“Restoring That Faith in My Shoulder”: A Qualitative Investigation of How and Why Exercise Therapy Influenced the Clinical Outcomes of Individuals With Rotator Cuff–Related Shoulder Pain

Abstract

Objective Rotator cuff-related shoulder pain is the most common form of shoulder pain. Exercise therapy is a first-line recommended treatment for rotator cuff-related shoulder pain. However, the causal mechanisms underpinning the beneficial effects of exercise for rotator cuff-related shoulder pain are not well understood. Moreover, how individuals with lived experience of rotator cuff-related shoulder pain believe exercise helped or did not help is unknown. This study aimed to gain insights into how individuals with rotator cuff-related shoulder pain believe exercise influenced their shoulder pain and identify the clinical conditions that promoted or inhibited their beliefs. Methods This qualitative study was underpinned by a critical realist approach to thematic analysis. Participants were recruited using hybrid purposive and convenience sampling techniques. Each participant attended an online semistructured interview. The data were coded by 2 members of the research team (JKP & NC) and verified by a third (BS). Recruitment continued until theoretical sufficiency was achieved. Participants reviewed and validated preliminary causal explanations. Results Three causal explanations were consistently expressed by 11 participants to explain the benefits of exercise therapy: (1) shoulder strength; (2) changes to psycho-emotional status; and (3) exercise has widespread health effects. However, the activation of these causal mechanisms depended on (1) the presence of a strong therapeutic relationship; (2) the provision of a structured and tailored exercise program; and (3) experiencing timely clinical progress. Conclusions Participants believed exercise improved their shoulder pain through associated health benefits, improved shoulder strength, and psychoemotional variables. Whether an exercise program was able to cause a clinical improvement for an individual with rotator cuff-related shoulder pain was contingent on clinical contextual features. Thus, the clinical context that an exercise program is delivered within may be just as important as the exercise program itself. Impact Exercise is a recommended primary, first-line intervention to manage rotator cuff-related shoulder pain. The results of this study suggest that a positive experience and outcome with exercise for rotator cuff-related shoulder pain is contingent on several clinical contextual features, such as a strong therapeutic relationship. The clinical context an exercise program is prescribed and delivered should be considered by clinicians.

Is exercise therapy therighttreatment for rotator cuff‐related shoulder pain? Uncertainties, theory, and practice

“…This is concordant with recent research illustrating that individuals often want and expect exercise from their physiotherapist, as described by a participant in the Subialka et al (2022) qualitative assessment (Jensen et al, 2022;Subialka et al, 2022): I'm just looking for them to teach me how to do the exercises I need to do at home to keep that range of motion going and to knock that pain level down without major surgery. (Subialka et al, 2022) A qualitative investigation exploring how and why individuals with lived experience of RCRSP believed exercise helped their symptoms reported that all participants in the study had a positive experience with exercise, but only under certain conditions (Powell et al, 2023).…”

“…In 2017, the Lancet published the Right Care Series and defined the right care as 'care that is tailored for optimising health and wellbeing by delivering what is needed, wanted, clinically effective, affordable, equitable, and responsible in its use of resources' (Elshaug et al, 2017). Exercise for RCRSP is modestly effective (Babatunde et al, 2021;Naunton et al, 2020;Steuri et al, 2017), often desired (Maxwell et al, 2021;Powell et al, 2023;Subialka et al, 2022), relatively affordable, and cost-effective (Oppong et al, 2021). We submit that exercise is equitable and responsible in its use of resources, certainly when compared to surgery for the majority of cases (Lewis, 2022).…”

“…Everyone does the same thing approach. (Powell et al, 2023) Other commonly expressed barriers to engaging with an exercise programme are poor access to equipment, uncertainty about approximate recovery timeframe, lack of motivation and time, and beliefs and expectations about whether exercise is the appropriate treatment for their shoulder pain (O'Shea et al, 2022;Sandford et al, 2017). Conversely, cogent advice and education about their shoulder condition and how to perform their exercise programme, access to equipment, lack of exercise burden, and a supportive social network were key facilitators of engaging with an exercise programme (O'Shea et al, 2022;Sandford et al, 2017).…”

“…Improvement in muscle strength 'And then the second I started strength training, I felt, yeah, just doing one exercise, every part of my shoulder was engaged. I was feeling that instant connection between the exercise I was doing and a positive improvement in my shoulder' (Powell et al, 2023) Changes to psycho-emotional status 'Just restoring that faith in my shoulder, I suppose, which is what he got me to eventually do with all of the strength exercises' (Powell et al, 2023) Exercise…”

“…The uncertainty of how exercise the patient response. An approach similar to this has been described as being helpful by individuals with lived experience of RCRSP (Powell et al, 2023). This approach makes space for a plurality of exercise and movement types and parameters to be trialled depending on the individual's symptom irritability, preferences, and feedback.…”