Adherence Patterns and Dose Response of Physiotherapy for Rotator Cuff Pathology: Longitudinal Cohort Study

David Burns, Philip Boyer, Helen Razmjou, Robin Richards, Cari Whyne, David Burns, Philip Boyer, Helen Razmjou, Robin Richards, Cari Whyne

Abstract

Background: Physiotherapy is considered to be essential for the successful operative and nonoperative management of rotator cuff pathology; however, the extent to which patients adhere to assigned physiotherapy activities and how this impacts recovery is unknown.

Objective: The purpose of this study was to measure the rate and patterns of participation in physiotherapy for rotator cuff disorders, assess the dose response between physiotherapy activity and recovery, and explore patient factors predictive of physiotherapy participation.

Methods: We report a prospective longitudinal study of 42 patients undergoing physiotherapy for symptomatic rotator cuff pathology. The patients were issued a smartwatch that recorded inertial sensor data while they performed physiotherapy exercises both in the clinic and in the home setting. A machine learning approach was used to assess total physiotherapy participation from smartwatch inertial data. Primary outcomes were the Disabilities of the Arm Shoulder and Hand and numeric pain rating scale assessed every 4 weeks until 12 weeks follow-up. The relationships between participation, outcomes, and clinical patient variables were assessed in univariable analyses.

Results: Mean physiotherapy exercise participation in clinic and at home were 11 minutes per week and 33 minutes per week, respectively, with patients participating in physiotherapy on 41% of days assigned to treatment. Home physiotherapy participation decreased significantly over time (P=.03). There was a statistically significant and clinically meaningful relationship between cumulative physiotherapy participation and recovery demonstrated by pain scores at 8 weeks (P=.02) and 12 weeks (P=.05) and disability scores at 8 weeks (P=.04) and 12 weeks (P=.04). Low patient expectations and self-efficacy were associated with low rates of physiotherapy participation.

Conclusions: There was a low rate of participation in home shoulder physiotherapy exercise, and a statistically and clinically significant dose response of physiotherapy on treatment outcome in patients with rotator cuff pathology. The findings highlight the opportunity to develop novel methods and strategies to improve the participation in and efficacy of physiotherapy exercises for rotator cuff disorders.

International registered report identifier (irrid): RR2-10.2196/17841.

Keywords: machine learning; rehabilitation; rotator cuff; treatment adherence and compliance; wearable electronic devices.

Conflict of interest statement

Conflicts of Interest: DB and CW hold equity in Halterix Corporation, a digital physiotherapy company founded by David Burns.

©David Burns, Philip Boyer, Helen Razmjou, Robin Richards, Cari Whyne. Originally published in JMIR Rehabilitation and Assistive Technology (http://rehab.jmir.org), 11.03.2021.

Figures

Figure 1
Figure 1
Patient flow through clinical study as of April 28, 2020. Physiotherapy treatment and data collection was suspended for 16 patients enrolled in the study due to physical-distancing measures imposed during the COVID-19 pandemic. PT: physiotherapy.
Figure 2
Figure 2
Clinical improvement in (a) pain and (b) disability. NPRS: numeric pain rating scale. DASH: Disability of the Arm, Shoulder, and Hand.
Figure 3
Figure 3
Predicted binary classification of physiotherapy exercise activity and interexercise rest periods overlaid on triaxial accelerometer data. The repetitive oscillatory patterns of exercise are correctly identified by the model.
Figure 4
Figure 4
Total physiotherapy participation by (a) sessions per day, (b) minutes per day, and (c) days per week.
Figure 5
Figure 5
Changes in physiotherapy participation for (a) home and (b) clinic settings.
Figure 6
Figure 6
Patterns of physiotherapy participation for (a) days of the week and (b) time of the day (from midnight to midnight the next day).
Figure 7
Figure 7
Physiotherapy dose response. Participation was defined as the ratio of physiotherapy exercise measured for a patient to an expectation of 20 minutes per day (100%).

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