2/11/2017. Post-Operative Rehabilitation of. Repairs. KEW vs GJD

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1 Thank You Thanks to APTA-SPTS and SPTS Shoulder-SIG SIG for the kind invitation to present and share this information It is indeed an honor and privilege to be invited to participate and share information. Rehabilitation Following Rotator Cuff Repair: Early vs Delayed Rehabilitation Protocols (Accelerated vs Decelerated Rehab Programs: What is best and for Whom?) APTA-CSM San Antonio, TX. February, 2017 Course Learning Objectives: Upon completion of this educational session, learners should be able to: 1. Understand the importance of the surgical procedure, and the individual characteristics of the patient to customize the rehabilitation program to the patient 2. Synthesize the evidence supporting either the early (Accelerated) vs delayed (Decelerated) Programs 3. Apply the information to individual cases in their patient loads as to whether they should use the early (Accelerated) vs delayed (Decelerated) Programs 4. Analyze the success of their outcomes by synthesizing the information in this educational session into one s own clinical practice Socratic Debate: Post-Operative Rehabilitation of Rotator Cuff Repairs KEW vs GJD George J. Davies, DPT,ATC,CSCS Professor-Georgia Southern University-Armstrong Campus Sports Physical Therapist: Coastal Therapy, Savannah, GA., Gundersen Health System, LaCrosse, WI. Disclosures: Associate Editor, Sports Health Medline/ Elsevier-Book Royalties Index Medicus Human Kinetics-Book Royalties Williams & Wilkins-Book Royalties 2015 North American Seminars-DVD Royalties No Conflicts Disclosures: The following companies have provided research equipment support to Biodynamics & Human Performance Center-AASU: Arthrometrics, Atlanta, GA. Biodex, Shirley, N.Y. Boston Biomotion, N.Y. CDM Sport/Monitored Rehab Systems, Fort Worth, TX. DS2 Rehab Systems, Missouri City, TX. ERMI, Atlanta, GA. ExerTools, Petaluma, CA. Innovative Sports Inc, Chicago, IL. Performance Rehab Products, Kent, CT. Rehab Innovations, Inc., Omaha, NE. TheraBand, Hygenic Corporation, Akron, OH. No Conflicts 1

2 The Shoulder, 1934 E. A. Codman ASES-Rehabilitation Rehabilitation- tears affect ~ 30% of population > 60 yo tears affect ~ 60% of population > 80 yo ~450,000 operations per year Direct medical costs - $7 billion/year Arthroscopic R has increased 600% over past 10 years Arthroscopic repairs comprise greater than 95% of all R in USA Thigpen, CA, et.al. The American Society of Shoulder and Elbow Therapists consensus statement on rehabilitation following Arthroscopic rotator cuff repair. JSES. 25: , 535, 2016 We have all been Searching for the answers for a long time Rehabilitation Following Surgical Repairs Socratic Debate Accelerated Motion vs Delayed Motion: Effects on healing and failures Rehabilitation Following Surgical Repairs Socratic Debate-Speed of Rehab: Slowly: Medium: Fast: SOCRATIC DEBATE - If it is appropriate for the right patient. Whatever Kevin says I agree with him. If the patient meets the very precise criteria to begin an early motion rehabilitation program Epidemiological factors influencing surgery and rehab of repairs Several studies have noted that increasing age is a significant factor for diminished rotator cuff healing, Larger tears and fatty infiltration or atrophy also negatively affect rotator cuff healing. There is conflicting evidence to support postoperative rehabilitation protocols using early motion over immobilization following rotator cuff repair. Mall NA, et.al. Factors affecting rotator cuff healing. J Bone Joint Surg Am. 96(9):778-88, 2014 Rehabilitation-Trends 12 Factors associated with successful recovery following repair 4 categories: demographic, clinical, integrity, surgical procedure Demographic factors: age (older, less chance of tendon healing) <55 yo: 88-95% chance of tendon healing > 60 yo: 43-65% chance of tendon healing Implications: do not ignore S&S, because it will generally propagate 2

3 Rehabilitation-Trends 12 Factors associated with successful recovery following repair 4 categories: demographic, clinical, integrity, surgical procedure Clinical Factors: BMD, diabetes, obesity: outcomes Interesting factor: activity level prior to surgery More active: outcomes Best predictor of final strength was initial strength Pre-op stiffness: recovery time and RTA Importance of PRE-HABILITATION Rehabilitation-Trends 12 Factors associated with successful recovery following repair 4 categories: demographic, clinical, integrity, surgical procedure Integrity Factors: tear size, number of muscles involved, amount of tendon retraction, amount of fatty infiltration (tissue degeneration) More degenerated the tissue: outcomes Propagation injuries Implications: Early REHABILITATION Small tear repair: 97%; large tear: 59% Rehabilitation-Trends 12 Factors associated with successful recovery following repair 4 categories: demographic, clinical, integrity, surgical procedure Surgical procedure: Experienced high volume surgeon High volume hospital DR suture bridge repair Patient s tissue/bone/etc. -Repair Repair Rehabilitation Is immediate motion or delayed motion appropriate? It depends on multiple factors including: Patient characteristics, tear type, physician surgical techniques, rehab procedures In other words, the rehab program must consider all these variables, Therefore Rehab programs must be customized to the individual patient -Early Motion vs Delayed Motion We want to initiate PROM/AAROM/AROM/RROM early in the rehab program: To prevent stiffness Benefits articular cartilage To facilitate tissue alignment To increase morphological enhancement of the tissue healing response To active the surrounding muscles To prevent atrophy To prevent reflex dissociation To provide better outcomes BUT, DOES EARLY MOTION REALLY DO ALL THAT??? Applications Immediate motion is relatively indicated for selected patients: Younger patients Athletic patients Smaller/medium size tears Surgical technique & expertise Double row fixation Suture bridge/diamond Back techniques If you pick your patients wisely, you can always be successful!!! Applications Immediate motion is relatively contraindicated for selected patients: Older patients Inactive patients Large/massive size tears Poor quality tissue Surgical technique & expertise Single row fixation Surgical procedure 3

4 SOCRATIC DEBATE - Whatever Kevin says I agree with him. HOWEVER. It s more about what he does not say that is more important! Socratic Debate - It s not just about: The theoretical basis of the advantage of passive immediate motion is good for joints The theoretical basis of the advantage of soft tissue healing The theoretical advantages of stronger surgical procedures: double row, suture bridge, diamond back repairs based on biomechanical testing, fixation strength The theoretical basis of ideal rehab programs: PROM guidelines, what are safe exercises, etc. The theoretical basis of ideal rehab programs: based on cadaveric model research, EMG studies, selected rehabilitation studies with methodological flaws ETC. Socratic Debate - All these theoretical reasons sound great as to why we should do ACCELERATED REHABILITATION, But what does the research really say??? Socratic Debate - We all have a tendency to CHERRY-PICK the literature to support what we are presenting Sometimes we can learn more from the literature that does not support our philosophy or position we strongly BELIEVE IN, than just the literature that does theoretically support our position Rehab Post-operative rehab program is critical to the successful outcome following surgical repairs Every patient is different So we divide our patients Into various surgical Categories. Well... Duh The postoperative rehabilitation program is critical for the successful arthroscopic treatment of injury Koo, SS, et.al. Rehabilitation following arthroscopic rotator cuff repair. Clin Sports Med. 29: , 211, 2010 It is evident that a successful outcome after surgical repair is as much dependent on surgical technique as it is on rehabilitation Van der Meijden, OA, et.al. Rehabilitation after arthroscopic rotator cuff repair: current concepts review and evidence-based guidelines. Int J Sports Phys Ther. 7: , 2012 Rehab Post-operative rehab program is critical to the successful outcome following repairs of the surgical repair However, What does the research really say? 4

5 Bottom Line There is little evidence to support or refute the efficacy of common interventions for tears of the in adults. Ejnisman, B, et.al. Interventions for tears of the rotator cuff in adults. Cochrane Database Syst Rev *LEVEL OF EVIDENCE 1* 68 patients (avg age-63.2 years) Full-thickness crescent-shaped shaped tear of supraspinatus Repair-transosseous equivalent suture-bridge technique with SAD Rehab: Early PROM group-postop postop p PT day 2 Rehab: Delayed PROM group-postop postop PT 6 weeks Same rehab protocols healing-12 months US imaging Cuff, DJ, et.al. Prospective randomized study of Arthroscopic repair using an early vs delayed Postoperative PT protocol. JSES. 21: , 1455, 2012 *** *LEVEL OF EVIDENCE 1* ASES scores both improved, no SS differences SST-both improved, no SS differences Patient satisfaction - no SS differences ROM - no SS differences healing US at 12 months: Early PROM group 85% healing Delayed PROM group 91% healing Cuff, DJ, et.al. Prospective randomized study of Arthroscopic repair using an early vs delayed Postoperative PT protocol. JSES. 21: , 1455, 2012 Over a thirty-month period, 124 patients under the age of sixty-five years underwent arthroscopic repair of a fullthickness rotator cuff tear measuring <30 mm in width. Postoperatively, patients were randomized either to a traditional rehabilitation ti program with early range of motion or to an immobilization group with delayed range of motion for six weeks. Keener JD, et.al. Rehabilitation following arthroscopic rotator cuff repair: a prospective randomized trial of immobilization compared with early motion. J Bone Joint Surg Am. 96(1):11-9, 9, 2014*** Arthroscopic repair of small and medium fullthickness rotator cuff tears results in reliable improvements in clinical outcomes and a high rate of tendon integrity using a double-row repair technique in patients under the age of sixty-five years. There is no apparent advantage or disadvantage of early passive range of motion compared with immobilization with regard to healing or functional outcome. Keener JD, et.al. Rehabilitation following arthroscopic rotator cuff repair: a prospective randomized trial of immobilization compared with early motion. J Bone Joint Surg Am. Jan 1;96(1):11-9, 9, 2014 Systematic Review: 3 RCT s; 265 patients Primary outcome: tendon healing in the repaired cuff Results: Meta-analysis analysis revealed no significant difference in tendon healing in the repaired cuff between early motion and immobilization groups. No differences in secondary outcome measures at 1 year. Shen, C, et.al. Does immobilization after arthroscopic rotator cuff Repair increase tendon healing? A systematic review and meta-analysis? analysis? Arch Ortho Trauma Surg. 134(9): , 1285, 2014 Three level I and 1 level II randomized trials No statistically significant differences in ASES scores between delayed vs early motion rehabilitation (mean difference [MD], 1.4 The risk of re-tears after surgery did not differ statistically between treatment groups Chan K 1, et.al. Delayed versus early motion after arthroscopic rotator cuff repair: a meta-analysis. analysis. J Shoulder Elbow Surg. Nov;23(11):1631-9, 2014*** CONCLUSIONS: The current meta-analysis analysis did not identify any significant differences in functional outcomes and relative risks of recurrent tears between delayed and early motion in patients undergoing arthroscopic rotator cuff repairs. Chan K 1, et.al. Delayed versus early motion after arthroscopic rotator cuff repair: a meta-analysis. analysis. J Shoulder Elbow Surg. Nov;23(11):1631-9,

6 CONCLUSIONS: A statistically significant difference in forward elevation range of motion was identified; however, this difference is likely clinically unimportant (1 ) (7 -MCID with goniometry) Chan K 1, et.al. Delayed versus early motion after arthroscopic rotator cuff repair: a meta-analysis. analysis. J Shoulder Elbow Surg. Nov;23(11):1631-9, 2014 Conclusion: Repair failure rates do not significantly differ between patients randomized to early and delayed motion protocols following arthroscopic single tendon rotator cuff repair. Repair failure on MRI does not correlate with clinical outcome at 6 months or 1 year. However, better subjective outcome scores at 6 weeks are associated with higher rates of repair failure at 6 months. Williams, AA, et.al. Repair Integrity and Clinical Outcomes Following Arthroscopic -Repair: Repair: A Prospective, Randomized Trial of Early and Delayed Motion Protocols. OJSM, July, 2016 Rehabilitation 10 systematic reviews 11 RCTs Conflicting results and conclusions This updated review showed no differences for function, pain, ROM, or re-tears ratio between early and conservative rehabilitation Mazuquin, BE, et.al. Effectiveness of early compared with conservative Rehabilitation for patients having repair surgery: an overview of Systematic reviews. BJSM. Dec, 2016 Rehabilitation Prospective, randomized, investigator-blinded clinical trial The proportion of patients with tears at the 6- month post-op op MRIs were comparable (31% in delayed group; 34% in early group) Early motion was associated with lower WORC scores through post-op op period Failure rates were similar between the groups Sample size was too small to demonstrate the relation between tear morphology and rehab protocol Mazzocca, AD, et.al. The effect of early ROM on quality of life, clinical outcome, and repair integrity after arthroscopic repair. Arhtroscopy, Jan, 2017 Biopsychosocial Reasons Elevated fear-avoidance avoidance beliefs were associated with poorer improvement in functional status from intake to discharge among people in the following 2 of the 8 shoulder disease categories: 1) muscle, tendon, & soft-tissue tissue disorders 2) osteopathies, chondropathies, & acquires musculoskeletal deformities Bhagwant, S, et.al. Influence of fear-avoidance avoidance beliefs on functional status outcomes for people with musculoskeletal conditions of the shoulder. Phys Ther. 92: , 2012 Biopsychosocial Reasons 139 patients with shoulder pain Patients with high pain catastrophizing And low pain self-efficacy efficacy were Associated with worse scores on the SPADI Psychosocial factors are associated with patient complaints in shoulder disorders Menendez, ME, et.al. Psychological distress is associated with Greater perceived disability and pain in patients presenting to A shoulder clinic. JBJS-A. 97(24): , 2003, 2015 Biopsychosocial Reasons 169 patients with full-thickness tears SF-36 mental component summary had the strongest association with shoulder pain and function and ASES and SST Psychosocial factors are associated with patient complaints in shoulder disorders Wylie, JD, et.al. mental health has a stronger association With patient-reported shoulder pain and function than tear Size in patients with full-thickness tears. JBJS-A. 98(4): , 256, 2016 There is little consensus as to the most effective treatment of full thickness tears of the. Ainsworth, R, et.al. Exercise therapy for the conservative management of full thickness tears of the rotator cuff: a systematic review. Br J Sports Med. 41: , 210, 2007 Purpose was to compare the benefits and harms of non-operative and operative interventions on clinically important outcomes in adults with rotator cuff tears GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach 137 studies met eligibility criteria. All trials had high risk for bias. Seida JC 1,et.al. Systematic review: nonoperative and operative treatments for rotator cuff tears. Ann Intern Med. Aug 17;153(4):246-55, 55, 2010*** 6

7 CONCLUSION: Evidence on the comparative effectiveness and harms of various operative and nonoperative treatments for rotator cuff tears is limited and inconclusive. Seida JC 1,et.al. Systematic review: nonoperative and operative treatments for rotator cuff tears. Ann Intern Med. Aug 17;153(4):246-55, 55, 2010 Instead of being based on scientific rationale, traditionally most rehabilitation protocols are solely based on clinical experience and expert opinion. i (LEVEL V EVIDENCE) Van der Meijden, OA, et.al. Rehabilitation after arthroscopic rotator cuff repair: current concepts review and evidence-based guidelines. Int J Sports Phys Ther. 7: , 2012 Rehabilitation Consensus statement to aid clinical decision making during the rehab of patients after arthroscopic repairs. Overarching philosophy of rehab is centered on the principle of the gradual application of controlled stresses to the healing repair with consideration of tear size, tissue quality, and patient variables. Thigpen, C, et.al. The American Society of Shoulder and Elbow Therapists consensus statement on rehabilitation following Arthroscopic repair. JSES. 25(4):521-35, 2016 Rehabilitation framework: 2-week period of strict immobilization Staged introduction of protected PROM during weeks 2-6 postoperatively Restoration of AROM Progressive strengthening th beginning i at postoperative week 12 When appropriate, rehabilitation continues with a functional progression for return to athletic or demanding work activities Thigpen, CA, et.al. The American Society of Shoulder and Elbow Therapists consensus statement on rehabilitation following Arthroscopic rotator cuff repair. JSES. 25(4): , 535, 2016 Rehabilitation 164 patients Isometric strength: FF, IR, ER Pre-op and post-op op of 6, 12, 18, 24 months Muscle strength had slowest recovery in pain relief and the restoration of shoulder function Muscle strength in any direction did not correlate with post-op op patient satisfaction Muscle strength is highly correlated with pre- op quality of the muscle Shin, SJ, et.al. Recovery of muscle strength after intact arthroscopic repair according to preoperative tear size. AJSM. 44(4):972-80, 2016 Fallacy 1: If we do not start early PROM, then the patient will develop stiffness following repairs -Trends Trends 489 arthroscopic repairs Only 5% developed d postoperative stiffness Huberty, DP, et.al. Incidence and treatment of postoperative stiffness following arthroscopic rotator cuff repair. Arthroscopy. 25: , 890, 2009 Factors-Trends Surgical repairs of torn tendons frequently fail Immobilization vs PROM for 2 weeks immediate post-op, remobilization for 4 weeks Total ROM for PROM was < than immobilized group at both 2 & 4 weeks *** Immediate post-op op PROM was found to be detrimental to passive shoulder mechanics *** PROM results in increased scar formation in the subacromial space resulting in decreased ROM and increased joint stiffness PROM had no effect on collagen organization or tendon mechanical properties measured 6 weeks after surgery Peltz, CD, et.al. The effect of post-op op PROM on healing in a rat model. JBJS. 91-A:2421-9, 2009 Therefore, we conclude that after a short period of immobilization, increased activity is detrimental to both tendon mechanical properties and shoulder joint mechanics, presumably due to increased scar production. Peltz CD, et.al. Exercise following a short immobilization period is detrimental to tendon properties and joint mechanics in a rat rotator cuff injury model. J Orthop Res. Jul;28(7):841-5,

8 Factors-Trends Conclusions: Sling immobilization for 6 weeks after arthroscopic repair does not result in increased stiffness *** Slower rehab may improve the rate of tendon healing Parsons, BO, et.al. Does slower rehab after arthroscopic Repair lead to long-term stiffness? JSES, 19: , 1039, 2010 Factors-Trends Systematic Review: Conclusions: 7 articles Incidence of transient stiffness responsive to non-op op rehab was 10% Incidence of resistant stiffness that was permanent or required capsular release was 3.3% Resistant postop stiffness was reported in 1.5% of patients with immediate PROM rehab 4.5% of patients with 6-week sling immobilization 0% of patients with a modified protocol Denard, PJ, et.al. Prevention and management of stiffness after arthroscopic repair: systematic review and implications for healing. Arthroscopy. 27: , 848, 2011 *** Factors-Trends Conclusions: 7 articles Arthroscopic repair postop stiffness resistant to nonop management is uncommon despite an initial immobilization period With resistant postop stiffness, arthroscopic capsular release can successfully restore ROM *** Arthroscopic repair allows a delayed mobilization protocol that may be important in achieving healing. Denard, PJ, et.al. Prevention and management of stiffness after arthroscopic repair: systematic review and implications for healing. Arthroscopy. 27: , 848, 2011 Healing & Stiffness Retears are common outcomes of repairs Stiffness is not an uncommon outcome of repairs N=1533 arthroscopic repair Single surgeon Likert scale to assess shoulder stiffness by patient 6 weeks: ROM 12 weeks: partial recovery 24 weeks: full recovery Shoulders that were stiff before surgery, were more likely to be stiff s/p surgery (PRE-HAB) McNamara, WJ, et.al. The relationship between shoulder stiffness and Rotator cuff healing. JBJS-A. 98(22): , 1889, 2016*** Healing & Stiffness A stiffer shoulder at 6 and 12 weeks postoperatively correlated with better integrity at 6 months postoperatively Retear rate of patients with <20 of ER at 6 months was 7% Retear rate of patients with >20 of ER at 6 months was 15% (p<0.001) 001) In patients who developed stiffness after surgery, a rotator cuff repair was more likely to heal McNamara, WJ, et.al. The relationship between shoulder stiffness and Rotator cuff healing. JBJS-A. 98(22): , 1889, 2016 Fallacy 2: Early Physical Therapy helps improve the healing response and prevents re-tears A large number of factors must be taken into account before implementing a rehabilitation protocol after surgery One of the most important factors a rehabilitation protocol should take into account is the timing of biological healing of bone to tendon or tendon to tendon interface, depending on the type of rupture and repair. Conti, M, et.al. Post-operative operative rehabilitation after surgical repair of the rotator cuff. Chir Organi Mov. 93:S55-S63, S63, 2009 The threshold of fixation strength needed for early motion and healing is unknown. Mall NA, et.al. Factors affecting rotator cuff healing. J Bone Joint Surg Am. May 7;96(9):778-88, 2014 Factors 2 tendon repairs-40% failure Most fail in first 12 weeks SS force 300 N IS force 250 N fails at 250 N 12 weeks: 25% of strength of tendon 26 weeks: 85% of strength of tendon T. Romeo, ICCUS, Chicago, IL, July,

9 Timeline for Healing & Strength of Repairs Phases I II III IV V VI 4 8 months months months months Protection Restore Early Functional Recovery RTS Phase Recovery ROM Strength of skill sport 100 % 80 % X 70 % X 60 % X 40 % X 20 % X 0 % X Imaging studies reveal defect recurrence in approximately one-third of the tears. *** Newer techniques of stabilizing the damaged structures with surgeries, combined with delay in rehabilitation improved the number of successful surgeries Strength deficits may persist, particularly if permanent atrophy and fatty infiltration within the cuff muscles are demonstrated preoperatively Abrams, JS, et.al. Management of the failed rotator cuff Surgery: causation and management. Sports Med Arthrosc. 18: , 197, 2010 *** Recurrent tears occur more frequently in the early postoperative period. *** Survivorship analysis revealed 74% of all failures occurred atraumatically in the first 3 months 11% occurred between the 3 rd and 6 th month after repair Early failures are a prognostic factor for long-term outcomes. Efforts to improve healing during the initial 3 months have long- term implications for maintenance of cuff integrity and clinical outcomes. Kluger, R, et.al. Long-term survivorship of rotator cuff repairs using ultrasound and magnetic resonance imaging analysis. Am J Sports Med. 39: , 2081, 2011 *LEVEL OF EVIDENCE 1* 105 consecutive patients Small to medium sized full-thickness tears Abduction brace 4-5 weeks Group 1: early passive motion (AAROM - 3 to 4 times per day) Group 2: no passive motion Kim, YS, et.al. Is early passive motion exercise necessary after arthroscopic rotator cuff repair? Am J Sports Med. 40: , 821, 2012 *** *LEVEL OF EVIDENCE 1* Results: 3, 6, 12 month FU VAS No significant differences at all time points ROM - No significant differences at all time points *** Retears: Group 1: early passive motion 12% Group 2: no passive motion 18% (P=0.429) Kim, YS, et.al. Is early passive motion exercise necessary after arthroscopic rotator cuff repair? Am J Sports Med. 40: , 821, 2012 *** *LEVEL OF EVIDENCE 1* However, recent approaches show that longer immobilization may enhance tendon healing and quality Kim, YS, et.al. Is early passive motion exercise necessary after arthroscopic rotator cuff repair?. Am J Sports Med. 40: , 821, 2012 Factors-Trends *LEVEL II RCT* 64 patients with MRI (~8 months) evaluations after arthroscopic repairs Aggressive early passive rehab (manual therapy 2 x/day & unlimited self-passive stretching exercise) Limited early passive rehab (limited CPM exercise and limited self-passive exercise) Lee, BG, et.al. Effect of 2 rehab protocols on ROM and healing rates after arthroscopic repair: aggressive vs Limited early passive exercises. Arthroscopy. 28:34-42, 42, 2012 *** Factors-Trends Aggressive rehab group has SS increases in ROM: F, ABD, 0, 90, 90 at 3 months NO DIFFERENCES at 1 year Repair Integrity: Limited rehab: 9% Aggressive rehab: 23% *** Conclusions: Aggressive early ROM may increase the possibility of anatomic failure at the repaired Lee, BG, et.al. Effect of 2 rehab protocols on ROM and healing rates after arthroscopic repair: aggressive vs Limited early passive exercises. Arthroscopy. 28:34-42, 42, 2012 *** Factors-Trends A delayed gentle rehabilitation protocol with limits in ROM and exercise times after arthroscopic repair would be better for tendon healing without taking any substantial risks Lee, BG, et.al. Effect of 2 rehab protocols on ROM and healing rates after arthroscopic repair: aggressive vs Limited early passive exercises. Arthroscopy. 28:34-42, 42,

10 28 studies (1,729 repairs) Re-tears Early rehab: 13.7%; delayed: 10.5% (p=.36) For >5 cm tears, the risk of re-tear was greater for early versus delayed PROM for double-row anchor (DA) repairs (56.4% vs 20%, P =.002) Kluczynski MA 1, et.al. Early Versus Delayed Passive Range of Motion After Rotator Cuff Repair: A Systematic Review and Meta-analysis. analysis. Am J Sports Med. Oct, RCTs-482 patients No significant differences in shoulder function with either protocol Early ROM group: 3.5 in flexion at 1 year PO Early ROM exercise tended to cause higher rate of recurrent tendon tears and the effect became statistically significant after excluding 2 RCTs that recruited only those patients with small to medium-sized tears Chang, KV, et.al. Early vs delayed ROM exercise for Arthroscopic -Repair: Repair: a meta-analysis analysis of RCTs. AJSM. Aug, 2014 Surgery & Outcomes Tear size and thickness were not associated with pain and function Fatty infiltration, muscle atrophy, and tendon retraction were also not associated with pain and disability scores Factors unrelated to cuff anatomy such as mental health, comorbidities, age, and sex were associated with pain/function Curry, EJ, et.al. Structural characteristics are not associated with pain and function in tears: the ROW cohort study. Orthop J Sports Med. 3(5), 2015 After successful arthroscopic repair, there was a slight increase ( %) 13.9%) in muscle volume from preoperatively to final follow-up as seen on MRI Fatty infiltration according to the Goutallier grade was not reversed Some reversibility of supraspinatus muscle atrophy may exist in tendon- bone healing after arthroscopic repair Park, YB, et.al. Reversibility of supraspinatus muscle atrophy in Tendon-bone healing after arthroscopic repair. AJSM. 44(4): , 988, 2016 Rehabilitation 176 patients; age 56 yo Re-tears at 3 months: 9.1% Re-tears at 6 months: 3.4% Re-tears at 12 months: 2.8% Incidence of re-tears was associated with tear size and tendon degeneration The critical period for healing following repair, during which risks of re- tears are high, extends to the first 6 months Barth, J, et.al. Critical period and risk factors for retear Following Arthroscopic repair of. Knee Surg Sports Traumatol Arthrosc, Aug, 2016*** Rehabilitation The risk of re-tear is greatest for massive 3-tendon tears, which may require longer periods of protection Clinical relevance is the identification of patients at risk of re-tear and the adjustment of their rehabilitation strategy and time for return to activity Barth, J, et.al. Critical period and risk factors for retear following Arthroscopic repair of. Knee Surg Sports Traumatol Arthrosc, Aug, 2016 The timing of PROM after surgical repair of the has been shown to affect healing. Early AROM (<6 weeks after surgery) Delayed AROM (>6 weeks after surgery) 37 studies, (2251 repairs) 10 (649 repairs) in early group 27 (1602 repairs) in delayed group Kluczynski, MA, et.al. Does early vs delayed AROM affect healing After surgical repair? A systematic review and meta-analysis. analysis. AJSM. 44(3): , 791, 2016*** For tears (<3 cm) risk of structural tendon defect was higher in early vs delayed group For tears (>3 cm) the risk of structural tendon defect was higher in the early vs delayed group for all repair methods For tears (>5 cm) the risk of structural tendon failure was higher in the early vs delayed group Early AROM was associated with increased risk of structural defect for small and large tears, and thus, might not be advisable after repair Kluczynski, MA, et.al. Does early vs delayed AROM affect healing After surgical repair? A systematic review and meta-analysis. analysis. AJSM. 44(3): , 791, 2016 Fallacy 3: Early Physical Therapy obviously must be effective in rehabilitation programs 10

11 *LEVEL OF EVIDENCE 1* Conclusions: Early PROM after arthroscopic repair DID NOT guarantee: Early gain of ROM Pain Relief or enhance healing and prevent re-tears Kim, YS, et.al. Is early passive motion exercise necessary after arthroscopic rotator cuff repair? Am J Sports Med. 40: , 821, 2012 Fallacy 4: Early Physical Therapy obviously must help improve patient outcomes Isokinetic peak torque pre-test values The greatest improvement in strength consistently occurred during the first 6 months after surgery By using isokinetic strength evaluation, we found that recovery of strength after repair requires at least 1 year of rehabilitation Rokito, AS, et.al. Strength after surgical repair of the rotator cuff. J Shoulder Elbow Surg. 5:12-17, 17, 1996 Dynamic joint function is not completely restored by repair, thus compromising shoulder function and leading to long-term disability. Strength deficits persisted at 24 months for most patients GHJ mechanics and shoulder strength are not fully restored with current repair techniques Bey, MJ, et.al. In vivo shoulder function after surgical repair of a torn rotator cuff: glenohumeral joint mechanics, shoulder strength, clinical outcomes, and their interaction. Am J Sports Med. 39: , 2129, 2011 Rehabilitation To reach strength of the uninjured contralateral shoulder in all 3 planes of motion, recovery took: 6 months in patients with small tears and 18 months in patients with medium tears Patients with large-to to-massive tears showed continuous improvement in strength up to 18 months, however they did not reach strength of the contralateral shoulder at 24 months Recommend patients continue rehab beyond one year Shin, SJ, et.al. Recovery of muscle strength after intact arthroscopic repair according to preoperative tear size. AJSM. 44(4):972-80, 2016 Rehabilitation LOE I MRA had a significantly lower full- thickness re-tear rate for the DR than for the SR group (8% vs 24%) In selected patients at a high risk of shoulder stiffness and necessitating accelerated post-op op rehab, DR repair of the could lower re-tear rates. Franceschi, F, et.al. Double-row repair lowers the retear risk after accelerated rehabilitation. AJSM. 44(4):948-56, 2016*** Accelerated rehabilitation protocol after repair has been proposed for patients at risk of postoperative stiffness MRI showed a significantly lower full-thickness re-tear rate for the DR group than the SR group Francesco, F, et.al. Double row repair lowers the retear risk after Accelerated rehabilitation. AJSM. 44(4): , 957, 2016*** At both 6-month and 2-year follow-up, there was no significant differences in terms of the rate of stiffness In selected patients at a high risk of shoulder stiffness and therefore necessitating accelerated postoperative rehabilitation, DR repair of the could lower re-tear rates Francesco, F, et.al. Double row repair lowers the retear risk after Accelerated rehabilitation. AJSM. 44(4): , 957, 2016 Rehabilitation 433 patients Patient expressions regarding physical therapy as the strongest predictor of surgery Patients decision to undergo surgery is influenced more by low expectations regarding the effectiveness of physical therapy than by patients symptoms or anatomic features of the tear. Dunn, WR, et.al Neer Award: Predictors of failure of Non-operative operative treatment of chronic, symptomatic, full- thickness tears. JSES. 25(8): , 1311,

12 Sports Health Baumgarten, KM, et.al. 1(2): , 130, 2009 UGH UGH! Rehab AAOS Clinical Practice Guidelines Unit i v.1.1_ OPTIMIZING THE MANAGEMENT OF ROTATOR CUFF PROBLEMS: GUIDELINE AND EVIDENCE REPORT Adopted by the American Academy of Orthopaedic Surgeons Board of Directors, December 4, 2010 Clinical Practice Guidelines by the AAOS, 12/4/10: 31 recommendations 19-inconclusive because of absence of definitive evidence 4 moderate grade 6 weak grade 2 consensus statement of expert opinion (Level V) Pedowitz, RA, et.al. Optimizing the management of rotator cuff problems. J Am Acad Orthop Surg. 19: , 379, 2011 Rehab ***Post-Operative Rehabilitation Range of Motion Exercises 13. b. We cannot recommend for or against a specific time frame of shoulder immobilization without range of motion exercises after rotator cuff repair. ***Strength of Recommendation: Inconclusive Rehab Post-Operative Rehabilitation Active Resistance Exercises 13. c. We cannot recommend for or against a specific time interval prior to initiation of active resistance exercises after rotator cuff repair. Strength of Recommendation: Inconclusive SF-36 Mental Component Summary (SF- 36 MCS) The SF-36 MCS had the strongest correlation with the analog scale for shoulder pain Patient mental health may play an influential role in patient-reported pain and function in patients with full- thickness tears Wylie, JD, et.al. Mental health has a stronger association with patient- Reported shoulder pain and function than tear size in patients with Full-thickness tears. JBJS. 98: , 256, 2016 Sanders JO, et.al. The American Academy of Orthopaedic Surgeons appropriate use criteria on optimizing the management of full-thickness rotator cuff tears. members of the Writing, Review, and Voting Panels of the AUC on Optimizing the Management of Full-Thickness Rotator Cuff Tears. J Bone Joint Surg 96(8):683-4, 2014 The purpose of study was to determine common clinical practices among experts regarding -R and to assist them in counseling patients. We surveyed 372 members of ASES and the Association of Clinical Elbow and Shoulder Surgeons (ACESS) A consensus response (>50% agreement) was achieved on 49% (24 of 49) of the questions. Variability in responses likely reflects the fact that clinical practices have evolved over time based on clinical experience. Acevedo DC, et.al. A Survey of Expert Opinion Regarding Rotator Cuff Repair. J Bone Joint Surg Am. Jul 16;96(14),

13 Perhaps we need to change the Rehabilitation program to alter the outcomes: Rehabilitation-Trends Past studies have shown ~75% of patients following a repair will technically fail when defined as the is not intact again after surgery Despite these failure rates, most research studies have shown that patient satisfaction after surgery is still very high. This means the rehabilitation process may be far more important than the actual surgery Summary And Conclusions Congratulations And Thanks To SPTS 13