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Disclosures
Royalties and stock options
One Direct Health
Players Health
Consulting income
BREG
Arthrex
Research and education support
Arthrex
BREG
The Hawkins Foundation
Foundation for Physical Therapy
EARLY VS. DELAYED ROM OPTIMIZING POSTOPERATIVE ROTATOR CUFF REPAIR - - PowerPoint PPT Presentation
EARLY VS. DELAYED ROM OPTIMIZING POSTOPERATIVE ROTATOR CUFF REPAIR - - PowerPoint PPT Presentation
EARLY VS. DELAYED ROM OPTIMIZING POSTOPERATIVE ROTATOR CUFF REPAIR Disclosures Royalties and stock options One Direct Health Players Health Consulting income BREG Arthrex Research and education support
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- Immobilization alone was only used in 1 RCT
- ”protected” ROM most common comparison
- No apparent effect is < 3cm with NO IMMOBILIZATION (Sheps et al 2015)
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- Duration of problem
- Any “pre-op”
rehabilitation?
- Why did they have
surgery?
- Goals
- Cross fit vs laborer vs
golfer
#1 Timing and Expectations?
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- Duration of problem
- Any “pre-op”
rehabilitation?
- Why did they have
surgery?
- Goals
- Cross fit vs laborer vs
golfer
#1 Timing and Expectations?
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Timing & Size Matters
“Successful” clinical outcomes widely reported for
rotator cuff repair
(Wilson ’02; Galatz ’04; Burkhart ’01; Tauro et al ‘98; Gartsman ’98)
- 25%-95% anatomic failure of cuff repair reported
(Oh et al ‘09; Nho et al JSES ’09; Huijsmans et al ’07; Galatz et al ’04; Harryman et al ’91)
- When- 98% in 1st 6 months
- Repairs of tears > 4cm fail < 12 wks
(Miller et al AJSM ‘11)
- Repairs of tears < 3cm fail 3-6 months
(Iannotti et al JBJS ’13)
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Patient Outcome Expectation
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What Happens if this Fails?
Arthroscopic/Ope n Repair
Debridement/ tenotomy Reverse Total Ms Transfer
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#2 Education Sets Expectations
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ADL’s
Common mistakes:
Door management Bed mobility & rising from chair
Toileting & dressing
Est appropriate functional goals
ROM for desired tasks
Loading- how much after 12 weeks
Key Early Education
“this is your box” for the next 3 months
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#3 Standardized Post Op Plan
Rehabilitation plan to match the surgery and the patient
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50 100 150 200 250 300 <3cm >3 cm LOS (Days) Tear Size Tenodesis Tenotomy
Biceps & Tear Size Impact Length of Stay
* *
P <0.05
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Visits Over Time
P <0.05 P <0.05
Biceps Tenotomy Biceps Tenodesis
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10 20 30 40 50 60 70 80 High Average Low ASES Change Score Level of Utilization <3cm >3cm
High Utilizers Smaller Improvement with Small Tears
*
P <0.05
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Calcific tendonitis, adhesive capsulitis, PASTA [partial articular
surface tendon avulsion]-type rotator cuff repair, concomitant labral repair, or single-tendon cuff repair)
“Additional ROM exercise was effective is preventing stiffness
in 100 consecutive cases”
(Koo et al ’12)
Risk Factors for Stiffness
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Calcific tendonitis, adhesive capsulitis, PASTA [partial articular
surface tendon avulsion]-type rotator cuff repair, concomitant labral repair, or single-tendon cuff repair)
“Additional ROM exercise was effective is preventing stiffness
in 100 consecutive cases”
(Koo et al ’12)
Risk Factors for Stiffness
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PROM
(Uhl et al ‘10; Gaunt & Uhl JOSPT ‘11)
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ER then FE- ROM 1st
Hold vs. cycles….
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When Joint Mobilization?
Grade III mobilizations assessed in 9 cadaveric shoulders Measured strains & GAP distances on repaired (0 abd) in
anterior/superior repairs
< strain at 30 than 0 degrees abd 30 degrees abd mob similar to relaxed positions Higher with inferior glide 0 mm GAP distances at 30 degrees 1.06-1.46 mm at 0 degrees
Muraki et al. Manual Therapy. 2007 Aug; 12 (3): 231-9.
- When protocol begins to use AROM
- To end feel and not beyond
- Should be comfortable
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#4 Not just initiation of PROM….
➔Increased risk of “re-tear/non healing” with early
AROM
- < 3cm early 1.63x
- > 3m early 2.5x
- > 5cm 6x
➔~ 25% of strength &
stiffness @ 12 weeks
Schlegel et al ‘99; Arnoczky et al ‘88, Rodeo et al ‘93, St Pierre et al ‘95 Hsu et al ‘16
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- All suggested exercises < 40%
rotator cuff EMG 25-50% 40-60% >50%
#5 Controlled Loading & Return to Function
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Great < 90 then Fight Gravity
Lower trapeizus Middle trapezius Serratus anterior Posterior rotator cuff
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Then more dynamic exercieses
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#5 Matched Return to Activity to Patient
➔No heavy lifting 4-6 months ➔Sport progressions
- Golf 14-16 weeks
- Tennis 20-22 weeks
- Swimming 22-26 weeks
Fealy S et al. ’02; McKee MD et al. 00; Ellman et al ‘86; Charousset et al ‘08) Bjorkenheim, J. M. et al.
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Time to Function Healing
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