Ask an answerable question (PICO)：
Rotator cuff tear is one of the most common shoulder disease in adults. It often presents with shoulder pain and difficulty in shoulder elevation. Surgical repair often indicated if patients do not respond well to conservative treatment. After surgery, we often suggest patient to rehabilitate as soon as possible to prevent shoulder stiffness and muscle atrophy. However, some surgeons would delay rehabilitation to prevent re-tear of the rotator cuff. Thus, it is common in the clinical setting that patient would question care givers why they should or should not receive rehabilitation after the surgery. Thus, we would like to discuss the influence of early postoperative rehabilitation in patient with rotator cuff tear and answer this clinical question via evidence-based methods.
The Method and Analysis of Literature Review：
1. We would like to use evidence-based methods to set PICO questions to answer whether early postoperative passive range of motion training would influence patients outcomes after rotator cuff repair surgery.
2. Searching strategy:
We used Mesh term and Theasurus to set key words:
P: Rotator cuff repair, arthroscopic rotator cuff repair
I: early passive motion, early exercise
O: shoulder range of the motion
We used Bollean logic “AND, OR, and NOT” to search English databases from 2014-2018 in PubMed, Medline, CINAHL. Total thiry-three articles were recruited. After exclusion of irrelevant or repeated papers, 2 meta-analysis and 1RCT were finally included. We also used Oxford center for EMB in 2011 to analysis level of evidence.
Critical Appraisal：
1.Mazzocca, et al. (2017):
Early passive range of motion with shoulder joint with assisted forward elevation and external rotation were performed and patients were evaluated 3 weeks, 6 weeks, 12 weeks, 6 months and 1 year after surgery. The results showed that patients receiving early rehabilitation has better forward elevation and external rotation 3 weeks after surgery with p< 0.01. Less pain was also noted in patients receiving early rehabilitation 12 weeks after surgery with p= 0.04. Better quality of live was also noted 3 weeks, 12 weeks ad 1 year after surgery if patients received early rehabilitation with p= 0.04. (Level 2)
2. Chang, et al., (2015):
The authors analyzed patients subjecting to arthroscopic repair of the rotator cuff tear and compared their outcomes 6 and 12 months after surgery. They found that patients receiving early passive range of motion training had better forward elevation and external rotation of the shoulder joints. Re-tear of the rotator cuff was also found lower in patients subjecting to early rehabilitation with statistical significance. (Level 1)
3. Li, , et al., (2018) :
(1) Shoulder function: The results of the comprehensive study showed that the passive movement began early and within 2 weeks after surgery. In the short and medium term, the flexion and external rotation angles of the early exercise group were greater than those of the delayed exercise group. There are statistical differences.
(2) Tendon healing rate: Patients with large area tear before surgery had slow healing of tendon after EPM rehabilitation, but there was no significant difference compared with DPM rehabilitation (RR 0.90; 95% CI, 0.80-1.01; P = .06)。(Level 1)
Results, Conclusions and Recommendations：
In conclusion, early postoperative exercise could enhance quality of life without inducing more pain after surgery. Patients receiving early exercise after surgery may have better performances in shoulder forward elevation, abduction in the short term.
However, no difference was found in range of motion in the long term. Better outcomes were found in 92% of the patients subjecting to repair of the rotator cuff, despite early or late rehabilitation.
