Arthroscopic capsular shift surgery in patients with atraumatic shoulder joint instability: a randomised, placebo-controlled trial.

OBJECTIVES: To determine the effect of arthroscopic capsular shift surgery on pain and functional impairment for people with atraumatic shoulder (glenohumeral) joint instability. METHODS: We conducted a randomised, placebo-controlled clinical trial in a specialist secondary care facility. Patients aged 18 years and over who reported insecurity (apprehension) in their shoulder joint and had evidence of capsulolabral damage on arthroscopic examination were included. Patients were excluded if their shoulder apprehension symptoms were precipitated by a high velocity shoulder injury, they had bony or neural damage, a rotator cuff or labral tear, or previous surgery on the symptomatic shoulder. Sixty-eight participants were randomised and received diagnostic arthroscopy, followed by arthroscopic capsular shift or diagnostic arthroscopy alone. All participants received the same postoperative clinical care. The primary outcome was pain and functional impairment measured with the Western Ontario Shoulder Instability Index. The prespecified minimum clinically important effect was a reduction in pain and disability of 10.4 points. RESULTS: Mean reductions in pain and functional impairment for both groups were similar. Compared with diagnostic arthroscopy, arthroscopic capsular shift increased pain and functional impairment by means of 5 points (95% CI -6 to 16 points) at 6 months, 1 point (95% CI -11 to 13 points) at 12 months and 2 points (95% CI -12 to 17 points) at 24 months. CONCLUSIONS: Compared with diagnostic arthroscopy alone, arthroscopic capsular shift confers, at best, only minimal clinically important benefit in the medium term. TRIAL REGISTRATION NUMBER: NCT01751490.

Kinetic chain revisited: consensus expert opinion on terminology, clinical reasoning, examination, and treatment in people with shoulder pain.

BACKGROUND: The purpose of this study was to reach consensus on the most appropriate terminology and issues related to clinical reasoning, examination, and treatment of the kinetic chain (KC) in people with shoulder pain among an international panel of experts. METHODS: A 3-round Delphi study that involved an international panel of experts with extensive clinical, teaching, and research experience in the study topic was conducted. A search equation of terms related to the KC in Web of Science and a manual search were used to find the experts. Participants were asked to rate items across 5 different domains (terminology, clinical reasoning, subjective examination, physical examination, and treatment) using a 5-point Likert-type scale. An Aiken coefficient of validity (V) ≥0.7 was considered indicative of group consensus. RESULTS: The participation rate was 30.2% (n = 16), whereas the retention rate was high throughout the 3 rounds (100%, 93.8%, and 100%). A total of 15 experts from different fields and countries completed the study. After the 3 rounds, consensus was reached on 102 items: 3 items were included in the "terminology" domain; 17 items, in the "rationale and clinical reasoning" domain; 11 items, in the "subjective examination" domain; 44 items, in the "physical examination" domain; and 27 items, in the "treatment" domain. Terminology was the domain with the highest level of agreement, with 2 items achieving an Aiken V of 0.93, whereas the domains of physical examination and treatment of the KC were the 2 areas with less consensus. Together with the terminology items, 1 item from the treatment domain and 2 items from the rationale and clinical reasoning domain reached the highest level of agreement (V = 0.93 and V = 0.92, respectively). CONCLUSION: This study defined a list of 102 items across 5 different domains (terminology, rationale and clinical reasoning, subjective examination, physical examination, and treatment) regarding the KC in people with shoulder pain. The term "KC" was preferred and a agreement on a definition of this concept was reached. Dysfunction of a segment in the chain (ie, weak link) was agreed to result in altered performance or injury to distal segments. Experts considered it important to assess and treat the KC in particular in throwing or overhead athletes and agreed that no one-size-fits-all approach exists when implementing shoulder KC exercises within the rehabilitation process. Further research is now required to determine the validity of the identified items.

Progressive exercise compared with best practice advice, with or without corticosteroid injection, for the treatment of patients with rotator cuff disorders (GRASP): a multicentre, pragmatic, 2 × 2 factorial, randomised controlled trial.

BACKGROUND: Corticosteroid injections and physiotherapy exercise programmes are commonly used to treat rotator cuff disorders but the treatments' effectiveness is uncertain. We aimed to compare the clinical effectiveness and cost-effectiveness of a progressive exercise programme with a single session of best practice physiotherapy advice, with or without corticosteroid injection, in adults with a rotator cuff disorder. METHODS: In this pragmatic, multicentre, superiority, randomised controlled trial (2 × 2 factorial), we recruited patients from 20 UK National Health Service trusts. We included patients aged 18 years or older with a rotator cuff disorder (new episode within the past 6 months). Patients were excluded if they had a history of significant shoulder trauma (eg, dislocation, fracture, or full-thickness tear requiring surgery), neurological disease affecting the shoulder, other shoulder conditions (eg, inflammatory arthritis, frozen shoulder, or glenohumeral joint instability), received corticosteroid injection or physiotherapy for shoulder pain in the past 6 months, or were being considered for surgery. Patients were randomly assigned (centralised computer-generated system, 1:1:1:1) to progressive exercise (≤6 sessions), best practice advice (one session), corticosteroid injection then progressive exercise, or corticosteroid injection then best practice advice. The primary outcome was the Shoulder Pain and Disability Index (SPADI) score over 12 months, analysed on an intention-to-treat basis (statistical significance set at 1%). The trial was registered with the International Standard Randomised Controlled Trial Register, ISRCTN16539266, and EuDRACT, 2016-002991-28. FINDINGS: Between March 10, 2017, and May 2, 2019, we screened 2287 patients. 708 patients were randomly assigned to progressive exercise (n=174), best practice advice (n=174), corticosteroid injection then progressive exercise (n=182), or corticosteroid injection then best practice advice (n=178). Over 12 months, SPADI data were available for 166 (95%) patients in the progressive exercise group, 164 (94%) in the best practice advice group, 177 (97%) in the corticosteroid injection then progressive exercise group, and 175 (98%) in the corticosteroid injection then best practice advice group. We found no evidence of a difference in SPADI score between progressive exercise and best practice advice when analysed over 12 months (adjusted mean difference -0·66 [99% CI -4·52 to 3·20]). We also found no evidence of a difference between corticosteroid injection compared with no injection when analysed over 12 months (-1·11 [-4·47 to 2·26]). No serious adverse events were reported. INTERPRETATION: Progressive exercise was not superior to a best practice advice session with a physiotherapist in improving shoulder pain and function. Subacromial corticosteroid injection provided no long-term benefit in patients with rotator cuff disorders. FUNDING: UK National Institute for Health Research Technology Assessment Programme.

The prevalence of musculoskeletal pain and therapy needs in adults with Osteogenesis Imperfecta (OI) a cross-sectional analysis.

BACKGROUND: Osteogenesis Imperfecta affects approximately 1 in every 10,000 people. Musculoskeletal disorders and pain are common in adults with Osteogenesis Imperfecta, but specific knowledge of the problems people have is lacking. Access to therapy services for adults with Osteogenesis Imperfecta is variable. We designed this analysis to better understand the musculoskeletal disorders and consequent therapy needs for adults with Osteogenesis Imperfecta.  METHODS: This study was a cross-sectional analysis of outpatients with Osteogenesis Imperfecta. Adults attending a newly established multidisciplinary clinic at a tertiary centre in 2019 were included. A highly specialist physiotherapist worked within the clinic to offer therapy input if required and to refer patients to appropriate therapy as needed. People over the age of 18 were included if they had a diagnosis of Osteogenesis Imperfecta. Data were collected over a five month period using routinely collected clinical information and patient reported outcomes. RESULTS: Over five months 50 patients attended the clinic. Musculoskeletal pain was a significant feature reported by 84% of patients. Over 50% of patients reported persistent pain for longer than one year duration and the most common site of pain was in the spine (46%). No difference in pain between types of OI and age. Forty five per cent (n = 19) of patients reported moderate to severe problems with mobility on the EQ-5D with over half reporting problems with self-care and ability to carry out usual activities. Over 50% of patients in clinic also reported anxiety (EQ-5D). During the consultation 70% of patients received therapy input which was either advice in clinic or an onward referral to the appropriate service. The referral rate to specialist out-patient rehabilitation services at a tertiary centre was 30%. CONCLUSIONS: This analysis highlights the high prevalence of MSK pain in adults with OI and the effect on physical function and emotional wellbeing. This study demonstrates the diverse needs of the adult Osteogenesis Imperfecta population and the need for suitable multidisciplinary therapy services.

Management of atraumatic shoulder instability in physiotherapy (MASIP): a survey of physiotherapy practice.

BACKGROUND: The impact of atraumatic shoulder instability (ASI) on patients can be extensive, its management complex, with a biopsychosocial approach recommended. Currently how physiotherapists manage ASI is unknown or the extent to which current clinical practice aligns with existing evidence. At the time of this study no national guidelines or consensus to direct practice existed. METHODS: A cross-sectional electronic survey was distributed between July-September 2018, targeting UK-based physiotherapists managing shoulder pathology. Respondents were invited to describe their management of ASI, and rate their awareness and utilisation of various treatment techniques on a Likert-scale; median and interquartile ranges were calculated. Free text survey items were analysed using quantitative content analysis (QCA) to identify codes and categories. Means and percentages were calculated to summarise QCA and descriptive data. RESULTS: Valid survey responses were analysed (n = 135). Respondents had between 2 and 39 years of physiotherapy experience (mean = 13.9 years); the majority (71.1 %) reported that ASI made up < 10 % of their caseload. Only 22.9 % (n = 31/135) of respondents reported feeling 'very confident' in managing ASI; the majority feeling 'somewhat confident' (70.4 %, n = 95/135) or 'not confident' (6.7 %, n = 9/135). The majority of respondents (59.3 %) used an ASI classification system, > 90 % citing the Stanmore Classification. Physiotherapists adapted their management according to clinical presentation, responding to differing biopsychosocial needs of the patient scenario. Most respondents (> 80 %) did not use a protocol to guide their management. Exercise was the most utilised management approach for ASI, followed by education; novel treatment strategies, including cortical rehabilitation, were also reported. CONCLUSION: Findings indicate physiotherapists utilise a wide range of treatment strategies and respond to biopsychosocial cues when managing patients with ASI. The majority reported not being very confident in managing this condition, however only a minority use rehabilitation protocols to support their management. Some interventions that respondents reported using lacked evidence to support their use in ASI management and further research regarding effectiveness is required. Guidelines have been published since this survey; the impact of these will need evaluating to determine their effectiveness in the future.

The use of assistive technology in shoulder exercise rehabilitation - a qualitative study of acceptability within a pilot project.

BACKGROUND: Painful shoulders pose a substantial socioeconomic burden accounting for 2.4% of all primary care consultations in the UK. There is a strong evidence to indicate that the majority of this shoulder pain can be managed successfully with exercise based treatments and that common surgical procedures provide no extra benefit. Patient adherence and engagement is cited as an important factor in gaining positive outcomes. The MUJO System has been designed to help target the rehabilitation of the rotator cuff muscles which are commonly recommended for the management of shoulder pain. The purpose of this qualitative study was to evaluate the acceptability of the MUJO System amongst clinicians and patients. METHODS: A qualitative study was undertaken to look at the usability of the MUJO System both from clinicians' and patients' perspectives. Patients with shoulder problems were identified by an experienced physiotherapist using the study eligibility criteria. and invited to participate. Semi-structured interviews were performed with patients and clinicians to explore factors surrounding its acceptability and feasibility of use. The study was designed using Normalisation Process Theory as a theoretical basis for the inquiry. RESULTS: Seven physiotherapists and ten patients were interviewed in the study. The Internal and External Devices were seen as having the potential to rehabilitate the rotator cuff however it posed limitations towards more functional based exercises. Patients and clinicians found the visual feedback from the Patient App enhanced the rehabilitation experience. The Internal and External Devices were acceptable to all for rehabilitation providing the devices were available for use by the patients in the community. CONCLUSION: Patients and clinicians found the MUJO System acceptable as a modality to perform shoulder exercises. For the MUJO System to be taken up as a routine part of clinical practice patients need to be able to access the devices in the community. For the MUJO System to be taken up in clinical practice it needs to be workable within the context of the treatment pathway and not interfere with standard processes.

Does surgery followed by physiotherapy improve short and long term outcome for patients with atraumatic shoulder instability compared with physiotherapy alone? - protocol for a randomized controlled clinical trial.

BACKGROUND: Shoulder instability is a common problem affecting young adults. Stabilization surgery followed by physiotherapy rehabilitation has been shown to reduce the chance of further episodes of shoulder dislocation and to improve quality of life in patients who sustain a shoulder dislocation as a result of a high collision trauma, but it is unclear if surgical intervention is beneficial for patients with atraumatic shoulder instability who have structural damage at the shoulder. The aim of this randomized controlled clinical trial is to determine if the addition of surgical intervention to physiotherapy rehabilitation improves outcomes for patients with atraumatic shoulder instability who have sustained soft tissue damage at their joint. METHODS/DESIGN: 140 participants will be recruited. Patients with feelings of insecurity (apprehension) at their shoulder joint, which is not the result of a collision injury, with physical signs of shoulder joint instability will be invited to participate. Consenting participants will undergo arthroscopic investigation of the shoulder joint. Patients with capsulolabral damage will be randomly allocated using a concealed allocation procedure to either stabilization surgery immediately following the arthroscopic examination or no additional surgical procedure. All participants will then receive the same postoperative physiotherapy protocol for up to 6 months. Outcomes (pain, functional impairment and number of shoulder dislocations sustained) will be evaluated prior to surgery and, together with participant-reported improvement, again at 6, 12 and 24 months after randomization. The primary endpoint will be pain and functional impairment at 2 years. Participants, clinical staff (but not surgeons) and assessors will be blind to whether stabilization surgery was performed. Data analysis will be conducted on an intention-to-treat basis with the focus on estimation of the effect. DISCUSSION: This trial will have a direct and immediate impact on clinical decision making by establishing if patients presenting with soft tissue shoulder damage associated with atraumatic shoulder instability should be referred for stabilization surgery before commencing physiotherapy rehabilitation in order to ensure optimal outcome. This in turn will ensure effective, efficient use of scarce health resources to manage this common often disabling musculoskeletal condition. TRIAL REGISTRATION: Study was registered with National Institutes of Health Clinical Trials Protocol Registration System in December 2012.ClinicalTrials.gov Identifier: NCT01751490.

Collaborative care model versus usual care for the management of musculoskeletal and co-existing mental health conditions: a randomised feasibility mixed-methods study.

OBJECTIVE: This study aimed to assess the feasibility of a future trial comparing the collaborative care model with usual care for patients with musculoskeletal conditions and co-existing symptoms of anxiety and depression. DESIGN: A single-centre, parallel-arm, one-to-one, randomised controlled trial design using a mixed-methods approach was used. semistructured interviews and focus groups were conducted post intervention with all participants and staff respectively to explore acceptability towards the model and identify recommendations for improvements. SETTING: An orthopaedic rehabilitation outpatient tertiary hospital. PARTICIPANTS: Adult patients with musculoskeletal conditions and co-existing moderate or severe symptoms of anxiety and depression attending outpatient therapy appointments. INTERVENTION: The collaborative care model consisted of a tailored management programme to facilitate the integration of care provided by physical and mental healthcare professionals. A case manager screened and coordinated targeted mental health support for participants. Participants allocated to usual care had no support from the case manager. MAIN OUTCOMES MEASURE: Feasibility indicators (rates of recruitment, randomisation and retention), acceptability of clinical outcome measures, usage of additional resources and cost of intervention implementation. RESULTS: Of the 89 patients who provided consent to take part, 40 participants who matched the eligibility criteria were randomised to either the intervention (n=20) or usual care arm (n=20). Overall adherence to the intervention was 58.82%, while the withdrawal rate was 37.5% at 6 months. All of the 27 participants who were retained completed self-reported outcomes. Qualitative data highlighted that integrated mental health support was favourably perceived. In addition to prenegotiating protected psychology time, the need for operationalised communication between the case manager and clinicians was identified as a recommendation for a future trial. CONCLUSIONS: The trial and intervention were acceptable to patients and healthcare professionals. While the findings demonstrate the feasibility of trial recruitment, a future trial will require optimised retention strategies to improve adherence and withdrawal rates. TRIAL REGISTRATION NUMBER: NCT05018039.

Rehabilitation guidelines following arthroscopic shoulder stabilisation surgery for traumatic instability - a Delphi consensus.

BACKGROUND: There is no consistent approach to rehabilitation following arthroscopic shoulder stabilisation surgery (ASSS) in the UK. The aim of this study was to agree a set of post-operative guidelines for clinical practice. METHOD: Expert stakeholders (surgeons, physiotherapists and patients) were identified via professional networks and patient involvement and engagements groups. A three-stage online Delphi study was undertaken. Consensus was defined by the OMERACT threshold of 70% agreement. RESULTS: 11 surgeons, 22 physiotherapists and 4 patients participated. It was agreed patients should be routinely immobilised in a sling for up to 3 weeks but can discard earlier if able. During the immobilisation period, patients should move only within a defined "safe zone." Permitted functional activities include using cutlery, lifting a drink, slicing bread, using kitchen utensils, wiping a table, light dusting, pulling up clothing, washing/drying dishes. Closing car doors or draining saucepans should be avoided. Through range movements can commence after 4 weeks, resisted movements at 6 weeks. Patients can resume light work as they feel able and return to manual work after 12 weeks. Return to non-contact sports when functional markers for return to play are met was agreed. Return to contact sport is based on function & confidence after a minimum of 12 weeks. Additional factors to consider when determining rehabilitation progression: functional/physical milestones, patient's confidence and presence of kinesiophobia. The preferred outcome measure is the Oxford Instability Shoulder Score. CONCLUSION: This consensus provides expert recommendations for the development of rehabilitation guidelines following ASSS. CONTRIBUTION OF THE PAPER.

Rehabilitation following shoulder arthroscopic stabilisation surgery: A survey of UK practice.

Background: Optimal rehabilitation following arthroscopic shoulder stabilisation for traumatic anterior instability is unknown. The purpose of this study was to establish current UK practice for this patient group. Methods: A self-administered online questionnaire was developed and distributed to UK surgeons and physiotherapists. Results: 138 responses were received. Routine immobilisation was reported in 79.7% of responses with a cross-body sling being the preferred position (63.4%). Duration of immobilisation and timescales to initiate movement were highly variable. Return to light work was advised when patients felt able (25.4%) or after 6 weeks (26.1%). 58.7% recommended waiting for 12 weeks to return to manual work. 56% recommended non-contact sport could be resumed after 12 weeks. For contact sport, recommendations varied from 6 weeks (3.8%) to 6 months (5.8%). Psychological readiness was the most frequently cited criteria for return to play (58.6%). Factors such as hyperlaxity (40.6%), age (32.6%) and kinesiophobia (28.3%) were not considered as relevant as reported quality of surgical fixation (50%). Conclusion: There is no clear consensus regarding optimal post-operative rehabilitation following arthroscopic shoulder stabilisation. Further work is required to establish high value, personalised pathways for this patient group.

A systematic review to compare physiotherapy treatment programmes for atraumatic shoulder instability.

Background: Optimal physiotherapy treatment is uncertain for atraumatic shoulder instability (ASI), the primary aim of this systematic scoping review was to compare physiotherapy treatment programmes for people with ASI. The secondary aims were to evaluate outcome measures used and to compare the effectiveness of these programmes. Methods: CINAHL, EMBASE and Medline databases were searched for studies, except single case studies, published between 1950 and July 2021. 12 critical appraisal items covered three domains; internal validity, transferability to wider population and reporting. Results: Ten studies were included; one randomised controlled trial, 6 cohort studies and 3 case series. There were 491 participants. Treatment programmes included education, movement re-education, static posture correction, shoulder muscle strengthening, functional training, and adjuncts. All studies used patient reported outcome measures (PROMs), 7 of which reported a statistically significant improvement (p < 0.05) post-treatment. There was no clear relationship between programmes and outcomes. PROMs specific to shoulder instability were all found to detect statistically significant differences post-treatment. Discussion: There does not appear to be one optimal physiotherapy treatment programme for ASI. Future studies should use PROMs that are valid in the shoulder instability population and use more outcome measures that are specific to impairments being targeted.

Post-operative rehabilitation following traumatic anterior shoulder dislocation: A systematic scoping review.

Background: This systematic scoping review aimed to describe the content of post-operative rehabilitation programmes, and outcome measures selection following stabilisation surgery for traumatic anterior shoulder dislocation (TASD). Methods: An electronic search of Medline, EMBASE, CINAHL and AMED was conducted (2000-2021). Any cohort or clinical trial of patients receiving post-operative TASD rehabilitation were included. Study selection, data extraction and quality appraisal were undertaken by two independent reviewers. Results: Twelve studies including fourteen treatment programmes were eligible. Period of post-operative immobilisation ranged from 1 day to 6 weeks, with exercise introduced between 1 and 7 weeks. Strengthening exercises were introduced between 1 and 12 weeks. Two studies described "accelerated" rehabilitation programmes, differing in immobilisation period and exercise milestones. No increased recurrence was reported in professional footballers. Two studies compared rehabilitation programmes, one not randomised, the other 18 years old. There was variability in selected outcomes measures, with only 4 studies using a common measure. Discussion: There is minimal evidence to guide post-operative rehabilitation, variability in immobilisation periods and when exercise is introduced. There is no consensus on the definition of accelerated rehabilitation, or outcome measure selection. Clinical consensus of standardised terminology and stages of rehabilitation is required prior to efficacy studies.

Collaborative care model versus usual care for people with musculoskeletal conditions and co-existing anxiety and depression: protocol for a feasibility mixed-methods randomised controlled trial.

BACKGROUND: In the UK 17.8 million people have musculoskeletal pathophysiology, which becomes universal with age. Levels of discomfort and incapability correlate with symptoms of anxiety and depression. People with sufficient symptoms who seek care can benefit from collaborative diagnosis and treatment of mental and physical health organised by a case manager. This paper presents the protocol for a feasibility trial of collaborative care in an orthopaedic setting. AIMS: To determine the feasibility and acceptability of providing collaborative care for patients with musculoskeletal conditions and co-existing symptoms of anxiety and depression identified on a screening tool in a physical and occupational therapy out-patient setting. METHOD: A two-arm parallel-group randomised controlled trial will recruit 40 adult out-patients with at least moderate anxiety and depression, who have been referred for physiotherapy and occupational therapy. Participants will be allocated on a 1:1 ratio to collaborative care or to usual care. Co-primary outcomes will be key feasibility indicators collected at baseline and at 6 months. A qualitative study will be conducted post-intervention to explore the acceptability and potential improvements to the collaborative care model. RESULTS: This study will investigate the use of the collaborative care model for patients with musculoskeletal and co-existing moderate or severe levels of anxiety or depression. CONCLUSIONS: The results will provide important evidence to determine a future trial.

International physical therapists consensus on clinical descriptors for diagnosing rotator cuff related shoulder pain: A Delphi study.

BACKGROUND: There is a lack of standardized criteria for diagnosing rotator cuff related shoulder pain (RCRSP). OBJECTIVE: To identify the most relevant clinical descriptors for diagnosing RCRSP. METHODS: A Delphi study was conducted through use of an international physical therapists expert panel. A 3-round Delphi survey involving an international panel of physical therapists experts with extensive clinical, teaching, and research experience was conducted. A search query was performed in Web of Science, along with a manual search, to find the experts. The first round was composed of items obtained from a previous pilot Delphi study along with new items proposed by the experts. Participants were asked to rate items across six clinical domains using a five-point Likert scale. An Aiken's Validity Index ≥ 0.7 was considered indicative of group consensus. RESULTS: Fifteen experts participated in the Delphi survey. After the three rounds, consensus was reached on 18 clinical descriptors: 10 items were included in the "subjective examination" domain, 1 item was included in the "patient-reported outcome measures" domain, 3 items in the "diagnostic examination" domain, 2 items in the "physical examination" domain", and 2 items in the "functional tests" domain. No items reached consensus within the "special tests" domain. The reproduction of symptoms in relation to the application of load, the performance of overhead activities, and the need of active and resisted movement assessment were some of the results with greatest consensus. CONCLUSION: In this Delphi study, a total of 18 clinical descriptors across six clinical domains were agreed upon for diagnosing RCRSP.

The association between crawling as a first mode of mobilisation and the presentation of atraumatic shoulder instability: a retrospective cohort study.

BACKGROUND AND PURPOSE: To investigate if there is an association between whether an infant crawls as their first mode of mobilisation and the subsequent presentation of atraumatic shoulder instability. PATIENTS AND METHODS: A retrospective cohort of 50 consecutive patients who had presented to a national specialist centre for shoulder instability with a diagnosis of atraumatic instability was compared with a cohort of 50 participants who did not have shoulder instability. Primary outcomes were presence of atraumatic shoulder instability and whether or not the patient crawled as their first mode of mobility. A Pearson chi-squared test was used to evaluate associations. RESULTS: There was a significant association between crawling and shoulder instability (X 2(1) ≥ 11.93, p = 0.001) with a higher prevalence of non-crawlers in the group with shoulder instability compared to the control group. INTERPRETATION: There may be an association between developmental milestones and atraumatic shoulder instability. It cannot be concluded from this study whether association is causal and additional research is needed to further investigate this relationship. Asking patients presenting with shoulder instability about their developmental milestones as part of a full subjective history could guide a more targeted sensorimotor rehabilitation programme.

Shoulder Pain Diagnosis, Treatment and Referral Guidelines for Primary, Community and Intermediate Care.

These care pathway guidelines for the shoulder have been written in collaboration with the NHS Evidence Based Interventions (EBI) programme. The EBI programme is a partnership between the Academy of Medical Royal Colleges, NHS Clinical Commissioners, the National Institute for Health and Care Excellence, as well as NHS England and Improvement.

Progressive exercise compared with best-practice advice, with or without corticosteroid injection, for rotator cuff disorders: the GRASP factorial RCT.

BACKGROUND: Rotator cuff-related shoulder pain is very common, but there is uncertainty regarding which modes of exercise delivery are optimal and the long-term benefits of corticosteroid injections. OBJECTIVES: To assess the clinical effectiveness and cost-effectiveness of progressive exercise compared with best-practice physiotherapy advice, with or without corticosteroid injection, in adults with a rotator cuff disorder. DESIGN: This was a pragmatic multicentre superiority randomised controlled trial (with a 2 × 2 factorial design). SETTING: Twenty NHS primary care-based musculoskeletal and related physiotherapy services. PARTICIPANTS: Adults aged ≥ 18 years with a new episode of rotator cuff-related shoulder pain in the previous 6 months. INTERVENTIONS: A total of 708 participants were randomised (March 2017-May 2019) by a centralised computer-generated 1 : 1 : 1 : 1 allocation ratio to one of four interventions: (1) progressive exercise (n = 174) (six or fewer physiotherapy sessions), (2) best-practice advice (n = 174) (one physiotherapy session), (3) corticosteroid injection then progressive exercise (n = 182) (six or fewer physiotherapy sessions) or (4) corticosteroid injection then best-practice advice (n = 178) (one physiotherapy session). MAIN OUTCOME MEASURES: The primary outcome was Shoulder Pain and Disability Index (SPADI) score over 12 months. Secondary outcomes included SPADI subdomains, the EuroQol 5 Dimensions, five-level version, sleep disturbance, fear avoidance, pain self-efficacy, return to activity, Global Impression of Treatment and health resource use. Outcomes were collected by postal questionnaires at 8 weeks and at 6 and 12 months. A within-trial economic evaluation was also conducted. The primary analysis was intention to treat. RESULTS: Participants had a mean age of 55.5 (standard deviation 13.1) years and 49.3% were female. The mean baseline SPADI score was 54.1 (standard deviation 18.5). Follow-up rates were 91% at 8 weeks and 87% at 6 and 12 months. There was an overall improvement in SPADI score from baseline in each group over time. Over 12 months, there was no evidence of a difference in the SPADI scores between the progressive exercise intervention and the best-practice advice intervention in shoulder pain and function (adjusted mean difference between groups over 12 months -0.66, 99% confidence interval -4.52 to 3.20). There was also no difference in SPADI scores between the progressive exercise intervention and best-practice advice intervention when analysed at the 8-week and 6- and 12-month time points. Injection resulted in improvement in shoulder pain and function at 8 weeks compared with no injection (adjusted mean difference -5.64, 99% confidence interval -9.93 to -1.35), but not when analysed over 12 months (adjusted mean difference -1.11, 99% confidence interval -4.47 to 2.26), or at 6 and 12 months. There were no serious adverse events. In the base-case analysis, adding injection to best-practice advice gained 0.021 quality-adjusted life-years (p = 0.184) and increased the cost by £10 per participant (p = 0.747). Progressive exercise alone was £52 (p = 0.247) more expensive per participant than best-practice advice, and gained 0.019 QALYs (p = 0.220). At a ceiling ratio of £20,000 per quality-adjusted life-year, injection plus best-practice advice had a 54.93% probability of being the most cost-effective treatment. LIMITATIONS: Participants and physiotherapists were not blinded to group allocation. Twelve-month follow-up may be insufficient for identifying all safety concerns. CONCLUSIONS: Progressive exercise was not superior to a best-practice advice session with a physiotherapist. Subacromial corticosteroid injection improved shoulder pain and function, but provided only modest short-term benefit. Best-practice advice in combination with corticosteroid injection was expected to be most cost-effective, although there was substantial uncertainty. FUTURE WORK: Longer-term follow-up, including any serious adverse effects of corticosteroid injection. TRIAL REGISTRATION: Current Controlled Trials ISRCTN16539266 and EudraCT 2016-002991-28. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 48. See the NIHR Journals Library website for further project information.

The rotator cuff is a group of muscles and tendons that stabilise the shoulder and allow it to move. Problems with the rotator cuff are very common. Symptoms include pain, which can affect a person's ability to work, sleep well or perform daily tasks. It is not known which treatments work best for shoulder pain, how exactly they should be delivered and whether or not people do better if they are given a steroid injection. The GRASP (Getting it Right: Addressing Shoulder Pain) trial tested whether or not people with a rotator cuff disorder would do better after a progressive exercise programme (supervised by a physiotherapist over six appointments spread out over 16 weeks) compared with a one-off best-practice advice session with a physiotherapist. The trial also tested whether or not giving a corticosteroid injection in the shoulder before starting either regime would help people recover more. We assessed the cost of delivering these treatments to the NHS. We recruited 708 people from 20 NHS-based musculoskeletal centres in the UK. People were allocated to one of four treatment groups at random: (1) progressive exercise (six or fewer physiotherapy sessions), (2) best-practice advice (one physiotherapy session), (3) corticosteroid injection then progressive exercise (six or fewer physiotherapy sessions) or (4) corticosteroid injection then best-practice advice (one physiotherapy session). Trial participants were asked to complete a questionnaire that asked about their level of shoulder pain and their ability to perform basic daily tasks before treatment, and then again at 8 weeks and at 6 and 12 months. Participants' shoulder pain and function improved over time in each of the four treatment groups. The GRASP trial showed that there was no difference between the best-practice advice session with a physiotherapist and the more comprehensive exercise programme. Corticosteroid injection improved people's shoulder pain and function, but only by a small amount and in the short term. No serious side effects were observed during the 12-month follow-up period. Best-practice advice in combination with corticosteroid injection is likely to be most cost-effective to the NHS.

Use of virtual consultations in an orthopaedic rehabilitation setting: how do changes in the work of being a patient influence patient preferences? A systematic review and qualitative synthesis.

OBJECTIVES: To systematically review qualitative studies reporting the use of virtual consultations within an orthopaedic rehabilitation setting and to understand how its use changes the work required of patients. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement, we conducted a systematic review of papers to answer the research question 'How do changes in the work of being a patient when using communication technology influence patient preferences?' Electronic databases were searched for studies meeting the inclusion criteria in April 2020. RESULTS: The search strategy identified 2057 research articles from the database search. A review of titles and abstracts using the inclusion criteria yielded 21 articles for full-text review. Nine studies were included in the final analysis. Six studies explored real-time video conferencing and three explored telephone consultations. The use of communication technology changes the work required of patients. Such changes will impact on expectations for care, resources required of patients, the environment of receiving care and patient-clinician interactions. This adjustment of the work required of patients who access orthopaedic rehabilitation using communication technology will impact on their experience of receiving care. It is proposed that changes in the work of being a patient will influence preferences for or against the use of communication technology consultations for orthopaedic rehabilitation. CONCLUSION: We found that the use of communication technology changes the work of being a patient. The change in work required of patients can be both burdensome (it makes it harder for patients to access their care) and beneficial (it makes it easier for patients to access their care). This change will likely to influence preferences. Keeping the concept of patient work at the heart of pathway redesign is likely to be a key consideration to ensure successful implementation. PROSPERO REGISTRATION NUMBER: CRD42018100896.

Empathy in Action in Healthcare (EACH): A mixed methods study of nurses' and therapists' empathy.

BACKGROUND: Despite a plethora of research on empathy and its associated constructs, there is little evidence exploring clinicians' perceptions of their empathy and its impact on service level outcomes. METHODS: The aim of this single centre mixed methods study was to investigate nurses' and therapists' empathy levels and explore their views regarding its impact on clinical decision making at a national specialist orthopaedic centre. Data were collected from 126 respondents using an online validated empathy scale (Jefferson scale) supplemented by interviews with a convenience sample of 20 respondents. Questionnaire data were analysed using descriptive and inferential statistics. Qualitative interview data were subjected to a standard process of inductive thematic analysis prior to seeking relationships between the two datasets. RESULTS: There was a statistically significant difference in empathy levels between nurses and therapists (p = 0.031), with nurses scoring lower than therapists. Interview findings identified four key themes; displaying empathy, therapeutic use of self, influences and impacts, and learning. Differences between empathy scores and participants' subjective accounts of empathy were apparent. CONCLUSION: Empathy is an important construct built upon personal and professional experiences. Previous research reports empathy as a positive tool, however, our data suggest that its inappropriate use might also have a negative impact on service delivery and health outcomes.

Development and implementation of the physiotherapy-led exercise interventions for the treatment of rotator cuff disorders for the 'Getting it Right: Addressing Shoulder Pain' (GRASP) trial.

OBJECTIVES: The Getting it Right: Addressing Shoulder Pain (GRASP) trial is a large-scale, multicentre, 2×2 factorial randomised controlled trial investigating clinical and cost-effectiveness of a progressive exercise programme versus best-practice advice, with or without corticosteroid injection, for treating people with rotator cuff disorders. Here we describe the development, implementation and details of the physiotherapy-led interventions. METHODS: Medical Research Council guidance for developing complex interventions were used, taking into account clinical guidelines, expert and patient opinion, research evidence, current practice variation, and deliverability. A stakeholder meeting of 26 experts, clinicians, researchers, and patient representatives was used to design key components of the interventions. Stakeholders prioritised strengthening posterior rotator cuff muscles and using practical, easy-to-do exercises. The interventions were designed to be deliverable across the UK National Health Service. RESULTS: Progressive exercise consists of up to six sessions with a physiotherapist over 16 weeks. The best-practice advice consists of one face-to-face session with a physiotherapist with substantially greater reliance on self-management. Both interventions include self-management advice, home-exercise instruction, and behaviour-change strategies to target exercise adherence. All participants receive a Participant Information Booklet. The best-practice advice intervention is a self-guided system of progressively challenging exercises, with demonstration videos and written materials. The progressive exercise intervention has a wider range of exercise options, and greater flexibility for tailoring, progression, supervised practice and feedback. CONCLUSION: GRASP has recruited 708 participants and will provide high quality evidence to inform management of people with shoulder pain due to a rotator cuff disorder. Results are anticipated in 2020. TRIAL REGISTRATION NUMBER: ISRCTN16539266; EudraCT number:2016-002991-28.