Telerehabilitation in Individuals With Rotator Cuff Tear

The majority of patients presenting with shoulder pain are those with rotator cuff problems. Although telerehabilitation is a promising field in many areas, there is still limited high-quality research with strong evidence of its effectiveness for musculoskeletal problems. In this study, online rehabilitation and face-to-face rehabilitation will be compared in people with partial rotator cuff tears.

The prevalence of shoulder pain increases with age and is mostly associated with inadequate treatment of symptoms. A large part of the patients who apply to the clinic with the complaint of shoulder pain are individuals with rotator cuff problems. Partial rotator cuff (RM) tear is defined as tears that can be seen on the superior, inferior, or both sides of the cuff. It is stated that the most critical risk factors for RM tear are age, dominant arm, and trauma. The degenerative process is generally considered normal in age-related tears and is seen in 20% of individuals over the age of 65. The Coronavirus disease (COVID-19), is still the most important global concern. People with chronic diseases have been known to delay getting healthcare services due to fear of the risk of infection following the COVID-19 pandemic. This could lead to increased morbidity and mortality due to delay and disruption in access to treatment applications needed for patient populations other than COVID-19. At this stage, one of the applications that can be effective for disturbed patient healing processes is the Telerehabilitation application, which has proven its effectiveness in previous epidemics (EBOLA, SARS, etc.), when patients are treated remotely after and after treatment. Especially during the COVID-19 pandemic, there has been an increase in the need for Internet-based remote treatment approaches, as it allows both patients and physiotherapists to advance the treatment process without the risk of infection. In the next decade, telerehabilitation options are expected to diversify and become widespread in assessing and treating many diseases with emerging technologies. Studies have shown that despite the growing number of applications of telerehabilitation worldwide, evidence for clinical effectiveness is still limited. In addition, the effectiveness of telerehabilitation for musculoskeletal problems has not been fully demonstrated due to the lack of a specific standard for telerehabilitation and the variability of the approaches used. In conclusion, although telerehabilitation is a promising field in many areas, there is still a limited amount of good-quality research with strong evidence. Therefore, this study aimed to compare the effects of internet-based telerehabilitation and face-to-face rehabilitation practices on pain, range of motion, functionality, and quality of life in patients with partial rotator cuff injury.

Study groups will be randomized by Researcher 3 using the Research Randomizer (https://www.randomizer.org). Researcher 1 will be blinded when selecting a treatment group. Rehabilitation practices for both groups will be conducted by the Researcher 1 and outcome evaluation will be conducted by the Researcher 2. The Researcher 2 will not know which group the data of the patient he/she is evaluating belongs to.

The treatments of the participants who meet the inclusion criteria in the study will be conducted remotely via instant video communication. The Specialist Physiotherapist will apply the necessary exercises, verbal guidance or repetition of the movements shown, according to the patient's condition, synchronized via instant video and audio calls (Whatsapp or Zoom).

The treatments of the participants that meet the inclusion criteria of the study will be administered by Specialist Physiotherapist. The progress of the patients will be regularly followed up on a weekly basis, and treatments will be applied in accordance with the program in rehabilitation.

Week 1 Posterior capsule stretching Passive range of motion Wand exercises in supine position Scapular adduction exercise Ball rolling on the table (<90°) Coldpack (15min) Week 2 Wand exercises while standing. Ball roll on wall (>90°) Ball roll on the table (90°) Weightless External Rotation exercises Functional PNF movements Week 3 Resistive scapulothoracic strengthening Ball scrolling on the table (resistive) Week 4 Single handed ball roll on the table (>90°) External rotation exercise with 0.5-1kg weight in side lying Strengthening exercises, shoulder in 90° scapulation for 10s Week 5 External rotation with 0.5-1 kg weight in side lying Strengthening exercises by keeping the shoulder in 90° scapulation for 10s Week 6-8 Dynamic hugs and push up plus Ball throwing and catching

Week 1 Posterior capsule stretching Passive range of motion Wand exercises in supine position Scapular adduction exercise Ball rolling on the table (<90°) Coldpack (15min) Week 2 Wand exercises while standing. Ball roll on wall (>90°) Ball roll on the table (90°) Weightless External Rotation exercises Functional PNF movements Week 3 Resistive scapulothoracic strengthening Ball scrolling on the table (resistive) Week 4 Single handed ball roll on the table (>90°) External rotation exercise with 0.5-1kg weight in side lying Strengthening exercises, shoulder in 90° scapulation for 10s Week 5 External rotation with 0.5-1 kg weight in side lying Strengthening exercises by keeping the shoulder in 90° scapulation for 10s Week 6-8 Dynamic hugs and push up plus Ball throwing and catching

Patients' pain levels at rest, during activity, and at night will be assessed using a Visual Analog Scale (VAS). The score is determined by measuring the distance (mm) on a 10 cm line between the "no pain" anchor and the patient's mark, providing a score range of 0 to 100. A higher score indicates greater pain intensity.

The range of motion values of the participants will be recorded using the universal goniometer, which is an objective tool used in clinical range of motion measurement.The flexion, scapular abduction, internal and external rotation values of the shoulder joint will be measured in the supine position with a universal goniometer in accordance with the procedure in the literature.

Delsys Biometrics Datalite WS450, a surface EMG system, will be used to evaluate the function of the shoulder muscles. Previous studies and the website of the SENIAM project of the European Union Biomedical Health and Research Program (http://www.seniam.org/) will be accepted as reference.

Hand, Shoulder and Hand Disability Questionaire will be used to assess the functional state of the participants. The possible score ranges from 0 to 100 points. 0 points represent full unrestricted upper limb function and 100 points represent the maximum possible functional impairment.

The ASES section on patient self-reports is a condition-specific scale, i.e. it is for a specific condition that is intended to measure functional limitation and shoulder pain. The total pain score and the functional score are equally weighted (50 points each) and are combined to obtain a total score out of a possible 100 points.

The Modified Constant-Murley Scale is widely used to assess disability associated with shoulder injuries, but has been criticized for its use of inaccurate terminology and the lack of a standardized methodology. The Constant-Murley score (CMS) is a 100-points scale composed of a number of individual parameters. The higher the score, the higher the quality of the function.

Short Form-12 will be used to assess quality of life related to physical and mental health. Two summary scores are reported from the SF-12 - a mental component score (MCS-12) and a physical component score (PCS-12). SF-12 PCS mean scores ranged between 48.3 and 49.2, and SF-12 MCS mean scores ranged between 48.0 and 49.6.

The satisfaction levels of the participants will be assessed using the Global Change Scale. Subjects are asked to rate their post-treatment status on a 5-point scale (-2: I am much worse, -1: I am worse, 0: I am the same, 1: I am better, 2: I am much better). A high score is considered a sign of high satisfaction.

Participants' levels of anxiety and depression will be assessed using the Hospital Anxiety and Depression Scale. The Hospital Anxiety and Depression Scale is a self-report rating scale of 14 items on a 4-point Likert scale (range 0-3). It is designed to measure anxiety and depression (7 items for each subscale). The total score is the sum of the 14 items, and for each subscale the score is the sum of the respective seven items (ranging from 0-21); 0-7 (Normal) 8-10 (Mild) 11-15 (Moderate) 16-21 (Severe).

Inclusion Criteria: Presence of bursal facial tear 1 cm below the tear degree; presence of complaints of shoulder pain lasting for a minimum of 1 and a maximum of 6 months; having been diagnosed with partial rotator cuff tear by an orthopedist who is an expert in the field; no shoulder instability; inadequate response to non-operative treatment (corticosteroid injection, anti-inflammatory drugs, rest and physiotherapy and rehabilitation); not using corticosteroid drug; being between the ages of 18-60; to have sufficient knowledge, skills and technological tools to access the Tele-Rehabilitation application. Exclusion Criteria: Presence of malignancy affecting the shoulder region; disc herniations that may cause shoulder pain; individuals with inflammatory joint disease; osteoarthritis of the humeral head; history of surgery affecting the shoulder; inability of the patient to cooperate; systemic problems that cannot be controlled with medication.

Agostini M, Moja L, Banzi R, Pistotti V, Tonin P, Venneri A, Turolla A. Telerehabilitation and recovery of motor function: a systematic review and meta-analysis. J Telemed Telecare. 2015 Jun;21(4):202-13. doi: 10.1177/1357633X15572201. Epub 2015 Feb 22.

Ainsworth R, Lewis JS. Exercise therapy for the conservative management of full thickness tears of the rotator cuff: a systematic review. Br J Sports Med. 2007 Apr;41(4):200-10. doi: 10.1136/bjsm.2006.032524. Epub 2007 Jan 30.

Assad-Uz-Zaman, M., Islam, M. R., Rahman, M. H., Wang, Y. C., & McGonigle, E.. Kinect controlled NAO robot for telerehabilitation. Journal of Intelligent Systems, 20213; 0(1), 224-239.

Berton A, Longo UG, Candela V, Fioravanti S, Giannone L, Arcangeli V, Alciati V, Berton C, Facchinetti G, Marchetti A, Schena E, De Marinis MG, Denaro V. Virtual Reality, Augmented Reality, Gamification, and Telerehabilitation: Psychological Impact on Orthopedic Patients' Rehabilitation. J Clin Med. 2020 Aug 7;9(8):2567. doi: 10.3390/jcm9082567.

Boykin, R. E., Heuer, H. J., Vaishnav, S., & Millett, P. J. Rotator cuff disease-basics of diagnosis and treatment. Rheumatology Reports, 2010; 2(1), e1-e1.

Carlsson AM. Assessment of chronic pain. I. Aspects of the reliability and validity of the visual analogue scale. Pain. 1983 May;16(1):87-101. doi: 10.1016/0304-3959(83)90088-X.

Contreras CM, Metzger GA, Beane JD, Dedhia PH, Ejaz A, Pawlik TM. Telemedicine: Patient-Provider Clinical Engagement During the COVID-19 Pandemic and Beyond. J Gastrointest Surg. 2020 Jul;24(7):1692-1697. doi: 10.1007/s11605-020-04623-5. Epub 2020 May 8.

Celik D. Turkish version of the modified Constant-Murley score and standardized test protocol: reliability and validity. Acta Orthop Traumatol Turc. 2016;50(1):69-75. doi: 10.3944/AOTT.2016.14.0354.

Celik D, Atalar AC, Demirhan M, Dirican A. Translation, cultural adaptation, validity and reliability of the Turkish ASES questionnaire. Knee Surg Sports Traumatol Arthrosc. 2013 Sep;21(9):2184-9. doi: 10.1007/s00167-012-2183-3. Epub 2012 Aug 30.

Danhieux K, Buffel V, Pairon A, Benkheil A, Remmen R, Wouters E, van Olmen J. The impact of COVID-19 on chronic care according to providers: a qualitative study among primary care practices in Belgium. BMC Fam Pract. 2020 Dec 5;21(1):255. doi: 10.1186/s12875-020-01326-3.

Diercks R, Bron C, Dorrestijn O, Meskers C, Naber R, de Ruiter T, Willems J, Winters J, van der Woude HJ; Dutch Orthopaedic Association. Guideline for diagnosis and treatment of subacromial pain syndrome: a multidisciplinary review by the Dutch Orthopaedic Association. Acta Orthop. 2014 Jun;85(3):314-22. doi: 10.3109/17453674.2014.920991. Epub 2014 May 21.

Dominguez-Romero JG, Jimenez-Rejano JJ, Ridao-Fernandez C, Chamorro-Moriana G. Exercise-Based Muscle Development Programmes and Their Effectiveness in the Functional Recovery of Rotator Cuff Tendinopathy: A Systematic Review. Diagnostics (Basel). 2021 Mar 16;11(3):529. doi: 10.3390/diagnostics11030529.

Düger, T., Yakut, E., Öksüz, Ç., Yörükan, S., Bilgütay, B. S., Ayhan, Ç., . . . Yakut, Y. (2006). Kol, omuz ve el sorunları (disabilities of the arm, shoulder and hand-DASH) anketi Türkçe uyarlamasının güvenirliği ve geçerliği. Fizyoterapi Rehabilitasyon, 17(3), 99-107.

Edwards P, Ebert J, Joss B, Bhabra G, Ackland T, Wang A. EXERCISE REHABILITATION IN THE NON-OPERATIVE MANAGEMENT OF ROTATOR CUFF TEARS: A REVIEW OF THE LITERATURE. Int J Sports Phys Ther. 2016 Apr;11(2):279-301.

Edwards PK, Ebert JR, Littlewood C, Ackland T, Wang A. A Systematic Review of Electromyography Studies in Normal Shoulders to Inform Postoperative Rehabilitation Following Rotator Cuff Repair. J Orthop Sports Phys Ther. 2017 Dec;47(12):931-944. doi: 10.2519/jospt.2017.7271. Epub 2017 Jul 13.

Erdfelder, E., Faul, F., & Buchner, A. GPOWER: A general power analysis program. Behavior Research Methods, Instruments, & Computers, 1996; 28(1), 1-11. doi:10.3758/BF03203630

Franchignoni F, Vercelli S, Giordano A, Sartorio F, Bravini E, Ferriero G. Minimal clinically important difference of the disabilities of the arm, shoulder and hand outcome measure (DASH) and its shortened version (QuickDASH). J Orthop Sports Phys Ther. 2014 Jan;44(1):30-9. doi: 10.2519/jospt.2014.4893. Epub 2013 Oct 30.

Gava V, Ribeiro LP, Barreto RPG, Camargo PR. Effectiveness of physical therapy given by telerehabilitation on pain and disability of individuals with shoulder pain: A systematic review. Clin Rehabil. 2022 Jun;36(6):715-725. doi: 10.1177/02692155221083496. Epub 2022 Mar 1.

Hailey D, Roine R, Ohinmaa A, Dennett L. Evidence of benefit from telerehabilitation in routine care: a systematic review. J Telemed Telecare. 2011;17(6):281-7. doi: 10.1258/jtt.2011.101208. Epub 2011 Aug 15.

Hill CL, Gill TK, Shanahan EM, Taylor AW. Prevalence and correlates of shoulder pain and stiffness in a population-based study: the North West Adelaide Health Study. Int J Rheum Dis. 2010 Aug;13(3):215-22. doi: 10.1111/j.1756-185X.2010.01475.x.

Holmgren T, Hallgren HB, Oberg B, Adolfsson L, Johansson K. Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomised controlled study. Br J Sports Med. 2014 Oct;48(19):1456-7. doi: 10.1136/bjsports-2014-e787rep.

Itoi E, Tabata S. Conservative treatment of rotator cuff tears. Clin Orthop Relat Res. 1992 Feb;(275):165-73.

Kamper SJ, Maher CG, Mackay G. Global rating of change scales: a review of strengths and weaknesses and considerations for design. J Man Manip Ther. 2009;17(3):163-70. doi: 10.1179/jmt.2009.17.3.163.

Katz, N. B., & Tenforde, A. S. Telerehabilitation for Musculoskeletal Injuries. In Telerehabilitation 2022; (pp. 197-212). Elsevier.

Koçyiğit, H., Aydemir, Ö., Fişek, G., Ölmez, N., & Memiş, A. K. Form-36 (KF-36)'nın Türkçe versiyonunun güvenilirliği ve geçerliliği. Ilaç ve tedavi dergisi, 1999; 12(2), 102-106.

Michener LA, McClure PW, Karduna AR. Anatomical and biomechanical mechanisms of subacromial impingement syndrome. Clin Biomech (Bristol, Avon). 2003 Jun;18(5):369-79. doi: 10.1016/s0268-0033(03)00047-0.

Ohannessian R, Duong TA, Odone A. Global Telemedicine Implementation and Integration Within Health Systems to Fight the COVID-19 Pandemic: A Call to Action. JMIR Public Health Surveill. 2020 Apr 2;6(2):e18810. doi: 10.2196/18810.

Otman, A. S. Tedavi hareketlerinde temel değerlendirme prensipleri Pelikan yayıncılık. 2014; pp: 66-70

Pallant, J. SPSS survival manual: A step by step guide to data analysis using IBM SPSS. Routledge.2020

Pastora-Bernal JM, Martin-Valero R, Baron-Lopez FJ. Cost analysis of telerehabilitation after arthroscopic subacromial decompression. J Telemed Telecare. 2018 Sep;24(8):553-559. doi: 10.1177/1357633X17723367. Epub 2017 Aug 17.

Pastora-Bernal JM, Martin-Valero R, Baron-Lopez FJ, Estebanez-Perez MJ. Evidence of Benefit of Telerehabitation After Orthopedic Surgery: A Systematic Review. J Med Internet Res. 2017 Apr 28;19(4):e142. doi: 10.2196/jmir.6836.

Powell JK, Schram B, Lewis J, Hing W. Physiotherapists nearly always prescribe exercise for rotator cuff-related shoulder pain; but why? A cross-sectional international survey of physiotherapists. Musculoskeletal Care. 2023 Mar;21(1):253-263. doi: 10.1002/msc.1699. Epub 2022 Sep 11.

Rogante M, Grigioni M, Cordella D, Giacomozzi C. Ten years of telerehabilitation: A literature overview of technologies and clinical applications. NeuroRehabilitation. 2010;27(4):287-304. doi: 10.3233/NRE-2010-0612.

Sgroi TA, Cilenti M. Rotator cuff repair: post-operative rehabilitation concepts. Curr Rev Musculoskelet Med. 2018 Mar;11(1):86-91. doi: 10.1007/s12178-018-9462-7.

Stawicki SP, Jeanmonod R, Miller AC, Paladino L, Gaieski DF, Yaffee AQ, De Wulf A, Grover J, Papadimos TJ, Bloem C, Galwankar SC, Chauhan V, Firstenberg MS, Di Somma S, Jeanmonod D, Garg SM, Tucci V, Anderson HL, Fatimah L, Worlton TJ, Dubhashi SP, Glaze KS, Sinha S, Opara IN, Yellapu V, Kelkar D, El-Menyar A, Krishnan V, Venkataramanaiah S, Leyfman Y, Saoud Al Thani HA, Wb Nanayakkara P, Nanda S, Cioe-Pena E, Sardesai I, Chandra S, Munasinghe A, Dutta V, Dal Ponte ST, Izurieta R, Asensio JA, Garg M. The 2019-2020 Novel Coronavirus (Severe Acute Respiratory Syndrome Coronavirus 2) Pandemic: A Joint American College of Academic International Medicine-World Academic Council of Emergency Medicine Multidisciplinary COVID-19 Working Group Consensus Paper. J Glob Infect Dis. 2020 May 22;12(2):47-93. doi: 10.4103/jgid.jgid_86_20. eCollection 2020 Apr-Jun.

Turolla A, Rossettini G, Viceconti A, Palese A, Geri T. Musculoskeletal Physical Therapy During the COVID-19 Pandemic: Is Telerehabilitation the Answer? Phys Ther. 2020 Aug 12;100(8):1260-1264. doi: 10.1093/ptj/pzaa093. No abstract available.

Turkmen E, Analay Akbaba Y, Altun S. Effectiveness of video-based rehabilitation program on pain, functionality, and quality of life in the treatment of rotator cuff tears: A randomized controlled trial. J Hand Ther. 2020 Jul-Sep;33(3):288-295. doi: 10.1016/j.jht.2019.08.004. Epub 2020 Mar 17.

Wang S, Chapple CM, Quinn D, Tumilty S, Ribeiro DC. Dosage of joint mobilisation for the management of rotator cuff-related shoulder pain: protocol for a scoping review. BMJ Open. 2022 Jun 3;12(6):e056771. doi: 10.1136/bmjopen-2021-056771.

Ware J Jr, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care. 1996 Mar;34(3):220-33. doi: 10.1097/00005650-199603000-00003.

Xie Y, Szeto GP, Dai J, Madeleine P. A comparison of muscle activity in using touchscreen smartphone among young people with and without chronic neck-shoulder pain. Ergonomics. 2016;59(1):61-72. doi: 10.1080/00140139.2015.1056237. Epub 2015 Jul 28.

Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983 Jun;67(6):361-70. doi: 10.1111/j.1600-0447.1983.tb09716.x.