An early, intensive and complementary aquatic rehabilitation protocol after arthroscopy rotator cuff repair: consensus through a Delphi study

Rotator cuff problems such as tendinosis and rupture result in a decrease in shoulder function and are common in elderly people [1]. Their incidence ranges from 33% to 81% [2], while that of rotator cuff tears ranges from 5% to 39% in the general population, increasing significantly with age [3]. Such tears are the most common non-traumatic upper limb cause of disability in people over 50 years [4]. The main causes of rotator cuff ruptures are direct injury or trauma and degeneration due to repetitive stress [5]. Rupture of the rotator cuff tendons can cause pain, weakness, alteration in glenohumeral movements and sometimes instability [6]; in addition, after five years, asymptomatic partial or total ruptures usually trigger pain [7].

Nonoperative treatments can be used to manage most rotator cuff tears, especially in patients with lower demands. Rotator cuff tendons do not heal spontaneously, however, and surgical treatment is often required in patients who have persistent symptoms and functional impairment after conservative treatment [8]. One adverse effect of rotator cuff surgery is stiffness, whose incidence is estimated to be between 4.9% and 32.7% [9,10,11,12]. Stiffness is more likely if rehabilitation is too conservative [11,12,13], and it tends to decrease if an arthroscopic operation has been performed [10]. Early rehabilitation protocols achieve significant improvements in range of motion (ROM) in the short and medium term compared to more conservative protocols that begin rehabilitation later [13,14,15,16,17,18,19]. The early introduction of aquatic therapy will allow fast improvement of glenohumeral ROM [20,21,22,23]; in addition, an aquatic environment appears safe for the integrity of the sutures [20,22,24,25] and thus helps reduce secondary post-operative complications such as the appearance of sub-acromial adhesions and glenohumeral capsule contracture [20] and stiffness [9,10,11,12].

Few studies have examined the suitability of an aquatic rehabilitation programme in combination with standard treatment after rotator cuff surgical repair [20,23,26,27]. Previous studies demonstrate that an aquatic environment offers favourable conditions for the recovery of these injuries. The fact that water acts to compensate the force of gravity means that it is the ideal environment to reduce joint impact and can be very beneficial in rehabilitation and recovery processes [28], and slow arm elevations (<30°/s) are advantageous for improving joint mobility with low mechanical solicitation [29]. Electromyography studies indicate the aqueous environment requires less muscle activity than activities on land for exercise [30,31], making rehabilitation exercises within an aquatic environment safe for the integrity of the sutures [30,32]. In addition, it is better and safer to start early rehabilitation exercises in water, since the buoyancy of the water decreases workloads and may help to decrease tensile stress and protect repaired tendons [33].

This study describes the design of an early, intensive and complementary aquatic rehabilitation protocol after arthroscopic rotator cuff repair based on the Delphi method.

The design of the protocol was based on three main ideas: the temporal structure of the aquatic sessions, the early improvement of the articular balance of the glenohumeral joint after surgical repair of the rotator cuff, and the safety of sutures during the active functional work in the water.

Temporal structure of the aquatic sessions. The main consideration when designing the protocol was that the improvement of the articular balance of the glenohumeral joint was directly proportional to the duration of the aquatic rehabilitation sessions and the number of sessions per week. Therefore, the proposed protocol for this study was four aquatic rehabilitation sessions of 45 minutes, one per week; this assumed that, being complementary, two rehabilitation sessions per week were carried out in the hospital. However, the experts did not agree on this proposal. The statement 4 (supplementary 2) achieved 67.3% consensus. Furthermore, the statement 8 (supplementary 2) achieved only a 45.5% consensus. Therefore, neither of the two statements reached the 80% consensus established by this protocol, thus invalidating them.

To determine the duration of the aquatic sessions, it was necessary to analyse the responses to the statements in the second round. The experts reached 100% consensus on the statement 2 (supplementary 3). In contrast, the statement 1 (supplementary 3) only received a 72.72% consensus, thus failing to reach the minimum 80% consensus. On analysing the responses, it was determined that the optimal duration of the aquatic sessions in this protocol is 30 minutes.

In the second round, the experts were also asked about the ideal duration of the aquatic sessions to reach the goals of early improvement of the articular balance of the glenohumeral joint proposed in this protocol. Neither of the two statements presented managed to reach the required 80% consensus. The statement 3 (supplementary 3) only achieved 63.63%. In addition, the statement 4 (supplementary 3) only achieved 45.45%.

These responses are difficult to interpret: 100% consensus was reached when the statements were asked with working time intervals: statements 1 and 2 (supplementary 3) a; however, no consensus was reached regarding the ‘ideal’ length of the aquatic sessions, even though the agreed upon 30 minutes was one of the proposed time slots. It is possible that the word ideal may have generated controversy, since it can also mean optimal or excellent [55], and for each expert their ideal length of the sessions will depend on their clinical experience [41] and the method of aquatic therapy they use.

To determine the number of aquatic sessions to be carried out each week, the responses from the second round were also analysed. Statement 7 (Supplementary 3), achieved a consensus of 72.72%. Statement 8 (Supplementary 3), achieved a consensus of 90.90%, and statement 9 (Supplementary 3), achieved a consensus of 90.90%. From the analysis of the responses, it was determined that the optimal number of sessions needed to achieve early joint balance is three sessions a week.

The proposed protocol was designed to last three weeks: This assumed it was intensive and complementary with two rehabilitation sessions per week at the hospital, and was aimed at gaining joint balance early after surgery.

Reaching consensus on the length of the aquatic sessions was not easy, as can be seen in the statistical results. The Kappa Fleiss coefficient in both the first and the second round was 0.09, which is interpreted as poor agreement between multiple observers [54]. This result could be due to different factors. The first is the few studies currently exist on water recoveries after surgical repair of the rotator cuff [20,23,26,27]. The second is the variety of therapeutic approaches that exist in the aquatic environment: Water Specific Therapy (WST), Halliwick, Bad Ragaz Ring Method (BRRM), Clinical Ai Chi, Aquatic motor-cognitive therapy (AMCT) and, Aquatic Passive Manual Handling (APMH). The third is that each therapist approaches their patients according to their clinical experience and the method they think is most appropriate [41].

The consensus reached in this study modified the time structure that had initially been proposed: from 45 minutes of exercises per session and four sessions per week for three weeks (Supplementary 1) to 30 minutes of work per session and three sessions per week for three weeks (Tab. 5). The experts agreed that this organisation is the most appropriate for achieving early improvement in ROM of the glenohumeral joint after arthroscopic repair of the rotator cuff.

Early improvement of joint balance. Another key principle in the design of the protocol was that early rehabilitations enable short and medium term improvements in joint balance [13,14,15,16,17,18,19], especially in aquatic rehabilitations [20,21,22,23]. This idea was supported by the experts since the statement 7 (supplementary 2) achieved a 90.9% consensus.

Active functional work. The other main idea in the design of the protocol was that active functional work should be performed from the first session of aquatic rehabilitation (in the second and third week after rotator cuff surgery) to allow an early recovery of normal movement patterns [20]. This active functional work can be performed in the early stages since water is a protective environment for the sutures [20,24,25,56]. The protocols of the studies carried out so far in aquatic rehabilitation after rotator cuff surgery focus on gaining joint balance by performing movements in a single plane of space, starting with passive movements on the first phase of rehabilitation and with active range of motion (AROM) exercises in the second phase of rehabilitation [20,23,26,27]. In contrast to the studies carried out so far, the protocol designed for this study proposes a new aquatic work approach. It proposes active functional work based on combining movements in the three planes, always at low speed and according to the rule of no pain. The patient performs the exercises actively from the first work session in the water, which starts in the second or third week after the rotator cuff surgery and after the approval of the surgeon to start the rehabilitation protocol.

This idea was agreed upon by the experts. All the questions in the first round of the Delphi that referred to active functional work and water as a protective environment for sutures received more than the minimum 80% consensus.

It would be necessary, however, to analyse why the experts did not agree on the statement that the muscle electromyographic activity is reduced when exercises are performed in the water. In the second wave of the Delphi, the experts were provided with various electro-myographic articles indicating that muscle activation is lower in water [24,30,31,32,57]. Even so, no agreement was reached, since the statement statement 11 (supplementary 3) only achieved a 72.72% consensus. Perhaps the statement should specify “exercises performed at low speeds” in order to obtain a clearer response.

The study has some limitations. Being an innovative study, it was decided that the group of experts would be made up only of physiotherapists who are experts in aquatic rehabilitation and that the consensus for statements would be set at 80%. In addition, the sample is limited. In future studies intended to validate aquatic rehabilitation protocols, the possibility of having a larger sample should be considered, and these should include participants from other specialities, such as surgeons and rehabilitation doctors, who are experts in rotator cuff surgery and rehabilitation.

Our findings, both regarding the evaluation of the expert competence coefficient (K) and the responses to the two rounds of statements in the Delphi study, were based on the opinions, knowledge and experience in aquatic rehabilitation of the experts who participated. One of the main limitations of the Delphi method is that the survey only captures the expert's view of the problem. There can be no doubt that such data can be highly imprecise depending on the perspective of the interviewee regarding the issue in question [58]

Therefore, our findings should be regarded with some caution, and further control cases, pilot tests and clinical trials with larger samples will be necessary. To assess the effectiveness of the agreed protocol, a pilot test will be carried out, and if the results are successful, a clinical trial with a control group will be conducted.

The experts agreed that early, intensive and complementary aquatic rehabilitation protocol is recommended after arthroscopy rotator cuff repair. This study could be a new step forward in trying to unify action criteria and serve as a basis for planning future studies.