Maximizing Muscle Function in Cuff-Deficient Shoulders: A Rehabilitation Proposal for Reverse Arthroplasty.

PURPOSE: The purpose of this review is to describe the role of altered joint biomechanics in reverse shoulder arthroplasty and to propose a rehabilitation protocol for a cuff-deficient glenohumeral joint based on the current evidence.Methods and Materials: The proposed rehabilitation incorporates the principles of pertinent muscle loading while considering risk factors and surgical complications. RESULTS: In light of altered function of shoulder muscles in reverse arthroplasty, scapular plane abduction should be more often utilized as it better activates deltoid, teres minor, upper trapezius, and serratus anterior. Given the absence of supraspinatus and infraspinatus and reduction of external rotation moment arm of the deltoid in reverse arthroplasty, significant recovery of external rotation may not occur, although an intact teres minor may assist external rotation in the elevated position. CONCLUSION: Improving the efficiency of deltoid function before and after reverse shoulder arthroplasty is a key factor in the rehabilitation of the cuff deficient shoulders. Performing exercises in scapular plane and higher abduction angles activates deltoid and other important muscles more efficiently and optimizes surgical outcomes.

Abnormal Pain Response After a Compensable Shoulder Injury.

BACKGROUND: The role of psychosocial factors has been established in patients with shoulder abnormalities. However, the prevalence of exaggerated pain behaviors and their association with the characteristics of injured workers have not been well studied. PURPOSE: To examine the prevalence of abnormal pain responses (APRs) in workers with active workers' compensation claims for a shoulder injury and to examine the differences between workers with APRs versus workers without APRs. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: An analysis of electronic data files of injured workers was completed. An APR was defined as an exaggerated pain response during a clinical examination, including facial grimacing, shaking, withdrawal, nonanatomic dermatome or myotome disturbances, increased tenderness, regional symptoms, and verbal utterances such as groaning, moaning, or gasping. To control for potential confounders, patients with positive APRs (APR group) were matched with injured workers without APRs (control group) seen in the same clinic and matched for sex, age, and surgical candidacy. RESULTS: Data from 1000 workers who had sustained a shoulder injury at work and who were referred for an early assessment by an orthopaedic surgeon and a physical therapist were reviewed. A total of 86 (9%) injured workers (mean age, 47 ± 11 years; 55 [64%] female) demonstrated APRs and were matched with 86 injured workers without APRs. There were no statistically significant between-group differences in the wait time, mechanism of injury, coexisting comorbidity, type of abnormality, or medication consumption. The APR group reported higher levels of disability (P < .0001) and psychological problems (P < .0001), presented with more inconsistency in range of motion (P = .04), and had more limitations at work (P = .02). CONCLUSION: The presence of an APR after a compensable shoulder injury was associated with higher reports of disability and psychological problems. Patients with positive APRs were more likely to be off work and less likely to perform full duties.

Outcome of Expedited Rotator Cuff Surgery in Injured Workers: Determinants of Successful Recovery.

BACKGROUND: Work-related rotator cuff injuries are a common cause of disability and employee time loss. PURPOSE: To examine the effectiveness of expedited rotator cuff surgery in injured workers who underwent rotator cuff decompression or repair and to explore the impact of demographic, clinical, and psychosocial factors in predicting the outcome of surgery. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Injured workers who were seen at a shoulder specialty program and who underwent expedited arthroscopic rotator cuff decompression or repair were observed for a period of 6 to 12 months based on their type of surgery and recovery trajectory. The primary outcome measure was the American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form. The impact of surgery was assessed by whether the change in the ASES score exceeded the minimal clinically important difference (MCID) of 17 points. Secondary outcomes were range of motion (ROM), medication consumption, and work status. RESULTS: One hundred forty-six patients (43 women [29%], 103 men [71%]; mean age, 52 years; SD, 8 years) completed the study. Sixty-seven (46%) patients underwent rotator cuff repair. The mean time between the date the patient consented to have surgery and the date of surgery was 82 (SD, 44) days. There was a statistically significant improvement in ASES score and ROM and work status (52 returned to regular duties and 59 to modified duties) (P < .0001). Eighty-four percent (n = 122) of patients exceeded the MCID of 17 points. Individual factors that affected patient overall disability were preoperative ASES, work status prior to surgery, access to care, and autonomy at work. Achieving a minimal clinically meaningful change was influenced by perceived access to care, autonomy and stress at work, and overall satisfaction with the job. CONCLUSION: Expedited rotator cuff surgery improved disability, ROM, and work status in injured workers. Successful recovery after work-related shoulder injuries may further be facilitated by improving the psychosocial work environment and increasing access to care.

The effect of expedited rotator cuff surgery in injured workers: a case-control study.

BACKGROUND: Expediting rotator cuff surgery is expected to facilitate recovery and return to work in injured workers. This case-control study examined the effect of expedited rotator cuff surgery on recovery and work status in injured workers. MATERIALS AND METHODS: Injured workers who had undergone an expedited rotator cuff surgery funded by parallel-pay insurance (study group) were compared with workers who had used the public health insurance (control group) while adjusting for sex, age, severity of pathology, and follow-up period. Disability was measured by the American Shoulder and Elbow Surgeons (ASES) Standardized Assessment Form score. The percentage of patients who exceeded the minimal clinically important difference of 17 points in the ASES was calculated. RESULTS: The study group waited less time to have surgery than the control group (P < .0001), reported less disability after surgery, and had a higher number of patients whose improvement exceeded the minimal clinically important difference (119 vs. 65, P < .0001). The study group was more likely to be working at the time of the final follow-up (P < .0001). The final multivariable regressions, which adjusted for unmatched variables, such as dominant side involvement, mechanism of injury, and associated operations that were different between groups, were consistent with univariable analyses indicating superior results in the study group. CONCLUSIONS: Injured workers who underwent expedited rotator cuff surgery reported less disability and had a more successful return to work after surgery than injured workers who waited longer for specialist assessment and surgery within the public health system.

Management of Acute Work-Related Shoulder Injuries by an Early Shoulder Assessment Program: Efficiency of Imaging Investigations.

Purpose: There has been a significant increase in the number of costly investigations of the shoulder joint over the past decade. The purposes of this study were to (1) describe the diagnostic imaging investigations ordered for injured workers seen at an Early Shoulder Physician Assessment (ESPA) program, (2) evaluate the impact of these investigations on final diagnosis and management, and (3) examine how efficient the program was by determining the appropriateness of referrals and whether costly imaging was justified. Methods: This was a retrospective review of the electronic files of injured workers who had been referred to an early assessment program because they had not progressed in their recovery or return-to-work plan within 16 weeks of the injury or reoccurrence. Results: The data of 750 consecutive patients-337 women (45%) and 413 men (55%), mean age 49 (SD 11) years-were reviewed. A total of 183 patients (24%) had been referred for further investigation. Of these, 90 (49%) were considered candidates for surgery (group 1), 58 (32%) had a change in diagnosis or management (group 2), and 17 (9%) had no change in diagnosis or management (group 3); 18 (10%) patients were lost to follow-up. We noticed a pattern in the type of diagnosis and the groups: full-thickness rotator cuff (RC) tear was the predominant diagnosis (Fisher's exact test [FET]=0.001, p<0.0001) for group 1. No statistically significant differences were found among the groups in the prevalence of labral pathology (FET=0.010, p=0.078), impingement syndrome (FET=0.012, p=0.570), partial-thickness RC tear (FET=0.004, p=0.089), or biceps pathology (FET=0.070, p=0.149). Ultrasound investigations were more prevalent in group 2 (FET=0.004, p=0.047). No pattern was found for use of magnetic resonance imaging and group allocation. However, all magnetic resonance arthrogram investigations (FET=0.007, p=0.027) had been ordered for patients who required labral or instability-related surgery. Conclusions: Of the injured workers we studied, 24% had further investigation, and the type and severity of pathology had affected the type of investigation. For the 165 patients who were included in groups 1-3, the ESPA was 90% efficient, with only 10% of patients not having had a change in diagnosis or management.

Objectif : le nombre d'investigations coûteuses pour blessures à l'épaule a beaucoup augmenté au cours des dix dernières années. La présente étude avait pour objectif de 1) décrire les investigations par imagerie diagnostique prescrites aux travailleurs blessés dans le cadre d'un programme d'évaluation médicale précoce de l'épaule (ÉMPÉ); 2) évaluer l'incidence de ces investigations sur le diagnostic final et la prise en charge; 3) examiner l'efficacité du programme en déterminant le bien-fondé des références et des examens d'imagerie. Méthodes : il s'agissait d'une revue rétrospective des dossiers électroniques de travailleurs blessés qui avaient été dirigés vers un programme d'évaluation précoce en raison d'un manque de progression par rapport à leur plan de rétablissement ou de retour au travail au bout de 16 semaines après la blessure ou une nouvelle blessure. Résultats : on a examiné les données de 750 patients consécutifs, soit 337 femmes (45 %) et 413 hommes (55 %), dont l'âge moyen était de 49 ans (écart-type : 11). En tout, 183 de ces patients (24 %) ont été dirigés vers un autre professionnel pour investigation supplémentaire. Sur ceux-ci, 90 (49 %) ont été considérés comme des candidats à l'intervention chirurgicale (groupe 1), le diagnostic ou la prise en charge a évolué chez 58 (32 %) d'entre eux (groupe 2) et la prise en charge ou le diagnostic a été confirmé chez 17 (9 %) d'entre eux (groupe 3); 18 (10 %) patients n'ont pas été revus. Nous avons remarqué une tendance dans le type de diagnostic et les groupes : le diagnostic de déchirure complète de la coiffe des rotateurs (CR) prédominait (test exact de probabilité de Fisher [TEPF]=0,001, p<0,0001) dans le groupe 1. On n'a constaté aucune différence importante du point de vue statistique dans les groupes pour ce qui est de la prévalence de pathologies du bourrelet (TEPF=0,010, p=0,078), du syndrome de conflit sous-acromial (TEPF=0,012, p=0,570), de la déchirure partielle de la CR (TEPF=0,004, p=0,089) et des pathologies du biceps (TEPF=0,070, p=0,149). Un plus grand nombre d'échographies a été observé dans le groupe 2 (TEPF=0,004, p=0,047). On n'a remarqué aucune tendance du recours à l'imagerie par résonnance magnétique par rapport aux groupes. Toutefois, toutes les arthrographies par résonnance magnétique (TEPF=0,007, p=0,027) ont été prescrites pour des patients qui nécessitaient une intervention relative au bourrelet ou à l'instabilité. Conclusions : parmi les travailleurs blessés que nous avons étudiés, 24 % ont fait l'objet d'une investigation supplémentaire. Le type et la gravité de la pathologie ont influencé le choix du mode d'investigation. Dans le cas des 165 patients des groupes 1 à 3, l'efficacité du programme d'ÉMPÉ s'est élevée à 90 %, le diagnostic ou la prise en charge n'ayant pas évolué que dans 10 % des cas.

Examining outcome of early physician specialist assessment in injured workers with shoulder complaints.

BACKGROUND: There is minimal research on demographics, type of injury and diagnosis of injured workers with shoulder problems. The purposes of this study were: 1) to document the demographics of patients with shoulder complaints referred to an Early Shoulder Physician Assessment (ESPA) Program and to describe the recommended management, and 2) to examine the relationship between patient characteristics and their subjective complaints of pain and functional difficulty. METHODS: This study involved a retrospective review of electronic files of injured workers mostly seen within the first 16 weeks of injury or recurrence. Measures of functional difficulty and pain were the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) and Numeric Pain Scale (NPS). RESULTS: Files of 550 consecutive patients, 260 females (47%), 290 men (53%) were examined. The average age was 49 (SD = 11, range 22-77), with 28 (5%) patients being 65 years of age or older. Patients who were not working were the most disabled group based on Quick DASH (F = 49.93, p < 0.0001) and NPS (F = 10.24, p = 0.002). Patients who were working full time performing regular duties were the least disabled according to both measures, the QuickDASH (F = 10.24, p = 0.002) and NPS (F = 7.57, p = 0.006). Patients waiting more than 16 weeks were slightly older (53 years of age vs. 49, p = 0.045) than those who met the criteria for early assessment with similar levels of pain and functional difficulty. Biceps pathology had the highest prevalence (37%). Full thickness tear had a prevalence of 14%. Instability, labral lesions and osteoarthritis of glenohumeral joint were uncommon conditions (3, 2 and 1% respectively). Fifty-five patients (10%) were surgical candidates and had higher scores on QuickDASH (F = 7.16, p = 0.008) and NPS (F = 4.24, p = 0.04) compared to those who did not require surgery. CONCLUSIONS: This study provides information on characteristics and prevalence of important variables in injured workers with shoulder problems and highlights the impact of these characteristics on pain and disability.

Association between Neuropathic Pain and Reported Disability after Total Knee Arthroplasty.

PURPOSE: To determine whether reporting neuropathic pain (NP) at an average of 5 years after total knee arthroplasty (TKA) was related to patient age, sex, preoperative comorbidity, arthritis self-efficacy, or disability before surgery and at 1 year after surgery. The estimate of NP prevalence and cross-sectional group differences were explored at 5 years after surgery. METHODS: A subsample of participants in a formal research study was contacted via mail approximately 5 years after undergoing surgery and were sent four questionnaires: the Western Ontario and McMaster Universities Osteoarthritis Index, the Patient Health Questionnaire, the Self-Administered Leeds Assessment of Neuropathic Signs and Symptoms (S-LANSS), and a satisfaction questionnaire. NP was defined as an S-LANSS score of 12 or more. RESULTS: Of 89 patients who met the inclusion criteria, data for 63 (71%) patients (47 women; mean age 67 [SD 8] y) were used for analysis. Of these 63, 9 (14%) were identified as having NP. None had a report of failure of prosthesis or other surgical complications according to most recent medical records. There was no relationship between preoperative patient characteristics and development of NP. However, the NP group on average had a higher report of stiffness (p=0.020), physical dysfunction (p=0.019), and pain (p=0.050) at 1 year after surgery. Cross-sectional comparisons showed higher levels of pain (p=0.001), stiffness (p=0.008), physical dysfunction (p=0.003), and depression (p=0.005) and lower satisfaction (p=0.018) at the time of the survey than the patients without NP. CONCLUSION: The estimated prevalence of NP was 14%. Patients with NP reported higher levels of disability as early as 1 year after surgery. They remained more disabled, with a higher level of depression and less satisfaction, at an average of 5 years after surgery.

Objet : Déterminer si la déclaration de douleurs neuropathiques cinq ans en moyenne après une arthroplastie totale du genou (ATG) est liée à l'âge, au sexe ou à la comorbidité préopératoire, l'auto-efficacité concernant l'arthrite ou l'invalidité du patient avant la chirurgie et un an après celle-ci. L'estimation de la prévalence de douleurs neuropathiques et les différences transversales entre les groupes ont été examinées cinq ans après l'opération. Méthodes  : Un sous-échantillon de participants à une étude officielle ont été joints par courriel environ cinq ans après avoir subi leur opération, et quatre questionnaires leur ont été envoyés: le Western Ontario et McMaster sur l'arthrose (WOMAC), le Questionnaire sur la santé du patient (QSP-9), l'auto-évaluation de Leeds des signes et des symptômes neuropathiques (A-ELSSN) et un questionnaire sur la satisfaction. Les douleurs neuropathiques étaient définies comme étant un résultat de ≥12 à l'A-ELSSN. Résultats : Parmi les 89 patients qui répondaient aux critères d'inclusion, les données de 63 (71 %) d'entre eux (47 femmes; âge moyen de 67 ans [ET 8]) ont été utilisées aux fins d'analyse. Parmi ces 63 personnes, 9 (14 %) avaient déclaré souffrir de douleurs neuropathiques. D'après la plupart des récents dossiers médicaux, personne n'avait signalé une défaillance de la prothèse ou d'autres complications chirurgicales. Il n'y avait aucun lien entre les caractéristiques préopératoires des patients et le développement de douleurs neuropathiques. Toutefois, le groupe souffrant de douleurs neuropathiques avait en moyenne signalé dans une proportion plus forte des raideurs (p=0,020), une dysfonction physique (p=0,019) et des douleurs (p=0,050) un an après la chirurgie. Au moment de l'enquête, les comparaisons transversales ont fait état de degrés élevés de douleurs (p=0,001), de raideurs (p=0,008), de dysfonction physique (p=0,003) et de dépression (p=0,005), ainsi que d'un degré inférieur de satisfaction (p=0,018) par rapport aux patients ne souffrant pas de douleurs neuropathiques. Conclusion : La prévalence estimée de douleurs neuropathiques était de 14 %. Les patients souffrant de douleurs neuropathiques ont signalé des niveaux supérieurs d'invalidité dès la première année suivant la chirurgie. Leur invalidité s'était accrue; ils souffraient davantage de dépression et étaient moins satisfaits, cinq ans en moyenne après la chirurgie.