Sports Medicine Research: In the Lab & In the Field: Predictors of Pain and Function in Patients with Symptomatic, Atraumatic Full-thickness Rotator Cuff Tears (Sports Med Res)
Monday, March 26, 2012

Predictors of Pain and Function in Patients with Symptomatic, Atraumatic Full-thickness Rotator Cuff Tears

Predictors of pain and function in patients with symptomatic, atraumatic full-thickness rotator cuff tears: a time-zero analysis of a prospective patient cohort enrolled in a structured physical therapy program.

Harris JD, Pedroza A, Jones GL; MOON (Multicenter Orthopedic Outcomes Network) Shoulder Group. Am J Sports Med. 2012 Feb;40(2):359-66. Epub 2011 Nov 17.

A high prevalence of functional asymptomatic rotator cuff tears exists, with symptoms commonly developing and progressing over time. Predicting which tears will become symptomatic and/or require surgery is a major clinical challenge.  Identifying the factors that relate function and pain in symptomatic rotator cuff tears would be instrumental in helping to identify at-risk individuals and guide treatment strategies.  Therefore, the purpose of this study was to determine the patient factors (modifiable and non-modifiable) associated with function and pain, based on the Western Ontario Rotator Cuff (WORC) index (a self-report questionnaire regarding quality of life) and American Shoulder and Elbow Surgeons (ASES) score (a self-report questionnaire regarding pain and function), in patients with symptomatic, atraumatic full thickness rotator cuff tears. 389 patients (18 to 100 years of age, unilateral full-thickness rotator cuff tear, significant weakness, pain with activities of daily living, impingement symptoms >3 months) who elected to participate in a non-operative physical therapy program were included in this study.  Patients completed a self-administered outcome questionnaire that included their demographics, WORC index, and ASES scores. The minimal clinically important difference (MCID; the smallest change in scores that patients perceive) for the WORC index and ASES scores are 11.7 and 6.4 points, respectively.  Additionally, patients underwent routine physical examination and determination of tear characteristics (i.e., tear size, tear retraction, and presence of scapulothoracic dyskinesis, humeral head migration, and/or muscle atrophy).  The following variables were determined to be associated with higher WORC and ASES scores (reflecting increased function): female sex, higher education levels, increased active abduction range of motion (ROM), and increased strength in forward elevation and abduction.  The modifiable parameters with greatest association (having MCID) were full muscle strength in forward elevation (increased WORC by 18.39 points compared to less strength) and abduction (increased WORC by 13.79 points compared to less strength), while increased active abduction and forward elevation ROM (every 10 degrees) were associated with increased ASES scores of only 0.78 and 0.85 points, respectively.  The following variables were determined to be associated with lower WORC and ASES scores (reflecting decreased function): male sex, atrophy of the supraspinatus and infraspinatus, and presence of scapulothoracic dyskinesia. Specifically, the presence of scapulothoracic dyskinesis was associated with a decrease in the WORC index and ASES scores of 6.85 and 4.07 points, respectively. Additionally, tear size was not identified as a significant predictor unless comparing isolated supraspinatus tears to multi-tendon tears (i.e., involving the supraspinatus, infraspinatus, and subscapularis).

This cross-sectional study identified several modifiable factors that related to function and pain in patients with symptomatic rotator cuff tears (e.g., scapulothoracic dyskinesis, range of motion in active abduction and forward elevation, as well as strength in abduction and forward elevation).  The authors conclude that rehabilitation programs should address these factors to improve and/or eliminate symptoms in patients with atraumatic, full-thickness rotator cuff tears.  However, before definitive recommendations can be made, it is important to consider the strength of the associations identified.  In particular, the parameters of increased active abduction and forward elevation ROM were associated with minimal increases in ASES score and therefore, modifying these factors alone may not be sufficient to be perceived as a clinically important difference.   Successful modification of a combination of several of these factors may be necessary to induce changes that patients may perceive as beneficial.  Additionally, in order to determine if successful modification of these factors improves clinical outcome, longitudinal follow-up investigations (e.g., clinical trials) are necessary.   Previous studies have identified rotator cuff tear size as a significant predictor of patient outcomes, with larger tears associated with both decreased shoulder function and patient satisfaction.  Surprisingly, tear size was not found to be significantly associated with pain and function in this study.  The cohort included only patients who elected non-operative rehabilitation treatment, excluding patients undergoing operative treatment.  It is likely that patients with symptomatic larger tears may have elected operative management, which may account for the discrepancy observed.  Nevertheless, this study has important clinical implications and it is likely that targeting these modifiable factors will improve patient pain and symptoms with the potential of converting symptomatic rotator cuff tears to asymptomatic tears.  Do you currently target any of the factors identified in this study to treat patients with rotator cuff tears?  Have you notice improved outcomes? Would the results of this study alter how you treat patients?

Written by: Katherine Reuther

Harris JD, Pedroza A, Jones GL, & MOON (Multicenter Orthopedic Outcomes Network) Shoulder Group (2012). Predictors of pain and function in patients with symptomatic, atraumatic full-thickness rotator cuff tears: a time-zero analysis of a prospective patient cohort enrolled in a structured physical therapy program. The American Journal of Sports Medicine, 40 (2), 359-66 PMID: 22095706

0 comments:

Post a Comment

When you submit a comment please click 'Subscribe by Email" (just below the comments) or "Subscribe to: Post Comments (Atom)" (at the bottom of this page) if you would like to receive a notification when another comment has been submitted to this post.

Please note that if you are using Safari and have problems submitting comments you may need to go to your preferences (privacy tab) and stop blocking third party cookies. Sorry for any inconvenience this may pose.