Mini CAT 1 – Amber Shaikh

Based on PICO from RT 2-WK 2

Clinical Question: As in the past, please briefly outline the scenario and state your clinical question as concisely and specifically as possible

KD is a 45 year old female patient who is 3 days post a left rotator cuff surgery. The surgery was a success and the patient is now in the post-op bed rest period. She has been told that she will need to take rest for a few days – weeks depending on her recovery but wants to know what she can do to fasten her recovery time and decrease her length of stay in the hospital. One Doctor suggested that early mobility can actually help her heal faster.

PICO Question:

Does early mobility in post-op after rotator cuff surgeries patients decrease length of hospital stay and improve overall recovery

P	I	C	O
Post-op patients	Early mobilization	Standard rehabilitation	Early recovery
Post-rotator cuff surgeries	Early rehabilitation	Sling immobilization	Decreased length of hospital stay
Rotator cuff repair patients	Early active and passive motions	immobilization	Improved recovery
Post operative patients after a joint injury	Early exercise introduction	6 weeks of immobilization	Improved post-op pain

Search Strategy:

Outline the terms used, databases or other tools used, how many articles returned, and how you selected the final articles to base your CAT on.

Cochrane Review	Science Direct	Google Scholar	PubMed
Search terms used	Search terms used	Search terms used	Search terms used
a.Early mobility + post operative patients: 266	a.Early mobility post rotator cuff surgery: 1,267	a.Early mobility post rotator cuff surgery + improved recovery: 5,700	a.Early mobility post rotator cuff surgery: 165
b. Early mobility + postop + rotator cuff repair = 6	b.Early mobility post rotator cuff surgery + last 5 years: 384	b.Early mobility post rotator cuff surgery + improved recovery+ last 5 years: 1734	b.Early mobility post rotator cuff surgery + last 5 years: 108
	c.Early mobility post rotator cuff surgery for improved recovery+ last 5 years: 194
Selection criteria	Selection criteria	Selection criteria	Selection criteria
This search was already very narrowed down, however I still looked at the more recent articles to see if they fit the search criteria I was looking for. I found that searching terms that compared early and delayed also helped narrow my search.	Science Direct is a great source to use. I Narrowed my search by only looking at articles that were published in the last 5 years. I also wanted to specify in the search criteria “improved recovery” so I could see how the early mobilization really affected the patients. I also looked for research articles rather then textbook content or just journals.	Google scholar I always a great resource to use, and a great first step in starting a research. However, it can be overwhelming at times since it can produce a lot of searches from various sources. I narrowed my selection criteria by looking for articles published in the last 5 years, as well as articles that were published in familiar science journals such as NIH, pubMed, wiley, cochrane, etc. I then looked to see if they satisfied my search criteria and the PICO question that I was asking.	Similar to the last few search sources I mentioned above, I first narrowed my search by looking at articles published in the last 5 years. I also looked to see if the articles focused on the question at hand of early rehabilitation. Finally I would check to see if the articles were either meta-analysis or comparative studies like RCTs as they offer higher level of evidence.

Articles Chosen (4 or more) for Inclusion (please copy and paste the abstract with link):

1.Early vs delayed mobilization following rotator cuff tear repair

Bakti, Nik, et al “Early versus Delayed Mobilization Following Rotator Cuff Repair.” Science Direct, Dehli Orthopedic Association, 2019,

www-sciencedirect-com.york.ezproxy.cuny.edu/science/article/pii/S0976566218303953

Abstract:

Rotator cuff tears are a common cause for pain and reduced function. Tears of the tendons of the cuff can be a result of a degenerative process or as a consequence of trauma. Management of cuff tears are surrounded by controversy from indications for surgical management to rehabilitation protocol post-surgical repair. The aim of post surgical rehabilitation is to improve functional outcome, reduce pain and promote tendon healing. In the case of rotator cuff repair, rehabilitation can be broadly divided into early passive range of motion (EPM) and delayed range of motion (DRM).

The EPM regime is defined by minimal immobilisation of the shoulder and passive mobilisation of the joint within the first post-operative period. In contrast, DRM immobilises the shoulder joint up to six weeks post-operatively. Proponents of EPM state various advantages of their rehabilitation protocol including improved range of motion and earlier return to normal activities of daily living. However, there has also been concern that this rehabilitation regime may result in an increased rate of re-rupture.

Since this is a highly controversial issue, various high quality literature have been published looking to clarify which regime is best following rotator cuff surgery. Reviewing these articles, it appears that there is an increase rate of re-tear of the repaired rotator cuff tendon when the EPM regime is employed. Statistical significance however was limited by small sample sizes. Range of motion post-repair also appears to be associated with post-operative rehabilitation regime. As expected, the EPM regime has been shown to improve range of motion post-repair. Despite this, literature reports patients managed with the DPM showed a statistically better patient reported outcome measure.

We conclude that based on the evidence we currently have, early range of motion post rotator cuff repair is related with an increase risk of re-tear. The DPM regime reduces this risk with the possible complication of reduced range of shoulder movement. This problem is thought to be an easier clinical issue to deal with compared to re-rupture of the repaired rotator cuff tendon. There is however lack of data to achieve statistical significance in most of these analysis. There is a definite need for a large, multi-centre single blinded randomised controlled trial to further shed light on this controversial topic.

2. Accelerated Rehabilitation following Reverse Total Shoulder Arthroplasty

Jonathan Lee, Paolo Consigliere, Ernest Fawzy, Laura Mariani, Caroline Witney-Lagen, Luis Natera, Berta Buch, Ehud Atoun, Giusseppe Sforza, Eyal Amar, Ofer Levy, “Accelerated Rehabilitation Following Reverse Total Shoulder Arthoplasty.” Journal of Shoulder and Elbow Surgery 2021.

https://www-sciencedirect.com.york.ezproxy.cuny.edu/science/article/pii/S1058274620309630

Abstract:

Introduction

Postoperative rehabilitation is considered essential and indeed routine practice following rTSA. However, the optimal approach to postoperative rehabilitation is unknown, based on protocols for anatomic TSA, published literature is sparse, as is the quantity and quality of research evidence.

Objective

To outline the accelerated rehabilitation protocol (with immediate activity and no immobilization at all) following reverse total shoulder arthroplasty (rTSA) and assess its safety and effectiveness compared to the more conservative rehabilitation protocols of immobilization in a sling for 6 weeks and 3 weeks.

Material and methods

Between July 2005 and October 2017, 357 consecutive rTSA in 320 patients underwent a primary rTSA and were included in the study. Patients were divided into 3 groups depending on rehabilitation protocol (6 weeks or 3 weeks postoperative immobilization respectively for group 1, 2 and no-immobilization for group 3). Patients were assessed preoperatively and reviewed at 3 weeks, 3, 6, 12 months and yearly thereafter postoperatively. Constant Score (CS), Subjective Shoulder Value (SSV), patient satisfaction and pain scores were used at each appointment and patients assessed both clinically and radiographically.

Results

Mean age at surgery was 76 years (range 40 – 93). At 1-year follow-up, Constant Score (CS) improved from 16.6 (adjusted 23.9) to 63.2 (adjusted 91.5) in group 1 (n=114), from 21.5 (adjusted 30.7) to 67.7 (adjusted 98.4) in group 2 (n=125) and from 22.6 (adjusted 31.3) to 66.6 (adjusted 94.9) in group 3 (n=118). Pain score improved from 3.1/15 preoperatively to 12.5/15 postoperatively in group 1, from 3.5/15 to 13/15 in group 2 and from 3.7/15 to 12.5/15 in group 3. SSV improved to 8.5/10, 8.6/10 and 8.1/10 for groups 1, 2 and 3 respectively. Mean range of movement (ROM) improved to 142° elevation and 131° abduction in group 1, 153° elevation and 144° abduction in group 2 and 149° elevation and 146° abduction in group 3. No statistically significance differences were observed in CS, SSV, patient satisfaction, pain and ROM between the three groups. Less postoperative complications were observed in group 3 (No immobilization).

Conclusion

Accelerated rehabilitation regime post rTSA without immobilization is safe and lead to reliable good clinical results and quick return to function. This study confirms non-inferiority of the accelerated rehabilitation regime with less postoperative complications related to falls. Accelerated rehabilitation regime post rTSA have further psychological and emotional advantage to the patient, with earlier return to normal function and regaining independence. We recommend the accelerated rehabilitation regime without immobilization following rTSA.

3.. Early Active Motion Versus Sling Immobilization After Arthroscopic Rotator Cuff Repair: A Randomized Controlled Trial

Sheps DM, Silveira A, Beaupre L, Styles-Tripp F, Balyk R, Lalani A, Glasgow R, Bergman J, Bouliane M; Shoulder and Upper Extremity Research Group of Edmonton (SURGE). Early Active Motion Versus Sling Immobilization After Arthroscopic Rotator Cuff Repair: A Randomized Controlled Trial. Arthroscopy. 2019 Mar;35(3):749-760.e2. doi: 10.1016/j.arthro.2018.10.139. PMID: 30827428.

https://www.physio-mg.de/wp-content/uploads/1-s2.0-S0749806318310235-main.pdf

Abstract:

Purpose:

To compare the effect of early mobilization (EM) with standard rehabilitation (SR) over the initial 24 months following arthroscopic rotator cuff (RC) repair.

Methods:

A total of 206 patients with full-thickness RC tears undergoing arthroscopic repair were randomized following preoperative assessment of shoulder range of motion (ROM), pain, strength, and health-related quality of life (HRQOL) to either EM (n = 103; self-weaned from sling and performed pain-free active ROM during the first 6 weeks) or SR (n = 103; wore a sling for 6 weeks with no active ROM). Shoulder ROM, pain, and HRQOL were reassessed at 6 weeks and 3, 6, 12, and 24 months postoperatively by a blinded assessor. At 6, 12, and 24 months, strength was reassessed. At 12 months, ultrasound verified RC integrity. Independent t tests assessed 6-week group differences and 2-way repeated measures analysis of variance assessed changes over time between groups.

Results:

The groups were similar preoperatively (P > .12). The mean age of participants was 55.9 (minimum, 26; maximum, 79) years, and 131 (64%) were men. A total of 171 (83%) patients were followed to 24 months. At 6 weeks postoperatively, EM participants had significantly better forward flexion and abduction (P < .03) than the SR participants; no other group differences were noted. Over 24 months, there were no group differences in ROM after 6 weeks (P > .08), and pain (P > .06), strength (P = .35), or HRQOL (P > .20) at any time. Fifty-two (25%) subjects (30% EM; 33% SR) had a full-thickness tear present at 12-month postoperative ultrasound testing (P > .8).

Conclusions:

EM did not show significant clinical benefits, but there was no compromise of postoperative ROM, pain, strength, or HRQOL. Repair integrity was similar at 12 months postoperatively between groups. Consideration should be given to allow pain-free active ROM within the first 6 weeks following arthroscopic RC repair.

4. The clinical effect of rehabilitation following arthroscopic rotator cuff repair

Li, Shuxiang et al. “The clinical effect of rehabilitation following arthroscopic rotator cuff repair: A meta-analysis of early versus delayed passive motion.” Medicine vol. 97,2 (2018): e9625. doi:10.1097/MD.0000000000009625

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5943887/

Abstract

Background:

The argument on the recommended rehabilitation protocol following arthroscopic rotator cuff repair remains to be resolved. So this meta-analysis was presented to evaluate the differences of clinical effects between the 2 distinct rehabilitation protocols after arthroscopic rotator cuff repair.

Methods:

The PubMed, Cochrane Library, Web of Science, and EMBASE were systematically searched. Only randomized controlled trials (RCTs) published up to July 25, 2017, comparing early passive motion (EPM) versus delayed passive motion (DPM) rehabilitation protocols following arthroscopic rotator cuff repair were identified. The primary outcomes included range of motion and healing rate, while the secondary outcomes were Constant score, American Shoulder and Elbow Society (ASES) score, and Simple Shoulder Test (SST) score. The exclusion criteria contained biochemical trials, reviews, case reports, retrospective studies, without mention about passive motion exercise, no assessment of outcomes mentioned above, and no comparison of EPM and DPM rehabilitation protocols.

Results:

Eight RCTs with 671 patients were enrolled in this study. The EPM resulted in improved shoulder forward flexion at short term, mid-term, and long-term follow-ups. The EPM group was superior to the DPM group in terms of external rotation (ER) at short-term and mid-term follow-ups. However, the DPM performed better long-term ASES score. These 2 protocols were equivalent in terms of ER at long term, ASES score at mid-term, SST score, Constant score, and healing rate. After excluding 2 RCTs that examined only small- and medium-sized tears, the pooled results of healing rate decreased from 82.4% to 76.6% in the EPM and 86.9% to 85.9% in the DPM.

Conclusion:

The meta-analysis suggests that the EPM protocol results in superior ROM recovery after arthroscopic rotator cuff repair but may adversely affect the shoulder function, which should be supported by further research. The healing rate at long-term follow-up is not clearly affected by the type of rehabilitation, but the EPM protocol might result in lower rates of tendon healing in the shoulder with large-sized tendon tears.

Summary of the Evidence:

Author (Date)	Level of Evidence	Sample/Setting (# of subjects/ studies, cohort definition etc. )	Outcome(s) studied	Key Findings	Limitations and Biases
1. Early vs delayed mobilization following rotator cuff repair Nik Bakti, Tony Antonios, Akshay Phadke, Bijayendra Singh 2019	Meta-analysis	-combined samples from 34 studies over last 20 years -total sample size of 2,251 subjects -649: mobilized early -1,502: mobilized 6 weeks after their surgery -tears were assessed as under the size of 3cm	The two major outcomes that were looked at in this metanalysis was 1.the rates of re-tears after (early or delayed) mobilized post repair 2.The second outcome is the rand of motion and functional recovery of the shoulder. This assessed whether mobilizing the arm early would lead to faster and increased range of motion.	-rotator cuff injuries can occur in both the young and elderly, and are usually managed surgically. The post op rehabilitation is not in question, whether early or delayed movement will be of most use. Rehabilitation allows for the shoulder to heal, while also restoring movement. Early mobilization was found to be helpful in allowing for improved range of motion when compared to those who did delayed mobilization 6 weeks after. Early mobilization does however come with its increased chances of re-tears. However since retears are more difficult to manage, delayed is perferred due to decreased complications.	-I believe one limitation is that this data has been looked at for a long span of time (20 years), and needs to be honed in and focused more. -Another limitation is also that it only looked at tears of particular sizes, and not that much data was available for tears under 1cm. -this article mentions that in order to arrive at a concrete answer, a RCT will need to be done looking at early mobilization in those with smaller tears.
2.Accelerate rehabilitation following reverse total shoulder athroplasty Jonathan Lee, Paolo Consigliere, Ernest Fawzy, Laura Mariani, Caroline Witney-Lagen, Luis Natera, Berta Buch, Ehud Atoun, Giusseppe Sforza, Eyal Amar, Ofer Levy 2021	RCT	-total 320 patients who underwent reverse total shoulder arthoplasty were included (mean age 76) -patients were divided into 3 groups: 1.6 weeks post op immobilization 2.3 weeks post op immobilization 3.no immobliziation for group 3 -patients were assessed at 3 weeks, 3, months, 6 months, 12 months and yearly after	-outcomes were assessed via Constant score, Subjective shoulder value, patient satisfaction and pain scores. -these scores were looked at at each appointment and the subjects were assessed clinically and radiographically -patients healing, risk of retears, and joint stiffness was assessed.	-the key finding of this was that accelerated and fastened rehabilitation with early mobilization and no/decreased immobilization period is safe and leads to good clinical results and faster return to function. -there is also more psychological and emotional advantage to early mobilization, as patients can regain independence and return to formal life functions faster.	-one limitation of this study is that it was done between 2005 and 2017. Even though a longer study and longer follow up is a good option, it can also lead to more drop out rates of subjects, leading to skewed results. -Another limitation of this study is that the mean age was 76, which may not give a clear conclusion since shoulder injuries can happen to those in any age group.
3.Early active motion vs sling immobilization after arhtoscopic rotator cuff repair: a RCT Sheps DM, Silveira A, Beaupre L, Styles-Tripp F, Balyk R, Lalani A, Glasgow R, Bergman J, Bouliane M 2018	RCT	-total of 206 patients with full thickness tears were chosen -these patients were randomized into two groups: 103 went to the (EM) early mobility group who performed pain free active ROM during the first 6 weeks, and 103 in the SR (standard rehabilitation) group who wore a sling for 6 weeks and had no active ROM.	The two main outcomes this study looked at was shoulder range or motion, shoulder pain, and health related quality of life. -these outcomes were compared with both the EM and SR group and were assessed at 6 weeks, 3 months, 6 months, 12 months and 24 months.	-this study looked at 206 patient with the mean age being 55.9, and 64% being men, and followed them for 2 years to see how their healing was progressing based on their time of mobility post-op. -They found that at 6 weeks, the group with early mobility had better flexion and abduction motion then compared to the standard rehabilitation group. But at the 24 month park, there was no clear difference in the groups. -Over all early mobility did not have strict clinical benefits, but did not compromise ROM, pain or quality of life.	-one limitation of this study it that it focused on the healing of full thickness tears, and the effects of mobility. It could have benefitted from also mentioning other sizes and ranges of tears as well. -this study also did not assess for those who suffered with retears and how those rates were impacted by the time of mobility. -while measuring the patients pain and quality of life, I feel that this study could have benefitted from having ways to assess emotional effects of the injury and using the sling. They should have also mentioned how they ensured compliance to the questionnaires.
4.the Clinical effect of rehabilization following arthroscopic rotator cuff repair Shuxiang Li, Han SUn, Xiaomin Luo, Kun Wang, Guofeng Wu, Jian Zhou, Peng Wang, Xiaoliang Sun 2018	Meta- analysis	-this study reviewed 8 randomized control trails with 671 subjects.	-outcomes that were looked at included shoulder range of motion (forward flexion and external rotation), healing rate, Constant score, American shoulder and elbow society score (ASES), and Simple Shoulder test score (SST) -this allowed for the assesment of both overall improvement in shoulder range of motion as well as shoulder function.	-Those with early passive motion showed improved flexion of the shoulder, and improved external rotation. -studies looking at the function of the shoulder (ASES score and the SST score) concluded that delayed passive movement is best for the function in the long term.	Ithis study was a great meta-analysis as it had a very large sample size and looked at multiple aspects of healing in both medium and large sized tendon tears. -I believe one way this study could have benefited is by also looking at the patients quality of life and how that is effected by their mobility status.

Conclusion(s):

Article 1: This article looks at the outcomes of rates of retears with increased range of motion and functional mobility. The article concluded that in tears that are less then 3cm delayed passive movement is more beneficial since early mobilization comes with increased risk of re-tears that will lead to a need for another reparative surgery which has increased complications. Delayed mobility comes with increased shoulder stiffness, that can be less serious then a retear.

Article 2: This article is a RCT in which 320 subjects are split between 3 groups, each group with a different length of time of immobilization. This article concluded that those in the groups with the least amount of time in immobilization, and early rehabilitation had better over all results in functioning and regaining strength. It also highlighted that returning to their way of life and regaining independence would benefit in how the patient emotionally heals as well.

Article 3: This article is a RCT in which 206 subjects were broken into 2 groups, one assessing early mobility within 6 weeks, and the other assessing standard rehabilitation (in which the subjects wore a sling and were immobilized for 6 weeks). They then followed these patients for 2 years, and found that early mobility in the firs 6 weeks showed the best outcome when it comes to pain, range of motion and quality of life, but showed no difference to the standard rehabilitation practices at 12-24 months.

Article 4: This study is a metanalysis that looks at 8 RCTs with a total of 671 patients and how early vs delayed mobilization affects the patients range of motion and functional status. This study concluded that early mobilization results in improved range of motion, but may adversely effect the shoulder function. Early mobilization could lead to less healing in those with large sized tendon ruptures, and should be better for those with smaller tears earlier on.

Overall conclusion:

The overall conclusion is that early mobilization after rotator cuff repair shows a lot of promise in decreasing hospital stay and improving recovery in tears less then 1cm, however there has not been enough statistical evidence to prove its efficacy. The idea is that early mobility post op will allow for decreased muscle stiffness, increased healing, and decreased chances of muscle atrophy. Studies also found that early rehabilitation will allow for increased and improved range of motion in the shoulder. However, it was also found that with decrease immobility time with the sling and early rehabilitation there is a increased chance of re-tears in the muscle, which could possibly require the patient to get re-operated on causing more complications. This would then make the patients hospital stay and recovery longer. The articles find that within the first 6 week window, early mobility allowed for increased decrease in pain and increase in range of motion, but those values became indifferentiable when compared to delayed mobility in a 2 year period Overall, risks vs benefits need to looked at. For those tears that are less then 1cm, early mobilization may be a good option. Over all, more research is needed before one can say for certain whether early mobilization should be considered standard of care, but it should be considered for those who have a small tear and need to return to their daily routine faster. All risks vs benefits should be discussed with the Clinician before making a treatment decision.

Clinical Bottom Line:

Article 1: This article being a meta-analysis comes with a lot of strengths as it looks at multiple established studies and summarizes their findings. This study also had a large total sample size of 2,251 subjects which all increases the strength of the evidence. This article also did a great job of summarizing rotator cuff injuries and what the treatment and rehabilitation options are. Some weaknesses are that it only included studies based on a limited size of tear, and does not include studies less then 1cm. This can effect the clinical bottom line because we don’t know how the duration of wait between surgery and mobilization would affect tears of smaller sizes.

Article 2: This article is a strong article since it is the most recent article supporting this PICO. It also has numerous strengths such as a large subject size. It also is a randomized control trail, which allows for limitations in bias and more accurate findings. Another strength is that this article looks at the improvement of these patients on a clinical and radiographical method, so it can really assess whether early mobilization is beneficial to the healing of the actual bone. A weakness would be that it has an average age of 76 in the patients. A lot of patients of different age groups need rotator cuff repairs, and this article would have benefited from seeing how different age groups fare with early vs delayed mobilization.

Article 3: This article had many strengths being that it was a recent randomized control trail, it allowed for a high level of evidence without much bias. It also had a decent sample size of 206 people. I also liked that this study followed the patients for up to 2 years, and had frequent check ins to see how they were progressing. I like how at 12 months, they used an ultrasound to verify the rotator cuff integrity, this allows us to see how the patients are healing anatomically. I also think this study has strengths in their strict inclusion criteria and randomization techniques. I feel however, this study could have benefitted from mentioning other thickness levels of the tears and how mobility affects that. I also think they should have highlighted more about how they ensured patient compliance to the questionnaires for the 2 year period.

Article 4: This article had a great deal of strengths. The main one being that it is a meta-analysis and looked at 8 different RCTs, allowing it have a very high level of evidence. It also included a very large sample size of 671 subjects allowing for increased accuracy. I also liked that this study looked at those large and medium sized tears and the effects of mobilization on both the range of motion and function of the joint. Some weaknesses include increased need for research when mentioning “shoulder function.” I also think they could have benefited by mentioning a time range in which these patient were followed and how their healing progressed.

Magnitude of any effects

I believe that the magnitude of effect was significant enough to allow for the discussion of patient and case based rehabilitation regimen rather then a set time line. Article 2 states that decreased immobilization time and increased mobility allows for better healing, pain management and quality life allowing the patient to regain their independence faster. However all the other articles summarize that early mobility is only useful for small tears and early on in the first 6 weeks, and have the possibility for causing increased complications and retears. Thus the magnitude of effect is not too strong, but does show that each patient should be used case based and depending on the size of the tear, the patients desire to gain independence, and the risk of complications, patients should be on a mobility rehabilitation time line that would be best suited.

Clinical significance

I believe that this PICO search shows great clinical significance in that patients who are healing after surgery can regain function and mobility in their shoulder faster and in a safer manner based on how early on they practice passive movement. As mentioned above, this should all be based on the degree of the tear and risk vs benefit assessment of further complications that can occur from moving the limb early, including further injury and retear.

Any other considerations

I think that this is an important topic to discuss and consider since it can affect people of all ages and everyone’s healing is so varied. I believe that further research needs to focus more on tears of a smaller magnitude, and how certain timelines of mobility affects that. I also would like to see research on how early mobility can effect healing in those of different age brackets, as elderly folk are more prone to injury then those who are younger and can heal faster. I also would like to see how early mobility can be affected by additional pain control methods such as medication. I know that a lot of the studies used ultrasound and radiographic methods of assess the healing, but if they included more pictures of that in the studies I think it would have been more helpful. Over all I think there is a lot of promise in the field of post-op rehabilitation, but more research is needed.