A pilot randomised controlled trial comparing three different physiotherapy interventions to treat rotator cuff tendinopathy/subacromial pain syndrome.

Participants are randomly assigned to one of three intervention groups: (i) isometric exercises (ii) isotonic concentric exercises (iii) isotonic eccentric exercises All groups will receive similar physiotherapy treatment directed at improving postural deficits, scapular control, shoulder muscle strength and flexibility. The variation in the intervention between the groups will be the specific type of rotator cuff strengthening exercises incorporated into the rehabilitation program: these will involve either (i) isotonic concentric; (ii) isotonic eccentric or (iii) isometric contractions, taught and prescribed in accordance with current best evidence. The treatment sessions will occur once per week over 4 consecutive weeks (weeks 2-5). Exercises: Treatment 1: re-training of scapular/humeral head movement patterns. Scapular control exercises will be patient specific and relate to symptom modification of scapular postures identified at assessment including scapular rotation and/or tilt. Once the patient has learned how to re-position the scapular so that for example, downward rotation and anterior tilt is corrected, they will perform scapular muscle strengthening exercises including (i) modified shrug drills in standing with arm abducted <30 degrees with elastic resistance band as tolerated. Treatment 2: rotator cuff strengthening (external rotation) exercises. These will be performed in standing, arm by side, elbow flexed to 90 degrees, using (i) elastic resistance band for concentric and eccentric and (ii) rigid band for isometric contractions. Treatment 3: rotator cuff strengthening (internal rotation) exercises. These will be performed in standing, arm by side, elbow flexed to 90 degrees, using (i) elastic resistance band for concentric and eccentric and (ii) rigid band for isometric contractions. Treatment 4: Flexibility exercises including (i) an anterior shoulder stretch (standing in corner of room or using door jamb) and (ii) thoracic extension range of motion exercises in either a) sitting or b) supine lie over rolled up towel. Also posterior muscle building including (iii) standing rows at 45 and 90 degrees using elastic resistance band as tolerated. The above exercises will be taught during the physiotherapy sessions and then performed independently and daily as part of a home exercise program with dose dependent on exercise type and specifically: 1) Scapular retraining (motor relearning) exercises, scapular shrugs and standing rows: 1-2 times daily, 1-2 sets of 20, 5-10 second rest in between each set. Progression of sets, repetitions and load dependent on individual participant ability to achieve control. 2) Rotator Cuff strengthening exercises: varies with muscle contraction group: Isotonic: 1-2 times daily, 1-2 sets of 20 repetitions, 5-10 second rest in between each set; Isometric: 1-2 times daily, 1 set of 3-5 repetitions with 10 second isometric hold, 5 second rest in between each hold. 1-2 times daily. 3) Flexibility: all exercises 1-2 sets daily; stretch held for 15 seconds and repeated 2-4 times with a 5-10 second rest in between each stretch, 1-2 times daily. Thoracic mobility:. 1 set of 10 reps with 5 second hold and 5-10 second rest in between sets. 1-2 times daily. Both scapular retraining and rotator cuff strengthening exercises will be taught/undertaken in standing but temporarily modifiable to side lie/prone positions dependent on patient symptoms and/or ability to control the scapular/humeral head in the standing position. The home program will take 15-20 minutes to complete each day with sets and repetitions as described above. At week 6 patients will be provided with an exercise sheet that they will use from week 6-12. The exercise sheet is the same for each group and will include most of the exercises taught and practiced during the physiotherapy intervention, as well as additional exercises designed to further increase strength, range and flexibility. Until they receive this exercise sheet at week 6, patients undertake their group specific home exercise program that consists only of the exercises they are taught during their physiotherapy sessions. The exercise sheet given at week 6 replaces the previous sheet. It incorporates most of the exercises already performed as part of the home exercise program during weeks 2-6 but progresses these so they are no-longer group specific. Specific exercises detailed on the exercise sheet include: 1): scapular setting through progressive range of motion; 2) rotator cuff internal/external rotation with elastic resistance band as tolerated 3): posterior muscle strengthening - (i) standing rows with resistance band as tolerated at 45, 90 and 120 degrees; single bent forward row with elastic resistance band as tolerated. 4): flexibility exercises: (i) thoracic mobility in sitting, (ii) thoracic mobility in lie over rolled towel; (iii) anterior shoulder stretch (pectorals in door jamb); At week 9, they will attend a check-review to ensure compliance with the exercise sheet. The assessment and treatment sessions will be carried out by a designated musculoskeletal Physiotherapist at each site, with at least 5 years experience. Prior to recruitment of participants into the study, all clinicians involved in assessment and treatment delivery will receive training in the techniques to be used in each group, as per the study protocol. All treatment interventions will be recorded on standardised report forms. The treatment sessions will be individual 1: 1 sessions lasting up to 30 minutes per session.