Occ health-presentation

Evidence Based Medicine and the Rotator Cuff

Chris Pullen

Introduction 1

UK (Linsell et al 2006 Rheumatology)

2.4% primary care consultations are shoulder based

USA (US Dept Health & Human Services)

4.5 million physician visits rotator cuff problems

Introduction 2

•Pathogenesis ?•Natural History ?•When to & when not to operate ?•Which operation ?

Introduction 3

Problems Multi-factorial nature of the pathology

Publications are small, single centre & retrospective

‘There is little evidence to support or refute the effectiveness of surgery for rotator cuff disease. All reviewed trials were highly susceptible to bias.’

Coughlan et al 2004 Cochrane database

Prevalence

MRI asymptomatic

(Sher et al 1995 JBJS)

Supported by US and cadaver studies

Why RCT become symptomatic ???

Ageing process ?

Natural History 1

Asymptomatic RCT 40% asymptomatic tear 51% symptomatic 39% increase in size

(Yamaguchi et al 2001 JSES)

Natural History 2

Partial thickness tears Arthrography on 40 of 61

patients with PTT(Yamanaka et al 1994 CORR)

Full thickness tears do not heal

(Fukuda et al 1994 CORR)

Pathogenesis

Mechanical (Neer 1972 JBJS)

Vascular (Moseley & Goldie 1963 JBJS)

Genetic (Harvie et al 2004 JBJS)

Cellular (Nirschl 1989 Instr Course Lect)

Non-operative Treatment 1

Impingement/Tendinitis High success rate approx

70% Retrospective study 616

patients (Morrison et al 1997 JBJS)

Prospective trial 100 patients impingement (Cummins et al 2009 JSES)


Rotator cuff tears Some patients have

successful outcome No reliable method of

predicting outcome Need for well-planned

randomized controlled trials(Ainsworth & Lewis 2007 Br J Sports

Med.)

Irreversible changes within cuff muscles after a tear (Coleman et al 2003 JBJS)


• Modalities• Exercises• Manual therapy• Corticosteroid injections• Ultrasound• Phonophoresis • Iontophoresis• Ice/Heat• NSAID

Exercise 1

Kuhn 2009 JSES

Exercise 2

Systematic review

Physical Therapy modalities used ROM Stretching & flexibility Strengthening Manual therapy

(Kuhn 2009 JSES)

Exercise 3

Pain

(Bang 2000, Brox et al 1993, Ludewig & Borstad 2003, Senbursa 2007, Walther 2004)

Strength

(Bang 2000, Haahr et al 2005, Walther et al 2004)

Function

(Bang 2000, Conroy & Hayes 1998)

Exercise 4

Two studies compared supervised physical therapy with home exercise (Walther et al 2004, Werner et al 2002)

Neither could show a statistically significant difference between the 2 exercise groups

Manual Therapy

The effect of manual therapy has been evaluated in a number of studies

(Bang 2000, Conroy & Hayes 1998, Senbursa et al 2007)

Corticosteroid Injections 1

For 50y CSI have been used for treatment of shoulder problems

Survey 96% practitioners believe CSI effective

Adverse effects well know Rat model (Tillander et al 1999 JSES)


(Koester et al 2007 JAAOS)

Corticosteroid Injection 3

Pain (Adebajo et al 1990 J Rheum, Akgun et al 2004 Clin Rheum, Blair et al 1996 JBJS)

ROM (Adebajo et al 1990 J Rheum, Blair et al 1996 JBJS)

Predictor for surgery (Cummins et al 2009

JSES)

MRI study accuracy of injection 24-31% CSI inaccurately placed Only injections into SA bursa helpful(Henkus et al 2006 Arthroscopy)


‘little evidence to support or refute the efficacy of common interventions for shoulder pain’

(Buchbinder et al 2003 Cochrane Database)

‘best evidence indicates that subacromial CSI is not efficacious in the treatment of rotator cuff disease’

(Koester et al 2007 JAAOS)

NSAID Integral to most non-operative treatment protocols

Systematic review 19 Randomized controlled trials Shoulder pain Useful in short term only (4 weeks) No benefit seen for a particular NSAID

(van der Windt et al 1995 J Clin. Epid.)

Other

US (Green et al 2003 Cochrane Database)

Phonophoresis (Klaiman et al 1998 Med Sci Sports Exerc)

Iontophoresis

Heat/Cold (Haahr et al 2005, Conroy et al 1998, Senbursa et al 2007)

Surgical Treatment 1

‘failed to provide evidence for differences in outcome between conservatively and surgically treated patients with SIS’

• Systematic review

(Dorrestijin et al 2009 JSES)


Dorrestijn et al 2009 JSES


Rotator cuff tear Systemic review (Wolf et al 2007 Am J Sports Med)

Despite possibility of re-tear RCR reduces pain & improves strength & function in symptomatic patients (Jost et al 2000 JBJS)


Variables Duration of symptoms

(Habernek et al 1999 Br J Sports Med)

Age(Feng et al 2003 J Ortho Surg, Hattrup 1995

JSES)

Surgical Treatment 5Variables

Gender (Romeo et al 1999 CORR)

Weakness (Bartolozzi et al 1994 CORR)

Tear size (Bartolozzi et al 1994 CORR)


Variables Acromiohumeral distance(Ellman et al 1986 JBJS, Gerber et al 2000

JBJS)

Atrophy & Degeneration(Goutallier et al 2003 JSES)


Variables Workers’ Compensation

Retrospective study 3.8 y follow-up

FTT & pending WC(Hawkins & Dunlop 1995 CORR)

• Presence WC claim did not adversely affect outcome(Iannotti 1994 JAAOS)

Conclusions 1

Non-operative treatment Trial minimum 6-12 weeks Physical therapy

Conclusions 2

Exercises ROM

Postural exercises Shoulder shrugs &

retraction Glenohumeral motion

Pendular exercises

Conclusions 3

Exercises Stretches

Anterior and posterior capsule

Strengthening Rotator cuff & scapular

stabilizers Theraband

Conclusions 4

MRI scan

Surgery

Conclusions 5

Conclusion 6

The End

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