Weekly Literature Review: Advances in Musculoskeletal Rehabilitation and Surgical Decision-Making

Monday: Preoperative Physical Therapy for Lumbar Disc Herniation

Citation: Oliveira, J. P., Casqueiro, M., Andrade, J. P., & Reizinho, C. (2025). Does preoperative physical therapy/prehabilitation affect outcome or complications after surgery for lumbar disc herniation? A systematic review. Brain and Spine, 5, 104386. https://doi.org/10.1016/j.bas.2025.104386

Summary: This systematic review examined whether prehabilitation improves outcomes following lumbar disc herniation surgery. The authors found that preoperative physical therapy consistently improved pain, function, mobility, and psychological readiness in the short term. However, these benefits largely dissipated by 6-12 months postoperatively, with outcomes converging between intervention and control groups. Supervised, higher-intensity programs demonstrated superior early benefits compared to home-based interventions. The review highlighted significant clinical heterogeneity across studies and called for diagnosis-specific, long-term trials with standardized protocols to better define prehabilitation's role in spine surgery recovery.

Tuesday: Economic Evaluations of Rehabilitation and Return-to-Work Programs

Citation: Kurnianto, A. A., Kovács, S., Ágnes, N., & Kumar, P. (2025). Economic evaluations of rehabilitation interventions: A scoping review with implications for return to work programs. Healthcare, 13(10), 1152. https://doi.org/10.3390/healthcare13101152

Summary: This scoping review synthesized economic evaluations of rehabilitation interventions, with emphasis on return-to-work (RTW) outcomes. The authors found that many rehabilitation programs demonstrated favorable cost-effectiveness, particularly for musculoskeletal and neurological conditions. Integrated approaches combining medical, psychological, and vocational components showed stronger RTW outcomes than medical-only models. However, significant gaps emerged in reporting standards, with many studies failing to fully adhere to CHEERS guidelines. Geographic representation was skewed toward high-income countries, and emerging technology-driven interventions (robotics, digital platforms) require more robust economic data. The review underscored the need for standardized methodologies and broader societal cost perspectives to inform policy decisions.

Wednesday: Combination vs. Single-Modality Physiotherapy for Rotator Cuff Pain

Citation: Lo, C.-S., Chen, K.-C., Shih, J.-C., Cheng, B., & Chao, W.-C. (2025). Comparative effectiveness of combination versus single-modality physiotherapy for rotator cuff-related shoulder pain: A systematic review and network meta-analysis. Journal of Clinical Medicine, 14(4765). https://doi.org/10.3390/jcm14134765

Summary: This network meta-analysis of 11 RCTs compared physiotherapy modalities for rotator cuff-related shoulder pain (RCRSP). Combination therapy (exercise plus manual therapy) demonstrated the greatest improvements in pain and function, though wide confidence intervals indicated statistical uncertainty. Exercise therapy alone provided moderate functional gains, while Kinesio taping offered moderate pain relief. Despite promising trends, no intervention achieved statistically significant superiority due to overlapping confidence intervals. The study's strength lay in its methodological rigor, utilizing Cochrane RoB 2.0 for bias assessment and standardizing follow-up to 12 weeks. The authors concluded that while combination therapy shows clinical promise, larger-scale trials are needed to confirm long-term efficacy and cost-effectiveness.

Thursday: Timing of Improvement in Operative vs. Nonoperative Rotator Cuff Treatment

Citation: Song, A., DeClercq, J., Ayers, G. D., Higgins, L. D., Kuhn, J. E., Baumgarten, K. M., Matzkin, E., & Jain, N. B. (2020). Comparative time to improvement in nonoperative and operative treatment of rotator cuff tears. Journal of Bone and Joint Surgery, 102(13), 1142–1150. https://doi.org/10.2106/JBJS.19.01112

Summary: This prospective cohort study utilized two-stage time-to-event analysis to compare improvement trajectories between operative and nonoperative treatment for rotator cuff tears. Nonoperative care demonstrated faster early improvement, with patients achieving a 40% probability of reaching minimal clinically important difference (MCID) in SPADI scores at 3.25 months versus only 6% for surgical patients. However, surgical intervention yielded superior long-term outcomes, with 96% of surgical patients achieving greater than 50% ASES improvement at 24.7 months compared to 66% of nonoperative patients. Propensity score weighting balanced baseline differences between groups. The study revealed that 12 nonoperative patients crossed over to surgery at a median of 5.4 months, highlighting the dynamic nature of treatment decision-making in clinical practice.

Friday: Patient-Defined Smallest Worthwhile Effect for Rotator Cuff Repair

Citation: Hansford, H. J., Buchbinder, R., Zadro, J. R., McAuley, J. H., Ferreira, M. L., Lewin, A., Page, R. S., & Harris, I. A. (2025). The smallest worthwhile effect on pain and function for rotator cuff repair surgery: A benefit-harm trade-off study. Trials, 26, 203. https://doi.org/10.1186/s13063-025-08902-x

Summary: This innovative benefit-harm trade-off study quantified patient expectations for rotator cuff repair surgery by determining the smallest worthwhile effect (SWE). Participants required an average 40% improvement in pain and function—translating to 28 points on the transformed WORC Index—for surgery to be considered worthwhile compared to alternatives. Notably, approximately one-third of participants would not consider surgery worthwhile even with complete symptom resolution. Female participants and those with higher self-rated health required significantly greater improvements to justify surgical intervention. The study demonstrated moderate-to-good test-retest reliability (ICC = 0.60-0.76) and distinguished SWE from traditional MCID thresholds, arguing that patient-derived, comparison-specific benchmarks are more appropriate for evaluating high-risk, high-cost interventions. These findings are informing power calculations for the Australian Rotator Cuff Trial.

Precision in Timing, Treatment Selection, and Patient-Centered Expectations

This week's literature focuses on a critical paradigm shift in musculoskeletal care: moving from standardized protocols to precision-based, temporally sensitive, and patient-aligned interventions.

Three interconnected themes emerge:

1. Temporal Dynamics Matter Both the lumbar prehabilitation and rotator cuff timing studies demonstrate that when patients improve differs dramatically by treatment modality. Prehabilitation provides short-term psychological and functional readiness but lacks sustained impact, while nonoperative rotator cuff care delivers rapid early relief that surgical approaches cannot match initially. However, surgical interventions ultimately produce deeper, more durable improvements. This temporal nuance challenges the binary "surgery versus conservative care" framework, suggesting clinicians must counsel patients on trajectories of recovery rather than static outcomes.

2. Integration Over Isolation The economic evaluation and combination physiotherapy studies reinforce that integrated, multimodal approaches consistently outperform single-intervention strategies. Whether combining exercise with manual therapy for shoulder pain or integrating medical, psychological, and vocational components for RTW programs, the evidence points toward synergistic effects that address the biopsychosocial complexity of musculoskeletal conditions. This has profound implications for reimbursement models and care delivery systems that remain siloed by discipline.

3. Patient Values Define Clinical Significance The smallest worthwhile effect study fundamentally challenges how we interpret clinical trial results. Traditional MCID thresholds may underestimate what patients actually need to justify surgical risks and costs. With one-third of patients unwilling to pursue surgery even for complete symptom resolution and substantial gender-based variations in benefit thresholds, these findings demand incorporation of patient-specific values into shared decision-making frameworks and trial design.

Clinical Implications: For physical therapists and healthcare decision-makers, this week's evidence suggests several action items:

• Implement prehabilitation selectively, focusing on psychological preparation and short-term optimization rather than expecting long-term outcome modification

• Advocate for integrated care pathways that combine exercise, manual therapy, and psychosocial support

• Develop temporally-informed patient education materials that accurately represent recovery trajectories for surgical versus conservative approaches

• Incorporate benefit-harm trade-off assessments into preoperative consultations, particularly for populations demonstrating higher SWE thresholds

• Support health economic research that captures productivity costs and societal perspectives, especially in underrepresented geographic regions

The literature this week collectively argues that optimal musculoskeletal care requires matching intervention intensity and timing to patient-specific recovery patterns, functional demands, and personal values, a departure from one-size-fits-all treatment algorithms toward truly personalized rehabilitation medicine.