A prospective randomized controlled trial comparing occupational therapy with home-based exercises in conservative treatment of rotator cuff tears

doi:10.1016/j.jse.2013.01.008

Journal of Shoulder and Elbow Surgery

Volume 22, Issue 9, September 2013, Pages 1173-1179

https://doi.org/10.1016/j.jse.2013.01.008 Get rights and content

Background

This pilot study evaluates the outcome after occupational therapy, compared to home-based exercises in the conservative treatment of patients with full thickness rotator cuff tears.

Methods

Forty-three adult subjects (range, 18-75 years), who had a full thickness rupture of the rotator cuff which was verified by magnetic imaging tomography, with clinical signs of a chronic rotator cuff impingement, and who were available for follow-up, were randomized to occupational therapy or to independent home-based exercises using a booklet. After drop-out, 38 patients were available for full examination at follow-up. Before therapy and after 2 months of conservative treatment, pain intensity, the Constant-Murley score, isokinetic strength testing in abduction and external rotation, functional limitation, clinical shoulder tests and health-related quality of life (EQ-5D) were evaluated.

Results

Two-thirds of the patients improved in clinical shoulder tests, regardless of the therapy group. There were no significant differences between the groups with reference to pain, range of motion, maximum peak force (abduction, external rotation), the Constant-Murley score, and the EQ-5D index. The only significant difference observed was the improvement in the self-assessed health- related quality of life (EQ-5D VAS) favoring home-based exercises.

Conclusion

Home-based exercise, on the basis of an illustrated booklet with exercises twice a day, supplies comparable results to formal occupational therapy in the conservative treatment of rotator cuff tears. The results of this pilot study suggest some potential advantages related to psychological benefits using home-based treatment.

Section snippets

Materials and methods

Between September 2010 and May 2011, 43 patients with unilateral, symptomatic, atraumatic rotator cuff tears were recruited by 3 centers for orthopedics, given that surgery was not recommended and they had elected to participate in the non-operative physical therapy treatment program. Surgery is usually recommended in younger patients, and if severe chronic pain at rest and impaired shoulder function is apparent. Patients were randomized, according to a computerized random-number generator, to

Statistics

Statistical analysis was performed using SAS V9.3 (SAS, Cary, NC, USA). For both ordinal and numerical scores, nonparametric statistics (rank sum test according to Wilcoxon-Mann-Whitney) were used as normal distributions could not safely be assumed. For categorical variables, Fisher’s exact test (instead of χ²-tests) was used to account for cells with low expected frequencies. The level of significance for every comparison was set to α = 0.05.

Results

Forty-three patients were recruited and enrolled in the study (Fig 1): 23 were randomized to occupational therapy and 20 to home-based, independent exercises. Thirty-eight patients (89%) completed the whole therapy and follow-up. Five patients had to be excluded from the study: 3 patients (1 with occupational, 2 with independent therapy) missed the 2 months' evaluation without giving any reasons. One patient in the home-based treatment group received a prescription from his general

Discussion

Most rotator cuff tears can be treated successfully by conservative management, including non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroid injections, and functional rehabilitation therapy.³ This is in concordance with clinical reports indicating that 88% of the shoulders had no or even slight pain more than 10 years after diagnosis under conservative management.¹²

Our findings suggest that a home-based therapy program on the basis of an illustrated booklet with independent

Conclusion

This clinical trial supports the concept of independent treatment with home-based exercises in the conservative management of rotator cuff tears. Using home-based exercises, improvements in pain, ROM, and strength, comparable to prescribed occupational therapy, can be expected. However, bearing in mind that this study was a pilot trial with a rather small sample size, a replication and further investigations of subgroup effects in a bigger trial, preferably with a noninferiority design, are

Acknowledgment

This study was supported by the Centre of Musculoskeletal Research (zmfu), Ulm University, Germany (SPZ.000317). The authors thank Dr. Stefanie Schilf for assistance and modeling the illustrations. The authors also wish to thank the ambulatory health and rehabilitation centre RehaPlus, Ulm, for their technical help and for providing measuring devices (Biodex 3).

Disclaimer

The authors, their immediate families, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article.

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Cited by (35)

Impact of Bracing and Therapy Services on Perioperative Costs for Patients Undergoing Distal Biceps Tendon Repair
2023, Journal of Hand Surgery
This study aimed to quantify and assess perioperative costs in an integrated healthcare system for patients undergoing distal biceps tendon (DBT) repair with and without the use of postoperative bracing and formal physical (PT) or occupational (OT) therapy services. In addition, we aimed to define clinical outcomes after DBT repair using a brace-free, therapy-free protocol.
We retrospectively reviewed all cases of DBT repairs within our integrated system from 2015 to 2021. We performed a retrospective review of a series of DBT repairs utilizing the brace-free, therapy-free protocol. For patients with our integrated insurance plan, a cost analysis was conducted. Claims were subdivided to assess total charges, costs to the insurer, and patient costs. Three groups were created for comparisons of total costs: (1) patients who had both postoperative bracing and PT/OT, (2) patients who had either postoperative bracing or PT/OT, and (3) patients who had neither postoperative bracing nor PT/OT.
A total of 36 patients had our institutional insurance plan and were included in the cost analysis. For patients using both bracing and PT/OT, these services contributed 12% and 8% of the total perioperative costs, respectively. Implant costs accounted for 28% of the overall cost. Forty-four patients were included in the retrospective review with a mean follow-up of 17 months. The overall QuickDASH was 12; two cases resulted in unresolved neuropraxia, and there were no cases of re-rupture, infection, or reoperation.
Within an integrated healthcare system, postoperative bracing and PT/OT services increase the cost of care for DBT repair and account for 20% of the total perioperative charges in cases where bracing and therapy are used. Considering the results of prior investigations indicating that formal PT/OT and bracing offer no clinical advantages over immediate range of motion (ROM) and self-directed rehabilitation, upper-extremity surgeons should forego routine brace and PT/OT utilization after DBT repair.
Therapeutic IV.
“You have (rotator cuff related) shoulder pain, and to treat it, I recommend exercise.” A scoping review of the possible mechanisms underpinning exercise therapy
2022, Musculoskeletal Science and Practice
Citation Excerpt :
Twenty-seven different exercise packages (one or multiple exercise interventions) were identified for the management of RCRSP (Table 5). The most frequently used exercise package was a multimodal program of resistance exercise, stretching exercise and mobility exercise (n = 27) (Heron et al., 2017; Akbaba et al., 2019; Baskurt et al., 2011; Calis et al., 2011; Celik et al., 2009a; Celik et al., 2009b; Chaconas et al., 2017; di Lorenzo et al., 2006; Dilek et al., 2016; Dunning et al., 2021; Krischak et al., 2013; Kromer et al., 2013; Kul and Ugur, 2019; Martins and Marziale, 2012; Marzetti et al., 2014; Menek et al., 2019; Pasin et al., 2019; Pekyavas and Ergun, 2017; Santello et al., 2020; Senbursa et al., 2011; Shah et al., 2014; Subasi et al., 2012; Subhash and Makhija, 2020). Multimodal exercise programs were used five times more (n = 109) than unimodal programs (n = 21).
Exercise is considered to be both essential and at the forefront of the management of rotator cuff-related shoulder pain (RCRSP). Despite this, many fail to substantially improve with exercise-based treatment. Hence, expanding the current knowledge about the possible mechanisms of exercise for RCRSP is critical.
To synthesise the range of mechanisms proposed for exercise in people with RCRSP.
Scoping review
A systematic search of the Physiotherapy Evidence Database (PEDro) was conducted from inception to July 3, 2022. Two reviewers conducted the search and screening process and one reviewer extracted the data from each study. Randomised clinical trials using exercise for the management of RCRSP of any duration were included. The PEDro search terms used were “fitness training”, “strength training”, “stretching, mobilisation, manipulation, massage”, “upper arm, shoulder, or shoulder girdle”, “pain”, and “musculoskeletal”. Data were analysed using quantitative and qualitative approaches.
626 studies were identified and 110 were included in the review. Thirty-two unique mechanisms of exercise were suggested by clinical trialists, from which 4 themes emerged: 1) neuromuscular 2) tissue factors 3) neuro-endocrine-immune 4) psychological. Neuromuscular mechanisms were proposed most often (n = 156, 77%). Overall, biomedical mechanisms of exercise were proposed in 95% of cases.
The causal explanation for the beneficial effect of exercise for RCRSP in clinical research is dominated by biomedical mechanisms, despite a lack of supporting evidence. Future research should consider testing the mechanisms identified in this review using mediation analysis to progress knowledge on how exercise might work for RCRSP.
Effectiveness of Home-Based Exercise for Nonspecific Shoulder Pain: A Systematic Review and Meta-analysis
2022, Archives of Physical Medicine and Rehabilitation
Citation Excerpt :
These 12 studies were published between 2003 and 2018. Of these, 8 studies (67%) were randomized controlled trials,17,37-41,43,45 and 4 studies (33%) were randomized controlled trials.13,36,42,44 The sample size in each study varied from 30-250 participants, with a total number of 935 participants.
To evaluate the effectiveness of home-based exercise to treat nonspecific shoulder pain (NSSP).
MEDLINE, Embase, Cumulative Index to Nursing and Allied Health, Cochrane Controlled Register of Trials, and Physiotherapy Evidence Database were searched from inception to January 2022.
Independent reviewers selected randomized controlled trials that compared the effects of home-based exercise alone with no treatment or other conservative treatments in individuals with nonsurgical painful shoulder disorders. The primary outcomes were shoulder pain intensity and function, and the secondary outcome was shoulder range of motion (ROM).
Two reviewers independently conducted data extraction. The risk of bias was assessed using the Cochrane Risk of Bias 2.0 tool, and the overall quality of the evidence was evaluated using the Grading of Recommendation Assessment, Development, and Evaluation approach.
Twelve studies were included in the review, and 10 studies were included in the meta-analysis. Low to moderate quality of evidence indicated that home-based exercise alone and other conservative treatments showed equal improvements in pain intensity reduction (mean difference [MD], 0.27; 95% confidence interval [CI], −0.12 to 0.65; I²=30%), function (standardized mean difference [SMD], 0.12; 95% CI, −0.14 to 0.38; I²=16%), flexion ROM (MD, 4.61; 95% CI, −1.16 to 10.38; I²=54%), and abduction ROM (MD, 3.74; 95% CI, −12.44 to 19.93; I²=82%). Very low quality of evidence indicated that home-based exercise alone was more effective than no treatment for pain intensity reduction (MD, −1.47; 95% CI, −2.33 to -0.61) and function improvement (SMD, −0.81; 95% CI, −1.31 to -0.31; large effect).
Home-based exercise alone may be equally effective as other conservative treatments and superior to no treatment for the treatment of NSSP. To draw firmer conclusions, further research is required to validate these findings.
Exercise as effective as surgery in improving quality of life, disability, and pain for large to massive rotator cuff tears: A systematic review & meta-analysis
2022, Musculoskeletal Science and Practice
Citation Excerpt :
The certainty of evidence was very low across all three time points (Table 4). Two studies (Ainsworth et al., 2009; Krischak et al., 2013) found no significant difference in flexion range between the experimental (n = 53) and control group (n = 50) at 2–3 months (REM, MD 10.84 95% CI, −17.47, 39.15, I2 = 77%, p = 0.45), three studies (Ainsworth et al., 2009; Gialanella et al., 2018; Moosmayer et al., 2014) (n = 203) also found no significant difference at 6 months (REM, MD 13.54 95% CI, −3.01, 30.10, 12 = 55%, p = 0.11) and this was replicated at 12 months in two studies (Ainsworth et al., 2009; Moosmayer et al., 2014) (n = 163) (REM, MD -1.84 95% CI, −22.97, 19.29, I2 = 61%, p = 0.86). The certainty of evidence was very low for 3 and 12 months and low for 6 months (Table 4).
To report the characteristics of exercise interventions and ascertain their effectiveness compared to surgery on quality of life, disability, and pain for people with large to massive rotator cuff tendon tears (L-MRCTTs).
Systematic review with meta-analysis of randomised controlled trials (RCTs).
Adults with L-MRCTTs defined as; >5 cm, 2 or more tendons.
Exercise as an intervention for L-MRCTTs.
Primary: quality of life, disability, and pain. Secondary: range of motion (ROM). The Consensus on Exercise Reporting Template (CERT) was used to extract data on the individual characteristics of each exercise intervention. The Cochrane Risk of Bias Tool V2 was used to assess study quality with the certainty of evidence assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria.
Five trials (n = 297 participants, average age 66.7 years, 55% male) were included in analysis. Three trials compared exercise to another non-surgical intervention and 2 trials compared exercise to surgery. At 12 months a significant improvement in pain of 0.47 (95% CI 0.07–0.88, I² = 53%, REM) favoured the surgical group and a significant improvement in shoulder external rotation ROM of 9° (95% CI 2.16–16.22, I² = 0%, FEM) favoured the exercise group. The median CERT score was 7/19 (range 4–12). The certainty of evidence was low or very low across all outcomes.
A paucity of high-quality research on the role of exercise in the management of L-MRCTTs exists with substantial discrepancies in the reporting of the exercise interventions in the published research.
Progressive exercise compared with best practice advice, with or without corticosteroid injection, for the treatment of patients with rotator cuff disorders (GRASP): a multicentre, pragmatic, 2 × 2 factorial, randomised controlled trial
2021, The Lancet
Corticosteroid injections and physiotherapy exercise programmes are commonly used to treat rotator cuff disorders but the treatments' effectiveness is uncertain. We aimed to compare the clinical effectiveness and cost-effectiveness of a progressive exercise programme with a single session of best practice physiotherapy advice, with or without corticosteroid injection, in adults with a rotator cuff disorder.
In this pragmatic, multicentre, superiority, randomised controlled trial (2 × 2 factorial), we recruited patients from 20 UK National Health Service trusts. We included patients aged 18 years or older with a rotator cuff disorder (new episode within the past 6 months). Patients were excluded if they had a history of significant shoulder trauma (eg, dislocation, fracture, or full-thickness tear requiring surgery), neurological disease affecting the shoulder, other shoulder conditions (eg, inflammatory arthritis, frozen shoulder, or glenohumeral joint instability), received corticosteroid injection or physiotherapy for shoulder pain in the past 6 months, or were being considered for surgery. Patients were randomly assigned (centralised computer-generated system, 1:1:1:1) to progressive exercise (≤6 sessions), best practice advice (one session), corticosteroid injection then progressive exercise, or corticosteroid injection then best practice advice. The primary outcome was the Shoulder Pain and Disability Index (SPADI) score over 12 months, analysed on an intention-to-treat basis (statistical significance set at 1%). The trial was registered with the International Standard Randomised Controlled Trial Register, ISRCTN16539266, and EuDRACT, 2016-002991-28.
Between March 10, 2017, and May 2, 2019, we screened 2287 patients. 708 patients were randomly assigned to progressive exercise (n=174), best practice advice (n=174), corticosteroid injection then progressive exercise (n=182), or corticosteroid injection then best practice advice (n=178). Over 12 months, SPADI data were available for 166 (95%) patients in the progressive exercise group, 164 (94%) in the best practice advice group, 177 (97%) in the corticosteroid injection then progressive exercise group, and 175 (98%) in the corticosteroid injection then best practice advice group. We found no evidence of a difference in SPADI score between progressive exercise and best practice advice when analysed over 12 months (adjusted mean difference −0·66 [99% CI −4·52 to 3·20]). We also found no evidence of a difference between corticosteroid injection compared with no injection when analysed over 12 months (−1·11 [–4·47 to 2·26]). No serious adverse events were reported.
Progressive exercise was not superior to a best practice advice session with a physiotherapist in improving shoulder pain and function. Subacromial corticosteroid injection provided no long-term benefit in patients with rotator cuff disorders.
UK National Institute for Health Research Technology Assessment Programme.
Exploring the needs of certified hand therapists regarding electronic applications
2018, Journal of Hand Therapy
Survey.
App technology may provide a beneficial clinical resource for CHTs.
This descriptive study examined beneficial components for inclusion in a potential app for certified hand therapists to use as a clinical resource based on a nationwide survey.
Certified hand therapist members of the American Society of Hand Therapists were surveyed to evaluate preferences of content to be included in a potential clinical app.
Most of the 341 respondents were Caucasian, female, 51-60 years old, with 21+ years' experience. Respondents preferred home program illustrations, video demonstrations, evidence-based resources, postoperative protocols, and functional outcome measures. Regarding app usage, 26.7% responded “definitely use the app” and 37.5% reported “highly likely to use the app” within a price range of $1-$20.
An ideal app should include home program media, evidence-based practice, postoperative protocols, and functional outcome measures related to reported diagnoses encountered in the clinic.
N/A.

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: The study protocol was approved by the Human Research Committee at Ulm University (Approval 212/10).

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ShoulderA prospective randomized controlled trial comparing occupational therapy with home-based exercises in conservative treatment of rotator cuff tears

Background

Methods

Results

Conclusion

Section snippets

Materials and methods

Statistics

Results

Discussion

Conclusion

Acknowledgment

Disclaimer

Arch Phys Med Rehabil

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Injury

J Shoulder Elbow Surg

Long term results of surgical repair of full thickness rotator cuff tears

Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial

BMJ

Conservative treatment of rotator cuff injuries

J Surg Orthop Adv

A clinical method of functional assessment of the shoulder

Clin Orthop Relat Res

Modeling valuations for EuroQol health states

Med Care

153 Accurately measuring outcomes after surgery for adult Chiari I malformation: determining the most valid and responsive instruments

Neurosurgery

Shoulder
A prospective randomized controlled trial comparing occupational therapy with home-based exercises in conservative treatment of rotator cuff tears