Shoulder Pain: Why More Treatment Is Not Always Better

What the GRASP trial found

The GRASP trial, published in The Lancet in2021, included more than 700 adults with a new episode of rotator cuff relatedshoulder pain. One group received a progressive exercise programme deliveredacross up to six physiotherapy sessions, while another received a singlebest-practice physiotherapy session with advice and a home exercise programme.Over 12 months, the more intensive supervised programme was not clearlysuperior to the best-practice advice approach for pain and disability. That isa useful finding for patients because it changes the emphasis from "Howmany treatments do I need?" to "Have we identified the right problem,given the right exercise and created a sensible plan for progression?"

Assessment still matters

Shoulder pain is an umbrella term ratherthan a diagnosis. Rotator cuff related pain, frozen shoulder, instability,arthritis, traumatic tendon injury and pain referred from the neck can looksimilar at first. Physiotherapy assessment considers the history, mechanism ofinjury, range of movement, strength, painful movements, neck and neurologicalfindings and the demands the shoulder must eventually tolerate. For manyrotator cuff presentations, the plan centres on education and progressiveloading of the shoulder and upper limb. The starting point may be very simple,but later exercises should increasingly resemble the work, gym, swimming,throwing or racquet demands the patient wants to return to.

The right amount of follow-up

The GRASP findings do not mean thateveryone needs only one visit. They suggest that routine high-frequencytreatment is not automatically better. Follow-up is most valuable when itchanges a decision: progressing resistance, checking strength, modifyingtechnique, dealing with a flare, confirming that motion is returning, orreconsidering the diagnosis when progress stalls. Hand-held dynamometry, rangemeasurements and functional tests can make these decisions more objective. Apatient who is steadily improving and independently progressing may needrelatively little supervision. Someone with major weakness after trauma, markedstiffness, recurrent instability or an unexpected course may need closer reviewor further imaging and medical input. Good physiotherapy is therefore notmeasured by the number of visits. It is measured by whether each visit addsvalue to recovery.

Selected research

1. Hopewell S, Keene DJ, Heine P, et al. Progressive exercisecompared with best practice advice, with or without corticosteroid injection,for rotator cuff disorders (GRASP). The Lancet. 2021;398(10298):416-428.doi:10.1016/S0140-6736(21)00846-1.

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