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Abstract

Objectives:

The objectives of this study were to (1) examine the overall recovery and satisfaction following an expedited rotator cuff (RC) decompression or repair at 3–6 months and (2) explore group differences (repair vs. decompression) in demographics, clinical, disability, and psychosocial factors.

Methods:

This was a prospective longitudinal study of injured workers whose surgery was expedited. The outcome measures were Quick disabilities of the arm, shoulder, and hand (QuickDASH), the Hospital Anxiety and Depression Scale (HADS), the readiness for return to work (RRTW) scale, and satisfaction with surgery and overall recovery.

Results:

Of 118 patients participated in the study, 106 patients, age: 51 (9), 71 males (67%) completed the study. Sixty-four (60%) patients underwent a RC repair and 42 (40%) had RC decompression. Patients improved on average in QuickDASH (p = 0.004), anxiety (p = 0.003), and depression scores (p = 0.004). The majority of patients (75%) were satisfied with surgery. In the decompression group, the pre-contemplation (PC) stage of the RRTW which documents the absence of desire or planning for return to work in the non-working sample (r = 0.81, p = 0.008) and the uncertain maintenance (UM) stage of the RRTW which explores the worker’s struggle to stay at work in the working sample correlated with physical disability as measured by the QuickDASH scores (r = 0.62, p = 0.0001). In the repair group, the above domains correlated with the depression HADS scores (PC: r = 0.64, p = 0.001 and UM: r = 0.57, p < 0.0001).

Conclusion:

Expedited RC surgery improved physical disability and mental well-being and was associated with a relatively high satisfaction at a maximum of 6 months. The poorer report of readiness for return to work was associated with higher physical disability in the decompression group and higher report of depression in the repair group. These differential associations may emphasize the importance of physical versus psychological management in patients with different levels of pathology.

Keywords

expedited surgery rotator cuff workers compensation

Background

Rotator cuff (RC) injuries have a significant impact on work productivity as indicated by high claims rates and costs attributed to these injuries.^1
–3 With ongoing symptoms and unsuccessful trials of conservative management such as medication, physiotherapy, and cortisone injections, surgery is indicated to relieve symptoms and improve overall function.

Although the literature shows a consistent pattern of less successful results in injured workers compared to the general population,^4

–7 majority of injured workers do benefit from surgery when it is deemed appropriate by the clinicians involved in the care of these patients.^4,7

–10

Apart from the severity of pathology, chronicity, age, sex, and mechanism of injury, the length of wait time to surgery is reported to affect recovery.^{8,11

–19} Considering the linear relationship between wait times to receive surgery and developing chronic disability,^20

–24 expediting surgery is expected to help with a more successful return to normal function. Expediting surgery in injured workers is not a new concept in Canada.^25
–27 However, there is only minimal information on the subject in the literature.^8,19,28 Considering, the enormous implications of RC injury for workers, employers, insurers, and health-care providers, further exploration of the impact of pathology on recovery and readiness to return to work will provide a more evidenced base care for this population.

The objectives of this study were twofold: (1) to examine the overall recovery and satisfaction with an expedited surgery in injured workers with RC pathology who had undergone a RC decompression or repair at 3–6 months and (2) to explore the potential group differences (repair vs. decompression) in demographic, clinical, disability, and psychosocial factors (e.g. anxiety, depression, readiness for return to work (RRTW)).

Methods and materials

Patient population

This was a prospective longitudinal study of consecutive injured workers with an active work-related shoulder injury who had undergone an expedited arthroscopic RC decompression or repair. The inclusion criteria were age ≥18 years, failed conservative treatment and diagnosis of tendonitis, and partial or full-thickness RC tear confirmed by surgery. Exclusion criteria were inability to speak or read English, advanced osteoarthritis of the glenohumeral joint, inflammatory arthropathy, and concurrent pathology of labrum that required a repair. Informed consent was obtained and the rights of the subjects were protected. This study received ethics approval from the Human Ethics Research Board of the Sunnybrook Health Sciences Centre, Toronto, Canada: REB#478-2015.

Demographic variables and clinical data

Demographic variables such as age, sex, dominant side, smoking, job demands, comorbidity (diabetes and hypertension), symptom duration, and mechanism of injury were documented at 2–3 weeks prior to surgery. Clinical examination included active range of motion (ROM) prior to surgery and at the final visit (3 months after RC decompression and 6 months after RC repair).

Outcome measures

Pre- and postoperative level of disability was measured by the Quick disabilities of the arm, shoulder and hand (QuickDASH)²⁹ and the Hospital Anxiety and Depression Scale (HADS).³⁰ All patients completed a satisfaction survey and the RRTW scale³¹ at the time of final visit. The actual work status was documented in three categories of regular duties, modified duties, and unable to work.

The QuickDASH has 11 questions and uses a Likert-type scale with higher numbers indicating more disability. The QuickDASH has established validity and reliability in patients with shoulder complaints.^29,32 The HADS is a 14-item scale,³⁰ of which 7 items relate to anxiety and 7 relate to depression. A score of 0 to 7 for either subscale is regarded as being in the normal range, a score of 8 to 10 is suggestive of the presence of the respective state, and a score of 11 or higher indicates probable presence of the mood disorder.³⁰ The HADS has acceptable measurement properties in patients with musculoskeletal conditions.³³

The RRTW is a 22-item scale³¹ which has different components for working (9 items) and non-working individuals (13 items). There are two stages for the working individuals. The uncertain maintenance (UM) which explores the worker’s struggle to stay at work and the proactive maintenance which examines the coping mechanism and strategies to make work manageable in highly difficult situations that may cause a setback. There are four stages for the non-working population. The pre-contemplation (PC) stage documents the absence of desire or plan about returning to work. The contemplation (C) stage refers to when the individual starts to consider return to work (RTW) in the near future. The preparation for action–self evaluative (PA-S) stage measures the degree of readiness to RTW, finding strategies to make work manageable and making an actual plan for RTW (e.g. having an actual date). Finally, the preparation for action–behavioral (PA-B) stage measures the degree of mental readiness and active involvement of the individual to build up strength to RTW.³¹ The RRTW scale has shown satisfactory construct validity for most of the stages in occupational rehabilitation³⁴ and has shown association with the actual work outcome.³⁵

The satisfaction with surgery and the overall recovery achieved at the time of final visit was documented on a five-point Likert-type scale as strongly agree, agree, neutral, disagree, and strongly disagree. Two questions were posed: (1) overall, I am satisfied with the results of surgery and (2) overall, I am satisfied with my recovery after surgery.

Surgical interventions

The severity of RC pathology (tendonitis, osseous impingement, presence, and size of tear) was documented at the time of surgery. Patients with tendonitis and subacromial impingement syndrome underwent RC decompression (acromioplasty and or resection of lateral clavicle). Patients with full-thickness tears of the RC underwent an arthroscopic repair of the tendon(s). The size of RC tear (largest dimension) was categorized as small (<1 cm), moderate (1–3 cm), large (>3–5 cm), and massive (≥5 cm).³⁶ Information on biceps pathology was documented for descriptive purposes.

Statistical analysis

The sample size calculation was based on the primary question, measuring recovery after surgery. We used the existing data of patients with shoulder problems, who had a 6-month follow-up, to calculate the sample size based on change in the primary measure of disability, QuickDASH. An effect size of 0.3³⁷ in mean score of the QuickDASH was chosen. The difference between pre and post QuickDASH was 25 out of 100. The standard deviation of the mean difference was 20. Sample size calculation was based on paired t test using the below formula: $N = {(Z a - Z b) SD / d}^{2}$ , where a = 0.05, Za = 1.65, b = 0.20, Zb = 0.84, SD = 20, d = 0.3 × 25= 7.5, $N = {(1.65 + 0.84) 20 / 7.5}^{2} = 44$ . Therefore, a minimum of 44 patients was deemed sufficient for the primary question. Due to lack of comparative studies between patients with RC repair and decompression using QuickDASH, a minimum of 40 patients in each group was deemed necessary to examine the group differences in disability and other factors as suggested by a study that had examined RC tear repairs.³⁸

The change in physical disability scores as measured by the QuickDASH and psychological measures as measured by HADS was examined by the Student’s paired t tests or non-parametric statistics for continuous data depending on the distribution of data. The differences between repair and decompression groups were examined by Fisher’s exact test (FET) or χ ² tests for categorical data and independent t tests for continuous data as appropriate. Satisfaction with surgery was examined in relation to postoperative QuickDASH and HADS scores using analysis of covariance to correct for preoperative scores. Correlation coefficients were calculated to measure the strength and direction of a linear relationship between physical and mental well-being (HADS scores) and the readiness for return to work domains. Statistical analysis was performed using SAS® version 9.1.3 (SAS® Institute, Cary, North Carolina, USA). Statistical results are reported using two-tailed p values with significance set at p < 0.05.

Results

One-hundred and eighteen patients met the inclusion criteria and entered into the study over a period of 1 year (February 2016 to February 2017) with 106 patients (response rate = 90%) completing the follow-up visit of up to 6 months. Sixty-four (60%) patients underwent an RC repair and 42 (40%) had an RC decompression (Table 1).

Table 1.

Characteristics of patients with and without RC repair.

Variables	Repair (N = 64)	Decompression (N = 42)	Group differences statistics, p values	Effect size^a
Age
Mean (SD)	54 (8)	47 (9)	t test = 4.53, p < 0.0001	d = 0.90 (0.49–1.30)
Sex (%)
Female	20 (31%)	15 (36%)	x ² = 0.23, p = 0.63	—
Male	44 (69%)	27 (64%)
Wait time (days)
Mean (SD)	47 (22)	62 (40)	t test = 2.22, p = 0.03	d = 0.44 (0.05–0.83)
Symptom duration
Month	8.8 (18.4)	8.7 (7.2)	t test = 0.00, p = 0.99	—
Co-morbidity
Diabetes	8 (13%)	7 (17%)	x ² = 0.36, p = 0.54	—
Hypertension	19 (30%)	9 (21%)	x ² = 0.89, p = 0.35	—
Smoking (%)	20 (31%)	14 (33%)	x ² = 0.05, p = 0.82	—
Mechanism of injury
Traumatic	58 (91%)	33 (79%)	x ² = 3.03, p = 0.08	—
Insidious	6 (9%)	9 (21%)
Surgical information
Acromioplasty	55 (86%)	39 (93%)	x ² = 1.20, p = 0.27	—
Lateral clavicle resection	11 (17%)	24 (57%)	x ² = 18.30, p < 0.0001	OR = 0.16 (0.06–0.38)
Biceps debridement	14 (22%)	13 (31%)	x ² = 1.10, p = 0.29	—
Biceps tenodesis	12 (19%)	1 (2%)	FTE = 0.009, p = 0.01	OR = 0.11 (0.01–0.84)
Tear size (repair group)
Small	5 (8%)
Moderate	34 (53%)	—
Large	9 (14%)
Massive	16 (25%)
Barriers to RTW (%)
Presence of yellow flags	28 (43%)	23 (55%)	x ² = 1.23, p = 0.27	—
Presence of black flags	36 (56%)	26 (62%)	x ² = 0.33, p = 0.56	—
Presence of blue flags	5 (8%)	5 (12%)	FTE = 0.20, p = 0.51	—

FTE: Fisher’s exact test; OR: odds ratio; SD: standard deviation; RC: rotator cuff; d: Cohen’s effect size.

^a ORs and effect sizes are presented for statistically significant group differences.

Change over time (recovery)

There was an overall improvement in all outcome measures. There was a statistically significant improvement in QuickDASH (p = 0.004), anxiety (p = 0.003), and depression scores (p = 0.004).

The ROM in active flexion, abduction, and external rotation improved at a statistically significant level only in the decompression group (p = 0.05–0.03).

Satisfaction with surgery and recovery

Seventy-seven percent (49/64) of the repair group and 71% (30/42) of the decompression group fell in the strongly agree/agree categories. Overall 75% (79/106) of the full sample felt satisfied with surgery. Fewer patients (repair: 66% vs. decompression: 57%, respectively) were satisfied with their overall recovery at the time of final assessment (Table 2).

Table 2.

Group differences in pre and post-operative outcome measures.^a

Variables	Repair (N = 64)	Decompression (N = 42)	Group differences statistics, p values	Effect size^b
Pre-op outcomes
QuickDASH	50 (21)	51 (22)	t = 0.38, p = 0.71	—
HADS anxiety
Normal	37 (58%)	18 (43%)
Borderline abnormal	14 (22%)	10 (24%)	x ² = 2.87, p = 0.24	—
Abnormal	13 (20%)	14 (33%)
HADS depression
Normal	42 (66%)	25 (60%)
Borderline abnormal	9 (14%)	10 (24%)	x ² = 1.67, p = 0.43	—
Abnormal	13 (20%)	7 (17%)
Post-op outcomes
QuickDASH	46 (21)	40 (19)	t test=1.77, p = 0.08	—
HADS anxiety
Normal	44 (69%)	29 (69%)
Borderline abnormal	7 (11%)	5 (12%)	x ² = 0.62, p = 0.73	—
Abnormal	10 (16%)	8 (19%)
HADS depression
Normal	47 (73%)	29 (69%)
Borderline abnormal	7 (11%)	5 (12%)	x ² = 0.27, p = 0.88	—
Abnormal	10 (16%)	8 (19%)
Pre-op active ROM
Flexion	141 (28)	144 (31)	t test = 0.54, p = 0.59	—
Abduction	136 (43)	139 (35)	t test = 0.37, p = 0.71	—
External rotation	56 (20)	61 (19)	t test = 1.47, p = 0.15	—
Post-op active ROM
Flexion	142 (34)	156 (22)	t test =2.60, p = 0.01	d = 0.52 (0.11–0.91)
Abduction	137 (34)	153 (28)	t test =2.47, p = 0.01	d = 0.43 (0.30–0.82)
External rotation	53 (20)	60 (15)	t test =2.16, p = 0.03	d = 0.49 (0.09–0.89)
Pre-op work status
Not-working	15 (23%)	8 (19%)
Working part time	3 (5%)	4 (9%)	FTE = 0.03, p = 0.55	—
Working full time	46 (72%)	30 (75%)
Post-op work status
Not-working	14 (21%)	7 (17%)
Working part time	7 (11%)	8 (19%)	FTE = 0.02, p = 0.49	—
Working full time	42 (66%)	27 (64%)
Retired	1 (2%)
Satisfaction with surgery
Strongly agree and agree	49 (77%)	30 (71%)
Neutral	8 (12%)	5 (12%)
Strongly disagree and disagree	5 (8%)	5 (12%)	FTE = 0.04, p = 0.73	—
N/A	2 (3%)	2 (5%)
Satisfaction with overall recovery
Strongly agree and agree	42 (66%)	24 (57%)
Neutral	12 (19%)	9 (21%)	FTE = 0.03, p = 0.56	—
Strongly disagree and disagree	8 (12%)	8 (20%)
N/A	2 (3%)	1 (2%)

d: Cohen’s effect size; FTE: Fisher’s exact test; HADS: Hospital Anxiety and Depression Scale; QuickDASH: Quick disabilities of the arm, shoulder and hand; OR: odds ratio; SD: standard deviation.

^a The HADS anxiety and depression scores are categorized as: normal (≤7), borderline abnormal (7–10) and abnormal (>11).

^b ORs and effect sizes are presented for statistically significant group differences.

There was a positive correlation between disability at follow-up as measured by the post-op QuickDASH score and satisfaction with surgical results (F = 6.27, p = 0.003) and the overall recovery (F = 8.65, p = 0.0003) after being adjusted for preoperative QuickDASH. Satisfaction with surgery was correlated with both anxiety (F = 6.37, p = 0.003) and depression scores (F = 5.74, p = 0.004). Similarly, satisfaction with the overall recovery was correlated with anxiety (F = 5.51, p = 0.005) and depression scores (F = 3.91, p = 0.02).

Group differences (impact of pathology on pre and postoperative factors)

The demographic and characteristics of the repair and decompression groups are shown in Table 1. Patients who had a repair were significantly older than the decompression group (54 vs. 47, p < 0.0001). The repair group waited a shorter time for surgery than the decompression group (47 days vs. 62 days, p = 0.03). There were no statistically significant group differences in pre or post-op QuickDASH, depression or anxiety scores or work status at follow-up (p > 0.05). The decompression group had a better ROM at follow-up (p values varying from 0.03 to 0.01). Satisfaction with surgery and overall recovery was comparable between groups (p > 0.05).

The results of correlation between RRTW and physical disability (QuickDASH) and depression scores showed differential characteristics between the RC repair group and the decompression group. In the decompression group, the PC stage of the RRTW which documents the absence of desire or planning for return to work in the non-working sample (r = 0.81, p = 0.008) and the UM stage of the RRTW which explores the worker’s struggle to stay at work in the working sample correlated with reported physical disability as measured by the QuickDASH scores (r = 0.62, p = 0.0001). In the repair group, the above domains correlated with the depression scores (PC: r = 0.64, p = 0.001 and UM: r = 0.57, p < 0.0001, respectively).

Discussion

In Canada, the workers compensation boards have assumed a greater role in managing the care of injured workers²⁵ to counterbalance the long wait lists for a specialist visit and surgery. At present, the Workplace Safety and Insurance Board (WSIB) finances preferred access to specialist assessment and expedited surgeries to facilitate the care of injured workers in Ontario, Canada. In the present study, there was an overall improvement in disability, anxiety, and depression scores of the entire sample following an expedited RC surgery at a relatively short period after surgery (3–6 months). Our results are consistent with the limited research in this area.^8,19,28 In a recent case-control study of injured workers,¹⁹ a RC-related surgery improved the disability and work status more significantly in the group whose surgery was expedited by the parallel pay system supported by the Ontario WSIB than the control group who used the publicly funded health-care system. In another study of injured workers, 146 patients who had an expedited RC surgery (46% had a RC repair) improved in disability, as measured by the American Shoulder and Elbow Surgeons (ASES) score, ROM, and work status.⁸ In general, acute traumatic tears in young individuals are reported to have a more successful result when repair is performed more promptly.^39

–42

In our sample, patients in the repair group were older which is not surprising in light of RC tear being more prevalent in older individuals. The decompression group had a longer conservative treatment before surgery. This finding is in line with our understanding of recovery following minor RC pathology such as tendonitis, bursitis, and osseous impingement as most patients are reported to improve with conservative treatment^43,44 and surgery should be considered only when conservative treatment is failed.

Both groups were similar in preoperative characteristics. At follow-up, the decompression group improved in ROM at a statistically significant level. This difference was not observed in patients with full-thickness RC tears which may indicate that patients with a more significant pathology require longer rehabilitation to achieve their optimal recovery and full ROM.

Readiness for return to work and physical and mental well-being

In patients with less pathology (decompression group), lack of intention to engage in return to work behavior in the non-working subgroup and higher struggle at work in the working subgroup were associated with higher report of physical disability which may emphasize the importance of physical rehabilitation in this group. The association between these domains and higher depression in the RC repair group provides an opportunity to offer psychological care in junction with physical rehabilitation to facilitate a successful recovery in patients with a more serious pathology.

Limitations

The present study examined the differences in patient demographic, clinical findings, disability, and psychosocial factors between patients who underwent a RC repair versus decompression at a maximum of 6 months after an expedited surgery which is considered a short follow-up after a repair. Whether these differences would reduce or increase as a function of time remains to be studied in future studies with longer follow-ups. In the present study, all injured workers underwent an expedited surgery to reduce bias related to unequal or delayed access to care. However, including a control group that utilizes the public health care may better highlight the impact of longer wait times for assessment, rehabilitation, and surgery on physical and mental well-being of workers with different levels of RC pathology.

Conclusions

Expedited RC surgery improved physical disability and mental well-being after a work-related injury and was associated with a relatively high satisfaction at a maximum of 6 months. The poorer readiness to RTW was associated with higher physical disability in the decompression group and higher depression in the repair group. These differential associations may emphasize the importance of physical versus psychological management in patients with different levels of pathology.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of following financial support for the research, authorship, and/or publication of this article: This study was funded by the Practice Based Research funds of the Sunnybrook Health Sciences Centre.

ORCID iD

Helen Razmjou

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Outcomes of expedited rotator cuff surgery in injured workers: Impact of pathology on readiness for return to work

Abstract

Objectives:

Methods:

Results:

Conclusion:

Keywords

Background

Methods and materials

Patient population

Demographic variables and clinical data

Outcome measures

Surgical interventions

Statistical analysis

Results

Change over time (recovery)

Satisfaction with surgery and recovery

Group differences (impact of pathology on pre and postoperative factors)

Discussion

Readiness for return to work and physical and mental well-being

Limitations

Conclusions

Footnotes

Declaration of conflicting interests

Funding

ORCID iD

References