The Effects of Conservative and Surgical Treatment on Rotator Cuff Tears on Pain and Function: A Critically Appraised Topic
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Abstract
Clinical Scenario: Rotator cuff (RTC) tears are characterized by pain, weakness, loss of function and are debilitating for the 4.5 million people who suffer from this injury yearly. The preferred treatment is controversial with surgical intervention/repair and conservative management being two viable options. This critical appraisal aims to investigate the existing evidence to determine which treatment method is most effective at decreasing pain and improving function as measured by patient-reported outcomes (PROs).
Focused Clinical Question: In patients with rotator cuff tears, what is the effect of conservative treatment compared to surgical intervention on pain and function?
Search Strategy: A comprehensive database search was conducted using CINAHL Plus, ProQuest Nursing Collection, PubMed, and Cochrane Library to answer the clinical question. The search terms utilized included rotator cuff tear repair, rotator cuff tear operative and non-operative, and rotator cuff surgery and conservative. Inclusion criteria included articles published from 2006 to current and clinical or experimental trials that utilized PROs for evaluation of pain and function. Exclusion criteria included bench trials, non-clinical trials, and patients with concomitant shoulder pathologies. Seven studies met the inclusion criteria and were included in this critical appraisal.
Evidence Quality Assessment: Peer-reviewed articles were assessed utilizing the PEDro scale and the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence (OCEBM). The studies reviewed ranged from 3-8 out of 10 on the PEDro scale and all OCEBM scores were a level 3.
Results and Summary of Search: The studies demonstrated variability in several aspects of patient presentation including population age, tear size, and tear type. While all studies utilized physical therapy led sessions for their conservative treatment, three studies also utilized a combination of analgesics, corticosteroid injections, and modalities. The surgical intervention in many of the studies was performed using mini-open arthroscopic repair; however, in some cases an open approach was performed. The Constant-Murley Score (CMS), a functional scale used to assess strength, range of motion, and activities of daily living in addition to the visual analog scale (VAS), for pain grading, were used as a primary or secondary outcome measure in all studies. Across all studies, both groups exhibited improvement with the surgical groups having greater improvements on the CMS and VAS. However, only three studies found the difference between surgical and conservative treatment statistically significant.
Clinical Bottom Line: Conservative treatment and surgical intervention are comparable in making clinically significant change to decrease pain and improve function for patients with rotator cuff tears. The consistent findings across the reviewed articles resulted in a SORT score ‘A’ for the evidence.
Implications: Conservative and surgical intervention make similar impacts on pain and function PROs for patients with rotator cuff tears, and appropriate education should take place to inform patients of their options, risks, and outcomes. Conservative treatment given its efficacy is a great option for high-risk surgical candidates. Future research should be conducted on specific patient populations and long-term intervention effects.
College
College of Nursing & Health Sciences
Department
Health, Exercise & Rehabilitative Sciences
Campus
Winona
First Advisor/Mentor
Nora Kraemer,PhD, LAT, ATC, CSCS
Second Advisor/Mentor
Brandon Donahue, DAT, LAT, ATC
Presentation Type
Oral Presentation
Format of Presentation or Performance
Pre-Recorded Video
The Effects of Conservative and Surgical Treatment on Rotator Cuff Tears on Pain and Function: A Critically Appraised Topic
Clinical Scenario: Rotator cuff (RTC) tears are characterized by pain, weakness, loss of function and are debilitating for the 4.5 million people who suffer from this injury yearly. The preferred treatment is controversial with surgical intervention/repair and conservative management being two viable options. This critical appraisal aims to investigate the existing evidence to determine which treatment method is most effective at decreasing pain and improving function as measured by patient-reported outcomes (PROs).
Focused Clinical Question: In patients with rotator cuff tears, what is the effect of conservative treatment compared to surgical intervention on pain and function?
Search Strategy: A comprehensive database search was conducted using CINAHL Plus, ProQuest Nursing Collection, PubMed, and Cochrane Library to answer the clinical question. The search terms utilized included rotator cuff tear repair, rotator cuff tear operative and non-operative, and rotator cuff surgery and conservative. Inclusion criteria included articles published from 2006 to current and clinical or experimental trials that utilized PROs for evaluation of pain and function. Exclusion criteria included bench trials, non-clinical trials, and patients with concomitant shoulder pathologies. Seven studies met the inclusion criteria and were included in this critical appraisal.
Evidence Quality Assessment: Peer-reviewed articles were assessed utilizing the PEDro scale and the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence (OCEBM). The studies reviewed ranged from 3-8 out of 10 on the PEDro scale and all OCEBM scores were a level 3.
Results and Summary of Search: The studies demonstrated variability in several aspects of patient presentation including population age, tear size, and tear type. While all studies utilized physical therapy led sessions for their conservative treatment, three studies also utilized a combination of analgesics, corticosteroid injections, and modalities. The surgical intervention in many of the studies was performed using mini-open arthroscopic repair; however, in some cases an open approach was performed. The Constant-Murley Score (CMS), a functional scale used to assess strength, range of motion, and activities of daily living in addition to the visual analog scale (VAS), for pain grading, were used as a primary or secondary outcome measure in all studies. Across all studies, both groups exhibited improvement with the surgical groups having greater improvements on the CMS and VAS. However, only three studies found the difference between surgical and conservative treatment statistically significant.
Clinical Bottom Line: Conservative treatment and surgical intervention are comparable in making clinically significant change to decrease pain and improve function for patients with rotator cuff tears. The consistent findings across the reviewed articles resulted in a SORT score ‘A’ for the evidence.
Implications: Conservative and surgical intervention make similar impacts on pain and function PROs for patients with rotator cuff tears, and appropriate education should take place to inform patients of their options, risks, and outcomes. Conservative treatment given its efficacy is a great option for high-risk surgical candidates. Future research should be conducted on specific patient populations and long-term intervention effects.
