rehabilitation of rotator cuff tears - rehabilitation of rotator cuff tears: a literature review and

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    Rehabilitation of rotator cuff tears: A literature review and evidence-based rehabilitation

    protocol

    Prof dr Ann Cools, PT, PhD Dept Rehab. Sciences & Physiotherapy

    Ghent University, BelgiumA Cools RC tears 2016

    Ann Cools - Nice June 2016

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    Epidemiology (Simon Lambert, EUSSER conference London 2012, Teunis et al. Syst Rev JSES 2014)

    A Cools RC tears 2016

    Classification of RC tears (Al-Hakim S&E 2015)

    Normal rotator cuff

    A Cools RC tears 2016

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    A Cools RC tears 2016

    Classification of RC tears (Al-Hakim S&E 2015)

    Common tear of the ageing cuff

    Remains stable because the fibrous endoskeleton remains attached

    Often acceptable restoration of function and pain after initial onset

    A Cools RC tears 2016

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    Classification of RC tears (Al-Hakim S&E 2015)

    The predominantly unstable cuff lesion

    Cable is slack and retracts medially

    Rotator interval widens allowing humeral head escaping anterosuperiorly

    A Cools RC tears 2016

    Classification of RC tears (Al-Hakim S&E 2015)

    The predominantly weak cuff lesion

    Tear extends posteriorly, through the posterior pillar

    Weak external rotation

    Slight posterio-superior subacromial shift

    A Cools RC tears 2016

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    Classification of RC tears (Al-Hakim S&E 2015)

    Massive rotator cuff tear

    All 3 muscles involved

    Unstable, weak and painful

    Often lesion LHB, synovitis, joint arthropathy

    A Cools RC tears 2016

    Classification of rotator cuff tears

    A Cools RC tears 2016

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    How active are the elderly?

    Master Athletes = “Active individuals aged 50yrs or older, who desire optimal levels of performance or wish to exercise for general health and have high expectations for sports medicine care, including return to sport or activity after injury”

    (Selected Issues for the Master Athlete and the Team Physician: A consensus statement. Med Sci Sports Exc 2010)

    A Cools RC tears 2016

    Exercise as a treatment for RC full thickness ruptures (Systematic Review Ainsworth & Lewis, BJSM 2007)

    – Exercise therapy, defined as strengthening and stretching, when included as a part of a treatment program, has a beneficial effect for patients who have symptomatic shoulders and radiological or arthroscopic evidence of full thickness RC tears

    – Not possible to determine if exercise alone or combined with other interventions offer the greatest benefit

    – Time-recommendations: 3-18 months

    A Cools RC tears 2016

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    Exercise as a treatment for RC full thickness ruptures (Kuhn MOON study JSES 2013)

    – Large multi-center Case Series study (N=452)

    – Conservative treatment following specific protocol

    – Follow-up 6-12 weeks with 3 options: (1) cured, (2) better, continue program, and (3) no better, offered surgery

    – Final follow up 1-2 year

    – Sign improvement of patient-reported outcomes

    – 75% successful,

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    General Guidelines for rehabilitation

    • Capsular mobilization to increase ROM • Stretching after capsular mobilization • Maximize RC strength • Maximize scapular position/motion as part of the

    scapulohumeral rhythm • Change workouts: lighter weights, different positions….

    A Cools RC tears 2016(Selected Issues for the Master Athlete and the Team Physician: A consensus statement. Med Sci Sports Exc 2010)

    Personal Experience

    Patients often have deficient rotator cuff: value of cuff training?

    Let’s try to optimize function without focussing too much on the structures…

    Re-education of daily and athletic activities with the purpose to postpone the final match…

    A Cools RC tears 2016

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    Conservative treatment RC tears (partial, irreparable)

    TREATMENT GOAL

    optimize function, in particular elevation above shoulder height ,

    with limited load on the RC

    A Cools RC tears 2016

    “structure”-based versus “function” based rehab

    Based on structure Based on function

    Ann Cools - Nice June 2016

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    Scientific base for Treatment Strategy (Uhl PM&R 2010, Gaunt et al. 2010, Levy JSES 2008, Ainsworth et al. Sz&E 2009, Murphy et al. JSES 2013)

    A Cools RC tears 2016

    Exercise program for RC tears

    2 exercises - semi-closed elevation exercises +/- 9

    progressions (Uhl et al. 2010, Lewis 2016, Gaunt et al. 2010) - “ant deltoid” exercises +/- 5

    progressions (Levy et al. 2008, Ainsworth at al. 2009)

    A Cools RC tears 2016

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    Semi-closed chain elevation exercises

    1. Closed chain pendulum exercises

    2. Bilateral bench slide < 90°

    3. Unilateral bench slide < 90°

    4. Unilateral bench slide > 90°

    5. Uniletaral bench slide > 90° + resistance

    6. Wall slide

    7. Wall slide + resistance

    8. Wall slide + resistance + open chain @ max elevation

    9. Wall slide – resistance + open chain @ max elevation

    A Cools RC tears 2016

    Semi-closed chain exercises without/with resistance (1)

    A Cools RC tears 2016

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    Semi-closed chain exercises without/with resistance (2)

    A Cools RC tears 2016

    Semi-closed chain exercises without/with resistance (3)

    A Cools RC tears 2016

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    “anterior deltoid” program

    1. Passive 2. Active – weight 3. Active + weight 4. Increasing inclination angle trunk 5. Seated – weight 6. Seated + weight

    A Cools RC tears 2016

    (Levy et al. JSES 2008) A Cools RC tears 2016

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    (Levy et al. JSES 2008) A Cools RC tears 2016

    EMG in SS < 10% MVC

    A Cools RC tears 2016

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    A Cools RC tears 2016

    A Cools RC tears 2016

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    3 stages of exercises:

    1. Passive

    2. Active

    3. With resistance and increase inclination A Cools RC tears 2016

    A Cools RC tears 2016

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    A Cools RC tears 2016

    A Cools RC tears 2016

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    Both: US + advise + steriod injection

    A: + exercise program

    Ex = Levy program

    Limitation: no comparison with other ex program

    A Cools RC tears 2016

    POSTOPERATIVE TREATMENT after RC repair

    Factors affecting the postoperative rotator cuff healing and rehabilitation program:

    1. Demographic factors (younger age, male) 2. Clinical factors (no diabetes, no obesity, no smoking, more

    sports activity and ROM pre-op)

    3. Factors related to cuff integrity (size of the tear, less fatty infiltration and retraction)

    4. Factors related to surgical procedure (no concomitant biceps of AC procedures)

    (Fermont et al. Prognostic factors for successful recovery after arthroscopic rotator cuff repari: a systematis literature review JOSPT 2014;44(3):153-163)

    A Cools RC tears 2016

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    GOALS of the rehabilitation (Thigpen et al. JSES 2016: Consensus statement on rehab after RC repair)

    Protect the repair Promote healing Gradually restore ROM Gradually restore muscle strength Gradually restore function A Cools RC tears 2016

    Protect the repair

    Soft tissue-to-bone healing is slow: starts with formation of fibrovascular tissue interface between tendon & bone (Rodeo JBJS 1993)

    At least 12 weeks of healing is necessary allowing pull-out strength of the repair (Sonnabend JBJS 2010)

    A Cools RC tears 2016

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    Factors that improve tendon-to-bone healing:

    • Pressure (Weiler Arthr 2002)

    • “Tendon” immobilisation (Ghodadra JOSPT 2009)

    • Positioning (abduction / scapular plane) (Hatakeyama AJSM 2001)

    (Ghodadra NS et al. Open, Mini-open and all-arthorscopic rotator cuff repair surgery: indications and implications for rehabilitation JOSPT 2009)

    A Cools RC tears 2016

    Immobilisation: Risk for frozen shoulder…

    incidence of 5% stiff shoulder after RC repair, with risk factors:

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    Early mobilisation: Risk for re-tear…

    Strong evidence that early initiation of rehabilitation and functional loading does not adversely affect clinical outcome (Syst Review Littlewood S&E 2015)

    Early ROM exercises accelerate recovery, but are likely to result in improper tendon healing in shoulders with large-sized tears (meta-analysis of RCT Chang AJSM 2014)

    A Cools RC tears 2016

    Summary…

    Individualized choice of rehabilitation program based on risk factors since no single rehabilitation protocol in general is superior to another (Chang AJSM 2014, Thomson et al. 2016)

    In at-risk patients (with calcific tendonitis, adhesive capsulitis, labral repair), a postoperative rehabilitation regimen that incorporates early closed-chain passive overhead motion can reduce the incidence of postoperative stiffness after arthroscopic rotator cuff repair. (Koo Arth 2011)

    A Cools RC tears 2016

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    What after surgery? (Antoni et al. 2016)

    A Cools RC tears 2016

    What after surgery? (Antoni et al. 2016)

    A Cools RC tears 2016

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