To evaluate the mid-point implementation of an evidence-informed physiotherapy exercise group to reduce or delay surgery for patients with shoulder pain at The Royal Melbourne Hospital.
This was an iterative pilot study evaluating the implementation and efficacy of a twelve-week group exercise program for patients with rotator cuff-related shoulder pain. Patients were referred from orthopaedic outpatient clinics over twelve months (July 2023 – June 2024). The primary outcome was diversion from surgery (number of patients added to surgical waitlist). Secondary outcomes included changes in outcome measures of pain and function (American Shoulder and Elbow Surgeons Score (ASES), Tampa Scale for Kineseophobia (TSK-11), and Clinical Global Impression (CGI)); anonymous patient feedback about their experience of the group; and identification of barriers to group attendance.
Thirty-two patients were referred in twelve months; 26 (81%) attended. Median age was 64 [IQR 58-70] years; 46% were male and one third did not speak English as their first language. The median symptom duration was 11 months [IQR 7-18 months]. Two thirds of patients had a cuff tear greater than 1cm. Participants attended a mean of 12 classes with 90% completing the program. After completion, one patient opted for shoulder surgery. Pain and function scores trended towards improvement, as measured by pre-post ASES (57.9 versus 62.3, where the maximum score 100 means no pain and excellent function, and the minimum clinically important difference is 12-17 points), TSK-11 (28.3 versus 26.6, where 11 is the best score and 44 the worst, representing severe fear of pain), and CGI where 76% of patients said their shoulder was "much improved" or "very much improved" after the group.
The patient experience survey revealed 67% agreed or strongly agreed that their shoulder pain was better since attending the group, and 93% agreed or strongly agreed that they would recommend this group to family or friends.
Barriers to attending included clinician factors (unsure of who to refer or how to refer) and patient factors (preference for therapy closer to home, unsuitable group day/time).
This study demonstrates that a physiotherapy exercise rehabilitation group can divert patients with shoulder pain from surgery. Patients who completed the group had improved shoulder pain and function after twelve weeks and they liked attending. Future work should address barriers to group attendance.
Positive mid-point data supports continuation of the group, with measures in place to address barriers. If outcomes are positive, scaling could meet the aim of "increasing availability of non-surgical treatment pathways," as outlined in the surgical reform blueprint.
Exercise
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