Exercise into Pain in Chronic Rotator Cuff-Related Shoulder Pain: A Randomized Controlled Trial with 6-Month Follow-Up

Abstract

Purpose: Exercise therapy is the first-line treatment in rotator cuff-related shoulder pain (RCRSP), and diverse types of exercise seem effective. However, it is not still clear if painful exercise should be allowed or avoided during exercises. The objective of this study was to investigate if exercise into pain is more effective than no pain in RCRSP.

Patients and methods: A randomized controlled trial was conducted in a physiotherapy clinic in Belgium. Forty-three participants with chronic RCRSP were randomly allocated to G1 (exercising into pain) or G2 (exercising without pain) in a 12-week intervention with 6-month follow-up. Primary outcome was the Shoulder Pain and Disability Index (SPADI); secondary outcomes were pain intensity, fear-avoidance beliefs, fear of pain, quality of life, strength, and range of motion. Outcomes were measured at baseline (T0), after 9 weeks (T1), 12 weeks (T2), and 6 months (T3) from the first session and analysed with linear mixed models.

Results: No between-group difference in SPADI (time-by-group interaction, p = 0.25) up to 6 months was found, with mean difference (G1-G2) at T1 = 5.78 (CI95%: -3.43,14.59; p = 0.33), at T2 = 0.93 (CI95%: -7.20,9.05; p = 0.82), at T3 = 4.15 (CI95%: -2.61,10.92; p = 0.33). No between-group differences were found for any other outcomes.

Conclusion: Pain provocation seems not to be necessary in RCRSP for achieving successful treatment effect in pain and disability reduction, fear-related beliefs, and quality of life up to 6 months.

Trial registration: ClinicalTrials.gov NCT04553289.

Keywords: exercise therapy; physical therapy modalities; rehabilitation; shoulder impingement syndrome; shoulder pain.

Figure 1

Flowchart diagram (modified CONSORT flowchart 2010). PROMs outcomes included: SPADI total, SPADI subscale pain, SPADI subscale function, VAS% in movement, VAS% at night, VAS% in the last 24h, FPQ-9 total, FPQ subscale severe, FPQ subscale medical, FPQ subscale minor, FABQ subscale physical activity, FABQ subscale work, EQ-5D index and EQ-VAS. Physical outcomes included: strength in external and internal rotation, strength in scaption, active ROM in external and internal rotation, active ROM in scaption, passive ROM in external and internal rotation, passive ROM in scaption. The data from a patient was considered lost at a specific time point for PROMs or physical outcomes if: 1) the data set was entirely missing for all the scores at that specific time point 2) if the patient partially filled in the questionnaire and this resulted in a more than three missing final scores for PROMs.

Figure 2

SPADI over time. T0= baseline, T1= after 9 weeks, T2= after 12 weeks, T3= after 6 months from the first physiotherapy session. Time was considered as categorical variable in the statistical analysis and therefore the difference between time points is equal between T0-T1, T1-T2, T2-T3. Each error bar was constructed using a 95% confidence interval of the mean.