Progressive early passive and active exercise therapy after surgical rotator cuff repair - study protocol for a randomized controlled trial (the CUT-N-MOVE trial)

Supraspinatus Muscle and Tendon Characteristics 1 Year After Surgical Rotator Cuff Repair Compared With Contralateral Shoulder: Data From the CUT-N-MOVE Trial

BACKGROUND

It is necessary to better understand the structural characteristics of the supraspinatus tendon and associated muscle after rotator cuff repair and in the event of retear.

PURPOSE

To study structural differences between the repaired and contralateral shoulders 1 year after rotator cuff repair in patients who received either progressive exercise therapy (PR) or usual care (UC) in a randomized controlled trial and to investigate whether there was interaction with tendon retear and limb dominance.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Patients with surgically repaired traumatic full-thickness rotator cuff tears involving the supraspinatus tendon were included. After surgery, they were randomized to PR or UC (active from postoperative week 2 or 6, respectively). The subacromial structures (acromiohumeral distance, supraspinatus tendon thickness, and vascularity) and the supraspinatus muscle thickness were examined with ultrasound at the 1-year follow-up.

RESULTS

A total of 79 patients were included. The characteristics of the 2 intervention groups (PR and UC) were comparable, including the Western Ontario Rotator Cuff Index score and number of retears. The authors found significantly thinner supraspinatus tendon (PR, P < .001; UC, P = .003) and reduced acromiohumeral distance (PR, P = .023; UC, P = .025) in the repaired versus the contralateral shoulders in both intervention groups. For neovascularization, there was no interlimb difference in either of the groups or between groups (PR vs UC). In patients with intact tendons, there was no interlimb difference in the muscle thickness, but in patients with tendon retear the muscle was significantly thinner on the repaired side (P = .024 and P < .001, respectively). When the dominant supraspinatus tendon was repaired (both groups), it was significantly thinner than the nondominant healthy tendon, but this difference was not seen when the nondominant supraspinatus tendon was repaired (P = .006).

CONCLUSION

One year after rotator cuff surgery, the repaired supraspinatus tendon was significantly thinner and the corresponding acromiohumeral distance was reduced. In patients with retear, the supraspinatus muscle was significantly thinner on the repaired side and early initiation of tendon-loading exercises did not affect these findings.

REGISTRATION

NCT02969135 (ClinicalTrials.gov identifier).

Maximum in-vivo joint contact forces double during active compared to assisted motion in the glenohumeral joint and decline long-term due to rotator cuff pathologies

Rehabilitation programs advocate early passive and assisted motion after rotator cuff repair to induce healing und maintaining range of motion while avoiding excessive strain on the repaired tendons. In-vivo glenohumeral joint contact forces reflect the compressive forces generated by the rotator muscles. In the present study, maximum in-vivo joint contact forces (FresMax) were determined to compare active and assisted execution of a single movement and the long-term development of joint compression forces. FresMax were measured in six patients who received instrumented, telemetric modified anatomical hemi endoprostheses of the shoulder joint between 2006 and 2008. Data were gathered 23 months postoperatively (2006-2010), were analysed and compared with measurements 133 months postoperatively. Additional imaging was obtained as x-rays and ultrasound examination. Data analysis was conducted by synchronizing video tapes and measured force curves. New imaging showed a rupture of the M. supraspinatus and progressive joint degeneration. FresMax nearly doubled during active compared to assisted execution of each of the four chosen movements. Over the course of 133 months post-surgery, the studied movements showed a decrease of active compression force, probably due to a ruptured supraspinatus, resulting in a lower active/assisted ratio. A long term follow up after eleven years, eight out of ten measured movements showed a decrease of FresMax. These results support current rehabilitation protocols recommending early passive and assisted motion to limit activation of the rotator muscles generating compressive forces. Following degeneration of the rotator cuff, active joint contact forces decrease over time.Level of evidence: III.

The effect of video-assisted training on upper extremity problems and functions after rotator cuff repair: a randomized controlled trial

Background/aim

The shoulder is the most mobile joint in the body, and is frequently exposed to injuries. The applied surgical treatments, protection of the shoulder after surgery, care in the use of the shoulder in activities of daily living (ADLs) and gradual exercise programs are all vital to the recovery process. The present study investigates the effect of video-assisted training (VAT) on upper extremity complications and functions after rotator cuff repair (RCR).

Materials and method

Included in this prospective, parallel two-armed, randomized controlled study were an experimental group (n: 24) that received VAT detailing early postoperative care for RCR and instructions on performing ADLs, and that had access to a 90-day gradual exercise program, and a control group (n: 24) that received routine care. The primary outcomes were upper extremity problems and functions, as assessed by the Disabilities of the Arm, Shoulder and Hand (DASH) and modified Constant-Murley scores (MCM), while secondary outcomes were complications that had developed within the past three months. The outcomes were measured at baseline, after six weeks and at three months.

Results

After 3 months, a statistically significant difference was noted in the DASH-Work (p = 0.001) and MCM ADLs scores (p = 0.003) of the two groups, and significant changes in which the scale scores of both groups when compared to the initial measurement. Only one patient in the VAT group developed complications after RCR at one month; there were no significant differences in the complications of the two groups (p = 0.235).

Conclusion

VAT can increase function in RCR patients. Healthcare professionals, especially nurses, can use the VAT method to improve shoulder function in patients after RCR.

Patient outcomes and return to play after arthroscopic rotator cuff repair in overhead athletes: a systematic review

BACKGROUND

Rotator cuff tear injuries in overhead athletes are common and may lead to chronic pain and joint disability, impairing sport participation and leading to premature retirement. The improvement of the patient reported outcome measures (PROMs) was evaluated, as were the time and level of return to sport and the rate of complication in overhead athletes who had undergone arthroscopic rotator cuff repair.

METHODS

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the 2020 PRISMA statement. In September 2022, the following databases were accessed: Pubmed, Web of Science, Google Scholar and Embase. No time constraints were used for the search. All the clinical trials investigating arthroscopic rotator cuff repair in overhead athletes were accessed.

RESULTS

Data from 20 studies were collected. The mean length of the follow-up was 40 months. All PROMs improved at last follow-up: Kerlan-Jobe Orthopaedic Clinic score (P = 0.02), visual analogue scale (P = 0.003), Constant score (P < 0.0001), University of California Los Angeles Shoulder score (P = 0.006) and American Shoulder and Elbow Surgeons' score (P < 0.0001). Elevation also improved (P = 0.004). No difference was found in external and internal rotation (P = 0.2 and P = 0.3, respectively). In total, 75.4% (522 of 692 of patients) were able to return to play within a mean of 6.4  ±  6.0 months. Of 692 patients, 433 (62.5%) were able to return to sport at pre-injury level. Fourteen out of 138 patients (10.1%) underwent a further reoperation. The overall rate of complications was 7.1% (20 of 280).

CONCLUSION

Arthroscopic reconstruction of the rotator cuff is effective in improving function of the shoulder in overhead athletes, with a rate of return to sport in 75.4% of patients within an average of 6.4 months.

LEVEL OF EVIDENCE

III, systematic review.

TRIAL REGISTRATION

Not applicable.

Finite element study of the biomechanical effects on the rotator cuff under load

Rotator cuff injuries account for 50% of shoulder disorders that can cause shoulder pain and reduced mobility. The occurrence of rotator cuff injury is related to the variation in shoulder load, but the mechanical changes in the rotator cuff caused by load remain unclear. Therefore, the mechanical results of the rotator cuff tissue during glenohumeral abduction and adduction were analyzed based on a finite element shoulder model under non-load (0 kg) and load (7.5 kg) conditions. The results showed that the maximum von Mises stress on the supraspinatus muscle was larger than that on the subscapularis, infraspinatus, and teres minor muscles during glenohumeral abduction. Compared with the non-load condition, the maximum von Mises stress on the supraspinatus muscle increased by 75% under the load condition at 30° abduction. Under the load condition, the supraspinatus joint side exhibited an average stress that was 32% greater than that observed on the bursal side. The von Mises stress on the infraspinatus muscle was higher than that in other rotator cuff tissues during adduction. The stress on the infraspinatus muscle increased by 36% in the load condition compared to the non-load condition at 30° adduction. In summary, the increased load changed the mechanical distribution of rotator cuff tissue and increased the stress differential between the joint aspect and the bursal aspect of the supraspinatus tendon.

Dry needling in a multimodal rehabilitation protocol following rotator cuff repair surgery: study protocol for a double-blinded randomized sham-controlled trial

BACKGROUND

Rotator cuff tear (RCT) is one of the main causes of shoulder pain and dysfunction. Rotator cuff repair (RCR) is a common surgical procedure for the management of RCTs. Presence of myofascial trigger points (MTrP) as a result of surgical procedure can aggravate postoperative shoulder pain. The purpose of this protocol is to describe a randomized controlled trial design to evaluate the effect of implementing 4 sessions of myofascial trigger point dry needling (MTrP-DN) within a multimodal rehabilitation protocol following RCR surgery.

METHODS

Forty-six participants aged 40-75 will be recruited having postoperative shoulder pain after RCR and meeting the inclusion criteria. Participants will be randomly divided into 2 groups: One group will undergo MTrP-DN, manual therapy, exercise therapy and electrotherapy and the other will receive sham dry needling (S-DN), manual therapy, exercise therapy and electrotherapy. This protocol will cover 4 weeks of intervention. The primary outcome measure will be the Numeric Pain Rating Scale (NPRS) for pain. Secondary outcome measures will be Shoulder Pain and Disability Index (SPDI), range of motion (ROM), strength and adverse events.

DISCUSSION

This is the first study to investigate the use of 4 sessions of MTrP-DN in combination with a multimodal rehabilitation protocol for postoperative shoulder pain, restriction, weakness and dysfunction following RCR. The results of this study may help to determine the effect of MTrP-DN on various outcomes after RCR surgery.

TRIAL REGISTRATION

This trial was registered at the ( https://www.irct.ir ), (IRCT20211005052677N1) on 19/2/2022.

Shoulder Rehabilitation Exercises With Kinematic Biofeedback After Arthroscopic Rotator Cuff Repair: Protocol for a New Integrated Rehabilitation Program

BACKGROUND

The recovery of scapular and humeral physiological kinematic parameters, as well as the sensorimotor control of movement, plays a primary role in the rehabilitation process after arthroscopic rotator cuff repair. A highly customized rehabilitation approach is required to achieve this aim. Biofeedback can be a useful tool, but there is poor evidence of its application in the rehabilitation after arthroscopic rotator cuff tear repair.

OBJECTIVE

The aim of this paper is to outline an innovative exercise-based rehabilitation program exploiting visual biofeedback for the recovery of patients arthroscopically treated for rotator cuff repair.

METHODS

For establishment of the innovative program, a multidisciplinary team involving experts in shoulder surgery, rehabilitation medicine, physical therapy, and biomedical and clinical engineering was formed. Starting from a conventional rehabilitation program, the team selected a set of exercises to be integrated with a biofeedback tool, named the INAIL (National Institute for Insurance against Accidents at Work) Shoulder and Elbow Outpatient program (ISEO program). ISEO is a motion analysis system based on inertial wearable sensors positioned over the thorax, scapula, humerus, and forearm. ISEO can return a visual biofeedback of humerus and scapula angles over time or of the scapula-humeral coordination, with possible overlap of patient-specific or asymptomatic reference values. A set of 12 progressive exercises was defined, divided into four groups based on humerus and scapula movements. Each group comprises 2-4 of the 12 exercises with an increasing level of complexity. Exercises can require the use of a ball, stick, rubber band, and/or towel. For each exercise, we present the starting position of the patient, the modality of execution, and the target position, together with notes about the critical factors to observe. The type of visual biofeedback to adopt is specified, such as the coordination between angles or the variation of a single angle over time. To guide the therapist in customizing the patient's rehabilitation program, a list of operative guidelines is provided.

RESULTS

We describe various applications of the ISEO exercise program in terms of frequency and intensity.

CONCLUSIONS

An innovative rehabilitation program to restore scapular and humeral kinematics after rotator cuff repair based on kinematic biofeedback is presented. Biofeedback is expected to increase patient awareness and self-correction under therapist supervision. Randomized controlled trials are needed to investigate the potential effect of the exercise-based biofeedback in comparison with conventional rehabilitation programs.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/35757.

Short-term effectiveness of high-load compared with low-load strengthening exercise on self-reported function in patients with hypermobile shoulders: a randomised controlled trial

OBJECTIVES

To investigate the short-term effectiveness of high-load versus low-load strengthening exercise on self-reported function in patients with hypermobility spectrum disorder (HSD) and shoulder symptoms.

METHODS

A superiority, parallel-group, randomised trial (balanced block randomisation, electronic concealment) including adult patients (n=100) from primary care with HSD and shoulder pain and/or shoulder instability ≥3 months. Patients received 16 weeks of shoulder exercises (three sessions/week): HEAVY (n=50, full-range, high-load, supervised twice/week) or LIGHT (n=50, neutral/mid-range, low-load, supervised three times). The primary outcome was the 16-week between-group difference in self-reported function measured with the Western Ontario Shoulder Instability Index (WOSI, scale 0-2100, 0=best, minimal important difference 252 points). Secondary outcomes were self-reported measures including quality of life and clinical tests including shoulder muscle strength and range of motion. An intention-to-treat analysis with multiple imputation was conducted by a blinded biostatistician using linear regression.

RESULTS

93 of 100 patients (93%) completed the 16-week evaluation. The mean WOSI score between-group difference significantly favoured HEAVY (-174.5 points, 95% CI -341.4 to -7.7, adjusted for age, sex, baseline score, clustering around clinic). The secondary outcomes were inconclusive, but patients in HEAVY were less likely to have a positive shoulder rotation test >180°, and more likely to rate an important improvement in physical symptoms. There were no serious adverse events, but HEAVY was associated with more transient muscle soreness (56% vs 37%) and headaches (40% vs 20%).

CONCLUSION

High-load shoulder strengthening exercise was statistically superior to low-load strengthening exercise for self-reported function at 16 weeks and may be used in primary care to treat patients with HSD and shoulder pain and/or instability to improve shoulder function in the short term. Further studies are needed to confirm the clinical relevance, and patients should be supported to manage associated minor adverse events.

TRIAL REGISTRATION NUMBER

NCT03869307.

Clinical Characteristics of 100 Patients with Hypermobility Spectrum Disorders and Shoulder Complaints With or Without Mechanical Symptoms: A Cross-Sectional Study

OBJECTIVE

The aims were to describe the clinical characteristics of patients with hypermobility spectrum disorders (HSD) and shoulder complaints with or without mechanical symptoms, and to compare characteristics between these groups.

DESIGN

Descriptive study.

SETTING

Primary care PARTICIPANTS: One-hundred patients with HSD and shoulder complaints for at least three months were included from primary care.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Medical history, self-reported (shoulder pain and function, discomfort due to other symptoms, fatigue, fear of movement, quality of life) and objective (strength, range of motion, proprioception) characteristics were collected by physiotherapists. Mechanical symptoms (Yes/No) were defined as self-reported shoulder instability, subluxation, and/or laxity.

RESULTS

Sixty-seven reported mechanical symptoms. Patients in both groups reported impairments related to shoulder pain, function, fatigue, fear of movement, and quality of life. Patients with mechanical symptoms were younger (mean (95% CI): 35.1 (32.3; 37.9) vs. 43.3 (38.4; 48.1) years), had longer symptom duration (median: 46 (36; 66) vs. 24 (9; 56) months), reported a previous shoulder dislocation (25% (16; 37) vs. 3% (0; 16)), experienced that their shoulder was loose (64% (52; 76) vs. 15% (5; 32)), and reported discomfort due to other symptoms (OR 1.48 (1.17; 1.87)). Furthermore, a larger proportion had received supplemental treatment (analgesic medication, steroid injection/surgery).

CONCLUSION(S)

Both groups with HSD and shoulder complaints presented with substantial shoulder-related impairments. Two-thirds reported mechanical symptoms, were younger, and more severely impaired than those without mechanical symptoms. These findings highlight the importance of managing mechanical shoulder symptoms to fully address the patients' impairments.

The Spine Physical Examination Using Telemedicine: Strategies and Best Practices

STUDY DESIGN

Technical note.

OBJECTIVES

To provide spine surgeons new to telemedicine with a structured physical examination technique based on manual motor testing principles.

METHODS

Expert experience describing a series of specific maneuvers for upper and lower extremity strength testing that can be performed using a telemedicine platform. In addition, we offer instruction on "setting up" for these visits and highlight special tests that can be used to diagnose specific cervical and lumbar spine conditions.

RESULTS

From our experiences in conducting telemedicine visits, we provide a means of testing and scoring upper and lower extremity strength for interpretation of weakness in the context of traditional manual motor testing. Also, we acknowledge the limitations of a remote examination and discuss maneuvers that cannot be performed remotely.

CONCLUSIONS

COVID-19 has drastically altered the delivery of care for patients with spine-related complaints. The need for social distancing has led to the widespread adoption of telemedicine. This technical note provides an urgently needed framework for the standardization of the remote physical exam. Validation of the exam as a diagnostic tool will be a crucial next step in studying the impact of telemedicine.

Evaluation of Interfascial Plane and Pericapsular Nerve Blocks to the Shoulder Joint: A Preliminary Analysis of Shoulder Anterior Capsular Block

INTRODUCTION

The aim of this study is to verify if the shoulder anterior capsular block (SHAC), combined with other nerve blocks, is effective in relieving shoulder pain, avoiding motor block and allowing an early rehabilitation program.

METHODS

Seventy-five consecutive patients with painful shoulder were treated with the SHAC, alone (30 patients) or in combination with a suprascapular nerve block (SSnb: 25 patients) or with pectoralis and serratus plane block (PECS-2: 20 patients). All blocks were performed with 0.2% ropivacaine plus 8 mg dexamethasone. All patients were treated with three-weekly physiotherapy sessions for the following 2 weeks and then with home exercises.

RESULTS

The post-procedural analgesic effect was strong in all groups, with a mean change in numeric rating scale (NRS) values of -6.05 in group 1, -6.25 in group 2, and -6.19 in group 3 (p < .0001), allowing all patients to complete an immediate physiotherapy session. Only a few patients needed to repeat the procedure 1 week after the first treatment for the recurrence of pain. From the treatment to the end of the follow-up, we noted a further drop in mean pain NRS values of 1.90 in group 1 and 1.80 in groups 2 and 3. No difference in effect over time was observed among the different groups. No adverse event or motor block was recorded.

CONCLUSION

This study demonstrates that the SHAC, alone or in combination with other peripheral nerve blocks, is an attractive alternative for shoulder pain management, especially when physiotherapy is required to recover shoulder function.

Post-surgery rehabilitation following rotator cuff repair. A survey of current (2020) Italian clinical practice

AIMS

To analyse the clinical practice of Italian physiotherapists within the framework of postoperative rehabilitation of rotator cuff (RC) surgery patients, and to compare it with similar studies carried out in other countries.

METHODS

A web-based, voluntary, cross-sectional survey with 27 closed multiple-choice questions was developed and submitted to Italian-based physiotherapists in order to assess their clinical practice.

RESULTS

Data from 1160 questionnaires were then analysed. Thirty-five percent of respondents (n = 413/1160) reported that they commence passive range of motion from the first postoperative week, while 49.2% (n = 571/1160) start during the second or third week. The majority of respondents (n = 603/1160, 52.0%) introduce active mobilisation between the fourth and the sixth week after surgery and 41.1% (n = 477/1160) introduce overhead movements between the fourth and the sixth week after surgery.

DISCUSSION AND CONCLUSIONS

When managing the postoperative rehabilitation of RC surgery patients, Italian physiotherapists' practice is congruent with the guidelines published by American Society of Shoulder and Elbow Therapists (ASSET) and also with other UK surveys. However, while Italian physiotherapists manage immobilisation periods, active and passive mobilisation and the return to sport activities, according to evidence-based best practice guidelines, there is less consistency with respect to physical exercise, patient follow-up and referral.IMPLICATIONS FOR REHABILITATIONItalian physiotherapists' practice with patients following rotator cuff (RC) repair complies with evidence-based practice guidelines regarding immobilisation periods, passive and active mobilisation, and return to sport activities.There is less consistency between reported/declared practice and available evidence concerning physical exercise, patient follow-up, and referral.Physiotherapist with Orthopaedic Manipulative Physical Therapy (OMPT) training is more aligned with the current literature compared to physiotherapists without specific training, in terms of managing rehabilitation programmes, period of immobilisation and therapeutic exercise.More careful adherence to the international guidelines is recommended, in order to manage patients following RC repair in accordance with the evidence and to achieve the best possible outcomes.

An online survey of clinical practice of Brazilian physical therapists on rehabilitation following rotator cuff repair

BACKGROUND

Physical therapy is essential to help patients to recover their movements and function following a rotator cuff repair. However, there are uncertainties regarding how long a sling should be used for and when exercises should be started.

OBJECTIVE

To investigate the current clinical practice of Brazilian physical therapists treating patients who had a rotator cuff repair. We also explored differences between shoulder specialists and non-specialists.

METHODS

An online survey with 38 questions, including a clinical case, regarding the physical therapy clinical practice for patients having a rotator cuff repair.

RESULTS

We analyzed 194 responses. Majority of participants were from the Southeast of Brazil (57.5%), had up to 10 years of clinical experience (61.4%) and were not shoulder-specialists (69.8%). Majority of the respondents stated that patients have their first post-operative physical therapy session within the first three weeks (51%). Patients usually use a sling for four to six weeks (60.6%). Passive mobilization is often started in the first-week post-surgery. Fifteen percent of shoulder specialists compared to only six percent of non-shoulder specialists would allow strengthening exercises to start between the first and third weeks post-surgery.

CONCLUSION

Physical therapists in Brazil seems to follow similar postoperative programs to other countries. Shoulder specialists allow a faster return to activities and start of strengthening exercises.

Effects of 12 Weeks of Progressive Early Active Exercise Therapy After Surgical Rotator Cuff Repair: 12 Weeks and 1-Year Results From the CUT-N-MOVE Randomized Controlled Trial

BACKGROUND

Traumatic full-thickness rotator cuff tears are typically managed surgically, followed by rehabilitation, but the load progression to reach an optimal clinical outcome during postoperative rehabilitation is unknown.

PURPOSE

To evaluate whether there was a superior effect of 12 weeks of progressive active exercise therapy on shoulder function, pain, and quality of life compared with usual care.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Patients with surgically repaired traumatic full-thickness rotator cuff tears were recruited from 2 orthopaedic departments and randomized to progressive active exercise therapy (PR) or limited passive exercise therapy (UC [usual care]). The primary outcome was the change in the Western Ontario Rotator Cuff Index (WORC) score between groups from before surgery to 12 weeks after surgery. Secondary outcomes included changes in the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire score, pain, range of motion, and strength. Adverse events were registered during the intervention period.

RESULTS

A total of 82 patients were randomized to the PR (n = 41) or UC (n = 41) group. All 82 patients (100%) participated in the 12-week assessment and 79 in the 1-year follow-up. At 12 weeks, there was no significant difference between the groups in the change in the WORC score from baseline adjusted for age, sex, and center (physical symptoms: P = .834; sports and recreation: P = .723; work: P = .541; lifestyle: P = .508; emotions: P = .568). Additionally, there was no between-group difference for the secondary outcomes including the WORC score at 1 year and the DASH score, pain, range of motion, and strength at 12 weeks and 1 year. Both groups showed significant improvements over time in all outcomes. In total, there were 13 retears (16%) at 1-year follow-up: 6 in the PR group and 7 in the UC group.

CONCLUSION

PR did not result in superior patient-reported and objective outcomes compared with UC at either short- or long-term follow-up (12 weeks and 1 year).

REGISTRATION

NCT02969135 (ClinicalTrials.gov identifier).

A randomised controlled trial of heavy shoulder strengthening exercise in patients with hypermobility spectrum disorder or hypermobile Ehlers-Danlos syndrome and long-lasting shoulder complaints: study protocol for the Shoulder-MOBILEX study

Background

Four out of five patients with hypermobility spectrum disorder (HSD) or hypermobile Ehlers-Danlos syndrome (hEDS) experience shoulder complaints including persistent pain and instability. Evidence suggests that patients with HSD/hEDS who experience knee and back complaints improve with exercise-based therapy. However, no study has focused on exercise-based treatment for the shoulder in this patient group. The potential benefits of strengthening the shoulder muscles, such as increased muscle-tendon stiffness, may be effective for patients with HSD/hEDS who often display decreased strength and increased shoulder laxity/instability.

The primary aim is to investigate the short-term effectiveness of a 16-week progressive heavy shoulder strengthening programme and general advice (HEAVY) compared with low-load training and general advice (LIGHT), on self-reported shoulder symptoms, function, and quality of life.

Methods

A superiority, parallel group, randomised controlled trial will be conducted with 100 patients from primary care with HSD/hEDS and shoulder complaints (persistent pain and/or instability) for more than 3 months. Participants will be randomised to receive HEAVY (full range of motion, high load) or LIGHT (neutral to midrange of motion, low load) strengthening programme three times weekly with exercises targeting scapular and rotator cuff muscles. HEAVY will be supervised twice weekly, and LIGHT three times during the 16 weeks. The primary outcome will be between-group difference in change from baseline to 16-week follow-up in the Western Ontario Shoulder Instability Index (WOSI, 0-2100 better to worse). Secondary outcomes will include a range of self-reported outcomes covering symptoms, function, and quality of life, besides clinical tests for shoulder strength, laxity/instability, and proprioception. Outcome assessors will be blinded to group allocation. Participants will be kept blind to treatment allocation through minimal information about the intervention content and hypotheses. Primary analyses will be performed by a blinded epidemiologist.

Discussion

If effective, the current heavy shoulder strengthening programme will challenge the general understanding of prescribing low-load exercise interventions for patients with HSD/hEDS and provide a new treatment strategy. The study will address an important and severe condition using transparent, detailed, and high-quality methods to potentially support a future implementation.

Trial registration

ClinicalTrials.gov NCT03869307. Registered on 11 March 2019.

Supplementary information

The online version contains supplementary material available at 10.1186/s13063-020-04892-0.

The role of telehealth as a platform for postoperative visits following rotator cuff repair: a prospective, randomized controlled trial

BACKGROUND

The application of telehealth for surgical follow-up has gained recent exposure in orthopedic care. Although the results following joint arthroplasty are encouraging, the role of telemedicine for postoperative care following arthroscopic rotator cuff repair still needs to be defined. The goal of this study was to evaluate the safety, efficacy, and socioeconomic benefits of telehealth as a platform for postoperative follow-up.

METHODS

This was a prospective, randomized controlled trial that enrolled 66 patients who underwent follow-up in the office vs. via telemedicine for postoperative visits at 2, 6, and 12 weeks after surgery. Post-visit surveys were administered to patients and physicians via e-mail, and the Student t test and Fisher exact test were used to compare responses.

RESULTS

In total, 58 patients (88%) completed the study (28 telehealth vs. 30 control). Patients in each group demonstrated similar pain scores at each follow-up visit (P = .638, P = .124, and P = .951) and similar overall satisfaction scores (P = .304). Patients in the telehealth group expressed a stronger preference for telehealth than their control counterparts (P < .001). Telehealth visits were less time-consuming from both a patient (P < .001) and physician (P = .002) perspective. Telehealth visits also required less time off work for both patients (P = .001) and caregivers (P < .001).

CONCLUSION

Patients undergoing arthroscopic rotator cuff surgery were able to receive safe and effective early postoperative follow-up care using telemedicine. The preference for telehealth increased for both surgeons and patients following first-hand experience. The use of a telehealth platform is a reasonable follow-up model to consider for patients seeking convenient and efficient care following arthroscopic rotator cuff repair.

Associations between shoulder symptoms and concomitant pathology in patients with traumatic supraspinatus tears

Background

The association between concomitant pathologic characteristics and preoperative symptoms in patients identified as eligible for surgical rotator cuff repair has been sparsely evaluated. The purpose was to explore the associations between preoperative shoulder symptoms and additional structural pathology or injuries identified during surgery in patients with traumatic supraspinatus tears.

Methods

This was a cross-sectional study including patients with traumatic supraspinatus tears. Preoperatively, patients reported pain and disability using a numeric pain rating scale from 0 to 10 and the Western Ontario Rotator Cuff Index. During surgery, the presence of prespecified structural injuries and pathologies including a full-thickness or partial supraspinatus tear, infraspinatus tear, subscapularis tear, hooked acromion, acromioclavicular joint osteoarthritis, biceps tendon pathology, labral tear, and cartilage lesion was recorded. Linear regression and analysis of covariance were used to assess associations.

Results

A total of 87 patients (52 male patients, 60%) were included (mean age, 60 years; standard deviation, 9.2 years). Of these patients, 69 (79%) had a full-thickness supraspinatus tear and 18 (21%) had a partial-thickness tear. Concomitant structural pathology was found in 79 patients (91%). No association was found between the number of structural shoulder pathologies and preoperative numeric pain rating scale or Western Ontario Rotator Cuff Index score, and no particular concomitant pathology was associated with worse patient-reported symptoms.

Conclusion

Pathology of the infraspinatus and subscapularis and other structural joint pathologies concomitant with supraspinatus tears were not correlated with preoperative self-reported pain and disability in patients scheduled to undergo rotator cuff surgery, suggesting that concomitant pathology adds little to the symptoms in patients with a traumatic supraspinatus tear.