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This is a plain English summary of an original research article

A single session with a physiotherapist, along with an exercise programme to follow at home, is an effective treatment for shoulder pain. In people with problems relating to the muscles around the shoulder (rotator cuff), this one-off session improved pain and function as effectively as a comprehensive programme of supervised physiotherapy.  An injection of steroid (corticosteroid, which reduces inflammation) could help at first but made no difference to long-term recovery.

The rotator cuff is a group of four muscles around the shoulder joint, which stabilise it and control movement. Problems with the rotator cuff are common and can cause long-lasting pain and disability. However, it is unclear how best to treat these problems.

A large, randomised trial was carried out in NHS Trusts across the UK. It tested combinations of treatments to find which improves shoulder pain and function most, and which is most cost-effective. The results suggest that a single session of physiotherapy advice plus an exercise programme to follow at home, is suitable for most people. Adding a corticosteroid injection might reduce pain during the first eight weeks.

The trial provides high-quality evidence to guide physiotherapy services, GPs, and commissioners about effective treatments for people with shoulder pain caused by rotator cuff disorders.

Further information on shoulder pain and rotator cuff disorders are available on the NHS website.

What’s the issue?

Shoulder pain is common, especially among people over 45; it accounts for 2 in every 100 GP appointments. Most (70%) shoulder pain is caused by disorder of the rotator cuff muscles, which hold the shoulder joint in place.

Previous reviews of research have found uncertainty about how best to treat rotator cuff disorders. Treatments have included rest, exercise, physiotherapy, corticosteroid injection, massage, and pain relief drugs. Some evidence suggests that exercise, physiotherapy advice and corticosteroid injections work better than no treatment.

This is the largest trial carried out to date on treatments for rotator cuff disorders. It looked at improvements in pain and function with different treatment approaches.

What’s new?

Researchers recruited more than 700 people through 20 NHS Trusts. They had shoulder pain related to the rotator cuff and were randomly assigned to receive either:

  • up to 6 sessions of an exercise programme (that builds up over 16 weeks),  tailored to them and supervised by a physiotherapist, plus exercises at home
  • one-off advice from a physiotherapist with a home exercise programme supported by a booklet and videos
  • a corticosteroid injection into the shoulder joint followed by the 6 sessions of physiotherapy
  • a corticosteroid injection into the shoulder joint followed by the one-off advice and home exercise programme.

Exercises at home were a core part of treatment, regardless of which group they were in. People were asked to do their exercises 5 days per week.

Trial participants filled out questionnaires about shoulder pain and function at the start of the study, after 8 weeks, 6 months and 12 months.

After 12 months, the trial found:

  • people reported similar improvements in pain and function, regardless of which physiotherapy they received; one-off advice worked as well as supervised exercise sessions
  • the corticosteroid injection reduced pain and disability at 8 weeks; however, there was no difference at 12 months.

The researchers looked at the value for money of each option. Their  analysis showed that one-off advice plus a corticosteroid injection could be the most cost-effective use of NHS resources, although there was some uncertainty about the finding as the injection only helped in the short-term.

Why is this important?

A one-off session with a physiotherapist, followed by a home exercise programme supported by a booklet and videos, is an effective treatment. People with shoulder pain relating to a rotator cuff disorder benefitted as much from this self-management approach as from a comprehensive programme of supervised exercise sessions with a physiotherapist (plus home exercises). The one-off session would free up time for both patients and physiotherapists; it could save NHS Trusts money.

Corticosteroid injections improved shoulder pain and function at 8 weeks. The trial suggested that people in most pain may benefit most, but the researchers say this was not certain from their results. By 12 months, the injection made no difference to pain or function.

The National Institute for Health and Care Excellence (NICE) has not issued guidelines on treatments for rotator cuff disorder. There is likely to be variation in the approaches used around the country. NHS Trusts and commissioning groups could incorporate the findings of this study into their routine treatment pathways for shoulder pain.

What’s next?

The researchers are working on a training package for physiotherapists which will allow them to deliver the one-off advice session, which delivers strategies to help people stick to the exercise plan, and progress through it without further supervision. The training package also gives physiotherapists access to the self-management exercise programmes used in the study. The researchers say that physiotherapists will be familiar with the exercises; implementing this programme would be straightforward.

Many physiotherapy services that took part in the trial are now using the one-off best practice advice system. However, the researchers warn that self-management is not suitable for everyone. Some people, such as those with low literacy, or those in intense pain, may still need more than one session with a physiotherapist.

Not everyone in the trial had recovered after 12 months. Future research should look at rotator cuff disorders which do not improve and explore what can be done for people who continue to have pain and disability.

You may be interested to read

This NIHR Alert is based on: Hopewell S, Keene DJ, Marian IR, and others. Progressive exercise compared with best practice advice, with or without corticosteroid injection, for the treatment of patients with rotator cuff disorders (GRASP): a multicentre, pragmatic, 2 × 2 factorial, randomised controlled trial. Lancet 2021;398:416–28

The trial website including all papers related to the project.

 

Funding: This research was funded by the NIHR Health Technology Assessment programme.

Conflicts of Interest: Sally Hopewell is a member of the NIHR Health Technology Assessment (HTA) Clinical Evaluation and Trials Committee.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.


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Commentaries

Study author

People with rotator cuff disorder are of working age, trying to get to hospital or to see a physiotherapist involves taking time off work and being able to travel and park and so on. The fact that good self-management supported by a physiotherapist is as good as having more appointments is good news.Self-management is not suitable for everybody. That’s a really important message to get across. A one-off appointment with really good self-management is suitable for most people but not all. Those in large amounts of pain, for example, or people who find self-management more difficult, may struggle with it.We have known there is some short-term benefit from corticosteroid injections, but trials had not had long-term follow up. At 8 weeks there was a small improvement only, but we didn’t see it at 6 or 12 months.For most people, a one-off session with a physiotherapist with high quality self-management would be suitable.Sally Hopewell, Professor of Clinical Trials and Evidence Synthesis, Oxford Clinical Trials Research Unit, University of Oxford 

Physiotherapist

I work as a physiotherapist in GP services and am the first contact for people with musculoskeletal issues (affecting joints, bones, muscles). I treat people with acute shoulder pain from initial diagnosis to longer-term management; this research is very relevant to my work.Overall, the most important outcome from this paper is about cost-effectiveness. It suggests that a one-off appointment with an appropriately qualified person, plus information, is all that may be needed for people with rotator cuff disorders.People may need guidance and reassurance that the one-off sessions are appropriate for them. Practitioners will need access to the information that was handed out in the study.It will be important to continue the follow up at 24 and 36 months to see what the longer-term outcomes of the treatments are. We need to know whether symptoms return, whether people come back for further steroid injections, and how they get on with self-management of exercises. This would give a longer-term assessment of cost-effectiveness, in keeping with the NHS Long Term Plan.Brian Campbell, Extended Scope and Musculoskeletal Physiotherapist and First Contact Practitioner, Tees Valley CCG 
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