Effectiveness of Supervised Motor Control Exercises on Rotator Cuff Tendinopathies
Condition: Shoulder Impingement Syndrome; Shoulder Rotator Cuff Tendinopathy
MeSH terms: Tendinopathy; Shoulder Impingement Syndrome
Study type: Interventional

Summary: 
      The shoulder is the most mobile joint in the body but still has the responsibility of
      ensuring a strong stability of our upper limbs during daily activities. The shoulder joint
      therefore requires a significant level of neuromuscular control at all times. The shoulder
      heavily relies on 4 key stabilizing muscles, known as the rotator cuff complex (RC). A
      tendinopathy of the RC may cause pain, significant muscle weakness, and a decrease in motor
      control of the shoulder during functional activities as well as work tasks. Individuals who
      have an RC tendinopathy often have neuromuscular and proprioceptive deficits. The objectives
      of this study are to evaluate the effectiveness of a brand new group strength and motor
      control exercise program for the upper extremities and to compare the effectiveness of this
      program to usual one-on-one physiotherapy care (such as manual therapy, motion exercises,
      strengthening, manual techniques) in reducing shoulder pain and improving overall function. A
      total of 33 participants suffering from an RC tendinopathy have been recruited; 16 have been
      assigned to the exercise group (EXP) and 17 participants have received usual physiotherapy
      care (CTL). Participants in the EXP group partook in the new exercise program 3 times / week
      for 6 weeks whereas participants in the CTL group received usual physiotherapy treatments
      twice / week with home exercises for 6 weeks. The results of this study will provide
      clinicians with a cost-effective and innovative treatment approach to treating shoulder pain.
      This study will provide active rehabilitation guidelines for reducing shoulder pain and the
      incidence of recurrence.
    

Detailed description: 
      The importance of our shoulders to everyday movement and activity is often not fully
      appreciated, until we are limited by injury or pain. The shoulder complex allow us to
      interact with our surroundings while acting as the functional link between our stable trunks
      and our free moving upper limbs. This is no easy task for highly mobile joints such as the
      shoulders. A shoulder injury can be functionally devastating to an individual, and can
      potentially place unnecessary financial stress on our health care system. Shoulder pain is
      currently among the most common reasons to visit a general practitioner or a physiotherapist
      today. Shoulder pain is third in prevalence, only to back and neck pain, and nearly
      two-thirds of adults suffer from shoulder pain at some point during their lives. Despite
      being an important focus for rehabilitative care, we have yet to confidently establish
      efficient and potentially cost effective methods for treating shoulder pathologies and pain.
      Among shoulder disorders, the rotator cuff (RC) muscles are the leading source of shoulder
      pain. Due to the vast mobility of the shoulder complex, it relies greatly on the stability
      and control provided by its supportive tissues, notably the rotator cuff muscles; often
      rendering them highly susceptible to injury. It has been noted that individuals affected by
      rotator cuff tendinopathies (RCt) often exhibit motor control and shoulder proprioception
      deficits. As noted by Cools and colleagues, rehabilitative training programs that focus on
      motor control are greatly needed for rehabilitation as well as to prevent re-injury.
      Accordingly, rehabilitation interventions should focus on motor (re)learning, targeting a
      better muscle coordination to reduce motor control impairments, optimize movement control,
      and improve muscle strength.

      Motor control rehabilitation: To address the motor control deficits among individuals
      affected by an RCt, we have developed a novel, structured, and supervised group
      exercise-based program focusing on neuromuscular reeducation. It is well documented in the
      scientific literature that motor control and proprioception exercises are crucial for healing
      among this population. However, the effectiveness of a group delivery method remains unknown.
      It is presently unclear how a group exercise program compares to one-on-one physiotherapy
      care for shoulder dysfunctions. The developed group program allows patients to individually
      progress their exercises based on their symptoms, while being guided and corrected by the
      supervising physiotherapist. This model allows several patients to access physiotherapy
      services simultaneously, while remaining cost and resource effective for the clinics. To
      appreciate the goal of the proposed exercise program, it is important to understand the
      physiological and biomechanical factors directly related to shoulder stability.

      Underlying mechanisms for shoulder stability: For its joint stability, the glenohumeral (GH)
      joint heavily depends on muscle strength, adequate synergistic activity between the
      neuromuscular structures, as well as a strong joint position sense (a subcategory of
      proprioception). Our ability to detect our limbs in space helps us to interact with our
      surroundings and contributes to the neuromuscular stability of our joints. A RCt is often
      associated with a subacromial impingement syndrome, where structures under the acromion
      become pinched during arm elevation. Such a compression during arm movements can include
      abnormal shoulder kinematics, as well as RC and scapular muscles performance deficits. This
      inadequate scapulothoracic muscle control is believed to contribute to a reduction of
      amplitude in posterior tilting and lateral rotation of the scapula, which causes the acromion
      to remain in a lower anterolateral position resulting in a dynamic narrowing of the
      subacromial space. Also, the abnormal muscle control is associated with superior migration of
      humeral head with respect to the glenoid fossa, which again leads to a dynamic narrowing of
      the subacromial space. These deficits contribute to the impingement of subacromial structures
      and often lead to the symptoms associated with an RCt. What makes the investigated approach
      unique in addressing RC disorders is the resource-effective exercise rehabilitation model the
      investigators propose; a motor control and strengthening approach well supported in the
      scientific literature and packaged in a conveniently resource-friendly protocol. This
      approach maximizes patient autonomy while being matched to a suitable level of
      physiotherapist supervision. The investigators believe that the Upper Extremity Neuromuscular
      Training Program (UpEx-NTP) provides a realistic and financially beneficial solution to a
      costly health care problem.

      Research Question: How will a 6-week UpEx-NTP improve shoulder function, pain, and joint
      position sense (JPS) in individuals affected by a rotator cuff (RC) tendinopathy compared to
      usual physiotherapy care? The primary objective of this randomized control trial (RTC) is to
      compare, in terms of symptoms and functional limitations, a group receiving a
      group-supervised rehabilitation program (UpEx-NTP) centered on strength and motor control
      training to a group receiving usual one-on-one physiotherapy clinical care in individuals
      affected by a RC tendinopathy of the shoulder. It is hypothesized that both the UpEx-NTP
      (Exp) and usual physiotherapy care (Ctl) groups will equally demonstrate statistically
      (p-value < 0.05) and clinically (all noted changes above their MCID : DASH questionnaire = 11
      points, WORC index = 12 points and the Numeric Rating Scale for pain = 2 points) significant
      changes in shoulder function and pain over a 6-week period in individuals with an RC
      tendinopathy and will be maintained over time, notably 12-weeks after the intervention.
    

Intervention name(s): Upper Extremity Neuromuscular Training Program; Usual Physiotherapy Care
Intervention type(s): Other; Other
Intervention description(s): Neuromuscular and strengthening shoulder exercises in a group setting.; One-on-one physiotherapy care in a clinical setting.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Investigator)
Primary purpose: Treatment
Keywords: Shoulder; Motor control; Usual physiotherapy care; Supervised exercise program