Although rotator cuff disorders are very common (about 70% of all patients with shoulder pain), the clinical effectiveness and cost-effectiveness of physiotherapy interventions is still unclear, mainly due to the fact that most trials are small sample size short term studies. Therefore the aim of the GRASP-trail was to investigate in a randomized trial the value of exercises, advice and corticosteroid injections. They randomized 708 patients with RC disorders into 4 groups: 1/ injection + + /- 6 sessions of tailored exercise therapy over 16 weeks, 2/ injection + one single session of physiotherapeutic advice, 3/ no injection + +/- 6 sessions of tailored exercise therapy over 16 weeks, and 4/ no injection + one single session of physiotherapeutic advise. Final follow-up of the primary outcome measure (SPADI Shoulder Pain and Disability Index) was performed after 1 year.
The authors found (quoting the abstract) that “progressive exercise was not superior to a best practice advice session with a physiotherapist in improving shoulder pain and function”, and “subacromial corticosteroid injection provided no long-term benefit in patients with rotator cuff disorders”. All groups revealed a statistically significant and clinically relevant change in the SPADI after 12 months.
To start with, we highly appreciate the quality of this study, with a huge sample size recruitment, the strong methodology, and the robust statistical analysis, however I believe it is important to put the message from this paper into the right perspective. Based on the abstract, one would think that the “advice” group did not perform any exercise, which is obviously a wrong interpretation. Both groups received an exercise program, and the “advice” group received optimal guidance for their self-management for their exercises with a booklet, exercise material, and videos. So the difference between both groups is self-management rather than the educational session as such. Additionally we can read that only 25% of the “progressive exercise” group completed all 6 sessions provided, meaning that also in this group a substantial proportion of self-management may have played a role in the final outcome. The natural course of the disorder also remains an enigma, since there was no control group without any intervention. With respect to the corticosteroid injection, there was a small benefit on short term (8 weeks), however the change in SPADI was smaller than the MCID (Minimal Clinically Important Difference).
How can we use these results in our clinical practice? To start with, it is important in a shared decision making context, to discuss with your patient his or her readiness to step into an exercise program with maximal self-management, and self-efficacy. Some patients need more assistance and follow-up than others. The value of clinical review and reassurance was also confirmed in this study, since the patient-reported global impression of treatment favored the group that received ongoing physiotherapy support. It is important to optimally guide your patients in the process of a home program, using a booklet, diary, videos etc. From my clinical experience, the patients experience most confidence from movies, made during the session, in which as a clinician we explain to the patient how to perform the exercise, while he or she is performing them. Let them make some mistakes, so you can correct them on the spot. Some of my patients use the video every time they do the exercises, so let them perform during the making of the video the number of repetitions you want them to do.
Hopewell, S, Keene D, Marian I et al. Progressive exercise compared with best practice advice, with or without corticosteroid injection, for the treatment of patients with rotator cuff disorders (GRASP): a multicenter, pragmatic, 2×2 factorial, randomized controlled trial. The Lancet Vol 398, July 2021, DOI 10.1016/S0140-6736(21)00846-1
Buchbinder R: Comment: Optimising treatment for patients with rotator cuff disorders. The Lancet Vol 398, July 2021, DOI 10.1016/S0140-6736(21)00987-9