An Open Letter from Past Presidents of the American Nurses Association.

Eight former ANA presidents urge nurses to consider nursing's values when they vote.

A prospective evaluation of survivorship of asymptomatic degenerative rotator cuff tears.

BACKGROUND: The purpose of this prospective study was to report the long-term risks of rotator cuff tear enlargement and symptom progression associated with degenerative asymptomatic tears. METHODS: Subjects with an asymptomatic rotator cuff tear in one shoulder and pain due to rotator cuff disease in the contralateral shoulder enrolled as part of a prospective longitudinal study. Two hundred and twenty-four subjects (118 initial full-thickness tears, fifty-six initial partial-thickness tears, and fifty controls) were followed for a median of 5.1 years. Validated functional shoulder scores were calculated (visual analog pain scale, American Shoulder and Elbow Surgeons [ASES], and simple shoulder test [SST] scores). Subjects were followed annually with shoulder ultrasonography and clinical evaluations. RESULTS: Tear enlargement was seen in 49% of the shoulders, and the median time to enlargement was 2.8 years. The occurrence of tear-enlargement events was influenced by the severity of the final tear type, with enlargement of 61% of the full-thickness tears, 44% of the partial-thickness tears, and 14% of the controls (p < 0.05). Subject age and sex were not related to tear enlargement. One hundred subjects (46%) developed new pain. The final tear type was associated with a greater risk of pain development, with the new pain developing in 28% of the controls, 46% of the shoulders with a partial-thickness tear, and 50% of those with a full-thickness tear (p < 0.05). The presence of tear enlargement was associated with the onset of new pain (p < 0.05). Progressive degenerative changes of the supraspinatus muscle were associated with tear enlargement, with supraspinatus muscle degeneration increasing in 4% of the shoulders with a stable tear compared with 30% of the shoulders with tear enlargement (p < 0.05). Nine percent of the shoulders with a stable tear showed increased infraspinatus muscle degeneration compared with 28% of those in which the tear had enlarged (p = 0.07). CONCLUSIONS: This study demonstrates the progressive nature of degenerative rotator cuff disease. The risk of tear enlargement and progression of muscle degeneration is greater for shoulders with a full-thickness tear, and tear enlargement is associated with a greater risk of pain development across all tear types. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Reliability of patient self-assessment of shoulder range of motion and strength after shoulder arthroplasty.

BACKGROUND: Patient-derived self-assessment potentially minimizes loss of valuable outcomes data, conserves medical resources, and benefits patients by saving valuable time out of work and travel expenses. The purpose of this study was to determine the physician-patient correlation of a patient-derived outcomes questionnaire that assesses range of motion (ROM) and strength after shoulder arthroplasty. METHODS: One hundred twenty consecutive patients completed a home-based questionnaire before their 1-year postoperative visit after shoulder arthroplasty. The questionnaire contained demographic information such as age, gender, type of surgery, education level, and income. Diagram-based questions, in which patients were asked to identify the image representing their own active shoulder ROM in various planes, were included. Patients were asked to perform a strength examination using premeasured zip-lock bags filled with water that correspond to predetermined weights up to 2.72 kg. The κ statistics were used to assess the degree of agreement between the patient's self-assessment and the clinician's measures. RESULTS: The κ statistics indicated moderate clinician-patient agreement (0.5-0.59) on items related to ROM and substantial to almost perfect agreement (0.62-0.92) on items related to strength (forward flexion and abduction). A majority of patients (>88%) correctly estimated their ROM within 1 grade of the clinician's measurement. Patients tended to err toward overestimating their ROM. CONCLUSIONS: This patient-derived questionnaire provides a moderate to high level of agreement with clinician assessment. This assessment questionnaire may be an important tool in facilitating both clinical and research follow-up of patient outcomes after shoulder arthroplasty.

Rehabilitation following arthroscopic rotator cuff repair: a prospective randomized trial of immobilization compared with early motion.

BACKGROUND: The influence of rehabilitation on the outcomes after arthroscopic rotator cuff repair remains unknown. The purpose of this study was to compare clinical results and tendon healing rates following arthroscopic rotator cuff repair utilizing two distinct rehabilitation protocols. METHODS: Over a thirty-month period, 124 patients under the age of sixty-five years underwent arthroscopic repair of a full-thickness rotator cuff tear measuring <30 mm in width. Postoperatively, patients were randomized either to a traditional rehabilitation program with early range of motion or to an immobilization group with delayed range of motion for six weeks. Clinical outcomes assessment included visual analog pain scale score, American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test (SST), relative Constant score, and strength measurements at six, twelve, and twenty-four months. Tendon integrity was assessed with ultrasonography at a minimum of twelve months postoperatively. RESULTS: There were no significant differences in patient age, tear size, or measures of preoperative function between groups at baseline. Final clinical follow-up was available for 114 subjects (92%). Active elevation and external rotation were better in the traditional rehabilitation group at three months. No significant differences were seen in functional scores, active motion, and shoulder strength between rehabilitation groups at later time points. Functional outcomes plateaued at six or twelve months except for the relative Constant score, which improved up to twenty-four months following surgery. Ninety-two percent of the tears were healed, with no difference between rehabilitation protocols (p = 0.46). CONCLUSIONS: Arthroscopic repair of small and medium full-thickness rotator cuff tears results in reliable improvements in clinical outcomes and a high rate of tendon integrity using a double-row repair technique in patients under the age of sixty-five years. There is no apparent advantage or disadvantage of early passive range of motion compared with immobilization with regard to healing or functional outcome.