EXERCISE THERAPY IN THE NON-OPERATIVE TREATMENT OF FULL-THICKNESS ROTATOR CUFF TEARS: A SYSTEMATIC REVIEW

. 2018 Jun;13(3):335–378.

First Author (Year)	Follow-up Period	Outcome Scale	Treatment groups (n = )	Intragroup difference	Statistically significant (*clinical significance)	Between group difference	Statistically significant
Itoi (1992)¹⁰⁹	3.4 yr (1 – 9 yr)	-Goniometer -Wolfgang criteria	G0: All patients (62) G1: Satisfied (15) G2: Unsatisfied (8)	(Post) Abduction (°): G0: 153.0 ° (+12.7 °) External rotation (°): G0: 47.1 ° (+7.1 °) Wolfgang criteria (avg. score 0-4): ** G0: 2.5→3.2 G1: 3.4→3.6 G2: 2.5→1.8	(Post) Abd & ER: NR Wolfgang criteria: G0: P < 0.05 G1: P < 0.05 G2: P > 0.05 (NS)	(Pre) Abduction (°): G1: 149.0 °; G2: 108.0 ° External rotation (°): G1: 55.0 ° G2: 50.0 °	(Pre) Abd: G1vs G2: p<0.05 ER: G1vs G2: p>0.05 (NS)
Bokor (1993)¹⁰⁵	7.6 yr (3.7 – 12 yr)	-Goniometry	G1: Non-surgical (53)	(Avg ROM): ‘Elevation’: 121 °→149 °	NR	NA	NA
Hawkins (1995)¹⁰⁸	3.8 yr	-Constant-murley mobility score	G1: Non-surgical (19) G2: Not satisfied w/ non- surgical (14)	(Pre→post) G1: 34.7→36.5 G2: 33.9→30.3	NR	(Pre→post) G1: 34.7→36.5 G2: 33.9→30.3	NR
Wirth (1997)¹¹⁴	>/= 2 yr	-NR	G1: Exercise therapy (60)	NR	NR	NA	NA
Palmer (1998)¹⁰¹	2 yr	-Goniometer	Aquatic Therapy (1)	(Pre→12 weeks) Flex: 90 °→160 ° Abd: 45 °→134 ° ER: NR→77 ° IR: NR°→60 ° Ext: 36 °→51 °	NR	NA	NA
Yamada (2000)¹¹⁵	4 yr (12 mo – 19 yr)	JOA Score	G1: Non-surgical (14) G2: Surgery (26)	(Percent improvement): G1: 17.9% G2: 18.1%	(Post) G1: P = 0.0501 G2: P < 0.001	NR	NR
Goldberg (2001)¹⁰⁷	6 mo Intervals 2.5 yr	NR	G1: Non-surgical (46)	NR	NR	NR	NR
Shibata (2001)¹²⁶	24 wk	-Goniometer	G1: 25 mg sodium Hyaluronate & 3 mL 1% lidocaine (38) G2: 2mg Dexamethasone & 3 mL 1% lidocaine (40)	(Pre→4 wk→24 wk) Abduction (°): G1: 122.8 °→151.6 °→147.7 ° G2: 111 ° → 143.7 °→139.6 ° External rotation (°): G1: 43.8 °→52.2 °→49.6 ° G2: 37.3 °→45.3 °→46.5 ° Internal rotation (lumbar (Lsp) or thoracic (Tsp) vertebrae): G1: Tsp: 12.3→11.3→11.8 G2: Lsp: 1.1→Tsp: 12.5→ NR	(4 wk) Abduction: G1: p<0.01* G2: p<0.01* External rotation: G1: p<0.001 G2: p<0.05* Internal rotation: G1: NS; G2: NS (24 wk) Abduction: G1: p<0.05* G2: p<0.05* External rotation: G1: p<0.05 G2: p<0.05* Internal rotation: G1: NS; G2: NS	NR	NR
Vad (2002)¹²⁰	3.1 yr (Range: 2-7 yr)	Goniometer	G1a: PT + meds (28) G1b: PT + meds + CS (12) G2: Failed G1a/b arthroscopy (32) G3: Primary surgery RCT repair (36)	(Pre→post) Abduction: G1: 68 °→108 ° (6.8 mo) G2: 74 °→110 ° (3.2 mo) G3: 72 °→116 ° (6.8 mo)	(Post) G1: p < 0.05* G2: p < 0.05* G3: p < 0.05*	(Post) G1b took less time (5.3 mo) than G1a (time NR) to reach maximum ADB ROM.	(Post) G1b vs G1a: p < 0.05
Piccoli (2004)¹⁰²	7 wk	-Goniometer	Single case	(Pre→7 wk) Flexion: 90 °→150 ° Extension: 22 °→56 ° Abduction: 80 °→139 ° Internal rotation: 30 °→68 ° External rotation: 45 °→89 °	NA	NA	NA
Ainsworth (2006)¹⁰⁴	Avg: 10.8 mo (Range: 2-36 mo)	NR	G1: Non-surgical (10) (Torbay rehab program)	NR	NR	NR	NR
Levy (2007)¹¹⁶	9 mo	-Constant-murley mobility score	G1: Non-surgical (17)	(Pre→≥9 mo) (Avg (range)): 12 (6-18) → 34 (24-40)	NR	NR	NR
Lunn (2007)¹¹⁹	50 mo	-Constant-murley mobility score	G1: Nonoperative (14) G2: Open repair (5)	(Pre→post) Constant-murley (score): G1: 30.3→34 G2: 32.8→34.8	NR	NR	NR
Ainsworth (2009)¹²⁷	12 mo	-“Visual estimation” (Flexion) -Goniometer (ER)	G1: PT + Exercise (30) G2: Control (Placebo) (no exercise) (30)	(3 mo) Elevation AROM (percent of cohort) G1: 71% improved by > 5 ° G2: 53% improved by > 5 ° (3 mo→6 mo→12 mo) ER PROM G1: 1.88 °→8.75 °→7.43 ° G2: 5.36 °→(-)3.7 °→4.4 °	NR	(3 mo→6 mo→12 mo) Elevation AROM G1: Values NR G2: Values NR (3 mo→6 mo→12 mo) ER PROM G1: 1.88 °→8.75 °→7.43 ° G2: 5.36 °→(-)3.7 °→4.4 °	Elevation AROM: G1 vs G2: 3 mo: p = 0.015 6 mo: p = 0.051 12 mo: p = 0.374 (NS) ER PROM: G1 vs G2: 3 mo: p = 0.889 (NS) 6 mo: p = 0.009 12 mo: p = 0.029
Baydar (2008)¹¹⁸	6 mo, 1 yr, 3 yr (Pt. report)	-Goniometer	G1: Non-surgical (20)	(Pre→6 mo) AROM: Flexion: 139 °→159.5 ° Abduction: 132.7 °→163.2 ° IR: 11.8 °→13.8 ° ER: 59.5 °→74.7 ° PROM: Flexion: 163 °→174 ° ER: 70.7 °→81.0 °	(6 mo) AROM: Flexion: p < 0.001 Abduction: p < 0.001* IR: p < 0.001 ER: p < 0.001* PROM: Flexion: p < 0.003 ER: p < 0.003	NA	NA
Moosmayer (2010/2014)^47,48 ‡	6mo, 1yr, 2yr 5 yr	-Goniometer	G1: Surgical (52) G2: PT (51) †G3: G2→G1 (9; 18%) †G4: PT only (39)	(Pre→6 mo→1 yr→ 5 yr) G1: Flexion: 87 °→147 °→166 °→171 ° Abd: 73.7 °→135 °→158 °→167 ° G2: Flexion: 89 °→147 °→156 °→164 ° Abd: 82 °→135 °→144 °→155 °	NR	(Post) Flx (°): G1: 171 °; G2: 164 ° Abd (°): G1: 167 °; G2: 155 °	(Post) Flx: G1 vs G2: p = 0.3 (NS) Abd: G1 vs G2: p = 0.15 (NS)
Tanaka (2010)¹¹³	G1: 2.4 yr G2: 2.2 yr	-Goniometer	G1: Non-surgical (subjects: 62 shoulders: 65) G2 Failed G1→surgery (subjects: 56 shoulders: 58)	(Post) Flx (°): G1: 143 °; G2: 135 ° ER (°): G1: 52.2 °; G2: 35 °	NR	(Post) Flx (°): G1: 143 °; G2: 135 ° ER (°): G1: 52.2 °; G2: 35 °	(Post) Flx: G1 vs G2: p = 0.77 (NS) ER: G1 vs G2: p < 0.001*
Gialanella (2011)¹²⁸	6 mo	-Constant-murley mobility score	G1: PT & CS (x1) (20) G2: PT & CS (x2) (20) G3: PT (control) (20)	(Pre→3 mo→ 6 mo) AROM (score): G1: 14.0→17.0→14.8 G2: 15.3→20.1→16.7 G3: 16.6→17.0→16.4	(3 mo) AROM: G1: p < 0.01 G2: p < 0.001 (6 mo) AROM: G2: P < 0.05	(Pre→3 mo→ 6 mo) AROM (score): G1: 14.0→17.0→14.8 G2: 15.3→20.1→16.7 G3: 16.6→17.0→16.4	(6 mo) AROM: G1 vs G2 vs G3: p = NS
Merolla (2011)¹	12 mo.	-Goniometer	G0: Conservative therapy (60) G1: ‘Successful’ (33) G2: G0→ surgery (27)	(Pre→3 mo→6 mo→12 mo) Flx AROM (°): G0: 108 °→160 °→150 °→145 ° Abd AROM (°): G0: 92 °→150 °→145 °→140 ° ER AROM (°): G0: 45 °→42 °→47 °→46 ° IR AROM (°): G0: 50 °→52 °→48 °→54 °	(3 mo, 6 mo, 12 mo) Flx AROM: G0: P<0.01* Abd AROM: G0: P<0.01* ER AROM: G0: P>0.05 (NS) IR AROM: G0: P>0.05 (NS)	NR	NA
Kijma (2012)¹¹⁰	12.9 yr	NR	G1: 43	NR	NR	NR	NR
Krischak (2013)¹²⁴	2 mo	-Goniometer	G1: Standard OT (22) G2: Home exercises (16)	(Pre→2 mo) AROM (°): Abduction: G1: 131.7 ° →159.7 ° G2: 127.4 °→151.3 ° Flexion: G1: 155.1 ° →164.6 ° G2: 148.9 ° →161.1 ° External rotation: G1: 39.9 °→47.2 ° G2: 42.4 °→48.8 °	NR	(2 mo) AROM (°): Abd: G1: 159.7 °; G2: 151.3 ° Flx: G1: 164.6 °; G2: 161.1 ° ER: G1: 47.2 °; G2: 48.8 °	(2 mo) AROM (°): Abd: G1 vs G2: p = 0.66 (NS) Flx: G1 vs G2: p = 0.64 (NS) ER: G1 vs G2: p = 0. 92 (NS)
Kuhn (2013)⁴⁰	1 yr	-Goniometer	G0: PT program‡ (422, 100%) G1: Cured (237, 62.2%) (no formal f/u scheduled) G2: Improved (continue PT) G3: No better (82, 29%) (offered surgery)	(Pre→6 wk→12 wk) AROM (degrees): Flexion: G0: 149 °→163.3 °→162.9 ° Abduction: G0: 136.8 °→154.9 °→154.7 ° ER at 0 ° Abd: G0: 52.9 °→55.6 °→55.8 ° IR at 0 ° Abd: G0: 45.32 °→46.36 °→52.27 °	NR	NR	NA
Benazzo (2014)⁹⁹	29 mo	NR	Non-surgical: (1)	(Pre→40 d→60 d) AROM (degrees): Flx: “unable”→100 °→”full ROM” Abd: “unable”→100 °→”full ROM” ER: “not impaired”→ ”full ROM” IR: “not impaired”→ ”full ROM”	NA	NA	NA
Boorman (2014)¹²³	29 mo	NR	G0: 3 mo supervised, non-operative§ G1: “Successful”(no surgery indicated) (70; 75%) G2: “failed” (underwent surgery) (23; 25%)	(Baseline) Forward Elevation: G1: 154 ° G2: 153 °	NA	(Baseline) Forward Elevation: G1: 154 ° G2: 153 °	(Baseline) Forward Elevation: G1 vs G2: p = 0.618 (NS)
Güzelant (2014)¹¹⁷	66 mo (mean)	-Goniometer	G1: “Conservative therapy” (33)	(Pre→Post) Flexion: 105 °→160 ° Abd-ER: 41 °→44 °	(Post) Flx: P<0.05 (p = 0.0272)* Abd-ER: p > 0.05 (NS)	NA	NA
Kukkonen (2014/2015)^52,125	24 mo	-Constant-murley mobility scale	G1: PT (55) G2: Acromioplasty & PT (58) G3: RC repair, acromioplasty & PT (54)	(Pre→6 mo→12 mo→24 mo) Constant-murley (score):** G1: 29.1→36.1→36.1→ 37.0 G2: 31.2→35→36→36.2 G3: 30.0→34.1→36.0→36.0	NR	(24 mo) Constant-Murley (score):** G1: 37.0 G2: 36.2 G3: 36.0	(24 mo) Constant-Murley: G1 vs G2 vs G3: p>0.05 (NS)
Collin (2015)¹⁰⁶	24 mo	-Anterior elevation -“ER with the elbow by the side” (ER1)	G1: “Rehab program” (45) (nonoperative)	(Pre→post) Anterior elevation > 160 ° (percent cohort): G1: NR→53% ER1 (percent cohort): G1: 31% →31%	NR	NA	NA
Lambers Heerspink (2015)⁴⁹	12 mo	-NR	G1: “Conservative Management” (31) G2: RC repair (25)	NR	NA	NR	NA
Baumer (2016)¹²¹	≥9 wk	-Goniometer	G1: PT (25) G2: Healthy controls (25)	(Pre→≥9 wk) AROM (°): Abd: G1:131.5 °→164.7 °; G2:180 ° Flx: G1: 140.7 °→169.4 °; G2: 180 ° ER: G1: 71.5 °→86.2 °; G2: 102.0 ° IR: G1: 40.2 °→55.4 °; G2: 64.7 ° PRROM (°): Abd: G1:135.2 °→164.3 °; G2:180 ° Flx: G1: 145.7 °→176.8 °; G2: 180 ° ER: G1: 74.3 °→88.4 °; G2: 103.6 ° IR: G1: 34.3 ° →43.8 °; G2: 57.3 °	(Pre→≥9 wk) AROM (°): Abd: G1: p = 0.01* Flx: G1: p < 0.01* ER: G1: p = 0.02* IR: G1: p = 0.03* PRROM (°): Abd: G1: p < 0.01* Flx: G1: p = 0.02* ER: G1: p = 0.01 IR: G1: p < 0.01*	(≥9 wk) AROM (°): Abd: G1: 164.7; G2: 180 ° Flx: G1: 169.4 °; G2: 180 ° ER: G1: 86.2 °; G2: 102.0 ° IR: G1: 55.4 °; G2: 64.7 ° PRROM (°): Abd: G1: 164.3 °; G2: 180 ° Flx: G1: 176.8 °; G2: 180 ° ER: G1: 88.4 °; G2: 103.6 ° IR: G1: 43.8 °; G2: 57.3 °	(≥9 wk) AROM (°): Abd: G1 vs G2: p=0.03 Flx: G1 vs G2: p = 0.05 ER: G1 vs G2: p < 0.01 IR: G1 vs G2: p = 0.08 (NS) PRROM (°): Abd: G1 vs G2: p=0.03 Flx: G1 vs G2: p = 0.33 (NS) ER: G1 vs G2: p < 0.01 IR: G1 vs G2: p < 0.01 (NS)
Christensen (2016)¹²²	≥5 mo	-Goniometer	G1: Non-operative(30) G2: Control (30)Δ	(Pre→≥5 mo) AROM (°): Flx G1: 132.5 °→133.9 ° (+1.4 °) Abd G1: 93.7 °→133.9 ° (+34.4 °) ER G1: 27.9 °→31.7 ° (+3.8 °)	(≥5 mo) Flx G1: p = 0.912 (NS) Abd G1: p = 0.005* ER: G1: p = 0.364 (NS)	NR	NA
Miller (2016)¹¹¹	12 wk	-Dynamic stereoradiography (DSX)	G1: Exercise therapy (5)	(Pre→12 wk) GH path length (percent of glenoid height): 67.2%→43.1% GH translation (percent of glenoid height): Superior-inferior: 17.1%→17.2% GH translation (percent of glenoid width): Anterior-posterior: 3.5%→3.2% Acromiohumaral distance (mm): Mean: 1.5 → 1.5 Minimum: 0.6 → 0.7	(12 wk) GH path length: P = 0.036* GH translation superior- inferior: p = 0.88 (NS) GH translation anterior- posterior: p = 0.89 (NS) Acromiohumaral distance: Mean: p = 0.81 (NS) Minimum: p = 0.31 (NS)	NA	NA
Mischke (2016)¹⁰⁰	13 visits (time NR)	Goniometer	Conservative therapy (1)	(Pre→visit 7→ visit 13) Shoulder Flx (°): 80 °→130 °→170 °	NA	NA	NA
Upadhyaya (2016)¹⁰³	10 yr	-NR	Non-operative treatment (1)	(Pre → 10 yr) Range of motion: “full ROM”→ “P/AROM symmetry”	NR	NA	NA
Moosmayer (2017)¹¹²	8.8 yr	-Constant-murley mobility scale	G1: Non-operative (49) G1a: Tear size < 9.9 mm (33) G1b: Tear size 10-19.9 mm (8) G1c: Tear Size ≥ 20 mm (8)	(≥ 8.8 yr) Abduction (°): G1a: 180 ° G1b: 163 ° G1c: 160 ° Flexion (°): G1a: 180 ° G1b: 168 ° G1c: 170 °	NR	(≥ 8.8 yr) Abduction (°): G1a & G1b: 180 ° G1c: 160 ° Flexion (°): G1a & G1b: 180 ° G1c: 170 °	(≥ 8.8 yr) Abduction (°): G1a & G1b vs G1c: p = 0.13 (NS) Flexion (°): G1a & G1b vs G1c: p = 0.08 (NS)

Abd, abduction; AROM, active range of motion; CS, corticosteroid; d, days; ER, external rotation; Flx, flexion; G, group; GH, glenohumeral; JOA, Japanese orthopedic association score; Mo, month; NA, not applicable; NR; not reported; NS; not statistically significant; PT, physical therapy; ROM, range of motion; Tsp ver, thoracic spine vertebrae, UCLA, University of California Los Angeles shoulder rating scale; wk, week; yr, year; *, clinical significance, indicates a statistical significant difference and a >20% difference; †, G3 and G4 are a subset of G2; Abd, abduction; ‡, all subjects began a physical therapy program and were reevaluated at 6 and 12 weeks, at those times patient were assigned to G1, G2, or G3 based on findings; §, all subjects underwent a 3 mo supervised program of nonoperative treatment & with an evaluated by orthopedic surgeon and assigned to G1 or G2; **, values estimated to nearest tenth based off graphical representation, as no specific numerical values reported with-in study.