Article Review: Clinical Trial Suggests that Pulley and Jackins Exercises after Rotator Cuff Repair are Effective Rehabilitation Techniques

A study published online on April 26 ahead of publication in the American Journal of Sports Medicine asks if pulley exercises 6 weeks after rotator cuff repair are a safe and effective rehabilitation method when compared to Jackins rotator cuff exercises. According to this study, the answer is yes, shoulder pulleys as effective, or at the least not inferior to, other methods currently used in the rehabilitation of the rotator cuff. 

The study used a group of 53 patients undergoing repair of the supraspinatus, in some cases, at the same time as subacromial decompression, subscapularis repair, infraspinatus repair, or biceps tenodesis. Patients were randomized to two treatment groups, pulley exercises (27 patients) or Jackins exercises (26 patients). After surgery, all study participants initially did Passive Range of Motion (PROM) exercises performed by and/or supervised by a physical therapist for 6 weeks regardless of grouping. The physical therapists treating the patients, and operating surgeons did not know which treatment group patients were in. Then following this initial treatment period, participants were randomized to use Jackins or pulley exercises. All exercises, Jackins or pulley, were done until scapation and flexion of the affected arm could be done without pain.

The version of Jackins exercises used in the study started with the patient in a supine position elevating their injured arm slowly with the assistance of the non-affected arm. When assisted arm raising could be fully done, the same exercise was done without assistance from the other arm. After arm elevation could be done without the assistance of the non-operative arm, the patient did the same exercise with progression from assisted active motion to unassisted active motion, but supine with the back lying at a 15° angle to the horizontal. Again, when both assisted and unassisted elevation of the injured arm could be achieved, 15° was added progressively to the position until the exercises were done in an upright position, 90° to the horizontal. Pulley group patients did rehabilitative shoulder pulley exercises.

An initial pilot study determined that group sizes of 22 or more patients per treatment group would be needed for a power of 0.80. For a matching control, the researchers compared motion and strength of the non-affected shoulder to the shoulder undergoing rehabilitation. To study patient outcomes, the Western Ontario Rotator Cuff Index (WORC), American Shoulder and Elbow Surgeons (ASES) Shoulder score, Single Assessment Numeric Evaluation (SANE) Shoulder Activity Level and Simple Shoulder Test (SST), range of motion, strength and scapular substitution. The researchers used the hypothesis that Rotator cuff rehabilitation using Shoulder pulleys would lead to both inferior patient outcomes and increased scapular substitution compared to other rehabilitation programs. 

After treatment, outcome scores demonstrated statistically significant improvements to shoulder flexion, abduction and internal rotation in patients using either Jackins or shoulder pulley exercises. External rotation did not improve by a statistically significant increment for either exercise. Both treatment groups showed improvements in strength, but the strength of the operative arm was still less than that of the unaffected arm by a statistically significant margin at the 12-month check in both groups. Additionally, there was no statistically significant difference between the interventions in terms of shoulder flexion, abduction, strength and internal rotation. The portion of the hypothesis which stated that shoulder pulley exercises would result in inferior patient outcomes was nullified, as pulley exercises were as effective as other exercises in this study. The other portion of the hypothesis, that those in the pulley group would have increased scapular motion or scapular substitution compared to the Jackins group was also nullified as there was no statistically significant difference between the groups in these scores. 

In conclusion, this study suggests that shoulder pulley exercises are at least as effective in post-operative rotator cuff rehabilitation as Jackins exercises in patients who have undergone arthroscopic supraspinatus repair. While additional studies are needed to confirm the results of this study, this initial evidence indicates that pulley exercises are not inferior in patient outcomes in post-operative rehabilitation of the rotator cuff, and are a safe and effective rehabilitation technique.

References
Baumgarten KM, Osborn R, Schweinle WE Jr, Zens MJ, Helsper EA. Are Pulley Exercises Initiated 6 Weeks After Rotator Cuff Repair a Safe and Effective Rehabilitative Treatment? A Randomized Controlled Trial. Am J Sports Med. 2016 Jul;44(7):1844-51. doi: 10.1177/0363546516640763. Epub 2016 Apr 26. PubMed PMID: 27159310.
Jackins S. Postoperative shoulder rehabilitation. Phys Med Rehabil Clin North Am. 2004;15(3):vi, 643-682. Doi: 10.1016/j.pmr.2004.01.002. Abstract.
Baumgarten KM, Vidal AF, Wright RW. Rotator Cuff Repair Rehabilitation: A Level I and II Systematic Review. Sports Health. 2009 Mar;1(2):125-30. Doi: 10.1177/1941738108331200. PubMed PMID: 23015863; 

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