Does early mobilisation after surgical repair of rotator cuff tears improve biomechanical and clinical outcomes?

Abstract

The number of rotator cuff repairs performed in the UK and worldwide is increasing every year. However, there are still controversies regarding when rehabilitation after surgery should start. Therefore, the aim of this thesis was to investigate the effectiveness of early rehabilitation compared to conservative after rotator cuff repairs.
First, a systematic review was performed to critically analyse and discuss the current literature. The systematic review demonstrated that early rehabilitation may be beneficial to improve ROM but not function; however, due to high risk of bias of existing primary studies further RCTs are still needed for consensus. Based on the systematic review findings an RCT was planned. The aim of the trial was to assess and to compare clinical and biomechanical outcomes of patients who were allocated to early or conservative rehabilitation after rotator cuff repairs. The objectives of the RCT were: to compare and to detail EMG and kinematic changes that occur during the rehabilitation period between groups, and to compare how much residual impairment patients still show after 6 months of surgery in comparison to a normal population. Ninety-nine patients were screened for inclusion, and 42 patients agreed to participate and had a baseline biomechanics assessment. Twenty-two patients who had the initial biomechanics assessment were excluded from the trial because they did not fit the inclusion criteria based on surgical requirements. Twenty patients were randomised to treatment with 10 in each group. The biomechanics assessments were performed before surgery and after 3 and 6 months. 3D kinematics and EMG activity of 5 muscles (upper trapezius, anterior deltoid, medium deltoid, posterior deltoid and biceps brachii) from six movement tasks. In addition, the Oxford Shoulder Score and EQ-5D-5L were also recorded. Overall, no differences were found between the Early and Conservative groups for biomechanical and clinical outcomes. However, at 6 months the post-operative patients in the Early group had better ROM than those in the Conservative group.
A further exploration of the data indicated that at 3 months patients who responded to treatment were those who used the sling for a shorter number of hours per day, independent of which group they were allocated to, had fewer surgical procedures and a shorter period between first symptoms and surgery.
The data from the 22 patients who underwent the initial assessment but did not meet the inclusion criteria were used in a third study to explore whether the biomechanics assessment used in the trial was capable of discriminating patients with different levels of tissue damage and therefore potentially support surgery planning. The discriminant analysis showed an accuracy of 91.9% of correct classification based on the tasks proposed.
In conclusion, early rehabilitation does not seem to improve outcomes more than a conservative protocol, although the amount of sling usage appears to be an important factor in recovery. The conclusions of the RCT must be considered carefully due to limitations. The RCT of this thesis was the first on the topic to use biomechanics to detail how patients progress from pre-surgery until 6 months post-surgery, therefore contributing to a thorough understanding of patients’ rehabilitation and recovery processes. In addition, the method of assessment proposed showed important discriminatory capacity, which can aid surgery planning by identifying different movement patterns.