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Effects of slow and accelerated rehabilitation protocols on range of motion after arthroscopic rotator cuff repair

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Objective: The aim of the study was to investigate the effects of the early initiation of passive and active range of motion exercises following arthroscopic rotator cuff repair. Methods: The study included 40 patients who underwent arthroscopic rotator cuff repair. Patients were quasi-randomly assigned into accelerated (ACCEL) protocol (n=19) and slow (SLOW) protocol (n=21) groups. Patients in both groups were treated with the same protocol. Active range of motion was begun at the 3rd week in the ACCEL group and the 6th week in the SLOW group. Range of motion was recorded at postoperative weeks 3, 5, 8, 12, and 24. Results: While active range of motion for all measurements improved across weeks, there were no differences between groups, with the exception of active total elevation which was greater at all time point measurements in the ACCEL group (p<0.05). Conclusion: The early initiation of passive and gentle controlled active motion exercise following rotator cuff repairs does not appear to affect range of motion in the first 6 postoperative months.
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Effects of slow and accelerated rehabilitation
protocols on range of motion after
arthroscopic rotator cuff repair
ORIGINAL ARTICLE
Acta Orthop Traumatol Turc 2014;48(6):642-648
doi: 10.3944/AOTT.2014.13.0125
İrem DÜZGÜN1, Gül BALTACI1, Elif TURGUT1, O. Ahmet ATAY2
1Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Hacettepe University, Ankara, Turkey;
2Department of Orthopedics and Traumatology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
Objective: e aim of the study was to investigate the effects of the early initiation of passive and active
range of motion exercises following arthroscopic rotator cuff repair.
Methods: e study included 40 patients who underwent arthroscopic rotator cuff repair. Patients
were quasi-randomly assigned into accelerated (ACCEL) protocol (n=19) and slow (SLOW) protocol
(n=21) groups. Patients in both groups were treated with the same protocol. Active range of motion
was begun at the 3rd week in the ACCEL group and the 6th week in the SLOW group. Range of motion
was recorded at postoperative weeks 3, 5, 8, 12, and 24.
Results: While active range of motion for all measurements improved across weeks, there were no dif-
ferences between groups, with the exception of active total elevation which was greater at all time point
measurements in the ACCEL group (p<0.05).
Conclusion: e early initiation of passive and gentle controlled active motion exercise following rota-
tor cuff repairs does not appear to affect range of motion in the first 6 postoperative months.
Key words: Exercise; manual therapy; rehabilitation; rotator cuff.
e indication for surgical treatment of rotator cuff tear
is a documented partial or full-thickness tear that has
not responded to conservative treatment and produces
symptoms that interfere with the patient’s normal func-
tioning.[1] Postoperative rehabilitation goals for patients
are to decrease pain, increase range of motion (ROM)
and return to normal functional activities at the earliest
time while preventing rerupturing of the repaired tissues.
Controlled and gradually increased loading of move-
ments and exercises are prerequisites for optimal tendon
healing.[2] Collagen that is stressed regains its forma-
tion and tensile strength better than collagen that is not
stressed.[3] Recent literature suggests that a period of im-
mobilization improves the quality of rotator cuff tendon
healing.[4-6] Peltz et al. reported detrimental effects on
passive shoulder mechanics of immediate postoperative
passive motion in an animal model and speculated that
decreased ROM and increased joint stiffness are caused
by increased scar formation in the subacromial space
due to passive motion.[5] However, others have suggested
that active ROM should not be initiated until the 6th
postoperative week and emphasized the importance of
Correspondence: İrem Düzgün, PT, PhD, Assoc. Prof. Hacettepe Üniversitesi Sağlık Bilimleri
Fakültesi, Fizyoterapi ve Rehabilitasyon Anabilim Dalı, 06100 Sıhhiye, Ankara, Turkey.
Tel: +90 312 – 216 26 32 e-mail: iremduzgun@hacettepe.edu.tr
Submitted: November 04, 2013 Accepted: July 06, 2014
©2014 Turkish Association of Orthopaedics and Traumatology
Available online at
www.aott.org.tr
doi: 10.3944/AOTT.2014.13.0125
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Düzgün et al. Effects of slow and accelerated rehabilitation protocols on ROM after rotator cuff repair 643
passive ROM exercises within the limitation of the heal-
ing tissues and pain in the first week after rotator cuff
repair.[7-9] Passive ROM exercises initiated the first day
after surgery followed by active ROM exercises at the 4th
week was found to have no adverse effects.[10]
ese contrasting findings indicate that postopera-
tive care is not definitive, as it is unknown if earlier mo-
tion is detrimental or beneficial to the postoperative goal
of reduced pain and improved function. erefore, the
aim of this study was to determine and compare the ef-
fects of an early rehabilitation protocol on ROM and
function following arthroscopic rotator cuff repair.
Patients and methods
Forty-eight subjects with Stage 2 or 3 rotator cuff tear as
determined by MRI[11] who underwent arthroscopic ro-
tator cuff repair for a full-thickness tear were included in
the study. Patients presenting with a central nervous sys-
tem disorder (n=1) or a peripheral nerve disorder (n=
3), who were not willing to cooperate with the rehabili-
tation duration (n=1) or who self-reported psychologi-
cal disorder (n=1) were excluded. All the patients had
non-traumatic degenerative tears.
Excluding two other patients lost to follow-up, the
remaining 40 patients who underwent arthroscopic ro-
tator cuff repair and were referred for rehabilitation by
a single orthopedic surgeon to the Sports Physiotherapy
Unit were enrolled in this study. Of these, 29 subjects
were recruited directly from a previous study by Düzgün
et al.[11] and 11 from the Sports Physiotherapy Unit (Fig.
1).
Written informed consent (Hacettepe University
Ethics Committee; FON 05/15-30) was obtained from
all patients. Both rehabilitation protocols, including all
possible risks and potential advantage were explained in
detail to patients following surgery.
Patients were quasi-randomly assigned to one of the
two groups based on their year of enrollment in the study.
e 19 patients presenting in the 1st year were placed in
the accelerated (ACCEL) protocol group (17 females, 2
males) and the 21 in the 2nd year were placed in the slow
(SLOW) protocol group (17 females, 4 males). Surgery
was performed according to the procedure described by
Düzgün et al.[11] e orthopedic surgeon with 19 years
of experience was blinded to the rehabilitation protocol
until the end of the study.
Fig. 1. Flowchart diagram.
Assessed for eligibility (n=48)
Six subjects were excluded from participation: CNS disorder (n=1); Peripheral nerve
disorder (n=3); not willing to cooperate (n=1); psychological disorder (n=1)
Randomized (n=42)
(2005 through 2013)
Allocated to SLOW
(n=22)
Allocated to ACCEL
(n=20)
Analyzed: (n=19)
No exclusions from analysis
Analyzed: (n=21)
No exclusions from analysis
Lost to Follow-up: (n=1)
Only lost to 24th week follow up
Lost to Follow-up: (n=1)
Only lost to 24th week follow up
Acta Orthop Traumatol Turc644
Treatments were performed by a single physiothera-
pist (İ.D.) with 10 years of experience and who was
blinded to the patients’ rotator cuff tear size and surgical
technique. Evaluations were performed by a single phys-
iotherapist (G.B.) with 13 years of experience and who
was blinded to group membership.
Patients enrolled in the ACCEL group were given 6
weeks of preoperative rehabilitation. e ACCEL pro-
tocol was initiated at the 2nd postoperative week and in-
cluded soft tissue mobilization for the scapulothoracic
and glenohumeral joint along with motion exercises. Ac-
tive ROM exercises with scapular plane elevation, flex-
ion and abduction was initiated at the 3rd week as long
as the patient reported no pain at rest with their sur-
gically repaired shoulder. Active exercises were delayed
by 1 week in 1 patient due to pain upon removal of the
support which later resolved. Light resistive elastic re-
sistance (era-Band, red color-coded) exercises were
initiated at the 4th postoperative week.[11] e ACCEL
protocol was applied 3 days a week for 6 weeks.[9]
In the SLOW group, soft tissue mobilization for the
scapulothoracic and glenohumeral joint along with pas-
sive ROM exercises were initiated at the 4th postopera-
tive week. Active ROM in scapular plane elevation, flex-
ion and abduction was initiated at the 6th week and light
resistive elastic resistance exercises at the 8th week.[11]
e protocol was applied 3 days a week for 14 weeks.[9]
Shoulder flexion, abduction, external and internal
rotation were measured using a manual medical goni-
ometer with the patient in the supine position.[12] Active
total elevation was determined with the patient seated to
avoid spinal tilting. Reference points were the axis of the
arm and the spinous processes of the thoracic spine. Pa-
tients actively elevated their arm in the sagittal plane[13]
and active internal rotation was performed by having the
patients lift their thumb up their back. A tape measure
was draped down the spine with the zero value placed at
T5. e distance from the tip of the thumb to T5 was
recorded to the nearest centimeter. Improving internal
rotation was indicated by a decreasing value in centime-
ters.[12] All measurements were performed at the 3rd, 5th,
8th, 12th, and 24th postoperative week by the same blind-
ed physiotherapist.
Statistical analysis was performed using repeated
measures analysis of variance. Range of motion was
compared between the protocols at each time point us-
ing the Student t-test. e level of significance was set
at p<0.05.
Results
ere were no significant differences in descriptive char-
acteristics between the two groups (p≥0.05) (Table 1).
ere were no surgical complications or adverse re-
sponses reported throughout the duration of the reha-
bilitation protocol in either group.
With the exception of internal rotation, active total
elevation and active internal rotation shoulder ROMs
improved across weeks but there were no differences
between protocols by week (Figs. 2 to 7). e ACCEL
group had significantly greater internal rotation than the
SLOW group when weeks were analyzed for all time
point measurements (p<0.05) (Table 2). Peak differ-
ences between both groups in terms of internal rotation
were detected at the 8th and 12th weeks (p=0.03).
Discussion
e timing for the initiation of postoperative motion
following arthroscopic rotator cuff repair remains con-
troversial. Similar to studies on postoperative ACL re-
habilitation,[14,15] patients in the current study received
the same rehabilitation protocol with passive, active, and
resistive exercises introduced at either the earlier (AC-
CEL) or later (SLOW) postoperative period. All pa-
tients demonstrated improvement in ROM through the
course of rehabilitation.
Previous studies have shown that rotator cuff repair
followed by rehabilitation significantly relieve pain, im-
prove functional activity level and ROM between a 1 and
5 year follow-up period.[16-22] A large portion of these
studies have focused on the effect of tear size, surgery
technique or physical characteristics[16,21,23] and appear to
suggest that active motion be initiated at the 6th week be-
cause of tendon healing.[5,8,18] Fewer studies have inves-
tigated the effect of different rehabilitation protocols on
postoperative responses.[10,24] Long-term follow-up stud-
Table 1. Physical characteristics of subjects.
ACCEL (n=19) SLOW (n=21) p
Mean±SD Min.-Max. Mean±SD Min.-Max.
Age (year) 57.68±7.8 40-69 57.2±10.1 39-75 0.864
Height (m) 1.56±0.07 1.5-1.7 1.59±.08 1.5-1.8 0.294
Weight (kg) 75.05±9.45 55-92 73.72±12.17 54-100 0.702
ies have indicated the durability of surgical intervention
but are often unable to adequately represent the effects
on the patient during the first six postoperative months.
Typically, patients are treated for less than 4 months in
an outpatient orthopedic physical therapy setting fol-
lowing rotator cuff repair.[25] is early time window is
important as it has a major impact on the patient as they
are attempting to return to normal functional activities
with minimal pain without causing long-term damage to
the repaired tissues. Several surgical intervention studies
have focused on technique and results, with minimal de-
tail provided about the utilized rehabilitation protocol.
In contrast, the current study outlines the rehabilitation
protocol in detail.
Animal model studies have provided scientific evi-
dence of the beneficial effects on the structural quality
Fig. 2. ACCEL vs. SLOW exion.
180
Degrees
90
60
30
120
150
03rd week 5th week 8th week
ROM - Flexion
12th week 24th week
ACCELERATED
SLOW
Fig. 3. ACCEL vs. SLOW abduction.
180
Degrees
90
60
30
120
150
03rd week 5th week 8th week
ROM - Abduction
12th week 24th week
ACCELERATED
SLOW
Fig. 4. ACCEL vs. SLOW external rotation.
90
Degrees
30
60
03rd week 5th week 8th week
ROM - External Rotation
12th week 24th week
ACCELERATED
SLOW
Fig. 5. ACCEL vs. SLOW internal rotation.
90
Degrees
30
60
03rd week 5th week 8th week
ROM - Internal Rotation
12th week 24th week
ACCELERATED
SLOW
Fig. 6. ACCEL vs. SLOW active total elevation.
180
Degrees
90
60
30
120
150
03rd week 5th week 8th week
ROM - Active Elevation
12th week 24th week
ACCELERATED
SLOW
Fig. 7. ACCEL vs. SLOW active internal rotation.
40
Degrees
20
10
30
03rd week 5th week 8th week
ROM - Spine Level Internal Rotation
12th week 24th week
ACCELERATED
SLOW
Düzgün et al. Effects of slow and accelerated rehabilitation protocols on ROM after rotator cuff repair 645
and strength of the healing tissue of a period of immo-
bilization and that it is not detrimental to ROM.[5,6]
However, as the mechanism of tissue damage and site
are different in the animal models than human subjects,
healing processes differ. In addition, the repair procedure
is also different between animal models and human sub-
jects and both factors affect the healing process. During
passive ROM, humans do not contract the rotator cuff
musculature while animals may isotonically or eccen-
trically contract these muscles unless they are anesthe-
tized. Tendon bone healing tissue quality is improved
with decreased loading.[26] Increased collagen organiza-
tion at the insertion site has been observed after 4 weeks
of immobilization and produces superior mechanical
properties at weeks 8 and 16.[4,27] Koh et al. concluded
that 8 weeks of immobilization did not yield a higher
rate of healing of medium-sized rotator cuff tears com-
pared with 4 weeks.[28] In both protocols, a period of
7 days of immobilization was observed to protect the
newly forming network of capillaries.[9] Cold application
was applied in both groups for the first 7 postoperative
days to reduce pain and inflammation and passive ROM
exercises were then initiated. Immobilization plays a
role in allowing healing and the natural phases of in-
flammation and proliferation.[15,29] e clinical question
is when to start movement following rotator cuff sur-
gery to determine what benefits and adverse events may
occur. Neither approach has been studied in an adverse
event during the first 6 months. However, long-term
follow-up and diagnostic imaging would reveal further
information on the durability of the repaired tissue fol-
lowing each protocol.
Active ROM in our patients was greater when ex-
ercises were initiated in the early postoperative period.
is data agrees with those of Klintberg et al.,[10] who
initiated active motion at the 4th postoperative week
while it is in contrast to an animal model that initiated
passive motion following 2 weeks of immobilization.[5]
Researchers reported increased stiffness and less ROM
in those animals undergoing passive motion early com-
pared to the continuously immobilized group.[5] One
explanation for these differing results may be in the vol-
ume of exercises prescribed. ose animals undergoing
passive motion intervention underwent 300 and 600
repetitions a day applied to their limbs compared to the
continuous immobilization group. e authors suggest
that the increased stiffness and less motion observed
in the motion group were due to excessive scar matrix
formation at the tendon insertion sites.[5] In the present
clinical study, patients were only subjected to 90 repeti-
tions of movement on any one day, assuming the patient
complied with the home exercise program on the days
they visited the clinic for treatment. During the 2nd week,
this volume was doubled in the ACCEL group with the
Table 2. Mean and standard deviation values for range of motion in active elevation, spine level internal rotation, external, internal rota-
tion, abduction and exion between two rehabilitation protocols through postoperative period.
Postop weeks 3rd week 5th week 8th week 12th week 24th week
Mean±SD Mean±SD Mean±SD Mean±SD Mean±SD
Active Elevation (degrees)
ACCEL Group 94.3±9.9 126.3±9.8 145.9±6.3 154.4±2.2 158.9±1.8
SLOW Group 70.9±17 95.6±9.2 116.4±8.3 141.4±5.9 153.7±4
Spine Level Internal
Rotation (centimeters)
ACCEL Group 33.1±2.9 29.5±2.9 19.7±2.6 13±2.9 6.3±2.2
SLOW Group 37.5±3.2 31.5±2.6 24.8±2.3 17.6±2.5 10.5±2
External Rotation (degrees)
ACCEL Group 36.5±6 48.2±5.6 55.8±6 68.3±5.3 86.3±2.4
SLOW Group 26.9±5.4 38.5±5.1 47.9±5.4 58.6±4.7 84.1±2.2
Internal Rotation (degrees)
ACCEL Group 56.9±4..3 61.3±4.3 72.7±3.7 80±3.7 88.2±2.1
SLOW Group 50.1±3.8 54.9±3.9 57.2±3.4 68.2±3.3 86.5±1.9
Abduction (degrees)
ACCEL Group 104.9±7.3 122.5±6.8 148.5±7.3 166±5.9 173.6±3.4
SLOW Group 94±6.6 108.3±6.1 126.5±6.6 151.9±5.3 171±3.1
Flexion (degrees)
ACCEL Group 134.9±8.7 150.1±5.6 159.6±5.3 171.3±3.1 175.6±1.8
SLOW Group 115.9±7.9 131.7±5 146.9±4.8 161.8±2.8 174.2±1.6
Acta Orthop Traumatol Turc646
addition of more exercises. However, the 50 to 66% in-
crease in the volume of exercise may account for the dif-
fering results of increased motions and reduced pain in
those individuals initiating early passive and active mo-
tions in the ACCEL protocol. Despite these differences,
it is important to note that by 6 months, the amount of
elevation and internal rotation were basically the same in
all patients regardless of the initial protocol. Harris et al.
showed that restoring full external rotation takes 1 year
after rotator cuff repair and full forward elevation 3 to 6
months in their study.[30] ese results may be related to
the frequency of exercises in our rehabilitation protocol.
On the other hand, patients with accelerated pro-
tocol received 18 and the patients in slow protocol 42
sessions of rehabilitation. Patients in the ACCEL group,
therefore, benefited in terms of cost-effectiveness and
such considerations maybe of importance to both the
patient and insurance.
is study had several limitations, including the lack
of baseline assessment and 1 year follow-up. e lack of
baseline assessment leaves in question whether the pro-
tocol or the individual in the groups accounted for the
differences observed. However, a preoperative baseline is
difficult to establish when performing clinical research
on rehabilitation as in clinical practice patients are not
often referred before surgery. In addition, the effect of
the two rehabilitation programs on tissue quality was
not addressed due to the lack of ultrasound or MRI
assessment. It is acknowledged that a clinical report of
good function and minimal pain does necessarily indi-
cate the absence of a re-tear of the rotator cuff.[31] Longer
term follow-up may reveal further insight on the ben-
efits and adverse effects of each protocol but were not
feasible in this study. erefore, the 6-month follow-up
duration could be considered another limitation of this
study. However, its primary aim was to report the early
results of the two different protocols.
Power characteristics of our study have shown post-
operative changes in the early period until the 24th week
(3rd, 5th, 8th, 12th, and 24th weeks). No data with such time
frame was found in the literature. Frequently performed
evaluations in this study present us the changes in ac-
tive ROM which in turn may give us an idea about the
repaired tissue.
In conclusion, in both early and late initiation of the
rehabilitation protocol, ROM eventually reaches nor-
mal values by 6 months. e initial 6 months following
surgery is critical to reestablish normal function. Re-
habilitation protocols and their effects on tissue repair
quality require further investigation to determine which
approach results in the greatest benefits.
Conflicts of Interest: No conflicts declared.
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Acta Orthop Traumatol Turc648

Supplementary resource (1)

... Auch in der asymptomatischen Bevölkerung liegt die Prävalenz zwischen 7-50% mit altersabhängig zunehmender Häufigkeit (16,(20)(21)(22) (6,11,30). Weiterhin erfolgten alle bis auf eine der prospektiv vergleichenden Studien nach einer arthroskopischen Operation (2)(3)(4)(5)(6)(7)(9)(10)(11)(12) trotz vergleichbarer Ergebnisse mittels ...
... Risikofaktoren wie das Alter sowie die Größe der Ruptur sind aufgrund der übereinstimmenden Ausschlusskriterien als Grund zu vernachlässigen, bzw. nehmen die Studien teilweise noch größere Rupturen in ihr Patientenkollektiv auf (5,12). ...
... Auch die aktive Abduktion weist im Verlauf eine deutliche Besserung von präoperativ 106 Abduktion (3,4,6,7,10,11) oder nur postoperativ (12). Die Studien mit progressivem Nachbehandlungsplan zeigten meist schon präoperativ deutlich bessere Werte (2,5). ...
Thesis
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Aufgrund der divergierenden Studienlage bezüglich der physiotherapeutischen Nachbehandlung nach operativer Rotatorenmanschettenrefixation erfolgte im Rahmen einer prospektiv randomisierten Studie die Evaluation zweier Nachbehandlungsmodelle nach operativer Refixation vollschichtiger RM-Rupturen in Mini-Open-Technik. Hierfür wurden 57 Patienten präoperativ, 3 Wochen, 6 Wochen sowie 6 Monate postoperativ nachuntersucht und ausgewertet. Die Scores beinhalteten den NRS-Score, Constant-Score, DASH-Score, ASES-Score, NHP-Score, SF-36-Score sowie eine sonographische Untersuchung zur Beurteilung der Reruptur nach 6 Monaten postoperativ. Einheitlich erfolgte die Ruhigstellung im Gilchrist-Verband für 6 Wochen. In der konservativen Nachbehandlungsgruppe wurden bis 6 Wochen postoperativ lediglich Pendelübungen durchgeführt, in der progressiven Nachbehandlungsgruppe erfolgte eine passive Beübung direkt postoperativ bis an die Schmerzgrenze mit Ausnahme der Adduktion. Im Gesamtkollektiv war eine Rerupturrate von 5,3% zu verzeichnen mit 3,7% in der konservativen und 6,7% in der progressiven Nachbehandlungsgruppe ohne signifikanten Gruppenunterschied (p=0,540). Bezüglich der klinischen und psychischen Ergebnisse zeigte sich 6 Monate postoperativ lediglich eine Einschränkung der aktiven Außenrotation in der konservativen Nachbehandlungsgruppe (46,2∘ vs. 39,7∘, p=0,031), sonst war kein signifikanter Gruppenunterschied zu sehen. Weiterhin erfolgten Subgruppenanalysen insbesondere hinsichtlich Alter und Geschlecht der Patienten. Dabei haben Patienten über 65 Jahren unabhängig von der Nachbehandlungsgruppe kürzer Analgetika eingenommen und waren 6 Wochen postoperativ weniger bewegungseingeschränkt. Aufgrund einer Tendenz zu vermehrten Rerupturen nach progressiver Nachbehandlung in der Literatur werden daher weiterführende Studien benötigt um zu evaluieren, ob ältere Patienten von einer vermehrten Ruhigstellung profitieren könnten. Diese Studie präsentiert im Gegensatz zu der überwiegend in der Literatur verwendeten arthroskopischen OP-Technik Ergebnisse nach RM-Refixation in Mini-Open-Technik. Damit liefert sie eine gute Grundlage für weiterführende Studien insbesondere in der Behandlung von größeren RM-Rupturen, welche ein erhöhtes Rerupturrisiko besitzen und von einer konservativen Nachbehandlung profitieren könnten.
... Management of RC tears depends on the tear's characteristics, such as tear severity, location and extent of the injury, tendon retraction, and muscle condition. Treatment of RC can be conservative or surgical [24][25][26][27][28]. Surgery is performed after trauma or a conservative treatment failure to improve shoulder function and relieve pain [29][30][31]. Among surgical techniques, arthroscopy is the most commonly performed because of minor trauma to the deltoid due to smaller incisions, less postoperative pain, and the possibility of addressing concomitant disorders [32][33][34][35][36][37][38][39][40][41][42][43][44][45]. ...
... As a result of the increasing incidence of RC ruptures and the risk of failure after surgical repair, questions have been raised regarding the cost-benefit ratio of surgical treatment compared with conservative management [2,3,[46][47][48][49][50][51][52][53]. The immobilisation with the sling, the physiotherapist's role, and the best postoperative week for reintroducing shoulder movement have been widely investigated [24,29,[54][55][56][57][58][59][60][61][62][63][64][65][66][67][68][69][70][71][72][73]. The best rehabilitation protocol aims to restore shoulder function, allowing the tendon healing process to prevent retear events [60,74]. ...
... We judged three trials as having a high risk of bias for incomplete outcomes data since they reported more than 20 % loss to follow-up [67,68] and unbalanced loss among the groups [78]. Two studies were judged as having a high risk of bias because outcomes were reported incompletely, so they cannot be entered in a meta-analysis [29,70]. Other potential bias was not identified. ...
Article
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Background: The purpose of this systematic review and meta-analysis is to compare the conservative and accelerated rehabilitation protocols in patients who underwent arthroscopic rotator cuff repair in terms of clinical outcomes and range of motions at 3, 6, 12, and 24-month follow-up. Methods: According to PRISMA guidelines, a systematic review of the literature was performed. For each included article, the following data has been extracted: authors, year, study design, level of evidence, demographic characteristics, follow-up, clinical outcomes, range of motions, and retear events. A meta-analysis was performed to compare accelerated versus conservative rehabilitation protocols after arthroscopic rotator cuff repair. The retear rate, postoperative Constant-Murley score and range of motions at 3, 6, 12, and 24 months of follow-up were the outcomes measured. Results: The search strategy yielded 16 level I-II clinical studies. A total of 1424 patients, with 732 patients and 692 in the accelerated and conservative group, were included. The average age (mean ± standard deviation) was 56.1 ± 8.7 and 56.6 ± 9 in the accelerated and conservative group. The mean follow-up was 12.5 months, ranging from 2 to 24 months. The meta-analysis showed no statistically significant differences in terms of retear rate between the groups (P = 0.29). The superiority of the accelerated group was demonstrated in terms of external rotation (P < 0.05) at 3-month follow-up; in terms of forward elevation, external rotation, abduction (P < 0.05), but not in terms of Constant-Murley score at 6-month follow-up; in terms of forward elevation (P < 0.05) at 12-month follow-up. No significant differences between the two group were highlighted at 24-month follow-up. Conclusions: No statistically significant differences in the retear rate among the accelerated and conservative group have been demonstrated. On the other hand, statistically and clinically significant differences were found in terms of external rotation at 3 and 6 months of follow-up in favour of the accelerated group. However, no differences between the two groups were detected at 24 months follow-up.
... In our study, GQOLI-74 scores in all aspects in the experimental group after intervention were higher than those in the control group, indicating that accelerated rehabilitation nursing can effectively improve the postoperative life quality of gastric cancer patients. It was consistent with the results reported by Sagar et al. [25]. In terms of complications, the total incidence of complications in the experimental group was significantly lower than that in the control group, suggesting that accelerated rehabilitation nursing can effectively reduce the incidence of postoperative complications in patients with gastric cancer. ...
Article
Objective: To explore the effect of accelerated rehabilitation nursing in patients after gastric cancer surgery. Methods: This prospective study included 88 gastric cancer patients who scheduled to receive surgery. According to the random number table, these patients were assigned to the control group and the experimental group. Patients in the control group received routine nursing, while those in the experimental group received accelerated rehabilitation nursing. Clinical-related parameters, nutritional index, physiological state, the quality of life (QOL), and complications were compared between the two groups. Results: Compared with the control group, postoperative time to get out of bed, anal exhaust time, recovery time of bowel sound, and the length of hospitalization were shortened (all P<0.05). Hemoglobin (Hb), serum total protein (TP), and albumin (Alb) level in both groups after intervention were significantly lower than those before intervention (all P<0.05). Meanwhile, Hb, serum TP, and Alb level in the experimental group after intervention were significantly higher than those in the control group (all P<0.05). Visual analogue scale (VAS) scores at different time points (12 h-5 d after surgery) in the experimental group were significantly reduced when compared with the control group (all P<0.05). Hamilton anxiety scale (HAMA) and Hamilton depression scale (HAMD) score in the two groups after intervention were markedly lower those before intervention (both P<0.05). At the same time, HAMA and HAMD score in the experimental group after intervention were lower than those in the control group (both P<0.05). Generic quality of life inventory-74 (GQOLI-74) scores in all aspects after intervention were higher than those before intervention (all P<0.05). Meanwhile, GQOLI-74 scores in all aspects in the experimental group after intervention were higher than those in the control group (all P<0.05). The total incidence of complications in the experimental group was significantly decreased when compared with the control group (P<0.05). Conclusion: For gastric cancer patients undergoing surgical treatment, accelerated rehabilitation nursing care can effectively promote their postoperative recovery of intestinal function, significantly improve their nutritional status, relieve their negative emotions, improve their quality of life, and reduce the incidence of complications. It is worth of clinical application.
... However, the timing of postoperative rehabilitation in these patients is still a matter of debate (8,11). In many studies, any important advantage or disadvantage of early or late-onset rehabilitation after arthroscopic RCR compared to each other could not be revealed (12)(13)(14)(15). However, there are studies that prefers the ER protocol because it provides better range of motion, causes less shoulder stiffness and muscle atrophy, increases patient satisfaction and facilitates return to daily life (16,17). ...
Article
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Aim: The aim of this study was to determine and compare the effects of early and delayed passive joint rehabilitation protocol on functional and quality of life outcomes in patients following arthroscopic rotator cuff repair (RCR). Material and Methods: A total of 202 patients who underwent arthroscopic RCR were included into the study. Ninety eight patients who started the rehabilitation program just after the arthroscopic RCR were comprised as early rehabilitation (ER) group, while 104 patients whose shoulder joint motion was not allowed for 3 weeks after surgery as delayed rehabilitation (of complications such as re-tear, frozen shoulder and infection that developed during the follow-up period. Both rehabilitation protocols were found to have a similar effect on patient-reported outcomes. Conclusion: At a mean follow-up time of 13 months, early and delayed onset postoperative rehabilitation programs are associated with similar functional and quality of life outcomes, and complication rates. Therefore, DR can be preferred primarily in patients with large tears. ER can be an option for the patients with small tears who has anticipation of early return to work and daily life.
Article
Repair tissue healing after rotator cuff repair remains a significant clinical problem, and excessive shoulder activity after surgical repair is believed to contribute to re-tears. In contrast, small animal studies have demonstrated that complete removal of activity impairs tendon healing and have advocated for an “appropriate” level of activity, but in humans the appropriate amount of shoulder activity to enhance healing is not known. As an initial step toward understanding the relationship between post-operative shoulder activity and repair tissue healing, the objectives of this study were to assess the precision, accuracy, and feasibility of a wrist-worn triaxial accelerometer for measuring shoulder activity. Following assessments of precision (±0.002 g) and accuracy (±0.006 g), feasibility was assessed by measuring one week of shoulder activity in 14 rotator cuff repair patients and 8 control subjects. Shoulder activity was reported in terms of volume (mean acceleration, activity count, mean activity index, active time) and intensity (intensity gradient). Patients had significantly less volume (p≤0.03) and intensity (p=0.01) than controls. Time post-surgery was significantly associated with the volume (p≤0.05 for mean acceleration, activity count, and mean activity index) and intensity (p=0.03) of shoulder activity, but not active time (p=0.08). These findings indicate this approach has the accuracy and precision necessary to continuously monitor shoulder activity with a wrist-worn sensor. The preliminary data demonstrate the ability to discriminate between healthy control subjects and patients recovering from rotator cuff repair and provide support for using a wearable sensor to monitor changes over time in shoulder activity. This article is protected by copyright. All rights reserved.
Article
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Objective To investigate the effectiveness of early rehabilitation compared with delayed/standard rehabilitation after rotator cuff repair for pain, function, range of movement, strength, and repair integrity. Design Systematic review and meta-analyses. Methods We searched databases and included randomised controlled trials (RCTs) comparing early with delayed/standard rehabilitation for patients undergoing rotator cuff repair surgery. We assessed risk of bias of the RCTs using the Cochrane RoB 2 tool. Results Twenty RCTs, with 1841 patients, were included. The majority of the RCTs were of high or unclear risk of overall bias. We found substantial variations in the rehabilitation programmes, time in the sling and timing of exercise progression. We found no statistically significant differences for pain and function at any follow-up except for the outcome measure Single Assessment Numeric Evaluation at six months (MD: 6.54; 95%CI: 2.24–10.84) in favour of early rehabilitation. We found statistically significant differences in favour of early rehabilitation for shoulder flexion at six weeks (MD: 7.36; 95%CI: 2.66–12.06), three (MD: 8.45; 95%CI: 3.43–13.47) and six months (MD: 3.57; 95%CI: 0.81–6.32) and one year (MD: 1.42; 95%CI: 0.21–2.64) and similar differences for other planes of movement. In terms of repair integrity, early mobilisation does not seem to increase the risk of re-tears (OR:1.05; 95%CI: 0.64–1.75). Discussion Current approaches to early mobilisation, based largely on early introduction of passive movement, did not demonstrate significant differences in most clinical outcomes, although we found statistically significant differences in favour of early rehabilitation for range of movement. Importantly, there were no differences in repair integrity between early and delayed/standard rehabilitation. Most rehabilitation programmes did not consider early active movement as soon as the patient feels able. With ongoing variation in rehabilitation protocols there remains a need for large high quality RCT to inform the optimal approach to rehabilitation after rotator cuff repair surgery.
Article
Rotator cuff tears are the most common cause of shoulder disability and can cause significant pain and dysfunction. This systematic review summarizes the latest research on rehabilitation following arthroscopic rotator cuff repair. Studies were eligible for inclusion if they pertained to postoperative rehabilitation following arthroscopic rotator cuff repair and were published between 2003 and 2019 with a level of evidence of 1 or 2. Two blinded reviewers screened, graded, and extracted data from articles and recommendations on various aspects of rehabilitation were summarized. A total of 4067 articles were retrieved from the database search and 22 studies were included for data extraction. We noted similar outcomes between early and delayed mobilization following surgery. Reviewed articles support the use of supervised physical therapy, bracing in 15 degrees external rotation, and adjunctive transcutaneous electrical nerve stimulation for pain management. Early isometric loading improved outcomes in 1 study. Evidence is lacking for exercise prescription parameters and postoperative rehabilitation of the subscapularis.
Conference Paper
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Conference Paper
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Amaç: Bu çalışmada madde bağımlılığı&aile işlevselliği, madde bağımlılığı&yalnızlık ve bağlanma stilleri çerçevesinde Bir Rüya için Ağıt filmindeki diyalogların, sahnelerin, örtülü ve açık mesajların da dikkate alınarak incelenmesi amaçlanmıştır. Yöntem: Çalışma bir nitel analiz yöntemi olan söylem analizi ile gerçekleştirilmiştir. Bulgular: Filmdeki bulgulara bakıldığında sağlıksız aile işlevselliğinin madde kullanımına başlamada etkileyici olduğunu Harry ve annesi Sara arasındaki ilişkiden ve Marion’un ailesiyle sorunlu ve sadece maddi beklenti taşıyan ilişkisinden çıkarmak mümkündür. Marion’un ailesiyle ve Harry’nin annesiyle ilişkisi çok sınırlı ve sürüklendikleri bağımlılığı fark edemeyecek kadar kopuktur. Filmde Sara’nın yalnızlık ve amaçsızlık sancısının madde ve teknoloji bağımlılığı üzerinde etkili olduğu görülmektedir. Yaşam boyu devam eden bağlanma sürecinin çocukluktan itibaren çok önemli olduğu bireylerin ilerideki yaşantısını etkilediği ve güvenli bağlanmanın bireyin ilerideki yaşantısını olumlu etkilediği bilinmektedir. Filmde Tyrone’un sürekli çocukluğunda annesiyle olan anılarına dönüş yapması, annesine benzeyen birini kız arkadaş olarak seçmesi yoksunluğunu hissettiği güven ve bağlanma ihtiyacını tatmin çabasıdır. Burada karakterin filmdeki rolünden güvenli bağlanmanın madde bağımlılığına başlamayı önleyici olduğu çıkarılabilmektedir. Sonuç: Madde bağımlılığını önlemede; aile ilişkilerinin güçlendirilmesi gerektiği, bireylerin aile danışmanlığı üzerine profesyonel destek almasının yararlı olacağı dul veya bekar orta yaş üstü yalnızlık sürecinin doğru yönetilmezse krize neden olabileceği bu anlamda bireylere özel sosyokültürel aktiviteler, kendi iç dinamiklerini harekete geçiren ve kapasite geliştirici çalışmalar ile bireylerin bu süreci kriz yaşamadan geçirmelerini mümkün kılabileceği düşünülmektedir.
Article
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Arthroscopic rotator cuff repair is a reliable option for symptomatic patients who have failed conservative treatments. Limited evidence exists regarding early rehabilitation time points (less than 1 year) and the influence of tear size. The authors sought to determine whether a difference exists in pre- and postoperative range of motion among small, medium, and large isolated rotator cuff tears treated arthroscopically.Patient- and tear-specific demographics were analyzed in a retrospective series of patients who had undergone arthroscopic rotator cuff repair. Two hundred seventy-four patients (153 [56%] men and 121 [44%] women; mean age, 53 years) were analyzed. Small tears (n=158 [58%]) were more common than medium (n=70 [25%]) and large (n=46 [17%]) tears. Shoulder range of motion was measured preoperatively and at 2 and 6 weeks, 3 and 6 months, and 1 year postoperatively. At nearly all time points pre- and postoperatively, large tears were significantly stiffer than small tears in external rotation and forward elevation (P<.05). It takes 1 year to fully regain external rotation after small and medium tears, whereas mild residual stiffness remains after large tears. Full forward elevation is restored by 3 months for small tears vs 6 months for medium and large tears.Significant tear size-dependent differences exist in shoulder range of motion after arthroscopic repair of isolated rotator cuff tears. These data can be used to manage patients' expectations for range of motion after arthroscopic rotator cuff repair to improve patient satisfaction.
Article
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In this study, we sought to compare the effects of the slow and accelerated protocols on pain and functional activity level after arthroscopic rotator cuff repair. The study included 29 patients (3 men, 26 women) who underwent arthroscopic repair of stage 2 and 3 rotator cuff tears. Patients were randomized in two groups: the accelerated protocol group (n=13) and slow protocol group (n=16). Patients in the accelerated protocol group participated in a preoperative rehabilitation program for 4-6 weeks. Patients were evaluated preoperatively and for 24 weeks postoperatively. Pain was assessed by visual analog scale, and functional activity level was assessed by The Disabilities of The Arm Shoulder and Hand (DASH) questionnaire. The active range of motion was initiated at week 3 after surgery for the accelerated rehabilitation protocol and at week 6 for the slow protocol. The rehabilitation program was completed by the 8th week with the accelerated protocol and by the 22nd week with the slow protocol. There was no significant difference between the slow and accelerated protocols with regard to pain at rest (p>0.05). However, the accelerated protocol was associated with less pain during activity at weeks 5 and 16, and with less pain at night during week 5 (p<0.05). The accelerated protocol was superior to the slow protocol in terms of functional activity level, as determined by DASH at weeks 8, 12, and 16 after surgery (p<0.05). The accelerated protocol is recommended to physical therapists during rehabilitation after arthroscopic rotator cuff repair to prevent the negative effects of immobilization and to support rapid reintegration to daily living activities.
Article
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To describe the clinical changes following two different physiotherapy treatment protocols after rotator cuff repair. A prospective, randomized pilot study with a two-year follow-up. Five women and nine men, 55 (40-64) years old, were included. The progressive group (n = 7) started with dynamic, specific muscle activation of the rotator cuff the day after surgery as well as passive range of motion. After four weeks of immobilization the loading to the rotator cuff increased and in a progressive manner throughout the rehabilitation. In the traditional group (n = 7) the rotator cuff was protected from loading. Patients were immobilized for six weeks and started with passive range of motion the day after surgery. No specific exercises to the rotator cuff were introduced during this period. A clinical evaluation was made preoperatively, 3, 6, 12 and 24 months after surgery. Pain rating during activity and at rest, patient satisfaction, active range of motion and muscle strength, Constant score, hand in neck, hand in back and pour out of a pot, as well as Functional Index of the Shoulder were used. At two years follow-up, the progressive group and traditional group scored pain during activity visual analogue scale (VAS) 2/0 mm and pain at rest 0/0 mm, respectively. The groups attained 170/175 degrees in active abduction in standing and 70/90 degrees in passive external rotation while lying in supine. Using Constant score, the groups attained 82/77 points respectively. The present study showed that the progressive protocol produced no adverse effects compared with the traditional protocol.
Article
While animal studies have shown better healing with a longer duration of protection without motion exercise after rotator cuff repair, supporting clinical studies are rare. The purpose of this study was to assess the effect of immobilization following rotator cuff repair and to determine whether there was any difference in clinical outcome related to the duration of immobilization. One hundred patients who underwent arthroscopic single-row repair of a posterosuperior rotator cuff tear (mean, 2.3 cm in the coronal-oblique plane and 2.0 cm in the sagittal-oblique plane) were prospectively randomized to be treated with immobilization for four or eight weeks. During the immobilization period, no passive or active range-of-motion exercise, including pendulum exercise, was allowed. According to the intention-to-treat protocol and full analysis set, eighty-eight patients were evaluated clinically and with magnetic resonance imaging postoperatively, after exclusion of twelve patients without postoperative clinical evaluation. Ranges of motion, clinical scores, and retear rates were compared between the four and eight-week groups. Ninety-eight patients were contacted by telephone at a mean of thirty-five months to investigate the clinical outcomes. The mean duration of immobilization was 4.1 weeks in the four-week group and 7.3 weeks in the eight-week group. There were nine full-thickness retears (10%), and 89% of the patients rated their result as excellent or good. There were five full-thickness retears in the four-week group and four in the eight-week group (p = 0.726). At the time of final follow-up, the two groups showed no differences in range of motion or clinical scores. However, the proportion showing stiffness was higher in the eight-week group (38% compared with 18%, p = 0.038). Eight weeks of immobilization did not yield a higher rate of healing of medium-sized rotator cuff tears compared with four weeks of immobilization. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
Article
Normal shoulder function requires a balanced relationship between glenohumeral mobility and glenohumeral stability. Restoration of shoulder function following an injury or surgery requires an appropriately outlined physical therapy program directed by the treating physician. Rehabilitation of the shoulder following a rotator cuff repair is variable and is dependent not only on the qualityof the repair, but also on the tear size and extent of medial retraction. The first phase of therapy focuses on pain control, restoration of motion within specific guidelines while preserving the integrity of the repair. When tendon healing is complete, active motion exercises are instituted. Strengthening exercises are added during the third phase of therapy, and functional strengthening is instituted prior to a return to full activity. It is important that the operating physician is intimately involved with creating the rehabilitation protocol of each patient and that there is an open line of communication between the physician, patient, and therapist.
Article
Little knowledge exists about the healing process of the tendon to bone insertion, and hence little can be done to improve tissue healing. The goal of this study is to describe the healing of the supraspinatus tendon to its bony insertion under a variety of loading conditions. Tendons were surgically detached and repaired in rats. Rat shoulders were then immobilized, allowed cage activity, or exercised. Shoulders that were immobilized demonstrated superior structural (significantly higher collagen orientation), compositional (expression of extracellular matrix genes similar to the uninjured insertion), and quasilinear viscoelastic properties (A=0.30±0.10 MPa vs. 0.16±0.08 MPa, B=17.4±2.9 vs. 15.1±0.9, and τ2=344±161s vs. 233±40 s) compared to those that were exercised, contrary to expectations. With this knowledge of the healing response, treatment modalities for rotator cuff tears can be developed.
Article
Surgical repairs of torn rotator cuff tendons frequently fail. Immobilization has been shown to improve tissue mechanical properties in an animal model of rotator cuff repair, and passive motion has been shown to improve joint mechanics in animal models of flexor tendon repair. Our objective was to determine if daily passive motion would improve joint mechanics in comparison with continuous immobilization in a rat rotator cuff repair model. We hypothesized that daily passive motion would result in improved passive shoulder joint mechanics in comparison with continuous immobilization initially and that there would be no differences in passive joint mechanics or insertion site mechanical properties after four weeks of remobilization. A supraspinatus injury was created and was surgically repaired in sixty-five Sprague-Dawley rats. Rats were separated into three postoperative groups (continuous immobilization, passive motion protocol 1, and passive motion protocol 2) for two weeks before all underwent a remobilization protocol for four weeks. Serial measurements of passive shoulder mechanics (internal and external range of motion and joint stiffness) were made before surgery and at two and six weeks after surgery. After the animals were killed, collagen organization and mechanical properties of the tendon-to-bone insertion site were determined. Total range of motion for both passive motion groups (49% and 45% of the pre-injury values) was less than that for the continuous immobilization group (59% of the pre-injury value) at two weeks and remained significantly less following four weeks of remobilization exercise. Joint stiffness at two weeks was increased for both passive motion groups in comparison with the continuous immobilization group. At both two and six weeks after repair, internal range of motion was significantly decreased whereas external range of motion was not. There were no differences between the groups in terms of collagen organization or mechanical properties. In this model, immediate postoperative passive motion was found to be detrimental to passive shoulder mechanics. We speculate that passive motion results in increased scar formation in the subacromial space, thereby resulting in decreased range of motion and increased joint stiffness. Passive motion had no effect on collagen organization or tendon mechanical properties measured six weeks after surgery.
Article
The purpose of this study was to determine full-thickness rotator cuff tear prevalence in patients 65 and older and to correlate tears with comfort, function, and co-morbidities. Two-hundred shoulders without prior surgery were evaluated with a Simple Shoulder Test, a Constant Score, and ultrasound. Full thickness tear prevalence was 22%. Adjusting for age and gender, those with tears had lower scores than those without (P < .001 for each). Adjusting for many potential confounders, with a 10-year age increase, the odds of a tear increased 2.69-fold (P = .005). For those with tears, scores were no different for those who had seen a physician for their shoulder compared to those who had not. Full-thickness cuff tear prevalence was 22% in those 65 and older. Tear prevalence increased with increasing age. Shoulder scores were poorer for those with tears.
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The effect of immobilization on the myotendinous junction of the calf muscles in the rat was studied histochemically, immunohistochemically and morphometrically with a transmission electron microscope. After 3 weeks of immobilization, the contact area between the muscle cells and tendineal collagen fibres was reduced by almost 50% in both type I (slow-twitch) and type II (fast-twitch) muscle fibres. The terminal finger-like processes of the muscle cells became shallow and cylindrical or were completely atrophied. Their basal membranes were slightly thickened. Histochemically, the most remarkable alteration in the myotendinous junction was the marked decrease in the sulphate containing glycosaminoglycans. In the basal lamina of the muscle fibres, the glycosaminoglycan and proteoglycan content was also reduced. Immunohistochemical analyses revealed that the amount of type III collagen was markedly increased on the myotendinous interface, but the amount and distribution of type I collagen was not affected by immobilization. These findings suggest that immobilization causes degenerative changes at the myotendinous junction, which, in turn, most likely decrease its tensile strength and may predispose it to rupture during activity.