PT vs. Surgery for Rotator Cuff Tear

Major ? Alert!
A while back we posted about a randomized controlled trial comparing decompression surgery with physiotherapy in the case of lumbar spinal stenosis. The outcome: Physiotherapy yielded similar outcomes as surgery!
Inspired by these findings, I prepared an inservice during my last clinical rotation in the form of a critically appraised topic on the current evidence comparing surgical to conservative treatment of rotator cuff tears.

The results:

– A total of 3 RCTs were published between 2014 & 2015.
– Patientgroups amounted to 56 (1), 103 (3), and 180(2) Patients
– Follow-Up Evaluations at 1 (1) (2) and 5 (3) years

Patientcharacteristics:
– No significant differences in age/gender across studies
– Symptoms since 1 (1) (3) and 2 (3) years
– Studies included degenerative, atraumatic ruptures (1) (2) (3) and traumatic ruptures (3)
– Affected tendons: Supraspinatus (2), supraspinatus + ≥1 additional (1) (3)

Exclusioncriteria:
– Trauma as onset of symptoms (1) (2)
– local & systemic diseases (1) (2) (3)
– previously operated shoulder (1) (2) (3)
– cognitive impairments influencing participation (1) (2) (3)

Interventions:
– Surgical protocol:
Open/miniopen (1) (3) or arthroscopic (2) surgery followed by ≥12 weeks of Physiotherapy mostly identical to the conservative protocol

– Conservative protocol:
inconsistent description (2) (3)
4-6 weeks: Maintain Glenohumeral/Scapular Mobility
6-12 weeks: Stabilitytraining, Increase Strength

Measurements:
– Primary outcome across all studies:
Constant Murley Score: Combines Shoulderfunction (65 Points) with subjective evaluation of disabilites (35 Points)

– Secondary:
…MRT post (1) (3), VAS (1) (3), several questionnaires (1) (3), SF-36 (3), Costs (2),…

Results:
– Heerspink (2015) (1): No significant difference in the per-protocol analysis. Statistically significant difference in the intention-to-treat (Surgery better than Physiotherapy). Difference below Minimal Clinically Important DifferenceHeerspink et al

– Kukkonen (2015) (2): No significant difference

Kukkonen et al

– Moosmayer (2014): Statistically significant difference. Surgery better than Physiotherapy. Difference below Minimal Clinically Important Difference

Moosmayer et al

 

– Re-rupture rate 20-73% (1) (3)
– Rupture progression ≥5mm in 37% of conservative shoulders.
– Costs: 2417€ for Physiotherapy, 5709€ for surgery

Appraisal:

Strengths:
– Patientgroups equal at baseline
– Appropriate randomization/blinding
– Intention-to-treat (1) (2) (3) and per-protocol analysis
– Subgroup analysis (intact vs. rerupture, rerupture vs. conservative)
– High follow up rate ≥95%

Limitations:
– Insufficient/inconsistent description of conservative Protocols (2) (3)
– Pragmatic Studies
– Cause and Extend of ruptures differ greatly
– Kukkonen (2015) (2): Included only well compensated, small, isolated ruptures. No info whether full-thickness or partial thickness tear. Patients had full ROM at inclusion => The CMS has great focus on ROM improvement. They have no follow-up MRI.

Clinical Bottom Line:
In practice, conservative protocols yield similar outcomes to surgical intervention. Patients with degenerative ruptures should be advised to start with a conservative treatment and only cross over to surgery if it doesn’t yield satisfactory results.
Concerning the re-rupture rate, further research should be done on prognostic factors indicating successful surgery.

Comment:
This is again fairly recent evidence underlining the power of our profession. In the end, we CAN prevent surgery in many cases. Furthermore, patients received the same physiotherapy as their conservative counterpart. What made the improvement? Really the surgery? And once again, physiotherapy could save a tremendous amount of money. so #GetPT1st

 

 

References:

1.
Heerspink, F. O. L., van Raay, J. J., Koorevaar, R. C., van Eerden, P. J., Westerbeek, R. E., van’t Riet, E., … & Diercks, R. L. (2015). Comparing surgical repair with conservative treatment for degenerative rotator cuff tears: a randomized controlled trial. Journal of Shoulder and Elbow Surgery, 24(8), 1274-1281.

2.
Kukkonen, J., Joukainen, A., Lehtinen, J., Mattila, K. T., Tuominen, E. K., Kauko, T., & Äärimaa, V. (2015). Treatment of Nontraumatic Rotator Cuff Tears.J Bone Joint Surg Am, 97(21), 1729-1737.

3.
Moosmayer, S., Lund, G., Seljom, U. S., Haldorsen, B., Svege, I. C., Hennig, T., … & Smith, H. J. (2014). Tendon repair compared with physiotherapy in the treatment of rotator cuff tears. J Bone Joint Surg Am, 96(18), 1504-1514.

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