Current concepts in the rehabilitation of rotator cuff related disorders

Abstract

Rotator cuff related disorders (RCRD) are common. Exercise-based rehabilitation can improve outcomes, yet uncertainty exists regarding the characteristics of these exercises. This scoping review paper summarises the key characteristics of the exercise-based rehabilitation of rotator cuff related disorders (RCRD). An iterative search process was used to capture the breadth of current evidence and a narrative summary of the data was produced. 57 papers were included. Disagreement around terminology, diagnostic standards, and outcome measures limits the comparison of the data. Rehabilitation should utilise a biopsychosocial approach, be person-centred and foster self-efficacy. Biomedically framed beliefs can create barriers to rehabilitation. Pain drivers in RCRSD are unclear, as is the influence of pain during exercise on outcomes. Expectations and preferences around pain levels should be discussed to allow the co-creation of a programme that is tolerated and therefore engaged with. The optimal parameters of exercise-based rehabilitation remain unclear; however, programmes should be individualised and progressive, with a minimum duration of 12 weeks. Supervised or home-based exercises are equally effective. Following rotator cuff repair, rehabilitation should be milestone-driven and individualised; communication across the MDT is essential. For individuals with massive rotator cuff tears, the anterior deltoid programme is a useful starting point and should be supplemented by functional rehabilitation, exercises to optimise any remaining cuff and the rest of the kinetic chain. In conclusion, exercise-based rehabilitation improves outcomes for individuals with a range of RCRD. The optimal parameters of these exercises remain unclear. Variation exists across current physiotherapy practice and post-operative rehabilitation protocols, reflecting the wide-ranging spectrum of individuals presenting with RCRD. Clinicians should use their communication and rehabilitation expertise to plan an exercise-based program in conjunction with the individual with RCRSD, which is regularly reviewed and adjusted.

1. Introduction

Rotator cuff related disorders (RCRD) are common, 40% of individuals report symptoms persisting longer than 12 months,¹ including significant pain, disturbed sleep, and a loss of function.² RCRD includes a spectrum of conditions such as tendinopathy, subacromial bursitis and acute and chronic tears.

Whilst several adjunct treatments exist, the value of education and exercise as the first line in the rehabilitation of RCRD is widely accepted.^{3, 4, 5, 6} Yet the characteristics of this rehabilitation and the subgroups of individuals most likely to benefit are unclear. Disagreement around terminology, pathoetiology, diagnostic standards, and outcome measures leads to a lack of comparable data.⁷ Uncertainty exists regarding the management of RCRD, the evidence base is extensive, yet several questions remain unanswered.

This scoping review paper aims to identify key characteristics of exercise-based rehabilitation of RCRD. A range of quantitative and qualitative sources will be summarised to provide an overview of the current concepts for all members of the multi-disciplinary team (MDT).

2. Methodology

The Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping reviews (PRISMA-ScR) was used as a basis for this review.⁸ The Cochrane, Cinahl, and Medline databases were searched with the support of a Trust librarian.

To ensure the breadth and range of current evidence for RCRD were covered whilst maintaining a focus on exercise-based rehabilitation an iterative process was used (Table 1), combining search terms in each concept using Boolean operator OR. Concepts one to four were then each combined with concept five using AND.

Table 1.

Search strategy.

Concept one: rotator cuff related shoulder pain	Concept two: rotator cuff tears	Concept three: massive cuff tears	Concept four: principles of rehabilitation	Concept five: exercise-based rehabilitation
Rotator cuff Shoulder pain Subacromial impingement Subacromial bursitis Painful arc syndrome Rotator cuff tendinopathy	Rotator cuff Partial thickness tear Full thickness tear Degenerative tear Traumatic tear	Massive rotator cuff tear Irreparable rotator cuff tear Shoulder Pseudo-paralysis	Rotator cuff Rehabilitation physiotherapy physical therapy Person-centred Shared decision making. Language Education Expectations Communication	Physiotherapy Physical therapy Rehabilitation Exercise Eccentric Isometric Heavy resistance Non-surgical Conservative

Reference list mining and citation searches were undertaken by hand. The first and final searches were undertaken on 30th July 2020 and 30th November 2020.

The titles and when required, abstracts from the search results were screened by one author against set inclusion and exclusion criteria (Table 2). For pragmatic reasons, the search was limited to papers published between 2016 and 2020 and in English with full text available. To maintain high methodological standards, systematic reviews and randomised controlled trials were included. Qualitative designs were included to reflect the breadth of the current evidence base. All other study designs were excluded. Papers used to inform the background to the paper, or those deemed seminal were all included.

Table 2.

Inclusion	Exclusion
Patient: adults with a clinical or radiological diagnosis of rotator cuff related shoulder pain of any duration.	Patient: adults with other shoulder diagnoses including but not limited to instability, frozen shoulder or arthritis.
Intervention: exercise-based rehabilitation.	Intervention: non-exercise-based treatments including but not limited to surgery, medications, injections, taping, electrotherapy or manual therapy.
Comparator: usual care, sham, or no treatment group.	Comparator: studies with only one arm that is eligible.
Outcome: any clinical or patient reported outcome measures.	Outcome: biomechanical or muscle activity outcome measures.

3. Results

The Prisma diagram for the search is shown in Fig. 1, 57 papers were included. Full-text papers were assigned for review by a single author to extract data including study design, study population, number of participants (or studies for systematic reviews), interventions, outcome measures, and results. Study design and level of evidence were used to describe the quality of the evidence. Due to the scoping nature of the review, a formal analysis of methodological quality or risk of bias was not performed. A narrative summary of the data was produced.

Fig. 1.

Prisma diagram.

4. Key concepts in the rehabilitation of RCRD

4.1. A biopsychosocial approach

Co-morbidities associated with increased risk of shoulder pain such as high BMI or metabolic disorders should be screened for⁹ and the individual’s ‘physiological age’ considered. Lifestyle factors associated with the risk of such disorders including diet, smoking, and low activity levels should be discussed. Rehabilitation professionals are uniquely placed to support patients in health-related behaviour change and a symptomatic shoulder should be considered a potential driver for such changes. A biopsychosocial assessment is considered good practice for individuals with persistent rotator cuff related shoulder pain and should consider how the individual’s pain beliefs, coping strategies, or social context could contribute to their symptoms.^10,11 Central nervous system involvement and sensitisation should also be considered in individuals with persistent shoulder pain including widespread hyperalgesia, pain disproportionate to structural findings, or altered pain pressure or cold thresholds.¹²

4.2. General principles of high quality RCRD rehabilitation

The uncertainty regarding optimal management of RCRD should be explained to the individual in terms that they can understand and without bias from the clinician.

General principles of tendinopathy management are useful in the rehabilitation of RCRD; education, controlled unloading, reloading, and prevention of recurrence.¹³ Considering the spectrum of clinical presentations of RCRD care should be individualised and person-centred.¹⁴ Rehabilitation should foster self-efficacy, hence active rather than passive modalities are favoured. If individuals fail to respond as expected, a shared decision-making approach should be used regarding ongoing management.

4.3. Communication and education in RCRD

Open questioning and active listening should be used to ensure that the individual’s specific ideas, concerns, and questions regarding their symptoms are explored.¹⁵

Rehabilitation requires self-efficacy, motivation, and compliance; hence early education is essential to ensure individuals are engaged in the process.¹⁶ The information provided to the individual must be appropriate for their level of health literacy and delivered with consideration of the individuals learning preferences.^{17, 18, 19}

5. Rotator cuff related shoulder pain (RCRSP) rehabilitation

The optimal rehabilitation for RCRSP is unclear, reflecting the often complex and varied presentation of the individuals with the condition. Exercise and education are recognised as core components of the rehabilitation of RCRSP by expert consensus,^20,21 yet wide variation in practice exists.^22,23

5.1. Managing expectations

The pain drivers in RCRSD remain uncertain,²⁴ yet biomedically framed beliefs are prevalent in individuals with RCRD²⁵ and can create barriers to rehabilitation.¹⁶ Hence, as with most non-traumatic musculoskeletal conditions, if suspicion of serious pathology is low initial diagnostic imaging is discouraged²⁶ and clinicians should be aware of the power of their language when discussing diagnoses.²⁷

Pain is frequently a significant factor for these individuals and can reduce tolerance of exercise-based interventions.²⁸ The influence of pain during exercise on outcomes is unclear, with improvements seen in both painful and pain-free groups.²⁹ It is generally accepted that pain may increase slightly during exercise but should remain tolerable and settle quickly.³⁰ Hence expectations and preferences around pain level should be discussed with the individual and a rehabilitation programme agreed which is tolerated and therefore engaged with. Clinicians should consider that this may result in an exercise prescription which initially aims to build self-efficacy and participation rather than induce physiological changes. Clinicians should regularly re-assess, review, and adjust the programme as the individual with RCRSP makes progress.

5.2. Exercise parameters

In the mid to long-term, higher dose or progressive and resisted exercises may provide greater improvement in pain and function in comparison to placebo, no treatment, lower dose, or non-resisted exercise.^31,32 Supervised and home exercise programmes appear equally effective in improving pain and function at around 12 weeks in this patient group.^,33,34

The optimal number of repetitions and sets for exercise-based rehabilitation is uncertain, more repetitions and sets may improve outcomes compared to fewer. A minimum duration of twelve weeks exercise-based rehabilitation is thought to be needed to see clinically significant improvements.³⁵ It is acknowledged in the evidence base that studies investigating exercise-based interventions must fully report doses to allow comparison of results.³⁶

Several randomised controlled trials have compared specific exercise parameters such as inclusion of stretches,³⁷ varying load,^{38, 39, 40} varying type of exercise,^{41, 42, 43} and the addition of novel exercises.^{44, 45, 46} Improvements in short term outcomes for each exercise-based intervention are common. However sample sizes are small and lack of significant difference between groups supports the uncertainty around the optimal variables for exercise-based rehabilitation.

5.3. Type of loading programme

The RCRSD literature reflects the uncertainty across wider tendinopathy research regarding types of loading. Varied responses between individuals with RCRSD to isometric loading⁴⁷ and a small, non-clinically significant improvement in pain after a twelve-week eccentric loading programme^{48, 49, 50, 51} are reported.

5.4. Scapular focused exercises

Scapular focused exercises may improve pain and function in RCRSP in the short term.⁵² Findings should be interpreted with caution due to small sample sizes and significant heterogeneity of intervention and outcome measures.^{53, 54, 55}

6. Rehabilitation of partial thickness (PTT) and full thickness (FTT) rotator cuff tears

6.1. Managing expectations

Non-traumatic rotator cuff tendon tears are part of the continuum of RCRD tendon pathology.⁵⁶ Tears are defined as structural failure of one or more of the rotator cuff tendons. Full thickness tears extend to the entire depth of the tendon, whilst partial thickness tears do not.⁵⁷

Comparing surgical and non-surgical management of individuals with rotator cuff tears is beyond the scope of this review. However, clinicians should be aware of risk factors associated with poor outcomes following non-operative treatment, including low expectations of physiotherapy treatment.⁵⁸ Hence individuals with symptomatic rotator cuff tears should be supported to understand their diagnosis and prognosis; that improvements in symptoms can occur despite structural changes to the tendons. Uncertainty around the natural history and progression of symptomatic rotator cuff tears to becoming irreparable and resulting in permanent loss of function, further complicates the issue and a multi-disciplinary approach to decision making is advocated. Younger, more active patients should be adequately counselled regarding this uncertainty.⁵⁹

6.2. Rehabilitation of non-operatively managed tears

A lack of agreement around definitions and diagnostics means considerable overlap exists in the literature. Several studies of exercise-based rehabilitation for RCRSP include individuals with PTT within their samples.^{31,32,34,36,37,40, 41, 42, 43, 44,47} Individuals with symptomatic non-traumatic PTT or FTT can be successfully managed using the same principles as RCRSP, education, and an individualised, progressive exercise prescription.^{59, 60, 61, 62} Individuals failing to show any improvement following 12 weeks rehabilitation should be referred on for further imaging and a specialist opinion.⁵⁷ Beliefs and expectations should be explored as part of the rehabilitation process. In individuals with persistently symptomatic FTT a strong preference in favour of surgical management has been reported.⁶³

6.3. Rehabilitation of post-operative rotator cuff repairs

Expert consensus regarding post-operative rehabilitation is limited by a lack of high-quality studies⁶⁴ and wide variation currently exists between individual surgeon’s post-operative protocols.⁶⁵

Concerns regarding the failure of surgical repairs drive the debate around protection and immobilisation versus early mobilisation and controlled load, preventing stiffness and further deconditioning of the soft tissues. Slings are used to protect the healing tissues but reported side effects including impaired gait and increased risk of falls and patient frustration due to delayed function and return to work.^66,67 A delay in the post-operative range of movement is argued to cause stiffness, weakness and be detrimental to the healing tendon structure. Descriptions of the individual’s experience or perceptions of post-operative rehabilitation suggest a preference for early mobilisation.⁶⁸

In the current literature there is a trend toward support for minimal sling use and controlled early mobilisation to improve outcomes following rotator cuff repair, with no impact on failure rates.^{64,69, 70, 71, 72} However, comparative studies frequently exclude individuals with larger repairs and concerns around higher re-tear rates in this population necessitates further work to clarify the risks and benefits of early mobilisation in this subgroup.^69,73,74

Currently, exercise-based rehabilitation following rotator cuff repair is often governed by time-dependent protocols. There is increasing support however that rehabilitation should be milestone-driven, individualised and consider the size and type of surgical repair, tissue quality, tendon healing, and patient characteristics.⁶⁰ In the absence of high quality RCT results, communication across the MDT is essential and allows Upper Limb Units safely implement accelerated post-operative rehabilitation protocols where clinically appropriate.

Once guidance and reassurance have been provided to individuals following rotator cuff repair, self-administered and supervised home exercises appear equally effective with unsupervised rehabilitation having lower health-care-associated costs,^75,76 In the absence of evidence based prognostic indicators and acknowledging the importance of individualised care, clinician’s expertise must be utilised to identify individuals likely to benefit from increased support post-operatively.

7. Rehabilitation of massive rotator cuff tears (MRCTs)

MRCTs involve full-thickness tears of two or more tendons or tears measuring more than 5 cm.⁷⁷ MRCTs are commonly surgically irreparable or are present in individuals with significant co-morbidities and hence surgical risk.

As with other classifications of a cuff tear, MRCTs can exist asymptomatically supporting the theory that individuals can compensate for a loss of cuff function. The Torbay anterior deltoid exercise programme is well established in the rehabilitation of MRCTs and when combined with functional rehabilitation can improve functional outcomes.⁷⁸

The premise of recruiting the anterior deltoid is to optimise the coupling forces around the shoulder and allow glenohumeral joint elevation without the upward sheering of the humeral head.⁷⁹ This effect may be enhanced if some active external rotation is preserved and an intact subscapularis tendon appears predictive of better outcomes. The involvement of 3 or more tendons is predictive of poorer outcomes.^77,78

The evidence base for exercise-based rehabilitation for MRCT is limited. Readers should be reminded that no level I studies were identified by this search and significant heterogeneity of the published research limits comparison or meta-analysis of treatment outcomes.⁸⁰ Clinically, the decision to proceed with non-operative management should be a collective one involving the individual, the surgeon, and the therapist and considering the individual’s expectations, functional aims, and tear characteristics.

The available evidence plus expert opinion does support the role of exercised based rehabilitation in this patient group.^{78, 79, 80, 81} Rehabilitation has also been shown to be cost-effective.⁸² The clinical significance of improvement in outcomes following rehabilitation and individual’s perceptions of the process remain unclear. Measures of general and emotional health can remain unchanged despite exercise-based rehabilitation following MRCT suggesting not all upper limb function is recovered.⁷⁸ Further work is needed to explore factors predictive of outcome following exercise-based rehabilitation for MRCT such as functional demand, the severity of symptoms, presence of glenohumeral joint osteoarthritis, tear size and retraction, amount of fatty infiltration, and muscle atrophy.

Experience dictates that the rehabilitation programme should be person-focused, considering the individual’s goals, functional requirements, and expectations. The anterior deltoid programme is a useful starting point for the exercise-based rehabilitation of MRCT. This should be supplemented by optimisation of any remaining cuff and the rest of the kinetic chain plus functional rehabilitation. Regular re-assessment is essential to support and progress the individual over the several month rehabilitation process.

8. Conclusion

Exercise-based rehabilitation improves outcomes for individuals with a range of RCRD. The optimal parameters of these exercises remain unclear. Variation exists across current physiotherapy practice and post-operative rehabilitation protocols, reflecting the wide-ranging spectrum of individuals presenting with RCRD.

Exercise-based rehabilitation for RCRSP should be person-centred and promote self-efficacy. Beliefs and expectations should be explored, expertise in communication skills is essential here. Individualised education should be provided to address any potential barriers, such as a strongly biomedically based understanding of RCRSP. Clinicians should use their rehabilitation expertise to plan an exercise-based program in conjunction with the individual with RCRSD, which is regularly reviewed and adjusted. Those who fail to improve following 12 weeks of exercised-based rehabilitation should have access to shared decision-making regarding their ongoing management, with input from across the MDT as required.

Limitations of this work reflect the broad scope of the review and challenges within the evidence base. Disagreement around definitions, diagnosis, and classification of RCRSD persist and heterogeneity of studies reduces opportunities to compare results. Direct comparison of the effectiveness of exercise-based rehabilitation to other treatments is problematic. Hence the rapidly expanding evidence base is shifting to include a wider range of study designs, providing insight into the experience of an individual with RCRSD and of those clinicians involved in their care.

Funding statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of competing interest

The authors have none to declare.