Digital Versus Conventional Physical Therapy for Chronic Shoulder Tendinopathy

Digital Care Program for Chronic Shoulder Tendinopathy Versus Conventional Physical Therapy: a Prospective, Randomized Controlled Study

This is a single-center, prospective, randomised, controlled study, with two parallel groups, designed to assess the clinical impact of a digital exercise program against conventional rehabilitation for shoulder tendonitis. The hypothesis is that all the clinical outcomes measured will significantly improve after the program, and patients using this novel system will attain at least the same outcomes than the ones attained by the conventional PT group.

Shoulder pain is highly prevalent, being the third main complaint in primary care settings.There is a wide range of reported incidence and prevalence rates, with a median of 24.8% of adults reporting shoulder pain every month. In developed countries, 1% of adults annually consult a primary care provider due to shoulder pain. Around 65 to 70% of shoulder pain complaints involve problems in the rotator cuff (RTC) tendons, with incidence rising higher after the 4th decade of life.Abundant data from across the world is available on the prevalence of RTC pathologies. RTC dysfunction represent a huge burden for healthcare systems, insurance companies and employers alike. Shoulder problems account for 2.4% of all general practitioner consultations in the UK, and 4.5 million visits to physicians annually in the USA. One study in the UK20 estimated that nearly £310 million is spent on medical appointments in the first 6 months of shoulder pain onset, and additional costs of surgical procedures are estimated at approximately £30 million/year, with up to 50% of these costs related to sick leave from paid employment. More than 300,000 surgical repairs for RTC pathologies are performed annually in the USA, and the annual financial burden of RTC management was also estimated at $3 billion. A myriad of international clinical practice guidelines have been put forth over the years, outlining the management of pain-causing shoulder disorders. Most causes of mild-to-moderate and gradual onset shoulder pain are treated initially with conservative care. Indeed, many recent studies and systematic reviews, as well as the American Academy of Orthopaedic Surgeons guidelines, support that firstly the patient should be directed to a physical therapy (PT) program and not surgery. For some specific conditions (e.g., symptomatic small to medium full-thickness RTC tears), strong evidence further supports that both PT and operative treatment attain significant improvements in patient-reported outcomes. Of note, another systematic review on treatment options for shoulder pain suggests that passive modalities, such as manual therapy, electrotherapy and taping should be avoided as mono-therapy but that they could, in specific cases, provide additional benefit when utilized in conjunction with therapeutic exercise programs. This suggests that the exercise component of PT is fundamental in the treatment of painful shoulder disorders. Regarding rehabilitation setting, some studies show that home-based therapy, based on exercise, could be as effective as conventional PT interventions. This is in line with the recent trends in healthcare delivery, moving away from inpatient care and towards home-based care with the intent of improving cost-effectiveness. Furthermore, the need for home-based digital solutions is now felt more acutely than ever, in the face of the current pandemic. In this context, solutions enabling home-based rehabilitation without requiring real-time human supervision can be key to improving effectiveness and lowering costs, while keeping all stakeholders safe. Indeed, there are studies demonstrating the potential and cost-effectiveness of shoulder postoperative care and rehabilitation through telehealth solutions. However, while evidence is growing that digital therapeutics (DTx) can improve outcomes, personalize care and decrease costs, there is still much ground to be explored in the field of digital therapy following RCR. Several studies can be found on the validation/development of systems/algorithms for monitoring shoulder motion to assist clinicians on patient evaluation but these do not meet the aforementioned needs and cannot be considered digital therapeutics. There have been some advances on new technologies for shoulder rehabilitation, namely using wearable sensors and augmented reality. Of note, some of these studies focus on systems based on inertial motion trackers that can be used by the patient at home, under remote monitoring from the physical therapist. However, these are either in very preliminary stages of development or validation, with no clinical validation studies performed, or are directed at rehabilitation after stroke. SWORD Health has developed a novel motion tracking-based digital biofeedback system for home-based physical rehabilitation - SWORD Phoenix - which is an FDA-listed class II medical device. The company has previously conducted two pilot studies (NCT03047252; NCT03045549) comparing a digital therapy program using this device against conventional face-to-face physical therapy. These studies have proven the feasibility, safety and effectiveness of this digital therapeutic on rehabilitation after total knee and hip arthroplasty. This is a single-center, prospective, randomised, controlled study, with two parallel groups, designed to assess the clinical impact of a digital exercise program against conventional rehabilitation for shoulder tendonitis. The hypothesis is that all the clinical outcomes measured will significantly improve after the program, and patients using this novel system will attain at least the same outcomes than the ones attained by the conventional PT group.

Blinding of investigators and patients regarding allocation arm will not be possible, given the nature of the intervention. Analysis of study results will be performed by an independent statistician at UCSF.

Home-based 8-week rehabilitation sessions using SWORD Phoenix®, under remote monitoring by a physical therapist

Patients in the digital intervention group will benefit from an 8-week program composed of therapeutic exercise, education and cognitive behavioural therapy (CBT) program provided by SWORD Health. Patients in this group will performed home-based rehabilitation sessions using SWORD Phoenix®, under remote monitoring by a physical therapist.

Patients in this group will benefit from a 8-week program consisting of two 30 min face-to-face PT sessions per week in an outpatient clinic setting, for a total of 16 sessions. The program includes commonly used interventions adapted by the physical therapist to the specific needs of the participant. In addition to the face-to-face sessions, PTs will also be communicating with participants in this group through a secure messaging system (Mychart) used at UCSF or, alternatively, through a telephone check-ins (10-15 min calls, up to twice per week).

Shoulder range of motion will be measured in the following exercises: shoulder flexion; shoulder abduction and external shoulder rotation at 90 degrees of abduction.

Shoulder pain level will be measured through the following question: "On a scale of 0 to 10, where 0 is no pain and 10 the worst pain imaginable, how would you rate your pain in the last 24 hours?"

Interest in undergoing surgery will be measured through the following question: "On a scale of 0 to 10, where 0 is not at all and 10 is extremely interested, how interested are you in undergoing shoulder surgery in the next 12 months"?

Measured through Work Productivity and Activity Impairment Questionnaire: Specific Health Problem v2.0 (WPAI:SHP)

Measured through the Patient Reported Outcomes Measurement Information System Computerized Adaptive Test (PROMIS-CAT) scales: Ability to participate in social roles and activities (version 2.0) and satisfaction with social roles and activities (version 2.0)

Measured through: g.1) adherence to exercise sessions; g.2) drop-out rates; g.3) treatment intensity (i.e. total number of exercise minutes)

Measured through the Net Promoter Score, by asking participants the following question: "On a scale from 0 to 10, how likely are you to recommend this program to a friend or colleague?"

Inclusion Criteria: Subjects aged between 18 and 80 years of age at enrolment Reporting intermittent or persistent shoulder pain for at least 12 weeks, and/or present at least 50% of the time in the past 6 months Lack of visual/audio or cognitive impairment interfering with the ability to understand or comply with the program Exclusion Criteria: Non-English speaking Residing outside greater SF area Known pregnancy Submitted to spinal surgery less than 3 months ago Symptoms and/or signs indicative of possible infectious disorder Referred pain from spine and/or thoracic outlet syndrome Active cancer diagnosis or undergoing treatment for cancer Cardiac, respiratory or other known disorder incompatible with at least 20 minutes of light to moderate physical activity Concomitant neurological disorder (e.g. stroke, multiple sclerosis, Parkinson's disease) Dementia or psychiatric disorders precluding patient from complying with a home-based exercise program Illiteracy and/or serious visual or auditory impairment interfering with communication or compliance

The study protocol will be made available in PDF format. Aggregate study results, with anonymised individual participant data will be made available in Excel format

Study protocol will be made available in clinicaltrials.gov and the excel file with the aggregate results will be made available upon study publication, for at least 5 years.