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Relief For Rotator Cuff Tears

Relief For Rotator Cuff Tears

CREATED Jun 4, 2013

NASHVILLE, Tenn. (Ivanhoe Newswire) - While athletes suffer from traumatic forms of the injury, for many others age is to blame for torn rotator cuffs. It's believed millions of Americans over 60 suffer from one. Every year 250,000 people go under the knife for relief, but now there's a surgery-free alternative you can do for free.

Just taking plates out of the cupboard was excruciating for Kay Subhawong.

She has a torn rotator cuff. The small muscles that hold the shoulder joint together have ripped apart.

"That type of rotator cuff tear occurs with aging just like getting wrinkles or gray hair," John E. Kuhn, MD, Chief of Shoulder Surgery at Vanderbilt University Medical Center, told Ivanhoe.

Kay thought her only option was an operation.

"I was really scared. I am not a fan of surgery," Kay said.

"It usually takes people about four months before they can even think to get back to any kind of labor type work and it usually takes a year to get a full recovery," Dr. Kuhn explained.

However, Vanderbilt's Dr. John Kuhn convinced Kay to skip surgery and do exercises instead.

Dr. Kuhn is director of the Moon Shoulder Group, a network of doctors researching the best options for bad shoulders.

"We found the exercises programs that were found to be effective at treating rotator cuff disease and consolidated them into one physical therapy program," John E. Kuhn, MD told Ivanhoe.

The program focuses on range of motion, flexibility, and strengthening .

"We do not expect the therapy program to make someone's tendon heal, but it does take their pain away," Dr. Kuhn explained.

Kay said that she was still miserable after six weeks of exercises, but after twelve weeks her arm didn't really hurt.

A new study of 452 rotator cuff tear patients found the exercise program helped 85 percent avoid surgery.

"The effects last for two, up to five years so far," Dr. Kuhn said.

Kay finished the program about five years ago.

"I really have not had trouble since," Kay explained.

Her shoulder misery is just a bad memory. Now, she's focusing on making good ones.

"I just pulled my suitcase all over Europe a few weeks ago," Kay said.

Dr. Kuhn said the exercise program has changed the way he practices. He said he's using therapy instead of surgery a lot more than he used to. The entire shoulder program is available for free online. The doctor said you should talk with your physician before starting it.

RESEARCH SUMMARY

BACKGROUND:  The rotator cuff is made up of tendons and muscles in the shoulder.  The tendons and muscles connect the upper arm bone with the shoulder blade and they hold the ball of the upper arm bone in the shoulder socket.  The combination means greater range of motion of any joint in the body.  A rotator cuff injury can include any type of irradiation or damage to the tendons and muscles.  Causes of an injury can include lifting, falling, and repetitive arm activities (usually those that are done overhead like throwing a baseball).  About 50 percent of rotator cuff injuries can heal with self-care or exercise therapy. (Source: www.mayoclinic.com).

SYMPTOMS:  Rotator cuff injury symptoms can include: shoulder weakness, loss of shoulder range of motion, inclination to keep the shoulder inactive, and pain and tenderness in the shoulder.  The most common symptom is pain.  A lot of times it is experienced when a person reaches for a comb, for example.  Lying on the shoulder can also be painful. (Source:www.mayoclinic.com)

INJURY:  The four major muscles, supraspinatus, infraspinatus, teres minor, and subscapularis, and their tendons connect the upper arm bone with the shoulder blade.  A rotator cuff injury, which is common, involves any type of damage or irritation to the muscles or tendons, including: 

  • Tendinitis:  tendons in the rotator cuff can become inflamed due to overuse, especially if you are an athlete.
  • Strain or tear: if tendinitis is left untreated, it can weaken a tendon and lead to chronic tendon degeneration or to a tendon tear.
  • Bursitis: the fluid-filled sac between the shoulder joint and rotator cuff tendons can become inflamed and irritated. (Source: www.mayoclinic.com

NEW TECHNOLOGY:  In the United States, at least ten percent of people over sixty, or close to six million people, will develop a rotator cuff tear.  Usually treatment for rotator cuff injuries involves exercise therapy.  Other treatments can include surgery, steroid injections, and arthroplasty.  Now, the physical therapy program out of Vanderbilt University Medical Center can effectively treat most patients with full-thickness rotator cuff tears and shoulder pain, without the need for surgery.  The study included 396 patients ages 18 to 100 who had atraumatic full-thickness tears that were documented by magnetic resonance imaging and no other abnormality.  Most patients were assigned to a physical therapy program, which included daily postural exercise, active-assisted motion, active training of scapula muscles, and active range of motion, also with anterior and posterior shoulder stretching.  They also performed three weekly rotator cuff and scapula exercises.  The patients returned at six and 12 weeks.  At this point they could decide that treatment was successful and did not need a follow-up, they had improved but would like to continue therapy, or the non-operative treatment had failed and they need arthroscopic rotator cuff repair.  The researchers contacted the patients by phone at one and two years to determine whether they had undergone surgery since their last visit.  At six weeks, the data showed that fewer than 10 percent of patients had decided to go forth with the surgery.  For patients to whom follow-up data was available at the two year mark, only two percent had the surgery.  The finding suggests that pain may be a less suitable indication for rotator cuff repair than is weakness or loss of function.  Researchers hope that future studies will identify risk factors that can predict progression to rotator cuff tears and symptom onset, but also which repaired tears are likely to fail.  Go to http://www.moonshoulder.com/ for more information. (Source: http://www.medscape.com/viewarticle/737461)  

INTERVIEW

John Edward Kuhn, MD, Chief of Shoulder Surgery at Vanderbilt University Medical Center, talks about a new shoulder procedure helping patients avoid surgery.

We want to talk about this study that kind of helped a lot of people avoid surgery. What prompted you to do this? 

Dr. Kuhn: Well, there are a lot of things. I am the Director of a research group called the Moon Shoulder Research Group which is 16 surgeons from nine sites across the country and we formed together to look and study shoulder disorders and problems that affect the shoulder. We are going to study rotator cuff disease and why rotator cuff repairs fail. My colleagues in Iowa said every farmer cannot take the time off that is required so they do not want surgery, and my colleagues in Colorado said everybody wants to have surgery because they are all active and they do crazy things out in Colorado. So as a group, we could not decide who needed surgery and who did not so we decided to do a study where we sent patients without a history of an injury through a rotator cuff physical therapy program. We knew some would do well without surgery and some would not, then we could compare the groups to help us decide what criteria are used to decide who needs surgery.

What is a rotator cuff tear? How often surgery is recommended and how often they fail?

Dr. Kuhn: The rotator cuffs are a series of small muscles that come off the shoulder blade, and their job is just to hold the joint together. They are not very powerful muscles and they do wear out as we get older. We know that approximately between 10% and 40% of people over the age of 60 have rotator cuff tears. If someone develops pain or symptoms with that rotator cuff tear, they will see a physician and many physicians will recommend surgery right away. We do not really understand if that is appropriate or not, but there is a lot of variation across the country in people who decide to have surgery and those who do not.

What do you do in the procedure? Are there different approaches to it or is it that standard?

Dr. Kuhn: It is typically done arthroscopically nowadays and the tendon that is detached from the humerus is repaired to the humerus bone.

What does that do for a patient? What is down time and recovery time like? 

Dr. Kuhn: The surgery itself is not particularly painful. It is done as an outpatient procedure now, but it usually takes people about four months before they can even think about getting back to any kind of labor-type work. It usually takes about a year to get a full recovery.

What does it cost?

Dr. Kuhn: I do not know the exact cost, but it is in the tens of thousands of dollars.

So with this study, you just kind of kicked surgery to the side and said let's try this? How did you come up with the different exercises people were going to use in this study?

Dr. Kuhn: One thing I do want to point out is there are two types of rotator cuff tears. There are traumatic rotator cuff tears where someone has a fall and rips their rotator cuff apart. Almost every surgeon across the country would recommend those get fixed acutely. The patient population we were looking at is people that come in with shoulder pain and they have an MRI which shows a rotator cuff tear. That type of rotator cuff tear occurs with aging, just like getting wrinkles or gray hair, and that is where the question of what is the best way to treat those comes in. The program we developed for the physical therapy we got from the literature; so, we did a systematic review of the literature. We found the exercise programs that were found to be effective at treating rotator cuff disease and consolidated them into one physical therapy program.

Walk us through the process. Did you bring the people in, show them how to do it, and then they just did it on their own or what was the process?

Dr. Kuhn: Patients were brought into the clinic and then enrolled in the study. Again, these were patients without a history of an injury but were found to have a rotator cuff tear on their MRI scan. We offered patients to enroll in this study and then sent them out with two physical therapy books and a video on how to do the exercises. One of the books was written for a physical therapist and the other one was written for patients. Everybody has different insurance plans so some patients have a lot of physical therapy benefits and some people do not, so we tried to cover all the bases. The patients would do their physical therapy program for six weeks and then return to see us. At that point, we would ask them one of three questions. If they were cured then we would say we will contact you later and see how you are doing as the months progress. If they were better, we would have them continue with the therapy program for another six weeks and if they are absolutely no better, we would then offer them surgery. Most patients continued doing therapy for another six weeks, so it took about 12 weeks. At the end of 12 weeks most of our patients were doing quite well.

Describe some of those exercises.

Dr. Kuhn: Well they really breakdown into two or three different things; one is flexibility. Sometimes these shoulders can be stiff in different planes and we work on stretching the shoulder. Another is strengthening the muscles about the shoulder, and the shoulder blade muscles are very important to treat this as well. Then we do some work on strengthening the rotator cuff muscles.

So weightlifting?

Dr. Kuhn: With very light weights or rubber bands.  

Talk about the results after the six weeks, then 12 weeks, and then two years? Is that what the follow-up was?

Dr. Kuhn: This is a large cohort of patients. We have 450 patients enrolled and have been following them now for six weeks, 12 weeks, one year, two years and we even have some at five years. What we found is patients usually decide to have surgery in the first 12 weeks or so. If they do the exercises and are doing well at 12 weeks, they do not tend to drop out. They continue to do well at one year, two years, and even five years for the patients we have followed for five years.

Do they continue the exercises after that 12 week period or do they drop it off completely? 

Dr. Kuhn: Some patients were doing exercises at home. We do not really follow that closely because at that point they are on a home exercise program. I suspect some patients do not do any exercises because they feel great and some patients, if they get a little bit of discomfort in their shoulder, will start to do the exercises again and then they will feel well again.

What were the effects of the exercises on the actual body? 

Dr. Kuhn: That is a good question. When we do not know exactly what is causing the pain in the patient's shoulder, there is a lot of data to suggest the rotator cuff tear itself is not what is causing the pain. If you do the math and say there is less than 10% of people in the country over the age of 60 with rotator cuff tears, that's six million Americans. We do 250,000 rotator cuff surgeries in the United States each year. That means we operate on less than 5% of all the people in the country with rotator cuff tears. So rotator cuff tears may not be painful. If we do surgery on a rotator cuff and repair it, somewhere between 25% and 30% of those will fail and yet the patients say thank you doctor, my pain is gone. Again, that suggests the rotator cuff tear is not the source of the pain. What we found is certain things that therapy can treat may be the source of the pain, like if a patient's shoulder is stiff or weak. The exercise program takes care of those things and the pain tends to go away.

The pain is the main problem, right? You can live with a rotator cuff tear if it is not painful?

Dr. Kuhn: Correct. Most patients come into our office with pain. If they come in with weakness the exercise program may help with that a little bit, but if they have profound functional loss or profound weakness, that is probably a better indication to do surgery than pain because we can help pain with physical therapy.

Did you see a difference in MRIs before and after? 

Dr. Kuhn: We are looking for funding now to get MRI studies on our patient's two years later and see how they look. We do not expect the therapy program is going to make someone's tendon heal, but it does take their pain away.

To know that a lot of people could be helped by this and with a PT program versus going under the knife, is the goal of this to show this possibility to other people who have rotator cuffs tear?

Dr. Kuhn: I think people with shoulder disorders need to know that physical therapy can be very effective at treating this. The effects last for up to five years so far and they may even last longer; we just do not have the data yet.

What is the next step besides the MRI funding? 

Dr. Kuhn: Well, that is what we would like to look at. We do not really know the natural history of rotator cuff disease. We know there are literally millions of Americans out there leading their lives without pain and disability, doing fine, and have rotator cuff tears, but we do not know how we can predict whose rotator cuff is going to tear large enough to get into big trouble. We hope to be able to answer that question if we can get funding to do research in the future.  

Are people still getting the PT versus surgery at this point or did it stop when the study stopped?

Dr. Kuhn: The study stopped, but clinically we use therapy a lot more than we used to. 

So it has changed the way you kind of approach things?

Dr. Kuhn: Absolutely.

Let's talk about Sue a little bit if we could. She was having problems and she said she could not even take plates out of a cupboard it was hurting so much.

Dr. Kuhn: She is a great patient, and like a lot of patients who enrolled in this, they were kind of surprised to learn there was an alternative to surgery. She was having a lot of difficulty initially. She did her physical therapy for six weeks and made some progress. Most of our patients come back in six weeks and tell me they are about 60% or 70% better, but I do not think she was quite that good at that point. She stayed on with it and after 12 weeks she was actually doing quite well.

She says it was three or two years ago that she did the study and she has still not had any pain.

Dr. Kuhn: Right. She is at least two years out now and is still doing quite well.

Does she still come in? Like you said, are they still coming in? Will she still come in for follow-ups for the study for up to five years? 

Dr. Kuhn: We are contacting our patients and mailing them questionnaires, but they are not coming in for an examination. We do tell all of our patients that if they have any trouble or their pain returns they should come back and we can repeat the MRI scan at that point. If we see the tear enlarging and they are starting to get functional problems, then we talk to them about surgery.

Are other doctors adopting this technique versus surgery?

Dr. Kuhn: When I present this data in Europe or Canada, they do not think there is anything unusual about this because that is how they manage their patients, but in the United States there is a lot of incentive for people to do surgeries. So this is a surprise to people who do surgeries here in the United States. 

Even to the surgeons who do it, they were not really aware of the PT benefits? 

Dr. Kuhn: They are becoming aware of it, but typically there is still a bit of debate about what is the right thing to do. Many surgeons say, ‘I am going to operate on these patients because I do not want their tears to get larger over time,' but there is really no evidence to tell us that operating on somebody will prevent that from happening. 

Are you hoping that more people will adopt this or at least look at it?

Dr. Kuhn: I know if it were my father I would definitely want him to do physical therapy. I am getting to the age where if I were found to have a rotator cuff tear, I probably would do physical therapy as well because I know it is effective at taking away the pain. If I was functioning well, had good strength, and could do all the activities I wanted to do I would really see no reason to have surgery.

You said the down time after surgery is about four months whereas the PT takes about three months.

Dr. Kuhn: During that PT time, most people can still work and do activities. In surgery a lot of patients will be immobilized for six weeks in a sling, then continue on with physical therapy, and the earliest they would be able to get back to activities would be about four months; some take a full year to get back.

Do you find patients are coming in looking for alternatives to surgery more now than they used to?

Dr. Kuhn: To some extent. I think patients are learning a lot about their conditions and if there is a non-operative approach to it, they certainly want to investigate that. Patients are getting much more educated than they used to be in the old days. 

Everything is out there now. Any other tips for people going through a rotator cuff injury and how to deal with it if they have surgery or decide to go through PT? Are there any suggestions or things that you wish they knew before they came in? 

Dr. Kuhn: My advice would be if you have a traumatic rotator cuff tear, a fall or an injury, or severe pain and loss of function, you probably should get your rotator cuff repaired surgically. If you have shoulder pain and an MRI scan shows you have a rotator cuff tear, you should certainly talk to your surgeon about the option of physical therapy. Our therapy programs are available online at www.MoonShoulder.com. Anyone can download and look at them. Your surgeon can download them and pass them out to you, and you can certainly try that first. If that fails then you can have surgery, but if it does well for you, you might avoid an operation. 

Like the sun and the moon? 

Dr. Kuhn: Yes. Moon stands for Multicenter Orthopedic Outcomes Network.

They can do them right at home online?

Dr. Kuhn: The booklets and our video are downloadable. We probably would still recommend having some guidance.

It is something you could present to your surgeon if you want to go in and say what about this?

Dr. Kuhn: Absolutely.

I think that is about all the questions I had. Anything else that I missed that you think is important for people to know?

Dr. Kuhn: There is one other thing, but I do not know if you want to include this in the story. We just presented this week at the meeting. We were able to look at the things that distinguished people who decided to have surgery from those who did well without surgery. Like I said, most patients who decided to have surgery did so in the first 12 weeks and we wanted to know what made that group different than the people who did well with the therapy. People that were more active decided to have more surgery and people that were younger seemed to want to have more surgery, but the biggest driver was something called expectations of treatment. If a patient thought physical therapy was not going to work, it would not work. If a patient thought physical therapy would work, it would work and that kind of surprised us. We are still trying to figure out what that means. 

A lot of it is inside their own head then? Were there any figures on that?

Dr. Kuhn: That was the most profound influence on whether somebody would do well with therapy.

Is it almost like a placebo?

Dr. Kuhn: Yes, and what that makes me think is if you could convince those other patients that therapy would work, it would work for them too. 

FOR MORE INFORMATION, PLEASE CONTACT:

John E. Kuhn, MD
Chief of Shoulder Surgery
Vanderbilt University Medical Center
www.MOONshoulder.com