MOON Shoulder Group Nabs Kappa Delta Ann Doner Vaughn Award

The 2024 Kappa Delta Ann Doner Vaughn Award has been bestowed upon the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Group for shifting the way physicians treat patients with atraumatic, symptomatic rotator cuff tears. The group’s research determined that physical therapy (PT) is an effective treatment for more than 70% of these patients to improve pain and patient-reported outcome measures (PROMs) followed for 10-plus years. This award recognizes research in musculoskeletal disease or injury with great potential to advance patient care.
 
According to the American Academy of Orthopaedic Surgeons (AAOS), nearly 2 million people in the United States visit their doctors each year for rotator cuff tears. This type of injury creates a significant economic burden to the U.S. health care system, as the prevalence of rotator cuff tears accelerates with age, and more than two-thirds of patients who have surgery are of working age.
 
“When I finished my training in 1994, we were taught that surgery was the preferred way to treat a rotator cuff tear,” said John E. Kuhn, M.D., chief of shoulder surgery and director of Vanderbilt Sports Medicine and director of the MOON Shoulder Group. “As the approach to treating rotator cuff tears remained unclear, we wanted a more thorough understanding of the disease to help define the indications for rotator cuff repair surgery and determine which patients would benefit from nonoperative treatment.”
 
Over the course of 10 years, the MOON Shoulder Group used its multicenter outcomes network to prospectively collect data on patients with rotator cuff disease to answer clinically important questions and better understand the natural history and treatment of rotator cuff disease.
 
To predict failure rates of nonoperative treatment of rotator cuff tears, the group developed a standard, evidence-based PT protocol that included a “gold standard” PT protocol, with elements derived from a systematic review. The cohort study enrolled patients aged 18 to 100 years with shoulder symptoms and MRI-documented, symptomatic, atraumatic, full-thickness rotator cuff tears (where the tendon is completely detached from the bone).
 
Patients were given two instructive rehabilitation books—one for physical therapists and another for home-based PT written at the eighth-grade level—with an accompanying DVD. The specific exercises included daily range of motion (postural exercises, active-assisted motion, active training of scapular muscles and active range of motion); daily flexibility (anterior and posterior shoulder stretching); and strengthening three times per week (rotator cuff and scapula exercises). Therapists were instructed to provide manual mobilization exercises as needed based on evidence that supports their use in impingement and to progress the patient to a home therapy program when ready. Based on the systematic review, heat and cold were recommended as modalities, but ultrasound was not.ⁱ
 
Patient outcome scores were tracked at entry into the study and during each follow-up visit at six weeks, 12 weeks, one year, and two, five, seven and 10 years. At the six-week mark, patients were given three options: no additional follow up if they considered themselves “cured”; continue PT for six more weeks if they were “improved”; and, if they were “no better”, they could elect to have surgery. At any point during the study, patients could opt to have surgery. Results from the research include: 

• At 10 years, PT was shown to be highly effective in more than 70% of patients with atraumatic, symptomatic, full-thickness rotator cuff tears in reducing pain and improving PROMs.
• Most patients who decided to have surgery within six months were driven primarily by their expectations of the effectiveness of physical therapy. In other words, if they thought PT would work, it worked. If they didn’t believe it would work, it didn’t.
• When comparing those who had surgery before six months and those who had surgery between six months and 10 years, worker’s compensation status and activity level were more important in predicting the need for surgery after six months.
• Structural factors (tear size, retraction), visual analog pain score and weakness were not predictors of having surgery and are likely not helpful in determining surgical indications.
• There was no correlation between rotator cuff tear anatomy and pain, the duration of symptoms, and patient activity level. 

“Our team was shocked when so many patients in the cohort improved with physical therapy, because it’s not at all what we expected,” said Kuhn. “We’re also optimistic about the finding that low expectations for therapy drives patients to having surgery because we can modify this variable by educating patients that physical therapy can work.”
 
The MOON Shoulder Group and other surgeons are engaged in the Arthroscopic Rotator Cuff Trial, a multicenter, randomized trial funded by the Patient Centered Outcomes Research Institute, where patients with symptomatic, atraumatic full-thickness rotator cuff tears are randomized to either treatment with PT or surgical repair of their rotator cuff tear to help determine which treatment option might be best suited for a particular patient. 
 
In addition to Kuhn, the MOON Shoulder Group includes the following researchers: Warren R. Dunn, M.D.; Rosemary Sanders, B.A.; Keith M. Baumgarten, M.D.; Julie Y. Bishop, M.D.; Robert H. Brophy, M.D.; James L. Carey, M.D.; Brian G. Holloway, M.D.; Grant L. Jones, M.D.; C. Benjamin Ma, M.D.; Robert G. Marx, M.D.; Eric C. McCarty, M.D.; Sourav K. Poddar, M.D.; Matthew V. Smith, M.D.; Edwin E. Spencer, M.D.; Armando F. Vidal, M.D.; Brian R. Wolf, M.D.; and Rick W. Wright, M.D.
 
In 1947, at its golden anniversary, the Kappa Delta Sorority established the Kappa Delta Research Fellowship in Orthopaedics, the first award ever created to honor achievements in orthopedic research. The first annual award, a single stipend of $1,000, was made available to the AAOS in 1949 and presented at the AAOS meeting in 1950. The Kappa Delta Awards have been presented by the AAOS to persons who have performed research in orthopedic surgery that is of high significance and impact. The sorority has since added two more awards and increased the award amounts to $20,000 each. Two awards are named for the sorority national past presidents who were instrumental in the creation of the awards: Elizabeth Winston Lanier and Ann Doner Vaughn. The third is known as the Young Investigator Award. 
 
With more than 39,000 members, the American Academy of Orthopaedic Surgeons is the world’s largest medical association of musculoskeletal specialists. The AAOS advances musculoskeletal health; it provides comprehensive education to help orthopedic surgeons and allied health professionals best treat patients. The AAOS is the source for information on bone and joint conditions, treatments and related musculoskeletal health care issues; and it leads the health care discussion on advancing quality.

Reference 
ⁱ Kuhn JE. Exercise in the treatment of rotator cuff impingement: a systematic review and a synthesized evidence-based rehabilitation protocol. J Shoulder Elbow Surg. 2009 Jan-Feb;18(1):138-60.