New Therapeutic Interventions and Imaging Techniques for Prolonged Shoulder Disorders

Shoulder complaints are one of the most common musculoskeletal ailments in general practice and a leading cause of work absence. While imaging findings are common in both symptomatic and asymptomatic shoulders, patient-specific characteristics such as obesity, depression and physical labor are risk factors for reported shoulder symptoms. Usually, general exercises have been considered useful in treating patients with shoulder symptoms, with the lack of evidence of specific tendon exercises. Biopsychosocial model is recommended in treatment of disabling musculoskeletal pain and to enhance self-management. Psychologically Informed Physical Therapy (PIPT) considers biopsychosocial framework in patient management, but it has not extensively been studied among patients with shoulder symptoms.

The RESPECT study is a single-center randomized longitudinal parallel-group superiority study that aims to evaluate the effectiveness and cost-effectiveness of routine and specific physical therapy interventions, focusing on tendon and biopsychosocial rehabilitation. In total, 300 study participants will be recruited from the North Ostrobothnia region through local occupational health care providers. The initial eligibility assessment will be done using a structured telephone interview, where potential participants will be evaluated against the inclusion and exclusion criteria, and the written information of the study will be distributed. The study includes diagnostic imaging at baseline and at 12 and 36 months, a baseline clinical PT visit for all participants and either routine occupationally led PT or five PT-guided sessions for the two interventional groups during the first six month-period, in three similar-sized groups. Electronic surveys will be asked to be filled at baseline prior to clinical visit as well as at three, six, twelve- and 36-months follow-up time points. Before the clinical visit, baseline imaging and patient records are preliminarily reviewed for exclusion criteria and, where applicable, participants are contacted and removed from the study.

The surveys cover a wide range of questions related to general health, details of employment, illnesses and medications, shoulder as well as generalized pain, demographic and socioeconomic factors, lifestyle, fear of pain and functional capacity. The electronic surveys also include validated Finnish versions of several structured questionnaires. Surveys are filled in and study data will be collected using an electronic data collection system (REDCap). In the baseline survey, participants are also instructed to fill in a traditional pain drawing. Follow-up surveys have additional questions regarding trauma, upper limb fractures and dislocations and newly diagnosed illnesses as well as their respective potentially caused shoulder dysfunction, planned or performed procedures of the upper limb and their nature, and confirmed or possible pregnancy. The personal participant-named activities in the PSFS will be carried over from the baseline questionnaire to the follow-up surveys, and the PSFS acts as the primary outcome of the study. Follow-up surveys also ask participants to check and report their prior PT, physician and other healthcare professional visits regarding shoulder symptoms as well as prior shoulder imaging from their respective occupational health care mobile applications, which are widely available in the Finnish occupational health care system.

Bilateral shoulder imaging using conventional radiographs (CRs), multiparametric US and contrast-enhanced MRI will be conducted for inter-modality comparison as well as correlative studies between imaging findings, symptoms and effectiveness of different rehabilitation interventions. The added diagnostic capability of modern US and MRI technological advances will also be tested, focusing on RC structures, against conventional US and MRI. Bilateral shoulder CRs will be imaged in three projections. From the CRs, shoulder anatomy, glenohumeral and acromioclavicular degeneration, indirect signs of RC tears as well as potential calcium deposits will be evaluated. Osteoarthritis of the glenohumeral joint will be graded according to Kellgren-Lawrence classification (grades 0 to 4), and osteoarthritis of the acromioclavicular joint will be graded according to Petersson classification (grades 0-3). Bilateral static and dynamic shoulder US will be imaged using high-end US machines with high frequency linear probes by highly experienced sonographers with at least 10 years of experience in musculoskeletal US. US will be done following the musculoskeletal US technical guidelines published by the European Society of Musculoskeletal Radiology, and shear wave elastography and superb microvascular imaging techniques will be implemented during the US examination. Bilateral contrast-enhanced shoulder MRI will be imaged using a 3T scanner and a dedicated shoulder coil. Non-contrast MRI sequences including Magnetic Resonance Fingerprinting will be imaged first for both shoulders, after which contrast enhanced sequences will be imaged in succession, starting with the symptomatic shoulder.

The number of individuals assessed for eligibility will be recorded and reported in published results. The projected progress of all enrolled participants will be scheduled at the time of recruitment to ensure the timely preliminary evaluation of imaging studies, rehabilitation and electronic surveys. The preliminary review of participant imaging, electronic surveys and patient records will be done by the primary investigator, a musculoskeletal radiology fellow, with available consultation from a board-certified musculoskeletal radiologist with eleven of years of experience and a physiatrist with ten years of experience. Considering the biopsychosocial concept of pain, information about imaging findings is not given to the participants during the study, however, participants are ensured that they are informed of all imaging findings requiring urgent medical attention, followed by exclusion from the study if applicable. This information is separately highlighted in the consent form. Participant retention will be improved and drop-out reduced by electronic reminders of surveys, PT sessions and follow-up imaging. Every reasonable effort to schedule sessions at participant-compatible times will be made and possibilities for rescheduling will be offered. In case of no-show, a request to schedule a new appointment will be sent.