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Published 7/1/2013
Maureen Leahy

Do Patients Get What They Expect?

Patients with low expectations of rehabilitation more likely to undergo surgery

Most patients with full-thickness rotator cuff tears (RCT) respond well to nonsurgical treatment; however, rehabilitation is not effective in all patients. A key predictor in indentifying which patients will respond to nonsurgical treatment may be patient expectations of the effectiveness of physical therapy (PT).

During the American Shoulder and Elbow (ASES) Specialty Day, Warren R. Dunn, MD, MPH, of Vanderbilt University Medical Center, Nashville, presented the results of a study that identified predictors of failure for nonsurgical treatment of chronic, symptomatic, full-thickness RCTs.

MOON Study Group
According to the Dr. Dunn, no consensus exists on the indications for surgical treatment of rotator cuff tears. The purpose of this study was to determine the effectiveness of an evidence-based PT protocol for the nonsurgical treatment of atraumatic full-thickness RCTs.

“In particular, we wanted to identify predictors of failure of a nonsurgical treatment regimen to assist with determining indications for surgery,” explained Dr. Dunn.

Dr. Dunn and his co-investigators in the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Group conducted the study. Inclusion criteria included patients aged 18 to 100 years with magnetic resonance imaging–documented symptomatic, atraumatic full-thickness RCTs. Patients with a history of shoulder injury, previous shoulder surgery, previous proximal humeral fracture, cervical spine or scapular pain, glenohumeral or inflammatory arthritis, adhesive capsulitis, bilateral tears, or dementia were excluded.

A total of 433 patients (233 females; 200 males; average age = 62) were enrolled in the study. The dominant arm was affected in 68 percent of patients. Additional demographic data collected included body mass index, race, education level, employment status, comorbidities, tobacco use, pain level, activity level, and patient expectations.

Patients underwent physical examinations before beginning PT and at 6- and 12-week follow-up. Patient-reported outcome measures were collected at baseline, 6- and 12-week, and 1-, 2-, and 5-year follow-ups. Patient expectations—based on answers to six questions from the Musculoskeletal Outcomes Data Evaluation System questionnaire—were measured at baseline and at 6- and 12-week follow-up.

Therapy rehabilitation
Working with physical therapists, all patients followed the same rehabilitation program. The regimen included daily range of motion and flexibility exercises and thrice-weekly strengthening exercises. Patients progressed to a home therapy program at the therapists’ discretion.

After 6 weeks of therapy, the patients could declare themselves “cured” and elect to discontinue PT, continue therapy for another 6 weeks, or undergo surgery. Data on whether patients underwent surgery were collected at each follow-up, which is currently ongoing at 5 years. Rehabilitation was considered unsuccessful if the patient ultimately underwent rotator cuff surgery.

Patient expectations of the effectiveness of physical therapy may be a key indicator for rotator cuff surgery.
Courtesy of Fusse\Thinkstock

Predictors of surgery
The researchers used a Cox regression model to determine the predictors of success or failure of rehabilitation, using time to surgery as the dependent variable. Overall, rehabilitation was unsuccessful in 87 patients (20 percent); most of these patients chose surgery within the first 12 weeks after initiating PT. After adjusting for independent variables, the strongest predictor of rehabilitation failure was patient expectations of PT (P < 0.0001), followed by higher activity level (P = 0.011).

Based on the data, the researchers noted that patient symptoms and anatomic features of the chronic rotator cuff tear may not be appropriate indications for surgery.

“Eighty percent of the patients responded to rehabilitation, which lasted up to 2 years,” explained Dr. Dunn. “The predictors of unsuccessful rehabilitation and subsequent surgery were not pain level, duration of symptoms, or severity of the cuff tear in terms of size and/or amount of retraction. Rather, the strongest predictors were the patients’ expectations of how much they thought rehabilitation would work and their shoulder-specific activity level.”

The research, summarized in “Defining Indications for Rotator Cuff Repair: Predictors of Failure of Nonoperative Treatment of Chronic, Symptomatic, Full-Thickness Rotator Cuff Tears,” earned the 2013 ASES Charles S. Neer Award.

Dr. Dunn’s coauthors include John E. Kuhn, MD; Keith M. Baumgarten, MD; Julie Y. Bishop, MD; Robert H. Brophy, MD; James L. Carey, MD, MPH; G. Brian Holloway, MD; Grant L. Jones, MD; C. Benjamin Ma, MD; Eric C. McCarty, MD; Edwin E. Spencer Jr, MD; Armando F. Vidal, MD; Brian R. Wolf, MD, MS; and Rick W. Wright, MD.

Disclosures: Dr. Dunn—Arthrex, Inc. Dr. Kuhn— Amgen Co; Invivo Therapeutics; Journal of Shoulder and Elbow Surgery; Techniques in Shoulder and Elbow Surgery. Dr. Baumgarten—Pfizer; Arthrex, Inc.; Wolters Kluwer Health - Lippincott Williams & Wilkins. Dr. Bishop—no conflicts. Dr. Brophy—Genzyme; American Journal of Sports Medicine (AJSM). Dr. Carey—AJSM. Dr. Holloway—Tornier. Dr. Jones—Arthrotek; Biomet; Genzyme. Dr. Ma—Moximed; Zimmer; Wyeth; Histogenics. Dr. McCarty—DJ Orthopaedics; Biomet; Elsevier; Orthopedics; AJSM. Dr. Spencer—Tornier; DePuy, A Johnson & Johnson Co. Dr. Vidal—Musculoskeletal Transplant Foundation; Stryker; Smith & Nephew. Dr. Wolf—Orthopaedic Journal of Sports Medicine. Dr. Wright—Flexion Therapeutics; ISTO Technologies; National Institutes of Health (NIAMS & NICHD); Smith & Nephew; Wolters Kluwer Health - Lippincott Williams & Wilkins.

Maureen Leahy is assistant managing editor of AAOS Now. She can be reached at leahy@aaos.org

Bottom Line

  • Most patients with full-thickness RCTs respond well to nonsurgical treatment.
  • Nonsurgical treatment is more likely to be unsuccessful in patients with full-thickness RCT who have low expectations of PT.
  • In this study, 80 percent of patients responded to rehabilitation; most patients who chose surgery did so within the first 12 weeks after initiating PT.
  • Cuff pathology, pain level, and duration of symptoms are not associated with failure of nonsurgical treatment for full-thickness RCTs.