The GRASP Trial: Comparing CS Injections with Advice and Exercise for Shoulder Pain
Rotator cuff complaints could possibly be self-managed
Read about one of the biggest studies within rotator cuff related shoulder pain and physiotherapy
About 1% of adults each year present with shoulder complaints at their GP. A whopping 70% of those are rotator cuff complaints. Evidence suggests that exercise can help, although long-term results are unknown; the same is true for corticosteroid injections. Corticosteroid injections (CSI) are often administered to lower inflammation and alleviate pain in this patient group. The aim of this study was to compare four groups:
- Best practice advice
- Best practice advice + CSI
- Progressive exercise program
- Progressive exercise program + CSI
This is a multicentre, pragmatic, superiority, randomized controlled trial using a 2 × 2 factorial design. Patients were recruited from 20 different health service administrations in the UK. If shoulder complaints due to the rotator cuff (tendinopathy, tendinitis, cuff tear) started in the last 6 months, and the patient was 18 years or older, they were eligible for the trial. The diagnostic criteria of the British Elbow and Shoulder Society (BESS) were used. Page 16 of this guideline shows a useful flowchart regarding the diagnosis of subacromial shoulder pain.
- Significant shoulder trauma
- Full-thickness tears requiring surgery
- Neuro diseases
- Other shoulder conditions
- Having received a CSI or a physiotherapy treatment in the past 6 months
How did the groups look?
- Best practice advice: one face-to-face session with a physiotherapist and a home exercise program supported by high-quality self-management materials.
- Best practice advice preceded by a CSI
- Progressive exercise program: individually tailored and prescribed and supervised by a physiotherapist involving up to six face-to-face sessions over 16 weeks.
- Progressive exercise program preceded by a CSI
A second injection could be given after 6 weeks if the patient reacted positively to the first.
Patients were equally divided into the four groups.
What did the face-to-face exercise sessions look like? The first appointment was 60 minutes long and covered the examination and exercise prescription part. The five others were 20-30 minutes long and focused on progressing or regressing the exercises according to the protocol.
Participants received a folder with advice, an exercise action planner, a diary, and instructions on the exercises. Resistance bands were used if required. Exercises were to be performed five times a week.
The best practice advice group did not receive the previously mentioned five sessions. The exercises, however, did differ in this group. They received a simple set of self-guided exercises (with video access) that they were able to progress en regress depending on their capability. The exercises were performed five times a week (as in the other group), unsupervised, in a simpler form.
Patients were allowed to receive other treatments during the trial, these were recorded as an outcome.
The mean age of the participants was 55 years with an equal male to female ratio. The mean symptom duration was 4 months and the overall baseline SPADI score 54/130 (more = worse).
There were no differences between any of the groups at any time-point, except at 8 weeks for receiving a steroid injection. It seemed that patients that received a CSI, had better pain and function scores compared to those that didn’t. In a subgroup analysis, the authors found that those with higher SPADI scores (= worse) had the greatest benefit of this injection for a short while.
Talk Nerdy To Me
This is a huge, excellent, and much-needed trial within physiotherapy. Statistically en methodologically this trial is superb and deserves its attention. There are only a few comments to be made.
First off, there is no control group which makes it hard to factor in natural history. Maybe these patients just got better from reassurance and some basic movements?
The second thing is probably getting discussed most online — and that’s the possible ‘spin’ or ‘false’ representation of the finding. The authors highlight that best practice advice works just as well as progressive exercises. However — as you can see in the methods — both groups received exercises and it is unclear where these differed, apart from the fact that the progressive exercise groups had the opportunity to follow six supervised sessions. So maybe a name change to ‘best practice advice + progressive home exercise group’ and ‘best practice advice + progressive supervised exercise group’ was more suitable.
When looking at the tables we see that barely 25% of the supervised exercise group attended the sixth session. Can we really call this supervised then?
Not all groups were equally effective and the authors note that at 8 weeks, patients that received a corticosteroid injection were slightly better off at that time point. However, is this a good time to receive a steroid injection? Some might find it to be early since these patients ‘only’ had pain for four months on average.
A final comment to be made is the fact that the patients received a plethora of exercises while the recent consensus statement clearly advises no more than three exercises.
Take Home Messages
After your exam, you can provide different pathways for your patients. Discuss if they would like to self-manage it with check-ups at certain time points, or if they would like supervised sessions for whatever reason (confidence and compliance might be two examples).