Skip Navigation
Department of Health and Human Services www.hhs.gov
 
Slide Tray
0 slides

Return to Slide Library

Slides

Add Presentation to Slide Tray Presentation:

Comparative Effectiveness of Nonoperative and Operative Treatments for Rotator Cuff Tears

Slides: 13–24 of 38
Clinical Outcomes of Interest 
Outcomes of interest include health-related quality of life, shoulder function, time to return to work, cuff integrity, pain, range of motion, and strength of the shoulder.
Four Domains Used To Assess Relevant Studies
The following four major domains were examined: risk of bias (low, medium, high), consistency (no inconsistency, inconsistency present, unknown, or not applicable), directness (direct, indirect), and precision (precise, imprecise). Four of the outcomes (health-related quality of life, shoulder function, cuff integrity and time to return to work) for each comparison of interest were given an overall evidence grade based on the ratings for the individual domains.

Four Domains Used To Assess Relevant Studies

Rating the Strength of Evidence From the CER
The EPC GRADE approach, based on the standard GRADE approach, was used to assess the quality of the body of evidence for each outcome. The overall strength of evidence was graded as high (further research is very unlikely to change the confidence in the estimate of effect), moderate (further research may change the confidence in the estimate of effect and may change the estimate), low (further research is likely to change the confidence in the estimate of effect and is likely to change the estimate), or insufficient (evidence either is unavailable or does not permit estimation of an effect).

Rating the Strength of Evidence From the CER

Early vs. Late Operative Intervention for Rotator Cuff Tears
Earlier operative treatment has been proposed to improve patient outcomes and result in an earlier return to work and decreased costs; therefore, patients face several decisional dilemmas, including whether to opt for early surgical intervention or if and when to forgo nonoperative treatment for operative intervention.

Early vs. Late Operative Intervention for Rotator Cuff Tears

Early vs. Late Surgical Intervention for Rotator Cuff Tears
One randomized controlled trial conducted by Moosmayer et al. compared early surgical repair vs. late surgical repair after failed nonoperative treatment. One hundred and three patients with small or medium-sized full-thickness rotator cuff tears were randomly assigned to nonoperative treatment, which consisted of manual techniques and exercises (n=51) or immediate surgical repair (n=52); 102 patients were followed for a minimum of 12 months. Nine of the patients initially randomized to nonoperative treatment were not satisfied with their degree of improvement after completing 15 treatment sessions, and were offered secondary surgery; these patients constituted the late surgery group. Patients receiving early surgery showed a trend towards superior function when compared with the delayed surgical group on the Constant-Murley Score (improvement of 41.5 points and 33.6 points, respectively); however, the level of significance was not reported and a selection bias may exist due to patients who refused surgery. Overall, evidence is too limited to draw conclusions about  the comparative effectiveness of early surgical  repair when compared to late surgical repair following nonoperative interventions and the level of evidence was low.

Early vs. Late Surgical Intervention for Rotator Cuff Tears

Comparative Effectiveness of Nonoperative vs. Operative Interventions for Rotator Cuff Tears
Five studies compared nonoperative to operative treatments, with a median sample size of 103 (IQR: 40 to 108). The mean ages in the studies ranged from 46.8 to 64.8 years. Males represented 55 percent of study participants. The interventions varied across studies, but generally the nonoperative arms included components such as steroid injection, stretching, and strengthening, and were compared with open repair or debridement.

Comparative Effectiveness of Nonoperative vs. Operative Interventions for Rotator Cuff Tears

Comparisons Studied for Nonoperative vs. Operative Interventions
The operative vs. nonoperative interventions that were studied were as follows: 
Shock-wave therapy vs. mini-open rotator cuff repair (RCR).
Steroid injection, physical therapy, and activity modification vs. open RCR.
Physical therapy (manual therapy and strengthening and stability exercises) vs. open or mini-open RCR. 
Physical therapy, oral medication, and steroid injection vs. open RCR vs. arthroscopic debridement.
Steroid injection, stretching, and strengthening vs. open RCR.
Two randomized controlled trials and three cohort studies compared nonoperative treatment vs. operative RCR. The nonoperative treatments across the five studies varied in their components. Four studies included either physical therapy (treatment components not specified) or stretching and strengthening exercises, with or without the addition of steroid injections, oral medications, activity modification, or manual therapy. One study examined the use of shock-wave therapy. Nonoperative treatments were compared to either open or mini-open RCR. One study included a third comparison group undergoing arthroscopic debridement.

Comparisons Studied for Nonoperative vs. Operative Interventions

Results for Comparative Effectiveness of Nonoperative vs. Operative Interventions
All groups showed significant improvements over the study period, regardless of the intervention. Most studies showed a significant difference in function, favoring repair over nonoperative interventions. However, the results were highly heterogeneous, with one study showing an absolute difference of 24.5 points on an 83-point scale in favor of the operative repair. This same study showed a significantly shorter time to maximum range of motion among the group undergoing arthroscopic debridement (3.2 months) when compared to the nonoperative and open repair groups (6.8 months each). In general, the level of evidence was low for nonoperative vs. operative interventions, and the findings were inconsistent within and across studies. Further, as with complex interventions, it is difficult to determine the relative contributions of each of the components in the nonoperative treatment regimes.

Results for Comparative Effectiveness of Nonoperative vs. Operative Interventions

Comparative Effectiveness of Nonoperative Interventions for Rotator Cuff Tears
Nonoperative interventions were examined in three comparative and seven uncontrolled studies. The studies included a median of 42 patients (interquartile range [IQR]: 25.3 to 73.3), with a median age of 61 years (IQR: 60.4 to 61.5). Males comprised an average of 50 percent of participants.

Comparative Effectiveness of Nonoperative Interventions for Rotator Cuff Tears

Comparative Effectiveness of Nonoperative Interventions for Rotator Cuff Tears: Overview
The nonoperative intervention comparisons studied were sodium hyaluronate vs. dexamethasone; rehabilitation vs. no rehabilitation; and physical therapy and oral medications with or without steroid injections. Because of the variety of interventions and the low quality of studies, no conclusions could be drawn about the most effective nonoperative patient-management strategy.

Comparative Effectiveness of Nonoperative Interventions for Rotator Cuff Tears: Overview

Comparative Effectiveness of Operative Repair for Rotator Cuff Tears
Thirty-two controlled studies making 13 comparisons assessed the effectiveness of different operative approaches for the repair of rotator cuff tears. Studies assessing operative treatments were categorized as focusing on an operative approach (e.g., open, mini-open, arthroscopic, debridement). Overall conclusions for operative approaches are challenging because of the wide variation in comparisons across studies.

Comparative Effectiveness of Operative Repair for Rotator Cuff Tears

Comparative Effectiveness or Operative Repair for Rotator Cuff Tears
In general, the studies showed few differences in function between interventions. Analysis of comparative studies provided a moderate level of evidence that functional patient outcomes were similar across each of the following surgical interventions: open vs. mini-open; mini-open vs. arthroscopic; open or mini-open vs. arthroscopic; and arthroscopic with or without acromioplasty. The strength of evidence was low for the remaining comparisons examined in the studies, precluding any conclusions regarding their comparative effectiveness.

Comparative Effectiveness or Operative Repair for Rotator Cuff Tears

Pages: Previous 1 [2] 3 4 Next