The rotator cuff muscles, (supraspinatus, infraspinatus, subscapularis and teres minor) have a vital role of strengthening and stabilising the shoulder joint, by holding the head of the humerus in the glenoid fossa and facilitating movement at the shoulder joint (Tortora & Dirrickson, 2011). A tear of these key muscles results in pain, weakness and loss of function (Solomon, Warwick & Nayagam, 2001).
Rotator cuff tears (RCTs) may occur from a violent traumatic incident, chronic impingement, minor trauma or instability of the shoulder (McRae, 2004) and may affect any of the rotator cuff muscles. RCTs are classified by the degree of tear (thickness) and the tear size, which impact on progression of the rehabilitation programme because of different degrees of damage at the time of surgery and also different extents of tissue repair (Ellenbecker & Bailie, 1989).
Rotator cuff repairs (RCRs) are usually done by arthroscopic surgery and McRae (2004) states that, “In every case, prolonged physiotherapy is usually required.” Physiotherapists follow a protocol or a surgeon’s instructions for rehab and treatment of RCR’s. The post-operative rehabilitation is patient specific depending on tear size, type, chronicity and fixation of the tendon, (Ellenbecker & Bailie, 1989). Rehabilitation starts from week 1 where passive range of motion exercises (PROMs) are undertaken, through to 4+ months where upper limb sporting activities can be completed, (Ellenbecker & Bailie, 1989).
Focusing on the first 4 weeks of physiotherapy rehabilitation, treatment programmes are usually PROMs (to avoid post-operative stiffness (Kim et el, 2012)) and resting the arm in a sling. Others argue full immobilisation of the shoulder is preferable and has a more effective healing than passive movements, as Kim et el (2012) states that PROM’s could increase scar formation in the subacromial space, resulting in a reduced range of movement.
Resources utilised during treatment are a physiotherapist to perform PROM’s and to educate the patient and a sling, which many protocols and Conti, Et el (2009) suggest must be worn for 6 weeks.
No matter how precise and technically excellent the surgery is, RCR patients cannot expect a successful outcome if post-operative care is poor (Kim et el, 2012).
To monitor whether the treatment given is having an effect, changes occurring throughout the rehabilitation programme should be measured. This measurement should be practical and easily obtainable and to provide useful information, must be reliable and valid (Miller, 1985).
One of the main goals post-operatively for a RCR patient is to restore function to the shoulder (Cuff & Pupello, 2012) and decisions to progress treatment are based on measurements of joint motion (Miller, 1985). Many protocols suggest the use of the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) as an outcome measure for a RCR. DASH is a functional outcome measure which the patient completes, consisting of 30 questions related to how the patient’s post-op limb functions, with a choice of five answers on a graded scale ranging from “no difficulty” to “unable”. Although this way of measurement is suggested in protocols, it may not be as practical as other measurements such as goniometry. DASH could be time consuming especially for patients with visual or cognitive problems. This is not practical for follow up appointments with time restrictions, whereas goniometry can be done quickly by the physiotherapist.
Goniometry, unlike DASH, measures the angle formed by the limb segments, which is used to measure joint motion(Miller,1985). Miller, (1985) also suggests that although functional outcome measures are useful to set patient goals, goniometric measurements can also provide functional information as well as precise changes in degrees, of range of motion/movement (ROM).
Measurement is conducted by placing the goniometer’s mechanical arms on bony landmarks and passively moving the limb into different movements. Measurements are compared as treatment progresses to assess improvement. For assessing RCR’s; flexion, abduction and external rotation were measured in my clinical setting.
Kim, et el, (2012) used goniometry to measure changes in ROM of the shoulder after RCRs and minimal changes such as 1 degree could be detected. ROM of the post-op shoulder can be easily comparable to the unaffected opposite limb to assess the progress of treatment. Kim, et el, (2012) recorded the position of the goniometer’s mechanical arms, which increased reliability.
Goniometry cannot be valid if the goniometer does not accurately reflect joint motion (Miller, 1985). However, the goniometer is accepted as a valid clinical tool and physiotherapists judge the validity based on anatomical knowledge, such as accurate alignment of the goniometer and correct palpation of the bony landmarks (Gajdosik & Bohannon, 1987). Reliability and accuracy can be increased by noting where the mechanical arms of the goniometer are placed, the position of the patient and use of the same equipment. Intra-reliability of goniometry is considered more reliable as it is easier to reproduce a method done by the same person (Miller, 1985). Validity of simple measurements may be reduced due to uncontrollable factors such as patient differences. However, Gajdosik & Bohannon,( 1987) states that, accurate skills, knowledge and “interpretation of results as measurements of ROM only, provide sufficient evidence to ensure content validity.”
There are many reasons why a physiotherapy rehabilitation programme consisting of PROM’s and sling immobilisation is chosen for RCR patients within the first 4 weeks of their post-operative care. Firstly, protocols and surgeons suggest this rehab programme and due to the fact that every RCR patient is different, in regards to surgical technique, functional demands of the patient, grade of lesion, number of tendons repaired and the quality of the tissue (Gajdosik & Bohannon, 1987) it is key that physiotherapists liaise with the surgeons (who will know, in greater depth, the previously mentioned differences regarding post-op care) and agree an appropriate treatment programme.
One of the main reasons physiotherapists perform PROM’s in the first 4 weeks is to prevent the patient developing stiffness or adhesive capsulitis of the shoulder (Gajdosik & Bohannon, 1987). Passive exercises help minimise loading at the repair site (Gajdosik & Bohannon, 1987) and also attempt to prevent articular blocks like adhesions. Gajdosik & Bohannon, (1987) suggest that passive movements must be carried out without causing pain, inside a safety range and with avoidance of maximum stretching. Although PROMs are thought to benefit patients by reducing the chance of post-op stiffness, some believe that this may disrupt the healing process of the rotator cuff (Cuff & Pupello, 2012). An alternative treatment method which is thought to create “a more optimal healing environment” (Cuff & Pupello, 2012) is complete immobilisation of the post-op shoulder, which can increase tendon-to-bone healing, as it increases the organisation of the collagen fibres (Kim et el, 2012).
Cuff & Pupello,( 2012) conducted a study comparing early ROM exercises performed by a physiotherapist from day 2 post-op, with a group immobilised for 6 weeks post-op, then following the same protocol of PROMs. They concluded that both groups demonstrated “very similar clinical outcomes and range of motion at 1 year after surgery” and then stated that there was no significant advantage for immediate PROMs after surgery. However, in their study, true immobilisation did not occur as the second group were instructed to do “gentle circular pendulums”. It was not made clear why the patients were instructed to do this, therefore this could be the same reason as performing PROMs- an attempt to prevent joint stiffness and adhesive capsulitis.
Kim et el, (2012) also conducted a study comparing PROMs from one day post-op with no PROMs until the brace was removed (4-5 weeks). This study also concluded that there was no significant differences between groups at a six month and a year follow up in regards to range of movement (measured by the physiotherapist) as well as pain levels, described by the patient.
Cuff & Pupello, (2012) suggests a benefit of an immobilisation period, where the patient does not have to attend physiotherapy appointments, is convenience to the patient and cutting expenses of treatment.
Alternatively, Roddey, et el,(2002) suggests supervised rehabilitation, 2-3 times a week, for 4 months. By attending physiotherapy appointments, it allows the physiotherapist to monitor the wound sites, correct and educate the patient on sling position and give the patient opportunity to ask any questions they may have regarding their treatment programme. For these reasons, passive exercises can be taught to the patient in a way for them to complete as part of a home exercises programme (HEP) which would be beneficial as the recommended “60 postoperative treatments sessions with a therapist” (Roddey, et el, 2002) isn’t viable due to the vast amount of patients needed to be seen and appointment vacancies with a NHS physiotherapist. Despite PROM exercises in the first 4 weeks apparently having no advantage with ROM and pain compared to immobilisation, I believe that treatment is beneficial to RCR patients.
In my personal experience, patients achieved a greater PROM measurement every follow up (7-10 days). This could be because of analgesia; all my patients were instructed to take medication for pain post-op. However, I think the reason for improvement was compliancy of my patients completing their PROM HEP and the opportunity to have appointments with a physiotherapist, by which patients could receive immediate feedback, modifications, education and motivation (Roddey, et el,2002). I believe that the first 4 weeks of treatment worked because all of my patients could do what was expected of them, in regards to the protocol, (Conti, Et el,2009). I saw some of my patients 5-6 weeks post-op and they could carry out active assisted ROM which is what they are supposed to achieve at that stage. None of my patients developed a stiff shoulder or adhesive capsulitis after their operation which is why I suggest that PROMs in the first 4 weeks are beneficial. Kazemi, (2000) states that, adhesive capsulitis is “a rather long, restrictive and painful course” therefore to avoid getting this complication is very beneficial. My patients were representative of the population at this point of their rehabilitation, however I only had a very small group of RCR patients which could decrease reliability and increase error. I cannot say whether they would represent the population 6 months or 1 year post-op as they were only in my care for up to 6 weeks.
Possible factors which could restrict treatment and improvement were failure of patients attend appointments, technique of the physiotherapist carrying out the PROMs, pain levels, compliancy in completing HEP, complications of the operation, surgeon recommendations and whether the patient followed post-op instructions of wearing their sling for the recommended time. Although none of my patients experienced or admitted to experiencing these restrictions.
In conclusion, although there is little evidence to suggest PROM exercises, in the first 4 weeks improves ROM and functions of the post-op shoulder, it is however considered that ROM exercises help prevent the development of adhesive capsulitis which is difficult to treat and cure (Cuff & Pupello, 2012). Although, due to lack of reliable experiments (e.g Cuff & Pupello, (2012) did not achieve complete immobilisation) and the fact that I didn’t have the benefit of a controlled immobilisation group, to assess whether they would have developed adhesive capsulitis or a stiff shoulder, it is unknown whether ROM exercises actually does prevent this complication. On the other hand, there is some evidence (Kim, et el, 2012) that PROMs could increase scar formation in the subacromial space. A balance needs to be struck in considering the weight to be given to these conflicting alternatives. This is perhaps best done by the surgeon given their knowledge of the different degrees of damage in each particular patient.
As there is no definitive evidence suggesting that PROMs have an advantage over an immobilisation period for an increase in ROM and functional capability, and due to my personal experience group only being small, I cannot conclude with certainty that PROM exercises are an advantage for a RCR patient in the first 4 weeks post-op. However, on the basis of my own personal experience I consider physiotherapy appointments to be beneficial to RCR patients in their first 4 weeks of rehabilitation, due to other reasons previously mentioned such as monitoring the wound sites and patient education.
References
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