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Abstract Number: 1114

Clinical Effectiveness of Exercise and Corticosteroid Injection for Subacromial Impingement Syndrome: A Randomised Controlled Trial

Edward Roddy1, Reuben Ogollah1, Irena Zwierska1, Praveen Datta2, Alison Hall1, Elaine Hay1, Sue Jackson2, Martyn Lewis1, Julie Shufflebotham3, Kay Stevenson2, Danielle van der Windt1, Julie Young1 and Nadine Foster1, 1Research Institute for Primary Care and Health Sciences, Keele University, Keele, United Kingdom, 2University Hospital of North Staffordshire, Stoke-on-Trent, United Kingdom, 3Staffordshire and Stoke-on-Trent Partnership Trust, Stoke-on-Trent, United Kingdom

Meeting: 2014 ACR/ARHP Annual Meeting

Keywords: corticosteroids, exercise, randomized trials and ultrasound, Shoulder Pain

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Session Information

Title: Fibromyalgia, Soft Tissue Disorders, Regional and Specific Clinical Pain Syndromes: Clinical Focus

Session Type: Abstract Submissions (ACR)

Background/Purpose: Subacromial impingement syndrome (SIS) is the most common cause of shoulder pain. It is commonly managed by 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 (1) 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: Study design was a 2×2 factorial randomised controlled trial. Adults with SIS were recruited from community musculoskeletal services and randomised equally to one of four treatment groups: (1) 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, or (4) unguided steroid injection and an exercise leaflet. Outcomes were collected at 6 weeks, 6 months 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. Secondary outcomes included SPADI pain and disability subscales, current shoulder pain intensity, patient’s global impression of change, and pain self-efficacy. 250 participants were required to detect a small-moderate effect size (0.4) in SPADI for the two main comparisons. Analysis was by intention-to-treat.

Results: 256 participants were recruited (48% male, mean age 54 years), 64 to each treatment group. Response rates for the primary outcome were 94% at 6 weeks, 88% at 6 months and 80% at 12 months.

Greater mean improvement in total SPADI score was seen with physiotherapist-led exercise than with the exercise leaflet at 6 months and 12 months: 3.02 (95%CI -3.00, 9.03) at 6 weeks, 9.48 (95%CI 3.30, 15.65) at 6 months, and 6.64 (95%CI 0.33, 12.96) at 12 months. Physiotherapist-led exercise led to greater mean improvement in SPADI pain subscale at 6 and 12 months, and in SPADI disability subscale at 6 months but not at 12 months. At 12 months, the physiotherapist-led exercise group showed a greater reduction in current shoulder pain intensity, stronger self-efficacy beliefs and more frequent patient reporting of being much or completely better.

Within-group improvement in total SPADI was seen in both injection groups but there were no significant between-group differences at any time-point: 2.99 (95%CI -3.03, 9.00) at 6 weeks, 3.38 (95%CI -2.79, 9.56) at 6 months, and -1.50 (95%CI -7.82, 4.82) at 12 months. There were no differences in secondary outcome measures between the injection groups at any time-point.

There was no significant interaction effect of combined US-guided injection and physiotherapist-led exercise at the primary endpoints of 6 weeks and 6 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 no additional benefit over unguided corticosteroid injection.


Disclosure:

E. Roddy,
None;

R. Ogollah,
None;

I. Zwierska,
None;

P. Datta,
None;

A. Hall,
None;

E. Hay,
None;

S. Jackson,
None;

M. Lewis,
None;

J. Shufflebotham,
None;

K. Stevenson,
None;

D. van der Windt,
None;

J. Young,
None;

N. Foster,
None.

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