Fahy et al. (2022)

Exercise for large to massive rotator cuff tears

The title states “exercise as effective as surgery for large to massive rotator cuff tears”

Yet, differences were small and not clinically meaningful and evidence was (very) low

So, further research is needed to answer this relevant clinical question

Introduction

This study was designed to determine the effectiveness of exercise compared to surgery on quality of life, disability, and pain for people with large to massive rotator cuff tears. This information is especially important because the majority of studies comparing both interventions only include small to moderate rotator cuff tears. In these studies most often exercise is the preferred treatment option. In those with large to massive rotator cuff tears, surgery is often avoided as high chances for retears are expected. To be able to effectively inform and advise these individuals, studies like this one are very welcome. So, what is the effectiveness of exercise for large to massive rotator cuff tears?

 

Methods

In this systematic review, randomized controlled trials or quasi-randomized controlled trials were eligible if they included adults who had a clinical diagnosis of large to massive rotator cuff tears meeting at least one of the following criteria:

  • Two or more tendons affected
  • Tear at least 3cm in size or “non-operable”

Studies had to examine the effectiveness of exercise for large to massive rotator cuff tears. Exercise modes consisted of active supported, closed chain, active mobilization with resistance, and proprioceptive shoulder exercises as a standalone intervention or as part of an active multimodal approach. The primary outcomes assessed were quality of life, disability, and pain, and the certainty of the evidence was assessed according to the GRADE criteria.

 

Results

In total, the search yielded 5 articles to include in the review. Three of the articles compared exercise to another non-surgical intervention and two trials compared exercise versus surgery. Pain scores at 12 months revealed a significant improvement in pain of 0.47 (95% CI 0.07-0.88) after surgery, supported by very low certainty of evidence.

exercise for large to massive rotator cuff tears
From: Fahy et al., Musculoskelet Sci Pract (2022)

 

Exercise was able to give a significant improvement in shoulder external rotation of 9° (95% CI 2.16-16.22) after 6 months, supported by low certainty evidence.

exercise for large to massive rotator cuff tears
From: Fahy et al., Musculoskelet Sci Pract (2022)

 

Questions and thoughts

Five articles were included in the results. But as this systematic review had two purposes, only 2 were eligible for answering the question of the effectiveness of exercise compared to surgery. However, in Figure 2, two exercise vs surgery trials were in the forest plot (Lambers Heerspink et al. 2015 and Moosmayer et al. 2014) but also one study comparing ultrasound, advice, and steroid injections when necessary with or without exercise was in the plot (Ainsworth et al. 2009). On top of those few studies included in the meta-analysis (and depicted here in the forest plot), the characteristics of those studies are very heterogeneous in my opinion. You probably also wonder why they compared 2 exercises vs surgery trials and 1 advice plus or minus exercise trial in the same analysis.

The results of the meta-analysis reveal 2 significant findings: surgery is better for reducing pain after 1 year with nearly 0.5 points on the VAS and exercise improves external rotation with 9° at the 6-month follow-up. Not clinically relevant, I hear you think, indeed.

Can I understand that the authors continued to publish their findings? Yes, of course, they formulated a relevant question and prospectively they have thought about the methodology needed to obtain an answer to their formulated question. Then they performed their search, all according to the rules, but their search appeared to find only a few studies. Should they have abandoned this research as there appears to be limited evidence according to their defined search? No, because the protocol was registered so they had to continue their review. Now at least we know that the evidence is limited. Does this review add much to the clinical field? No, unfortunately not. So is surgery as effective as exercise for large to massive rotator cuff tears as the title says? Or is exercise as effective as surgery? The certainty of the evidence was low to very low, which means that further research will very much likely change the conclusions of this review. Therefore, rather than the title suggests, no clear answer can be given based on these results.

 

Talk nerdy to me

As stated above, the differences were small and not clinically meaningful. Next to this, some problems arose with the defined inclusion criteria. According to the inclusion criteria, large to massive tears were defined to be “at least 3cm in size or non-operable”, but no further definition was provided as to how they defined the tear to be “non-operable”. Further, the review also included patients with concomitant shoulder conditions such as osteoarthritis secondary to rotator cuff tear arthropathy. Here we can question how this affected the results. Sadly, no percentages of patients with concomitant pathologies were reported here. These two aspects would be very necessary to be able to compare the results of this trial versus the characteristics of your patient. Unfortunately, here we are left in the dark.

If exercise was combined with alternative modalities such as joint mobilizations, injection therapy (corticosteroids), and/or analgesia the control group must have received the same alternative modalities. So, no issue there.

 

Take home messages

The statement and title of this paper seem to indicate that exercise is as effective as surgery for large to massive rotator cuff tears. Yet, the differences were small and not clinically meaningful. The certainty of the evidence was low to very low thus future studies will most likely change this study’s conclusions. Therefore, neither surgery nor exercise for large to massive rotator cuff tears is supported based on these findings alone.

A secondary purpose of this study was to report on the characteristics of the exercise interventions. Sadly, the authors came to the conclusion that the median CERT score was 7 out of 19. This score gives an indication of the completeness of reporting exercise interventions in RCTs. As you can see, reports of exercise trials are low and thus this makes it difficult to compare different interventions against one another. So a lot of work remains to be done!

 

Reference

Fahy, K., Galvin, R., Lewis, J., Mc Creesh, K., Exercise as effective as surgery in improving quality of life, disability, and pain for large to massive rotator cuff tears: A systematic review & meta-analysis, Musculoskeletal Science and Practice (2022), doi: https://doi.org/10.1016/ j.msksp.2022.102597.

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