A total of 224 physiotherapists started answering the survey, and 70.0% (157/224) completed the survey. Both complete (157/192; 70.0%) and incomplete (35/192; 30.0%) questionnaires were included in the data analysis if questions concerning the case vignette or general management for RCRSP were answered. Most responses (204/223; 91.5%) were recorded within the first four weeks., with the average survey completion time being 10 minutes and 23 seconds. The flowchart on the recruitment process is shown in Fig. 2.
Respondents` characteristics
The demographic characteristics of the respondents are shown in Table 1. Most respondents identified as female (69.6%, 133/192), non-academically qualified (71.9%, 138/192), working in private practice (80.7%, 155/192) in a metropolitan area (61.4%, 116/192) and reported to have a special interest in shoulder pain or RCRSP (65.0%, 124/192). Respondents had been qualified a mean of 19.5 years (SD = 13.0; range 0.25–45 years) and treating patients with shoulder pain for an average of 17.2 years (SD = 12.8; range 0–43 years).
Table 1
Respondents’ demographic information.
| Frequency (absolute) | Frequency in % |
Age (191/192) |
18–24 years 25–34 years 35–44 years 45–54 years 55–64 years > 64 years | 17 39 43 42 42 8 | 8.90% 20.42% 22.51% 21.99% 21.99% 4.20% |
Gender (191/192) |
Female Male | 133 58 | 69.63% 30.37% |
Location (189/192) |
Rural area Urban/metropolitan area | 73 116 | 38.62% 61.37% |
Work setting (192/192) |
Private practice Centre of therapy Rehabilitation clinic Hospital Other | 155 9 7 7 14 | 80.73% 4.69% 3.64% 3.64% 7.30% |
Special interest in shoulder pain or RCRSP (191/192) |
Yes No | 124 67 | 64.92% 35.08% |
Medical focus (192/192) |
Musculoskeletal diseases Musculoskeletal and other diseases Non-musculoskeletal diseases Not clinically working | 36 145 5 6 | 18.75% 75.52% 2.60% 3.12% |
Highest level of education (192/192) |
State examen/diploma PT (vocational school) Bachelor PT (university) Diploma PT (university) Master PT PhD/doctorate Bachelor, Master, Diploma not-PT (university) | 138 18 8 8 1 19 | 71.87% 9.37% 4.16% 4.16% 0.52% 9.89% |
Further educational qualifications and training (192/192) |
No Manual Therapy Taping Machine-based training Alternative practitioner Others | 11 130 114 89 35 131 | 5.73% 67.71% 59.37% 46.35% 18.23% 68.23% |
Average number of shoulder pain cases treated per month (191/192) |
< 5 6–10 11–20 21–30 > 30 none | 53 83 35 10 3 7 | 27.75% 43.45% 18.32% 5.23% 1.57% 3.66% |
Recommended care for the clinical vignette
Referrals
Most respondents did not recommend imaging (60.4%, 116/192) with physiotherapists working in non-private practice settings (66.7%, 16/24) more likely to recommend it than those working in private practice (33.55%, 52/155) (Pearson-Chi-square = 9.67, p = 0.003) (Fig. 3). Physiotherapy education, special interest in shoulder pain or RCRSP and work location were not associated with imaging decision.
Almost half of the physiotherapists surveyed (49.2%, 94/191) were unsure regarding referral for injection, while 42.9% (82/191) would not recommend injection (Fig. 3). Education, special interest, work location or setting were not significantly associated with referral decision.
Few respondents recommended referral for surgical opinion (4.2%, 8/192), most not recommending referral for surgical opinion (74.0%, 142/192). Referral for surgical opinion was not significantly associated with education, work setting, location, or special interest.
Management
Education
In line with guideline recommendations nearly all respondents (99%, 190/192) would provide some form of patient education for RCRSP management shown in Fig. 4. Most physiotherapists (87.0%, 167/192) would address activity modification, discuss recommended physiotherapy management (86. 5%, 166/192), the pathology of RCRSP (74.5%, 143/192), risk factors (65.6%, 126/192), factors influencing pain (65.1%, 125/192), and explore the relationship between pathological tendon changes and pain (57.8%, 111/192). Less frequently mentioned topics were indications for imaging (34.4%, 66/192) or timeframe and indication for injection or surgery (26.0%, 50/192). Those who selected "other" (11.46%, 22/192) recommended education on the role of scapula setting, cervical and thoracic spine, the influence of posture, prognosis, shoulder biomechanics, fear avoidance behaviours and pain management.
Exercise
Consistent with current treatment recommendations, 98.96% (190/192) of respondents would use some form of exercise therapy regarding the case vignette shown in Fig. 5. Most frequently reported strategies included specific exercise for the rotator cuff (67.2%, 129/192), scapula exercise (62.0%, 119/192), cervical and thoracic spine exercise (62.0%, 119/192), and global exercises for the entire upper limb kinetic chain (60.9%, 117/192). Less commonly reported exercise strategies were use of isokinetic exercises for the shoulder (12.5%, 24/192) or aerobic training (9.4%, 18/192). Open answer responses reported other exercise strategies such as ‘exercise to improve posture’ and ‘water-based exercises’.
Adjunctive treatment
Recommended use of adjunctive treatment is shown in Fig. 6, 96.4% (185/192) of respondents recommending the use of at least one modality. Most respondents would recommend mobilisation (65.6%, 126/192) followed by cervical or thoracic spine treatment (64.6%, 124/192). Almost half would suggest hot or cold therapy (47.4%, 91/192) or taping (47.4%, 91/192). Electrotherapy was recommended by 40.6% (78/192), and 23.4% (45/192) recommended some form of massage. Few respondents recommended acupressure (12.5%, 24/192), acupuncture/dry needling (9.4%, 18/192), manipulation (8.9%, 17/192), and rest (8.3%, 16/192). Treatment recommendations in the “other” category (21.88%, 42/192) were: myofascial trigger point therapy, osteopathy, and cross friction. Non-academically trained physiotherapists (45.4%, 69/152) were significantly more likely to recommend electrotherapy than academically trained physiotherapists (22.5%, 9/40), (Pearson-Chi-square = 6.88, p = 0.011). 73.0% (111/152) of non-academically trained physiotherapists selected between one and three interventions with conflicting evidence (massage, taping, electrotherapy) compared to 42.5% (21/40) of academically trained physiotherapists.
Information formats
Most respondents reported they would convey information (on exercises or general information) verbally (86.8%, 138/159), as well as in written or printed form (57.9%, 92/159). Less commonly information would be disseminated as video recordings on patients' mobile devices (42.8%, 68/159) or links to online videos or websites (20%,31/159).
Management frequency and duration
Most respondents recommended seeing patients with RCRSP weekly (61.6%, 98/159), or fortnightly (22.0%, 35/159) to review or adjust exercises as needed. Review frequency of every 3 weeks (2.0%, 3/159) or less frequently (1.0%, 1/159) was less common. Those who selected "other" (13.2%, 21/159), related frequency decisions to patient's needs, and compliance or described frequency changes during the treatment period from initially weekly to fortnightly sessions.
The expected duration of treatment for patients with RCRSP is shown in Fig. 7. Most (62.3%, 99/159) expected a treatment period of at least 3 months and 27.7% (44/159) expected treatment period of up to 8 weeks. The remainder selected "other" (10.1%, 16/159) citing duration was dependent on patient factors such as severity of the problem, state of irritation, or individual stress factors.
Qualitative results:
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When you recommend exercises, what instructions do you give this patient regarding pain during the exercises?
Respondents’ views regarding pain experience during rehabilitation exercise varied. The majority (54.3%, 82/151) reported no pain at all should be experienced during exercise. Of those reporting pain during exercise is acceptable (30.5%, 46/151), variance existed in the acceptable pain level. Acceptable pain was either based on the Visual Analog Scale (VAS) or Numeric Rating Scale (NRS), ranging from 2–6/10 or more subjectively thresholds such as “subthreshold pain” [P11] or “in a tolerable range” [P12]. Subjective terminology including “stabbing” [P28] and “inflammatory” [P18] was used to describe unacceptable pain.
2. When you recommend exercises, what instructions do you give this patient regarding load/intensity of resistance?
Most respondents (22.7%, 34/150) reported load intensity being based on patient symptoms, 16.0% (24/150) reported subjective terms when specifying load levels such as "low/mild" or "moderate/medium" (18.3%, 28/150), few (3.3%, 5/150) would exercise without load/resistance) while 6.7% (10/150) reported load being based on specific repetition ranges e.g. "30–70% of 1RM [one repetition maximum]”, [P135]. Progression of load was reported as being pain dependent by some respondents (2.7%, 4/150), others suggesting progressing load without specifying dependent variables (8.7%, 13/150).
Other open answers included "only exert enough load to maintain the quality of the movement and avoid compensation" [P27] or, "so that there is no forced breathing, and movement is controlled" [P115].
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When you recommend exercises, what instructions do you give that patient in terms of number of repetitions and sets?
Clinical considerations concerning repetitions and sets varied. Most respondents (57.4%, 85/148) cited specific repetitions and sets without providing reasoning ranging from 8 to 20 repetitions per set (94.1%, 80/85) and 2–5 sets (98.8%, 84/85). Where reasoning was given, repetition and set range related to the exercise type, "8–12 reps, 3 sets for strength, for flexibility 30–40 repetitions" [P46], or vague guidance was given such as "adapted to the pain" [P59], or "start low, then increase" [P63]. Statements that only contained a number were excluded from analysis, when it remained unclear whether repetitions or sets were described.
4. When you recommend exercise, what instructions do you give this patient regarding exercise frequency?
Most respondents suggested either daily exercise (80.1%, 117/146) or a frequence of several times per week (80.1%, 117/146). 51.3% (60/117) recommended daily exercise "once per day" [P100] or "2–5 times daily" [P98]. Many (35.9%, 42/117) favoured 2 to 5 exercise sessions per week, 12.8% (15/117) recommended exercise every second to third day. Rarely responses were clinically reasoned "not every day, because the muscles need regeneration time. Every other day would be ideal or at least 3 times a week (not consecutively)" [P103] or "strength every 1–2 days, mobilization several times a day" [P67]. Few would prescribe frequency depending on patient's pain, resilience, and exercise type. 15.1% (22/146) of responses were not included into analysis due to imprecision, e.g. "various" [P111], "increase if everything is ok" [P137] or "2–3" [P102]. 24.0% (46/192) did not provide any comment.
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When you recommend exercise, what instructions do you give this patient in terms of increasing (progression) and decreasing (regression) the load?
Respondents' thoughts on load progression and regression were similar in nature, with two categories becoming apparent: 1) "why" or "when" to increase or decrease load, and 2) "how" to increase or decrease it. Progression of load was reported based on patient factors (27.1%, 38/140). These included pain experience, improvement in function and other vague descriptors such a "with safe execution" [P21]. Regression of load was based on similar factors, most (75.0%, 99/132) citing increasing symptoms. The threshold and descriptors for pain experience triggering regression were varied. Some reported thresholds dependent on NRS pain levels "in case of NRS 5–10" [P 119], while others described latent pain experiences such as "if pain persists longer than 24h after exercise" [P13], or more subjective descriptors of pain thresholds such as “intolerable pain” [P8].
Addressing how to progress load, many respondents (29.3%, 41/140) described an increase in number of repetitions/sets, intensity of weight/resistance, role of gravity/initial position, range of motion, speed, or exercise difficulty. 27.1% (38/140) based progression on symptom behaviour and some (12.1%, 17/140) on specific timeframes e.g. weekly, fortnightly, after 3 to 6 weeks, or every three months. For load regression 18.9% (25/132) recommended reducing weight/resistance, number of repetitions and sets, amplitude of movement, and increasing rest periods between exercise sessions. 27.1% (52/192) did not provide any recommendations regarding progression and 31.3% (60/192) regarding regression.