April 4, 2016
EDMONTON — When it comes to rotator cuff repair, local orthopedic surgeons wondered for years why “cheaters” who didn’t wear their slings appeared to enjoy a better quality of life and an improved range of motion sooner than patients who did. Now the benefits of getting up and at ’em right after surgery have been proven through research.
There’s no downside to early mobilization of the shoulder joint after mini-open (small incision) rotator cuff repair surgery, according to their study published recently in The Bone & Joint Journal — co-authored by Alberta Health Services (AHS) orthopedic surgeons Dr. Robert Balyk and Dr. David Sheps, both assistant clinical professors in the Division of Orthopedic Surgery in the Faculty of Medicine & Dentistry at the University of Alberta.
“The anecdotal benefits of early active motion led us to question whether strict immobilization was truly required,” says Dr. Balyk, also chief of orthopedics at the Grey Nuns Community Hospital. “We know these patients are happier if they can move their shoulders sooner because it allows for an earlier return to daily activities. However, we did not know if early mobilization would lead to long-term complications, such as slower healing or a greater number of re-tears.”
Their trial compared outcomes following mini-open rotator cuff repair — a minimally invasive procedure that uses an arthroscope to confirm the presence and reparability of a rotator cuff tear. The surgeon then removes the arthroscope and splits the deltoid muscle through a small incision to repair the tear. Rotator cuff tears become more common in patients over
40 years of age; most patients who undergo the surgery are between 45 and 65.
Conventional rehabilitation following this procedure requires strict immobilization in a sling with no active motion of the shoulder for four to six weeks. However, Dr. Balyk often observed the “cheaters” — those who didn’t wear their slings as instructed — did, indeed, prosper.
“The obvious benefit to early mobilization is that patients can return to activities of daily living and work more quickly,” says Dr. Sheps, who is also facility medical director at the Sturgeon Community Hospital in St. Albert. “This can also have an economic impact, as patients who undergo mini-open rotator cuff surgery are often of working age, and a quicker return to activity and work may mean an earlier return to productivity.”
Dr. Robert Balyk, the senior orthopedic shoulder surgeon who took part in the study, says practice has evolved to reflect their research findings on the benefits of earlier mobilization.
“I tell my patients the sling is for their comfort. Feel free to use it or lose it,” says Dr. Balyk.
Of course, there is some common sense involved as well. While patients are told to do their usual daily activities as long as there is no pain, they are also advised not to do any resistance or heavy activities (more than 5 pounds) for the first three months after surgery.
Douglas Gilroyed, a retiree with an active lifestyle on his acreage near Westlock, knows first-hand the rehab benefits of early activity. After his surgery, he was instructed to do his usual daily activities as long as there was no pain, and to avoid heavy lifting for the first three months.
“I wore the sling home and, after that, I never wore it,” says the 69-year-old, who had surgery on both shoulders. “I keep pretty active. We had lots of work here last year. We put up the fence. Built a shop. I ride horses and look after them. You’ve got to keep busy.”
In total, 189 patients, recruited by seven regional shoulder surgeons, contributed to the study after undergoing the procedure at the Grey Nuns or the Sturgeon. Patients were then, at random, given early mobilization or standard rehabilitation. Progress was assessed at six weeks and again at three, six, 12 and 24 months.
At the six-week assessment, patients who began early active motion showed significantly better range of motion than those who wore their slings for six weeks. That difference disappeared at the three-month assessment, as the group that wore their slings caught up to the early mobilization group. No differences between groups were seen at six or 12 months, and by 24 months the final outcomes were the same in both groups.
Early mobilization did not result in any long-term complications, including no differences in healing or re-tear rates — the surgeons’ biggest concern.
“Although the final outcome was the same in both groups, recovery was quicker in the early mobilization group,” says Dr. Sheps. “Since the final outcome was not negatively impacted by early active motion, it may make sense to allow patients to remove their slings sooner.”
In the AHS Edmonton Zone, more than 1,000 rotator-cuff surgeries are performed each year, primarily at Grey Nuns Community Hospital (Covenant Health) in Mill Woods, Sturgeon Community Hospital in St. Albert and Leduc Community Hospital in Leduc.
Funders for this rotator-cuff research include M.S.I. Foundation ($50,000); Workers’ Compensation Board – Alberta ($30,000); Arthroscopy Association of North America ($25,000); and Edmonton Civic Employees Charitable Assistance Fund ($10,000).
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Alberta Health Services is the provincial health authority responsible for planning and delivering health supports and services for more than four million adults and children living in Alberta. Its mission is to provide a patient-focused, quality health system that is accessible and sustainable for all Albertans.
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