POST-OP MOBILIZATION TIMING

Four high quality and four moderate quality randomized controlled trials (Guity, 2023; Keener, 2014; Kjaer, 2021; Mazzocca, 2017; Cuff, 2012; De Roo, 2015; Duzgun, 2014; Koh, 2014) evaluated post-operative mobilization paradigms following rotator cuff repair. All 6 studies compared the outcomes of patients who began mobilization exercises of their shoulder within 0-2 weeks post-operatively against patients who delayed mobilization exercises for between 4-8 weeks post-operatively. In each of the reviewed studies, patients were immobilized in a sling for an equivalent length of time irrespective of group assignment. The consistency of sling use between groups allows our analysis to focus on “mobilization” as defined by the timing the first visit of supervised physical therapy. For nearly all measures, including post-operative rotator cuff healing, patient-reported outcome measures, and post-operative medication use, early and delayed mobilization paradigms yield similar outcomes.

Early mobilization favors improved range of motion (Cuff, 2012; Duzgun, 2014; Keener, 2014; Mazzocca, 2017) and quality of life patient-reported outcome measures (Mazzocca, 2017) when compared to patients who delayed mobilization, but these differences become negligible by 6 months post-operatively.

Delayed mobilization until 4-8 weeks post-operatively is associated with higher rates of post-operative healing. However, these differences do not reach statistical significance in the 5 best available evidence studies which analyzed rotator cuff integrity (Cuff, 2012; DeRoo, 2015; Keener, 2014; Koh, 2014; Mazzocca, 2017). Post-operative healing was analyzed by US and/or MRI from 7 days (Mazzocca et. al. 2017) through up to 2 years post-operatively (Keener, 2014; Koh, 2014).

In summary, early (0-2 weeks) or delayed (4-8 weeks) mobilization defined by initiation of passive and active-assistive range of motion interventions with supervised physical therapy yield similar outcomes in rotator cuff healing, range of motion, and patient-reported outcome scores. Early mobilization tends to favor improved range of motion through the first 6 months post-operatively while delaying mobilization exercises is associated with higher rates of post-operative healing particularly for tears of larger size.

Three prospective randomized trials (Sheps, 2019; Littlewood, 2021; Tirefort, 2019) examined early mobilization defined as discontinuation of sling use. Studies compared immediate weaning from sling and active range of motion to comfort compared to consistent sling use for 4-6 weeks following arthroscopic rotator cuff repair. Mobilization with physical therapist /surgeon instructed passive, or active assistive home exercise programs were the same in both groups for the first 4 weeks. Self-reported fidelity of sling use was assessed and different between groups as intended. Enrolled patients in Sheps, 2019 included full-thickness tears, 70% that were less than 3cm and 30% were greater than 3cm (excluding subscapularis), repaired arthroscopically with surgeon preference (at least 90% were double row/ trans-osseous equivalent) (Sheps 2019). No abduction pillow was used with sling. Enrolled patients in Littlewood et al included 89% full thickness and 11% partial thickness atraumatic rotator cuff tears (mean 2.7cm). Enrolled patients in Tirefort, 2019 included full thickness tears less than 3cm, considered small to medium. At 6 weeks (Sheps, 2019; Littlewood, 2021; Tirefort, 2019), early motion patients had significantly better active motion than the continuous sling use patients; no other group differences were noted. In follow-up over 24 months, Tirefort showed better SANE scores (85.8 ± 10.7 versus 79.4 ±11.6, p = 0.011) and lower VAS pain scores (0.8 ± 1.1 versus 1.5± 1.6, p = 0.031) in the no sling group, but no group differences in range of motion, and pain, strength, or health related quality of life were found in Sheps. The retear rate at 3 months in Littlewood was 40% in continuous sling use and 30% in early motion groups, at 12-months postoperative in Sheps was 30% in early motion versus 33% in continuous sling use groups, and there was no significant differences in tendon integrity at 6 months in Tirefort. In summary, outcomes are not adversely affected with immediate weaning from sling use allowing for active motion to comfort, compared to 4-6 weeks of standard sling use as it yields similar post-operative healing, functional outcomes, and patient-reported outcomes following arthroscopic rotator cuff repair. Early mobilization with immediate weaning from sling yields earlier improvements in active motion.

Risks and Harms of Implementing this Recommendation
Because the early and delayed mobilization protocols yield similar results there is no known harm from implementing this recommendation. Timing for discharge of sling use should be determined by shared decision making with the patient based on numerous patient specific factors that impact repair healing in order to reduce risk of retears during post-operative rehabilitation.

Future Research
This PICO question using the term mobilization was updated to include: 1. the timing of post-operative mobilization exercises, defined in the 6 studies reviewed here, as the initiation of supervised physical therapy intervention of manual passive range of motion, active assistive, and active motion exercises, and 2. immediate weaning sling use, defined in 3 studies. A physical therapy visit for mobilization passively or therapist active assistive exercises may not be the measure most indicative of stress on the healing repair. Absolute load and cyclic loading have been identified as factors affecting suture durability in biomechanical studies. Counting the number of physical therapy visits assumes that the amount of load and the cycles across the tendon-suture-bone interface are consistent for therapist assisted mobilization within each physical therapy session and home exercise protocols. Perhaps it is not surprising that there are few differences between early and delayed rehabilitation protocols when the measure of dosing is initiation of supervised physical therapy with variations in the timing of passive and active assisted range of motion or sling use. If researchers want to further elucidate the differential impacts of loading a rotator cuff repair, either a more finite measure of dosing should be used for mobilization (number of total cycles) or tracking use outside of a sling with activity monitors in supervised physical therapy, home exercises, and with active motion with activities of daily living should be utilized. Studies should evaluate short-term outcomes (6-12 weeks), or the rehabilitation protocols need to be more disparate. At minimum, future research should examine the dose and load of mobilization, home exercise, and active motion out of the sling over the course of post-operative care. Finally, more patient-centric disease-specific outcome measures such as the WORC quality of life score (Mazzocca et. al.) should be routinely incorporated to determine the direct impact on the patient of differing rehabilitation protocols.