What Is the Optimal Rotator Cuff Rehabilitation Program?If you went from surgeon-to-surgeon, state-to-state, and region-to-region in the United States you would not find one single rehab program used by all for patients who have had surgery for a rotator cuff tear. And that's true even though everyone agrees that patients must closely follow the postoperative Dos and Don'ts they are given. One of those Dos is to complete their rehab program from start to finish.
The authors of this study set out to review all of the published studies on rehabilitation for rotator cuff repairs. They wanted to see if there was enough evidence in a systematic review of this type to say just what is the optimal evidence-based rehab protocol for this problem.
They set their standard for studies to be included to those that were high-quality (Levels I and II) evidence. The studies had to involve randomized clinical trials of patients who had rehabilitation after surgery to repair the damaged rotator cuff.
Even after searching all of the most reputable databases, they only found 12 studies published over a 40-year period (1966 to 2008). And only four of those studies were appropriate because they met all the criteria set up by the review committee to qualify as a Level I or II high-quality evidence-based study. These four studies were limited to reviewing the results of continuous passive motion (CPM) after surgery and the use of supervised physical therapy versus unsupervised home exercise.
Before going on to describe the findings from these studies, the authors made it clear that each of these four studies had some weaknesses. The strength of the evidence was called into question because of those design flaws. So although they present the results, they advise the reader to consider the conclusions carefully.
Continuous passive motion (CPM) is a way to keep the arm moving with gentle range-of-motion. The arm is placed in a device that is set to whatever motion is desired. It is motorized and repetitively moves the arm through the preset arc of motion.
According to the two acceptable studies, CPM didn't really improve overall strength or function. But patients did get improved motion. And some patients (women and people over age 60), reported a greater reduction in pain compared to men or younger women. The authors concluded that CPM is safe and effective. But for the cost of the machine, it appeared more cost effective to rely on a program of passive range-of-motion.
In the studies comparing a supervised physical therapy program versus a home program of exercise, there was no advantage of one over the other. Outcome measures of the results included range-of-motion, strength, function, and patient satisfaction. For those who exercised at home, instruction was provided by the therapist either in an individual session during the first week after surgery or via a videotape used at hoome demonstrating the exercise program.
With only four high-level studies to use in a systematic review, the authors point out the need for some decent trials to investigate the optimal rehab program for rotator cuff repairs. Just looking at one aspect of rehab (whether that is CPM, physical therapy, exercise or some other intervention), is not likely to answer the question of what rehab program is best for patients to follow after rotator cuff surgery. The benefit of this study was to show clearly that we are a long way from publishing standard guidelines for this problem.
Keith M. Baumgarten, MD, et al. Rotator Cuff Repair Rehabilitation: A Level I and II Systematic Review. In Sports Health. March/April 2009. Vol. 1. No. 2. Pp. 125-130.
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