Littlewood et al (2015)

A Single Exercise vs Usual Physiotherapy for Shoulder Pain

Shoulder pain treatment could consist of just one exercise

'Usual' care seemed equally effective

Introduction

To this day it is unclear if multiple exercises are superior to a single exercise in patients suffering from rotator cuff tendinopathy. Incremental benefits of adding more exercises that theoretically stress the same tissues might not be valid. A single exercise could be a more pragmatic, time-saving, and the cheaper option compared to usual care.

 

Methods

This multicenter RCT included 86 patients with a primary complaint of shoulder pain for more than three months, with no or minimal resting pain. Shoulder pain had to be provoked by resisted lateral rotation or abduction.

Patients were excluded if they underwent shoulder surgery within the last 6 months, and had reasons to suspect systemic pathology including inflammatory disorders, cervical repeated movement testing affecting shoulder pain, and/or range of movement.

Thirty-one experienced clinicians took part and were trained by the lead author.

The patients in the intervention group were instructed to exercise twice daily for three sets of 10-15 repetitions. The single exercise was determined so the pain was reproduced, although not increased after cessation. Typically, the program started out with isometric abduction, and progressed to isotonic abduction. If symptom exacerbation after exercise was apparent, other movements like lateral rotation or flexion were explored. Although abduction was a popular first exercise, patients and physiotherapists were encouraged to take the most painful movement as an exercise. Meaning this could also be a bench press, tennis serve, reaching up to a shelf, etc.

Usual care consisted of physiotherapeutic treatment of exercise, education, advice, stretching, massage, acupuncture, electrotherapy, strapping, manual therapy, and or corticosteroid injections at the discretion of the physiotherapist.

The primary outcome measure was the SPADI questionnaire for pain and function measured at baseline, three, six, and 12 months.

 

Results

By six months the patients in the self-managed exercise group reported a 29.1-point change in SPADI score from baseline and the patients in the usual physiotherapy treatment group reported a 23.5-point change. No differences were apparent between groups at three, six, and 12 months.

Table 4 littlewood 2015 single exercise
From: Littlewood et al (2015), Clinical Rehabilitation

 

Questions and thoughts

So physiotherapy is no rocket science and we don’t ‘need’ all our bells and whistles — right? Are most of our modalities unnecessary? Maybe we should just appeal to natural history then? All patients were educated in progressing exercises. The movements had to be painful, yet not exacerbate symptoms post-exercise. Knowing pain can be reproduced and that moving is not inherently dangerous, might be a huge relief for patients. Could this limit catastrophizing, fear avoidance, and negative beliefs about prognosis? To be completely frank, we do not know if exercises have to be painful. We actually do not know any parameters at all. Maybe avoiding painful exercises might alter results? Lots of questions to be asked.

 

Talk nerdy to me

Overall, I think this is an interesting study setup. It turned out that neither of the two treatments was superior to one another. Yet, they both improved statistically and clinically significant.

The study has a number of limitations. Although it meant that all patients remained in the same group, there is a good chance that some participants of the intervention group received full treatment from the physiotherapist. The intervention group was provided with one exercise to perform at home. What about compliance? Is it lower since it’s home-based? Or is it higher since it’s a single less time-consuming exercise?

On top of that, the control group got extended treatments with a lot of variety among the 31 physiotherapists. The time invested in the patient during full treatment can build a therapeutic alliance and can positively influence results. Physiotherapists and patients can sit together, discuss goals and formulate what stimulates adherence. Feedback and assurance during exercises in-clinic might also stimulate adherence. On top of this, other contextual effects might enhance results in the multimodal treatment group. Knowing this, it’s even more surprising that no differences were found.

Since there is no difference in results between the two groups, one can hypothesize that everything but the exercises had no value. We could also state that both interventions have a minimal effect and that the natural history of the rotator cuff pathology has caused the greatest decrease in pain and increase in function. A third trial arm would be needed to evaluate this.

The patients and therapists were obviously not blinded — as is with a lot of physiotherapy trials. One might say there could be a performance bias for the intervention arm. The patients in the intervention group knew they were the most ‘interesting’ group.

One of the biggest limitations is that not every patient started treatment on the second measure at three months in the control group due to delays in the healthcare system. These results can therefore be taken with a grain of salt.

To end on a positive note, this study was methodologically sound, had a low risk of bias, and provided useful insight into this field.

 

Take Home Messages

  • Physical therapy for subacromial shoulder pain can potentially be very simple
  • A prime focus on a painful movement or activity and building it up gradually may be effective
  • Specific parameters regarding exercise therapy are still not known

 

Reference

Littlewood, C., Bateman, M., Brown, K., Bury, J., Mawson, S., May, S., & Walters, S. J. (2016). A self-managed single exercise programme versus usual physiotherapy treatment for rotator cuff tendinopathy: a randomised controlled trial (the SELF study). Clinical rehabilitation30(7), 686-696.

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