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.
D. van der Windt,
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ACR Meeting Abstracts - https://acrabstracts.org/abstract/clinical-effectiveness-of-exercise-and-corticosteroid-injection-for-subacromial-impingement-syndrome-a-randomised-controlled-trial/