At a 10-Year Follow-up, Tendon Repair Is Superior to Physiotherapy in the Treatment of Small and Medium-Sized Rotator Cuff Tears

At a 10-Year Follow-up, Tendon Repair Is Superior to Physiotherapy in the Treatment of Small and Medium-Sized Rotator Cuff Tears

To repair or not to repair, that is the question. This recent paper by Moosmayer et al (2019) appears to provide some much-needed evidence in relation to this question. The authors of this randomised controlled trial conclude: ‘At 10 years, the differences in outcome between primary tendon repair and physiotherapy for small and medium-sized rotator cuff tears had increased, with better results for primary tendon repair.’

When considering whether to go ahead with a surgical repair of the torn rotator cuff, both clinicians and patients are rightfully mindful of the long-term implications of such a decision. Therefore, this 10-year follow-up study is an important contribution to the evidence base.

However, it can be seductive to think that this study supports the need for rotator cuff repair surgery in people with small to medium-sized rotator cuff tears. As always, the devil is in the detail and it is important to read beyond the headline conclusion reported in the abstract.

There are many points of discussion that this paper raises. But, in this short blog, I will focus on statistical significance versus clinical importance and the confidence interval.

The headline figure from Moosmayer et al (2019) is that there is a statistically significant difference between the two treatment groups (surgery versus physiotherapy) in favour of the surgical group with reference to the primary outcome measure, the Constant score. However, statistical significance tells you nothing about clinical importance. For example, you might have a statistically significant difference of 0.4 points on a visual analogue scale but that difference is not recognizable or meaningful to clinicians or patients. However, with regards to this study, the difference between groups is reported as 9.6 points on the Constant Score and a clinically important difference is 10 points. So, this is close and any critique suggesting this is not relevant based on lacking 0.4 points is open to challenge given the uncertainty around determining clinically important differences.

But, and there is a big but here, the point estimate, i.e. 9.6 points on the Constant Score, does not tell the whole story. When we do research, we recruit a sample of patients rather than the whole population and then we attempt to infer the results from this sample to the wider population. Given that the smaller sample cannot be fully representative of the whole population, e.g. everyone with rotator cuff tears, there is always some uncertainty around the treatment effects observed in the sample. Often we express this uncertainty in terms of confidence intervals, i.e. the range of values In which the true population value lies. So, although the estimate of 9.6 points difference on the Constant Score might represent the sample, it doesn’t necessarily reflect the difference in the population and so we need to express a degree of uncertainty.

Despite current convention, it is interesting to note that Moosmayer et al (2019) do not report such confidence intervals in the abstract. But, when reading the full paper, they are easily accessible in Table IV where the confidence interval is reported as 3.6 to 15.7. This means that in the population of patients with rotator cuff tear, surgical repair is superior to physiotherapy and the difference in clinical outcomes, measured on the Constant Score, might range from 3.6 points (clinically meaningless) to 15.7 points (clinically meaningful).

Where from here? Well, there is still a degree of uncertainty. All thing being equal (and that is open to question), surgery offers superior clinical outcomes to physiotherapy at 10-years as measured by the Constant Score. But, that superiority might not be clinically recognisable to the patient and clinician and any decision to undergo surgery needs to consider the risk, burden, e.g. time off work, and patient preference. So, the clinical discussion might be along the following lines; ‘you have a rotator cuff tear, we have different treatment options including surgical repair, physiotherapy, or we could wait and see. Surgical repair seems to offer better clinical outcomes 10 years after surgery, not so after 1, 2 or 5 years, but the extent of this benefit is unclear. If you do opt for surgery then you need to think about the risk and burden of surgery and whether that is acceptable to you given that the clinical importance of long-term benefits are unclear.

Management of rotator cuff tears remains challenging with much uncertainty. My own view is that we need to be more balanced in reporting such research and remain open to the current uncertainty.

Thanks for making it this far – comments welcome and appreciated.

Chris

My name is Gareth, and despite conventional wisdom, I'm a man trying to do two things at once.

Understanding how to become a clinical academic is not as straight forwards as it should be, unless you know one. I hope this blog can help. My name is Gareth, I’m an MSK physio, and I’m trying to become a clinical academic, and this is how I got ‘here’. Clinically, ‘here’ for me is being 39 years old and one of a dying breed of NHS physio’s. I’m a physio without an acronym. I’m neither an ESP, or an ACP, or an FCP, because ultimately, I want to be a physio. But I want to be a physio with the ability to challenge practice and try to answer some of the many questions I have, and luckily, I’ve stumbled across a way in which I hope I can do that……one day.

I’ve been through the standard clinical journey.

Phase 1 - Knowing nothing

Phase 2 - Immersion in as many paradigms for assessment and treatment as possible.

Phase 3 - Disillusionment with the lack of consistent outcomes and now thankfully,

Phase 4 – some peace with the uncertainty of clinical practice and often equipoise.

This long, expensive journey included numerous courses, lost weekends, a masters, quite a lot of reading; and you know what? It’s been great and I love being a physio despite the uncertainties. I remain jealous of those who have strong opinions, despite the uncertainty surrounding musculoskeletal diagnosis, mechanisms of treatment effects and how to measure them. I know I’d be a rubbish NHS manager and I’ve never wanted to be an ESP (as utilising more invasive treatments in this world of uncertainty doesn’t suit me). What I want to do, is see if I can answer just some of the questions, I have from clinical practice to improve outcomes for patients. It is this desire that has brought me ‘here’, on a pathway to hopefully achieving an NIHR fellowship. The journey so far has been a world of exciting opportunities and challenges that have given me the best years of my 18-year career. If you choose to read on, then do so knowing that this is not a ‘look what I’ve achieved’ kind of blog; and is far more of a ‘I really would like to raise awareness that these amazing opportunities exist for physios like me and Chris Littlewood twisted my arm a little bit’ kind of blog.

In 2014, having been a Band 7 physio for 10 years, I achieved a split clinical / research role which allowed me two days a week, working in the Research and Development team at my NHS Trust. Here I acted as site lead for physio-lead orthopaedic studies (principal investigator) and was provided with training on the practicalities of setting up and running a research trial. This mix of training and on-the-job experience whetted my appetite to start to do my own research. However, finding a vehicle for this ambition is not easy. In 2017, however, I discovered the Health Education England (HEE) funded Masters to Doctorate Bridging Programme (MDBP).

https://www.birminghamhealthpartners.co.uk/education/clinical-academic-careers-programmes/pre-doctoral-bridging-programme/

This competitive internship supports clinicians who wish to become clinical academics via the HEE-NIHR funded Integrated Clinical Academic fellowships (link below).  This internship provided me with 15 hours of taught lectures on a variety of research topics, gave me access to the University library, provided with a network of supportive people with the same ambition as me and most importantly, provided me with the essential academic support I needed in the shape of Dr Chris Littlewood and Dr Seth O’Neill. From this point onwards, despite numerous challenges, I haven’t looked back and I will now be applying for the Clinical Doctoral Research Fellowship in April 2020. A fully salaried 3-year training fellowship which will allow me to develop the skills necessary to become a researcher in my own rite, whilst developing as a clinician and ensuring that my role can be integrated into my department on completion.

https://www.nihr.ac.uk/explore-nihr/academy-programmes/hee-nihr-integrated-clinical-academic-programme.htm

Working with Chris and Seth over the last 18-months has been challenging and rewarding in equal measure. We first constructed a plan back in November 2017. A publication plan to answer questions that will inform a trial that will be part of my fellowship (should I be successful). So far, I’ve published 2 papers as lead author, presented posters at national and international conferences and completed my first platform presentation this year. I’ve got one or two papers in the pipeline and more presentations later this year. I’ve obtained smaller HEE grants which have funded travel, accommodation and training opportunities which have enabled me to collaborate with international experts in my field of interest (Greater Trochanteric Pain Syndrome, if you’re interested..).

The working relationship with my academic supervisors has gone well and has opened more doors for me. It has also enabled me to obtain a 10-month secondment at Keele University to lead on a qualitative research study which is embedded within a pilot RCT.

https://www.keele.ac.uk/racer/

This experience of working in a Clinical Trials Unit, has also been invaluable. The chance to discuss and develop ideas with people from such a range of backgrounds is such a privilege and makes my clinical work even more rewarding. Even better still, I’ve met some great people and enjoyed a beer or two along the way. Its not been without its challenges. There are plenty of hurdles to overcome and juggling of priorities to manage. It’s also hard work; I feel like I’m almost doing a PhD, just to get on another one at times! But it has been really, really rewarding.

If you have got this far then part of you must want to pursue a career as a clinical academic. As you can see, my path has not been conventional. I took a split physio / research role almost 5-years ago now and only now really feel like I have some momentum. It can be challenging and frustrating and you HAVE to grow a thick skin pretty quickly! But there are opportunities out there that will help buy you time and most importantly, help you develop a team (YOUR TEAM IS EVERYTHING!). Once you’ve got those things then doors open and with a fair amount of hard work, you too could be ‘here’ or wherever it is on the clinical-academic pathway you wish to be.

If you’d like to get in touch about any of the above, please feel free. I’m happy to share my experiences; warts ‘n’ all.

My name’s Chris, and I’m an acdemic…

I qualified as a physiotherapist in 1998 and worked for 10 years as a clinician (UK NHS and private sector) before moving in to academia. My interest in research began very early in my training and while working full-time as a clinician I undertook an MSc in Health Services Research between 2003 and 2005. During this period I reached out to other active researchers asking if I could join them and also began writing for publication. This eventually led to a full-time position at a University and a PhD.

But, as I write this blog I have been away from clinical practice for over 10 years. My wife has been saying for a long time, ‘you can’t call yourself a physiotherapist because you don’t treat patients!’ I used to defend that point, but now I am happy to concede that she is right. I am an academic…

Let me explain my transition, my crisis of confidence and now my acceptance. As an academic, my day-to-day job includes identifying useful research questions, collaborating with patients, clinicians, and other academics for this purpose, writing grant applications, securing ethical approval, setting up and monitoring large-scale research studies, preparing reports and publications, presenting at conferences, managing a diverse group of people, and herding cats. There’s a lot more that my day-to-day job involves, including supervising, mentoring, reviewing, assessing, teaching but the reason for me stating these things is to highlight how different my role is now to that of a senior physiotherapist 10 years ago.

I often hear criticism of academics for not understanding the ‘real’ clinical world. I understand the basis for this criticism, but I think one problem is that some of this criticism is based on a lack of understanding of the academic role (yes, yes, I recognise it’s far more complicated than that but this is a blog trying to deal with one aspect of a complex issue).

Let me give you an example. The SPeEDy study (surgery versus physiotherapist-led exercise for traumatic tears of the rotator cuff) was an idea conceived over two years ago. Many clinical physiotherapists would ask me; ‘what about traumatic rotator cuff tears, what should we do with them?’ Then, a patient approached me; ‘I’ve got this problem, here’s my history; what should I do?’ So, as an academic, I looked in to the research literature. I could see that clinical views were strong but there was a real case for uncertainty and a case for further research. I reached out to clinicians (surgeons and physiotherapist), patients, and other academics to develop an application for research funding. Last year this application was funded. We will work with expert clinicians (surgeons and physiotherapists) across eight hospitals in the UK. They will be integral to the development of this study. I also reached out to physiotherapists, asking them for their input on the physiotherapist-led exercise intervention, rather than relying on my individual views. We are now in the process of setting this study up, developing study processes, seeking ethical approval etc etc. This is now my day-to-day role.

So, what is my intention for writing this blog? Principally to highlight the different skill sets; it’s not an ‘us’ versus ‘them’ type scenario, but rather a recognition of different skill sets. I recently stopped delivering my ‘rotator-cuff’ courses for a number of reasons, but a part of this was me recognising my role as an academic and naturally my case for uncertainty, which is not always a good outcome from a clinical course. I am far more comfortable now with uncertainty, not knowing, but wanting to find out the ‘right’ answer. As a young clinician I valued my training in McKenzie’s method of Mechanical Diagnosis & Therapy (MDT) tremendously. I spent a lot of time and money on this training and it helped my confidence so much. But then I began the diploma in MDT and realised that many of the claims were not substantiated. Overnight I went from a confident clinician to a blubbering idiot! This was difficult because much of my clinical efficiency and reputation had developed in relation to this approach. Essentially. I had become conflicted without knowing.

Of course, I still have conflicts, often unconscious. But I have the luxury of not having that clinical pressure when designing and delivering research. This links to the concept of equipoise which is an important concept underpinning research. Essentially if you’re an advocate of an approach then legitimately the clinical and research communities can ask whether you are the best person to be leading that research.

Working together is the answer, recognising the different skill sets.

Thanks for making it this far.

Chris