Exercise therapy after corticosteroid injection for moderate to severe shoulder pain: large pragmatic randomised trial

Dickon P Crawshaw, Philip S Helliwell, Elizabeth M A Hensor, Elaine M Hay, Simon J Aldous, Philip G Conaghan, Dickon P Crawshaw, Philip S Helliwell, Elizabeth M A Hensor, Elaine M Hay, Simon J Aldous, Philip G Conaghan

Abstract

Objective: To compare the effectiveness of subacromial corticosteroid injection combined with timely exercise and manual therapy (injection plus exercise) or exercise and manual therapy alone (exercise only) in patients with subacromial impingement syndrome.

Design: Pragmatic randomised clinical trial.

Setting: Primary care based musculoskeletal service. Patients Adults aged 40 or over with subacromial impingement syndrome with moderate or severe shoulder pain.

Interventions: Injection plus exercise or exercise only.

Main outcome measures: Primary outcome was the difference in improvement in the total shoulder pain and disability index at 12 weeks.

Results: 232 participants were randomised (115 to injection plus exercise, 117 to exercise only). The mean age was 56 (range 40-78), 127 were women, and all had had a median of 16 weeks of shoulder pain (interquartile range 12-28). At week 12 there was no significant difference between the groups in change in total pain and disability index (mean difference between change in groups 3.26 (95% confidence interval -0.81 to 7.34), P=0.116). Improvement was significantly greater in the injection plus exercise group at week 1 (6.56, 4.30 to 8.82) and week 6 (7.37, 4.34 to 10.39) for the total pain and disability index (P<0.001), with no differences at week 24 (-2.26, -6.77 to 2.25, P=0.324).

Conclusions: In the treatment of patients with subacromial impingement syndrome, injection plus exercise and exercise only are similarly effective at 12 weeks. Trial registration ISRCT 25817033; EudraCT No 2005-003628-20.

Conflict of interest statement

Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare that (1) DPC and PGC have support from Arthritis Research UK for the submitted work. All authors declare no interests under (2), (3), and (4).

Figures

https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4787631/bin/crad717769.f1_default.jpg
Recruitment flowchart, including reasons for non-inclusion and exclusion

References

    1. Van der Windt DA, Koes BW, de Jong BA, Bouter LM. Shoulder disorders in general practice: incidence, patient characteristics, and management. Ann Rheum Dis 1995;54:959-64.
    1. Linsell L, Dawson J, Zondervan K, Rose P, Randall T, Fitzpatrick R, et al. Prevalence and incidence of adults consulting for shoulder conditions in UK primary care; patterns of diagnosis and referral. Rheumatology (Oxford) 2006;45:215-21.
    1. Croft P, Pope D, Silman A. The clinical course of shoulder pain: prospective cohort study in primary care. Primary Care Rheumatology Society Shoulder Study Group. BMJ 1996;313:601-2.
    1. Neer CS 2nd. Impingement lesions. Clin Orthop Relat Res 1983;173:70-7.
    1. Ostor AJ, Richards CA, Prevost AT, Speed CA, Hazleman BL. Diagnosis and relation to general health of shoulder disorders presenting to primary care. Rheumatology (Oxford) 2005;44:800-5.
    1. Chard MD, Hazleman R, Hazleman BL, King RH, Reiss BB. Shoulder disorders in the elderly: a community survey. Arthritis Rheum 1991;34:766-9.
    1. Hay EM, Thomas E, Paterson SM, Dziedzic K, Croft PR. A pragmatic randomised controlled trial of local corticosteroid injection and physiotherapy for the treatment of new episodes of unilateral shoulder pain in primary care. Ann Rheum Dis 2003;62:394-9.
    1. Van der Windt DA, Koes BW, Deville W, Boeke AJ, de Jong BA, Bouter LM. Effectiveness of corticosteroid injections versus physiotherapy for treatment of painful stiff shoulder in primary care: randomised trial. BMJ 1998;317:1292-6.
    1. Winters JC, Sobel JS, Groenier KH, Arendzen HJ, Meyboom-de Jong B. Comparison of physiotherapy, manipulation, and corticosteroid injection for treating shoulder complaints in general practice: randomised, single blind study. BMJ 1997;314:1320-5.
    1. Green S, Buchbinder R, Glazier R, Forbes A. Systematic review of randomised controlled trials of interventions for painful shoulder: selection criteria, outcome assessment, and efficacy. BMJ 1998;316:354-60.
    1. Green S, Buchbinder R, Hetrick S. Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev 2003;2:CD004258.
    1. Sauers EL. Effectiveness of rehabilitation for patients with subacromial impingement syndrome. J Athl Train 2005;40:221-3.
    1. Morrison DS, Frogameni AD, Woodworth P. Non-operative treatment of subacromial impingement syndrome. J Bone Joint Surg Am 1997;79:732-7.
    1. Engebretsen K, Grotle M, Bautz-Holter E, Sandvik L, Juel NG, Ekeberg OM, et al. Radial extracorporeal shockwave treatment compared with supervised exercises in patients with subacromial pain syndrome: single blind randomised study. BMJ 2009;339:b3360.
    1. Brox JI, Staff PH, Ljunggren AE, Brevik JI. Arthroscopic surgery compared with supervised exercises in patients with rotator cuff disease (stage II impingement syndrome). BMJ 1993;307:899-903.
    1. Brox JI, Gjengedal E, Uppheim G, Bohmer AS, Brevik JI, Ljunggren AE, et al. Arthroscopic surgery versus supervised exercises in patients with rotator cuff disease (stage II impingement syndrome): a prospective, randomized, controlled study in 125 patients with a 2 1/2-year follow-up. J Shoulder Elbow Surg 1999;8:102-11.
    1. Kuhn JE. Exercise in the treatment of rotator cuff impingement: a systematic review and a synthesized evidence-based rehabilitation protocol. J Shoulder Elbow Surg 2009;18:138-60.
    1. Arroll B, Goodyear-Smith F. Corticosteroid injections for painful shoulder: a meta-analysis. Br J Gen Pract 2005;55:224-8.
    1. Brox JI, Roe C, Saugen E, Vollestad NK. Isometric abduction muscle activation in patients with rotator tendinosis of the shoulder. Arch Phys Med Rehabil 1997;78:1260-7.
    1. Carette S, Moffet H, Tardif J, Bessette L, Morin F, Fremont P, et al. Intraarticular corticosteroids, supervised physiotherapy, or a combination of the two in the treatment of adhesive capsulitis of the shoulder: a placebo-controlled trial. Arthritis Rheum 2003;48:829-38.
    1. Calis M, Akgun K, Birtane M, Karacan I, Calis H, Tuzun F. Diagnostic values of clinical diagnostic tests in subacromial impingement syndrome. Ann Rheum Dis 2000;59:44-7.
    1. MacDonald PB, Clark P, Sutherland K. An analysis of the diagnostic accuracy of the Hawkins and Neer subacromial impingement signs. J Shoulder Elbow Surg 2000;9:299-301.
    1. Saunders S, Cameron G. Injection techniques in orthopaedic and sports medicine. W B Saunders, 1997.
    1. ACPOM. A clinical guideline for the use of injection therapy by physiotherapists. Chartered Society of Physiotherapy, 1999.
    1. Bang MD, Deyle GD. Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. J Orthop Sports Phys Ther 2000;30:126-37.
    1. Senbursa G, Baltaci G, Atay A. Comparison of conservative treatment with and without manual physical therapy for patients with shoulder impingement syndrome: a prospective, randomized clinical trial. Knee Surg Sports Traumatol Arthrosc 2007;15:915-21.
    1. Roach KE, Budiman-Mak E, Songsiridej N, Lertratanakul Y. Development of a shoulder pain and disability index. Arthritis Care Res 1991;4:143-9.
    1. Williams JW Jr, Holleman DR Jr, Simel DL. Measuring shoulder function with the shoulder pain and disability index. J Rheumatol 1995;22:727-32.
    1. Tennant A, Conaghan PG. The Rasch measurement model in rheumatology: what is it and why use it? When should it be applied, and what should one look for in a Rasch paper? Arthritis Rheum 2007;57:1358-62.
    1. Foster NE, Dziedzic KS, van der Windt DA, Fritz JM, Hay EM. Research priorities for non-pharmacological therapies for common musculoskeletal problems: nationally and internationally agreed recommendations. BMC Musculoskelet Disord 2009;10:3.
    1. Watson J, Helliwell P, Morton V, Adebajo A, Dickson J, Russell I, et al. Shoulder acute pain in primary healthcare: is retraining effective for GP principals? SAPPHIRE—a randomized controlled trial. Rheumatology (Oxford) 2008;47:1795-802.
    1. Bamji AN. Treatment of shoulder pain. Ann Rheum Dis 2004;63:607.
    1. Van der Windt DA, Koes BW, Boeke AJ, Deville W, De Jong BA, Bouter LM. Shoulder disorders in general practice: prognostic indicators of outcome. Br J Gen Pract 1996;46:519-23.
    1. Kuijpers T, van der Windt DA, Boeke AJ, Twisk JW, Vergouwe Y, Bouter LM, et al. Clinical prediction rules for the prognosis of shoulder pain in general practice. Pain 2006;120:276-85.
    1. Ekeberg OM, Bautz-Holter E, Tveita EK, Juel NG, Kvalheim S, Brox JI. Subacromial ultrasound guided or systemic steroid injection for rotator cuff disease: randomised double blind study. BMJ 2009;338:a3112.
    1. Adebajo AO, Nash P, Hazleman BL. A prospective double blind dummy placebo controlled study comparing triamcinolone hexacetonide injection with oral diclofenac 50 mg TDS in patients with rotator cuff tendinitis. J Rheumatol 1990;17:1207-10.
    1. Petri M, Dobrow R, Neiman R, Whiting-O’Keefe Q, Seaman WE. Randomized, double-blind, placebo-controlled study of the treatment of the painful shoulder. Arthritis Rheum 1987;30:1040-5.
    1. Vecchio PC, Hazleman BL, King RH. A double-blind trial comparing subacromial methylprednisolone and lignocaine in acute rotator cuff tendinitis. Br J Rheumatol 1993;32:743-5.
    1. Blair B, Rokito AS, Cuomo F, Jarolem K, Zuckerman JD. Efficacy of injections of corticosteroids for subacromial impingement syndrome. J Bone Joint Surg Am 1996;78:1685-9.
    1. McInerney JJ, Dias J, Durham S, Evans A. Randomised controlled trial of single, subacromial injection of methylprednisolone in patients with persistent, post-traumatic impingement of the shoulder. Emerg Med J 2003;20:218-21.
    1. Plafki C, Steffen R, Willburger RE, Wittenberg RH. Local anaesthetic injection with and without corticosteroids for subacromial impingement syndrome. Int Orthop 2000;24:40-2.
    1. Roland M, Torgerson DJ. What are pragmatic trials? BMJ 1998;316:285.
    1. Naredo E, Cabero F, Beneyto P, Cruz A, Mondejar B, Uson J, et al. A randomized comparative study of short term response to blind injection versus sonographic-guided injection of local corticosteroids in patients with painful shoulder. J Rheumatol 2004;31:308-14.

Source: PubMed

Sponsors et collaborateurs

Les conditions médicales

Interventions en matière de drogue

3
S'abonner