SEPTEMBER 2020
StriveHub Fab 5
FALL ALREADY?
It’s hard for me to fathom that we are less than a month away from the official start of Fall! This year the seasons officially change on September 22nd. When I parked the car today, the temperature outside was 88 degrees. The warm weather is still rolling, even as the earlier sunsets are hard to ignore. I was talking with Blake the other day about his “Fourth Grade Orientation” coming up on September 3rd. He was sort of paying attention…until I mentioned it was this week. He shot to attention and gave me a look that was equal parts stunned denial and cautious optimism. Priceless! The stunned denial was in part the realization that time flew by and his summer vacation was nearly over. It has certainly been a different summer for all of us. We didn’t travel anywhere or do all that much, yet the time seemed to fly anyway. As a family we found ourselves doing a lot more together; walks, board games, reading and movie nights have been mainstays this summer. I think the cautious optimism component was all about getting to see his friends again. His last school year, like that of most kids, ended from a distance. His school is going back to the classroom with the hopes of making
PTSMC Celebrates Clinical Excellence!
Congratulations to Tom Kirsch & Mike Krukiel - the two successfully completed a year-long program of didactic coursework, mentorship and manual therapy skills to graduate from our Orthopaedic Residency Program! We are proud to recognize their hard work to advance their clinical reasoning, hands-on skills and physical therapy orthopedic knowledge. (Read one of their PICO projects at the end of this PULSE!) This was an unprecedented year due to the pandemic, Tom and Mike handled the challenges with resiliency and success. They showed adaptability to transitioning to online learning, schedule changes and a change in program leadership. We look forward to continuing to watch them positively impact PTSMC and the physical therapy profession! From left to right: Alan Balavender, Danielle Dunn, Mike Krukiel, and Tom Kirsch.
it work. He is generally a good student, and if you asked him what his favorite subject is, he would be quick to enthusiastically answer “lunch and recess!” Some things never change! Fall is traditionally a very busy time for everyone personally and at PTSMC. For our PTSMC parents of school age children, our many PTSMC students and our Athletic Trainers the start of this school year mirrors Blake’s stunned denial and cautious optimism. The variety of modified school schedules is mind blowing. We must add “fluid” and “adaptable” to our traditional busy fall! Our current trends suggest PTSMC will continue to move closer to our original projections. I am truly grateful for all the PTSMC employees who have been and continue to be fluid, adaptable and busy. Whatever the circumstances, our aim always remains the same: to improve the quality of peoples’ lives by providing unmatched experiences, clinical excellence and lifelong relationships. I thank you for delivering on our mission. Let’s have a great fall! Alan
Patient Trends New Patients per Month
Visits per Month
“I am very impressed with the incremental improvements in strength and mobility as a result of my physical therapy sessions and home exercises. I highly recommend physical therapy (specifically PTSMC) as a part of a full recovery regiment for all people recovering from surgery or injury. I am amazed and grateful. Thank you for your expertise and care!” - Groton “Your facility is the perfect environment for someone who needs physical therapy. Every step of the way has been a very positive experience. My therapist Sean Walsh has been exceptional. Thank you.” - Waterbury “Channing (Harwood), the PT I work with, listens and responds. Additionally, he mixes up the exercises, which avoids monotony. Most satisfying and surprising is the progress I have made since beginning therapy.” - Plainville “Before I even started my sessions, my doctor faxed my prescription to the wrong place, and the office staff at PT for Life handled it quickly and efficiently. My physical therapist explains everything to me in a way so that I can understand my diagnosis and why my injury may have happened and what to do about it as far as treatment and which excercises help which tendons and muscles. So much thorough information. I feel safe here!” - Southbury “I was greeted with respect and the staff has a very thorough understanding of the how our bodies work. We talked about the issues and tried several different approaches to alleviate them. After the first week, they tried a different treatment that really worked. My only regret is that I didn't come to them earlier. I lived with back pain for over a year. I am pain free now with full mobility. I would and have recommended this group to friends, family and co-workers.” - Westbrook
CLINICIAN’S CORNER
THE USE OF NEURODYNAMICS IN THE ASSESSMENT AND TREATMENT OF ADVERSE NEURAL TENSION By Alyson Whelan, PT, MSPT Physical Therapist at PTSMC Essex I had the opportunity to attend MT-3, Maitland Intermediate Spinal Seminar, last October. During the weekend-long course, assessment and treatment of the cervical, lumbar and thoracic spine were reviewed. For those of you unfamiliar with the Maitland approach, Maitland believes in treating the patient’s comparable sign. A clinician is able to attain the comparable signs through thorough assessment of one’s A/PROM, passive physiological intervertebral movements (PPIVMS), combined movements, and CPAs and UPAs. During this course, neurodynamic testing was reviewed and discussed as another source for our patients’ pain, and thus, another treatment option. Neurodynamics is the study of the mechanics and physiology of the nervous system. There are mechanical and physiological aspects of the nervous system, pathomechanics and pathophysiology. Pathomechanics is the mechanosensitivity of the attachments, branches and tunneling of the nervous system. Often times, these structures tend to be the source of pain in our “stiffness” dominant patients. In contrast, pathophysiology involves the vascular supply to the nervous system. It is believed that our “pain” dominant patients suffer from an inflammatory response and or altered axonal plasma flow. Adverse neural tension occurs when there is entrapment or compression of the nervous system affecting the mobility and ability to transmit tension in the nervous system. As physical therapists, we are able to assess neural tension through base testing. The base tests most commonly used include passive neck flexion, SLR, SLUMP and prone knee bend, in the lumbar spine. In the cervical spine, upper limb tension testing is used to assess tension of the median, radial and ulnar nerves. Assessment of dural tension in our spinal population is important because the dural sleeve of the nerve root extends beyond the neural foramen by approximately two inches. This results in tension that can affect the nerve root both proximally and distally. The most common sites of dural adhesions occur at C5, T6 and L4. If a base test reproduces the comparable sign, then the test may be used to help treat and alleviate tension in the nervous system. Once it has been determined that dural tension exists through administering a base test, the clinician can then choose to use that base test as a treatment option for their patient. The base test, if not used as a treatment technique, can be useful during the re-assessment of the patient to ensure the proper treatment technique was chosen. When using a base test as a treatment option, the therapist must identify whether they are treating a “stiffness” or “pain” dominant patient. Our “stiffness” dominant patients generally respond well to flossing and gliding the proximal segment, utilizing grade III and IV mobilizations. Our “pain” dominant patients may tolerate flossing and gliding of the distal segment, with grade I and II mobilizations, staying short of the pain.
An example of a treatment technique involving neurodynamics is lumbar rotation with SLR. In this instance, the patient presented with positive dural tension of their sciatic nerve through assessment of SLR. Here the clinician positions the patient in supine, the involved leg adducted across their body, keeping the knee extended, as in a SLR. The clinician is facing the patient, placing one hand on the patient’s shoulder and the other on the pelvis. The clinician begins to oscillate the pelvis to create lumbar spine rotation. In summary, adverse mechanical tension in the nervous system may be due to entrapment or compression of the nervous system, thus affecting the mobility and ability to transmit tension in the nervous system. Neurodynamic testing may be a useful tool in both the assessment and treatment of our spinal population complaining of radiating and referred pain. Use of nerve glides based on positive dural tension test may help to alleviate symptoms associated with referred pain due to an adherent dural structure. Determination of grades of mobilization, amplitude of mobilization and number of oscillations of the involved structure are determined based on the classification of the patient, pain versus stiffness. In our pain dominant population, beginning distally, short of pain with grade I and II mobilization may be beneficial. In contrast, our stiffness dominant population can begin proximally, with joint mobilization/stretching into the barriers of resistance. Reference: Maitland-Australian Physiotherapy Seminars. 1985-2017. MT-3: Intermediate Spinal
STUDENT PROGRAM UPDATE We’re pleased to welcome the following students completing clinician rotations with PTSMC! Leana Bein (Quinnipiac University) will be working with Kristina Lipeika and Lindsey Scianna in Watertown. William Cutrone (Quinnipiac University) will be working with Ashley Tighe in Wallingford. Jonathan Foster (Sacred Heart University) will be working with Meghan Blanusa in Naugatuck. Connor Gavin (UCONN) will be working with Tom Kirsch in Avon.
HUMAN RESOURCES CURRENT JOB OPPORTUNITIES 401(k)
Employees who would like to make a change to their 401(k) biweekly contributions for the 4th quarter of 2020 must complete the request by Friday, September 16, 2020 to be effective with the October 7, 2020 payroll. Login to your John Hancock account at: myplan.johnhancock.com. Click Manage, then Contribute.
Patient Services Coordinator Essex Fairfield Wethersfield Windsor
Physical Therapy Aide Branford Danbury Essex Guilford Naugatuck New Haven New Milford Southbury
Check www.PTSMC.com/job-openings for our most up-to-date postings, and feel free to share! Call Karen or email at karen.havlicek@ptsmc.com if you are interested in a position.
New and Revised Company Policies All employees received an email from Karen Havlicek regarding revisions to the following policies: • PTSMC Specialty Certification Process and Policy – New policy • PTSMC Holiday Time Off Policy – Clarifies works schedules for holiday weeks and early closings The PTSMC Holiday Time Off Policy has been revised. Note the change for early closing on the day before or after a holiday. Directors have the discretion to adjust the clinic business hours on the following days: • The day before Thanksgiving • The day after Thanksgiving • Christmas Eve • New Year’s Eve On these days, all employees will be paid ONLY for hours worked. Employees shall adjust their schedule to work their expected hours. Examples: If the director choses to close at 4:00 on New Year’s Eve, a full-time employee, who works an 8 hour day, 5 days per week, hours are 10:30 am to 7:00 pm., shall adjust their workday to complete an entire day by working 7:30 am - 4:00 pm. If a director chose to close at 1:00 on Christmas Eve, schedules shall be adjusted to work 7:00 am – 1:00 pm and hours short shall be made up on other days that work week. Please read both policies and reach out to Karen Havlicek at Karen.Havlicek@ptsmc.com or Sandra Boccialetti at Sandra.Boccialetti@ptsmc.com with any questions.
To Complete and Approve Your Timesheet Timesheet Reminders • Complete your timesheet daily. • Do not complete ahead of time in case your schedule changes. • Approve your hours by the end of the pay period. • If timesheets are not completed by Friday at 8:30 pm at the end of the pay period, your hours will be processed with the following pay period in 2 weeks. • Check your email for biweekly timesheet reminders.
SEPTEMBER BIRTHDAYS Nick Scott Peter Decoteau Shradha Rana Lauren MacDonald Matt Baronowski Samantha Dassatti Ian Bergere Jacey Bissell Pete Cambi Melissa Boutagy Carson Mendoza Joe Caligiuri Mario Paredes Meghan DiPisa Brian Greer Mike Durand Ariana Caruso Linda Lepeak Wanda Figueroa Madelyn Vianney Amy Bellone Skylar Vumback Sam Donahue
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Westbrook Admin Middletown Essex Avon Fairfield Westbrook Branford Southington Guilford & Admin Branford Naugatuck Orange New Milford & Southbury Watertown Admin Naugatuck Guilford Admin Middletown West Hartford Essex Guilford
SEPTEMBER ANNIVERSARIES Dana Earle Dave Lawrence Julianne Balavender Linda Lepeak Miguel Santiago Shradha Rana Bill Chapin Christine Raffone Erik Olsen Fred Havlicek Gabby Didiano Rick Purdy Russ Woodman Mary Clark Sarah Alkire Allyson Melillo
Physical Therapist Information Systems Coordinator Office Assistant PSC Physical Therapist Physical Therapist
Southington Admin Admin Guilford West Hartford Middletown
Physical Therapist PSA Physical Therapist Partner & Director Physical Therapist Physical Therapist Physical Therapist Physical Therapist PT Aide Patient Benefits Coordinator Patient Benefits Advisor
Branford New Haven Southbury New Haven Middletown New Haven New Haven New Haven New Haven Admin
Heather Feiner
Athletic Trainer
Admin
Erin Walsh
Partner & Director
Waterbury
Cindy Hales
Admin
EMPLOYEE NEWS
NEW EMPLOYEES
Caitlyn Ayotte, New London Physical Therapist
Kylie Fox, Watertown PT Aide
Jennifer Bastos, Naugatuck PT Aide
Jessah Doctor, Waterbury PT Aide
Sean Doenias, West Hartford PT Aide
Connor Doherty, Wethersfield PT Aide
Randi Gallagher, East Hampton PSC
Charles Henry, Guilford PT Aide
Charles Mazzarella, Watertown PT Aide
Cynthia Mazzarella, Watertown PSC
Sarah Peterson, Guilford PSC
Debra Philcox, Naugatuck PSC
Sona Pinela, New Haven PT Aide
Michael Rutt, West Hartford PT Aide
Emily Sargent, Newington PT Aide
Sophia Shea, Watertown PT Aide
Shirley Siguenza, Danbury PT Aide
Amanda Staheli, New Haven PSC
Sheena Trivedi, West Hartford PT Aide
Skylar Vumback, Essex PT Aide
Not Pictured
Adam Antunes, Naugatuck PT Aide Kayla Broyles, Plainville PT Aide Hailey Boulanger, Watertown PT Aide Ariana Kelly, Newington PT Aide Roy O’Neil, Southbury PT Aide
By Jim Hungerford, CPA Director of Accounting and Finance
Should You Lease or Buy Your Next Car If you’ve ever gone car shopping, you’ve probably been given the opportunity to lease a car. On the surface, a car lease seems too good to be true. You get to drive home in a brand new car for a lower monthly payment than if you got a loan to buy the car. Then, in two or three years, you have the option of buying out the lease and keeping the car or trading in for another new car. What’s not to like? Why wouldn’t it be better to lease?
THE UPSIDE TO LEASING Brand new car Leasing is about luxury and convenience. You get the luxury of a new car and the convenience of not having to worry about maintenance. That’s not to say you can go two years without an oil change, however, because the car is new, you hopefully won’t have to worry about any major repairs, which would be covered by warranty if they were to occur. Lower monthly payment In most cases, the monthly payments on a lease are less than if you get a loan to buy the car at normal interest rates over three or four years. Most leases have little to no money down options to entice you to lease the car. Less commitment Leases make sense if you only need a car for a defined period of time. If you know you need to replace a car now but your family is growing and you know you might need a bigger car in two or three years, a lease can help you bridge that time period.
THE DOWNSIDE TO LEASING You don’t own anything You never own anything when you lease. Although leasing may seem less expensive over the next two years, in the long run, you’ll always have a monthly payment. Yes, cars depreciate. Yet if you keep them long enough you’ll still have something of value that you can sell. Perpetual payments With a lease, once your lease term is up, you either turn in the car and lease a new one, or buy the lease out for another period of time. This can sometimes equate to 7 or 8 years (or more) of car payments. You can only drive so far If you drive a lot, a lease is not for you. Dealers make money on leases because they collect your lease payments and then can resell the car as a two- or three-year-old certified used car. But the more miles on the car when you turn it in, the less a dealer can sell it for. Most car leases will charge between 12 -20 cents for each mile you drive over a certain limit. Most leases set a cap between 12,000 to 15,000 miles per year.
You’ll need excellent credit Leases require top-notch credit. Although you can get a car loan even with bad credit, that’s not the case with a lease. Wear and tear charges The dealer will charge you at lease end for any excessive “wear and tear”, as defined by them, on the leased car when you turn it in. This means any dents, dings, interior damage, window cracks, etc. could end up costing you more money before they will release you from the lease. It’s not easy to get out of a lease If you buy a car and six months later you can’t afford the payments, you always have the option of selling it. Not so with a lease. It’s difficult, if not impossible, to end a lease. Many people found out just how difficult it was to end a lease early during the height of the pandemic – lease companies are not concerned if you are unemployed or face financial hardship. Negotiating a lease is complicated Understanding how leases are priced is more complicated than understanding a purchase of a car. Lease prices have terminology such as: • Capitalized cost: Similar to the initial price of the vehicle. • Term: The length of the lease. • Mileage allowance: How many miles are included each year. • Money factor: This is the confusing one. The money factor is similar to an interest rate, so the lower, the better. • Residual value: The car’s “value” at the end of the lease. A higher residual value can lower your monthly payment, but make it harder to get out of the lease if you need to. A lower residual value means higher monthly payments but a lower buy-out option at the end. While it’s unusual that it would be a good deal to buy the car you leased when your term is up, a lower residual could make it easier to sell the lease or trade-in the lease mid-term. Insurance and tax The annual insurance cost for a leased car is usually higher than for a purchased car. Also, you still pay the property taxes on a leased vehicle, even though you do not own the car. Aside from the advantage of ownership giving you an asset — even if it’s a depreciating one — clearly there are many variables to take into account.
What Happened in SEPTEMBER of 2000?
Spirit day
September 10, 2000 - The 52nd Annual Primetime Emmy’s were held. Shows with the most nominations in major categories were The Sopranos (10), The West Wing (9), The Practice (9), Everybody Loves Raymond (8), RKO (7), Will & Grace (7), Frasier (6), and Friends (6). The West Wing won nine awards that night, a record for most wins that was broken in 2015 by Game of Thrones, which won 12 awards for its 5th season.
Waterbury
Fairfield
September 15, 2000 - The 2000 Summer Olympics began in Sydney, Australia. The United States would go on to win the most gold (37) and overall medals (93).
Clinics that Opened in SEPTEMBER Naugatuck in 2008 (pictured celebrating an upgrade to a bigger space in 2017)
Southbury in 2014 (pictured in their ugly sweaters from 2019)
Next Month
CRAZY SOCK DAY - Friday, September 18th Show your PTSMC spirit by wearing your craziest socks!
Fairfield in 2019
PTSMC UPDATES! Mike McGowan, Windsor Physical Therapist, welcomed baby boy, Quinton McGowan on August 1st. He was born at 7 lbs, 6 oz and 21.5 inches long.
Matt Baronowski, Avon Physical Therapist, proposed to his girlfriend Becca in Portsmouth, NH.
New Milford
SoCIAl Media Sensation Mary Clark, New Haven Physical Therapist
Mary Clark (left), PT, M. Ed, LMT, New Haven Physical Therapist and Women’s Health Specialist, visited the Well for Women back in February (before social distancing). The Well, one of our community partners, provides a "sanctuary for women from all over Connecticut," offering massage, yoga and group support, specializing in services for pre-and-post-pregnant women and seniors. Mary and the founder, Julie Robbins (right), filmed a collaborative video explaining how their services are an excellent complement to physical therapy for women’s health and pre-and-post-natal care. View the video on our Facebook page at www.facebook.com/ptsmc.
Video Call Etiquette Remote video calls are now normal and expected in everyone’s lives personally and professionally. Here are a few tips for a positive and professional video call experience. 1. Environment: a. Find a quiet place to minimize interruptions b. Turn your cellphone on to silent, or leave elsewhere for limited distraction c. Mute your microphone when you’re just listening in case of dogs barking, landscaping noises, sirens, etc. d. Use a headset/headphones if you have them 2. Background: a. Minimize what can be seen – less is more! b. A mixture of natural and artificial light looks best, coming from behind the camera, projecting on to you c. Avoid being back lit by bright lights or windows, this will make you difficult to see 3. Camera: a. If the presenter’s camera is on, turn yours on too! Who wouldn’t want to see your smiling face? b. Be aware of body placement within camera frame – don’t be too far or get too close; show just your chest, shoulders and face c. Place your device on a flat surface so camera is level, and be sure your device is not tilted too much 4. Professionalism a. Download the meeting platform before the scheduled call. Be on time! b. Dress in work appropriate attire from waist up c. In the unlikely event that you need to excuse yourself from the meeting, utilize chat feature, mute volume & turn off camera
#GetMoving
a Festive Fall Challenge
Leaves crunching, pumpkin spice smelling, apple picking... too much? NEVER! Fall is just around the corner and we couldn’t be more excited! Finally, some weather we can breathe in, stay outdoors without dripping with sweat, and you guessed it - #GETMOVING.
October is one of the best times of the year to get moving. The cooler weather makes for a much more comfortable experience being active outside, which means fun and festive activities that get you off of Netflix...that is, unless you’re watching Halloween Town and Hocus Pocus. In other words, there is no better time for a #GetMoving challenge! This time around there will be other festive “wellness challenges” intertwined with the usual fitness challenges. Staying healthy is not only about physical activity, after all! Not only are we encouraging getting your body moving, there will also be challenges that focus on nutrition, hydration, nature, coming together in the virtual world, and of course, fun! This challenge runs for 4 weeks: Sunday, October 4th – Saturday, October 31st. The Challenge: Be active for 30+ minutes for 16 of the 28 days and you will earn a reward. Hungry for a bigger challenge? Achieve 24+ days of activity and you’ll earn the “next level prize!” There will be opportunities to earn extra points on bonus days, and they are as easy as participating in weekend fall-themed challenges - no burpees required, flannel shirts and hot apple cider recommended. Once again, we will be using the Slack app to submit activities and support each other over the four weeks. Each DAY you #GetMoving, post your activity in the group and it will count towards your running total. Your post can include a picture of your activity, you, your watch, your view, your dog, or a description without a picture. Other participants will be able to see your post on the app, like the post and offer some additional support. No one outside of the group will see your posts. The Slack group will also be where you get the latest challenge information, updates, and fun activities. How to sign up: email Mallory at the PTSMC Wellness Program email, Wellness@ptsmc.com. Sign-ups will run through October 3rd. Once the group is established there will be an email sent out with more detailed instructions for participants. We can’t wait for all things Fall, and of course, to #GetMoving together!
PTSMC is proud to support Healing Meals!
For the 3rd year in a row, PTSMC employees will be participating in the Eversource Hartford Marathon races to raise money for Healing Meals Community Project. Healing Meals is a non-profit that prepares and delivers delicious, organic meals to families dealing with a health crisis. This year, they have also been delivering meals to healthcare workers treating COVID-19. There are two ways to help!
1. Register to run, walk, or bike one of the virtual Hartford Marathon Races (marathon, half marathon, 10k, 5k) and fundraise for Healing Meals. 2. Donate to Healing Meals fundraising campaign. To learn more, register or donate, visit www.ptsmc.com/fundraiser.
Orthopaedic Residency Program PICO Project: Upper Extremity Mike Krukiel and Tom Kirsch Over each 3-month semester the residents complete a PICO Project- one for each area of the body. PICO is a format used in evidence-based practice to answer a question regarding intervention or clinical question using an extensive literature search. PICO stands for Patient/Problem, Intervention, Comparison, Outcome would like to measure or achieve. Here is their research and findings from the latest semester, Upper Extremity.
Question: Is early range of motion following rotator cuff surgery more optimal than delayed range of motion for improving range of motion, quality of life, and return to PLOF? P: Any person, regardless of age, that underwent arthroscopic rotator cuff repair surgery of any size I: Initiation of early ROM following RTC surgery C: Delayed ROM following RTC surgery O: We performed a thorough literature search in order to determine the most optimal timing for initiation of physical therapy and ROM training in patients post op RTC surgery. We used a computer assisted literature search that was conducted via Pubmed and CINHAL databases using various key terms relating to physical therapy, rotator cuff repair, and delayed or immediate ROM. During our review we located multiple systematic reviews, some with meta-analysis that reviewed RCTs comparing various start times of physical therapy and ROM training in patients after RTC surgery. Currently, there is no consensus on the optimal timing for immobilization, initiation of rehab, and beginning ROM. Most of the time it seems that current protocols are prescribed by surgeon experience and expert opinion rather than tissue healing properties and scientific rationale. The current issue is that we have not come to an agreement on the proper amount of time to protect the RTC repair while still avoiding creating excessive stiffness of possible adhesive capsulitis due to prolonged immobilization. Therefore, our goal is to perform a thorough literature review in order to determine what the evidence says about timing for initiation of PROM and rehab for post-operative rotator cuff patients. Kluczynski et al. performed meta-analysis and systematic review of RCTs level that directly compared RC healing early versus delayed PROM after repair, along with level 1-4 RCTs that did not directly compare early versus delayed but still met inclusion criteria. The inclusion criteria included full RC tears, post op rehab described in detail, and healing assessed 1 year post op using MRI, US, arthrogram, or combination of imaging techniques. The early mobilization group was defined at 1-3 weeks after surgery, while the delayed group was defined as initiating PROM at 3-6 weeks. This review did not look at function, QOL, or ROM, however, strictly looked at the tendon healing. The results of the first analysis looking at level 1 RCTs that directly compared early versus delayed PROM after RCT showed no significant
differences between groups; 13.7% retear rates in early group versus 10.5% in delayed group with 182 repairs in early group and 171 in delayed group. In the second analysis, they broke up the results in each study to group the results into tear size and type of surgery. They found no significant differences overall when looking at the data, however, when breaking it down by size of tear and surgical approach, they found some significant differences. For tears less than 3cm with use of transosseous with single row suture, retear rates were lower in the early group versus delayed. However, for tears greater than 5cm, using double row suture anchor, risk of retear rate was greater in the early mobilization group. Therefore, we can be more confident that there is minimal evidence to show that early mobilization has a greater risk for retear rates, except some evidence showing that larger tears may benefit from a more delayed approach, but further research is warranted. Gallagher et al. performed a systematic review of the literature to identify level 1 and 2 evidence that directly compared early versus delayed rehabilitation following arthroscopic rotator cuff repair; inclusion criteria included level 1 and 2 studies, at least 6 months of clinical follow up, direct comparison early versus delayed rehab, and use of clinical and radiographic measures to quantify healing. Outcome measures included constant shoulder score, simple shoulder test, ASES, DASH, and anatomic outcomes including rotator cuff healing using CT, MRI, or US. Gallagher et al. found that there were no significant differences in retear rates when comparing early versus delayed rehab after arthroscopic repair. For ROM, all studies, other than 1, observed at least 1 dimension of significant increased ROM in early versus delayed PROM within the first 3-6 months. However, only 1 article found significant difference when observing 12 month follow up. No significant differences were found for functional outcome measures or
pain long term; however, a couple of studies found some significant difference favoring the early rehabilitation group for pain and function early on in rehab between 3-6 months post op. Overall, this review showed that at 1 year follow up, there was not a significant difference in outcomes for early versus delayed rehab. The only difference seems to be at the 3-6 month mark for ROM, function and pain levels seem to be lower in the early rehab group. A 2017 systematic review of meta analyses by Saltzman et al. aimed to compare early-motion and delayed-motion rehabilitation protocols after arthroscopic rotator cuff repair to determine the comparative efficacy on patient outcomes. Inclusion criteria being any meta analyses that compared the outcomes of arthroscopic rotator cuff repair with early postoperative motion vs. delayed postoperative motion protocols. Their review included 6 level II, 2 level I, and 1 level IV meta analyses. There was variability in the way the included meta analyses determined the cutoff of early motion or delayed motion. Early motion was considered when AROM started within 6 weeks from date of surgery or when PROM with a range of 1 to 3 weeks. Delayed motion was considered when AROM/PROM began after more 3-6 weeks from date of surgery. Saltzman et al. found that there was no clear superiority in clinical outcomes scores between the two timeframes. Tendon healing results were found to be either no different or in favor of delayed motion but no difference was noted in rotator cuff retear rates postoperatively. Several of the included meta analyses included subgroup analyses which suggested that larger preoperative tear sizes have significantly greater retear rates with early-motion rehabilitation. Further investigation into exactly which tear types and sizes put the patient at greatest risk for retear is warranted. Which may begin with closer attention to the repair technique for larger tears, as repair methods might influence the association between postoperative rehabilitation and repair integrity. The majority of meta-analyses found significantly better range of motion with early motion up to a year postoperatively for forward elevation and up to 6 months for external rotation, but significant differences were not reported for functional improvements and strength at 12 months postoperatively. Overall Saltzman et al. stated that the highest level of evidence suggests that early motion rehabilitation after rotator cuff repair results in superior postoperative ROM for up to 1 year, however, functional outcomes and retear rates may be comparable, however, it is important to remember that there is a lack of uniformity in rehabilitation protocols for both groups and heterogeneity in the definitions of early and delayed motion may affect outcomes. Another 2017 systematic review by Houck et al. aimed to compare early vs. delayed motion rehabilitation protocols after rotator cuff repair to determine which meta analyses provide the best available evidence. This review included 7 meta-analyses; 1 level I, 4 level II, and 2 level III. Inclusion criteria consisted of meta analyses that compared early passive motion and delayed motion rehabilitation protocols. Early passive motion was clearly defined as shoulder ROM exercises beginning within postoperative days 1-7 and delayed motion was defined as immobilization for 4-6 weeks barring pendulum exercises. ROM and tendon healing were the most commonly analyzed outcomes across all studies.
The authors’ hypothesis that early motion rehabilitation would increase ROM was supported however, many of the studies concluded that the risk of retear was much more prominent with early motion and that better healing rate was demonstrated with the delayed motion protocol. No studies found immobilization to be superior to early motion, however, most studies suggested that early motion would increase ROM and therefore reduce recovery time. Three of the studies suggested that tear size contributed to the choice of rehabilitation to ensure proper healing of the shoulder. The authors mention several case series that have shown good outcomes with delayed motion rehabilitation for repair of large tears, but high-quality studies do not exist to compare rehabilitation protocols in these patients. Further studies are needed to determine the optimal timing of PROM after rotator cuff repair due to lack of a confident conclusion of the included meta analyses. Overall, they concluded that the best available evidence suggests that early motion improves ROM after rotator cuff repair but increases the risk of rotator cuff retear. Several lower quality meta analyses indicated that tear size may be a critical factor and dependent variable for determining success with either early or delayed motion after a rotator cuff repair and this does warrant further, more detailed research. Based on the evidence we have portrayed, there is not enough evidence to support a significant difference between immediate or delayed physical therapy when looking at the long term effects. Retear rates also do not seem to be significantly different for delayed vs immediate ROM. Although, some research supports that in larger tears it may be beneficial to delay ROM to reduce retear rates. Current evidence shows that in the long term, greater than 1 year, there is not a significant difference in ROM, function, or QOL based on the initiation of rehab; immediately or delayed. Therefore, until more research is performed to determine the most optimal time to initiate ROM training, it is important to form a therapeutic alliance with the patient and work together to determine which course of action is preferred by the patient, as both early and delayed have similar long term outcomes. References: Gallagher, B. P., Bishop, M. E., Tjoumakaris, F. P., & Freedman, K. B. (2015). Early versus delayed rehabilitation following arthroscopic rotator cuff repair: A systematic review. Physician and Sportsmedicine, 43(2), 178–187. https://doi.org/10.1080/00913847.2015.1025683 Houck, D. A., Kraeutler, M. J., Schuette, H. B., McCarty, E. C., & Bravman, J. T. (2017). Early Versus Delayed Motion after Rotator Cuff Repair: A Systematic Review of Overlapping Meta-analyses. American Journal of Sports Medicine, 45(12), 2911–2915. https://doi.org/10.1177/0363546517692543 Kluczynski, M. A., Nayyar, S., Marzo, J. M., & Bisson, L. J. (2015). Early Versus Delayed Passive Range of Motion after Rotator Cuff Repair: A Systematic Review and Meta-analysis. American Journal of Sports Medicine, 43(8), 2057–2063. https://doi.org/10.1177/0363546514552802 Saltzman, B. M., Zuke, W. A., Go, B., Mascarenhas, R., Verma, N. N., Cole, B. J., … Forsythe, B. (2017). Does early motion lead to a higher failure rate or better outcomes after arthroscopic rotator cuff repair? A systematic review of overlapping meta-analyses. Journal of Shoulder and Elbow Surgery, 26(9), 1681–1691. https://doi.org/10.1016/j.jse.2017.04.004