Abstract
Background and Purpose Both traditional and progressive rotator cuff repair rehabilitation protocols often delay active motion of the shoulder for 6 weeks or more. The early inclusion of a comprehensive aquatic-assisted exercise program presents a unique approach to postoperative management. The purpose of this case study is to describe a comprehensive evidence-based, aquatic-assisted rehabilitation program following arthroscopic rotator cuff repair.
Case Description A 73-year-old woman with a nonretracted, medium-size, full-thickness tear (2.5 cm) of the supraspinatus tendon underwent arthroscopic rotator cuff repair and was referred for postoperative physical therapy. The rehabilitation program was initiated at 2 weeks postoperatively and consisted of concurrent land- and aquatic-based interventions over 6 weeks for a total of 18 physical therapy visits.
Outcomes Improvements were made in all 5 patient-reported outcome measures that were recorded weekly over the course of care. Improvements reached or exceeded minimal detectable change levels for the Shoulder Pain and Disability Index and the Penn Shoulder Score. Her numeric pain rating scale score at rest decreased from 4/10 at the initial evaluation to 2/10 at 8 weeks postoperatively and with activity decreased from 9/10 to 6/10. Shoulder strength and range of motion values also exhibited improvement over the course of care. No adverse events occurred during the case study.
Discussion This case study illustrates the safe inclusion of low-stress aquatic exercises as an early adjunct to traditional land-based rotator cuff repair rehabilitation programs in small- to medium-size repairs. Further studies are needed to determine the long-term effectiveness of adding aquatic therapy to traditional postoperative programs.
Rotator cuff injury is a common condition that has been reported to affect more than 40% of the US population over 60 years of age.1 It is estimated that more than 250,000 rotator cuff repairs are performed annually in the United States.2 The very first rotator cuff repair was performed by Dr Ernest Amory Codman in 1911 using an open technique.3 From 1996 to 2006, the number of rotator cuff repair procedures increased by 141%.1 During that same period, arthroscopic procedures increased by 600%, whereas open procedures increased by only 34%.1
The goals of postoperative rotator cuff rehabilitation are to protect the repair, promote healing, gradually restore motion and strength, and return the individual to normal functioning.3 The success of shoulder rehabilitation relies on several key factors: endurance training of the rotator cuff, protection of the cuff musculature from adverse forces, restoring normal flexibility of the joint capsule, ensuring correct thoracic posture, and scapular positioning for optimal scapulohumeral rhythm. Remobilization of an immobilized rat tendon has been shown to result in acceleration of collagen synthesis and the enzymes that promote cross-link formation.4 Collagen that is mobilized with the right amount of stress at the right time will lead to better structural organization and capillary growth than collagen that is not stressed.4–6 This ability, by which cells respond to mechanical cues with biochemical effects, is called mechanotransduction.
Appropriate and safe low-stress controlled motion exercises may be initiated during the proliferative phase of healing and progressed through the remodeling phase. It has been shown that blood flow increases 7-fold in tendons, and up to 20-fold in muscles, during exercise.5 Conversely, prolonged rotator cuff immobilization has been shown to have long-term negative effects, such as joint stiffness and fibrosis, muscular atrophy, fatty degeneration and infiltration, and impaired return to normal functioning.6–8 The concepts associated with the management of postoperative mobilization and immobilization following rotator cuff repairs remain a fundamental and unanswered question and can affect the patient's recovery. Caution should be used postoperatively, as evidence has shown a recurrent cuff tear rate between 25% and 94% in repaired tendons that were chronically atrophied.9–11 Galatz et al11 reported a re-tear rate of up to 94.4% (17/18 patients), with the majority of the failures being repairs of large to massive tears involving at least 2 tendons. It is important to note that their patients had started seated pulley active-assisted range of motion (AAROM) exercises on day 1 postoperatively. The shoulder pulley AAROM exercise has been shown to elicit 17.6% of maximal muscle activity in the supraspinatus muscle12 and may have played a role in the high rate of re-tears in the study by Galatz et al.11
Before discussing when it is appropriate to initiate exercises after rotator cuff repair, one must possess a thorough comprehension of the 4 phases of healing,5 as well as the process of tendon healing to bone. Immediately after an injury, the first phase to occur is the clotting phase. It is usually completed within 5 minutes but may take up to 48 hours. The inflammatory phase is the second phase of healing and generally lasts about a week. However, it may persist much longer if acute treatment mismanagement occurs (inadequate immobilization, additional trauma, poor adherence to ice treatments and medications). During the inflammatory phase, there is an influx of platelets, macrophages, monocytes, and neutrophils that release chemotactic agents to recruit blood vessels, fibroblasts, and intrinsic tenocytes.13
If the duration of inflammation during the inflammatory phase is kept to a minimum, the third phase of healing, or proliferative phase, can typically begin around day 5 or 6. It is in this phase that the formation of new type III collagen by fibroblasts is accentuated. The proliferative phase can last 4 to 6 weeks or more. During days 7 through 14, the repair exhibits the greatest rate of collagen formation and cross-linking and, therefore, increased tensile strength.5 Tendon to bone healing is evidenced at 6 weeks with the development of a partial fibrous interzone.14 It is very important to note that the new tendon-bone junction is a disorganized scar that forms mostly by way of a reparative process, not a regenerative process. This new junction consists primarily of type III immature collagen tissue, not mature type I collagen. Therefore, it does not have the same mechanical tensile properties and histological appearance as the original native tendon-bone junction. However, carefully supervised, controlled mobilization will lead to a scar with better structural organization and capillary growth.5 The studies by Blickenstaff et al15 and Grana et al16 showed the first Sharpey-like fibers to be present as early as 3 weeks after fixation of tendon to bone in rabbit models. Sharpey fibers are composed of collagen and are considered to be one of the main structures that bridge the gap from bone to tendon. They also are considered to be one of the earliest signs of osseous integration.16 Primate studies have shown that it takes approximately 12 weeks or longer for the number of Sharpey fibers to become significant to prevent pullout of the bone-tendon repair.3,9,17
The final phase of healing is the maturation or remodeling phase. This phase typically starts around day 20 and is reported to last up to a year or longer.5 It is during this phase that immature type III collagen is replaced by mature type I collagen, and the number of collagen cross-links increases.13 The strength of the scar increases as the collagen becomes denser and organizes itself along lines of stress. As noted earlier, avoiding a re-tear is of paramount importance. Therefore, attempts to accelerate the protocol through aggressive stretching and increasing tensile loads should be avoided at all costs.
Traditional protocols typically involve 6 weeks or more of immobilization in a sling, depending on many variables: the size, thickness, quality, location, shape, and chronicity of the tear; the surrounding cuff muscle quality; the age of the patient; the health characteristics and comorbidities of the patient; the patient's goals; the patient's access to care; the surgeon's rehabilitation philosophy and experience; the surgical repair fixation technique used; the quality and density of bone; the mechanism of cuff failure; and the postoperative stability of the repair.9,18,19 To minimize the deleterious effects commonly associated with 6 weeks or more of immobilization, the early initiation of low-stress buoyancy-assisted exercises may help to prevent muscular atrophy and fatty infiltration, trigger collagen synthesis via mechanotransduction, reactivate neuromuscular control pathways, and stimulate motivation and self-efficacy.
Only a few protocols have been reported in the literature that mention the use of aquatics to augment rotator cuff rehabilitation, and most only provide a brief notation that it can be incorporated.9,18,20 The purpose of this case report is to detail and describe the implementation of a unique comprehensive evidence-based, aquatic-assisted rotator cuff repair rehabilitation protocol for a medium-size supraspinatus tendon tear. The postoperative rehabilitation protocol that was used is shown in eAppendix 1. The patient gave informed consent prior to participation.
Patient History and Systems Review
The patient is a 73-year-old, female nonsmoker who works as a traveling registered nurse. Her comorbidities include a cervical fusion procedure that was performed 11 years previously without any residual left upper extremity weakness and a history of fibromyalgia, which she noted did not cause pain or weakness in her upper extremities. A screening examination of the cervical spine (ie, Spurling test) was performed to rule out any coexisting pathologies that may mimic a shoulder condition or affect outcomes. Range of motion (ROM) and strength testing of the uninvolved shoulder was within functional limits. She originally reported injuring her left shoulder 2 years prior from trauma related to tripping on a curb and landing on her elbow. At that time, she was managed conservatively with physical therapy and a corticosteroid injection. She was able to return to full-capacity work approximately 1 year postinjury. Approximately 8 to 9 months after returning to work, her left shoulder pain returned, and a magnetic resonance imaging (MRI) test was performed. The MRI detailed a medium-size, full-thickness tear of the supraspinatus tendon, a type III acromion, and subacromial bursitis. Full-thickness rotator cuff tear sizes are commonly defined according to DeOrio and Cofield21 as: small (1 cm or less), medium (1–3 cm), large (3–5 cm), or massive (greater than 5 cm). The patient reported an inability to reach upward to groom and style her hair, disturbed sleep as a result of left shoulder pain, inability to push and pull medication carts, and inability to lift heavy objects and patients. She was unable to participate in recreational swimming and was unable to continue working as a traveling nurse.
Approximately 2 years after the initial trauma, the patient underwent arthroscopic surgical repair of her supraspinatus tendon. A subacromial decompression was also performed to remove the type III acromion, the coracoacromial ligament, and the subacromial bursa. The patient was immobilized in a shoulder sling with an abduction pillow for 4 weeks. An Empi Continuum (Empi Inc, St Paul, Minnesota) home transcutaneous electrical nerve stimulation (TENS) unit with 4 sterile electrodes was applied to the operated shoulder immediately following surgery for pain control. The parameters for the shoulder TENS acute pain protocol were as follows: 2-channel simple modulated pulse protocol; pulse rate of 100 pulses per second; pulse width of 300 microseconds; cycling time of 12 seconds, 30 minutes/session; and subcontractile intensity level. She was instructed to use the home TENS unit as needed following surgery. She was prescribed 5 mg of Percocet (Endo Pharmaceuticals, Malvern, Pennsylvania) to be taken every 4 to 6 hours for pain relief until her pain subsided. The patient's surgeon was asked to review the aquatic-assisted protocol and was in agreement that she would be an appropriate candidate.
Examination
The initial physical therapist evaluation was delayed by the patient until 2 weeks postsurgery, as she had a preplanned vacation. She was instructed to remove the sling only for her home exercises, while showering, and during physical therapy sessions. Four arthroscopic portal sites around the left shoulder were closed and fully healed. The left upper trapezius muscle and anterior shoulder region were mildly tender to palpation. Initial left shoulder passive range of motion (PROM) values are summarized in Table 1. Active range of motion (AROM) and strength testing of the left shoulder were contraindicated at this time (ie, only 2 weeks postoperatively). Grip strength was measured using a Jamar hand dynamometer (Lafayette Instrument Co, Lafayette, Indiana) with the adjustable handle in the second position and with the patient seated and the elbow flexed 90 degrees: left 17.7 kg of force, right 30.4 kg of force (mean of 3 trials). The patient self-reported her pain level using an 11-point numeric pain rating scale (NPRS).22 Scores range from 0 to 10, with 0 being “no pain” and 10 being “the worst imaginable pain.” She rated her pain 4/10 at rest and 9/10 with attempts to move her left upper extremity.
Left (Involved) Shoulder Range of Motion and Strength Values Over the 6 Weeks of the Aquatic-Assisted Protocola
Clinical Impression
The patient appeared to be an excellent candidate for participation in an aquatic-assisted protocol for several reasons. She had a 2-year history of a chronic rotator cuff tear. Rotator cuff tears in older individuals are often characterized by tendon thinning from chronic degeneration and critical zone hypovascularity.5 Additionally, the quality of chronic rotator cuff tears is often in question due to presence of fatty infiltration and lack of neuromuscular control. Caution would be indicated due to the medium size and chronicity of the tear, so the aquatic environment would aid in the control of adverse forces on the repair.23 The warm water environment also may reduce any discomfort from her fibromyalgia history.24 The comfort and ease of performing exercises in a warm, buoyant environment early in the recovery process tend to be motivational and may promote self-efficacy.
Intervention
The aquatic-assisted rotator cuff repair rehabilitation protocol began at the end of week 2 and lasted through the end of week 8. This protocol incorporates numerous controlled motion/buoyancy-assisted motion techniques performed in a SwimEx pool (SwimEx Inc, Fall River, Massachusetts). For postoperative weeks 3 through 6, the patient attended 2 aquatic physical therapy sessions and 1 land-based physical therapy session. During postoperative weeks 7 and 8, the patient attended 2 land-based physical therapy sessions and 1 aquatic-based physical therapy session. During each aquatic session, land-based manual physical therapy treatments were performed prior to entry into the pool. Manual therapy during recovery phases 1 and 2 consisted of grade I/II joint mobilizations in all planes and gentle PROM. Manual therapy treatments during phase 3 progressed to include grade III/IV joint mobilizations as needed, shoulder submaximal concentric cuff strengthening exercises, and gentle rhythmic stabilization exercises.
For the duration of the case study, the patient attended physical therapy sessions 3 times a week for a total of 18 visits, totaling 10 aquatic sessions and 8 land-based sessions. To augment the physical therapy program, the patient was provided both land-based and aquatic-based home exercise programs (HEPs) for each of the phases of recovery. The 3 aquatic-based HEPs that were used are presented in eAppendixes 2, 3, and 4. A HEP adherence diary was provided at the initial visit and was briefly reviewed with the patient prior to each session. The patient continued her land-based rehabilitation program 3 times a week following the completion of this 6-week case study.
The main components and milestones at which specific exercises and techniques were implemented throughout this aquatic-assisted protocol are summarized in Table 2. For comparison purposes, additional rotator cuff rehabilitation protocols found in the recent literature also are summarized in Table 2. Seven of the 8 protocols cited indicate that shoulder PROM should be initiated within 1 to 2 days after surgery. The current protocol recommends initiating physical therapy 1 day after surgery to educate the patient about limited shoulder PROM.
Current Rotator Cuff Repair Rehabilitation Protocol and Those Cited in the Literaturea
Buoyancy-assisted AAROM was initiated in the pool after 2 weeks postoperatively. Aquatic exercises were initially performed at a slow, deliberate speed of 30°/s using the audible sound of a metronome for pacing. They were gradually increased to a speed of 45°/s and finally progressed to a speed of 60°/s. A study by Kelly et al23 showed that the buoyancy of water assists movement (in this case, shoulder scaption) so that at the speed of 30°/s only 3.93% of maximal voluntary contraction (MVC) is required in the supraspinatus muscle (compared with 16.68% of MVC to perform land-based antigravity shoulder scaption to 90° of elevation at this speed). Hence, the use of buoyancy-assisted devices (eg, a water noodle) may additionally reduce gravitational forces and percent MVC levels. Long et al25 designated muscle activation greater than 15% of maximal voluntary isometric contraction to be potentially indicative of higher loads than desirable in a newly repaired rotator cuff; 3.93% of MVC is well below this threshold. The use of various cut sizes of a water noodle placed in the patient's hand was an innovative component of the aquatic-assisted protocol. The amount of buoyancy assistance provided by each length of water noodle (Fig. 1) varies and is summarized in Table 3. As healing progressed and the patient's strength improved, smaller lengths of water noodle were used. The procedure that was utilized to determine the amount of buoyancy assistance provided by various lengths of water noodle is depicted in Figure 2.
Water noodles (SPRI Products Inc, Libertyville, Illinois) cut to size.
Water Noodle Size Key and Amount of Buoyancy Assistance Provided by Each Sized Piecea
Buoyancy assessment. Weights were added on top of the water noodle (SPRI Products Inc, Libertyville, Illinois) until it was completely submerged. Weights were then weighed.
Outcomes
No adverse events were experienced during the course of the aquatic-assisted rehabilitation protocol. Left shoulder ROM measurements were obtained in the supine position with a standard goniometer and were documented weekly. The results are summarized in Table 1. Isometric strength of the left shoulder was measured in the later phases of recovery using a Chatillon strain gauge (AMETEK Measurement Corporation & Calibration Technologies Division, Largo, Florida) and are summarized in Table 1.
Numerous outcome measures were utilized to document recovery from weeks 3 through 8 of this protocol. Data were collected at weekly intervals and are summarized in Table 4. To measure pain, the Pain Disability Questionnaire (PDQ) and the NPRS were utilized. The PDQ and NPRS have been shown in the literature to be reliable and valid outcome measures.22,26
Patient-Reported Outcome Scores Over the Course of the 6 Weeks of Treatmenta
Improvement with shoulder function was measured with 3 different outcome measures to allow for comparison with other studies: the short form of the Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH); the Shoulder Pain and Disability Index (SPADI); and the Penn Shoulder Score (PSS). These 3 outcome measures have been shown in the literature to be valid and reliable measures of shoulder function.27–29
An important aspect of recovery throughout the rehabilitation process is the assessment of self-efficacy, positive self-image, and confidence. Patients' outlook regarding themselves and their ability to succeed may play a large role early in the recovery process. The Perceived Wellness Survey (PWS) was utilized to obtain a measurement of the patient's self-efficacy. The data collected are summarized in the eTable. The PWS has been shown to be a valid and reliable measure of wellness.30 The goal of this survey is to measure the 6 dimensions of an individual's wellness. Each of these dimensions is interdependent and interacts with the other dimensions. There are no “ideal values” or any minimal detectable change (MDC) data for the 6 dimensions. Questions in the survey that relate to the individual's outlook about future physical abilities are presented in the physical, emotional, and spiritual categories. Patient satisfaction was not measured in this case study. However, individuals may advocate for early mobilization and movement in an effort to feel as if they are being an active participant in their recovery.
Discussion
This case report introduces a unique approach to rotator cuff repair rehabilitation through the early inclusion of a comprehensive aquatic-based exercise program. Exercise prescription was based on scientific evidence presented in the current literature and in electromyographic studies. Although patient participation and adherence at home have always been essential, they are becoming increasingly important in the current health care environment of limited visits and high copayments. Low-stress aquatic exercises, performed both in the clinic and at home or in a local gym, can be a practical and valuable addition to the process of recovery from rotator cuff repair.20,23,31 There were no adverse events as a result of implementing the aquatic-assisted rehabilitation protocol.
As shown in Table 4, the initial raw score on the PDQ decreased by 30 points; however, it did not reach the MDC level, which is 36 points or more. This decrease may have been due to the fact that the PDQ is an activity-based outcome measure and most functional tasks were not allowed until after the case study was completed (after 8 weeks postoperatively). Pain levels at rest on the NPRS decreased from an initial level of 4/10 at 2 weeks postoperatively to 2/10 at 8 weeks postoperatively. With activity, pain decreased from 9/10 initially to 6/10 at 8 weeks postoperatively. The patient reached the MDC level on 2 of the 3 functional outcome measures (SPADI and PSS). Scores on the QuickDASH outcome measure did improve; however; they did not reach threshold MDC levels. Regarding the PWS, scores on the emotional and spiritual dimensions increased over the duration of the case study. However, scores on the physical dimension decreased slightly. As functional activities were contraindicated during the 6 weeks of the case study, these long-standing restrictions may have affected the patient's view of her future physical abilities.
The patient's outcomes may have been greater if the supraspinatus tendon tear in our case study had not been chronic in nature (less than 1 year from injury). Chronic rotator cuff tears often become avascular and thinner, infiltrate with fat tissue, and can retract from their insertion site as time progresses.3,6,20 The patient's advanced age may have played a role in her outcome as well. Older individuals tend to heal more slowly and have poorer outcomes.3 As noted, she was not able to start the protocol until 2 weeks postoperatively due to her preplanned vacation. She also had a medical history inclusive of fibromyalgia. These factors may have played a role in her outcomes and documented shoulder stiffness.
Candidates interested in following the aquatic-assisted protocol must be carefully selected, as not all patients with rotator cuff tears may be candidates for participation in this rehabilitation program. Even though aquatic exercises are presented at earlier time frames, many customary parameters of traditional rotator cuff programs should still be followed.23 Ideal candidates include those who are experiencing elevated pain or who have a low pain threshold and those who have a heavy or large upper extremity. Additional candidates for aquatic rotator cuff repair rehabilitation may include those who tend to be overzealous and eager to move their arm instead of being immobilized in a sling for 6 weeks or more.
A key advantage to initiating controlled and protected motion early in the recovery process is neuromuscular facilitation and the restoration of normal scapulohumeral movement patterns in preparation for the strengthening phase.20,23,31 It has been shown in the literature that initial gains in muscular strength are not due to muscular hypertrophy but rather to recruitment of an increased number of motor units and the rate at which they fire (rate coding theory).32 This finding may help to prevent the development of dyssynergic movement patterns, muscle guarding and fatty infiltration, cuff atrophy and inhibition, and joint capsule contraction and adhesions.23,31
As noted, mechanical stresses also have been shown to play a role in triggering key biochemical signals that modulate the healing process of tendon and bone.13 This finding may provide another key advantage to early incorporation of buoyancy-assisted, low percent MVC movements. These mechanisms are not yet fully understood, and more clinical research will contribute to the formulation of optimal postoperative management parameters.13 Another key benefit that may be obtained with early mobilization protocols (such as documented improved shoulder AROM at 3 months postoperatively 8,33) is the potential for an earlier return to gainful employment for those individuals who work in occupations with low physical demands and hence a savings on reduced indemnity costs and lost wages.
Future studies are needed to test the safety and efficacy of using aquatic exercise for early mobilization as part of a comprehensive rotator cuff repair rehabilitation program.20,23 Electromyographic studies that analyze the effect that various size pieces of water noodles such as those used in this case study have on the percent MVC in the supraspinatus muscle would provide valuable insight on exercise prescription during the early phases of recovery. Outcome measures that are not functionally based and that do not contain a majority of questions involving tasks that require active or resisted movements may be better suited to determine protocol effectiveness during the early phases of recovery from rotator cuff repair surgery.20 Investigations that compare the long-term outcomes of rotator cuff repair rehabilitation protocols with and without the early use of aquatic exercises will allow for understanding of optimal treatment parameters and prescription.20
Footnotes
Dr Burmaster and Dr Stiebel provided concept/idea/project design. All authors provided writing and consultation (including review of manuscript before submission). Dr Burmaster provided data collection, data analysis, project management, facilities/equipment, and clerical/secretarial support. The authors thank Select Medical Corporation for use of their physical therapy center and SwimEx pool during the patient's recovery.
Institutional review board approval was obtained from Arcadia University prior to initiation of this case study.
- Received April 21, 2014.
- Accepted July 14, 2015.
- © 2016 American Physical Therapy Association
References
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