Hybrid versus in-clinic rehabilitation for non-traumatic shoulder pain within a standardized digital care pathway: a prospective longitudinal observational study
In a prospective observational study of patients with non-traumatic shoulder pain managed within a standardized digital care pathway, hybrid rehabilitation (combining supervised and home-based sessions) demonstrated similar time to clinical discharge and functional outcomes compared to fully in-clinic rehabilitation, suggesting it is a practical alternative for those unable to attend regular in-person sessions despite limitations regarding causal inference due to non-random allocation.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
Shoulder pain is a common human experience, often lingering long after a specific injury has healed. For many, the path to recovery involves physical therapy, where a specialist guides a patient through exercises designed to restore strength and movement. Traditionally, this care happens entirely inside a clinic, requiring the patient to visit the therapist multiple times a week. This setup works well for some, but for others, life gets in the way. Work schedules, long commutes, or family duties can make attending three supervised sessions every week impossible, leading people to drop out of treatment or never start it at all. In recent years, a middle ground has emerged: hybrid rehabilitation. This approach mixes a few in-person visits with home exercises that patients do on their own, supported by digital instructions. The big question for doctors and patients alike is whether this flexible, mixed approach works just as well as the traditional, fully supervised model, or if the extra freedom comes at the cost of slower or incomplete recovery.
A team of researchers in Spain set out to answer this question by watching how real patients fared in a routine clinical setting. They did not force patients into random groups; instead, they observed how people naturally ended up in one of two paths based on their daily lives. Some patients, whose schedules allowed them to visit the clinic three times a week, received standard, fully supervised care. Others, who faced significant barriers like long travel times or rigid work shifts, were assigned to a hybrid path. This hybrid group attended just one supervised session a week and completed two unsupervised sessions at home, guided by a mobile app. Crucially, both groups followed the exact same digital care system. This system acted as a digital assistant, recording test results, calculating how much strength or movement was missing, and generating a personalized exercise plan for each person. The goal was not to test a new drug or a new theory, but to see if the way care was delivered changed the time it took for a patient to get better.
The researchers tracked 164 people who started the program between March and September 2025. They focused their final analysis on the 129 people who successfully finished the program and met the strict criteria for being "cured." To be considered discharged, a patient had to show almost no difference in strength between their injured and healthy shoulders, regain full range of motion, and report almost no pain during movement. The study found that the time it took to reach this state of recovery was remarkably similar for both groups. On average, patients in the hybrid group took about 84 days to finish, while those in the fully in-clinic group took about 85 days. The difference was so small that it was likely just a matter of chance rather than a true advantage for one method over the other.
Beyond the timeline, the actual results of the treatment were nearly identical. Both groups started with significant pain and weakness, with an average pain level of nearly 7 out of 10. By the time they finished, pain in both groups had dropped to around 1 or 2 out of 10. Similarly, the measure of physical impairment, which started at roughly 15 points out of a possible 36, fell to less than 2 points for everyone. The researchers also looked at a standard measure of shoulder function known as the Constant–Murley score, which assesses how well a shoulder works in daily life. At the end of treatment, both groups scored almost perfectly, with averages of 93.77 and 93.75 out of 100. Even the rate at which patients stuck to their exercise plans was high in both groups, with the hybrid group completing about 90 percent of their prescribed sessions and the in-clinic group completing about 93 percent.
The study does not claim that hybrid rehabilitation is a perfect replacement for in-clinic care for every single person, nor does it prove that the two methods are exactly the same in every possible situation. Because the patients were not randomly assigned, there could be hidden differences between the groups that the researchers could not measure. Consequently, the findings do not establish equivalence, non-inferiority, or causal comparative effectiveness between the two approaches. However, the data describes observed outcomes where both groups achieved similar recovery times and functional results within the same care pathway. This suggests that for people with non-traumatic shoulder pain who cannot attend three weekly clinic visits, a hybrid model may be a practical alternative. It allows patients to receive the same structured, personalized guidance and rigorous testing as those who can attend in person, without the barrier of daily travel. The findings offer a reassuring message: when the logistics of life make a traditional schedule impossible, a flexible approach that mixes clinic visits with home work can lead to similar observed recovery outcomes.
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