Shoulders to Shoulder: Need for shared decision making in rotator cuff treatment!   June 18th, 2018

​Although evidence on psychosocial factors affecting the prognosis after rotator cuff repairs is scarce, a recent systematic review (Coronado et al., 2018) reported that preoperative patient expectationis an important predictorof patient-reported outcomes in patients after rotator cuff surgery. Furthermore, it reported that preoperative patient expectation may be a modifiable target for enhancing recovery.Greater preoperative expectations are consistently and independently associated with significantly better performance on multiple outcomes after rotator cuff repair. Whereas factors such as tear size, and repair technique were not significant predictors (Henn et al., 2007). 

These results seem obvious, considering the evidence existing in other musculoskeletal problems. But do we take expectations sufficiently into accountin research and in clinical practice? These findings provide substantial evidence that patients’ expectations are an important factor to target, both for expectations regarding conservative as well as surgical treatments.

The United Kingdom Rotator Cuff Tear Trial was a multi-centred three-way parallel group randomised trial comparing arthroscopic rotator cuff repair surgery versus open/mini-open rotator cuff repair surgery versus Rest then Exercise (RtE = not physiotherapy and not involving face-to-face communication with a therapist) for rotator cuff tears of the shoulder (Carr et al., 2014). The trial was halted because only 17% of the patients allocated to the RtE group remained in their initial group and 77% of the group crossed over to the surgery group during or after completing the RtE treatment (Carr et al., 2017). 

From qualitative analyses, it seemed that three factors were of influencein the decision to switch to surgical treatment (Minns et al., 2018).

1)Impact of symptoms and diagnosis: Long duration of severe pain and prior failed conservative treatment.

2)Perceptions and expectations of treatment: RtE was often experienced negatively because of prior failure or lack of time to rest and patients felt the tendon should be fixed. Surgeons were perceived to believe “tears need repairing”.

3)Professional communication: Patients reported varying views in the decision making, going from no joint-decision up to good communication explaining the role of the rotator cuff.

These results highlight the importance to strive for “Equipoise”, meaning the treatments under comparison should have equal value and acceptability. However, both patients and clinicians often have strong treatment preferences. This makes it extremely difficult for clinicians, patients and researchers in trials and underlines the limitation that trials most often are not designed for personalized care. 

For clinical purposes it is clear that shared-decision makingis extremely important. To achieve aligned agreement on the treatment plan (e.g. yes to surgery), the communication stylefrom the caregiver towards the patient, represents a key element. In a recent study by Lawrence et al. (Lawrence et al., 2017), where preoperative counselling by the surgeon was tested whether or not it changed the patients’ expectations for shoulder surgery, no alteration on expectations could be detected. The question remained whether the type of information transformation or the content was the cause for these results. It is found that patients have trouble to recall the content of such a counselling session, even right after the dialogue. Furthermore, they seem to seek information from the internet and shape their expectations and believes respectively. Interestingly, patients felt better informed after preoperative counselling if multimedia tools were involved, even if the content remained the same. 

Furthermore, the content of preoperative counselling sessions in clinics may be strongly based on the biomechanical modelfor shoulder pain and dysfunction, where anatomy and rotator cuff function are mainly addressed. Yet, different studies have highlighted a lack of a relation between structural damage and clinical picture and the authors pointed out, that outcome after surgery does not (Carr et al., 2017) or only moderately (Raman et al., 2017) relate to the size of tear, or surgery technique etc. There are structural predictors for poor outcome after rotator cuff repair e.g. muscle quality like fatty infiltration (Raman et al., 2017), yet again there is evidence that function does not necessarily relate to cuff integrity. As it is shown that patients, who re-tore after surgery still achieved functional improvement of their shoulder (Carr et al., 2017). Correspondingly all this evidence highlights the role of non-specific therapeutic factors

The alignment of preoperative expectationsbetween patients and caregivers needs to be better understood and looked at. Communication style, multimedia involvement and educational content shape the patients’ perspectives. Therefore, we need to “put our shoulders to the” development of interventions which support shared decision-making and align the expectations of caregivers and patients. With this aim, clearer and more comprehensive insight in pain mechanisms, pain drivers and maintainers of rotator cuff problems is required for patients and caregivers. We strive to move together, shoulder to shoulder, to an informed consent.

Ariane Schwank & Mira Meeus

Ariane is a Swiss physiotherapist holding a Master Degree from the University of Melbourne, Australia. She is a clinical specialist for upper limb and works at Kantonsspital Winterthur (Zurich), where she sees mainly shoulder patients. Combining now her work as clinical specialist in the hospital with scientific activities as a PhD student at the University of Antwerp. She is involved in the European Society for Shoulder and Elbow Rehab (EUSSER), as well as the network “Physiotherapie experten Schulter/Ellbogen”.

Mira is professor at the University of Antwerp and Ghent, in the departments of Rehabilitation Sciences and Physiotherapy and focusses her research on unravelling and targeting central pain processing in different chronic pain populations.

2018 Pain in Motion

References and further reading

Coronado RA, Seitz AL, Pelote E, Archer KR, Jain NB. Are Psychosocial Factors Associated With Patient-reported Outcome Measures in Patients With Rotator Cuff Tears? A Systematic Review. Clin Orthop Relat Res. 2018 Apr;476(4):810-829.

Henn RF, Kang L, Tashjian RZ, Green A. Patients' preoperative expectations predict the outcome of rotator cuff repair. J Bone Joint Surg Am. 2007 Sep;89(9):1913-9.

Carr AJ, Rees JL, Ramsay CRR, Fitzpatrick R, Gray A, Moser J, et al. Protocol for the United Kingdom rotator cuff study (UKUFF) a randomised controlled trial of open and arthro-scopic rotator cuff repair. Bone Joint Res 2014;3(May(5)):155–60.

Carr A, Cooper C, Campbell MK, Rees J, Moser J, Beard DJ, Fitzpatrick R, Gray A, Dawson J, Murphy J, Bruhn H, Cooper D, Ramsay C. Effectiveness of open and arthroscopic rotator cuff repair (UKUFF): a randomised controlled trial. Bone Joint J. 2017 Jan;99-B(1):107-115.

Minns Lowe CJ, Moser J, Barker KL. Why participants in The United Kingdom Rotator Cuff Tear (UKUFF) trial did not remain in their allocated treatment arm: a qualitative study. Physiotherapy. 2018: in press.

Carr A, Cooper C, Campbell MK, Rees J, Moser J, Beard DJ, Fitzpatrick R, Gray A, Dawson J, Murphy J, Bruhn H, Cooper D, Ramsay C. Effectiveness of open and arthroscopic rotator cuff repair (UKUFF): a randomised controlled trial. Bone Joint J. 2017 Jan;99-B(1):107-115.

Lawrence, C., Zmistowski, B. M., Lazarus, M., Abboud, J., Williams, G., & Namdari, S. (2017). Expectations of Shoulder Surgery are not Altered by Surgeon Counseling of the Patient. Joints5(3), 133.

Raman, J., Walton, D., MacDermid, J. C., & Athwal, G. S. (2017). Predictors of outcomes after rotator cuff repair—A meta-analysis. Journal of Hand Therapy30(3), 276-292.