Introduction

Massive irreparable rotator cuff tears under the umbrella of Rotator Cuff Related Shoulder Pain are debilitating and can lead to pain, reduced range of motion, and, hence, compromised quality of life. The literature describes both physiotherapy and surgical interventions, but identifying which patients will benefit most from physiotherapy remains a challenge. The study aimed to address this gap by conducting a Delphi study to reach an expert consensus on predictors of response to physiotherapy in this patient population​ having massive rotator cuff tears.

Methods

Multiple experts working in physiotherapy and orthopedic surgery were included in this Delphi-consensus study. In a Delphi study, consensus is sought on a particular topic by independently and anonymously collecting expert opinions. Evidence that is brought up has to go through three rounds where consensus can only be reached when a certain threshold of agreement is reached. In this study, evidence was collected on irreparable massive rotator cuff tears.

Eligible participants were physiotherapists with at least ten years of experience in musculoskeletal physiotherapy or research with a clinical caseload and orthopedic surgeons specializing in shoulder surgery or research combined with a clinical caseload.

In Round 1, the experts provided at least six factors they believed were associated with either a successful or unsuccessful response to physiotherapy. A successful response to physiotherapy was defined as either:

• The patient deciding not to need surgery anymore and/or
• A regain of sufficient pain-free overhead range of motion to allow them to carry out their everyday functions important to them.

The identified predictors were evaluated in Round 2 and rated by participants using a Likert scale to assess their importance in predicting physiotherapy outcomes.

In Round 3, the participants received feedback from Round 2 and were asked to rate the modifiability of each predictor by physiotherapists.

Results

Eighty-eight experts completed Round 1, and 70 participants remained through Round 3, representing a retention rate of 79.54%. 344 statements were initially generated, of which 45 predictors were identified in Round 1. Twenty-two predictors reached consensus as important for predicting the outcome of physiotherapy, and of those, 12 factors were considered modifiable by physiotherapists. These could be divided into 4 clinician factors and 8 patient factors.

According to the experts, the following factors should be considered to predict outcomes of physiotherapy in patients with massive irreparable rotator cuff tears. Note that a factor predicting a successful outcome is indicated by “+” and a factor predicting an unsuccessful outcome is followed by “-”.

Modifiable (by physiotherapists) patient factors:

• Positive expectations: +
• High level of motivation to participate: +
• Having realistic expectations: +
• Kinesiophobia: –
• Clinical evidence of force production in the remaining intact parts of the rotator cuff: +
• Good passive range of motion: +
• The ability of the patient to achieve a good range of active shoulder flexion when lying supine: +
• Early intervention with physiotherapy: +

Modifiable (by physiotherapists) clinician factors:

• Sufficient dosage and quality of exercise prescription: +
• The ability of the physiotherapist to provide a high-quality explanation: +
• Realistic and collaborative goal-setting directed specifically toward the patient’s goals: +
• Strong therapeutic alliance between the patient and physiotherapist: +

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Unmodifiable (by physiotherapists) patient factors:

• High levels of catastrophizing: –
• The presence of widespread pain: –
• A high level of self-efficacy: +
• The presence of a complete tear of the subscapularis muscle: –
• The presence of depression or anxiety: –
• A patient having a previous positive experience of physiotherapy: +
• Being physically active and having active hobbies: +
• High levels of baseline pain: –
• Glenohumeral arthritis/arthropathy: –
• Strong biomechanical beliefs particularly around the damage to the tendons: –

Key Non-Modifiable Predictors:

• Tear of subscapularis: A biomechanical factor identified as predictive of poor outcomes.
• Glenohumeral arthropathy: Structural changes in the joint that limit response to physiotherapy.
• Biomechanical Factors: Good passive and active range of motion (especially in supine) and the force production of intact parts of the rotator cuff were associated with better outcomes​​.

Questions and thoughts

Some factors didn’t reach a consensus regarding whether they were modifiable or not or if these were important or not. Sometimes the surgeons and physiotherapists disagreed. This was true for the following factors:

• Catastrophizing: surgeons saw this as an unmodifiable factor, but physiotherapists indicated it as a modifiable factor. The difference may lie in the fact that physiotherapists get to spend a lot more time with their patients than surgeons generally do.
• Self-efficacy: again, surgeons indicated that this factor was unmodifiable whereas physiotherapists indicated that they were able to improve people’s self-efficacy.
• High levels of baseline pain: Surgeons found this an important factor to consider, but physiotherapists did not. The thought here is that surgeons possibly see more patients who have tried physiotherapy earlier on with unsatisfactory outcomes of physiotherapy or who did not tolerate physiotherapy due to pain
• Strong biomedical beliefs about damage to the tendons: physiotherapists indicated that these beliefs were important and modifiable, while surgeons see it as not important and not modifiable by physiotherapists.

This may be partly due to physiotherapists and orthopedic surgeons seeing different patient profiles or patients in other stages of their suffering from massive irreparable rotator cuff tears or getting to spend more time with their patients.

Talk nerdy to me

By using a Delphi consensus methodology, this study gives us a framework to gather and analyze expert opinions. It is important to study these factors now more in-depth in prospective studies.

Differences in clinical and geographical contexts may influence expert perspectives. This study focused on experts from high- and middle-income countries, since in low-income countries often other treatment methods are being employed. This may imply that the conclusions drawn here may not be retained in lower-income countries.

The results of this study are highly relevant for physiotherapists working with patients suffering from massive irreparable rotator cuff tears in clinical settings where access to both surgical and non-surgical options is available. However, the findings may be less applicable in settings where surgical options are limited or where patients present with differing healthcare expectations​.

Take home messages

For patients suffering from massive irreparable rotator cuff tears, physiotherapy assessments should focus on passive range of motion testing, active range of motion testing in supine, and measuring force production of the remaining intact rotator cuff parts. These are key biomechanical factors that may help identify patients who may have a high likelihood of improving with physiotherapy. You can use this information to optimally dose the exercise program. When you can tailor a high-quality program, you may have a patient in front of you who will positively respond to your treatment. If you can further work on improving kinesiophobia, patient expectations, catastrophizing, self-efficacy, and motivation and decrease anxiety/depression levels, and lower biomedical beliefs around tendon damage, you set the path for treatment success. As a physiotherapist, you can improve your treatment outcomes by communicating about the condition of massive irreparable rotator cuff tears on a high-quality level, building a strong therapeutic alliance, setting realistic expectations, and tailoring realistic and specific functional goals collaboratively with the patient. And don’t forget to reduce baseline pain using certain techniques and motivating the patient to get physically active!

Reference

Ó Conaire E, Rushton A, Jaggi A, Delaney R, Struyf F. What are the predictors of response to physiotherapy in patients with massive irreparable rotator cuff tears? Gaining expert consensus using an international e-Delphi study. BMC Musculoskelet Disord. 2024 Oct 12;25(1):807. doi: 10.1186/s12891-024-07872-6. PMID: 39395963; PMCID: PMC11470710.

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