Internet-based management of rotator cuff disease: a pilot and feasibility randomised controlled trial

(i) standard advice and exercise via online pamphlet; (ii) pamphlet in (i) + video delivery; (iii) pamphlet in (i) & videos in (ii) and individualised daily feedback. Participants will enter their pain and fatigue following each set of exercise and will receive individualised feedback about whether they should progress or regress exercise based on this. Education will be identical in all groups, only the delivery mode will differ. The education pamphlet and information has been custom designed for this study. Education will include the causes, pain mechanisms, exercise treatments and their efficacy and mechanisms, and other treatments and their efficacy. Emphasis will be placed on addressing knowledge gaps and barriers and enablers to recommended care. For example, challenging participants’ understanding of the relevance of tendon structure and imaging, expectations from exercise interventions, and pain and exercise self-efficacy. In each group participants will have free access to the pamphlet (group 1), pamphlet and videos (group 2/3) to watch as many times as they desire we advise that they watch the videos at least 1-2 times to comprehend the advice and instructions). The pamphlet is A4 pages and there is a series of <6 minute videos totally 20-30 minutes. The inidvidualised daily feedback in group 3 is provided via an online computer algorithm in response to the level of pain and fatigue the participants reports after each set of exercise. Exercise intervention: This will be identical for all groups, only the delivery mode will differ. The intervention will include shoulder elevation (from 10-150 degrees because extremes are usually provocative) and external rotation (full range). Elevation can be performed into shoulder abduction, scaption or flexion, depending on acceptable pain response (pain that is 'minimal' or less than 5/10 with activity and any increase in pain after exercise settles to pre-exercise levels relatively quickly ie within 12-24 hours). If pain during exercise is beyond 5/10 participants are advised to reduce weight, repetitions or range of motion until pain response is acceptable, or revert to isometric hold exercise until pain with through range exercise is acceptable. Exercise will be performed once per day over 12 weeks (3 sets of 15 repetitions and 4 seconds per cycle for isotonic exercise [2 second concentric and 2 second eccentric phase] or 6 sets of 30 seconds if isometric exercise is commenced initially). Exercise progression will be based on 1) achieving the prescribed dosage (sets, repetitions, time under tension) if this is not possible initially due to pain response or fatigue; 2) Then progressing load using a hand-held weight (elevation) or a theraband (external rotation) so that fatigue is achieved after 14-16 repetitions (otherwise they will be encouraged to use a heavier or lighter weight or theraband). Participants will be provided with education about how to progress and regress exercise based on acceptable pain response. Particioants will be advised to increase exercise exetrnal load if pain during exercise is acceptable and muscular fatigue is not experienced after the allocated repetitions. Regression (reduced load) will occur if pain is beyond what has been defined as acceptable. If the participant is not using a weight they regression will involve reducing the repetitions or range of motion, or reverting to an isometric hold exercise. The exercise and education components have been designed by board certified physiotherapists based on expert consensus and available evidence. They will be delivered completely remotely, without any clinician input or guidance.