Effectiveness of Adding a Large Dose of Shoulder Strengthening to Current Nonoperative Care for Subacromial Impingement: A Pragmatic, Double-Blind Randomized Controlled Trial (SExSI Trial)

The efficacy of exercise therapy for rotator cuff related shoulder pain according to the FITT principle: a systematic review with meta-analyses

OBJECTIVE: To evaluate the efficacy of exercise interventions with differing frequency, intensity, type and time (FITT) on shoulder pain and disability in people with rotator cuff related shoulder pain (RCRSP). DESIGN: Intervention systematic review with meta-analyses. LITERATURE SEARCH: Electronic searches were conducted up to May 2023. STUDY SELECTION CRITERIA: Randomized controlled trials (RCTs) comparing the effects of exercise interventions differing in prescription according to the FITT principle, in people with RCRSP. DATA SYNTHESIS: Separate meta-analyses comparing exercise type (specific versus non-specific exercise) and intensity (high versus low) were conducted. GRADE was used to evaluate the certainty of evidence. RESULTS: Twenty-two RCTs (n=1281) were included. There was moderate certainty evidence that motor control exercise programs, when compared to non-specific exercise programs, significantly reduced disability in the short- (SMD: -0.29; 95%CI: -0.51 to -0.07; n=323; 7 RCTs) and medium-term (SMD: -0.33; 95%CI: -0.57 to -0.09; n=286; 5 RCTs), but not pain in the short-term (SMD: -0.19; 95%CI: -0.41 to 0.03; n=323; 7 RCTs). Uncertainties remained regarding other exercise types (eccentric and scapula-focused exercise programs) versus non-specific exercise programs, and exercise intensity due to low to very low certainty evidence. No trials were identified that compared different frequencies or times. CONCLUSION: For adults with RCRSP, motor control exercise programs were probably slightly superior to non-specific exercise programs. However, it is unclear if the effects were due to motor control exercise or to other program characteristics such as progression and tailoring.

FITT Odyssey: A Scoping Review of Exercise Programs for Managing Rotator Cuff Related Shoulder Pain

OBJECTIVE: To summarize the FITT (frequency, intensity, time, type) components of exercise programs included in randomized controlled trials (RCTs) that compared 2 or more programs for managing rotator cuff related shoulder pain (RCRSP). DESIGN: Scoping review. LITERATURE SEARCH: Electronic searches were conducted up to May 2023. STUDY SELECTION CRITERIA: RCTs comparing the effects of 2 or more types of exercise programs, differing in prescription according to the FITT principle, in people with RCRSP. DATA SYNTHESIS: We extracted data from each trial report so that we could answer items 1-10 and 13-15 from the Consensus on Exercise Reporting Template (CERT). Descriptive analysis of the exercise programs was performed by summarising and presenting the FITT characteristics, and other relevant CERT characteristics (material, provider, delivery, tailoring). RESULTS: FITT characteristics from 46 exercise programs included in 22 trials were extracted. The exercise programs were divided into 4 categories (defined in accordance to the original authors' description and proposed rationale): motor control (n=8), scapula-focused (n=7), eccentric (n=8), and non-specific exercise programs (n=28). Five programs were allocated to 2 different categories. The different program types had similar parameters. Exercise programs frequency ranged from 2 to 7 times per week, dose ranged from 1 to 3 sets and 4 to 30 repetitions per sets and exercise program duration ranged from 4 to 16 weeks. CONCLUSION: There was considerable variability in the parameters used to prescribe exercises for RCRSP. Clinicians seeking guidance on FITT parameters derived from trials should do so cautiously because there was no one size-fits-all approach.

Is exercise therapy the right treatment for rotator cuff-related shoulder pain? Uncertainties, theory, and practice

BACKGROUND

Exercise therapy is a popular non-surgical treatment to help manage individuals with rotator cuff-related shoulder pain (RCRSP) and is recommended in all clinical practice guidelines. Due to modest effect sizes, low quality evidence, uncertainty relating to efficacy, and mechanism(s) of benefit, exercise as a therapeutic intervention has been the subject of increasing scrutiny.

AIMS

The aim of this critical review is to lay out where the purported uncertainties of exercise for RCRSP exist by exploring the relevant quantitative and qualitative literature. We conclude by offering theoretical and practical considerations to help reduce the uncertainty of delivering exercise therapy in a clinical environment.

RESULTS AND DISCUSSION

Uncertainty underpins much of the theory and practice of delivering exercise therapy for individuals with RCRSP. Nonetheless, exercise is an often-valued treatment by individuals with RCRSP, when provided within an appropriate clinical context. We encourage clinicians to use a shared decision-making paradigm and embrace a pluralistic model when prescribing therapeutic exercise. This may take the form of using exercise experiments to trial different exercise approaches, adjusting, and adapting the exercise type, load, and context based on the individual's symptom irritability, preferences, and goals.

CONCLUSION

We contend that providing exercise therapy should remain a principal treatment option for helping individuals with RCRSP. Limitations notwithstanding, exercise therapy is relatively low cost, accessible, and often valued by individuals with RCRSP. The uncertainty surrounding exercise therapy requires ongoing research and emphasis could be directed towards investigating causal mechanisms to better understand how exercise may benefit an individual with RCRSP.

Reproducibility of Exercise Interventions in Randomized Controlled Trials for the Treatment of Rotator Cuff-Related Shoulder Pain: A Systematic Review

OBJECTIVE

To determine the reproducibility of exercise therapy interventions in randomized controlled trials for rotator cuff-related shoulder pain (RCRSP).

DATA SOURCES

Data sources included Medline, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, and SPORTDiscus from studies published from database inception to April 23, 2022.

STUDY SELECTION

Randomized controlled trials studying the use of exercise therapy for RCRSP.

DATA EXTRACTION

Two reviewers extracted exercise reporting details from all studies using the Template for Intervention Description and Replication (TIDieR) and the modified Consensus on Exercise Reporting Template (CERT). The same 2 reviewers assessed risk of bias of all studies using Cochrane Risk of Bias Tool version 2.0.

DATA SYNTHESIS

For 104 studies meeting inclusion criteria, the average number of items reported on the TIDieR was 5.27 (SD 2.50, range 1-12 out of 12) and 5.09 (SD 4.01, range 0-16 out of 16) on the CERT. Improved reporting over time was seen on both the TIDieR and CERT dating back to 1993 and through April 23, 2022. When comparing groups of studies published before and after the TIDieR (2014) and CERT (2016) were established, a statistically significant increase in median scores was noted on the TIDieR (P=.02) but not the CERT (P=.31). Quality of exercise therapy reporting was highest in studies with "low risk" of bias, and lowest in studies with "high risk" of bias on the RoB-2.

CONCLUSION

Overall exercise reporting in trials for RCRSP is incomplete despite the development of the TIDieR and CERT checklists. This has implications for translating evidence into practice.

Level of pain catastrophising determines if patients with long-standing subacromial impingement benefit from more resistance exercise: predefined secondary analyses from a pragmatic randomised controlled trial (the SExSI Trial)

OBJECTIVE

The primary aim was to investigate the effectiveness of adding more resistance exercise to usual care on pain mechanisms (including temporal summation, conditioned pain modulation (CPM) and local pain sensitivity) and pain catastrophising in people with subacromial impingement at 16 weeks follow-up. Second, to investigate the modifying effect of pain mechanisms and pain catastrophising on the interventions' effectiveness in improving shoulder strength and disability METHODS: 200 consecutive patients were randomly allocated to usual exercise-based care or the same plus additional elastic band exercise to increase total exercise dose. Completed add-on exercise dose was captured using an elastic band sensor. Outcome measures recorded at baseline, 5 weeks, 10 weeks and 16 (primary end point) weeks included temporal summation of pain (TSP) and CPM assessed at the lower leg, pressure pain threshold at the deltoid muscle (PPT-deltoid), pain catastrophising and the Shoulder Pain and Disability Index.

RESULTS

Additional elastic band exercise was not superior to usual exercise-based care in improving pain mechanisms (TSP, CPM and PPT-deltoid) or pain catastrophising after 16 weeks. Interaction analyses showed that pain catastrophising (median split) modified the effectiveness of additional exercises (effect size 14 points, 95% CI 2 to 25), with superior results in the additional exercise group compared with the usual care group in patients with less pain catastrophising.

CONCLUSION

Additional resistance exercise added to usual care was not superior to usual care alone in improving pain mechanisms or pain catastrophising. Additional exercise was, however, superior in improving self-reported disability in patients with lower levels of pain catastrophising at baseline.

TRIAL REGISTRATION NUMBER

NCT02747251.

Exercise for rotator cuff tendinopathy: Proposed mechanisms of recovery

Rotator cuff (RC) tendinopathy is a common recurrent cause of shoulder pain, and resistance exercise is the first-line recommended intervention. Proposed causal mechanisms of resistance exercise for patients with RC tendinopathy consist of four domains: tendon structure, neuromuscular factors, pain and sensorimotor processing, and psychosocial factors. Tendon structure plays a role in RC tendinopathy, with decreased stiffness, increased thickness, and collagen disorganization. Neuromuscular performance deficits of altered kinematics, muscle activation, and force are present in RC tendinopathy, but advanced methods of assessing muscle performance are needed to fully assess these factors. Psychological factors of depression, anxiety, pain catastrophizing, treatment expectations, and self-efficacy are present and predict patient-reported outcomes. Central nervous system dysfunctions also exist, specifically altered pain and sensorimotor processing. Resisted exercise may normalize these factors, but limited evidence exists to explain the relationship of the four proposed domains to trajectory of recovery and defining persistent deficits limiting outcomes. Clinicians and researchers can use this model to understand how exercise mediates change in patient outcomes, develop subgroups to deliver patient-specific approach for treatment and define metrics to track recovery over time. Supporting evidence is limited, indicating the need for future studies characterizing mechanisms of recovery with exercise for RC tendinopathy.

Identifying Conservative Interventions for Individuals with Subacromial Pain Syndrome Prior to Undergoing a Subacromial Decompression: A Scoping Review

Background

Subacromial decompression (SAD) surgery remains a common treatment for individuals suffering from subacromial pain syndrome (SAPS), despite numerous studies indicating that SAD provides no benefit over conservative care. Surgical protocols typically recommend surgery only after exhausting conservative measures; however, there is no consensus in the published literature detailing what constitutes conservative care "best practice" before undergoing surgery.

Purpose

To describe conservative interventions received by individuals with SAPS prior to undergoing a SAD.

Study Design

Scoping review.

Methods

An electronic search using MEDLINE, CINAHL, PubMed, and Scopus databases was conducted. Peer-reviewed randomized controlled control trials and cohort studies published between January 2000 and February 2022 that included subjects diagnosed with SAPS who progressed to receive a SAD were eligible. Subjects who received previous or concurrent rotator cuff repair with SAPS were excluded. Conservative interventions and treatment details that subjects received prior to undergoing a SAD were extracted.

Results

Forty-seven studies were included after screening 1,426 studies. Thirty-six studies (76.6%) provided physical therapy (PT) services, and six studies (12.8%) included only a home exercise program. Twelve studies (25.5%) specifically detailed the delivered PT services, and 20 studies (42.6%) stated who provided the PT interventions. Subacromial injections (SI) (55.3%, n=26) and non-steroidal anti-inflammatories (NSAIDs) (31.9%, n=15) were the next most frequently delivered interventions. Thirteen studies (27.7%) included combined PT and SI. The duration of conservative care varied from 1.5 months to 16 months.

Conclusion

Conservative care that individuals with SAPS receive to prevent advancement to SAD appears inadequate based on the literature. Interventions, such as PT, SI, and NSAIDs, are either underreported or not offered to individuals with SAP prior to advancing to surgery. Many questions regarding optimal conservative management for SAPS persists.

Level of Evidence

n/a.

Does the addition of motor control or strengthening exercises to education result in better outcomes for rotator cuff-related shoulder pain? A multiarm randomised controlled trial

OBJECTIVE

To compare the short-term, mid-term and long-term effects between three interventions (education only, education and strengthening exercises, education and motor control exercises) for rotator cuff-related shoulder pain (RCRSP) on symptoms and function.

METHODS

123 adults presenting with RCRSP took part in a 12-week intervention. They were randomly assigned to 1 of 3 intervention groups. Symptoms and function were evaluated at baseline and at 3 weeks, 6 weeks, 12 weeks and 24 weeks using the Disability of Arm, Shoulder and Hand Questionnaire (QuickDASH) (primary outcome) and Western Ontario Rotator Cuff Index (WORC). Linear mixed modelling was used to compare the effects of the three programmes on the outcomes.

RESULTS

After 24 weeks, between-group differences were -2.1 (-7.7 to 3.5) (motor control vs education), 1.2 (-4.9 to 7.4) (strengthening vs education) and -3.3 (-9.5 to 2.8) (motor control vs strengthening) for the QuickDASH and 9.3 (1.5 to 17.1) (motor control vs education), 1.3 (-7.6 to 10.2) (strengthening vs education) and 8.0 (-0.5 to 16.5) (motor control vs strengthening) for the WORC. There was a significant group-by-time interaction (p=0.04) with QuickDASH, but follow-up analyses did not reveal any clinically meaningful between-group differences. There was no significant group-by-time interaction (p=0.39) for the WORC. Between-group differences never exceeded the minimal clinically important difference of QuickDASH or WORC.

CONCLUSION

In people with RCRSP, the addition of motor control or strengthening exercises to education did not lead to larger improvements in symptoms and function compared with education alone. Further research should investigate the value of providing stepped care by identifying individuals who may only need education and those who would benefit from the addition of motor control or strengthening exercises.

TRIAL REGISTRATION NUMBER

NCT03892603.

"You have (rotator cuff related) shoulder pain, and to treat it, I recommend exercise." A scoping review of the possible mechanisms underpinning exercise therapy

BACKGROUND

Exercise is considered to be both essential and at the forefront of the management of rotator cuff-related shoulder pain (RCRSP). Despite this, many fail to substantially improve with exercise-based treatment. Hence, expanding the current knowledge about the possible mechanisms of exercise for RCRSP is critical.

OBJECTIVE

To synthesise the range of mechanisms proposed for exercise in people with RCRSP.

DESIGN

Scoping review METHODS: A systematic search of the Physiotherapy Evidence Database (PEDro) was conducted from inception to July 3, 2022. Two reviewers conducted the search and screening process and one reviewer extracted the data from each study. Randomised clinical trials using exercise for the management of RCRSP of any duration were included. The PEDro search terms used were "fitness training", "strength training", "stretching, mobilisation, manipulation, massage", "upper arm, shoulder, or shoulder girdle", "pain", and "musculoskeletal". Data were analysed using quantitative and qualitative approaches.

RESULTS

626 studies were identified and 110 were included in the review. Thirty-two unique mechanisms of exercise were suggested by clinical trialists, from which 4 themes emerged: 1) neuromuscular 2) tissue factors 3) neuro-endocrine-immune 4) psychological. Neuromuscular mechanisms were proposed most often (n = 156, 77%). Overall, biomedical mechanisms of exercise were proposed in 95% of cases.

CONCLUSIONS

The causal explanation for the beneficial effect of exercise for RCRSP in clinical research is dominated by biomedical mechanisms, despite a lack of supporting evidence. Future research should consider testing the mechanisms identified in this review using mediation analysis to progress knowledge on how exercise might work for RCRSP.

The influence of exercise on clinical pain and pain mechanisms in patients with subacromial pain syndrome

Background

Few studies have investigated the underlying mechanisms for unilateral subacromial pain syndrome (SAPS). Therefore, this study examined (1) if 8‐weeks of exercise could modulate clinical pain or temporal summation of pain (TSP), conditioned pain modulation (CPM), and exercise‐induced hypoalgesia (EIH) and (2) if any of these parameters could predict the effect of 8‐weeks of exercise in patients with unilateral SAPS.

Methods

Thirty‐seven patients completed a progressive abduction exercise program every other day for 8‐weeks. Worst shoulder pain in full abduction was rated on a numeric rating scale (NRS). Pain pressure thresholds (PPTs), TSP, CPM, EIH, Shoulder Pain and Disability Index (SPADI), Pain Catastrophizing Scale (PCS), PainDETECT questionnaire (PD‐Q), Pain Self‐Efficacy Questionnaire (PSE‐Q) and Pittsburgh Sleep Quality Index (PSQI) were assessed before and after intervention.

Results

The intervention improved worst pain intensity (p < 0.001), increased the CPM (p < 0.001), improved the sleep scores (p < 0.005) and reduced the PainDETECT ratings (p < 0.001). No changes were observed in PPT, TSP, EIH, SPADI, PCS and PSE‐Q (all p > 0.05). In a linear regression, the combination of all baseline parameters predicted 23.2% variance in absolute change in pain after 8 weeks. Applying backwards elimination to the linear regression yielded that baseline pain intensity combined with TSP predicted 33.8% variance.

Conclusion

This explorative study suggested reduction in pain, improved sleep quality and increased CPM after 8‐weeks of exercise. Furthermore, the results suggests that low pain intensity and high TSP scores (indicative for pain sensitisation) may predict a lack of pain improvement after exercise.

Tailored exercise and manual therapy versus standardised exercise for patients with shoulder subacromial pain: a feasibility randomised controlled trial (the Otago MASTER trial)

OBJECTIVES

The aim of this study was to assess whether it was feasible to conduct a full trial comparing a tailored versus a standardised exercise programme for patients with shoulder subacromial pain.

DESIGN

Two-arm, patient-blinded and assessor-blinded, randomised controlled feasibility trial.

METHODS

Twenty-eight participants with shoulder subacromial pain were randomly allocated into one of two intervention groups-tailored or standardised exercise. Participants in the tailored exercise programme received exercises and manual therapy tailored to their scapular and shoulder movement impairments. Participants in the standardised exercise programme received progressive strengthening exercise. The primary outcome measures were (1) the participant recruitment rate; (2) the proportion of participants enrolled from the total number screened; (3) drop-out rates; and (4) adherence to the rehabilitation programme. Other outcome measures were: (5) pain levels; (6) Patient-Specific Functional Scale; (7) the Shoulder Pain and Disability Index; and (8) pain self-efficacy. We compared changes in pain and disability scores between groups using a repeated mixed-model analysis of variance. Since this is a feasibility study, we did not adjust alpha for multiple comparisons, and considered 75% CI as the probability threshold at 3-month follow-up. Health-related quality of life was assessed using the Short-Form 12 and quality-adjusted life years (QALYs) were estimated.

RESULTS

The recruitment rate was 3 participants per month, the proportion of participants enrolled was 23%, the drop-out rate was 14% and the overall adherence to the rehabilitation programme was 85%. No between-group differences were found for most outcome measures. Adverse events (n=2, only in the tailored group) were minor in nature and included skin injury or pain following taping.

CONCLUSIONS

Our feasibility trial showed that additional strategies are required for improving recruitment, enrolment and minimising drop-out of participants into the trial and making it feasible to conduct a full trial.

TRIAL REGISTRATION NUMBER

ANZCTR: 12617001405303.

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

OBJECTIVES

To investigate the short-term effectiveness of high-load versus low-load strengthening exercise on self-reported function in patients with hypermobility spectrum disorder (HSD) and shoulder symptoms.

METHODS

A superiority, parallel-group, randomised trial (balanced block randomisation, electronic concealment) including adult patients (n=100) from primary care with HSD and shoulder pain and/or shoulder instability ≥3 months. Patients received 16 weeks of shoulder exercises (three sessions/week): HEAVY (n=50, full-range, high-load, supervised twice/week) or LIGHT (n=50, neutral/mid-range, low-load, supervised three times). The primary outcome was the 16-week between-group difference in self-reported function measured with the Western Ontario Shoulder Instability Index (WOSI, scale 0-2100, 0=best, minimal important difference 252 points). Secondary outcomes were self-reported measures including quality of life and clinical tests including shoulder muscle strength and range of motion. An intention-to-treat analysis with multiple imputation was conducted by a blinded biostatistician using linear regression.

RESULTS

93 of 100 patients (93%) completed the 16-week evaluation. The mean WOSI score between-group difference significantly favoured HEAVY (-174.5 points, 95% CI -341.4 to -7.7, adjusted for age, sex, baseline score, clustering around clinic). The secondary outcomes were inconclusive, but patients in HEAVY were less likely to have a positive shoulder rotation test >180°, and more likely to rate an important improvement in physical symptoms. There were no serious adverse events, but HEAVY was associated with more transient muscle soreness (56% vs 37%) and headaches (40% vs 20%).

CONCLUSION

High-load shoulder strengthening exercise was statistically superior to low-load strengthening exercise for self-reported function at 16 weeks and may be used in primary care to treat patients with HSD and shoulder pain and/or instability to improve shoulder function in the short term. Further studies are needed to confirm the clinical relevance, and patients should be supported to manage associated minor adverse events.

TRIAL REGISTRATION NUMBER

NCT03869307.

Writing up your clinical trial report for a scientific journal: the REPORT trial guide for effective and transparent research reporting without spin

The REPORT guide is a ‘How to’ guide to help you report your clinical research in an effective and transparent way. It is intended to supplement established first choice reporting tools, such as Consolidated Standards of Reporting Trials (CONSORT), by adding tacit knowledge (ie, learnt, informal or implicit knowledge) about reporting topics that we have struggled with as authors or see others struggle with as journal reviewers or editors. We focus on the randomised controlled trial, but the guide also applies to other study designs. Topics included in the REPORT guide cover reporting checklists, trial report structure, choice of title, writing style, trial registry and reporting consistency, spin or reporting bias, transparent data presentation (figures), open access considerations, data sharing and more. Preprint (open access): https://doi.org/10.31219/osf.io/qsxdz.