Your trial compared various formats for delivery of exercise therapy to people with subacromial pain. How common is subacromial pain?

Subacriomial pain is considered to be the most common cause of shoulder complaints, accounting for 50–70 per cent of all shoulder- related contacts in primary care.

What evidence is there that exercise therapy is effective? What are its known benefits for subacromial pain?

There is moderate-level evidence to support the use of exercise therapy in the management of subacromial pain.

Exercise therapy has been found to reduce pain and improve function and is recommended as a principal component in the management of subacromial pain.

What issues led you to consider formats to deliver the exercise therapy other than one-to-one supervised therapy?

As physiotherapists, we tend to favour one-to-one session supervised therapy.

However, there is a growing body of evidence that less individualised modes of delivery, such a group and minimally supervised interventions, may provide similar and even better outcomes in patients with musculoskeletal pain.

At the same time, the continued increase in our life expectancy presents a major challenge for our healthcare system, and will reduce our ability to deliver treatment, as resources become more limited.

Thus, ways to improve the capacity of our healthcare system is of high priority.

Had any other trials compared various formats for delivering exercise therapy to people with subacromial pain?

Other trials have compared different formats of exercise therapy for subacromial pain, but to our knowledge this is the first trial to include a treatment arm with a group intervention and cost in the evaluation.

How did group-based exercise compare to supervised one-to-one exercise sessions?

Overall, group-based exercise provided similar improvements to one-to-one sessions, as there were no important differences in clinical outcomes and patient satisfaction between the two groups.

What about home-based exercise; how did that compare on efficacy and cost?

Home-based exercise demonstrated equal improvement to group and individual exercise approaches.

Interestingly, we observed that adherence to exercise, progression parameters and patient satisfaction did not differ across groups despite the less intensive supervision and attention received in the home-based exercise intervention.

The home-based exercise intervention was also associated with lowest direct and productivity costs, but relative large variations in costs prevented us drawing any firm conclusion about the potential cost savings.

Where does research in this area need to progress now?

The current evidence suggests that the effectiveness of exercise therapy is not related to the modes of delivery, and physiotherapists should consider alternatives to one-to-one supervised sessions for the management of subcaromial pain.

Still, we need to examine whether the effectiveness of different modes of delivery are affected by individual patient preference and characteristics.

David Høyrup Christiansen is a musculoskeletal physiotherapist, senior researcher and associate professor at the Department of Occupational Medicine, University Research Clinic, Regional Hospital Gødstrup and Department of Clinical Medicine, Aarhus University in Denmark. His key research interests are prognosis research and interventions to prevent and rehabilitate musculoskeletal disorders.