SUPERVISED EXERCISE VS UNSUPERVISED EXERCISE

Both a physical therapist instructed home exercise program and physical therapy supervision of the independent home exercise program improve patient pain and function outcomes in patients following arthroscopic rotator cuff repair for full-thickness tears isolated to only the supraspinatus (Karppi 2020). A randomized trial of patients having undergone arthroscopic repair for small rotator cuff tear compared a single session instruction of a 2-phase (AAROM; strengthening) home exercise program to a program that included additional visits to a physical therapist who supervised the patient doing the same independent home exercise program. There were no clinically meaningful differences in pain and function outcomes (Constant score, subjective shoulder value) at 3 months and 1 year follow up.

To evaluate traditional multimodal physical therapy compared to an independent home exercise program (HEP) for rehabilitation following rotator cuff repair, two conflicting studies (moderate quality) were identified (Lisinski 2012; Hayes 2004). Hayes et al (2004) supervised physical therapy treatment consisted of manual therapy, pain management with modalities, exercise and advice. The results showed that at 6, 12 and 24 weeks post-operative, comparable improved outcomes in strength (evaluated with manual muscle testing only), range of motion, and self-reported outcomes were demonstrated for individualized supervised physiotherapy treatment and standardized unsupervised home exercise program progressed by the surgeon only, though functional deficits of 14% and 32% were reported in the individualized physiotherapy group and standardized home exercise group, respectively, at 24 weeks post-operatively. Methodological limitations include a high number (28%) of patients (9/32) allocated to the independent home exercise program group crossed over to the supervised therapy group with analysis conducted by group allocation only. Additionally, missing data accounted for up to 31% of assessment results for the PT group, and 44% of assessment results for the HEP group, increasing risk of type II error. In contrast, Lisinski et al also conducted a randomized trial showing supervised multi-modal physical therapy treatment (manual therapy, mobilization exercises and strengthening) compared to an independent home exercise program that resulted in improved short term (3 and 6 week) outcomes (AROM; Pain VAS).

Risks and Harms of Implementing this Recommendation
There are potential harms of cost and resources when physical therapist interventions for postoperative rehabilitation following rotator cuff repair is limited only to supervision of the same exercises done independently at home and is not consistent with skilled physical therapy management.

Future Research

Future research should evaluate short- and long-term pain, function and clinical outcomes and compare traditional post-operative physical therapy management that is multimodal (manual therapy including mobilization and mobilization exercises, neuromuscular control training, functional activities, and continual assessment and progression/modification of home exercise program) to phased post-operative surgeon instructed home exercise programs for rehabilitation of patients following full-thickness rotator cuff repairs. Future research is needed to identify which patients may need traditional multimodal physical therapy, including neuromuscular re-education and manual therapy, compared to a home-directed program. Future studies that are stratified by tear size are also needed. The one high-level study referenced above was done on a small tear population only and may not be applicable to larger tears.