105 CLINICAL OUTCOME AFTER OUTPATIENT REHABILITATION IN NA 5 Discussion This RCT showed that MR was more effective than UC to improve shoulder, arm and hand functional capability, as assessed with the SRQ-DLV, in patients with NA and scapular dyskinesia. Moreover, the observed improvements were retained after a followup period of 18 weeks (36 weeks from start MR). MR focused on motor relearning of scapular stability and coordination combined with self-management strategies to cope with and reduce persisting pain and experienced fatigue. The overall goal is to improve daily functioning and reduce activity limitations in daily life. Based on a pre-determined minimal clinically relevant improvement (SRQ-DLV ≥12), the number needed to treat was 4. These results are in line with our previously published pilot and reported clinical and patient experiences. 1, 6, 36, 182 The positive effect of our MR on the primary outcome was not reflected in the secondary outcomes However, although not significant, there seemed to be a visible trend in almost all secondary outcomes in favour of MR compared to UC, reflecting better functioning, less pain and fatigue, and better self-management and participation. The absence of significant changes or group differences in the strength measurements, with exception of pinch grip, was coherent with the focus of physical therapy within our MR, specifically aimed at restoring motor control, scapular stability and coordination, whereas physical therapy in UC mainly had a focus on strength training and massage. 8 Another large difference in our MR compared to UC was occupational therapy focused on improving self-management strategies to cope with and reduce persisting pain and experienced fatigue which was clearly underrepresented in UC. Although the effect of occupational therapy was not reflected in the secondary outcomes (e.g. SEPESCA, PSEQ or CIS-fatigue), this was also included in the SRQ-DLV domains such as sleep, leisure, work and daily activities. Therefore, the primary outcome measure (SRQ-DLV) covered multiple domains which our MR, with combined physical and occupational therapy, addresses. A significant difference in the time since onset NA was found between both groups. Post hoc analysis showed no difference in results of the primary outcome measure when ‘time since onset NA’ was added as covariate. Nevertheless, there was difference in time since onset which on average was 15 months longer in the MR compared to the UC group. We believe that the difference may have led to an underestimation of the observed effect size. Since patients shortly after an NA episode are more likely to show spontaneous nerve recovery, 6 and this can be expected to coincide with better functional improvement. Furthermore, for patients who have been struggling with the functional consequences of NA for a longer period of time, it was probably more difficult to normalize motor control, reverse maladaptive movement patterns, 2, 122 and change behaviour to self-manage NA symptoms. Therefore, we expect that a comparable time since onset of NA in both groups would have led to a larger effect size in favour of MR. The lower time since onset may have been a reason for the higher drop-out rate in the UC compared to the MR group, since in five UC participants the reason for drop-out was a recurrent NA episode and recurrence rate of NA is larger in the first year after an initial NA episode. 7 The effect of spontaneous recovery in UC, with a lower time since onset of NA, raises the question on the optimal timing of MR. Should we start as soon as possible to supercharge functional recovery or should we wait and see until residual complaints impede daily
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