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

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

What is the impact of early rehabilitation following rotator cuff repairs on clinical and biomechanical outcomes? A randomised controlled trial

Background: The number of rotator cuff repairs performed worldwide is increasing every year. However, there are still controversies regarding when rehabilitation after surgery should start. Objectives: To assess and to compare clinical and biomechanical outcomes of patients who were randomised and allocated to early or conservative rehabilitation after rotator cuff repairs. Methods: Twenty patients were randomised to two treatment groups. The biomechanical assessments were performed before surgery and at three and six months, consisting of 3D kinematics and muscle activity from 5 muscles (upper trapezius, anterior deltoid, middle deltoid, posterior deltoid and biceps brachii) from six movement tasks. In addition, the Oxford Shoulder Score and EQ-5D-5L were also recorded. At 12 months an ultrasound scan was performed to check the repair integrity. Results: Overall, both groups had similar results for function and health-related quality of life. However, at six months patients in the early group had better range of motion (ROM) than those in the conservative group, especially for shoulder flexion (Early: median=152.1° vs Conservative: median=140.0°). The number of re-tear events was higher in the early group (5 vs 1), and of these only two patients reported symptoms at 12 months. Conclusion: Early rehabilitation may improve ROM but it does not seem to be superior to a conservative management in improving function and quality of life. In addition, more re-tear events were observed in the early group. However, the results should be interpreted with caution due to the small sample size

Determination of the motor unit behavior of lumbar erector spinae muscles through surface EMG decomposition technology in healthy female subjects

Introduction: The aims of this study were to determine the motor unit behavior of the erector spinae muscles and to assess whether differences exist between the dominant/non-dominant sides of the back muscles. Methods: Nine healthy women, aged 21.7 years (±0.7), performed a back extension test. Surface electromyographic decomposition data were collected from both sides of the erector spinae and decomposed into individual motor unit action potential trains. The mean firing rate for each motor unit was calculated, and a regression analysis was performed against the corresponding recruitment thresholds. Results: The mean firing rate ranged from 15.9 to 23.9 pulses per second (pps) and 15.8 to 20.6 pps on the dominant and non-dominant sides, respectively. However, the early motor unit potential s of the non-dominant lumbar erector spinae muscles were recruited at a lower firing rate. Conclusions: This technique may further our understanding of individuals with back pain and other underlying neuromuscular diseases

Rehabilitation following rotator cuff repair: A survey exploring clinical equipoise among surgical members of the British Elbow and Shoulder Society

Background We investigated clinical equipoise across surgical members of the British Elbow and Shoulder Society (BESS) in relation to rehabilitation following rotator cuff repair. Method An online survey explored clinical equipoise regarding early patient-directed versus standard rehabilitation after rotator cuff repair to inform the design of a national randomised controlled trial (RCT). It described different clinical scenarios relating to patient age, tear size, location and whether other patient-related and intra-operative factors would influence equipoise. Results 76 surgeons completed the survey. 81% agreed/ strongly agreed that early mobilisation might benefit recovery; 57% were neutral/ disagreed that this approach risks re-tear. 87% agreed/ strongly agreed that there is clinical uncertainty about the effectiveness of different approaches to rehabilitation. As age of the patient and tear size increased, the proportion of respondents who would agree to recruit and accept the outcome of randomisation reduced, and this was compounded if subscapularis was torn. Other factors that influenced equipoise were diabetes and non-secure repair. Conclusion Surgical members of BESS recognise uncertainty about the effectiveness of different approaches to rehabilitation following rotator cuff repair. We identified a range of factors that influence clinical equipoise that will be considered in the design of a new RCT

Role of physiotherapy in supporting recovery from breast cancer treatment: A qualitative study embedded within the UK PROSPER trial

Objectives To explore the experiences of women with breast cancer taking part in an early physiotherapy-led exercise intervention compared with the experiences of those receiving usual care. To understand physiotherapists' experience of delivering the trial intervention. To explore acceptability of the intervention and issues related to the implementation of the Prevention Of Shoulder Problems (PROSPER) programme from participant and physiotherapist perspective. Design Qualitative semistructured interviews with thematic analysis. Setting UK National Health Service. Participants Twenty participants at high risk of shoulder problems after breast cancer surgery recruited to the UK PROSPER trial (10 each from the intervention arm and control arm), and 11 physiotherapists who delivered the intervention. Trial participants were sampled using convenience sampling. Physiotherapists were purposively sampled from high and low recruiting sites. Results Participants described that the PROSPER exercise intervention helped them feel confident in what their body could do and helped them regain a sense of control in the context of cancer treatment, which was largely disempowering. Control arm participants expressed less of a sense of control over their well-being. Physiotherapists found the exercise intervention enjoyable to deliver and felt it was valuable to their patients. The extra time allocated for appointments during intervention delivery made physiotherapists feel they were providing optimal care, being the 'perfect physio'. Lessons were learnt about the implementation of a complex exercise intervention for women with breast cancer, and the issues raised will inform the development of a future implementation strategy. Conclusions A physiotherapist-delivered early supported exercise intervention with integrated behavioural strategies helped women at risk of shoulder problems following breast cancer treatment to feel more confident in their ability to mobilise their arm post-surgery. A physiotherapist-delivered early supported exercise intervention with integrated behavioural strategies may address the sense of powerlessness that many women experience during breast cancer treatment. Trial registration number ISRCTN35358984

Effectiveness of early versus delayed rehabilitation following rotator cuff repair: systematic review and meta-analyses

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

Evaluación isocinética de los músculos de la rodilla en jugadores de fútbol : análisis discriminante

Introdução: a atividade muscular em jogadores de futebol pode ser medida por meio do dinamômetro isocinético, que é um instrumento confiável para avaliação do desempenho humano. Objetivos: conduzir análises isocinéticas e discriminar quais variáveis diferenciam a categoria sub-17 (S17) da profissional (PRO).Métodos:Trinta e quatro jogadores de futebol (n=17 para cada categoria) foram avaliados. As variáveis isocinéticas utilizadas para a análise de extensão-flexão do joelho foram: pico de torque (Nm), trabalho total (J), potência média (W), ângulo de pico de torque (graus), razão agonista/antagonista (%), testadas em três velocidades (60°/s, 120°/s e 300°/s), com cada série contendo cinco repetições. Três análises discriminantes foram feitas usando o método Wilk's Lambda para identificar quais variáveis fariam uma discriminação significativa entre as duas categorias. Resultados: as variáveis discriminantes a 60°/s na categoria PRO foram: pico de torque extensores, trabalho total flexores, potência média de extensores e razão agonista/antagonista; e para os S17 foram: trabalho total de extensores, pico de torque de flexores e potência média de flexores. A 120°/s para a categoria PRO as variáveis discriminantes foram: pico de torque de flexores e potência média de extensores; para os S17 foram: trabalho total de extensores e potência média de flexores. A 300°/s, as variáveis encontradas para as categorias PRO e S17 foram, respectivamente: potência média de extensores e trabalho total de extensores. Conclusão: as variáveis isocinéticas para os músculos do joelho flexores e extensores foram capazes de fazer uma discriminação significativa entre jogadores de futebol PRO e S17.Introduction: muscle activity in soccer players can be measured by isokinetic dynamometer, which is a reliable tool for assessing human performance. Objectives: to perform isokinetic analyses and to determine which variables differentiate the under-17 (U17) soccer category from the professional (PRO). Methods: thirty four players were assessed (n=17 for each category). The isokinetic variables used for the knee extension-flexion analysis were: peak torque (Nm), total work (J), average power (W), angle of peak torque (deg.), agonist/ antagonist ratio (%), measured for three velocities (60°/s, 120°/s and 300°/s), with each series containing five repetitions. Three Wilks' Lambda discriminant analyses were performed, to identify which variables were more significant for the definition of each of the categories. Results: the discriminative variables at 60°/s in the PRO category were: extension peak torque, flexion total work, extension average power and agonist/antagonist ratio; and for the U17s were: extension total work, flexion peak torque and flexion average power. At 120°/s for the PRO category the discriminant variables were: flexion peak torque and extension average power; for the U17s they were: extension total work and flexion average power. Finally at 300°/s, the variables found in the PRO and U17 categories respectively were: extension average power and extension total work. Conclusion: isokinetic variables for flexion and extension knee muscles were able to significantly discriminate between PRO and U17 soccer players.Introducción: la actividad muscular en jugadores de fútbol puede ser medida por medio del dinamómetro isocinético, que es un instrumento confiable para evaluación del desempeño humano. Objetivos: conducir análisis isocinéticos y discriminar qué variables diferencian la categoría sub-17 (S17) de la profesional (PRO). Métodos: fueron evaluados treinta y cuatro jugadores de fútbol (n=17 para cada categoría). Las variables isocinéticas utilizadas para el análisis de extensión-flexión de la rodilla fueron: pico de torque (Nm), trabajo total (J), potencia media (W), ángulo de pico de torque (grados), razón agonista/antagonista (%), probadas en tres velocidades (60°/s, 120°/s y 300°/s), con cada serie conteniendo cinco repeticiones. Fueron realizados tres análisis discriminantes usando el método Wilk's Lambda para identificar qué variables harían una discriminación significativa entre las dos categorías. Resultados: las variables discriminantes a 60°/s en la categoría PRO fueron: pico de torque extensores, trabajo total flexores, potencia media de extensores y razón agonista/antagonista; y para los S17 fueron: trabajo total de extensores, pico de torque de flexores y potencia media de flexores. A 120°/s para la categoría PRO las variables discriminantes fueron: pico de torque de flexores y potencia media de extensores; para los S17 fueron: trabajo total de extensores y potencia media de flexores. A 300°/s, las variables encontradas para las categorías PRO y S17 fueron, respectivamente: potencia media de extensores y trabajo total de extensores. Conclusión: las variables isocinéticas para los músculos de la rodilla flexores y extensores fueron capaces de hacer una discriminación significativa entre jugadores de fútbol PRO y S17

Clinical and cost-effectiveness of individualised (early) patient-directed rehabilitation versus standard rehabilitation after surgical repair of the rotator cuff of the shoulder: protocol for a multi-centre, randomised controlled trial with integrated Quintet Recruitment Intervention (RaCeR 2).

Introduction: Despite the high number of operations and surgical advancement, rehabilitation after rotator cuff repair has not progressed for over 20 years. The traditional cautious approach might be contributing to sub-optimal outcomes. Our aim is to assess whether individualised (early) patient-directed rehabilitation results in less shoulder pain and disability at 12 weeks after surgical repair of full-thickness tears of the rotator cuff compared to current standard (delayed) rehabilitation. Methods and analysis: The rehabilitation after rotator cuff repair (RaCeR 2) study is a pragmatic multi-centre, open label, randomised controlled trial with internal pilot phase. It has a parallel group design with 1:1 allocation ratio, full health economic evaluation, and Quintet Recruitment Intervention. Adults awaiting arthroscopic surgical repair of a full-thickness tear are eligible to participate. Upon completion of surgery, 638 participants will be randomised. The intervention (individualised early patient-directed rehabilitation) includes advice to the patient to remove their sling as soon as they feel able, gradually begin using their arm as they feel able and a specific exercise programme. Sling removal and movement is progressed by the patient over time according to agreed goals and within their own pain and tolerance. The comparator (standard rehabilitation) includes advice to the patient to wear the sling for at least four weeks and only to remove while eating, washing, dressing or performing specific exercises. Progression is according to specific timeframes rather than as the patient feels able. The primary outcome measure is the Shoulder Pain and Disability Index (SPADI) total score at 12-week post-randomisation. The trial timeline is 56 months in total, from September 2022. <br/

Current physical therapy care of patients undergoing breast reconstruction for breast cancer: a survey of practice in the United Kingdom and Brazil

Background In both the United Kingdom (UK) and Brazil, women undergoing mastectomy should be offered breast reconstruction. Patients may benefit from physical therapy to prevent and treat muscular deficits. However, there are uncertainties regarding which physical therapy program to recommend. Objective The aim was to investigate the clinical practice of physical therapists for patients undergoing breast reconstruction for breast cancer. A secondary aim was to compare physical therapy practice between UK and Brazil. Methods Online survey with physical therapists in both countries. We asked about physical therapists’ clinical practice. Results 181 physical therapists completed the survey, the majority were from Brazil (77%). Respondents reported that only half of women having breast reconstruction were routinely referred to physical therapy postoperatively. Contact with patients varied widely between countries, the mean number of postoperative sessions was 5.7 in the UK and 15.1 in Brazil. The exercise programs were similar for different reconstruction operations. Therapists described a progressive loading structure over time: range of motion (ROM) was restricted to 90° of arm elevation in the first two postoperative weeks; by 2–4 weeks ROM was unrestricted; at 1–3 months muscle strengthening was initiated, and after three months the focus was on sports-specific activities. Conclusion Only half of patients having a breast reconstruction are routinely referred to physical therapy. Patients in Brazil have more intensive follow-up, with up to three times more face-to-face contact with a physical therapist than in the UK. Current practice broadly follows programs for mastectomy care rather than being specific to reconstruction surgery