Thank You...definitions, treatment approaches, and outcomes of management techniques. J Shoulder...

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Thank You Thanks to RUSH & 2017 Chicago Sports

Medicine Symposium 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.

George J. Davies, DPT,ATC,CSCSProfessor-Georgia Southern University-Armstrong Campus

Sports Physical Therapist: Coastal Therapy, Savannah, GA.,

Gundersen Health System, LaCrosse, WI.

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Disclosures:

Associate Editor, Sports HealthElsevier-Book RoyaltiesHuman Kinetics-Book RoyaltiesWilliams & Wilkins-Book RoyaltiesNorth American Seminars-DVDRoyalties

No Conflicts

Medline/Index Medicus2015

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

Rehabilitation Following Massive

Rotator Cuff Repairs(What is best and for

Whom?)

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Rehab-Massive RTC TearsRehab-Massive RTC Tears PubMed Search: 7/15/17: Rehabilitation

AND massive rotator cuff tears 125 references: 2017: 12 2016: 9 2015: 12 2014: 9 2013: 4 46 articles in past 5 years

Rehab-Massive RTC TearsRehab-Massive RTC Tears PubMed Search: 7/15/17: Rehabilitation AND

massive rotator cuff tears

125 references: 2017: 12 2016: 9 2015: 12 2014: 9 2013: 4

46 articles in past 5 years

Rehab-Massive RTC TearsRehab-Massive RTC TearsIn this report we describe

the clinical and pathological findings of cuff-tear arthropathy in twenty-six patients and discuss the differential diagnosis and a hypothesis on the pathomechanics that lead to its development.

Neer CS 2nd, Craig EV, Fukuda H. Cuff-tear arthropathy.J Bone Joint Surg Am. 1983. 65(9):1232-44.

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Rehab-Massive RTC TearsRehab-Massive RTC TearsAlthough treatment of cuff-tear arthropathy is extremely difficult, the preferred method appears to be a resurfacing total shoulder replacement with rotator-cuff reconstruction and special rehabilitation.

Neer CS 2nd, Craig EV, Fukuda H. Cuff-tear arthropathy.J Bone Joint Surg Am. 1983. 65(9):1232-44.

Rehab-Massive RTC TearsRehab-Massive RTC Tears Massive rotator cuff tears (MRCT) include a

wide variety of lesions in terms of tear pattern, functional impairment, and reparability.

There is insufficient evidence to establish an evidence-based treatment algorithm for MRCTs.

Treatment is based on patient factors and associated pathology, and includes personal experience and data from case series.

Lädermann A, et.al. Massive rotator cuff tears: definition and treatment. Int Orthop. 2015. 39(12):2403-14

Rehab-Massive RTC TearsRehab-Massive RTC TearsSystematic Review - 16 studiesThe most consistent definition was a massive rotator cuff tear with active elevation less than 90°, but studies inconsistently included stiffness, external rotation loss, arthritic changes, neurologic status, and painThere were 6 different techniques:

1) nonoperative rehabilitation2) rotator cuff repair, 3) muscle transfer4) hemiarthroplasty5) reverse total shoulder arthroplasty6) reverse total shoulder arthroplasty with muscle transfer***-SCRPostoperatively, all approaches showed improvement.

Tokish JM,… Hawkins RJ. Pseudoparalysis: a systematic review of term definitions, treatment approaches, and outcomes of management techniques.J Shoulder Elbow Surg. 2017. 26(6):e177-e187 ***

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Rehab-Massive RTC TearsRehab-Massive RTC Tears Pseudoparalysis of the shoulder has a variable

definitions in the literature without consideration of degree or sub-stratification of other confounders such as the presence of arthritis or pain

The literature supports treating this condition with any variety of treatments

We propose an algorithm to serve as a treatment guideline to aid in surgical decision making for this condition

Tokish JM,… Hawkins RJ. Pseudoparalysis: a systematic review of term definitions, treatment approaches, and outcomes of management techniques.J Shoulder Elbow Surg. 2017. 26(6):e177-e187.

Rehab-Massive RTC TearsRehab-Massive RTC TearsThe treatment modality specifically chosen for the massive, irreparable rotator cuff tear must be tailored to the individual patient, their needs and expectations, and their ability to comply with intensive rehabilitation!!!

Delaney RA, et.al. Nonarthroplasty options for the management of massive and irreparable rotator cuff tears.Clin Sports Med. 2012. 31(4):727-48.

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RTC RTC *** 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 3rd and 6th 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. 39:2071-2081, 2011

Rotator Cuff RehabilitationRotator Cuff Rehabilitation“The threshold of fixation strength needed for early motion and RTC healing is unknown.”

Mall NA, et.al. Factors affecting rotator cuff healing. J Bone Joint Surg Am. May 7;96(9):778-88, 2014

Timeline for Healing & Strength of RTC Repairs ???

Phases I II III IV V VI4 months

8 months 12 months

16 months

Protection Phase

RestoreROM

Early Strength

Functional Recovery

Recovery of skillsport

RTS

100 %80 % X 70 % X60 % X40 % X20 % X

0 % XJP Warner, MDHarvard

Best Guess!!!Based on animal studies,Cadaveric studies and Biomechanical lab StudiesNO HUMAN DATA!!!

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RTC Factors-TrendsRTC Factors-TrendsSling immobilization

for 6 weeks after arthroscopic RTC 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 RTC Repair lead to long-term stiffness?JSES, 19: 1034-1039, 2010

RTC RTC *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. 40:815-821, 2012

Rotator Cuff RehabilitationRotator Cuff Rehabilitation 6 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 with larger tears

Chang, KV, et.al. Early vs delayed ROM exercise forArthroscopic RTC-Repair: a meta-analysis of RCTs.AJSM. Aug, 2014

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Rotator Cuff RehabilitationRotator Cuff Rehabilitation 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 MA1, et.al. Early Versus Delayed Passive Range of Motion After Rotator Cuff Repair: A Systematic Review and Meta-analysis.Am J Sports Med. Oct, 2014

Rotator Cuff RehabilitationRotator Cuff Rehabilitation 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 RTC tears , and thus, might not be advisable after RTC repair

Kluczynski, MA, et.al. Does early vs delayed AROM affect RTC healingAfter surgical repair? A systematic review and meta-analysis.AJSM. 44(3): 785-791, 2016

RTC RehabilitationRTC RehabilitationThe 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 RTC.Knee Surg Sports Traumatol Arthrosc, Aug, 2016

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Biopsychosocial ReasonsBiopsychosocial Reasons

Biopsychosocial ReasonsBiopsychosocial ReasonsElevated fear-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 disorders

2) osteopathies, chondropathies, & acquires musculoskeletal deformities

Bhagwant, S, et.al. Influence of fear-avoidance beliefs on functional status outcomes for people with musculoskeletal conditions of the shoulder. Phys Ther. 92:992-1005, 2012

Biopsychosocial Reasons Biopsychosocial Reasons 139 patients with shoulder pain Patients with high pain

catastrophizing And low pain self-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 withGreater perceived disability and pain in patients presenting to A shoulder clinic. JBJS-A. 97(24):1999-2003, 2015

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Biopsychosocial ReasonsBiopsychosocial Reasons 169 patients with full-thickness

RTC 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 associationWith patient-reported shoulder pain and function than tearSize in patients with full-thickness RTC tears. JBJS-A. 98(4):251-256, 2016

Rotator Cuff ResearchRotator Cuff Research 433 subjects, 87 underwent surgery with 88%

follow-up at 2 years The median age was 62 years, and 49% were

female patients Multivariate modeling, identified patient

expectations regarding physical therapy (P < .0001) as the strongest predictor of surgery.

Higher activity level (P = .011) and not smoking (P = .023) were also significant predictors of surgery.

Dunn WR, et.al. MOON Shoulder Group, et al. 2013 Neer Award: predictors of failure of nonoperative treatment of chronic, symptomaticfull-thickness rotator cuff tears. JSES. 2016 . 25(8):1303-11.

ASES-Rehabilitation-RTCASES-Rehabilitation-RTC Document represents the

FIRST consensus rehabilitation statement developed by a multidisciplinary society of international rehabilitation professionals specifically for the postoperative care of patients with arthroscopic RTCR. (117 references)

Thigpen, CA, et.al. The American Society of Shoulder and Elbow Therapists’ consensus statement on rehabilitation following Arthroscopic rotator cuff repair. JSES. 25:521-535, 2016

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ASES-Rehabilitation-RTCASES-Rehabilitation-RTCPurpose: Aid clinical decision making during the rehabilitation of patients after arthroscopic RTC repair


ASES-Rehabilitation-RTCASES-Rehabilitation-RTCOverarching Philosophy of

Rehabilitation: Centered on the principle of the gradual application of controlled stresses to the healing RTC repair with consideration of RTC tear size, tissue quality, and patient variables


ASES-Rehabilitation-RTCASES-Rehabilitation-RTCPhase-to-phase

progression is based on:1) Achievement of

milestones 2) Criterion-Based 3) Impairment-based


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RTCRTCIn other words, the rehab

program must consider all these variables, Therefore…Rehab programs must be

customized to the individual patient

Rehab-Massive RTC TearsRehab-Massive RTC Tears To review the evidence for the

effectiveness of therapeutic exercise for the treatment of full thickness (including massive and inoperable) tears of the rotator cuff.

There is consensus that the outcome of rotator cuff tendon surgery in the elderly is generally very poor.

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. 2007. 41(4):200-10.***

Rehab-Massive RTC TearsRehab-Massive RTC TearsIn all studies an improvement in

outcome scores was reported. Findings suggest that some

evidence exists to support the use of exercise in the management of full thickness rotator cuff tears.

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. 2007. 41(4):200-10.

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Rehab-Massive RTC TearsRehab-Massive RTC TearsA cohort study of 10 patients evaluating the change from baseline to twelve weeks in the shoulder function of patients undergoing a program of anterior deltoid strengthening and functional rehabilitation.

In spite of the long-standing nature of many of their shoulder problems, this rehabilitation program was shown to improve shoulder function in this group of patients.

Ainsworth R. Physiotherapy rehabilitation in patients with massive, irreparable rotator cuff tears. Musculoskeletal Care. 2006, 4(3):140-51

Rehab-Massive RTC TearsRehab-Massive RTC TearsThe variation shown in the

quality of life scores reflects the age group of this cohort who had a mean age of 75.5 years. All patients deemed their pain

and function to have improved over the three-month period.

Ainsworth R. Physiotherapy rehabilitation in patients with massive, irreparable rotator cuff tears. Musculoskeletal Care. 2006, 4(3):140-51

Rehab-Massive RTC TearsRehab-Massive RTC TearsPatients with massive rotator cuff tears who were treated with an anterior deltoid rehabilitation program. We recommend that a structured deltoid rehabilitation program is suitable for elderly patients with massive rotator cuff tears.

Levy O, et.al. The role of anterior deltoid reeducation in patients with massive irreparable degenerative rotator cuff tears. J Shoulder Elbow Surg. 2008. 17(6):863-70.

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Rehab-Massive RTC TearsRehab-Massive RTC Tears Patients, completed a 3-month

Anterior Deltoid Reeducation (ADR) program

Eighteen of the 30 patients completed the program and had a follow-up at 24 months.

Among these 18 cases, there were significant mean improvements between pre-ADR and follow-up outcome scores among all variables (P < .005)

Yian EH, et.al. Anterior deltoid reeducation for irreparable rotator cuff tears revisited. J Shoulder Elbow Surg. 2017 May 5 ***

Rehab-Massive RTC TearsRehab-Massive RTC TearsThe ADR program had a

success rate of only 40%.A 3-month ADR program

had limited success to treat irreparable RCTs.

Results of this study could not reproduce the high rate of satisfactory results of 82% found in a previous study.

Yian EH, et.al. Anterior deltoid reeducation for irreparable rotator cuff tears revisited. J Shoulder Elbow Surg. 2017 May 5.

Rehab-Massive RTC TearsRehab-Massive RTC TearsAdaptive muscle activation strategies following a massive rotator cuff tear (MRCT) are inadequately understood, and the relationship among muscles during everyday activities has not been considered.

Hawkes DH, et.al. Shoulder muscle activation and coordination in patients with a massive rotator cuff tear: an electromyographic study.J Orthop Res. 2012. 30(7):1140-6. ***

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Rehab-Massive RTC TearsRehab-Massive RTC Tears

In MRCT patients, a reorganization of muscle activation strategy along the upper limb kinetic chain is aimed at reducing demand on the glenohumeral joint.

Hawkes DH, et.al. Shoulder muscle activation and coordination in patients with a massive rotator cuff tear: an electromyographic study.J Orthop Res. 2012. 30(7):1140-6. ***

Rehab-Massive RTC TearsRehab-Massive RTC TearsIncreased activation of the latissimus dorsi and teres major muscles is an attempt to compensate for the deficient rotator cuff.

Re-education towards an alternate neuromuscular control strategy appears necessary to restore function.

Hawkes DH, et.al. Shoulder muscle activation and coordination in patients with a massive rotator cuff tear: an electromyographic study.J Orthop Res. 2012. 30(7):1140-6.

Rehab-Massive RTC TearsRehab-Massive RTC TearsControlled mobilization of

augmented rotator cuff repairs during postoperative rehabilitation may provide mechanotransductive cues capable of guiding tissue regeneration and restoration of rotator cuff function.

***Rothrauff BB, et.al. The Rotator Cuff Organ: Integrating Developmental Biology, Tissue Engineering, and Surgical Considerations to Treat Chronic Massive Rotator Cuff Tears. Tissue Eng Part B Rev. 2017 Feb 9. ***

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STRATIFY THE PATIENT BASED ON THE SIZE OF THE TEAR

Small tears (good tissue quality)

Faster speed Rehab

Medium - large tears (adequate tissue)Moderate speed rehab

Large - massive tear (poor tissue, tenuous repair)

Slow speed rehab ***

Top 8 List for Rehabilitation for Massive RTC Tears

Goals of RehabilitationGoals of Rehabilitation 1) Protect the RTC surgical repair 2) Facilitate early healing by mechanotransductive

cues capable of guiding tissue regeneration and restoration of rotator cuff function.

3) Gain full PROM as appropriate based on the surgery and patient variables

4) Prevent selective hypomobility of the surrounding tissues but protect the healing RTC surgical repair

5) Reestablish, if possible, the dynamic caudal glide and humeral head stability and control

6) Work on TAS, TBS 7) Do not overly stress the healing tissue 8) Work for restoration of specificity of function for the

patient

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A good day in the clinic!

Current Concepts inRehabilitation of Rotator CuffPathology: Nonsurgical andPostoperative ConsiderationsEllenbecker, TS, Davies, GJ. Orthopaedic Knowledge Update:

Sports Medicine 5, Chapter 23© 2016 American Academy of

Orthopaedic Surgeons

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Goals of RehabilitationGoals of Rehabilitation1) Protect the RTC surgical repair

Goals of RehabilitationGoals of Rehabilitation 2) Facilitate early healing by

mechanotransductive cues capable of guiding tissue regeneration and restoration of rotator cuff function.

Goals of RehabilitationGoals of Rehabilitation 3) Gain full PROM as appropriate based

on the surgery and patient variables: 45°, 90, 0°

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ASES-Rehabilitation-RTCASES-Rehabilitation-RTCSome surgeons and scientists

believe that a 6-week period of strict immobilization is preferred

However, there is no clear human evidence to support strict immobilization vs early protected ROM with limits of <90° of FE and <30° of ER within the first 6 weeks


Rehabilitation-RTCRehabilitation-RTC


Goals of RehabilitationGoals of Rehabilitation 4) Prevent selective hypomobility of the

surrounding tissues but protect the healing RTC surgical repair

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Goals of RehabilitationGoals of Rehabilitation 5) Reestablish, if possible, the dynamic caudal

glide and humeral head stability and control

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Dynamic Caudal Glide

“Dynamic Caudal Glide”Rotator Cuff Muscles (SS, IS, TM) Perform As A Functional Dynamic Unit Depressing The HumerusConcomitantly With Shoulder Abduction, flexion and scaption.

Inman Force Couple.Inman, et al. JBJS 26: 1-30, 1944

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E-Stim:ER

ASES-Rehabilitation-RTCASES-Rehabilitation-RTCDeltoid

Re-educationProgramusingBiofeedback

Goals of RehabilitationGoals of Rehabilitation6) Work on TAS, TBS

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Goals of RehabilitationGoals of Rehabilitation 7) Do not overly stress the healing tissue

Goals of RehabilitationGoals of Rehabilitation8) Work for restoration of specificity

of function for the patient

Rehab-Massive RTC TearsRehab-Massive RTC TearsSuperior capsule reconstruction

(SCR) is a recently-developed surgical technique for the treatment of massive, irreparable rotator cuff tears.

As this technique has only been recently developed, an evidence-based rehabilitation protocol has not been previously designed.

Pogorzelski J, …. Millett PJ. SUPERIOR CAPSULE RECONSTRUCTION FOR MASSIVE ROTATOR CUFF TEARS - KEY CONSIDERATIONS FOR REHABILITATION. Int J Sports Phys Ther. 2017 Jun;12(3):390-401.***

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Rehab-Massive RTC TearsRehab-Massive RTC Tears The existing evidence is supplemented by the

experience of the senior author who has performed more than forty superior capsule reconstruction procedures to date.

Rehabilitation protocol consists of four distinct phases:

1) maximal protection 2) range of motion and muscular endurance 3) muscular strength 4) return to activity.Pogorzelski J, …. Millett PJ. SUPERIOR CAPSULE RECONSTRUCTION FOR MASSIVE ROTATOR CUFF TEARS - KEY CONSIDERATIONS FOR REHABILITATION. Int J Sports Phys Ther. 2017 Jun;12(3):390-401.

Superior Capsular ReconstructionSuperior Capsular Reconstruction

Rehab-Massive RTC TearsRehab-Massive RTC Tears

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Rehab - SCRRehab - SCR

Slideboard-assisted scaption for deltoid activation.

Rehab - SCRRehab - SCR

Slideboard-assisted forward elevation in the scapular plane.

Rehabilitation-RTCRehabilitation-RTCMounting evidence that eccentric

exercise is not only a therapeutic intervention influencing muscle morphology, but also targets unique alterations to neuromuscular control because it is beneficial to peripheral and central neural activity:

Alpha motorneuron recruitment/firing Sarcolemma activity Corticospinal excitability Brain activation Lepley, L, et.al. Eccentric exercise to enhance neuro-muscular control. Sports Health. 9(4):333-340, 2017

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Rehab – SCR Rehab – SCR

Seated, assisted forward elevation with external rotation resistance.

RTC RTC Dynamic joint function is not completely restored by RTC 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 RTC 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. 39:2117-2129, 2011

Rehabilitation-RTCRehabilitation-RTC 164 Patients Isometric strength in FF, IR, ER @

6,12,18,24 months FU To reach the strength of the uninjured contralateral

shoulder in all 3 planes of motion, recovery took: 1) 6 months in patients with small tears 2) 18 months in patients with medium tears 3) Patients with large-to-massive tears showed

continuous improvement in strength up to 18 months; however, they did not reach the strength of the contralateral shoulder at final follow-up

Shin S J, et.al. Recovery of Muscle Strength After Intact ArthroscopicRTCR According to Preoperative Rotator Cuff Tear Size.Am J Sports Med. Apr;44(4):972-80, 2016 ***

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Rehabilitation-RTCRehabilitation-RTC This study recommends that

regardless of pain relief and improved shoulder function, patients with larger than medium tears should be encouraged to continue with rehabilitation for the maximal restoration of muscle strength beyond 1 year postoperatively.

Shin S J, et.al. Recovery of Muscle Strength After Intact ArthroscopicRTCR According to Preoperative Rotator Cuff Tear Size.Am J Sports Med. Apr;44(4):972-80, 2016

SummaryAnd

Conclusions

Goals of RehabilitationGoals of Rehabilitation 1) Protect the RTC surgical repair 2) Facilitate early healing by mechanotransductive

cues capable of guiding tissue regeneration and restoration of rotator cuff function.

3) Gain full PROM as appropriate based on the surgery and patient variables

4) Prevent selective hypomobility of the surrounding tissues but protect the healing RTC surgical repair

5) Reestablish, if possible, the dynamic caudal glide and humeral head stability and control

6) Work on TAS, TBS 7) Do not overly stress the healing tissue 8) Work for restoration of specificity of function for the

patient

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Congratulations and Thanks To Rush for Chicago Sports Medicine Symposium-2017

Thank You...definitions, treatment approaches, and outcomes of management techniques. J Shoulder...

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