Rotator Cuff Rehab Therapy or Psychiatry Derek Cuff
Rotator Cuff Rehab: Therapy or Psychiatry? Derek Cuff, M. D. Suncoast Orthopaedic Surgery and Sports Medicine Gulfcoast Orthopaedic Rehab Conference-August 27 nd 2017
Goals 1. Discuss psychosocial aspects of RTC rehab 2. Identify risk factors to look out for
Therapy or Psychiatry?
Therapy or Psychiatry? • Post-op management very important • Therapy vital component • Deviation from post-op protocol can result in failures
Therapy or Psychiatry? • RTC protocol – 6 weeks of immobilizer – Pendulums 3 times a day with active elbow/wrist/hand – Start passive at 6 weeks – Active assisted at 8 weeks – Progress active at 10 weeks – Strengthening at 12 weeks
Therapy or Psychiatry? • Disregarding post op immobilization • Not attending therapy sessions • Not tolerating pain of therapy sessions • Not complying with post-operative restrictions
Therapy or Psychiatry? • Workers Compensation – Many have secondary gain issues – Not much incentive to improve – Some don’t want to return to work
• “Prospective evaluation of postoperative compliance and outcomes after rotator cuff repair in patients with and without workers' compensation claims” • Cuff et al. JSES 2012
Therapy or Psychiatry? • Study design – 42 consecutive WC patients undergoing RTCR – 50 control patients – Documented sling wear at follow up visits – Documented number of physical therapy visits attended – Basically evaluating for non-compliance with protocol
Results- Compliance • 52% of Work Comp patients with documented episode of non-compliance • 55% noncompliant to immobilizer • 45% noncompliant to PT • 36% noncompliant to both • 4% of controls with documented episode
Results- ASES Score 100 90 80 70 60 50 Non WC 40 WC 30 20 10 0 ASES PRE ASES POST
Results- SST Score 12 10 8 Non WC 6 WC 4 2 0 SST PRE SST POST
Results- VAS Score 10 9 8 7 6 5 Non WC 4 WC 3 2 1 0 VAS PRE VAS POST
Therapy or Psychiatry • Not all Work Comp patients were noncompliant – 52% were – 48% were not – There is a subset that wants to get better
Results- ASES Score 100 90 80 70 60 50 Good WC 40 Bad WC 30 20 10 0 ASES PRE ASES POST
Results- SST Score 12 10 8 Good WC 6 Bad WC 4 2 0 SST PRE SST POST
Results- VAS score 10 9 8 7 6 5 Good WC 4 Bad WC 3 2 1 0 VAS PRE VAS POST
Therapy or Psychiatry? • What I learned – Mental component of secondary gain – Work comp= high degree of noncompliance – Not all bad – Have to be careful and document everything
Therapy or Psychiatry • Post op pain after ARTC repair is common • Challenge to both patient and surgeon • Highly variable • Multiple factors may be involved
• Cuff et al. 2016 • Evaluation of Factors Affecting Acute Postoperative Pain Levels after Arthroscopic Rotator Cuff Repair • Purpose- Evaluate multiple pre-operative and operative factors that may be predictive of and correlate with acute post-operative pain levels after arthroscopic rotator cuff repair.
Therapy or Psychiatry? • 181 patients (101 males, 80 females) • Avg. age 63. 3
Materials and Methods • Single shot interscalene block • Hydrocodone 7. 5/325 APAP 1 -2 q 4 -6 hours • VAS scoring • Pain score POD #1, #7 and #90.
Materials and Methods • Pre-op factors evaluated – Subjective pain tolerance (extremely high, above average, below average, extremely low) – Pre op narcotic use – Smoking – Gender – Age – Preop VAS – Workers Comp
Materials and Methods • Intra-op factors – Tear size (partial, small, medium, large) – Number of anchors used – Repair technique (single row vs TOE)
Results • #1 Factor affecting post op pain: – Patients subjective pain tolerance – Those patients rating themselves having “extremely high pain tolerance” had the highest correlation with elevated VAS on POD #1 and #7
Subjective Pain Tolerance 10 9 8. 9 7. 3 8 Extremely High 7 Above Avg 6 Averge 5 Below Avg 4 Extremely Low 3 2 1 0 POD #1 POD #7 POD #90
Results • Other factors affecting post op pain – Pre op narcotic use – POD #1 - 8. 7 – POD #7 - 6. 1
Results • Other factors affecting post op pain – POD #7 – Smokers – Younger decade of life
Results • Factors that did not correlate: – Tear size – # of anchors used – Work comp claims – Pre op VAS – Gender – Single or double row
Therapy or Psychiatry? • Why did “extremely high pain tolerance” patients struggle? – Ability of a patient to judge their pain tolerance not rooted in objective data or fact – May have a disproportionate view of their ability to tolerate post-op pain – Now a question on all my pre op assessments
Therapy or Psychiatry? • Beware of the patient who says: – “Hey therapist, I just want you to know that I have a really high pain tolerance” – Watch out for pre op narcotic users – Smokers and younger patients as well
• Wylie et al. 2016 “Mental Health Has a Stronger Association with Patient. Reported Shoulder Pain and Function Than Tear Size in Patients with Full-Thickness Rotator Cuff Tears”
Therapy or Psychiatry? • 169 patients – SF-36 – VAS pain and function – ASES score • • Tear size Tear retraction Age Sex BMI Smoking status Work Comp Medical comorbidities
Therapy or Psychiatry • SF-36 had highest correlation with: – VAS scores – ASES scores
Therapy or Psychiatry?
Therapy or Psychiatry?
Therapy or Psychiatry? • Stick to prescribed protocol • Understand the orthopaedic pathology • Data shows you may be treating more than the orthopaedic issue
Conclusion • Mental component to patient interactions • Identifying problem patients • Treating the patient, not just the injury
THANK YOU
- Slides: 39