Exercise Into Pain in Chronic Rotator Cuff-Related Shoulder Pain: A Randomized Controlled Trial With 6-Month Follow-Up [Letter]

Dear editor

We read with interest the article by Claudia Cavaggion et al, “Exercise into Pain in Chronic Rotator Cuff-Related Shoulder Pain: A Randomized Controlled Trial with 6-Month Follow-Up.”¹ While the authors should be commended for their comparative approach to exercise with and without pain, several aspects require clarification to enhance the study’s impact.

Title and Hypothesis

The current title is somewhat misleading, failing to adequately reflect the study’s objective and outcomes. A more descriptive title, such as

Comparing Exercise with Pain versus Exercise without Pain on Disability, Pain, Fear of Pain, Fear-Avoidance Beliefs, Strength, and Range of Motion in Patients with Chronic Rotator Cuff-Related Shoulder Pain: A Randomized Clinical Trial with 6-Month Follow-Up,

would be more appropriate. The term “Clinical Trial” better reflects the study’s design, given the absence of a true control group. Furthermore, while objectives are stated, the absence of clearly defined null and alternative hypotheses hinders a comprehensive interpretation of the results.

Intervention Protocol

The exercise protocol raises concerns. The limited number of supervised sessions (1 session per week, total nine over 12 weeks), particularly during the initial phase, may not have been sufficient for patients to properly learn and adhere to the program. More frequent supervised sessions initially, followed by a transition to unsupervised exercise, would likely have been more effective. Additionally, while the exercises are described, crucial details like the starting number of repetitions and sets, initial resistance levels, and progression guidelines are lacking.

Stretching Technique

The description of the posterior shoulder tissue stretching technique lacks important details. Information regarding patient and therapist positioning, therapist hand placement, number of repetitions, and hold times would enhance understanding and reproducibility of the intervention.

Participant Characteristics

The broad age range (18–65 years) is a concern. Chronic rotator cuff pain in younger adults often differs from pain and limited range of motion in older individuals, where degenerative changes or capsular adhesions, rotator cuff tears are more common.² This wide age range could introduce significant variability and potentially confound the results.

Baseline Data

Including baseline scores for the Shoulder Pain and Disability Index, fear of pain, and fear-avoidance beliefs in the inclusion criteria would have provided a clearer picture of the chronicity of the condition and allowed for more robust subgroup analyses.³

Conclusion

Addressing these points will significantly improve the clarity and reliability of the study’s findings, strengthen the study’s contribution to evidence-based practice, and ultimately contributing to better clinical practice.