Session 2: Rotator cuff: OPTIMISING THE OUTCOME OF EXERCISE AND CORTICOSTEROID INJECTION IN PATIENTS WITH SUBACROMIAL IMPINGEMENT SYNDROME: A FACTORIAL RANDOMISED TRIAL

摘要

Purpose: Subacromial impingement syndrome (SIS) is the most common cause of shoulder pain. Management commonly involves exercise and corticosteroid injection yet how these are best delivered is uncertain. The SUPPORT trial investigated whether better outcomes in pain and function are achieved with (I) physiotherapist-led individualised, supervised and progressed exercise rather than a standardised advice and exercise leaflet, and (2) ultrasound (US)-guided subacromial corticosteroid injection rather than unguided injection. Methods: A 2x2 factorial randomised controlled trial. Adults with SIS were recruited and randomised to one of four treatment groups: (I) US-guided steroid injection and physiotherapist-led exercise, (2) US-guided steroid injection and an exercise leaflet, (3) unguided steroid injection and physiotherapist-led exercise, (4) unguided steroid injection and an exercise leaflet. Outcomes were collected at 6 weeks, 6 and 12 months by postal questionnaire. The primary outcome measure was the Shoulder Pain and Disability Index (SPADI), compared at 6 weeks for the injection interventions and 6 months for the exercise interventions. Results: 256 participants were recruited. Greater mean improvement in total SPADI score was seen with physiotherapist-led exercise than with the exercise leaflet at 6 months but not 6 weeks or 12 months: - 1.60 (95%CI -6.99, 3.90) at 6 weeks, -8.23 (95%CI -14.14, -2.32) at 6 months, and -4.25 (95%CI -11.48, 2.99) at 12 months. Similar improvements were seen in the SPADI pain and disability subscales. The physiotherapist-led exercise group showed more positive illness perceptions, less impact on work performance at 6 months and greater reduction in current shoulder pain intensity at 12 months. Conclusion: Physiotherapist-led exercise in patients with SIS leads to greater improvements in pain and function than providing a standardised advice and exercise leaflet. Ultrasound-guidance confers little additional benefit over unguided corticosteroid injection.