Self-Training Versus Physiotherapist-Supervised Rehabilitation of the Shoulder in Patients Treated With Arthroscopic Subacromial Decompression: A Clinical Randomized Study.

Self-Training Versus Physiotherapist-Supervised Rehabilitation of the Shoulder in Patients Treated With Arthroscopic Subacromial Decompression: A Clinical Randomized Study Anderson NH, Sojbjerg JO, Johannsen HV, Sneppen O (Shoulder and Elbow Clinic, Department of Orthopaedics, University of Aarhus, Aarhus, Denmark), J Shoulder Elbow Surg. 1999;8:99-101.

This randomized, clinical study compared physical therapist-supervised rehabilitation with a self-training program applied for the first 6 weeks after arthroscopic subacromial decompression. The inclusion criteria were persistent impingement pain for more than 8 months without evidence of full-thickness rotator cuff tears and no results or disappointing results after at least 6 months of conservative treatment. The study consisted of 43 consecutive patients (17 women, 26 men) with a mean age of 46 years (range=24-64 years). The average duration of symptoms before treatment was 40 months, ranging from 10 to 120 months. The Constant Shoulder Score was used to measure outcomes. The Constant score was calculated before surgery and randomization and at 3, 6, and 12 months after surgery.

The rehabilitation program consisted of daily passive pendulum exercises for the first 2 weeks. Active training was started 2 weeks after the operation, and the pendulum exercises were continued only if needed. After 6 weeks, strengthening exercises with rubber tubes, which were focused on strengthening the internal and external rotator muscles of the shoulder, were started. Subjects who were randomized into the self-training group were instructed at day 1 after surgery and provided with a written instruction leaflet. Therefore, they handled all subsequent rehabilitation by themselves. They were seen by the surgeon at normal postoperative checkups, and they received further instruction at 6 weeks and at 3, 6, and 12 months after the operation. Subjects who were randomized into the supervised therapy group were instructed by a physical therapist from day 1 after surgery, and they saw the therapist each day during the hospital stay. Written instructions were given for home exercise, and the subjects saw the therapist for 1 hour each week for the subsequent 6 weeks. The physical therapist assisted the subjects with exercises, and the therapist was free to modify or add exercises to fit the individual patient during this period.

No significant difference was found between the groups with regard to age, sex, duration of symptoms, dominant extremities, partial rotator cuff ruptures, worker's compensation cases, and work that was demanding on the shoulder. Four patients (2 in each group) had a partial rotator cuff tear and underwent arthroscopic debridement at the time of surgery. The results of the pain and abduction-power subscores plus the full Constant score demonstrated that all categories in both groups were significantly improved after 12 months. The authors found that patients supervised by the physical therapist had a significantly poorer pain scale after 3 months of rehabilitation versus the self-training group. No other statistical difference was seen between the 2 groups in any of the analyzed parameters.

The authors discussed the fact that patients have severe pain just after surgery and that intensive training seemed to contribute to a long rehabilitation course. They attributed this observation to the significantly poorer pain ratings that the therapy group reported at 3 months after the operation compared with the self-training group. However, the authors did note that both groups had significantly higher Constant scores at 3 months compared with the preoperative score.

Because no difference was seen between the 2 groups, the authors pooled all results into one population to get a sense of the course of improvement after arthroscopic decompression compared with the opposite non-operated extremity. They found an average sick leave of just more than 8 weeks. In addition, they found a significant improvement in shoulder function as early as 3 months after the operation and again at 6 months after the operation. Although further improvement was registered during the last 6 months, it was not significant. Therefore, they concluded that a 6-month follow-up gives a good indication of the final result. When compared with the opposite extremity, the authors found significantly lower results in the operated shoulder after 12 months.

The authors concluded that there is no beneficial effect of physical therapist-guided rehabilitation when compared with a simple self-training regimen in patients with subacromial impingement treated with arthroscopic decompression.

Brian G Leggin, PT, OCS Penn Therapy and Fitness University of Pennsylvania Health System Philadelphia, Pa