Efficacy of standardized manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial.
Subject: Exercise (Research)
Clinical trials (Research)
Physical therapy (Research)
Therapeutics, Physiological (Research)
Authors: Bennell, K.
Wee, E.
Coburn S.
Green, S.
Harris, A.
Staples, M.
Forbes, A.
Buchbinder, R.
Pub Date: 07/01/2011
Publication: Name: New Zealand Journal of Physiotherapy Publisher: New Zealand Society of Physiotherapists Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 New Zealand Society of Physiotherapists ISSN: 0303-7193
Issue: Date: July, 2011 Source Volume: 39 Source Issue: 2
Topic: Event Code: 310 Science & research
Accession Number: 288537992
Full Text: Introduction

The objective of this study was to investigate the efficacy of a programme of manual therapy and exercise treatment compared with placebo intervention for patients with chronic rotator cuff disease. The interventions used were a combined manual therapy and exercise regime, and a placebo regime that applied sham ultrasound and a light application of non-therapeutic gel to the shoulder region.

Methods

One hundred and twenty participants were recruited over a three and a half year period. The participants were randomly allocated to either the active or placebo treatment groups. Both groups received 10 sessions with a physiotherapist; one session per week for ten weeks. The active treatment group received a standardised manual therapy regime that incorporated soft tissue massage, passive glenohumeral joint mobilisation, scapular retraining, postural taping and spinal mobilisation. The active treatment regime also included a home exercise programme incorporating general strengthening exercises, scapular stabilisation and postural correction. On completion of the supervised treatment sessions, the active group was instructed to continue their home exercise programme for a further 10 weeks. The placebo group had no further intervention after the initial ten treatment sessions. A variety of validated outcome measures were used at baseline (prior to intervention), at 11 weeks (immediately after treatment) and at 22 weeks.

Results

Both groups achieved a statistically significant in-group improvement during the assessment period. At the 11-week assessment, there were no significant differences between treatment groups in any of the primary outcome measures used. However, the active group did show significantly greater improvements in some secondary measures, these were; self reported and objective measures of strength.

At 22 weeks, the active group demonstrated a statistically significant advantage compared with the placebo group in one primary measure; the Shoulder Pain and Disability Index (SPADI). The authors state that several other secondary measures favoured the active treatment group; shoulder pain and disability index function score, muscle strength, interference with activity and health related quality of life.

Conclusion

A combination of interventions of manual therapy and exercises did not distinguish the groups in the short term. It was postulated that, given the significantly greater improvements in the active treatment group, the benefits of manual therapy and exercise might be more apparent in the longer term. The authors also state that physiotherapy may be more relevant for improving function rather than pain in rotator cuff disease. If pain is the primary problem, medication or cortisone injection may be more appropriate treatment options.

Commentary

This study has been conducted with robust methodology. The standardised treatment intervention applied to the active treatment group is described in detail in the paper by Bennell et al (2007). This treatment intervention is holistic and covers a broad range of standard physiotherapy manual therapy and exercise regimes. Therefore, the intervention is pertinent to current, usual physiotherapy treatment for rotator cuff disease. The primary outcome measures were the SPADI, average pain on movement (numerical rating scale) and participants perceived global rating of overall change.

The only statistically significant difference between groups involving the primary outcome measures was in the SPADI at 22 weeks. The authors report that several secondary measures favoured the active treatment group at 22 weeks but do not report the statistics for these measures; therefore, it is assumed that whilst the treatment group achieved superior results, the between group comparisons were not statistically significant. The results pertaining to the interventions are not what physiotherapists wish to read. However the authors explain in detail the strengths and weaknesses of this study and the various confounding factors. In reading this paper, one senses some frustration from the authors that the results did not differentiate the groups more clearly and that there may possibly have been a clinically acceptable difference between the groups, if not a statistical difference.

This paper thoroughly reviews and refers to many issues relating to both the treatment of rotator cuff disease and the research relating to this topic. The paper clearly outlines the results and compares these with other related studies. In addition, an in-depth description of the issues relating to the outcome measures and statistics used in the study are included. Knowledge of outcome measures and statistics would help the reader correctly interpret this information, but this is a paper of interest for clinical physiotherapists.

Barry Donaldson, PhD, Dip Phys, Dip MT

Redwood Physiotherapy Clinic

Christchurch

Bennell K, Wee E, Coburn S, Green S, Harris A, Staples M, Forbes A and Buchbinder R (2010): Efficacy of standardized manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial. BMJ 340: c2756. (Abstract prepared by Barry Donaldson)

REFERENCES

Bennell K, Coburn S, Wee E, Green S, Harris A, Forbes A, Buchbinder R (2007): Efficacy and cost-effectiveness of a physiotherapy program for chronic rotator cuff pathology: a protocol for a randomized, double-blind, placebo-controlled trial. BMC Musculoskeletal Disorders 8:86.
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