Telerehabilitation and internet-based management of rotator cuff related pain: a pilot and feasibility randomised controlled trial

The intervention will be delivered via a tailored online website for participants. The intervention groups include: *Group (ii): Detailed education, advice and exercises + “virtual physiotherapist” (performance of exercises is entered into a website and it provides guidance for modification) *Group (iii): Detailed education, advice and exercises + “virtual physiotherapist” + weekly telerehabilitation session via Zoom with physiotherapist. We hypothesize the addition of a weekly telerehabilitation session for Group (iii) will improve the personalization and personability of the program while still using an online platform. We anticipate this will improve adherence to the program and result in superior results of primary and secondary outcomes in group (iii) compared to group (i) and group (ii). The online website has been specifically designed for this trial. It is built to encourage self-navigation throughout the website. The online website was built by an IT expert in conjunction with a physiotherapy shoulder expert. It will include the education material, which is a document around rotator cuff related pain including anatomy, physiology, contributing factors, treatment and advice including activity modification and recommended care. This is provided in both written and video format. It also includes the exercise intervention, which is provided in both written and video exercises. There will be two exercises: shoulder elevation in standing; and shoulder external rotation in side-lying. Three sets of 15 repetitions of each exercise will be performed. The exercise will be individualised based on pain (pain should be minimal during the exercise, i.e. less than 5/10 on a 10-point numerical rating scale), and capacity (they should feel they are not able to perform more than 2 additional repetitions at the end of each set of 15). Participants are encouraged to modify the exercises (either make easier or more difficult) as per their self-perceived levels of pain. If they find the exercise too easy, they are prompted to increase the exercise intensity by adding external load in increments of 1kg. Each day they should ensure that they can perform the exercise with acceptable pain (<5/10). If this is not the case they will be advised to regress, i.e. reduce the weight, or revert to an isometric holding exercise (holding a weight statically). If there is still unacceptable pain (5/10 or above) they will be advised to rest for that day. Participants are required to complete their exercises daily, unless their pain symptoms guide them to rest for the day and try again the following day. Participants in group (ii) and group (iii) are expected to enter what exercises they completed (and any modifications) into a daily recording page within the website. This will track adherence to the program and allow the monitoring of progression of exercise and participation throughout the trial. All participants will be required to complete an online survey at baseline, at six weeks and at twelve weeks at the conclusion of the study. Participants will be required to complete an initial baseline Zoom session, and participants in group three will be required to complete a weekly telerehabilitation session. This weekly telerehabilitation session will be completed via Zoom, an online videoconference platform. It will be set up at an agreed upon time between the physiotherapist and the participant. The aim of the session is to assess exercise technique, suggest progressions if indicated and answer any participant questions. It is expected to take between 10-30 minutes per week. Participants will be provided with education at baseline and required to complete a questionnaire regarding this education to measure knowledge improvement. The education intervention has been developed with input from multidisciplinary expert shoulder clinicians.