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Evidence Based Medicine and the Rotator Cuff

Evidence Based Medicine and the Rotator Cuff. Chris Pullen. Introduction 1. UK (Linsell et al 2006 Rheumatology) 2.4% primary care consultations are shoulder based USA (US Dept Health & Human Services) 4.5 million physician visits rotator cuff problems. Introduction 2. Pathogenesis ?

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Evidence Based Medicine and the Rotator Cuff

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  1. Evidence Based Medicine and the Rotator Cuff Chris Pullen

  2. Introduction 1 • UK (Linsell et al 2006 Rheumatology) • 2.4% primary care consultations are shoulder based • USA (US Dept Health & Human Services) • 4.5 million physician visits rotator cuff problems

  3. Introduction 2 • Pathogenesis ? • Natural History ? • When to & when not to operate ? • Which operation ?

  4. Introduction 3 • Problems • Multi-factorial nature of the pathology • Publications are small, single centre & retrospective ‘There is little evidence to support or refute the effectiveness of surgery for rotator cuff disease. All reviewed trials were highly susceptible to bias.’ Coughlan et al 2004 Cochrane database

  5. Prevalence • MRI asymptomatic (Sher et al 1995 JBJS) • Supported by US and cadaver studies • Why RCT become symptomatic ??? • Ageing process ?

  6. Natural History 1 • Asymptomatic RCT • 40% asymptomatic tear • 51% symptomatic • 39% increase in size (Yamaguchi et al 2001 JSES)

  7. Natural History 2 • Partial thickness tears • Arthrography on 40 of 61 patients with PTT (Yamanaka et al 1994 CORR) • Full thickness tears do not heal (Fukuda et al 1994 CORR)

  8. Pathogenesis • Mechanical (Neer 1972 JBJS) • Vascular (Moseley & Goldie 1963 JBJS) • Genetic (Harvie et al 2004 JBJS) • Cellular (Nirschl 1989 Instr Course Lect)

  9. Non-operative Treatment 1 • Impingement/Tendinitis • High success rate approx 70% • Retrospective study 616 patients (Morrison et al 1997 JBJS) • Prospective trial 100 patients impingement (Cummins et al 2009 JSES)

  10. Non-operative Treatment 2 • Rotator cuff tears • Some patients have successful outcome • No reliable method of predicting outcome • Need for well-planned randomized controlled trials (Ainsworth & Lewis 2007 Br J Sports Med.) • Irreversible changes within cuff muscles after a tear (Coleman et al 2003 JBJS)

  11. Non-operative Treatment 3 • Modalities • Exercises • Manual therapy • Corticosteroid injections • Ultrasound • Phonophoresis • Iontophoresis • Ice/Heat • NSAID

  12. Exercise 1 Kuhn 2009 JSES

  13. Exercise 2 • Systematic review • Physical Therapy modalities used • ROM • Stretching & flexibility • Strengthening • Manual therapy (Kuhn 2009 JSES)

  14. Exercise 3 • Pain (Bang 2000, Brox et al 1993, Ludewig & Borstad 2003, Senbursa 2007, Walther 2004) • Strength (Bang 2000, Haahr et al 2005, Walther et al 2004) • Function (Bang 2000, Conroy & Hayes 1998)

  15. Exercise 4 • Two studies compared supervised physical therapy with home exercise (Walther et al 2004, Werner et al 2002) • Neither could show a statistically significant difference between the 2 exercise groups

  16. Manual Therapy • The effect of manual therapy has been evaluated in a number of studies (Bang 2000, Conroy & Hayes 1998, Senbursa et al 2007)

  17. Corticosteroid Injections 1 • For 50y CSI have been used for treatment of shoulder problems • Survey 96% practitioners believe CSI effective • Adverse effects well know • Rat model (Tillander et al 1999 JSES)

  18. Corticosteroid Injections 2 (Koester et al 2007 JAAOS)

  19. Corticosteroid Injection 3 • Pain (Adebajo et al 1990 J Rheum, Akgun et al 2004 Clin Rheum, Blair et al 1996 JBJS) • ROM (Adebajo et al 1990 J Rheum, Blair et al 1996 JBJS) • Predictor for surgery (Cummins et al 2009 JSES) • MRI study accuracy of injection • 24-31% CSI inaccurately placed • Only injections into SA bursa helpful (Henkus et al 2006 Arthroscopy)

  20. Corticosteroid Injections 4 ‘little evidence to support or refute the efficacy of common interventions for shoulder pain’ (Buchbinder et al 2003 Cochrane Database) ‘best evidence indicates that subacromial CSI is not efficacious in the treatment of rotator cuff disease’ (Koester et al 2007 JAAOS)

  21. NSAID • Integral to most non-operative treatment protocols • Systematic review 19 Randomized controlled trials • Shoulder pain • Useful in short term only (4 weeks) • No benefit seen for a particular NSAID (van der Windt et al 1995 J Clin. Epid.)

  22. Other • US (Green et al 2003 Cochrane Database) • Phonophoresis (Klaiman et al 1998 Med Sci Sports Exerc) • Iontophoresis • Heat/Cold (Haahr et al 2005, Conroy et al 1998, Senbursa et al 2007)

  23. Surgical Treatment 1 ‘failed to provide evidence for differences in outcome between conservatively and surgically treated patients with SIS’ • Systematic review • (Dorrestijin et al 2009 JSES)

  24. Surgical Treatment 2 Dorrestijn et al 2009 JSES

  25. Surgical Treatment 3 • Rotator cuff tear • Systemic review (Wolf et al 2007 Am J Sports Med) • Despite possibility of re-tear RCR reduces pain & improves strength & function in symptomatic patients (Jost et al 2000 JBJS)

  26. Surgical Treatment 4 • Variables • Duration of symptoms (Habernek et al 1999 Br J Sports Med) • Age (Feng et al 2003 J Ortho Surg, Hattrup 1995 JSES)

  27. Surgical Treatment 5 • Variables • Gender (Romeo et al 1999 CORR) • Weakness (Bartolozzi et al 1994 CORR) • Tear size (Bartolozzi et al 1994 CORR)

  28. Surgical Treatment 6 • Variables • Acromiohumeral distance (Ellman et al 1986 JBJS, Gerber et al 2000 JBJS) • Atrophy & Degeneration (Goutallier et al 2003 JSES)

  29. Surgical Treatment 7 • Variables • Workers’ Compensation • Retrospective study 3.8 y follow-up • FTT & pending WC (Hawkins & Dunlop 1995 CORR) • Presence WC claim did not adversely affect outcome (Iannotti 1994 JAAOS)

  30. Conclusions 1 • Non-operative treatment • Trial minimum 6-12 weeks • Physical therapy

  31. Conclusions 2 • Exercises • ROM • Postural exercises • Shoulder shrugs & retraction • Glenohumeral motion • Pendular exercises

  32. Conclusions 3 • Exercises • Stretches • Anterior and posterior capsule • Strengthening • Rotator cuff & scapular stabilizers • Theraband

  33. Conclusions 4 • MRI scan • Surgery

  34. Conclusions 5

  35. Conclusion 6

  36. The End

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