Continuous passive motion after repair of the rotator cuff. A prospective outcome study

Bibliometric and visualized analysis of scientific publications on rehabilitation of rotator cuff injury based on web of science

Background

Since the discovery of rehabilitation as an intervention for rotator cuff injury, its impact on the recovery of rotator cuff injury has attracted crucial attention, and the number of related studies is increasing worldwide. There were no bibliometric and visualized analysis studies in this field. This study aimed to investigate the research hotpots and trends in the rehabilitation of rotator cuff injury via bibliometric and visualized analysis and to identify the future development of clinical practice.

Method

The publications regarding rehabilitation of rotator cuff injury from inception to December 2021 were obtained from the Web of Science Core Collection database. The trends of publications, co-authorship and co-occurrence analysis and visualized analysis were carried out using Citespace, VOSviewer, Scimago Graphica software, and R Project.

Results

A total of 795 publications were included in this study. The number of publications significantly increased yearly. The United States published the highest number of related papers and the papers published by the United States had the highest citations. The University of Laval, the University of Montreal and Keele University were the top 3 most contributive institutions. Additionally, the Journal of Shoulder and Elbow Surgery was the journal with the highest number of publications. The most common keywords were "rotator cuff", "rehabilitation", "physical therapy", "management", and "telerehabilitation".

Conclusion

The total number of publications has shown a steady upward trend. The cooperation between countries globally was still relatively lacking, and therefore it is necessary to strengthen cooperation between different countries and regions to provide conditions for multi-center, large sample, and high-quality research. In addition to the relatively mature rehabilitation of rotator cuff injury such as passive motion or exercise therapy, telerehabilitation has also attracted much attention with the progress of science.

EFFECTS OF A DEEP LEARNING-BASED SMARTPHONE APPLICATION ON SHOULDER ABDUCTION KINEMATICS AND BRAIN ACTIVATION IN ADHESIVE CAPSULITIS: A RANDOMIZED CONTROLLED TRIAL

Patients with adhesive capsulitis (AC) demonstrate limited shoulder movement, often accompanied by pain. Common treatment methods include pain medication, and continuous passive movement (CPM). However, it is sometimes difficult to improve the reduction of pain and movement using a CPM intervention because the patient’s interest is diminished. In this study, we developed an innovative deep learning-based smartphone application (Funrehab exercise game (FEG)) to provide accurate kinematics movement and motivation as well as high-intensity and repetitive movements using deep learning. We compared the effects of CPM and FEG on brain activity and shoulder range of motion in patients with AC. Sixteen patients (males, [Formula: see text]; females, [Formula: see text]; mean age, [Formula: see text] years) with acute AC were randomized into either CPM group or FEG group 4 days/week for 2 weeks. The outcome measures were shoulder abduction kinematics movement and electroencephalography (EEG) brain activity (bilateral prefrontal, bilateral sensorimotor cortex, and somatosensory association cortex) during the intervention. The analysis of variance (ANOVA) test was performed at [Formula: see text], and the analysis demonstrated that FEG showed superior effects on shoulder abduction kinematics and brain [Formula: see text] and [Formula: see text]-wave activations compared to CPM. Our results provide a novel and promising clinical evidence that FEG can more effectively improve neurophysiological EEG data and shoulder abduction movements than CPM in patients with AC.

Conservative versus accelerated rehabilitation after rotator cuff repair: a systematic review and meta-analysis

Background

The purpose of this systematic review and meta-analysis is to compare the conservative and accelerated rehabilitation protocols in patients who underwent arthroscopic rotator cuff repair in terms of clinical outcomes and range of motions at 3, 6, 12, and 24-month follow-up.

Methods

According to PRISMA guidelines, a systematic review of the literature was performed. For each included article, the following data has been extracted: authors, year, study design, level of evidence, demographic characteristics, follow-up, clinical outcomes, range of motions, and retear events. A meta-analysis was performed to compare accelerated versus conservative rehabilitation protocols after arthroscopic rotator cuff repair. The retear rate, postoperative Constant-Murley score and range of motions at 3, 6, 12, and 24 months of follow-up were the outcomes measured.

Results

The search strategy yielded 16 level I-II clinical studies. A total of 1424 patients, with 732 patients and 692 in the accelerated and conservative group, were included. The average age (mean ± standard deviation) was 56.1 ± 8.7 and 56.6 ± 9 in the accelerated and conservative group. The mean follow-up was 12.5 months, ranging from 2 to 24 months. The meta-analysis showed no statistically significant differences in terms of retear rate between the groups (P = 0.29). The superiority of the accelerated group was demonstrated in terms of external rotation (P < 0.05) at 3-month follow-up; in terms of forward elevation, external rotation, abduction (P < 0.05), but not in terms of Constant-Murley score at 6-month follow-up; in terms of forward elevation (P < 0.05) at 12-month follow-up. No significant differences between the two group were highlighted at 24-month follow-up.

Conclusions

No statistically significant differences in the retear rate among the accelerated and conservative group have been demonstrated. On the other hand, statistically and clinically significant differences were found in terms of external rotation at 3 and 6 months of follow-up in favour of the accelerated group. However, no differences between the two groups were detected at 24 months follow-up.

[Continuous Passive Motion in Orthopaedic Rehabilitation of the Shoulder Girdle - A Literature Survey]

BACKGROUND

Continuous passive motion (CPM) of the shoulder is predominantly used during postoperative rehabilitation of the shoulder girdle. It is often used after rotator cuff repair (RM suture). Incapacity to work and therapy of shoulder diseases cause significant costs for the healthcare system in Germany.

METHODS

In a literature analysis, studies and reviews of the CPM treatment in scientific databases were therefore identified and analysed with regard to the functional outcome particular after shoulder joint surgery. The quality of the studies was evaluated using the Cochrane Collaboration's Risk of Bias Tool.

RESULTS

After rotator cuff suturing, clinical studies have predominantly shown a faster improvement in pain level and shoulder mobility when using CPM treatment compared to other forms of treatment. In the case of frozen shoulder, only studies with the scope of CPM in conservative treatment could be identified. Here predominantly faster pain reduction could be observed. Studies addressing CPM in the therapy of Impingement of the shoulder, fracture of the humeral head or arthroplasty of the glenohumeral joint could not be identified. The health economic effects of CPM use are controversially discussed. In the available studies, equipment and other costs are assessed differently.

CONCLUSION

The analysed clinical studies showed overall positive effects, e. g. a faster improvement of pain level and shoulder mobility, in the postoperative therapy of the shoulder after rotator cuff repair as well as in the conservative therapy of shoulder stiffness for the CPM treatment compared to other forms of treatment. For other entities no meaningful studies are available in the literature to date. Since the health economic effects of the use of CPM have been discussed controversial so far, potential health economic benefits of the use of CPM treatment should be evaluated in future studies.

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 Historical Analysis of Randomized Controlled Trials in Rotator Cuff Tears

Background and objectives: Our research aimed to evaluate the quality of reporting of randomized controlled trials (RCTs) linked to rotator cuff (RC) tears. The present study analyzed factors connected to the quality of the RCTs and trends in the quality of reporting through time. Materials and Methods: The online databases used to search all RCTs on the topic of RC surgery completed until March 2020 were PubMed and Ovid (MEDLINE). The quality of reporting was evaluated using the modified Coleman methodology score (MCMS) and the consolidated standards of reporting trials (CONSORT). Results: The online search found 957 articles. Finally, 183 studies were included in the quantitative synthesis. A total of 97 (53%) of 183 studies had a level of evidence I and 86 (47%) of 183 studies had a level of evidence II, according to the Oxford Center of Evidence Based Medicine (EBM). A statistically significant difference in MCMS between articles written before 2010 and articles written after 2010 was found. Articles written after 2010 had, on average, the highest Coleman score. The average number of CONSORT checklist items for each article across all analyzed RCTs was 21.67. The 37 studies completed up to 2010 averaged a number of checklist items of 19.97 and the studies completed between 2011 and 2019 averaged a number of checklist items of 22.10. A statistically significant difference in the number of checklist items between articles written before 2010 and articles written after 2010 was found. Articles written after 2010 had on average more checklist items. However, low correlation (0.26) between the number of checklist items for each article and the respective Coleman score was found. On the other hand, articles with the CONSORT diagram had a significantly high Coleman score. Conclusions: An improvement in the quantity and quality of RCTs relating to RC surgery over the analyzed period was found.

Comparison of surgical outcomes between rotator cuff repair with and without rotator interval capsular release for rotator cuff tears to prevent and improve postoperative stiffness: a meta-analysis

BACKGROUND

A common complication of rotator cuff (RC) repair is a postoperative stiffness. Postoperative stiffness may develop and lead to inferior functional outcomes. Rotator cuff repair with additional rotator interval (RI) capsular release can be done to prevent postoperative stiffness in rotator cuff tears. However, routine rotator interval capsular release in rotator cuff repair is controversial. Therefore, we conducted a systematic review and meta-analysis to compare the postoperative outcomes between RC repair with and without RI capsular release for RC tears with and without concomitant stiffness.

METHOD

We searched all comparative studies that compared postoperative outcomes (VAS, CS, ASES, complications and ROM at 3, 6 and 12 months) of RC repair with and without RI capsular release for RC tears with and without concomitant stiffness from PubMed and Scopus databases from inception to the February 1, 2020.

RESULTS

Seven of 255 studies (six comparative studies and one RCT) (N = 803 patients) were eligible; 2 and 5 studies were included in the pooling of RC repair and RI release without concomitant stiffness and stiffness, respectively; 2, 6, 3, 6, 3, 5, 7, 7, and 7 studies were included in pooling of VAS, CS, ASES at 6 and 12 months and range of motion (internal, external rotation and forward flexion) at 3, 6 and 12 months, respectively. The UMD of VAS, CS and ASES scores at 6- and 12-month follow-up for the RC repair and RI release group was 0.48 (95% CI: 0.05, 0.90), 0.93 (-1.70, 3.56), -2.27 (-5.30, 0.76), -0.04 (-0.24, 0.15), 1.66 (0.77, 2.55) and 1.58 (0.21, 2.96) scores when compared to RC repair alone with and without concomitant stiffness. In terms of ROM, forward flexion for the RC repair and RI release group was -4.60 (-10.61, 1.41), -7.11 (-15.47, 1.25) and -0.70 (-2.51, -1.11) degrees at 3, 6 and 12 months, respectively, when compared to RC repair alone. For external rotation, RC repair and RI release were -0.12 (-8.27, 8.03), -3.98 (-12.09, 4.14) and -2.65 (-5.35, 0.04) degrees at 3, 6 and 12 months, respectively, when compared to RC repair alone. For internal rotation in RC repair and RI release, the values were -1.22 (-1.97, - 0.48), -1.01 (-1.79, -0.23) and -0.19 (-1.13, 0.74) degrees at 3, 6 and 12 months, respectively, when compared to RC repair alone. There were no differences with a RR of 0.92 (0.46, 1.84) between the two groups in terms of complications. After subgroup analysis, RC repair with RI release had no clinically significant differences for pain, function and ROM when compared to RC repair alone in RC tear patients with and without preoperative stiffness.

CONCLUSIONS

RC repair with RI release in patients with and without preoperative stiffness had no statistically significant differences for pain, function (CS and ASES) and range of motion (FF, ER and IR) when compared to RC repair alone in RC injury patients.

LEVEL OF EVIDENCE

II.

Physical therapy and precision rehabilitation in shoulder rotator cuff disease

PURPOSE

To describe the main features of the rehabilitation protocols for RC disease based on the phases of tendon healing and to investigate about the use of wearable devices as monitoring systems.

METHODS

We performed a comprehensive search of PubMed, Medline, Cochrane, CINAHL, and EMBASE databases using various combination of the keywords "rotator cuff," "rotator cuff tear," "rehabilitation protocol," "accelerated," "conservative," "stiffness," "exercises," and "wearable devices." All articles concerning precision orthopaedic rehabilitation therapy in rotator cuff disease were retrieved.

RESULTS

To date, rehabilitation protocols are not comparable due to wide heterogeneity of RC diseases. Wearable technologies are becoming a revolutionary tool for movement and posture monitoring.

CONCLUSION

Rehabilitation protocols for RC disease should be tailored on the basis of the different phases of tendon healing. Wearable devices hold the promise to offer a new outlook for long-term follow-up during the postoperative period providing information to the clinician about patient's status.

The effect of concomitant coracohumeral ligament release in arthroscopic rotator cuff repair to prevent postoperative stiffness: a retrospective comparative study

PURPOSE

This study was to evaluate the efficacy and safety of coracohumeral ligament (CHL) release from the coracoid process concomitant with arthroscopic rotator cuff repair for preventing postoperative stiffness.

METHODS

Data on patients who underwent arthroscopic rotator cuff repair with a minimum follow-up of 1 year were collected retrospectively. Propensity score matching (1-to-1) was performed between a no-releasing group (Group I) and CHL-releasing group (Group II). In total, 76 patients in each group were matched. Clinical outcomes were assessed and compared between the two groups, including range of motion (ROM) and visual analogue scale for pain (pVAS) at postoperative 3 months, 6 months, and 1 year. The integrity of the repaired tendon was assessed at 1-year follow-up using either magnetic resonance imaging or ultrasonography.

RESULTS

External rotation (ER) at side at postoperative 3 months in Group II was better than that in Group I (48.6° ± 11.6° vs. 38.4° ± 13.0°, P < 0.001). When evaluating only patients with a small-to-medium sized tear at postoperative 3 months, ER at side was 49.8° ± 10.9° in Group II versus 37.8° ± 13.1° in Group I (P < 0.001). In patients with a large-to-massive sized tear, however, there was no significant difference in ER at side at postoperative 3 months (n.s.). There was no significant difference in ROM and functional scores at postoperative 6 months and 1 year, and there was no significant difference in healing failure rate (6 cases in Group I (7.9%), 2 cases in Group II (2.6%); n.s.). No complications of the CHL release procedure occurred.

CONCLUSIONS

In arthroscopic rotator cuff repair, CHL release from the coracoid process without creating a rotator interval defect could be an effective and safe method to prevent early postoperative stiffness, especially ER at side in patients with a small-to-medium sized tear. Therefore, CHL release can be used as a selective procedure to prevent postoperative stiffness in patients that may benefit from this procedure with decreased preoperative ER compared to the normal side.

LEVEL OF EVIDENCE

Level III.

Early and Delayed Postoperative Rehabilitation after Arthroscopic Rotator Cuff Repair: A Comparative Study of Clinical Outcomes

BACKGROUND

The duration of immobilization after arthroscopic rotator cuff repair and the optimal time to commence rehabilitation are still the subject of ongoing debates. This study was undertaken to evaluate the functional outcome and rotator cuff healing status after arthroscopic rotator cuff repair by comparing early and delayed rehabilitation.

METHODS

Totally, 76 patients with small, medium, and large sized rotator cuff tears underwent arthroscopic repair using the suture-bridge technique. In early rehabilitation group, 38 patients commenced passive range of motion at postoperative day 2 whereas 38 patients assigned to the delayed rehabilitation group commenced passive range of motion at postoperative week 3. At the end of the study period, clinical and functional evaluations (Constant score, the University of California, Los Angeles [UCLA] shoulder score) were carried out, subsequent to measuring the range of motion, visual analogue scale for pain, and isokinetic dynamometer test. Rotator cuff healing was confirmed by magnetic resonance imaging at least 6 months after surgery.

RESULTS

No significant difference was obtained in range of motion and visual analogue scale between both groups. Functional outcomes showed similar improvements in the Constant score (early: 67.0-88.0; delayed: 66.9-91.0; p<0.001) and the UCLA shoulder score (early: 20.3-32.3; delayed: 20.4-32.4; p<0.001). Furthermore, rotator cuff healing showed no significant differences between the groups (range, 6-15 months; average, 10.4 months).

CONCLUSIONS

Delayed passive rehabilitation does not bring about superior outcomes. Therefore, early rehabilitation would be useful to help patients resume their daily lives.

Outcomes After Limited or Extensive Bursectomy During Rotator Cuff Repair: Randomized Controlled Trial

PURPOSE

To evaluate the effects of extensive bursectomy (EB) and limited bursectomy (LB) during arthroscopic rotator cuff repair.

METHODS

In the EB group (n = 39), subacromial bursae were thoroughly removed from anterior to posterior and lateral to medial. In the LB group (n = 39), bursectomy was minimized to allow torn cuff visualization and tendon repair. Visual analog scale pain scores, passive forward flexion, external rotation at the side (ER), and internal rotation at the back were measured at 5 weeks and 3, 6, and 12 months after surgery. At each time point, bursal thickness was measured and repair integrity was assessed by sonography or magnetic resonance imaging.

RESULTS

The analysis included 36 patients in the LB group and 35 in the EB group. Group visual analog scale pain scores were not significantly different at any time (P > .05 for all). Forward flexion and internal rotation at the back showed no intergroup difference during follow-up. However, ER was significantly better in the LB group at 6 months and 1 year postoperatively (31° ± 15° vs 22° ± 16° [P = .020] and 40° ± 19° vs 27° ± 20° [P = .009], respectively). Integrity failures were not significantly different at 5 weeks and at 3, 6, and 12 months (P > .05 for all). Marked bursal thickening (>2 mm) was more frequently observed in the EB group (18 of 32 in the LB group and 27 of 32 in the EB group) at 6 months (P = .014).

CONCLUSIONS

EB during arthroscopic rotator cuff repair appears to have no benefit in terms of reducing pain. More adhesions in the subacromial space after EB may result in slower motion recovery, especially in terms of ER. The extent of bursectomy did not affect tendon integrity. However, marked bursal thickening was more frequently observed in the EB group.

LEVEL OF EVIDENCE

Level I, randomized controlled study.

The Effects of a Standard Postoperative Rehabilitation Protocol for Arthroscopic Rotator Cuff Repair on Pain, Function, and Health Perception

Purpose  There is still conflicting evidence to support postoperative rehabilitation protocols using immobilization following rotator cuff repair over early motion. The objective of the study was to evaluate the evolution of pain, shoulder function, and patients' perception of their health status up to 1 year after cuff rotator repair and a standard postoperative rehabilitation protocol consisting of 4 weeks of immobilization followed by a 2-week assisted controlled rehabilitation.

Methods  Descriptive, longitudinal, uncontrolled case-series study was performed on 49 patients who underwent arthroscopic rotator cuff repair following traumatic or degenerative lesions. VAS scale for pain, Constant–Murley score for function, and SF-12 score for quality of life were used as outcome measures and were administered before the rehabilitation treatment, at the end of the 2-week rehabilitation, 3 months, and 1 year after surgery.

Results  VAS pain score decreased significantly along the follow-up reaching almost a nil value after 1 year (0.2). Function as measured by Constant–Murley score had a significant improvement during follow-up, reaching a mean value of 84.6. The short form (SF)-12 score increased over time reaching 46.3 for the physical and 43.8 for the psychological dimension, respectively, at 1 year.

Conclusion  The present study confirmed an excellent outcome at 1 year after rotator cuff repair using a traditional 4-week immobilization followed by a 2-week rehabilitation protocol without evidence of tendon un-healing or re-tearing.

Level of Evidence  This is a level IV, therapeutic case series.

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

Background

Rotator cuff tear is a common cause of shoulder disability and results in patients predominantly complaining of pain and loss of motion and strength. Traumatic rotator cuff tears are typically managed surgically followed by ~ 20 weeks of rehabilitation. However, the timing and intensity of the postoperative rehabilitation strategy required to reach an optimal clinical outcome is unknown. Early controlled and gradually increased tendon loading has been suggested to positively influence tendon healing and recovery. The aim of this trial is therefore to examine the effect of a progressive rehabilitation strategy on pain, physical function and quality of life compared to usual care (that limits tendon loading in the early postoperative phase) in patients who have a rotator cuff repair of a traumatic tear.

Methods

The current study is a randomized, controlled, outcome-assessor blinded, multicenter, superiority trial with a two-group paralleled design. A total of 100 patients with surgically repaired traumatic rotator cuff tears will be recruited from up to three orthopedic departments in Denmark, and randomized to either a progressive early passive and active movement program or a limited early passive movement program (usual care). The primary outcome measure will be the change from pre-surgery to 12 weeks post-surgery in the Western Ontario Rotator Cuff Index questionnaire. Secondary outcomes include the Disabilities Arm, Shoulder and Hand questionnaire (DASH), range of motion, strength and tendon healing characteristics from ultrasound measurements at 12 months follow up.

Discussion

We hypothesized that patients who receive the progressive rehabilitation strategy will benefit more with respect to pain reduction, physical function and quality of life than those who receive care as usual. If this is confirmed our study can be used clinically to enhance the recovery of patients with traumatic rotator cuff tear.

Trial registration

ClinicalTrials.gov, NCT02969135. Registered on 15 November 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2839-5) contains supplementary material, which is available to authorized users.

Conservative treatment of rotator cuff tear in older patients: a role for the cycloergometer? A randomized study

BACKGROUND

To date, there are no published data on the use of devices in the management of rotator cuff tear (RCT).

AIM

The aim of this study was to evaluate the effect of supervised arm cycloergometer training on pain during activities and shoulder functionality in patients with symptomatic full-thickness RCT.

DESIGN

This is a prospective randomized controlled pilot study.

SETTING

Outpatients of our Rehabilitation Unit.

POPULATION

In this pilot study, 40 elderly outpatients (>70 years) with RCT were randomized to two groups: cycloergometer (CYC) vs. control patients.

METHODS

All patients underwent a common outpatient rehabilitation exercise program consisting of ten 30-min sessions (5 sessions/week). At discharge, CYC patients received 15-min training with an arm cycloergometer and were invited to use the cycloergometer at home 20 min/twice a day. Control patients were invited to continue the standard exercises. During the 6-month study period CYC patients, but not control patients, received educational reinforcement monthly from the nurse of the telemedicine service. Outcomes assessed, between admission (T0) and 6-month follow-up (T6), were: pre to postpain during activities, active and passive ROMsum, ROM-painsum, revised Constant Total Score, and Health Assessment Questionnaire (HAQ).

RESULTS

At T6, CYC patients showed a significant improvement in all outcome measures with respect to T0 (all: P<0.001). CYC patients showed also significant improvement in passive forward elevation, abduction, and external rotation of shoulder, as well as in active ROMsum and ROM-painsum in all single shoulder movements, and significant improvement in the HAQ items: dressing/grooming, eating, hygiene, reach, and common daily activities. At T6 the CYC group had lower pain during activities (P<0.01) and higher revised constant total score (P<0.01), ROM-painsum (P<0.05) and active ROMsum (P<0.05) than control patients. Home cycloergometer use was inversely associated to pain during activities (P<0.01) and revised Constant Total Score (P<0.01) at T6.

CONCLUSIONS

A short program of shoulder passive exercises and cuff strengthening exercises followed by regular use of the cycloergometer for 6 months at home can reduce pain and improve shoulder functionality in RCT patients.

CLINICAL REHABILITATION IMPACT

Our findings indicate that the cycloergometer may be useful in patients with RCT when regularly used at home and suggest use of this mechanical device in rehabilitation programs for these patients.

Rehabilitation following rotator cuff repair: A work of the Commission Rehabilitation of the German Society of Shoulder and Elbow Surgery e. V. (DVSE) in collaboration with the German Association for Physiotherapy (ZVK) e. V., the Association Physical Therapy, Association for Physical Professions (VPT) e. V. and the Section Rehabilitation-Physical Therapy of the German Society for Orthopaedics and Trauma e. V. (DGOU)

Background

Tears and lesions of the rotator cuff are a frequent cause of shoulder pain and disability. Surgical repair of the rotator cuff is a valuable procedure to improve shoulder function and decrease pain. However, there is no consensus concerning the rehabilitation protocol following surgery.

Objectives

To review and evaluate current rehabilitation contents and protocols after rotator cuff repair by reviewing the existing scientific literature and providing an overview of the clinical practice of selected German Society of Shoulder and Elbow Surgery e. V. (DVSE) shoulder experts.

Materials and methods

A literature search for the years 2004-2014 was conducted in relevant databases and bibliographies including the Guidelines International Network, National Guidelines, PubMed, Cochrane CentralRegister of Controlled Trials, Cochrane Database of Systematic Reviews, and the Physiotherapy Evidence Database. In addition, 63 DVSE experts were contacted via online questionnaire.

Results

A total of 17 studies, four reviews and one guideline fulfilled the inclusion criteria. Based on these results and the obtained expert opinions, a four-phase rehabilitation protocol could be developed.

The Effect of Early Range of Motion on Quality of Life, Clinical Outcome, and Repair Integrity After Arthroscopic Rotator Cuff Repair

PURPOSE

To compare the effect of early versus delayed motion protocols on quality of life, clinical outcomes, and repair integrity in patients who have undergone arthroscopic single-tendon rotator cuff repair.

METHODS

This was a prospective, randomized, investigator-blinded clinical trial. Seventy-three patients from a single surgeon's practice who underwent arthroscopic repair of a single-tendon rotator cuff tear were randomized to either an early motion protocol (starting 2 to 3 days after surgery) or a delayed motion protocol (starting 28 days after surgery). The primary outcome measure was the Western Ontario Rotator Cuff index (WORC). Secondary outcome measures included clinical outcome scores, integrity of the repair on 6-month magnetic resonance imaging scans, pain scores, physical examination data, and ultrasonography. Study participants were followed up at 3, 6, and 12 weeks; 6 months; and 1 year postoperatively.

RESULTS

There was no statistically significant difference in WORC scores at 6 months (529 ± 472 in delayed group vs 325 ± 400 in early group, P = .08). Mixed-effects analysis indicated the early group maintained lower WORC scores throughout the postoperative period (estimated difference of 191, P = .04). The proportions of patients with tears on the 6-month postoperative magnetic resonance imaging scan were comparable (31% in delayed group vs 34% in early group, P = .78).

CONCLUSIONS

There was no difference between the delayed and early motion groups in WORC scores at 6 months after surgery. Early motion was associated with lower WORC scores throughout the postoperative period; however, both groups had a similar trajectory of improvement, suggesting both protocols have the same effect on patient-reported improvement. Although failure rates were similar between the groups, the sample size was not sufficient to support a statement regarding the relation between tear morphology and the rehabilitation protocol.

LEVEL OF EVIDENCE

Level II, lesser-quality randomized controlled trial.

Rehabilitation after Rotator Cuff Repair

BACKGROUND

Rotator cuff tears are a very common condition that is often incapacitating. Whether non-surgical or surgical, successful management of rotator cuff disease is dependent on appropriate rehabilitation. If conservative management is insufficient, surgical repair is often indicated. Postsurgical outcomes for patients having had rotator cuff repair can be quite good. A successful outcome is much dependent on surgical technique as it is on rehabilitation. Numerous rehabilitation protocols for the management of rotator cuff disease are based primarily on clinical experience and expert opinion. This article describes the different rehabilitation protocols that aim to protect the repair in the immediate postoperative period, minimize postoperative stiffness and muscle atrophy.

METHODS

A review of currently available literature on rehabilitation after arthroscopic rotator cuff tear repair was performed to illustrate the available evidence behind various postoperative treatment modalities.

RESULTS

There were no statistically significant differences between a conservative and an accelerated rehabilitation protocol . Early passive range of motion (ROM) following arthroscopic cuff repair is thought to decrease postoperative stiffness and improve functionality. However, early aggressive rehabilitation may compromise repair integrity.

CONCLUSION

The currently available literature did not identify any significant differences in functional outcomes and relative risks of re-tears between delayed and early motion in patients undergoing arthroscopic rotator cuff repairs. A gentle rehabilitation protocol with limits in range of motion and exercise times after arthroscopic rotator cuff repair would be better for tendon healing without taking any substantial risks. A close communication between the surgeon, the patient and the physical therapy team is important and should continue throughout the whole recovery process.

Early active rehabilitation after arthroscopic rotator cuff repair: a prospective randomized pilot study

OBJECTIVE

To compare two different rehabilitation strategies, primary passive motion versus early isometric loading of the rotator cuff.

DESIGN

Prospective randomized controlled observer-blinded pilot study.

SETTING

Institute of Physical Medicine and Rehabilitation.

SUBJECTS

Thirty patients after rotator cuff surgery.

INTERVENTION

All participants were randomly assigned to one of the two outpatient treatment groups: primary passive motion versus early isometric loading of the rotator cuff. Both groups were treated for 12 weeks and performed additionally a home exercise program.

MAIN MEASURES

The primary outcome measure for functional assessment was the Constant Murley score. The secondary outcome measures were the Disabilities of the Arm, Shoulder and Hand score (DASH), active range of motion, pain level and strength. Patients were assessed before, 6, 12 and 24 weeks after surgery.

RESULTS

Repeatedly measured metric variables were compared by the Quade rank analysis of covariance and revealed substantially better Constant Murley scores in the early activated group at all 3 assessments (6 weeks: 41 [31;45] versus 30 [23;37]; 12 weeks: 68 [56;77] versus 59 [53;62]; 24 weeks: 79 [76;81] versus 66 [62;74]; data as median [25%;75%]). Postoperative changes of Constant score were in favour of the active group with the biggest difference at week 12 (28 [38;12] versus 9 [27;-4]). Maximal pain levels showed clear more reduction 6 and 24 weeks after surgery in the early activated group.

CONCLUSIONS

This pilot study with early isometric loading of the rotator cuff shows better function and less maximal pain. Further research is warranted to confirm our results.

Effectiveness of early compared with conservative rehabilitation for patients having rotator cuff repair surgery: an overview of systematic reviews

AIM/OBJECTIVE

The aim is to critically analyse and discuss the current literature and determine the effectiveness of rehabilitation for patients after surgical repair of rotator cuff tears for range of motion (ROM), pain, functional status and retear rates; in addition, an update of new literature is included.

DESIGN

Overview of systematic reviews.

DATA SOURCES

A search was performed with no restrictions to date of publication and language in the following databases: EBSCO, AMED, CINAHL, SPORTDiscus, EMBASE, Cochrane, LILACS, MEDLINE, PEDro, Scielo, SCOPUS and Web of Knowledge. The PRISMA guideline was followed to develop this review and the R-AMSTAR tool was used for critical appraisal of included reviews.

ELIGIBILITY CRITERIA

Only systematic reviews and randomised controlled trials (RCTs) comparing the effectiveness of early with conservative rehabilitation, after surgical repair of the rotator cuff, were included. Moreover, the studies should report ROM, pain, functional status and/or retears rates before and after 3-24 months of the surgery.

RESULTS

10 systematic reviews and 11 RCTs were included for the final analysis. Conflicting results and conclusions were presented by the systematic reviews, the use of primary studies varied; also the methodological quality of the reviews was diverse. This updated review, with new meta-analysis, showed no difference for function, pain, ROM or retears ratio between early and conservative rehabilitation.

SUMMARY/CONCLUSIONS

Early mobilisation may be beneficial, particularly for small and medium tears; however, more studies with higher quality are required, especially for patients with large tears who have been given less attention.

Evaluation of Repair Tension in Arthroscopic Rotator Cuff Repair: Does It Really Matter to the Integrity of the Rotator Cuff?

BACKGROUND

Repair tension of a torn rotator cuff can affect healing after repair. However, a measurement of the actual tension during arthroscopic rotator cuff repair is not feasible. The relationship between repair tension and healing of a rotator cuff repair remains unclear.

PURPOSE/HYPOTHESIS

The purpose of this study was to evaluate the effect of repair tension on healing at the repair site. The hypothesis was that repair tension would be a major factor in determining the anatomic outcome of rotator cuff repair.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Arthroscopic rotator cuff repairs (132 patients) for full-thickness rotator cuff tears were analyzed. An intraoperative model was designed for the estimation of repair tension using a tensiometer. Magnetic resonance imaging (MRI) was performed approximately 1 year (mean [±SD], 12.7 ± 3.2 months) postoperatively for the evaluation of healing at the repair site. Multivariable analysis was performed for tear size, amount of retraction, and fatty degeneration (FD) of rotator cuff muscles.

RESULTS

The mean repair tension measured during the arthroscopic procedure was 28.5 ± 23.1 N. There was a statistically significant correlation between tension and tear size (Pearson correlation coefficient [PCC], 0.529; P < .001), amount of retraction (PCC, 0.619; P < .001), and FD of the supraspinatus (Spearman correlation coefficient [SCC], 0.308; P < .001) and infraspinatus (SCC, 0.332; P < .001). At the final follow-up (12.7 ± 3.2 months), healing failure was observed in 18.2% (24/132), and repair tension also showed a significant inverse correlation with healing at the repair site (SCC, 0.195; P = .025). However, when sex, age, tear size, amount of retraction, tendon quality, and FD of rotator cuff muscles were included for multivariable logistic regression analysis, only FD of the infraspinatus showed an association with the anatomic outcome of repair (Exp(B) = 0.596; P = .010).

CONCLUSION

Our intraoperative model for the estimation of rotator cuff repair tension showed an inverse correlation of repair tension with healing at the repair site, suggesting that complete healing is less likely with high-tension repairs. A significant association was observed on MRI between a high level of FD of the infraspinatus and repaired tendon integrity.

Are Pulley Exercises Initiated 6 Weeks After Rotator Cuff Repair a Safe and Effective Rehabilitative Treatment? A Randomized Controlled Trial

BACKGROUND

There are few level 1 or 2 evidence studies that examine rehabilitation after rotator cuff repair. Pulleys have been used in postoperative shoulder rehabilitation with the intention of improving range of motion and developing strength. There is a concern that the use of pulleys in rehabilitation of rotator cuff repairs may contribute to excessive scapular motion (scapular substitution) and potentially inferior outcomes.

HYPOTHESIS

Rotator cuff repair patients treated with pulley exercises would have increased scapular substitution and inferior patient-determined outcome scores, range of motion, and strength compared with patients treated with an alternative rehabilitation program without pulleys.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 27 patients who underwent rotator cuff repair were randomized to a rehabilitation group that used pulleys initiated 6 weeks postoperatively, and 26 patients followed a rehabilitation protocol without pulleys. Inclusion criteria were patients undergoing arthroscopic rotator cuff repair. Exclusion criteria were large to massive rotator cuff tears, revision rotator cuff repair, glenohumeral osteoarthritis, adhesive capsulitis, and a symptomatic contralateral shoulder. Outcomes of intervention were patient-determined outcome scores (Western Ontario Rotator Cuff Index [WORC], American Shoulder and Elbow Surgeons [ASES] Shoulder Score, Single Assessment Numeric Evaluation [SANE], Shoulder Activity Level, and Simple Shoulder Test [SST]), range of motion, scapular substitution, and strength. Outcomes were determined at 6, 12, 18, 26, and 52 weeks. A power analysis determined that 22 patients were needed per group to have a power of 0.80, α = 0.05, and effect size of f = 0.5.

RESULTS

Both groups had statistically significant improvements in WORC, ASES Shoulder Score, SST, and SANE scores over time after rotator cuff repair (P < .0001). There were no differences between the interventions for WORC (P = .18), ASES Shoulder Score (P = .73), SANE (P = .5), Shoulder Activity Level (P = .39), or SST (P = .36). Both interventions demonstrated improvements in shoulder flexion (P = .002), abduction (P = .0001), external rotation (P = .02), strength (P ≤ .0002), and scapular substitution (P ≤ .07) over time after rotator cuff repair. However, there was no difference in range of motion (P ≥ .26), strength (P ≥ .20), or scapular substitution (P ≥ .17) between interventions.

CONCLUSION

A rotator cuff repair rehabilitation program that uses pulleys does not result in inferior outcomes, as determined by patient-determined outcome scores, measurements of scapular substitution, range of motion, and scaption strength.

REGISTRATION

ClinicalTrials.gov NCT01819909.

Shoulder Electromyography Measurements During Activities of Daily Living and Routine Rehabilitation Exercises

Study Design Controlled laboratory study. Background The activity of the rotator cuff muscles has not previously been measured with indwelling electromyography (EMG) comparing ambulation and other movements. Knowledge of the relative contribution of these muscles during various tasks may help to guide rehabilitation progression. Objective To measure activity of the rotator cuff muscles and other shoulder muscles during normal ambulation, shirt and sling donning and doffing, and rehabilitation tasks commonly performed after rotator cuff surgery. Methods In 28 volunteers (15 men, 13 women; mean age, 32.2 years), indwelling EMG activity was measured in the supraspinatus, infraspinatus, teres minor, and subscapularis muscles during various tasks; and surface EMG activity was measured in the middle deltoid, biceps, and upper trapezius muscles. Results Using median EMG activity, in general, donning and doffing a shirt or sling recruited the rotator cuff muscles more than the other 7 tasks tested. Self-ranging motion using pulleys, especially in the scapular plane, was also consistently associated with greater recruitment of the shoulder muscles. Pendulum exercises, passive range of motion by a physical therapist, and self-ranging motion with a dowel recruited the shoulder muscles to a lesser extent. Conclusion Our results demonstrate that rehabilitation tasks such as pendulum exercises, passive range of motion by a physical therapist, and self-ranging motion with a dowel show low EMG activity, whereas pulleys in the sagittal plane and scapular plane show greater activity. Scapular plane activity was consistently higher than sagittal plane activity. Of all the tasks assessed, ambulation without a sling and donning and doffing a sling and a shirt consistently showed the highest activity. J Orthop Sports Phys Ther 2016;46(5):375-383. Epub 6 Apr 2016. doi:10.2519/jospt.2016.6090.

Double-Row Repair Lowers the Retear Risk After Accelerated Rehabilitation

BACKGROUND

Recently, an accelerated rehabilitation protocol after rotator cuff (RC) repair has been proposed for patients at risk of postoperative stiffness.

PURPOSE

To investigate, in patients undergoing early accelerated mobilization, whether double-row (DR) repair provides better clinical outcomes and a lower retear rate compared with single-row (SR) configurations.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 58 patients were randomized to undergo either SR or DR repair. After 2 years of follow-up, 12 men and 13 women (mean age, 61.8 years; range, 52-67 years) in the SR group and 15 men and 10 women (mean age, 58.9 years; range, 51-69 years) in the DR group were evaluated. To assess the retear rate, magnetic resonance imaging of the shoulder was performed at 2-year follow-up. The clinical evaluation was based on the modified University of California, Los Angeles (UCLA) shoulder score and range of motion (ROM) measurements.

RESULTS

Magnetic resonance arthrography showed a significantly lower full-thickness retear rate for the DR group than for the SR group (8% vs 24%, respectively; P < .05). Conversely, at both 6-month and 2-year follow-up, there was no statistically significant difference in terms of the rate of stiffness in the SR and DR groups (8% vs 12% and 0% vs 0%, respectively; P > .05). No clinical differences were recorded regarding the UCLA score (SR group: mean, 32.6 [range, 30-35]; DR group: mean, 33.3 [range, 29-35]; P = .61) and ROM.

CONCLUSION

In selected patients at a high risk of shoulder stiffness and therefore necessitating accelerated postoperative rehabilitation, DR repair of the RC could lower retear rates.

I.S.Mu.L.T - Rotator Cuff Tears Guidelines

Despite the high level achieved in the field of shoulder surgery, a global consensus on rotator cuff tears management is lacking. This work is divided into two main sessions: in the first, we set questions about hot topics involved in the rotator cuff tears, from the etiopathogenesis to the surgical treatment. In the second, we answered these questions by mentioning Evidence Based Medicine. The aim of the present work is to provide easily accessible guidelines: they could be considered as recommendations for a good clinical practice developed through a process of systematic review of the literature and expert opinion, in order to improve the quality of care and rationalize the use of resources.

Knowing the speed limit: weighing the benefits and risks of rehabilitation progression after arthroscopic rotator cuff repair

Rotator cuff repairs have increased. Although clinical trials have examined the effect of immobilization and timing of passive range of motion (ROM) on patient outcomes and structural integrity, there is controversy as to the timing and progression for therapy. Primary goals are restoring function while maintaining the structural integrity of the repair. We advocate for a protocol of 4 to 6 weeks of immobilization, followed by protected passive ROM, which is followed by a gradual progression to active ROM and then appropriate resistance exercise program for most all rotator cuff repairs. The rate of progression should be adjusted individually.

Rehabilitation following surgical repair of the rotator cuff: a systematic review

BACKGROUND

Surgery to repair rotator cuff (RC) tears is a commonly performed orthopaedic procedure with the aim of reducing pain and improving function. Surgery is followed by rehabilitation and recommendations for postoperative rehabilitation include; exercise therapy, continuous passive motion machines and aquatic therapy. Currently, there is uncertainty in the literature as to what constitutes best postsurgical rehabilitation.

OBJECTIVE

To systematically review postsurgical research investigations to provide clinical guidance regarding postsurgical management.

DATA SOURCES

A keyword search of Medline, Cinahl, Amed, Embase and Cochrane databases from September 1993 to September 2013.

STUDY SELECTION

Reviewer assessment using inclusion and exclusion criteria of randomised controlled trials.

DATA EXTRACTION

Data pertaining to research design, intervention and subjects was extracted from included papers by one author. The data was grouped by reference to the objectives of the study and collated in themes.

DATA SYNTHESIS

Narrative synthesis of the data was used to describe the effects of the intervention. The methodological quality and risk of bias of the included studies was assessed using the standardised Physiotherapy Evidence Database scale. Eleven studies met the inclusion criteria. All the studies were of fair to good methodological quality. No one rehabilitation protocol was found to be superior to another. The findings of this review suggested that following RC repair, patients should expect improvement in pain, ROM and function.

CONCLUSION

This review concludes that no single rehabilitation protocol is superior to another following RC repair. Studies with larger study populations and longer term follow up are required to investigate this further.

Early Versus Delayed Passive Range of Motion After Rotator Cuff Repair: A Systematic Review and Meta-analysis

BACKGROUND

Postoperative rehabilitation has been shown to affect healing of the rotator cuff after surgical repair. However, it is unknown whether an early or delayed rehabilitation protocol is most beneficial for healing.

PURPOSE

To determine whether early versus delayed passive range of motion (PROM) affects rotator cuff (RC) retear rates after surgery.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

A systematic review of the literature published between January 2003 and February 2014 was conducted. Retear rates were compared for early (within 1 week after surgery) versus delayed (3-6 weeks after surgery) PROM using χ(2) or Fisher exact tests as well as relative risks (RR) and 95% CIs. In the first analysis, data from evidence level 1 studies that directly compared early versus delayed PROM were pooled; and in the second analysis, data from level 1 to 4 studies that did not directly compare early versus delayed PROM were pooled. The second analysis was stratified by tear size and repair method.

RESULTS

Twenty-eight studies (1729 repairs) were included. The first analysis of level 1 studies did not reveal a significant difference in retear rates for early (13.7%) versus delayed (10.5%) PROM (P = .36; RR = 1.30 [95% CI, 0.74-2.30]). The second analysis revealed that for ≤3 cm tears, the risk of retear was lower for early versus delayed PROM for transosseous (TO) plus single-row anchor (SA) repairs (18.7% vs 28.2%, P = .02; RR = 0.66 [95% CI, 0.47-0.95]). For >5 cm tears, the risk of retear was greater for early versus delayed PROM for double-row anchor (DA) repairs (56.4% vs 20%, P = .002; RR = 2.82 [95% CI, 1.31-6.07]) and for all repair methods combined (52.2% vs 22.6%, P = .01; RR = 2.31 [95% CI, 1.16-4.61]). There were no statistically significant associations for tears measuring <1 cm, 1 to 3 cm, 3 to 5 cm, and >3 cm.

CONCLUSION

Evidence is lacking with regard to the optimal timing of PROM after RC repair; however, this study suggests that tear size may be influential.

Rehabilitation following rotator cuff repair: a systematic review

BACKGROUND

The aim of this systematic review was to evaluate the effectiveness of rehabilitation programmes following surgical repair of the rotator cuff with emphasis upon length of immobilisation and timing of introduction of load.

METHODS

An electronic search of CENTRAL, MEDLINE and PEDro was undertaken to August 2014 and supplemented by hand searching. Randomised controlled trials were included, quality appraised using the PEDro scale and synthesised via meta-analysis or narrative synthesis, based upon levels of evidence, where appropriate.

RESULTS

Twelve studies were included. There is strong evidence that early initiation of rehabilitation does not adversely affect clinical outcome but there is a marginally higher, statistically non-significant, incidence of tendon re-tear (OR 1.3; 95% CI 0.72 to 2.2). There is strong evidence that initiation of functional loading early in the rehabilitation programme does not adversely affect clinical outcome.

DISCUSSION

Concern about early initiation of rehabilitation and introduction of gradual functional load does not appear warranted but this should be considered in a context of potential for Type II error. There is further need to evaluate approaches that foster early initiation of rehabilitation and gradual introduction of functional load as well as considering key outcomes such as return to work.

Effect of Postoperative Passive Motion on Rotator Cuff Reconstruction With Acellular Dermal Matrix Grafts in a Rat Model

BACKGROUND

Although postoperative rehabilitation is critical for rotator cuff tendon-to-bone healing and shoulder function recovery, no standardized protocol has been established.

HYPOTHESIS

Postoperative immediate passive motion is detrimental to tendon-to-bone remodeling and tendon maturation after rotator cuff acellular dermal matrix (ADM) grafting, although postoperative delayed passive motion does no harm.

STUDY DESIGN

Controlled laboratory study.

METHODS

Male Sprague-Dawley rats underwent rotator cuff reconstruction with ADM grafts. Their shoulders were immobilized for 2 weeks thereafter. The rats were assigned to 3 different rehabilitation protocols: (1) immobilization without passive motion (nonpassive motion [N-PM], controls), (2) immobilization with immediate passive motion (I-PM), and (3) immobilization with delayed passive motion (D-PM). Specimens obtained 2, 6, and 12 weeks postoperatively were analyzed histologically, and semiquantitative histomorphological measurements of collagen organization, vascularity, and cellularity were obtained; the area of interest was divided into 2 zones, the midsubstance of the graft and the graft-bone interface. Another set of samples taken at 12 weeks was subjected to biomechanical analysis.

RESULTS

At 2 weeks, there was no significant difference among the groups in terms of semiquantitative histomorphological measurements of collagen organization, vascularity, and cellularity. At 6 weeks, collagen organization at the insertion site was significantly poorer in I-PM than in N-PM and D-PM rats (P = .0095). At 12 weeks, collagen organization at the insertion site and midsubstance of ADM grafts was also significantly poorer in I-PM rats (P = .0125 and P = .0018, respectively), and ultimate load-to-failure was lower in this group (P = .0043).

CONCLUSION

While postoperative immediate passive motion was detrimental to remodeled tendon-to-bone healing and to the tendon maturation of ADM grafts placed in the rotator cuff tendon defects, delayed passive motion did no harm.

CLINICAL RELEVANCE

For patients with 6-week immobilization after rotator cuff reconstruction, we recommend that early passive motion be started no sooner than 3 weeks after surgery. Immediate early passive motion should be avoided.

Electromyographic analysis of the rotator cuff in postoperative shoulder patients during passive rehabilitation exercises

BACKGROUND

Numerous rehabilitation protocols exist for postoperative rotator cuff repairs. Because the goal of early rehabilitation is to prevent postoperative adhesions while protecting the repaired tendons, it would be advantageous to know which range-of-motion exercises allow the rotator cuff to remain the most passive in a painful, guarded, postsurgical shoulder.

METHODS

Twenty-six subjects who had undergone subacromial decompression, distal clavicle resection, or a combination of both procedures volunteered to participate within the first 4 days after surgery. Fine-wire electrodes were inserted into the subject's supraspinatus (SS) and infraspinatus (IS). Muscle activity was recorded at resting baseline (BL) and during 14 exercises that have been found in the passive phase of rotator cuff protocols and tested in healthy subjects. Each exercise was compared with BL activity as well as with other exercises in the same movement group.

RESULTS

The SS remained as passive as BL during therapist- and self-assisted external rotation, therapist-assisted elevation, pendulums, and isometric internal rotation and adduction. The IS was activated greater than BL for all 14 exercises studied.

CONCLUSION

Of the 14 exercises studied, 6 allowed the SS and 0 allowed the IS to remain as passive as quiet-stance BL in postsurgical subacromial decompression/distal clavicle resection patients.

Prospective randomized study of arthroscopic rotator cuff repair using an early versus delayed postoperative physical therapy protocol

BACKGROUND

This study evaluated patient outcomes and rotator cuff healing after arthroscopic rotator cuff repair using a postoperative physical therapy protocol with early passive motion compared with a delayed protocol that limited early passive motion.

MATERIALS AND METHODS

The study enrolled 68 patients (average age, 63.2 years) who met inclusion criteria. All patients had a full-thickness crescent-shaped tear of the supraspinatus that was repaired using a transosseous equivalent suture-bridge technique along with subacromial decompression. In the early group, 33 patients were randomized to passive elevation and rotation that began at postoperative day 2. In the delayed group, 35 patients began the same protocol at 6 weeks. Patients were monitored clinically for a minimum of 12 months, and rotator cuff healing was assessed using ultrasound imaging.

RESULTS

Both groups had similar improvements in preoperative to postoperative American Shoulder and Elbow Surgeons scores (early group: 43.9 to 91.9, P < .0001; delayed group: 41.0 to 92.8, P < .0001) and Simple Shoulder Test scores (early group: 5.5 to 11.1, P < .0001; delayed group: 5.1 to 11.1, P < .0001). There were no significant differences in patient satisfaction, rotator cuff healing, or range of motion between the early and delayed groups.

CONCLUSIONS

Patients in the early group and delayed group both demonstrated very similar outcomes and range of motion at 1 year. There was a slightly higher rotator cuff healing rate in the delayed passive range of motion group compared with the early passive range of motion group (91% vs 85%).

Factors that impact rehabilitation strategies after rotator cuff repair

Multiple factors influence rehabilitation strategies after rotator cuff repair. These variables may also impact the overall success of the surgical intervention. Physicians and rehabilitation specialists should be aware of prognostic indicators that can provide therapeutic guidance and offer insights into eventual clinical outcomes. The success of surgical and rehabilitative interventions is often evaluated in terms of patient-reported outcome measures, return to activity, and pain. Although these factors are somewhat interdependent, each of them independently influences the final result. This article presents a comprehensive overview of the recent literature in this area to provide insight as to the short- and long-term outcomes that patients should expect based on their unique presentations. This article examines both intrinsic and extrinsic patient factors to help therapists develop customized rehabilitation programs that optimize surgical outcomes.

Immediate passive motion versus immobilization after endoscopic supraspinatus tendon repair: a prospective randomized study

INTRODUCTION

Rehabilitation programs after rotator cuff repair should allow recovery of shoulder function without preventing tendon healing. The aim of this randomized prospective study was to compare the clinical results after two types of postoperative management: immediate passive motion versus immobilization.

PATIENTS AND METHODS

We followed 100 patients, mean age 55 years old, who underwent arthroscopic repair of a non-retracted supraspinatus tear. Patients were randomized to receive postoperative management of immediate passive motion or strict immobilization for 6 weeks. A clinical evaluation was performed in 92 patients, and CT arthrography in 82. Mean follow-up was 15 months.

RESULTS

The mean preoperative Constant score improved significantly from 46.1 points to 73.9 at the final follow-up. The rate of intact cuffs was 58.5%. Functional results were statistically better after immediate passive motion with a mean passive external rotation of 58.7° at the final follow-up versus 49.1° after immobilization (P=0.011), a passive anterior elevation of 172.4° versus 163.3° (P=0.094) respectively, a Constant score of 77.6 points versus 69.7 (P=0.045) respectively, and a lower rate of adhesive capsulitis and complex regional pain syndrome. Results for healing seemed to be slightly better with immobilization, but this was not statistically significant: the cuff had a normal appearance in 35.9% of cases after immobilization compared to 25.6% after passive motion, an image of intratendinous addition was found in 25.6% versus 30.2%, punctiform leaks in 23.1% versus 20.9%, and recurrent tears in 15.4% versus 23.3% respectively.

DISCUSSION

The rehabilitation program that results in better tendon healing by preventing postoperative stiffness has not yet been identified. Our results suggest that early passive motion should be authorized: the functional results were better with no significant difference in healing.

Rotator Cuff Repair Rehabilitation: A Level I and II Systematic Review

Background

There is no consensus for the optimal postoperative rehabilitation protocol after rotator cuff repairs.

Objective

To determine if there is sufficient level I or II evidence available in the literature for establishment of a uniform, optimal rotator cuff rehabilitation protocol.

Data Sources

A systematic review of level I and II English-language, prospective, randomized controlled trials published between 1966 and 2008 was performed. MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, and secondary references were appraised for studies that met the inclusion criteria. Search terms included rotator cuff, supraspinatus, infraspinatus, subscapularis, teres minor, rehab, rehabilitation, physical therapy, and physiotherapy.

Study Selection

Inclusion criteria were English-language level I or level II studies, including randomized clinical trials involving the rehabilitation of rotator cuff repairs. Exclusion criteria were non-English language, level IV or V studies, or studies involving shoulder rehabilitation of diagnoses other than rotator cuff repairs. Three independent reviewers arrived at a consensus for including 4 studies in this review out of 12 studies identified by the literature search.

Data Extraction

Included studies underwent worksheet quality appraisal independently by each of the 3 authors identifying strengths, weaknesses, and biases. The quality appraisal was then discussed among the authors and consensus reached regarding the strengths, weaknesses, and value of the included studies.

Results

Two studies examined the use of continuous passive motion for rotator cuff rehabilitation, and 2 studies compared an unsupervised, standardized rehabilitation program to a supervised, individualized rehabilitation program. These studies did not support the use of continuous passive motion in rotator cuff rehabilitation, and no advantage was shown with a supervised, individualized rehabilitation protocol compared to an unsupervised, standardized home program. Each investigation had weaknesses in study design that decreased the validity of its findings.

Conclusion

There is not enough high-level evidence to develop an evidence-based medicine approach to rotator cuff rehabilitation. There is a need for well-designed level I and level II trials to elucidate the optimal rotator cuff repair rehabilitation protocol.

RETRACTED ARTICLE: Clinical effectiveness of continuous passive motion (CPM) following femoroacetabular impingement surgery in adolescents

PURPOSE

This study hypothesizes that the use of continuous passive motion (CPM) following open femoroacetabular impingement (FAI) surgery in the adolescent population improves clinical outcomes in terms of the modified Harris hip score (mHHS).

METHODS

Twenty-nine symptomatic adolescent FAI patients were postoperatively divided into one of three groups; no CPM, two days of inpatient CPM, and two weeks of CPM. mHHS was used preoperatively and postoperatively at six weeks, three months, six months, and nine months in all cases. Kruskal-Wallis (KW) analysis was performed to determine statistical differences in mHHS. mHHS was then re-evaluated using the Mann-Whitney test.

RESULTS

There were no statistically significant differences in hip scores between the three groups preoperatively (p = 0.158). There were statistically significant differences (p < 0.001) in mHHS between the three groups at all postoperative time periods. The group that received two weeks of CPM had the best outcome scores.

CONCLUSION

The results of this study suggest that postoperative CPM use following open hip preservation surgery for symptomatic FAI in adolescents improves clinical outcomes. These benefits seem to be related to the duration of CPM.

LEVEL OF EVIDENCE

Retrospective comparative study, Level III. Patients treated one way compared with patients treated another way at the same institution.

Is early passive motion exercise necessary after arthroscopic rotator cuff repair?

BACKGROUND

Early passive motion exercise has been the standard rehabilitation protocol after rotator cuff repair for preventing postoperative stiffness. However, recent approaches show that longer immobilization may enhance tendon healing and quality.

PURPOSE

To elucidate whether early passive motion exercise affects functional outcome and tendon healing after arthroscopic rotator cuff repair.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

One hundred five consecutive patients who underwent arthroscopic repair for small to medium-sized full-thickness rotator cuff tears were included. Patients with large to massive tears and concomitant stiffness or labral lesions were excluded. Patients were instructed to wear an abduction brace for 4 to 5 weeks after surgery and to start active-assisted shoulder exercise after brace weaning. Fifty-six patients were randomly allocated into group 1: early passive motion exercises were conducted 3 to 4 times per day during the abduction brace-wearing period. Forty-nine patients were allocated into group 2: no passive motion was allowed during the same period. Range of motion (ROM) and visual analog scale (VAS) for pain were measured preoperatively and 3, 6, and 12 months postoperatively. Functional evaluations, including Constant score, Simple Shoulder Test (SST), and American Shoulder and Elbow Surgeons (ASES) score, were also evaluated at 6 and 12 months postoperatively. Ultrasonography, magnetic resonance imaging, or computed tomography arthrography was utilized to evaluate postoperative cuff healing.

RESULTS

There were no statistical differences between the 2 groups in ROM or VAS for pain at each time point. Functional evaluations were not statistically different between the 2 groups either. The final functional scores assessed at 12 months for groups 1 and 2 were as follows: Constant score, 69.81 ± 3.43 versus 69.83 ± 6.24 (P = .854); SST, 9.00 ± 2.12 versus 9.00 ± 2.59 (P = .631); and ASES score, 73.29 ± 18.48 versus 82.90 ± 12.35 (P = .216). Detachment of the repaired cuff was identified in 12% of group 1 and 18% of group 2 (P = .429).

CONCLUSION

Early passive motion exercise after arthroscopic cuff repair did not guarantee early gain of ROM or pain relief but also did not negatively affect cuff healing. We suggest that early passive motion exercise is not mandatory after arthroscopic repair of small to medium-sized full-thickness rotator cuff tears, and postoperative rehabilitation can be modified to ensure patient compliance.

Mobilizing the stiff hand: combining theory and evidence to improve clinical outcomes

The purpose of this narrative review is to provide a clinically reasonable guide to intervention choices, by combining a sound understanding of theory with available research evidence. The pathology of contracture formation is presented within the context of tissue repair. The soft tissue response to stress is explained and the optimal "dose" of treatment is discussed. The evidence behind the use of exercise, joint mobilization, continuous passive motion, casting motion to mobilize stiffness, and mobilizing splinting is examined. Recommendations regarding treatment implementation and future research needs are highlighted. The importance of mobilizing splinting and exercise as treatment modalities in the management of joint contracture is demonstrated.

LEVEL OF EVIDENCE

5.

The effectiveness of continuous passive motion on range of motion, pain and muscle strength following rotator cuff repair: a systematic review

Objective: To systematically review the evidence on the effect of continuous passive motion, combined with usual physiotherapy management, on increasing shoulder joint range of motion and muscle strength, and reducing shoulder pain in adults following rotator cuff repair, compared with standard physiotherapy.

Data sources: A comprehensive search in available bibliographic electronic databases was undertaken to locate eligible studies. Reference tracing was also used to locate studies.

Review methods: Randomized controlled trials reporting on the effect of continuous passive motion on increasing shoulder joint range of motion and muscle strength and reducing shoulder pain in adults following rotator cuff repair were included in the review. The PEDro scale was used to determine the methodological quality of the studies. Data were summarized in a narrative form because of their heterogeneity.

Results: Four randomized controlled trials were eligible for this review. One Japanese article was excluded as the text was unavailable in English. The methodological quality of the included studies averaged 7.67. Continuous passive motion was found to improve shoulder range of motion in two studies. One study found a decrease in pain in the intervention group and one study found that continuous passive motion improves muscle strength.

Conclusion: Continuous passive motion is safe to use with physiotherapy treatment following rotator cuff repair surgery. It may help to prevent secondary complications post operatively.

Does slower rehabilitation after arthroscopic rotator cuff repair lead to long-term stiffness?

HYPOTHESIS

Conservative rehabilitation after arthroscopic rotator cuff repair does not result in long-term stiffness and improves rates of tendon healing.

MATERIALS AND METHODS

We retrospectively evaluated 43 patients with full-thickness rotator cuff tears who underwent a standardized, conservative protocol of full-time sling immobilization without formal therapy for 6 weeks after arthroscopic repair. At 6 to 8 weeks of follow-up, we categorized patients as "stiff" if they demonstrated forward elevation of less than 100° and external rotation of less than 30° passively; all others were designated "nonstiff." Active range of motion in forward elevation, external rotation, and internal rotation was assessed at 3 months, 6 months, and 1 year. American Shoulder and Elbow Surgeons (ASES) and Constant-Murley scores were assessed at 1 year. Follow-up magnetic resonance imaging (MRI) was obtained in all patients to assess tendon healing.

RESULTS

Ten patients (23%) were considered stiff after rotator cuff surgery. At 1 year, there was no difference in mean forward elevation (166° vs 161°, P = .2), external rotation (62° vs. 58.4°, P = .5), or internal rotation (T7.4 vs T8.2, P = .07) between the stiff and nonstiff groups, respectively. There were no differences in final ASES (83 vs 79, P = .57) and Constant-Murley scores (77 vs. 74, P = .5). Repeat MRI suggested a trend toward a lower retear rate among the stiff patients (70% intact in stiff group vs 36% in nonstiff group, P = .079). Two clinically significant cuff retears occurred in the nonstiff cohort.

DISCUSSION

Concerns for recalcitrant stiffness have led some to favor early postoperative therapy. We found that early restriction of motion did not lead to long-term stiffness after arthroscopic rotator cuff repair, even in patients who were clinically stiff in the early postoperative period.

CONCLUSIONS

Sling immobilization for 6 weeks after arthroscopic rotator cuff repair does not result in increased long-term stiffness and may improve the rate of tendon healing.

Effects of one-month continuous passive motion after arthroscopic rotator cuff repair: results at 1-year follow-up of a prospective randomized study

The study included 100 patients who underwent an arthroscopic rotator cuff repair. All patients suffered about a rotator cuff tear that was repaired arthroscopically with a suture anchor technique. Immediately postoperatively, patients were randomly allocated to one of two different postoperative physiotherapy regimens: passive self-assisted range of motion exercise (controls: 46 patients) versus passive self-assisted range of motion exercise associated with use of continuous passive motion (CPM) for a total of 2 h per day (experimental group: 54 patients), for 4 weeks. After this time, all the patients of both groups underwent the same physical therapy protocol. An independent examiner assessed the patients at 2.5, 6 and 12 months particularly about pain with the VAS scale (0-10) and the range of motion (ROM). Our findings show that postoperative treatment of an arthroscopic rotator cuff repair with passive self-assisted exercises associated with 2-h CPM a day provides a significant advantage in terms of ROM improvement and pain relief when compared to passive self-assisted exercise alone, at the short-term follow-up. No significant differences between the two groups were observed at 1 year postoperatively.

The effect of postoperative passive motion on rotator cuff healing in a rat model

BACKGROUND

Surgical repairs of torn rotator cuff tendons frequently fail. Immobilization has been shown to improve tissue mechanical properties in an animal model of rotator cuff repair, and passive motion has been shown to improve joint mechanics in animal models of flexor tendon repair. Our objective was to determine if daily passive motion would improve joint mechanics in comparison with continuous immobilization in a rat rotator cuff repair model. We hypothesized that daily passive motion would result in improved passive shoulder joint mechanics in comparison with continuous immobilization initially and that there would be no differences in passive joint mechanics or insertion site mechanical properties after four weeks of remobilization.

METHODS

A supraspinatus injury was created and was surgically repaired in sixty-five Sprague-Dawley rats. Rats were separated into three postoperative groups (continuous immobilization, passive motion protocol 1, and passive motion protocol 2) for two weeks before all underwent a remobilization protocol for four weeks. Serial measurements of passive shoulder mechanics (internal and external range of motion and joint stiffness) were made before surgery and at two and six weeks after surgery. After the animals were killed, collagen organization and mechanical properties of the tendon-to-bone insertion site were determined.

RESULTS

Total range of motion for both passive motion groups (49% and 45% of the pre-injury values) was less than that for the continuous immobilization group (59% of the pre-injury value) at two weeks and remained significantly less following four weeks of remobilization exercise. Joint stiffness at two weeks was increased for both passive motion groups in comparison with the continuous immobilization group. At both two and six weeks after repair, internal range of motion was significantly decreased whereas external range of motion was not. There were no differences between the groups in terms of collagen organization or mechanical properties.

CONCLUSIONS

In this model, immediate postoperative passive motion was found to be detrimental to passive shoulder mechanics. We speculate that passive motion results in increased scar formation in the subacromial space, thereby resulting in decreased range of motion and increased joint stiffness. Passive motion had no effect on collagen organization or tendon mechanical properties measured six weeks after surgery.

Early loading in physiotherapy treatment after full-thickness rotator cuff repair: a prospective randomized pilot-study with a two-year follow-up

Objective: To describe the clinical changes following two different physiotherapy treatment protocols after rotator cuff repair.

Design: A prospective, randomized pilot study with a two-year follow-up.

Subjects: Five women and nine men, 55 (40—64) years old, were included.

Intervention: The progressive group (n = 7) started with dynamic, specific muscle activation of the rotator cuff the day after surgery as well as passive range of motion. After four weeks of immobilization the loading to the rotator cuff increased and in a progressive manner throughout the rehabilitation. In the traditional group (n = 7) the rotator cuff was protected from loading. Patients were immobilized for six weeks and started with passive range of motion the day after surgery. No specific exercises to the rotator cuff were introduced during this period.

Main measures: A clinical evaluation was made preoperatively, 3, 6, 12 and 24 months after surgery. Pain rating during activity and at rest, patient satisfaction, active range of motion and muscle strength, Constant score, hand in neck, hand in back and pour out of a pot, as well as Functional Index of the Shoulder were used.

Results: At two years follow-up, the progressive group and traditional group scored pain during activity visual analogue scale (VAS) 2/0 mm and pain at rest 0/0 mm, respectively. The groups attained 170/175° in active abduction in standing and 70/90° in passive external rotation while lying in supine. Using Constant score, the groups attained 82/77 points respectively.

Conclusion: The present study showed that the progressive protocol produced no adverse effects compared with the traditional protocol.

Post-operative rehabilitation after surgical repair of the rotator cuff

Today advances in techniques and materials for rotator cuff surgery allow the repair of a large variety of types or extensions of cuff lesions in patients from a wide range of age groups who have different kinds of jobs and participate in different kinds of sports, and who have widely different expectations in terms of recovery of functions and pain relief. A large number of factors must be taken into account before implementing a rehabilitation protocol after rotator cuff surgery. These mainly include the technique (materials and procedure) used by the surgeon. Moreover, tissue quality, retraction, fatty infiltration and time from rupture are important biological factors while the patient's work or sport or daily activities after surgery and expectations of recovery must also be assessed. A rehabilitation protocol should also take into account the timing of biological healing of bone to tendon or tendon to tendon interface, depending on the type of rupture and repair. This timing should direct the therapist's choice of correct passive or assisted exercise and mobilisation manoeuvres and the teaching of correct active mobilisation movements the patient has to do. Following accepted knowledge about the time of biological tissue healing, surgical technique and focused rehabilitation exercise, a conceptual protocol in four phases could be applied, tailoring the protocol for each patient. It starts with sling rest with passive small self-assisted arm motion in phase one, to prevent post-op stiffness. In phase two passive mobilisation by the patient dry or in water, integrated with scapular mobilisation and stabiliser reinforcement, are done. Phase three consists of progressive active arm mobilisation dry or in water integrated with proprioceptive exercise and "core" stabilisation. In phase four full strength recovery integrated with the recovery of work or sports movements will complete the protocol. Because of the multi-factorial aspects of the problem, the best results can be obtained through a full transfer of information from the surgeon to the therapist to optimise timing and sizing of the individual rehabilitation protocol for each patient.

Indications for surgery in clinical outcome studies of rotator cuff repair

Full-thickness tears of the rotator cuff are common, but there is no clear consensus regarding indications for rotator cuff surgery. Because some patients with full-thickness rotator cuff tears who are asymptomatic or symptomatic can be successfully treated nonoperatively, clinical outcome studies of rotator cuff repair should describe the subjects in detail to allow appropriate interpretation of the results. However, we hypothesized the indications for surgery are poorly described in outcome studies of rotator cuff surgery. We undertook a detailed literature review over 11 years of six major orthopaedic journals to assess whether the indications for surgery were described adequately in studies of rotator cuff repair. Eighty-six papers fit the criteria for the study and were reviewed. Limitations of activities of daily living (31%), failure of nonoperative treatment (52%), duration of nonoperative treatment (26%), and history of nocturnal pain (16%) were reported in a minority of papers overall. The patients' characteristics and indications for surgery were not described in a majority of clinical outcome studies of rotator cuff repair. It is important for these factors to be considered and reported because, without this information, the reasons for and results of rotator cuff repair are difficult to interpret.

LEVEL OF EVIDENCE

Level III, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.