Both
manual physical therapy (MPT) and corticosteroid injections (CSI)
significantly improve symptoms in patients with shoulder impingement
syndrome (SIS), but physical therapy may be less costly to the
healthcare system, according to a new study.
Objective: To compare the effectiveness of 2 common nonsurgical treatments for SIS.
Design: Randomized, single-blind, comparative-effectiveness, parallel-group trial. (ClinicalTrials.gov: NCT01190891)
Setting: Military hospital–based outpatient clinic in the United States.
Patients: 104 patients aged 18 to 65 years with unilateral SIS between June 2010 and March 2012.
Intervention: Researchers randomly assigned consecutive patients aged 18 to 65 years with unilateral shoulder pain to receive CSI or MPT. Patients were referred from family practice and orthopedic clinics. None had had physical therapy or corticosteroid injections within the previous 3 months.
The CSI group received up to 3 injections of 40 mg triamcinolone acetonide 1 month apart. The injections were administered by a family practice physician with sports medicine fellowship training.
Matched to individual impairment, the MPT intervention consisted of a combination of joint and soft-tissue mobilizations, manual stretches, contract-relax techniques, and reinforcing exercises directed to the shoulder girdle or thoracic or cervical spine. Patients were treated twice weekly over a 3-week period and prescribed home exercises.
Ten CSI patients crossed over to receive physical therapy, and 9 in the MPT group crossed over to receive injections.
Measurements: The primary outcome was change in Shoulder Pain and Disability Index scores at 1 year. Secondary outcomes included the Global Rating of Change scores, the Numeric Pain Rating Scale scores, and 1-year health care use.
Results: After 1 year, both the CSI group (n = 52) and the MPT group (n = 46) had a greater than 50% improvement in the Shoulder Pain and Disability Index (SPADI), with neither group being superior. The between-group difference in the SPADI, a 13-item, self-administered questionnaire that includes pain and disability subscales, was 1.55% (95% confidence interval [CI], –6.3% to 9.4%; P = .70). The minimal clinically important difference for the SPADI is a change between 8 and 13 points (6% to 10%).
Ratings on the Global Rating of Change (GRC) scale improved by 3 points (95% CI, 2 - 4) for each group. The GRC measures overall perceived changes in quality of life, with a score of 3 or more points being clinically meaningful.
Self-reported pain intensity as measured by the 11-point Numeric Pain Rating Scale significantly improved from baseline (P < .05) in both groups, but neither intervention was superior (between-group difference 0.4 (95% CI, –0.5 to 1.2; P = .42).
During the 1-year follow-up, patients receiving CSI had more SIS-related visits to their primary care provider (60% vs. 37%) and required additional steroid injections (38% vs. 20%), and 19% needed physical therapy. Transient pain from the CSI was the only adverse event reported.
Conclusion: Both groups experienced significant improvement. The manual physical therapy group used less 1-year SIS-related health care resources than the CSI group.
Objective: To compare the effectiveness of 2 common nonsurgical treatments for SIS.
Design: Randomized, single-blind, comparative-effectiveness, parallel-group trial. (ClinicalTrials.gov: NCT01190891)
Setting: Military hospital–based outpatient clinic in the United States.
Patients: 104 patients aged 18 to 65 years with unilateral SIS between June 2010 and March 2012.
Intervention: Researchers randomly assigned consecutive patients aged 18 to 65 years with unilateral shoulder pain to receive CSI or MPT. Patients were referred from family practice and orthopedic clinics. None had had physical therapy or corticosteroid injections within the previous 3 months.
The CSI group received up to 3 injections of 40 mg triamcinolone acetonide 1 month apart. The injections were administered by a family practice physician with sports medicine fellowship training.
Matched to individual impairment, the MPT intervention consisted of a combination of joint and soft-tissue mobilizations, manual stretches, contract-relax techniques, and reinforcing exercises directed to the shoulder girdle or thoracic or cervical spine. Patients were treated twice weekly over a 3-week period and prescribed home exercises.
Ten CSI patients crossed over to receive physical therapy, and 9 in the MPT group crossed over to receive injections.
Measurements: The primary outcome was change in Shoulder Pain and Disability Index scores at 1 year. Secondary outcomes included the Global Rating of Change scores, the Numeric Pain Rating Scale scores, and 1-year health care use.
Results: After 1 year, both the CSI group (n = 52) and the MPT group (n = 46) had a greater than 50% improvement in the Shoulder Pain and Disability Index (SPADI), with neither group being superior. The between-group difference in the SPADI, a 13-item, self-administered questionnaire that includes pain and disability subscales, was 1.55% (95% confidence interval [CI], –6.3% to 9.4%; P = .70). The minimal clinically important difference for the SPADI is a change between 8 and 13 points (6% to 10%).
Ratings on the Global Rating of Change (GRC) scale improved by 3 points (95% CI, 2 - 4) for each group. The GRC measures overall perceived changes in quality of life, with a score of 3 or more points being clinically meaningful.
Self-reported pain intensity as measured by the 11-point Numeric Pain Rating Scale significantly improved from baseline (P < .05) in both groups, but neither intervention was superior (between-group difference 0.4 (95% CI, –0.5 to 1.2; P = .42).
During the 1-year follow-up, patients receiving CSI had more SIS-related visits to their primary care provider (60% vs. 37%) and required additional steroid injections (38% vs. 20%), and 19% needed physical therapy. Transient pain from the CSI was the only adverse event reported.
Conclusion: Both groups experienced significant improvement. The manual physical therapy group used less 1-year SIS-related health care resources than the CSI group.
Rhon DI, Boyles RB, Cleland JA. One-Year Outcome of Subacromial Corticosteroid Injection Compared With Manual Physical Therapy for the Management of the Unilateral Shoulder Impingement Syndrome: A Pragmatic Randomized Trial. Ann Intern Med. doi online 5.8.2014
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