Occ health-presentation

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Occ health-presentation

  1. 1. Evidence Based Medicine and the Rotator Cuff<br />Chris Pullen<br />
  2. 2. Introduction 1<br />UK (Linsell et al 2006 Rheumatology) <br />2.4% primary care consultations are shoulder based<br />USA (US Dept Health & Human Services)<br />4.5 million physician visits rotator cuff problems<br />
  3. 3. Introduction 2<br /><ul><li>Pathogenesis ?
  4. 4. Natural History ?
  5. 5. When to & when not to operate ?
  6. 6. Which operation ?</li></li></ul><li>Introduction 3<br />Problems<br />Multi-factorial nature of the pathology<br />Publications are small, single centre & retrospective<br />‘There is little evidence to support or refute the effectiveness of surgery for rotator cuff disease. All reviewed trials were highly susceptible to bias.’<br /> Coughlan et al 2004 Cochrane database<br />
  7. 7. Prevalence<br />MRI asymptomatic <br /> (Sher et al 1995 JBJS)<br />Supported by US and cadaver studies<br />Why RCT become symptomatic ???<br />Ageing process ?<br />
  8. 8. Natural History 1<br />Asymptomatic RCT<br />40% asymptomatic tear<br />51% symptomatic<br />39% increase in size<br />(Yamaguchi et al 2001 JSES)<br />
  9. 9. Natural History 2<br />Partial thickness tears<br />Arthrography on 40 of 61 patients with PTT<br />(Yamanaka et al 1994 CORR)<br />Full thickness tears do not heal<br />(Fukuda et al 1994 CORR)<br />
  10. 10. Pathogenesis<br />Mechanical (Neer 1972 JBJS)<br />Vascular (Moseley & Goldie 1963 JBJS)<br />Genetic (Harvie et al 2004 JBJS)<br />Cellular (Nirschl 1989 Instr Course Lect)<br />
  11. 11. Non-operative Treatment 1<br />Impingement/Tendinitis<br />High success rate approx 70%<br />Retrospective study 616 patients (Morrison et al 1997 JBJS)<br />Prospective trial 100 patients impingement (Cummins et al 2009 JSES)<br />
  12. 12. Non-operative Treatment 2<br />Rotator cuff tears <br />Some patients have successful outcome<br />No reliable method of predicting outcome <br />Need for well-planned randomized controlled trials<br />(Ainsworth & Lewis 2007 Br J Sports Med.)<br />Irreversible changes within cuff muscles after a tear (Coleman et al 2003 JBJS)<br />
  13. 13. Non-operative Treatment 3<br /><ul><li> Modalities
  14. 14. Exercises
  15. 15. Manual therapy
  16. 16. Corticosteroid injections
  17. 17. Ultrasound
  18. 18. Phonophoresis
  19. 19. Iontophoresis
  20. 20. Ice/Heat
  21. 21. NSAID</li></li></ul><li>Exercise 1<br /> Kuhn 2009 JSES<br />
  22. 22. Exercise 2<br />Systematic review <br />Physical Therapy modalities used<br />ROM<br />Stretching & flexibility<br />Strengthening<br />Manual therapy<br />(Kuhn 2009 JSES)<br />
  23. 23. Exercise 3<br />Pain <br /> (Bang 2000, Brox et al 1993, Ludewig & Borstad 2003, Senbursa 2007, Walther 2004)<br />Strength<br />(Bang 2000, Haahr et al 2005, Walther et al 2004)<br />Function <br />(Bang 2000, Conroy & Hayes 1998)<br />
  24. 24. Exercise 4<br />Two studies compared supervised physical therapy with home exercise (Walther et al 2004, Werner et al 2002)<br />Neither could show a statistically significant difference between the 2 exercise groups<br />
  25. 25. Manual Therapy<br />The effect of manual therapy has been evaluated in a number of studies<br />(Bang 2000, Conroy & Hayes 1998, Senbursa et al 2007)<br />
  26. 26. Corticosteroid Injections 1<br />For 50y CSI have been used for treatment of shoulder problems<br />Survey 96% practitioners believe CSI effective<br />Adverse effects well know<br />Rat model (Tillander et al 1999 JSES)<br />
  27. 27. Corticosteroid Injections 2<br /> (Koester et al 2007 JAAOS)<br />
  28. 28. Corticosteroid Injection 3<br />Pain (Adebajo et al 1990 J Rheum, Akgun et al 2004 Clin Rheum, Blair et al 1996 JBJS)<br />ROM (Adebajo et al 1990 J Rheum, Blair et al 1996 JBJS)<br />Predictor for surgery (Cummins et al 2009 JSES)<br />MRI study accuracy of injection<br />24-31% CSI inaccurately placed<br />Only injections into SA bursa helpful<br />(Henkus et al 2006 Arthroscopy)<br />
  29. 29. Corticosteroid Injections 4<br />‘little evidence to support or refute the efficacy of common interventions for shoulder pain’<br />(Buchbinder et al 2003 Cochrane Database)<br />‘best evidence indicates that subacromial CSI is not efficacious in the treatment of rotator cuff disease’<br />(Koester et al 2007 JAAOS)<br />
  30. 30. NSAID<br />Integral to most non-operative treatment protocols<br />Systematic review 19 Randomized controlled trials<br />Shoulder pain<br />Useful in short term only (4 weeks)<br />No benefit seen for a particular NSAID<br />(van der Windt et al 1995 J Clin. Epid.)<br />
  31. 31. Other<br />US (Green et al 2003 Cochrane Database)<br />Phonophoresis (Klaiman et al 1998 Med Sci Sports Exerc)<br />Iontophoresis <br />Heat/Cold (Haahr et al 2005, Conroy et al 1998, Senbursa et al 2007)<br />
  32. 32. Surgical Treatment 1<br /><ul><li> Systematic review</li></ul>(Dorrestijin et al 2009 JSES)<br />‘failed to provide evidence for differences in outcome between conservatively and surgically treated patients with SIS’<br />
  33. 33. Surgical Treatment 2<br />Dorrestijn et al 2009 JSES<br />
  34. 34. Surgical Treatment 3<br />Rotator cuff tear<br />Systemic review (Wolf et al 2007 Am J Sports Med)<br />Despite possibility of re-tear RCR reduces pain & improves strength & function in symptomatic patients (Jost et al 2000 JBJS)<br />
  35. 35. Surgical Treatment 4<br />Variables<br />Duration of symptoms (Habernek et al 1999 Br J Sports Med)<br />Age<br />(Feng et al 2003 J Ortho Surg, Hattrup 1995 JSES)<br />
  36. 36. Surgical Treatment 5<br />Variables<br />Gender (Romeo et al 1999 CORR)<br />Weakness (Bartolozzi et al 1994 CORR)<br />Tear size (Bartolozzi et al 1994 CORR)<br />
  37. 37. Surgical Treatment 6<br />Variables<br />Acromiohumeral distance<br />(Ellman et al 1986 JBJS, Gerber et al 2000 JBJS)<br />Atrophy & Degeneration<br />(Goutallier et al 2003 JSES)<br />
  38. 38. Surgical Treatment 7<br />Variables<br />Workers’ Compensation<br />Retrospective study 3.8 y follow-up<br />FTT & pending WC<br />(Hawkins & Dunlop 1995 CORR)<br /><ul><li>Presence WC claim did not adversely affect outcome</li></ul> (Iannotti 1994 JAAOS)<br />
  39. 39. Conclusions 1<br />Non-operative treatment<br />Trial minimum 6-12 weeks<br />Physical therapy<br />
  40. 40. Conclusions 2<br />Exercises<br />ROM<br />Postural exercises <br />Shoulder shrugs & retraction<br />Glenohumeral motion<br />Pendular exercises<br />
  41. 41. Conclusions 3<br />Exercises<br />Stretches<br />Anterior and posterior capsule<br />Strengthening<br />Rotator cuff & scapular stabilizers<br />Theraband<br />
  42. 42. Conclusions 4<br />MRI scan <br />Surgery<br />
  43. 43. Conclusions 5<br />
  44. 44. Conclusion 6<br />
  45. 45. The End<br />

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