Physical therapy versus natural history in outcomes of rotator cuff tears: the Rotator Cuff Outcomes Workgroup (ROW) cohort study.

BACKGROUND: We compared the outcomes of patients who performed physical therapy versus those who did not in a longitudinal cohort of patients undergoing nonoperative treatment of rotator cuff tears. We also assessed whether there was a dose effect in which the pain and functional outcomes in patients performing physical therapy plateaued. METHODS: From February 2011 to June 2015, a multicenter cohort of patients with rotator cuff tears undergoing nonoperative treatment completed a detailed health and demographic questionnaire and the Shoulder Pain and Disability Index (SPADI) at baseline and 3, 6, 12, and 18 months. Longitudinal mixed models were used to assess whether physical therapy in the first 3 months predicted SPADI scores and dose effect. RESULTS: Among the 55 patients in our cohort, the performance of physical therapy within the first 3 months predicted better SPADI scores versus nonperformance of physical therapy at 3 months (P = .02). Scores were similar between groups at 6, 12, and 18 months. A threshold of 16 physical therapy sessions was observed for pain and functional improvement during follow-up, after which significant improvement was not seen. CONCLUSIONS: Patients who performed physical therapy within the first 3 months had statistically significant improvements in pain and function as measured by the SPADI score at 3 months compared with patients who did not report performing physical therapy. Depending on the minimal clinically important difference used for the SPADI score, our results could be interpreted as meeting the minimal clinically important difference threshold or not. Improvement in outcomes was observed up to 16 sessions of physical therapy, after which outcomes plateaued.

A systematic review of cost-effective treatment of postoperative rotator cuff repairs.

OBJECTIVE: The Bundled Payments for Care Improvement initiative combines payment of multiple services for episodes of care into 1 bundle. Rotator cuff repair is a likely candidate for future inclusion. The objective of this study was to determine cost-effective, high-quality postoperative rehabilitation dosing and cryotherapy for patients undergoing rotator cuff repair based on systematic review of the literature. METHODS: Systematic review of level I and level II articles was performed in PubMed, Cochrane Databases, and PEDro. Conference references and bibliographies were also reviewed. For postoperative therapy, keywords included rotator cuff, rotator cuff repair, exercise therapy, exercise, unsupervised, self-care, postoperative period, physical therapy, and physiotherapy; for cryotherapy, keywords included rotator cuff repair, shoulder, cryotherapy, and ice. RESULTS: Five studies compared postoperative outcomes in participants assigned to supervised therapy vs. unsupervised therapy. Three found no difference between groups. One found improved outcomes in supervised therapy. Limitations included that therapies were not consistently defined and significant methodologic issues were present, decreasing the applicability and validity of the results. Five articles examined cryotherapy outcomes in the postoperative shoulder. Two studies showed improved patient outcomes with cryotherapy vs. no cryotherapy; 2 studies showed no decrease in joint space temperatures at 90 minutes but decrease in temperature at 4 to 23 hours postoperatively. One study indicated that an ice bag and Ace bandage might be as effective as continuous, compressive cryotherapy units using patient-reported outcomes. CONCLUSION: Further studies are needed to determine effective dosing of physical therapy after rotator cuff repair. Cryotherapy is favorable and cost-effective using simple methods for delivery.

Nonoperative Treatment of Rotator Cuff Tears.

Rotator cuff tears are common with prevalence increasing with age. Diagnosis by physical examination may require a cluster of tests. Although radiographs can be helpful, MRI, MRI arthrography, and ultrasound represent the most used imaging technique to identify rotator cuff tears. Although surgery is sometimes necessary, a large portion of patients may respond to conservative treatment including physical therapy and injections. Physical therapy should include restoring the range of motion, addressing any pectoralis minor or posterior capsule stiffness, and restoring motor control/strength to the scapula and rotator cuff. Other conservative treatments may include nonsteroidal anti-inflammatory drugs, corticosteroid injects, and platelet-rich plasma.