233. Clinical Effectiveness of Exercise and Corticosteroid Injection for Subacromial Impingement Syndrome: A Randomized Controlled Trial

Background: Subacromial impingement syndrome (SIS) is the most common cause of shoulder pain. Management commonly involves exercise and CS injection yet how these are best-delivered is uncertain. The SUPPORT trial investigated whether better outcomes in pain and function are achieved with physiotherapist-led individua- lized, supervised and progressed exercise rather than a standardized advice and exercise leaflet; and US-guided subacromial CS injection rather than unguided injection. Methods: Design: 2 (cid:2) 2 factorial randomized controlled trial. Adults with SIS were recruited from musculoskeletal interface services and randomized equally to one of four treatment groups: US-guided steroid injection and physiotherapist-led exercise; US-guided steroid injection and an exercise leaflet; unguided steroid injection and physiotherapist-led exercise; and unguided steroid injection and an exercise leaflet. Outcomes were collected at 6 weeks, 6 and 12 months by postal questionnaire. The primary outcome measure was the Shoulder Pain and Disability Index (SPADI), compared at 6 weeks for the injection interventions and 6 months for the exercise interventions. Secondary outcomes included SPADI pain and disability subscales, current shoulder pain intensity, patient’s global impression of change, and pain self-efficacy. 250 participants were required to detect a small-moderate effect size (0.4) in SPADI for the two main comparisons. Analysis was by intention-to-treat. Results: 256 participants were recruited (48% male, mean age 54 years), 64 per treatment group. Response rates for the primary outcome were: 6 weeks, 94%; 6 months, 88%; and 12 months, 80%. Greater mean improvement in total SPADI score was seen with physiotherapist-led exercise than with the exercise leaflet at 6 months and 12 months: 3.02 (95% CI (cid:3) 3.00, 9.03) at 6 weeks, 9.48 (95% CI 3.30, 15.65) at 6 months and 6.64 (95% CI 0.33, 12.96) at 12 months. Physiotherapist-led exercise led to greater mean improvement in SPADI pain subscale at 6 and 12 months, and in SPADI disability subscale at 6 months but not at 12 months. At 12 months, the physiotherapist-led exercise group showed a greater reduction in current shoulder pain intensity, stronger self-efficacy beliefs and more frequent patient reporting of being much or completely better. Within-group improvement in total SPADI was seen in both injection groups but there were no significant between-group differences at any time point: 2.99 (95% CI (cid:3) 3.03, 9.00) at 6 weeks, 3.38 (95% CI (cid:3) 2.79, 9.56) at 6 months, and -1.50 (95% CI (cid:3) 7.82, 4.82) at 12 months. There were no differences in secondary outcome measures between the injection groups at any time point. There was no significant interaction effect of combined US-guided injection and physiotherapist-led exercise at the primary endpoints of 6 weeks and 6 months. Conclusion: Physiotherapist-led exercise in SIS leads to greater improvements in pain and function than providing a standardized advice and exercise leaflet. US-guidance confers no additional benefit over unguided CS injection.