Prehabilitation for the management of rotator cuff surgery

Abstract

Rotator cuff tears are a common cause of shoulder pain in the general community. Approximately one-third of patients with rotator cuff tears proceed to surgery following the failure of conservative treatments such as physiotherapy, non-steroidal anti- inflammatory drugs, opioid analgesics, and cortisone injections. However, rotator cuff tears continue to develop over time, and the burden of illness for patients awaiting rotator cuff repair is substantial, resulting in loss of strength, functional status, and poor quality of life. This dissertation proposes a three-stage approach for the management of rotator tears in patients awaiting surgery, which includes an accurate and reliable evaluation of shoulder range of motion (ROM) and strength, a pre-operative intervention to improve function and quality of life, and an appraisal of potential prognostic factors that can lead to better future clinical outcomes. Therefore, the organisation of this thesis is divided into three sections covering shoulder assessment, intervention, and prognosis. Chapter 1 introduces the concept of prehabilitation, a rapid systematic review, evidence gaps in the literature, and the rationale for shoulder prehabilitation. Prehabilitation is defined as enhancing a patient's functional ability before surgery to improve clinical outcomes following surgery. The rapid systematic review included only high-quality studies based on the National Health and Medical Research Council (Australia) evidence guidelines and the Physiotherapy Evidence Database (PEDro) rating scale. Only pre-operative exercise intervention studies for surgical knee and hip populations were identified. To date, no studies have investigated the efficacy of prehabilitation for patients scheduled for shoulder surgery. This finding necessitated a review of the considerable body of research on rotator cuff tears. Chapter 2 provides a synthesis of the current literature regarding shoulder anatomy, biomechanics of the rotator cuff, epidemiology, aetiology and classification of rotator cuff tears, shoulder assessment methods, an overview of management options, evidence for post-operative rehabilitation, and prognostic factors and potential predictors of outcome associated with rotator cuff surgery. Chapter 3 presents a published study examining the intra- and inter-rater reliability of a variety of testing protocols to measure ROM and strength in healthy participants. The objective measurement of ROM and strength is an integral part of the physical examination of patients with rotator cuff tears and is vital in quantifying improvement after conservative or surgical intervention. Correctly evaluating and interpreting objective shoulder measurements informs the clinical reasoning underlying treatment. Since pre- operative ROM and strength are potentially modifiable predictors for rotator cuff repair success, a precise assessment using reliable instruments and testing methods is essential. The outcomes of this study supported the selection of assessment methods for a randomised controlled trial (Chapter 7) on shoulder prehabilitation. Chapter 4 presents a published systematic review and meta-analysis on the reliability of the Kinect and ambulatory motion-tracking devices to measure shoulder ROM. According to our reliability study findings in Chapter 3, existing methods for evaluating shoulder ROM are less reliable. Emerging inertial sensor technologies and optical markerless motion-tracking systems are valid alternatives to standard ROM assessment methods. However, reliability must also be established before this technology can be used routinely in clinical settings. Chapter 5 presents a published validity and reliability study on the HumanTrak system to measure shoulder ROM in healthy subjects. Based on our findings in Chapter 4, we evaluated the clinical potential of using a movement analysis system that combines inertial sensors with the Microsoft Kinect (HumanTrak) to measure shoulder ROM reliably and accurately. Chapter 6 is a systematic review and meta-analysis of prehabilitation for the management of orthopaedic surgery. The initial rapid systematic review in Chapter 1 only identified orthopaedic prehabilitation programmes for patients undergoing lower limb joint arthroplasty, anterior cruciate ligament reconstruction, and spinal surgery. Given the growing research and clinical adoption of prehabilitation over the past decade, we undertook an updated and more comprehensive systematic review to identify and critically appraise the content and reporting of prehabilitation programmes for all orthopaedic surgeries. Exercise therapy is commonly first line treatment for older patients with non-traumatic rotator cuff tears. Despite growing evidence that exercise therapy and surgery can achieve comparable clinical outcomes, there is a paucity of high-quality studies on the impact of pre-operative exercise or education for patients awaiting rotator cuff surgery. Hence, the main aim of this thesis is to investigate the efficacy of a combined pre-operative exercise and education programme on function and quality of life before and after rotator cuff surgery. Chapter 7 is a randomised control trial (RCT) investigating whether the addition of a pre-operative exercise and education programme to usual care for patients awaiting rotator cuff surgery is more effective than usual care alone. Fifty patients with unilateral rotator cuff tears received either an 8-week shoulder exercise and education prehabilitation (SPrEE) programme or usual care (UC). The SPrEE programme compared to UC resulted in superior and statistically significant improvements in the primary outcomes of SPADI, WORC and SF-36 in the pre-operative phase. The SPrEE program was not more effective than UC alone in improving primary outcomes at 3-, 6- or 12 month follow-up timepoints. There were no statistically significant between-group differences in SPrEE and UC secondary outcomes for surgical or non-surgical patients. Chapter 8 investigated any correlations between pre-operative magnetic resonance imaging (MRI) characteristics and patient-reported outcome measures for patients who underwent rotator cuff repair or no surgery and received either prehabilitation or usual care in the RCT (Chapter 7). Prognosis-based prehabilitation can effectively identify patients who will derive the greatest benefit. Chapter 9 summarises thesis findings, strengths, and directions for future research to optimise function and quality of life prior to rotator cuff surgery