Dr. Bruno Fles Mazuquin from the University of Central Lancashire in the U.K., and colleagues conducted an overview of systematic reviews comparing the effectiveness of early and conservative rehabilitation after rotator cuff repair.
The final analysis included 10 systematic reviews and 11 randomized controlled trials. Most of the systematic reviews were published between 2014 and 2015.
Only reports on chronic tears (i.e., those not caused by trauma or accidents) were included. All patients were under the supervision of a rehabilitation therapist.
“The starting time for rehabilitation also had great variance among the primary studies, from the same day post-surgery to four weeks in the early management, and from four to eight weeks in the conservative group,” the authors note.
Based on two studies with 207 patients, there were no statistically significant differences in pain at six or 24 months of follow-up.
Nor were there statistical differences in American Shoulder and Elbow Surgeons questionnaire score between the early rehabilitation and conservative rehabilitation groups at six months (based on three studies with 312 patients), 12 months (two studies with 214 patients) or 24 months (two studies with 207 patients).
Similarly, there were no statistical differences in the Constant-Murley score between the early and conservative rehab groups, based on three studies with 312 patients at six months and two studies with 214 patients at 12 months.
In addition, there were no differences between the early and later groups in Simple Shoulder Test scores at six or 12 months, glenohumeral flexion ROM at six or 24 months, or retear rate at 12 months.
The findings indicate that early mobilization does not improve functional outcomes, pain or range of motion when compared with conservative rehabilitation, nor does it cause a higher retear rate, the authors conclude.
They note that there’s a lack of consensus on which is the best approach due to the heterogeneity of protocols and methodological quality of reviews and primary studies.
“The rehabilitation protocol used after rotator cuff repair is extremely important, but there is controversy regarding the ideal prototype,” says Dr. Joaquin Sanchez-Sotelo, consultant and professor of orthopedic surgery and director of shoulder and elbow surgery at the Mayo Clinic in Rochester, Minn.
The current trend is to delay passive range of motion, he says.
“This is due in part to the widespread use of arthroscopic surgery, as well as a relatively high rate of incomplete tendon healing or retear reported by some authors,” says Dr. Sanchez-Sotelo, who was not part of the study.
However, patients are quite limited for a number of weeks after surgery, and their overall experience could potentially be improved with faster recovery, he says, noting that long-term physical therapy also has financial implications for healthcare systems.
Dr. Arun Ramappa, chief of sports medicine and shoulder surgery at Beth Israel Deaconess Medical Center in Boston, says early range of motion has been postulated to more rapidly normalize range of motion, reduce pain, and normalize function.
“However, there is concern that it will lead to increased retear or failure rates of rotator cuff repair,” he writes in an email to Reuters Health.
Immediate range of motion after rotator cuff repair is not essential for producing good postoperative outcomes, says Dr. Ramappa, who was not involved in the study.
“This study highlights the need to use different study designs in the future to answer a question that remain unanswered despite much good quality research performed to date,” says Dr. Sanchez-Sotelo.
The main features of future studies should include subgroup analysis, compliance monitoring, and a homogeneous method to assess healing, he says.
The corresponding author did not respond to requests for comments.
- Mazuquin BF, Wright AC, Russell S, et al. Effectiveness of early compared with conservative rehabilitation for patients having rotator cuff repair surgery: an overview of systematic reviews. Br J Sports Med. 2016 Dec 30. pii: bjsports-2016-095963. doi: 10.1136/bjsports-2016-095963. [Epub ahead of print]