Profiling Patients With Rotator Cuff Related Shoulder Pain: What Factors Influence Outcomes With Non-operative Care in a Secondary Care Specialist Shoulder Clinic?

Aims and Objectives The overall aim of the study is to examine the factors associated with the outcome of non-surgical care among a cohort of people referred to a specialist shoulder clinic.

The objectives of the study are as follows:

1. To conduct a prospective cohort study of adults with RCRSP presenting to a secondary care clinic in the mid-west suitable for non-operative management.
2. To determine the association between key patient characteristics (demographics, level of disability, comorbidities, etc) and outcome following physiotherapy management of RCRSP.

Introduction Shoulder pain is the third most common musculoskeletal symptom reported in primary care and has a prevalence of up to 26% in the general population (Rangan et al., 2016). It is a disabling condition, and when symptoms persist, it can impair quality of life, increase psychological distress and reduce the ability to maintain employment (Ackerman et al., 2018). Disorders of the rotator cuff muscle and tendons are the most commonly diagnosed cause of shoulder pain. A strong body of research evidence currently exists recommending non-surgical management (e.g. exercise) as the preferred first-line treatment for rotator cuff disorders (Littlewood et al., 2018). Shoulder surgery is more than twice as expensive as conservative approaches, and more importantly, has not been shown to produce superior outcomes in terms of pain and function compared to no treatment or non-surgical management (Beard et al., 2018, Ryösä et al., 2017, Ketola et al, 2013). Despite this, surgery rates continue to rise (Rangan et al., 2018).

Non-operative management includes the use of analgesia, physiotherapist led exercise and advice, and judicious use of corticosteroid injections (LaFrance et al., 2022). However, many patients are not receiving guideline based care in the primary care setting and are being unnecessarily referred to secondary care (Maxwell et al., 2022). In addition, due to resource constraints, long waiting times exist within primary care physiotherapy negatively impact patient outcomes and increase overall costs of care (Deslauriers et al., 2019). Recent evidence has found that a single advice and education session with a trained physiotherapist followed by a home self-management programme, produced equivalent outcomes to a control intervention of up to six face-to-face physiotherapy session for people with rotator cuff disorders (Marian et al., 2020). A recent systematic review by the research team of this model of care has confirmed this finding applies across a range of musculoskeletal disorders. While this research suggests that a 'less is more' approach can be successful in managing musculoskeletal pain, it is likely that some patient cohorts will require more intensive input, as illustrated in studies of low back where those with higher levels of mental health disorders needed more intensive multi-disciplinary input (Haglund et al., 2019). Therefore, it is important to identify predictors of negative outcomes with non-operative care so that an intervention can be developed which aims to address any modifiable prognostic factors.