Physiotherapy after subacromial decompression surgery: development of a standardised exercise intervention

Group-based exercise, individually supervised exercise and home-based exercise have similar clinical effects and cost-effectiveness in people with subacromial pain: a randomised trial

QUESTION

What are the relative effects of group-based exercise, individual exercise and home-based exercise on clinical outcomes and costs in patients with subacromial pain?

DESIGN

Multicentre, three-arm, randomised controlled trial with concealed allocation and intention-to-treat analysis.

PARTICIPANTS

A total of 208 patients referred to municipal rehabilitation for management of subacromial pain in six municipalities in the Central Denmark Region.

INTERVENTIONS

Patients were randomly allocated to group-based exercise rehabilitation (GE), individual exercise rehabilitation (IE) or home exercise rehabilitation (HE) for a period of 8 weeks.

OUTCOME MEASURES

The primary outcome measure was the shortened version of the Disabilities of the Arm, Shoulder and Hand questionnaire (Quick-DASH). The secondary outcome measures included the EQ-5D-5L index, pain intensity, fear avoidance, psychological wellbeing, and the participant's perception of improvement and satisfaction. Healthcare and productivity costs were extracted from national health and social registers.

RESULTS

There was no important between-group difference in Quick-DASH scores at 6 months: adjusted mean differences GE minus IE -2 (95% CI -9 to 5), GE minus HE -2 (95% CI -9 to 5) and HE minus IE 1 (95% CI -6 to 7). The estimates of the between-group differences were able to exclude any clinically important differences in the three regimens' effects on health benefits according to the EQ-5D-5L index and other secondary outcomes. The total average costs were highest for the IE group and lowest for the HE, but not statistically different across groups.

CONCLUSION

In people with subacromial pain, group-based exercise, individually supervised exercise and home-based supervised exercise regimens have similar benefits. The home exercise intervention was associated with lowest costs.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03055117.

Effectiveness of Standardized Physical Therapy Exercises for Patients With Difficulty Returning to Usual Activities After Decompression Surgery for Subacromial Impingement Syndrome: Randomized Controlled Trial

BACKGROUND

Little is known about the effectiveness of exercise programs after decompression surgery for subacromial impingement syndrome. For patients with difficulty returning to usual activities, special efforts may be needed to improve shoulder function.

OBJECTIVE

The purpose of this study was to evaluate the effectiveness at 3 and 12 months of a standardized physical therapy exercise intervention compared with usual care in patients with difficulty returning to usual activities after subacromial decompression surgery.

DESIGN

A multicenter randomized controlled trial was conducted.

SETTING

The study was conducted in 6 public departments of orthopedic surgery, 2 departments of occupational medicine, and 2 physical therapy training centers in Central Denmark Region.

PATIENTS

One hundred twenty-six patients reporting difficulty returning to usual activities at the postoperative clinical follow-up 8 to 12 weeks after subacromial decompression surgery participated.

INTERVENTION

A standardized exercise program consisting of physical therapist-supervised individual training sessions and home training was used.

OUTCOME MEASURES

The primary outcome measure was the Oxford Shoulder Score. Secondary outcome measures were the Constant Score and the Fear-Avoidance Beliefs Questionnaire.

RESULTS

At 3 and 12 months, follow-up data were obtained for 92% and 83% of the patients, respectively. Intention-to-treat analyses suggested a between-group difference on the Oxford Shoulder Score favoring the exercise group at 3 months, with an adjusted mean difference of 2.0 (95% confidence interval=-0.5, 4.6), and at 12 months, with an adjusted mean difference of 5.8 (95% confidence interval=2.8, 8.9). Significantly larger improvements for the exercise group were observed for most secondary and supplementary outcome measures.

LIMITATIONS

The nature of the exercise intervention did not allow blinding of patients and care providers.

CONCLUSION

The standardized physical therapy exercise intervention resulted in statistically significant and clinically relevant improvement in shoulder pain and function at 12 months compared with usual care.