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A trial that evaluated the clinical and cost effectiveness of physiotherapy treatments for rotator cuff disorders suggests cost savings can be made while maintaining positive patient outcomes.

Someone with their hand on their shoulder

The GRASP (Getting it Right: Addressing Shoulder Pain) trial compared a comprehensive supervised physiotherapy exercise programme versus a single session of best practice physiotherapy advice, with or without corticosteroid injection, in adults with a rotator cuff disorder.

Rotator cuff disorders are one of the most common causes of shoulder pain, accounting for around 70% all shoulder conditions. People with rotator cuff disorders often experience significant shoulder pain and impaired function. Treatment options include rest, advice, medication, exercise, manual therapy, and corticosteroid injections. However, use of these treatments can be highly variable. There is also considerable uncertainty around their effectiveness, mode of delivery and possible long-term harm.

Associate Professor Sally Hopewell said: “Given the uncertainty around treatment options, we wanted to explore how best to treat this really common shoulder condition, in the most efficient way. Our findings are particularly relevant given the pandemic where it has been harder to deliver traditional face-to-face physiotherapy care over multiple sessions and where NHS resources are stretched.”

The GRASP trial, funded by the National Institute of Health Research Health Technology Assessment Programme, was a large multicentre randomised controlled trial. 708 adults with rotator cuff related shoulder pain that started within the last six months were recruited from 20 UK NHS Trusts. Participants were allocated to either progressive exercise (up to 6 sessions with a physiotherapist), or best practice advice (one session with a physiotherapist). Additionally, participants were also allocated to either having a corticosteroid injection, or not having an injection, before having their physiotherapy treatment. The primary outcome measure was shoulder pain and function using the patient-reported SPADI (Shoulder Pain and Disability Index) scale, over 12 months.

The results of the GRASP trial are published in The Lancet. They showed that the progressive exercise intervention was not superior to a best practice advice session with a physiotherapist. “We found that corticosteroid injection improved people’s shoulder pain and function in the short-term, but this effect was not maintained in the longer term” said Sally. “So, we are able to recommend that a single session of best practice physiotherapy advice, supported with high quality self-management materials, is likely to be the most cost-effective treatment for use of NHS resources”.

“I think one caveat I have is that self-management isn't necessarily the right thing for everybody. If people are in huge amounts of pain or have a really severe disability within their shoulder, self-management may not be right for them.”

Dr David Keene, who led the development of the physiotherapy programmes, added “The high quality of treatment delivery and levels of engagement in the trial are a testament to the commitment of hundreds of patients and physiotherapy and research-support staff in the NHS. Together we have been able to produce robust evidence that will help guide treatment decisions for this very common shoulder condition.”

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