Reference: Lancet. 2021 Jul 31;398(10298):416-428
Pain and functional limitations due to disorders of the rotator cuff can last for 2 years (or longer) without treatment. Therapies with demonstrated efficacy include rest, oral analgesics such as acetaminophen or non-steroidal anti-inflammatory drugs, exercise, manual therapy, and corticosteroid injections to reduce local tissue inflammation and pain. The short and long-term effectiveness of a physiotherapist-prescribed exercise program plus or minus corticosteroid injections remains uncertain, however.
The GRASP trial evaluated 708 adult patients with a new episode of shoulder pain from a rotator cuff disorder randomized in a 2-by-2 factorial design. The four treatment groups included a progressive home exercise program with or without subacromial injection and a best practice advice intervention, also with or without injection. The progressive home exercise program was tailored for each patient and supervised by a physiotherapist via 6 single face-to-face sessions over 16 weeks. The best practice advice intervention consisted of a single face-to face session with a physiotherapist and a home exercise program supported by self-management materials. Pain and disability were measured using the Shoulder Pain and Disability Index (SPADI) score (range 0-130 points), with a mean baseline score of 54 points. Comparisons were made between (1) all the patients who received a progressive home exercise program and those who received a best practice advice intervention, and (2) all the patients who received a subacromial corticosteroid injection and those who did not receive an injection.
Each treatment group demonstrated an improvement in SPADI score over baseline. However, there were no differences in SPADI scores between patients who received a supervised progressive exercise or those who received a single best practice advice session (adjusted mean score of 28.7 vs 29.4 points, respectively). The SPADI scores over 12 months were also not significantly affected by steroid injection (adjusted mean score of 28.5 vs 29.6 points). The only significant difference in SPADI score was observed at 8 weeks, with a small between-group adjusted difference of -5.64 points (95% CI -9.93 to -1.35 points) in favor of injection. The progressive exercise program did seem to slightly improve a secondary outcome of patient-reported global impression of treatment compared with best practice advice.
The researchers didn’t blind steroid injections or physiotherapy sessions, but that is inherent given the nature of the interventions being tested. More important, however, may be the lack of outcome assessment in the short term or very short term. It is fairly well-established at this point that steroid injections of the shoulder don’t meaningfully affect outcomes at one year, but patients are more often looking for relief in the next 1-4 weeks. This theoretically allows for better physical therapy participation. So, while the GRASP trial indicates that neither a supervised exercise program nor steroid injection was better than best practice advice for treatment of rotator cuff shoulder pain in the long term, there is still uncertainty regarding the benefit of steroid injection and its impact on physical therapy participation in the short term.
For more information, see the topics Management of Rotator Cuff Impingement and Management of Rotator Cuff Tear in DynaMed.
DynaMed EBM Focus Editorial Team
This EBM Focus was written by Vincent Lemaitre, PhD, Medical Writer at DynaMed. Edited by: Alan Ehrlich, MD, Executive Editor at DynaMed and Associate Professor in Family Medicine at the University of Massachusetts Medical School; Dan Randall, MD, Deputy Editor at DynaMed; Carina Brown, MD, Assistant Professor at Cone Health Family Medicine Residency; Katharine DeGeorge, MD, MS, Associate Professor of Family Medicine at the University of Virginia and Clinical Editor at DynaMed; Nicole Jensen, MD, family physician at WholeHealth Medical; Tanya Tupper, RT(N), CNMT, PET, Senior Medical Writer at DynaMed; and Christine Fessenden, Editorial Operations Assistant at DynaMed.