CONSERVATIVE APPROACHES TO ROTATOR CUFF TEARS

CONSERVATIVE APPROACHES
TO ROTATOR CUFF TEARS
Bone and Muscle
Repair
You have presented the key information on your topic in the correct sequence, as required by the
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content and theme of each slide that the audience merely refers to – they should be able to take in a
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them.
WHAT IS A ROTATOR CUFF TEAR?
Rotator cuff tears (RCT) are the
most common source of
shoulder pain with up to 40% of
all shoulder pain being
diagnosed as a Rotator Cuff tear
(Gialanella et al., 2011).
Nice use of images
(Sechrest, 2009)
In this study we compare the two conservative approaches to
rotator cuff tears
Corticosteroid Injection
Rehabilitation exercise therapy
Gialanella et al., 2011, Effects. Pain Medicine, 12: 1559-1565
(Sechrest, 2009)
THE RELEVANT BIOLOGY WITHIN
CONSERVATIVE APPROACHES
•Corticosteroids can be divided into two categories;
Glucorticoids and Mineralocorticoids (Campbell et al., 2009).
•Glucocorticoids are used in intra articular Injections
which are primarily used as an anti inflammatory drug
(Campbell et al., 2009).
Too much text in these bullet points, it’s hard to read quickly
• Primary effect of Glucocorticoids is to disable the action
of synthesis of inflammatory proteins through suppression
of the genes that embed them (Campbell et al., 2009)(Barnes.,
2006).
Corticosteroid activation of gene expression (Barnes, 2006)
• Muscle regeneration requires Necrosis (cell death) which
allows for myogenisis (Myoblasts are precursor cells)
(Campbell et al., 2009).
•Myoblasts (Activated Satellite cells) are located between
the Sarcomeer and the lamina of myofibres, and are
activated by a reaction to damaged muscle (Bennett., 2012).
Bennett, M., 2012, Week 6 Biol1040, ‘Skeletal Muscle’, University of QLD, Brisbane.
Campbell et al., 2009, Biology, 8th Edition
Barnes, P.J. 2006, Br J Pharmacol.; 148(3): 245–254
Myofibre disection of regeneration of a muscle fibre
DIFFERENTIATING CONSERVATIVE TREATMENTS
• Information on the effectiveness of Corticosteroids
(Glucocorticoids) treatment on Rotator Cuff Tears are inconclusive
at best (Gialanella et al., 2011).
• Corticosteroids have been correlated to Osteoporosis, growth
retardation in children, easily bruised skin and metabolic effects
which can all be linked back to the Endocrinal effects of
Corticosteroids (Barnes., 2006).
Numerous grammatical errors, you need to proof read more thoroughly
• Corticosteroids are thought only provide therapeutic pain relief
and only exercise rehabilitation actually provides a long term
solution (Gialanella et al., 2011).
•Conservative treatment for Rotator Cuff tears are on the rise due
to higher success rates and as a result, Surgical solutions to
Rotator Cuff tears are on the decline (Baydar et al., 2008).
Again this is too much text
Baydar, M 2009, ‘Effic.cons.’, Rheum. Int., 29, No. 6: 623-628.
EFFECTS OF CORTICOSTEROIDS INJECTION IN RCT
(GIALANELLA ET AL., 2011)
AIM
• ‘The aim of this study was to evaluate the effect of intraarticular injections of
corticosteroids (triamcinolone A.K.A. TA) in patients with symptomatic rotator cuff tears
(RCT)’ (Gialanella et al., 2011).
It’s not appropriate to quote the paper when describing the aim, you should use your own words
METHOD
• 60 patients who had a professional diagnosis of a RCT were chosen and had to meet
the following criteria of a full-thickness RCT, conservative treatment first preference and
no older than 75yrs.
The patients were assigned into three groups of twenty.
• ’TA1’ Had a single intra articular injection of 40 mg TA (glucocorticoid)
• ’TA2’ Had two intra articular injections of 40 mg TA, the first injection after baseline
evaluations and the second injection 21 days afterwards.
• Control Group had no Corticosteroid treatment.
The patients were checked up on after 6 months.
THE EFFICACY OF CONSERVATIVE TREATMENT IN
FULL THICKNESS RCT – (BAYDAR ET AL., 2008).
AIM
‘The aim of this study was to investigate the efficacy of conservative treatment in
patients with symptomatic full-thickness rotator cuff tears by using objective and
subjective measurements’ (Baydar et al., 2008).
METHOD
• 20 patients with RCT (confirmed by MRI) with the baseline categories being the age,
sex, LH/RH shoulder, hand dominance, and length of symptoms.
•
Various measurements of strength and rotational motion of the should taken at
baseline and taken again after 6 months. Follow ups were done by telephone at
1 year and 3 years (functional/lifestyle questionnaires).
•
The treatment included activity modification, non steroidal anti-inflammatories and a
specific exercise program. All patient were managed with a 3-week course of
outpatient physical therapy (Baydar et al., 2008).
EFFECTIVENESS OF CORTICOSTEROIDS
This is a really difficult slide to read, it’s crowded, jumbled
and complex tables take time to analyse
Figure 1 & 2 (Gialanella et al, 2011)
TA1 indicates group of patients who
received a single injection of
Glucocorticoid.
TA2 is patients who received two
injections of Glucocorticoid at 21-day
intervals.
Figure 2
Group TA1 (n = 20)
Group TA2 (n = 20)
Control Group (n = 20)
Baseline
3 Months
6 Months
Baseline
3 Months
6 Months
Baseline
3 Months
6 Months
Total
constant
score
23.7 ± 11
34.7 ± 14
28.0 ± 15
24.8 ± 10
35.6 ± 12
29.2 ± 11
30.5 ± 15
30.7 ± 15
29.9 ± 14
Constant
ADL
5.2 ± 2.6
7.7 ± 4.1
6.6 ± 3.9
5.4 ± 2.4
7.5 ± 2.8
6.9 ± 3.0
7.4 ± 5.4
7.4 ± 5.1
7.3 ± 5.2
Constant
active ROM
14.0 ± 7.4
17.0 ± 8.8
14.8 ± 8.6
15.3 ± 6.9
20.1 ± 8.7
16.7 ± 6.7
16.6 ± 8.5
17.0 ± 8.6
16.4 ± 8.5
• Pain at night and Activity pain scores with TA(1 and 2) at 6 months (GREEN) were lower
than the baseline (RED) as well as being lower than the Control Group.
• This correlation points to the idea that a single intra articular injection of 40 mg of TA
(Glucocortacoid) may be effective for controlling shoulder pain for 3 months in patients with
RCT (Gialanella et al, 2011).
•(Figure 2) TA1 & 2 ROM and ADL activities are greatly enhanced at 3 month (RED) interval,
where as Control Group (GREEN) shows no improvement and if anything a decrease in
mobility.
EFFICIENCY OF CONSERVATIVE TREATMENT
(NO CORTICOSTEROIDS)
• Six months after treatment of RCT with conservative
methods (Exercise Rehab programs, NSAID) there was a
significant increase in strength and mobility.
Figure 3
Mobility (as a %)
Baseline (%)
6 mths (%)
Abduction 60°/s
72.3
87.8
Abduction 180°/s
84.9
93.3
•There was improvements in everything, Abduction,
external and internal rotation and increase of strength in
each group (Figure 3 & 4)(Baydar et al.,2008).
External rotation
60°/s
38.7
74.8
External rotation
180°/s
46.7
78.7
Internal rotation
60°/s
76.6
100.9
Internal rotation
180°/s
77.8
105.1
• At 6 months, 55% of patients said they were much better
and 45% said the situation had improved. No patients stay
the same or got worse (Baydar et al., 2008).
• However there isn’t any control group in which to judge
this off, as it was considered unethical to bar a patient
from any form of treatment for 6 months.
Figure 4
Isokinetic
Strength
Baseline
6 months
Elevation (°)
139.3 ± 23.8
159.5 ± 14.5
Abduction (°)
132.7 ± 31.6
163.2 ± 13.8
Internal
rotation (score)
11.8 ± 3.7
13.8 ± 2.6
External
rotation (°)
59.5 ± 16.1
74.7 ± 13.6
Passive
elevation (°)
163 ± 17.2
174 ± 9.9
Passive
external
rotation (°)
70.7 ± 16
81 ± 9.6
This is just a page of text, this is not taking advantage of the powerpoint presentation format
CORTICOSTEROIDS OR REHAB PROGRAMS?
•
The effects of Corticosteroids were shown to be quite beneficial in regards to
immediate and elongated pain relief. However the improvements in mobility, while
better than the control group of no corticosteroids, is minimal at best (Gialanella et al, 2011).
•
Without Corticosteroid injections there was still great results with increased strength,
mobility and reduced pain. The discrepancy between the two studies may come down
to different rehabilitation exercise programs (Baydar et al., 2008).
• There is still an unknown in regards to the potential (albeit unfounded) side
effects from Corticosteroid use which range from Osteoporosis to Endocrinal
disorders (Barnes., 2006).
Perhaps Corticosteroids only to be used in patients with high degrees of immobility
and pain?
•
The choice between going down either path is entirely dependant on the patient in
regards what size the Rotator Cuff tear is and to what the magnitude of pain and
disability is on the patient.
Both must be followed with a comprehensive exercise strengthening program as this
is the key to long term recovery.
HOW IT AFFECTS US
• It influences not only ourselves but also Medical Practitioners around the world in
regards to treatment options and protocols, as surgery should only be for extreme
cases of RCT and even then surgery is not anymore efficient than conservative
methods.
• There is still unknowns in relation to the effect of Corticosteroids on humans, as
more study needs to be conducted in this area. Because correlation does not imply
causality and thus needs clarification.
• The patients primary ability to be able to make a long term recovery and to fully
rehabilitate depends on the patients persistence in sticking to exercise programs
designated by qualified Medical Practitioners. But also medical staff having the
appropriate programs and instructions to give to the patients.
• Shoulder problems are a common day occurrence and Rotator Cuff tears (whether
they be small or big) make up to 40% of all shoulder (Gialanella et al., 2011).
So its likely yourself or someone you know will have a RCT some time in their future or
past, wouldn’t you like to have the best treatment options available to you?