber DA, Christensen EO, Søgaard K, Skou ST, et al. One-year effectiveness of high-load compared with low-load strengthening exercise on self-reported function in patients with hypermobile shoulders: a secondary analysis from a randomised controlled trial. Br J Sports Med. 2024;58(7):373–81.10.1136/bjsports-2023-107563Search in Google Scholar PubMed PubMed Central

[12] Sandal LF, Roos EM, Bogesvang SJ, Thorlund JB. Pain trajectory and exercise-induced pain flares during 8 weeks of neuromuscular exercise in individuals with knee and hip pain. Osteoarthr Cartil. 2016;24(4):589–92.10.1016/j.joca.2015.11.002Search in Google Scholar PubMed

[13] Primeau CA, Birmingham TB, Moyer RF, O’Neil KA, Werstine MS, Alcock GK, et al. Trajectories of perceived exertion and pain over a 12-week neuromuscular exercise program in patients with knee osteoarthritis. Osteoarthr Cartil. 2020;28(11):1427–31.10.1016/j.joca.2020.07.011Search in Google Scholar PubMed

[14] Heuts PHTG, Vlaeyen JWS, Roelofs J, de Bie RA, Aretz K, van Weel C, et al. Pain-related fear and daily functioning in patients with osteoarthritis. Pain. 2004;110(1):228–35.10.1016/j.pain.2004.03.035Search in Google Scholar PubMed

[15] Stochkendahl MJ, Kjaer P, Hartvigsen J, Kongsted A, Aaboe J, Andersen M, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J. 2018;27(1):60–75.10.1007/s00586-017-5099-2Search in Google Scholar PubMed

[16] Vlaeyen JWS, Crombez G, Linton SJ. The fear-avoidance model of pain. Pain. 2016;157(8):1588–9.10.1097/j.pain.0000000000000574Search in Google Scholar PubMed

[17] Kongsted A, Ris I, Kjaer P, Hartvigsen J. Self-management at the core of back pain care: 10 key points for clinicians. Braz J Phys Ther. 2021;25(4):396–406.10.1016/j.bjpt.2021.05.002Search in Google Scholar PubMed PubMed Central

[18] World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. Jama. 2013;310(20):2191–4.10.1001/jama.2013.281053Search in Google Scholar PubMed

[19] von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. PLoS Med. 2007;4(10):e296.10.1371/journal.pmed.0040296Search in Google Scholar PubMed PubMed Central

[20] The Danish Rheumatism Association. Treatment of hypermobility - prevention of pain and injuries. Søborg, Denmark: The Danish Rheumatism Association; 2015. https://www.gigtforeningen.dk/viden-om-gigt/diagnoser/hypermobilitet/behandling-af-hypermobilitet/.Search in Google Scholar

[21] Stomski NJ, Mackintosh S, Stanley M. Patient self-report measures of chronic pain consultation measures: a systematic review. Clin J Pain. 2010;26(3):235–43.10.1097/AJP.0b013e3181c84e76Search in Google Scholar PubMed

[22] Christiansen DH, de Vos Andersen N-B, Poulsen PH, Ostelo RW. The smallest worthwhile effect of primary care physiotherapy did not differ across musculoskeletal pain sites. J Clin Epidemiol. 2018;101:44–52.10.1016/j.jclinepi.2018.05.019Search in Google Scholar PubMed

[23] Salaffi F, Stancati A, Alberto Silvestri C, Ciapetti A, Grassi W. Minimal clinically important changes in chronic musculoskeletal pain intensity measured on a numerical rating scale. Eur J Pain. 2004;8(4):283–91.10.1016/j.ejpain.2003.09.004Search in Google Scholar PubMed

[24] Kjærbæk F, Juul-Kristensen B, Skou ST, Søndergaard J, Boyle E, Søgaard K, et al. The association between number of shoulder diagnoses and positive clinical tests with self-reported function and pain: A cross-sectional study of patients with hypermobile joints and shoulder complaints. Musculoskelet Sci Pract. 2022;62:102624.10.1016/j.msksp.2022.102624Search in Google Scholar PubMed

[25] Dolsø M, Juul-Kristensen B, Skou ST, Søgaard K, Søndergaard J, Juhl CB, et al. Psychological factors and symptom duration are associated with exercise-based treatment effect in people with hypermobile shoulders: A secondary analysis of a randomised controlled trial. Musculoskelet Sci Pract. 2023;66:102798.10.1016/j.msksp.2023.102798Search in Google Scholar PubMed

[26] Tinkle BT, Bird HA, Grahame R, Lavallee M, Levy HP, Sillence D. The lack of clinical distinction between the hypermobility type of Ehlers-Danlos syndrome and the joint hypermobility syndrome (a.k.a. hypermobility syndrome). Am J Med Genet A. 2009;149a(11):2368–70.10.1002/ajmg.a.33070Search in Google Scholar PubMed

[27] Aubry-Rozier B, Schwitzguebel A, Valerio F, Tanniger J, Paquier C, Berna C, et al. Are patients with hypermobile Ehlers-Danlos syndrome or hypermobility spectrum disorder so different? Rheumatol Int. 2021;41(10):1785–94.10.1007/s00296-021-04968-3Search in Google Scholar PubMed PubMed Central

[28] Coussens M, Lapauw B, Banica T, De Wandele I, Pacey V, Rombaut L, et al. Muscle strength, muscle mass and physical impairment in women with hypermobile Ehlers-Danlos syndrome and hypermobility spectrum disorder. J Musculoskelet Neuronal Interact. 2022;22(1):5–14.10.5348/100049D05MC2020RASearch in Google Scholar

[29] Radojčić MR, Arden NK, Yang X, Strauss VY, Birrell F, Cooper C, et al. Pain trajectory defines knee osteoarthritis subgroups: a prospective observational study. Pain. 2020;161(12):2841–51.10.1097/j.pain.0000000000001975Search in Google Scholar PubMed PubMed Central

Received: 2024-10-29
Revised: 2025-05-09
Accepted: 2025-05-10
Published Online: 2025-06-02

© 2025 the author(s), published by De Gruyter

This work is licensed under the Creative Commons Attribution 4.0 International License.

Articles in the same Issue

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  2. Abstracts presented at SASP 2025, Reykjavik, Iceland. From the Test Tube to the Clinic – Applying the Science
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  17. Pain and health-related quality of life among women of childbearing age in Iceland: ICEPAIN, a nationwide survey
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  21. Understanding the experiences of Canadian military veterans participating in aquatic exercise for musculoskeletal pain
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  31. An action plan: The Swedish healthcare pathway for adults with chronic pain
  32. Team-based rehabilitation in primary care for patients with musculoskeletal disorders: Experiences, effect, and process evaluation. A PhD synopsis
  33. Persistent severe pain following groin hernia repair: Somatosensory profiles, pain trajectories, and clinical outcomes – Synopsis of a PhD thesis
  34. Systematic Reviews
  35. Effectiveness of non-invasive vagus nerve stimulation vs heart rate variability biofeedback interventions for chronic pain conditions: A systematic review
  36. A scoping review of the effectiveness of underwater treadmill exercise in clinical trials of chronic pain
  37. Neural networks involved in painful diabetic neuropathy: A systematic review
  38. Original Experimental
  39. Knowledge, attitudes, and practices of transcutaneous electrical nerve stimulation in perioperative care: A Swedish web-based survey
  40. Impact of respiration on abdominal pain thresholds in healthy subjects – A pilot study
  41. Measuring pain intensity in categories through a novel electronic device during experimental cold-induced pain
  42. Robustness of the cold pressor test: Study across geographic locations on pain perception and tolerance
  43. Experimental partial-night sleep restriction increases pain sensitivity, but does not alter inflammatory plasma biomarkers
  44. Is it personality or genes? – A secondary analysis on a randomized controlled trial investigating responsiveness to placebo analgesia
  45. Investigation of endocannabinoids in plasma and their correlation with physical fitness and resting state functional connectivity of the periaqueductal grey in women with fibromyalgia: An exploratory secondary study
  46. Educational Case Reports
  47. Stellate ganglion block in disparate treatment-resistant mental health disorders: A case series
  48. Regaining the intention to live after relief of intractable phantom limb pain: A case study
  49. Trigeminal neuralgia caused by dolichoectatic vertebral artery: Reports of two cases
  50. Short Communications
  51. Neuroinflammation in chronic pain: Myth or reality?
  52. The use of registry data to assess clinical hunches: An example from the Swedish quality registry for pain rehabilitation
  53. Letter to the Editor
  54. Letter to the Editor For: “Stellate ganglion block in disparate treatment-resistant mental health disorders: A case series”
  55. Corrigendum
  56. Corrigendum to “Patient characteristics in relation to opioid exposure in a chronic non-cancer pain population”
https://doi.org/10.1515/sjpain-2024-0072
Keywords for this article
joint instability; exercise therapy; shoulder; pain management
Creative Commons
BY 4.0

Articles in the same Issue

  1. Editorial Comment
  2. Abstracts presented at SASP 2025, Reykjavik, Iceland. From the Test Tube to the Clinic – Applying the Science
  3. Quantitative sensory testing – Quo Vadis?
  4. Stellate ganglion block for mental disorders – too good to be true?
  5. When pain meets hope: Case report of a suspended assisted suicide trajectory in phantom limb pain and its broader biopsychosocial implications
  6. Transcutaneous electrical nerve stimulation – an important tool in person-centered multimodal analgesia
  7. Clinical Pain Researches
  8. Exploring the complexities of chronic pain: The ICEPAIN study on prevalence, lifestyle factors, and quality of life in a general population
  9. The effect of peer group management intervention on chronic pain intensity, number of areas of pain, and pain self-efficacy
  10. Effects of symbolic function on pain experience and vocational outcome in patients with chronic neck pain referred to the evaluation of surgical intervention: 6-year follow-up
  11. Experiences of cross-sectoral collaboration between social security service and healthcare service for patients with chronic pain – a qualitative study
  12. Completion of the PainData questionnaire – A qualitative study of patients’ experiences
  13. Pain trajectories and exercise-induced pain during 16 weeks of high-load or low-load shoulder exercise in patients with hypermobile shoulders: A secondary analysis of a randomized controlled trial
  14. Pain intensity in anatomical regions in relation to psychological factors in hypermobile Ehlers–Danlos syndrome
  15. Opioid use at admittance increases need for intrahospital specialized pain service: Evidence from a registry-based study in four Norwegian university hospitals
  16. Topically applied novel TRPV1 receptor antagonist, ACD440 Gel, reduces temperature-evoked pain in patients with peripheral neuropathic pain with sensory hypersensitivity, a randomized, double-blind, placebo-controlled, crossover study
  17. Pain and health-related quality of life among women of childbearing age in Iceland: ICEPAIN, a nationwide survey
  18. A feasibility study of a co-developed, multidisciplinary, tailored intervention for chronic pain management in municipal healthcare services
  19. Healthcare utilization and resource distribution before and after interdisciplinary pain rehabilitation in primary care
  20. Measurement properties of the Swedish Brief Pain Coping Inventory-2 in patients seeking primary care physiotherapy for musculoskeletal pain
  21. Understanding the experiences of Canadian military veterans participating in aquatic exercise for musculoskeletal pain
  22. “There is generally no focus on my pain from the healthcare staff”: A qualitative study exploring the perspective of patients with Parkinson’s disease
  23. Observational Studies
  24. Association between clinical laboratory indicators and WOMAC scores in Qatar Biobank participants: The impact of testosterone and fibrinogen on pain, stiffness, and functional limitation
  25. Well-being in pain questionnaire: A novel, reliable, and valid tool for assessment of the personal well-being in individuals with chronic low back pain
  26. Properties of pain catastrophizing scale amongst patients with carpal tunnel syndrome – Item response theory analysis
  27. Adding information on multisite and widespread pain to the STarT back screening tool when identifying low back pain patients at risk of worse prognosis
  28. The neuromodulation registry survey: A web-based survey to identify and describe characteristics of European medical patient registries for neuromodulation therapies in chronic pain treatment
  29. A biopsychosocial content analysis of Dutch rehabilitation and anaesthesiology websites for patients with non-specific neck, back, and chronic pain
  30. Topical Reviews
  31. An action plan: The Swedish healthcare pathway for adults with chronic pain
  32. Team-based rehabilitation in primary care for patients with musculoskeletal disorders: Experiences, effect, and process evaluation. A PhD synopsis
  33. Persistent severe pain following groin hernia repair: Somatosensory profiles, pain trajectories, and clinical outcomes – Synopsis of a PhD thesis
  34. Systematic Reviews
  35. Effectiveness of non-invasive vagus nerve stimulation vs heart rate variability biofeedback interventions for chronic pain conditions: A systematic review
  36. A scoping review of the effectiveness of underwater treadmill exercise in clinical trials of chronic pain
  37. Neural networks involved in painful diabetic neuropathy: A systematic review
  38. Original Experimental
  39. Knowledge, attitudes, and practices of transcutaneous electrical nerve stimulation in perioperative care: A Swedish web-based survey
  40. Impact of respiration on abdominal pain thresholds in healthy subjects – A pilot study
  41. Measuring pain intensity in categories through a novel electronic device during experimental cold-induced pain
  42. Robustness of the cold pressor test: Study across geographic locations on pain perception and tolerance
  43. Experimental partial-night sleep restriction increases pain sensitivity, but does not alter inflammatory plasma biomarkers
  44. Is it personality or genes? – A secondary analysis on a randomized controlled trial investigating responsiveness to placebo analgesia
  45. Investigation of endocannabinoids in plasma and their correlation with physical fitness and resting state functional connectivity of the periaqueductal grey in women with fibromyalgia: An exploratory secondary study
  46. Educational Case Reports
  47. Stellate ganglion block in disparate treatment-resistant mental health disorders: A case series
  48. Regaining the intention to live after relief of intractable phantom limb pain: A case study
  49. Trigeminal neuralgia caused by dolichoectatic vertebral artery: Reports of two cases
  50. Short Communications
  51. Neuroinflammation in chronic pain: Myth or reality?
  52. The use of registry data to assess clinical hunches: An example from the Swedish quality registry for pain rehabilitation
  53. Letter to the Editor
  54. Letter to the Editor For: “Stellate ganglion block in disparate treatment-resistant mental health disorders: A case series”
  55. Corrigendum
  56. Corrigendum to “Patient characteristics in relation to opioid exposure in a chronic non-cancer pain population”
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