Epidemiology (Simon Lambert, EUSSER conference London 2012)

Transcription

1 Rehabilitationof rotator cuff tears: A systematic review and evidence-based rehabilitation protocol Prof dr Ann Cools, PT, Ph Dept Rehab. Sciences & Physiotherapy A Ghent Cools RC tears University, 2014 Belgium Epidemiology (Simon Lambert, EUSSER conference London 2012) How activeare the elderly? Master Athletes= Active individuals aged 50yrs or older, who desire optimal levels of performance or wish toexerciseforgeneralhealth andhave high expectationsforsportsmedicinecare, including return to sport or activity after injury (Selected Issues for the Master Athlete and the Team A Cools Physician: RC tears 2014 A consensus statement. Med Sci Sports Exc 2010) 1

2 Exerciseas a treatment forrc full thickness ruptures (Ainsworth& Lewis, BJSM 2007) Systematic Review Exercise therapy, defined as strengthening and stretching, whenincludedas a part of a treatment program, has a beneficialeffect forpatientswhohave symptomatic shoulders and radiological or arthroscopic evidence of full thickness RC tears Effect should only be considered as modest. Not possible to determine if exercise alone or combined with other interventions offer the greatest benefit Time-recommendations: 3-18 months Exercise as a treatment for RC full thickness ruptures (Ainsworth et al. BJSM 2007) Conclusion Notsufficienthigh-qualitystudies onthe outcomeof exercise therapy on RC tears Only full thickness tears were included Recent studies look promising Levy et al. JSES 2008: anterior deltoid training improves function in massive irreparable degenerative RC tears BaydarRheumInt 2009: satisfactoryresultsafter6 months regarding function, pain and strength Exercise as a treatment for RC full thickness ruptures (Ainsworth et al. BJSM 2007) Kuhn et al. JSES 2013: MOON shoulder group Large multi-centercase Series study(n=452) Conservative treatment following specific protocol Follow-up 6-12 weeks with3 options: (1) cured, (2) better, continue program, and(3) no better, offered surgery Finalfollow up 1-2 year Sign improvement of patient-reported outcomes <25% go tosurgery Cut off point forsuccess/failure +/-12 weeks 2

3 General Guidelines for rehabilitation Capsular mobilization to increase ROM Stretching after capsular mobilization Maximize RC strength Maximize scapularposition/motion as part of the scapulohumeral rhythm Change workouts: lighterweights, different positions. (Selected Issues for the Master Athlete and the Team Physician: A consensus statement. Med Sci Sports Exc 2010) Personal Experience Patientsoftenhave deficientrotator cuff: value of cuff training? Let s try to optimize function without focussingtoomuchon the structures Re-education of daily and athletic activities with the purpose to postpone the final match Conservative treatment RC tears (partial, irreparable) TREATMENT GOAL optimizefunction, in particular elevation above shoulder height, with limitedload on the RC 3

4 Scientific base for Treatment Strategy (Uhl et al. PM&R 2010) (Levy et al. JSES 2008) EMG in SS in +/-5% MVC Exercises with low RC load 4

5 Semi-closed chain exercises without/with resistance Progression to open chain 3 stages of exercises: 1. Passive 2. Active 3. With resistance and increase inclination 5

6 Exercises deltoid (Levy et al. JSES 2008) Exercises deltoid (Levy et al. JSES 2008) 6

7 Additional therapeutic interventions Taping to unload the deltoid-pain, based on Shoulder Symptom Modification Procedure (SSMP) (lewis BJSM 2008) POSTOPERATIVE TREATMENT after RC repair Factors affectingthe postoperativerotator cuff repair rehabilitation program: 1. Surgical approach 2. Sizeof the tear 3. Tissue quality 4. Fixation method 5. Locationof the tear (Ghodadra NS et al. Open, Mini-open and all-arthorscopic rotator cuff repair surgery: indications and implications for rehabilitation JOSPT 2009) 7

8 POSTOPERATIVE TREATMENT after RC repair Factors affectingthe postoperativerotator cuff repair rehabilitation program: 6. Type of tear 7. Mechanism of failure 8. Timing of surgery 9. RC tissue qualityantand post of tearsite (Ghodadra NS et al. Open, Mini-open and all-arthorscopic rotator cuff repair surgery: indications and implications for rehabilitation JOSPT 2009) POSTOPERATIVE TREATMENT after RC repair Factors affectingthe postoperativerotator cuff repair rehabilitation program: 10. Patient characteristics 11. Access to care 12. Physician philosophical approach (Ghodadra NS et al. Open, Mini-open and all-arthorscopic rotator cuff repair surgery: indications and implications for rehabilitation JOSPT 2009) GOALS of the rehabilitation Protect the repair Promote healing Gradually restore ROM Gradually restore muscle strength Gradually restore function 8

9 Protect the repair Soft tissue-to-bonehealingis slow: starts with formation of fibrovascular tissue interface betweentendon& bone (Rodeo JBJS 1993) At least12 weeks of healingis necessaryallowingpull-outstrengthof the repair (Sonnabend JBJS 2010) Factors that improve tendon-to-bone healing: Pressure (Weiler Arthr 2002) Tendon immobilisation (Ghodadra JOSPT 2009) Positioning(abduction/ scapular plane) (Hatakeyama AJSM 2001) (Ghodadra NS et al. Open, Mini-open and all-arthorscopic rotator cuff repair surgery: indications and implications for rehabilitation JOSPT 2009) Risk for frozen shoulder incidenceof 4.9% stiff shoulder after RC repair, with risk factors: <50y, workers compensation insurance (HubertyArthr2009) + important risk factor is pre-operative stiffness (SECEC-EUSSER meeting Lyon 2011) Lyon 2011: a stiff shoulder is a complication, not a failure of surgery Sling immobilization for 6 weeks after arthroscopic rotator cuff repair does notresult in increased long-term stiffness and may improve the rate of tendon healing. (Parsons JSES 2010) 9

10 Risk for frozen shoulder No differences regarding pain at rest, but better results regarding pain during activity and functional outcome after accelerated rehab protocol (Düzgün Acta Orthop Trauma Turc 2010) In at-risk patients (with calcifictendonitis, adhesive capsulitis, labralrepair), a postoperative rehabilitation regimen that incorporates early closed-chain passive overhead motion can reduce the incidence of postoperative stiffness after arthroscopic rotator cuff repair. (Koo Arth 2011) ClinicalTakeHome Message POSTOPERATIVE TREATMENT: Let the tissue heal! Closedchainlow loadexercisesto improve ROM with mimimal load on the RC Progressive Functional training after 6-12 weeks What after surgery?(schumann et al. AJSM 2010) 10

11 What after surgery?(schumann et al. AJSM 2010) 11

12 Take home message Take care of the degenerative changes in the shoulder, but Remindyouoftenhave todeal with an active elderly patient Thereis still hope aftershoulder arthroplasty! (Gent, Belgium) 12