Characteristics of included studies
The PRISMA study flow chart is displayed in Fig. 1. Five additional articles were extracted from the reference list of other studies. 2116 articles were identified after removing duplicates. Thirteen RCTs[8, 13–15, 22, 23, 27–33] with 1406 patients conformed to our inclusion criteria and were included in this study (Table 1). Among them, 7 RCTs[8, 13–15, 27–29] met the criteria for early passive motion (EPM) vs. delayed passive motion (DPM) and 7 RCTs[8, 13–15, 27–29] for early active motion (EAM) vs. delayed active motion (DAM). A total of 331 patients (n = 331 shoulders) were EPM and 292 patients (n = 292 shoulders) were DPM. The mean age ranged from 54.5 to 64.6 years in the EPM group and 55.2 to 65.1 years in the DPM group. 52.65% (N = 328) were female. A total of 416 patients were EAM and 407 patients were DAM. The mean age ranged from 52.32 to 57.68 years in the EAM group and 50.43 to 57.2 years in the DAM group. 43.25% (N = 356) were female. The final follow-up timing in the included studies ranged from 4 to 24 months (most of them are 12 months). Risk of bias assessment was presented in supplementary Fig. 1 and publication bias was assessed with funnel plots in supplementary Fig. 2 ~ 7 for each outcome. Grade-Assessment-of-Quality-of-Evidence was presented in supplementary Table 2.
Table 1
Patient Characteristics in the Included Studies
Study | LOE | Country | Study design | Patient (male/ female) | Tear size (cm)/ Surgical technique | Mean age (range/SD) | Immobilized device/ (removal timing of EM, DM group) | Rehabilitation protocol | Image method/ follow-up | Outcome evaluation |
Early motion (timing) | Delayed motion (timing) |
Arndt 20122 | 1 | France | RCT | 92 (34/58) | Partial and full-thickness tear (NA)/ Single or double row | 55.3 | Sling/ (POW 6, POW 6) | *EPM (POD 1) | *DPM (POW 6) | CT/ 3, 6, 12, > 12 months | Constant score/ forward flexion / external rotation/ retear rate |
Cuff 201211 | 1 | USA | RCT | 68 (38/30) | full-thickness tear/ Transosseousequivalent suture-bridge technique | 63.2 | Shoulder immobilizer / (POW 6, POW 6) | EPM (POD 2) EAM (POW 6) | DPM (POW 6) DAM (POW 7) | Ultrasound /6, 12 months | ASES score/ SST/ forward flexion/ external rotation/ internal rotation/ cuff healing rate |
Kim 201223 | 1 | South Korea | RCT | 105 (44/61) | full-thickness tear (< 3)/Single or double row or suture bridge | 60 | Brace/ (POW4 ~ 5, POW4 ~ 5) | #EPM (POD 1) | #DPM (POW 4 ~ 5) | Ultrasound, CT, MRI/ 3, 6, 12 months | VAS/ constant score/ SST/ ASES/ forward flexion/ external rotation/ Internal rotation/ detachment rate |
Lee 201228 | 1 | South Korea | RCT | 64 (41/23) | Full-thickness tear (1–5)/ Single row | 54.87 (39–66) | Sling/ (POW 6, POW 6) | *EPM (POD 1) | *%DPM (POW 3) | MRI/ 3, 6, 12 months | VAS/ UCLAS/ active strength/ forward flexion/ external rotation/ retear rate/healing rate |
Düzgün 201413 | 1 | Turkey | RCT | 40 (6/34) | Full-thickness tear (1–5)/ Side-to-side repair | 57.43 (8.97) | N/A | EPM (POW2) EAM (POW 3) | DPM (POW4) DAM (POW 6) | NA/ 1, 3, 5, 8, 12, 16, 24 months | Active Elevation / forward flexion/ external rotation/ internal rotation |
Keener 201422 | 1 | USA | RCT | 124 (73/51) | Full-thickness tear (< 3) / Double row | < 65 | Sling/ (POW 6, POW 6) | EPM (POW 1) EAM (POW 6) | DPM (POW 6) DAM (POW 12) | Ultrasound/ 6, 12, > 12 months | VAS/ ASES/ SST/ constant score/ abduction strength/ external rotation strength/healing and retear rate |
De Roo 201512 | 1 | Belgium | RCT | 130 (59/71) | Full-thickness tear (< 5)/ Single or double Row | 64.8 (9.85) | Brace/ (POW 6, POW 6) | EPM (POD 1) EAM (POW 5) | DPM (POW 5) DAM (POW 6) | Ultrasound/ 6 weeks,4 months | SST, SPADI, constant score/ UCLAS/ active strength/ forward flexion/ external rotation |
Sheps 201542 | 1 | Canada | RCT | 189 (115/74) | Full-thickness tear (< 5)/ mini-open rotator cuff repair | 55.16 (35–86) | Sling/ (as needed, POW 6) | EAM (POD 1) | DAM (POW 6) | Ultrasound, MRI/ 6 weeks, 3, 6, 12, 24 months | VAS/ forward flexion/ external rotation/ internal rotation/abduction/ Scapular plane elevation |
Mazzocca 201735 | 1 | USA | RCT | 58 (40/18) | Full-thickness tear (NA)/ Transosseouse quivalent suture-bridge technique | 54.53 (7.5) | Sling/ (POW 6, POW 6) | EAM (POD 2) | DAM (POW 5) | MRI/ 1, 3, 6, 12, 24 weeks | VAS/ WORC/ ASES/SST/SANE/ constant score/ forward flexion/ external rotation/ failure rate |
Zhang 201747 | 1 | China | RCT | 132 (69/63) | Full-thickness tear (3–5)/NA | 51.38 (11.84) | Brackets/ (POW 6, POW 6) | EAM (POD 3) | DAM (POW 6) | X-ray/ 3, 6, 12 months | VAS/ UCLAS/ constant score/ forward flexion/ external rotation/ re-tear rate |
Jenssen 201819 | 1 | Norway | RCT | 118 (69/49) | Full-thickness tear (< 3) / Single row | 55.5 (34–73) | Sling, brace/ (POW3, POW6) | #EAM (POW3) | #DAM (POW 6) | MRI/ 6 weeks, 3, 6, 12 months | VAS for satisfaction/ forward flexion/ external rotation/abduction /healing/ atrophy/fatty infiltration/ WORC/ constant score |
Tirefort 201944 | 1 | Switzerland | RCT | 80 (37/43) | Full-thickness tear (< 3)/double row | 54.1 (27–78/9.87) | Sling/ (NA, POW 5) | EPM (POD 1) EAM (POD 1) | DPM (POD1) DAM (POW 5) | Ultrasound / 10 days, 1.5, 3, 6 months | VAS/ SANE/ ASES/ forward flexion/ external rotation |
Sheps 201943 | 1 | Canada | RCT | 206 (131/75) | Full-thickness tear (1–5)/ single row or double row/ Transosseouse | 55.9 (26–79) | Sling/ (as needed, POW 6) | EAM (POD 1) | DAM (POW 6) | Ultrasound/ 6 weeks, 3, 6, 12, 24 months | VAS/ forward flexion/ external rotation/ internal rotation/abduction/ scaption/ strength/ WORC/ SF-36 Scores |
RCT: randomized control trial; POD: postoperative day; POW: postoperative week; EM: early motion; DM: delayed motion; EAM: early active motion or early active-assist motion; DAM: delayed active motion; EPM: early passive motion; DPM: delayed passive motion; ASES: American Shoulder and Elbow Surgeons Score; SST: Simple Shoulder Test; UCLAS: University of California at Los Angeles Score; SPADI: Shoulder Pain And Disability Index; WORC: Western Ontario Rotator Cuff index; SANE: Single Assessment Numeric Evaluation; DASH: Disabilities of The Arm Shoulder and Hand; SF-36 Scores: 36-Item Short Form +: median; *: active motion start POW 6; #: active motion start after removal of sling/brace; %: anterior elevation only and external rotation start from POW 3 |
Range of Motion
6 studies[8, 13–15, 27, 29] with 493 patients reported this outcome for final follow-up. EPM group showed better anterior flexion (MD 1.40, 95%CI, 0.55–2.25, p = 0.01, Quality of Evidence: Moderate) (Fig. 2A) compared to DPM, and there was no statistically significant difference for external rotation (MD 1.86, 95% CI, -0.53-4.25, p = 0.13, Quality of Evidence: Moderate) (Fig. 2B). Besides, two studies[13, 29] with 104 patients showed better abduction in EPM (MD 2.73, 95% CI, 0.74–4.71, p = 0.007, Quality of Evidence: Moderate) compared to DPM (Fig. 2C). On the other hand, EAM appeared to have better anterior flexion (MD 1.57, 95%CI, 0.62–2.52, p = 0.001, Quality of Evidence: Moderate) and external rotation (MD 1.59, 95%CI, 0.36–2.82, p = 0.01, Quality of Evidence: High) (Fig. 3A) (Fig. 3B). There was no statistically significant difference for abduction (MD 0.74, 95% CI, -1.97-3.45, p = 0.59, Quality of Evidence: High) (Fig. 3C). Additional follow-up outcomes were presented in supplementary Figs. 8 ~ 10, and 12 ~ 15.
Retear Rate
Compared to DPM/DAM, EPM/EAM demonstrated no significant difference in retear rate with mean difference 1.44 (95% CI, 0.83–2.52, p = 0.17, Quality of Evidence: Moderate) / 1.24 (95% CI, 0.68–2.25, p = 0.88, Quality of Evidence: High) in 5 studies[8, 13–15, 27]with 435 patients/ 5 studies[22, 23, 30, 32, 33] with 565 patients respectively (Fig. 4).
Functional score (CMS and SST)
Three studies[8, 15, 27] with 321 patients showed no statistically significant difference in CMS (1.65, 95% CI, -3.03, 6.34, p = 0.49) (supplementary Fig. 11.2) between EPM and DPM. Similarly, there was no statistically significant difference in the Simple Shoulder Test (MD 0.35, 95% CI, -0.30, 1.00, p = 0.029) (supplementary Fig. 11.3). On the other hand, EAM appeared to have better CMS compared to DAM (2.30, 95% CI, -2.46, 7.06, p = 0.34) (supplementary Fig. 16.1)[30, 32, 33]. Additional follow-up outcomes were presented in supplementary Fig. 11.
Visual Analogue Scale (VAS)
Five studies[22, 23, 30–32] with 635 patients reported this outcome for final follow-up. There was no statistically significant difference in VAS score between EAM and DAM (MD -0.17, 95% CI, -0.44-0.11, p = 0.24) (supplementary Fig. 16.5). Additional follow-up outcomes were presented in supplementary Fig. 16.
Subgroup Analysis
In order to further evaluate large sized tear as a risk factor of retear. Two studies[8, 15] for small to medium size of tear from passive motion protocols were excluded, EPM demonstrated no significant difference in retear rate compared to DPM with mean difference 2.07 (95% CI, 0.96–4.43, p = 0.06, Quality of Evidence: Moderate). By excluding two studies[23, 33] for small to medium size of tear from active motion protocols, EAM demonstrated no significant difference in retear rate compared to DAM with mean difference 1.27 (95% CI, 0.63–2.59, p = 0.5, Quality of Evidence: High) (Fig. 4).