Evidence
Alert

Physiotherapist-led exercise eases shoulder pain but ultrasound guidance for injections makes no difference, study finds

A large trial of interventions for people with shoulder pain showed that they benefitted more from personalised exercise programmes supervised by physiotherapists than from an exercise leaflet and standard advice. It also showed that guiding shoulder injections using ultrasound provided no added benefit over the usual, non-guided approach to these injections.

Pain associated with structures around the shoulder joint is called subacromial pain syndrome (SAPS). SAPS is common, and accounts for half of all shoulder pain.

All participants in this trial received a steroid injection into the subacromial space next to the shoulder joint, but some injections were guided by ultrasound and some were unguided. All participants were encouraged to exercise, but for some this was guided by physiotherapists and for others this was provided via a standardised exercise leaflet.

Participants reported greater improvements in pain and shoulder function when a physiotherapist prepared and supervised their exercise programme. This involved up to six clinic-based sessions with the physiotherapist plus a home exercise programme. Participants who had the physiotherapist-guided exercise were more likely to carry out the daily exercises at home than those provided with the exercise leaflet.

Ultrasound guidance makes steroid injections more precise. But it requires specialist skills, training and equipment and therefore adds cost. The study found guided injections were no more beneficial than non-guided injections.

What’s the issue?

About one in ten adults experience SAPS and it is usually treated without surgery. They may have a steroid injection into the subacromial space in the shoulder and be sent home with a standard leaflet with advice about regular shoulder exercises.

For some people, this initial intervention does not reduce their pain.  This could be because they are not performing the recommended exercises, because the exercises are not sufficiently personalised, or because the needle is placed inaccurately when the steroid injection is given. Some experts argue that ultrasound imaging, which shows the tissue and the needle, might improve precision and outcomes.

Small trials of ultrasound-guided injections have produced mixed results. And there is little information on the best way to deliver exercise treatments. This study – the largest of its kind – offers reliable data on the best way to help people with SAPS.

What’s new?

The study randomly placed 256 adults with SAPS into one of four treatment groups:

  1. guided injection and exercise leaflet
  2. unguided injection and exercise leaflet
  3. guided injection and physiotherapist-led exercise programme
  4. unguided injection and physiotherapist-led exercise programme.

Individuals were followed up at six weeks, six months and a year after treatment. Researchers recorded pain and other symptoms on a scale and asked about time off work and other relevant measures.

The results showed:

  • Physiotherapist-led exercise improved pain and function scores after six months compared to the standard leaflet. However, the differences in improvements were reduced by 12 months.
  • More people in the physiotherapist-led exercise groups reported that they performed daily exercises after six weeks (86% versus 64%) and six months (63% vs 51%) than those who received the leaflet. But by 12 months, the difference in how often the exercises were performed had disappeared.
  • Using ultrasound to guide steroid injections did not improve symptoms compared with unguided injections.

Overall, the results indicate that personalised exercise programmes help people with SAPS but ultrasound guidance for steroid injections makes no difference to outcomes.

Why is this important?

The study shows that people with SAPS benefit from physiotherapist-led exercise programmes, which are tailored to individual needs, supervised in up to six sessions and supplemented with a home exercise programme. This approach was more effective at six months than simply sending patients home with a leaflet that contains standardised exercise advice and instruction. It is likely that this benefit was not seen at 12 months because people were performing the exercises less often by then. The challenge is to keep people doing exercises over the longer-term.

However, the results challenge the idea that steroid injections into the subacromial space should be guided by ultrasound imaging. The study found no improvement in symptoms over unguided injections to justify the additional cost and additional expertise required.

What’s next?

The evidence shows that patients with SAPS would benefit from an exercise programme that is individualised, supervised and progressed over time by physiotherapists. But it suggests the added cost of using ultrasound to guide steroid injections is not worth it, at least for first-time shoulder injections.

Unguided injections would potentially reduce the cost of treatment since the additional specialist skills, training and equipment needed to guide injections by ultrasound would not be needed.

The study showed that only half of patients, including those on the physiotherapist-led programme, were still performing daily exercise after twelve months. Further research is needed to find ways to maintain exercise behaviour – and accompanying reductions in symptoms – in the medium-to-long term.

You may be interested to read

The full study: Roddy E, and others. Optimising outcomes of exercise and corticosteroid injection in patients with subacromial pain (impingement) syndrome: a factorial randomised trial. British Journal of Sports Medicine 2020;0:1-11

Systematic review of exercise for shoulder pain: Naunton J, and others. Effectiveness of progressive and resisted and non-progressive or non-resisted exercise in rotator cuff related shoulder pain: a systematic review and meta-analysis of randomized controlled trials. Clinical Rehabilitation. 2020;34:1198-1216

A further systematic review: Gutiérrez-Espinoza H, and others. Effect of supervised physiotherapy versus home exercise program in patients with subacromial impingement syndrome: A systematic review and meta-analysis. Physical Therapy in Sport. 2020;41:34-42

NHS information on shoulder impingement

Funding

This research was supported by the NIHR Research for Patient Benefit programme.

Commentaries

Study author

This evidence is ready for implementation to ensure patients have access to physiotherapist-led exercise programmes, and to reduce the use of ultrasound guidance for first-time shoulder injections.

Previous small research studies had suggested that ultrasound-guided injection into the subacromial space produces greater improvement in shoulder pain and function than unguided injection. Our trial is the largest to date to compare these two approaches to shoulder injection, and it was surprising that we found no additional benefit from ultrasound-guided injection, compared with usual unguided injection.

Edward Roddy, Reader in Rheumatology and Honorary Consultant Rheumatologist, Keele University

Member of the public

This paper could influence how the condition is treated in future. For example, clinical commissioning groups (CCGs) might be more likely to pay for physiotherapist-led sessions within NHS services, rather than home-based one off treatments.

Physiotherapist-led sessions require more clinical time and more appointment time, which will need to be costed. However, as they may have better outcomes, there might be less need for repeat sessions, referrals and injections, reducing costs to the service. Additionally, this paper argues for a reduction in the unnecessary use of ultrasound equipment, which would also reduce clinical time and costs.

Charlotte Marlow, Public Contributor, Dymchurch, Kent

Physiotherapist

This research will provide confidence in current common physiotherapy practice: patient-specific exercise regimes, that are clinically-reasoned, and based on symptom reporting and testing. It could help to educate physiotherapists and orthopaedic consultants on the success of such exercise programs.

The findings can also help commissioning groups understand the need for face-to-face appointments with instructed physiotherapy (in non-pandemic times), and can help patients understand the importance and benefit of following an exercise plan.

The COVID-19 situation has presented significant challenges within outpatient physiotherapy. Alongside seeing patients face to face and coping with staff redeployment to pressured areas of the hospital, telephone and video appointments have become a more common occurrence.

Although these alterations in standard practice have meant development of new skills and assessment techniques has been necessary, those patients who are appropriate for virtual appointments have benefitted well during a difficult time.

David Sprot, Lead Senior Physiotherapist (Foot and Ankle Specialist), Chesterfield Royal Hospital NHS Trust

Conflicts of Interest

None declared.