Treatment of Subacromial Shoulder Pain by Individual or Group Physiotherapy Following Corticosteroid Injection
Treatment of Subacromial Shoulder Pain by Individual or Group Physiotherapy Following Corticosteroid Injection
The aim of this study is therefore to examine the clinical effectiveness and provide an
 economic analysis of individual versus group physiotherapy, following corticosteroid
 injection, for management of Subacromial Impingement (SAI) of the shoulder.
This trial was a single blind, randomised, equivalence trial comparing rotator cuff
 rehabilitation classes with traditional individual physiotherapy in subacromial impingement
 of the shoulder. A total of 200 patients were planned to be recruited from patients with
 painful shoulder referred to the Ulster Community and Hospitals Trust and community
 physiotherapy at the Ulster, Ards and Bangor sites or injection clinics at the Ulster
 Hospital. Local General Practitioners were also informed of the study and invited to refer
 appropriate patients.

 Intervention - Triamcinolone 40 mg (1 ml) and 6 weekly rotator cuff rehabilitation classes
 Control - Triamcinolone 40 mg (1 ml) and routine physiotherapy 6 sessions weekly for 6 weeks

 The injection technique involving a lateral approach to the subacromial space was used. An
 interval of between 1 and 3 weeks was allowed between injection and commencement of classes
 or physiotherapy.

 Classes were planned to be run by a rotating group of physiotherapists with at least 1 year
 of musculoskeletal outpatient's experience. They were to receive instruction on the protocol
 to use in the classes. Classes were to consist of six 30 min sessions on a weekly basis. A
 minimum of 5 and maximum of 10 participants were to attend. Advice was to be given on the
 nature of the condition. Subjects were to be instructed and supervised in exercises for
 scapulo-humeral mobility, scapulo-humeral stability and specific rotator cuff rehabilitation
 exercises. Subjects were to be introduced to ongoing classes as they are recruited to the
 trial.

 Six sessions of routine physiotherapy at weekly intervals were to be undertaken. Treatment
 was to be based on evidence-based guidelines for the treatment of shoulder impingement
 (Evidence-based clinical guidelines for the diagnosis, assessment and physiotherapy
 management of shoulder impingement syndrome Chartered Society of Physiotherapists 2005) and
 consist of mobilisation techniques and supervised exercises and stretches. A therapist with
 at least 1 year of musculoskeletal outpatients experience was to provide treatments.
Inclusion Criteria:

 -  unilateral shoulder pain of more than 4 weeks duration and a Shoulder Pain and
 Disability Index (SPADI) score of >= 30 as this represents significant disability.
 Shoulder pain is defined as pain in the shoulder region, including the upper arm,
 elicited by active or passive shoulder movement. The diagnosis of "subacromial pain"
 is defined by range as no limitation in passive range of movement or restriction of
 passive range of movement mainly in abduction rather than external rotation.

 Exclusion Criteria:

 -  inability to give informed consent

 -  physiotherapy or injection treatment for current shoulder pain in previous 3 months

 -  blood coagulation disorders

 -  bilateral shoulder pain

 -  evidence of systemic infection

 -  abnormal shoulder X-ray defined as significant glenohumeral or subacromial joint space
 narrowing suggesting osteoarthritis of glenohumeral joint or complete rotator cuff
 rupture,

 -  evidence of rotator cuff tear, tested by external rotation lag sign, drop sign,
 internal rotation lag sign and static muscle resistance in external rotation, internal
 rotation and abduction,

 -  history of significant trauma to the shoulder,

 -  inflammatory joint disease,

 -  history of cerebrovascular accident,

 -  allergy or contraindication to Triamcinolone/contraindication to injection.

 -  evidence of referred pain from cervical spine disease.

 -  pregnancy or breast feeding

 -  patients whose first language is not English