'If he thought that I was going to go and hurt myself, he had another thing coming': Treatment experiences of those with large to massive rotator cuff tears and the perspectives of healthcare practitioners

OBJECTIVE

To explore the treatment experiences of those diagnosed with large to massive rotator cuff tears and the perspectives of healthcare practitioners providing their care.

DESIGN

A qualitative descriptive study using reflexive thematic analysis.

SETTING

In-person focus groups were undertaken in a clinical setting (private practice [n = 1]; public outpatient [n = 2]). Semi-structured interviews were conducted online via Microsoft Teams.

PARTICIPANTS

Patients diagnosed with these tears (n = 12) and healthcare practitioners (n = 11).

RESULTS

Two interlinking themes were identified based on the care received and provided for patients with symptomatic large to massive rotator cuff tears:1) Positive treatment experiences and management: Education, clear communication and reassurance around prognosis were the foundation of positive patient-clinician care. Sub-themes of pain relief, exercise prescription and confidence in their pathway underpinned this experience. This proficiency in care was affirmed by some healthcare practitioners who spoke about the importance of confidence and experience in their management plan even in times of poor progress.2) Negative treatment experiences and management: Uncertainty, delays and exacerbation of pain flawed the patient-clinician care. Sub-themes of inappropriate pain relief, inappropriate exercise prescription and uncertainty impacted their care. Some healthcare practitioners acknowledged knowledge gaps led to uncertainty especially when choosing the next step of care and were quick to escalate care to deflect this uncertainty.

CONCLUSIONS

The findings suggest discordance exists between the patient's experiences and expectations when the delivery of care was by less experienced and confident healthcare practitioners in the management of this condition. This highlights the need for improved education and support for healthcare practitioners.

Exercise as effective as surgery in improving quality of life, disability, and pain for large to massive rotator cuff tears: A systematic review & meta-analysis

QUESTIONS

To report the characteristics of exercise interventions and ascertain their effectiveness compared to surgery on quality of life, disability, and pain for people with large to massive rotator cuff tendon tears (L-MRCTTs).

DESIGN

Systematic review with meta-analysis of randomised controlled trials (RCTs).

PARTICIPANTS

Adults with L-MRCTTs defined as; >5 cm, 2 or more tendons.

INTERVENTION

Exercise as an intervention for L-MRCTTs.

OUTCOME MEASURES

Primary: quality of life, disability, and pain. Secondary: range of motion (ROM). The Consensus on Exercise Reporting Template (CERT) was used to extract data on the individual characteristics of each exercise intervention. The Cochrane Risk of Bias Tool V2 was used to assess study quality with the certainty of evidence assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria.

RESULTS

Five trials (n = 297 participants, average age 66.7 years, 55% male) were included in analysis. Three trials compared exercise to another non-surgical intervention and 2 trials compared exercise to surgery. At 12 months a significant improvement in pain of 0.47 (95% CI 0.07-0.88, I² = 53%, REM) favoured the surgical group and a significant improvement in shoulder external rotation ROM of 9° (95% CI 2.16-16.22, I² = 0%, FEM) favoured the exercise group. The median CERT score was 7/19 (range 4-12). The certainty of evidence was low or very low across all outcomes.

CONCLUSION

A paucity of high-quality research on the role of exercise in the management of L-MRCTTs exists with substantial discrepancies in the reporting of the exercise interventions in the published research.

Large to massive rotator cuff tendon tears: a protocol for a systematic review investigating the effectiveness of exercise therapy on pain, disability and quality of life

Background: Chronic non-traumatic rotator cuff tendon tears are inextricably linked with the natural process of aging often resulting in severe disability, poor quality of life and an added burden to the health care system. The occurrence of rotator cuff tendon tears increases exponentially with every decade of life to approximately 60% in individuals over 80 years of age. Exercise is a commonly prescribed intervention although research on its efficacy is in its infancy and often conflicting. The purpose of this systematic review is to investigate the effectiveness of exercise interventions for people diagnosed with large to massive rotator cuff tendon tears.

Methods: This systematic review will adhere to the PRISMA reporting guidelines. A comprehensive search of five databases will be conducted. Randomised clinical trials (RCT) or quasi-randomised control trials will be included if they evaluate exercise as the core intervention or as part of the intervention in the management of large to massive rotator cuff tears. To quantify response to treatment we will compare changes in pain, disability and quality of life (QoL). The Consensus on Exercise Reporting Template (CERT) will be used to characterise the different types of exercise intervention. The Cochrane Risk of Bias Tool will be used to assess study quality.

A narrative synthesis with meta-analysis will be performed, and the certainty of evidence will be assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria.

Discussion: This review will synthesise the totality of GRADE A and B evidence on the effectiveness of exercise for large to massive rotator cuff tendon tears. It will provide clinically important information and guidance for immediate implementation by clinicians, health policymakers and may be used to guide future research.

PROSPERO registration: 244502 (24/03/2021)

Large to massive rotator cuff tendon tears: a protocol for a systematic review investigating the effectiveness of exercise therapy on pain, disability and quality of life

Background: Rotator cuff tendon tears are inextricably linked with the natural process of aging often resulting in severe disability, poor quality of life and an added burden to the health care system. The occurrence of rotator cuff tendon tears increases exponentially with every decade of life to approximately 60% in individuals over 80 years of age. Exercise is a commonly prescribed intervention although research on its efficacy is in its infancy and often conflicting. The purpose of this systematic review is to investigate the effectiveness of exercise interventions for people diagnosed with large to massive rotator cuff tendon tears. Methods: This systematic review will adhere to the PRISMA reporting guidelines. A comprehensive search of five databases will be conducted. Randomised clinical trials (RCT) or quasi-randomised control trials will be included if they evaluate exercise as the core intervention or as part of the intervention in the management of large to massive rotator cuff tears. To quantify response to treatment we will compare changes in pain, disability and quality of life (QoL). The Consensus on Exercise Reporting Template (CERT) will be used to characterise the different types of exercise intervention. The Cochrane Risk of Bias Tool will be used to assess study quality. A narrative synthesis with meta-analysis will be performed, and the certainty of evidence will be assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Discussion: This review will synthesise the totality of GRADE A and B evidence on the effectiveness of exercise for large to massive rotator cuff tendon tears. It will provide clinically important information and guidance for immediate implementation by clinicians, health policymakers and may be used to guide future research. PROSPERO registration: 244502 (24/03/2021)

Moral distress, advocacy and burnout: theorizing the relationships

Burnout is a major contributor to shortages of experienced nurses. The research literature shows a correlation between moral distress and burnout in critical care nurses. This paper reports on part of an interpretive interactionist study concerning nurses' experiences of moral distress which prompted attempts to advocate for vulnerable patients. One critical incident is used as an example of the qualitative findings of the study. In this paper, we theorize about what happened when nurses advocated for their patients by challenging medical treatments which the nurses believed to be both inappropriate and to contributing to patient suffering. When attempts at advocacy were unsuccessful, the nurses experienced intensified moral distress, frustration and anger. Being an unsuccessful advocate resulted in nurses being relocated within the hospital, nurses being scapegoated and/or burning out. The theoretical links which this paper makes between advocacy, moral distress and burnout are supported by empirical data from the study.

Being a midwife or doing midwifery?

As a profession, we need to be more conscious of the way in which our discipline has been subsumed into techno-rational science and away from our 'with women' focus. The ACMI Philosophy says that we value 'being with' women as the foundation for midwifery practice, therefore the concept 'being with' should be a competency which is reflected in the ACMI Professional Standards and Competencies. Currently, there is no Professional Standard for "Being With Women": all midwifery care has been subsumed under the rubric of problem-solving. The problem-solving approach is part of the modernist, techno-rational approach to human life experiences. Problem-solving, I am claiming, has been over-generalised and imposed upon human experiences where it is not appropriate. This paper argues against adopting problem-solving as the framework for practice because this means that every aspect of midwifery care has to be problematised. This paper concludes by suggesting one way in which our philosophy could be honoured in our professional standards and competencies.

Postmodern feminist emancipatory research: is it an oxymoron?

Many nurse-researchers who use feminist methods believe that postmodernism undermines the scientific and emancipatory aspirations of our discipline and they are therefore wary of postmodern theories. One of the main threats of postmodernism is the critique of humanism because humanism forms the ethical foundation for both nursing and feminism. These critiques expose the dark underside of humanistic ideals and show how, paradoxically, humanism has functioned to oppress people. The arguments presented here help emancipatory researchers to defend their practices, both in relation to research participants and in the ways in which the subjects is theorized. The conclusion is that postmodernism can be compatible with politically motivated, humanistically-based inquiry.

Praxis methodology: action research without a group

Critical action research is a compelling method for nursing research because it offers a sensitive and qualitative way to study change processes in action. Action research is of limited use to nurse researchers because it relies on group participation whereas most nursing work which we may want to research involves one to one relationships with clients. This paper presents a modification of critical action research. It is termed 'Praxis Research' and it is suitable for research projects that aim to empower individuals, rather than groups. The steps in the praxis research process are described as an on-going spiral of practice, self-reflection, scholarly inquiry and theorising which leads to changed practice.

Poverty, welfare and single teenage mothers: a primary health care concern

This paper draws upon the international literature to support the thesis that poverty is more the cause, then the effect, of single teenage childbearing. The paper demonstrates that the rate of single teenage births has dramatically declined over the past twenty years while the level of government support for sole parents has significantly increased over the same period (an example of current rates of payment is included). The author asserts that there is no direct relationship between the level of welfare support and the incidence of adolescent childbearing. Midwives who function as primary health care providers should be aware of the socio-political environment as it affects disadvantaged young women.