Does The Type of Exercise Influence Outcome in Rotator Cuff Related Shoulder Pain
Condition: Shoulder Pain; Rotator Cuff Injury; Rotator Cuff Tendinitis; Rotator Cuff Impingement Syndrome
MeSH terms: Shoulder Pain; Tendinopathy; Shoulder Impingement Syndrome; Rotator Cuff Injuries
Study type: Interventional

Summary: 
      Rotator cuff related shoulder pain (RCRSP) is the most common shoulder disorder and its
      chronicization leads to multiple consequences such as early retirement, absenteeism from
      work, decreased participation and quality of life and expensive yearly healthcare costs (128
      739 687 $ according to CNESST). Even though scientific evidence has shown that prioritising
      physiotherapy exercises over surgery for the initial management of RCRSP is a great way to
      save on healthcare costs without compromising quality, it does not always result in a
      resolution of symptoms and patients' quality of life can still be affected thereafter: up to
      30% of people with RCRSP remain symptomatic despite rehabilitation interventions. This lack
      of therapeutic success could be explained by a multitude of factors, but a central issue that
      can explain a lack of improvement is an inappropriate dosage or choice of exercises
      prescribed. The purpose of this study is to compare the effectiveness of 3 non-operative
      methods of delivering shoulder management (2 types of exercises and an advice and education
      only group) on symptoms and functional limitations for people with RCRSP. Results from this
      project should help us further our knowledge on which non-operative treatment to promote with
      patients presenting with RCRSP, thus decreasing the proportion of individuals experiencing
      pain even after going through a rehabilitation program.
    

Detailed description: 
      Context : Musculoskeletal injuries lead to the second largest number of years lived with a
      disability, just behind mental health problems. Among those, shoulder problems are widespread
      and become even more common over the years. 70% of the population will experience an episode
      of shoulder pain during their lifetime and 30% of people over 65 years old live with daily
      shoulder pain. Unfortunately, the resolution of shoulder pain is often slow and incomplete
      and about 40 to 50% of symptomatic individuals will still experience pain one year after the
      onset of their painful episode. Rotator cuff related shoulder pain (RCRSP) is the most common
      type of injury in this region. This is a broad term that includes subacromial conflict
      syndrome, rotator cuff tendinopathy, and non-traumatic tears of rotator cuff tendons. There
      is ample evidence to suggest that physiotherapy exercises are the preferred approach as the
      first intervention for managing this condition, without having an impact on the quality of
      recovery. Unfortunately, for many patients, this approach does not lead to a significant
      decrease in symptoms and may result in a decrease in their quality of life. This lack of
      therapeutic success could be explained by a multitude of factors: psychosocial, physical,
      genetic, lifestyle, complex problems related to pain and lack of adherence to the exercise
      program. Another important element that may explain this lack of improvement is an
      inappropriate dosage and / or choice of prescribed exercises.

      Objectives : The primary objective of this randomized clinical trial is to compare the short,
      medium, and long-term effects, in terms of symptoms and functional limitations, of three
      different options (education, strengthening, motor control) for the management of individuals
      with RCRSP. A secondary objective is to explore the effects of these interventions on
      shoulder control (acromiohumeral distance), subacromial structures (thickness of the
      supraspinatus and infraspinatus tendons), kinesiophobia and pain catastrophization.

      Methods : 123 individuals between the ages of 18 and 75 with RCRSP for more than 3 months
      will be recruited and randomly assigned to one of three 12-week interventions: 1) counseling
      and education only; 2) scapulohumeral and scapulothoracic muscles strengthening exercises; 3)
      Motor control program paired with global exercises. Before being assigned to their respective
      group, patients will undergo an initial assessment including self-administered questionnaires
      on symptoms and functional limitations (QuickDASH, WORC, BPI-SF, TSK, PCS) as well as
      ultrasound measurements of the shoulder (acromiohumeral distance and thickness of
      supraspinatus and infraspinatus tendons). The questionnaires will be administered again at 3,
      6, 12 and 24 weeks after the inclusion of the participants in the project and the ultrasound
      measurements will be re-evaluated at 12 weeks. Initial demographic data will be compared
      (independent t-test and square-test) to establish comparability of groups. Two-way ANOVA
      analyzes will be used to analyze and compare the effects of the three programs on the primary
      outcome (QuickDASH) and the other questionnaires (3 interventions x 5 times [0, 3, 6, 12 and
      24 weeks]) as well as for the ultrasound measurements (3 interventions X 2 times [0 and 12
      weeks]) (SPSS 25, proc GENLIN).

      Expected results : The hypothesis is that the two exercises groups will show better results
      in terms of symptoms and functional limitations compared to the group consisting solely of
      counseling and education. The motor control program should allow a faster improvement of
      symptoms and functional limitations than the reinforcement program because, by improving
      muscular recruitment patterns and scapular kinematics, it will reduce control deficits and
      thus the probabilities to feel pain. Finally, all groups should show a decrease in
      kinesiophobia and pain catastrophization, but the exercises groups should result in a larger
      one, as participants will have to move their arms in ranges previously limited by pain and /
      or fears related to pain, or perform muscle contractions of near maximal intensity.
    

Intervention name(s): Strengthening exercises program; Motor control exercises program; Education and advice
Intervention type(s): Other; Other; Other
Intervention description(s): Participants from this group will be given a progressive shoulder strengthening exercises program based on 1 RM that will involve isometric, concentric and eccentric contractions. The exercises will target shoulder internal/external rotators and abductors and the scapular muscles. They will have to exercise every other day for 12 weeks. At each session with the therapist (6 over a 12 week period), strength will be reassessed and the program will be progressed accordingly. Any questions or concerns will also be addressed and participants will be requested to complete a paper based or digital record of their exercise participation.; Each session will start with a series of clinical tests that will look at the influence of different corrections to alleviate symptoms during upper limb movements.The tests will be performed in a sequential format through four key areas: thoracic repositioning, scapula facilitation, humeral head procedures and neuromodulatory techniques. If a correction reduces pain, that technique will then be performed as exercises and incorporated into the participant's functional movement. In addition, motor control exercises during arm elevation, progressed through a standardized 6-phase retraining sequence, will be executed. Retraining phases will be graded according to: 1) resistance applied on the shoulder; and 2) use or non-use of feedback. Once participants reach pain free execution, the program will be progressed into re-education exercises according to the participants' work, sport and activities of daily living and will incorporate activities involving the upper and lower limbs.; Each participant will be given written information about the shoulder (anatomy and function), basic pain science and will be directed to the Internet to watch a series of carefully selected educational videos. Comprehensive written advice will include: Information about the shoulder and the condition; Pain neuroscience; Activity modification (when to increase and decrease); Pain management (night and day); A series of educational videos to watch with 2 questions to answer per video: a) what was the most important message? and b) was there anything you didn't understand in the video?
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment