Hybrid Versus In-clinic Rehabilitation for Non-traumatic Shoulder Pain in Routine Care.

Hybrid Versus In-clinic Rehabilitation for Non-traumatic Shoulder Pain Within a Standardized Digital Care Pathway: a Prospective Longitudinal Observational Study

This prospective longitudinal observational cohort study compared feasibility-allocated hybrid and in-clinic rehabilitation for adults with non-traumatic shoulder pain or dysfunction managed within the same standardized web- and mobile-supported semi-automated shoulder rehabilitation system (WMSSR). The primary outcome was observed time from baseline to documented clinical discharge among completed rehabilitation episodes. Secondary outcomes included total clinical deficit score, maximum pain per visit, number of painful tests per visit, Constant-Murley score at discharge, and adherence to prescribed rehabilitation sessions.

This prospective consecutive observational study was conducted in routine outpatient care at TDN Clínica (Navarra, Spain) to assess whether outcomes differ between two physiotherapy delivery formats for adults with non-traumatic shoulder pain/dysfunction managed within the same standardized web- and mobile-supported semi-automated shoulder rehabilitation system (WMSSR) between March and September 2025 and followed within the study until 11 November 2025. Allocation to format was feasibility-based (non-random) according to routine-care constraints (e.g., work schedule, transport, distance). Both formats were delivered at a nominal frequency of three sessions/week: hybrid (1 supervised in-person session plus 2 unsupervised home sessions supported by smartphone access to prescribed exercises) and in-clinic rehabilitation (3 supervised in-clinic sessions/week).

WMSSR integrates a structured assessment-prescription-reassessment process. Patients completed a standardized 24-test functional battery at baseline (visit 1) and at follow-up evaluations scheduled every 3-5 weeks until clinical discharge. The battery includes measures of strength (digital dynamometry), range of motion (manual goniometry), flexibility, and clinical tests. Pain intensity during test performance was recorded using a 0-10 visual analogue scale (VAS). Pain-related variables included maximum pain per visit, the number of test records with VAS >0 within the 24-test assessment, and a composite VAS used to summarize episode-level pain burden and support discharge assessment. Test scoring yields a total clinical deficit score. Clinical discharge was defined within the workflow using explicit criteria (deficit score threshold, symmetric strength, functional ROM, and low pain during tests).

Study objectives:

1) To describe and compare observed time from baseline to documented clinical discharge among completed rehabilitation episodes managed with hybrid versus in-clinic rehabilitation.

(2) To describe and compare discharge total clinical deficit score and Constant-Murley score between rehabilitation modalities.

(3) To describe longitudinal changes in maximum pain and the number of painful tests across assessment visits in both rehabilitation modalities.

(4) To describe adherence to prescribed rehabilitation sessions in each rehabilitation modality.

Inclusion Criteria Age 18-71 years

• Non-traumatic shoulder pain or dysfunction persisting for more than 3 months before study entry
• Access to a smartphone to view the prescribed exercise instructions

Exclusion Criteria:

• Acute fractures or dislocations
• Arthritis/osteoarthritis
• Osteosarcoma or osteomyelitis
• Recent shoulder surgery