Home Exercise vs PT for Reverse Total Shoulder Arthroplasty
Home Exercise vs PT for Reverse Total Shoulder Arthroplasty
The primary objective of this study is to compare outcomes between formal clinic based
 physical therapy (PT) rehabilitation and surgeon directed home therapy (HT) after reverse
 total shoulder arthroplasty (RSA) as measured by pain, range of motion, Single Assessment
 Numerical Evaluation (SANE), and American Shoulder and Elbow Surgery (ASES) scores at 6
 weeks, 3, 6, 12, and 24 months postoperatively. The secondary objective of this study is to
 determine if PT rehabilitation following RSA is associated with a higher level of
 postoperative complications, specifically acromial stress fractures or dislocation. This
 information will be useful to discern if PT is effective in providing pain relief more
 quickly, as well as improved motion and self-reported functional outcomes following RSA,
 which can assist surgeons and rehabilitation specialists in designing optimal care plans for
 this patient population. The project will also help to clarify if PT services place patients
 who have RSA at higher risk for acromial stress fractures or dislocation.
Reverse total shoulder arthroplasty (RSA) is a relatively new solution for the patient with
 osteoarthritis of the glenohumeral joint with a deficient rotator cuff, or patients with
 glenohumeral osteoarthritis with excessive erosion of the posterior glenoid. Since the
 approval of RSA in 2003, the utility has increased such that this procedure represented 33%
 of all shoulder arthroplasties performed in the United States in 2011, and represents greater
 than 90% in some European countries The RSA prosthesis is effective at providing improved
 active motion and function due the semi-constrained design--substituting for the centering
 effect of the rotator cuff and allowing the deltoid to elevate or abduct the arm with
 fixed-fulcrum kinematics without a functional rotator cuff. Many factors influence the
 potential for successful outcome following RSA: proper patient selection, surgeon experience
 level, prosthesis characteristics, surgical technique and approach, and postoperative
 rehabilitation. Prior researchers have explored the effect of surgical technique, type of
 prosthesis, and surgery indications on outcome following RSA, however there is no data
 published on the impact of postoperative rehabilitation following this surgery.

 A systematic review of the literature reveals that complications following RSA occur with
 four times greater incidence than complications following anatomic total shoulder
 arthroplasty (TSA). Complications following RSA which may be impacted by the exercises
 associated with physical therapy include instability and acromion stress fractures. A
 systematic review of the literature was conducted to determine if complication rates
 following RSA differ due to surgical approach, type of prosthesis (medialized or lateralized
 center of rotation), and the indication for the procedure. The authors of this review
 acknowledge that postoperative rehabilitation can impact the clinical and functional outcome
 of RSA and complication rate, however did not study this variable due to the heterogeneous
 approach to rehabilitation for the multi-center study.

 Experts in the field of shoulder rehabilitation have published clinical guidelines for
 rehabilitation following reverse shoulder arthroplasty. One set of published guidelines is
 based on biomechanical and basic science healing timeframes associated with the tissue
 attrition following RSA. The authors describe precautions to protect the prosthesis from
 dislocation and acromial stress fractures, and propose a slow progressive approach to
 restoring motion and functional strength. The clinical guidelines published by these authors
 contrast with a very progressive criterion based rehabilitation plan that allows early use of
 the arm and very little immobilization. Neither of these two proposed rehabilitation plans
 are associated with clinical trials that track clinical or functional outcome measures or
 complication rate. A chapter devoted to rehabilitation following RSA in the book "Reverse
 Shoulder Arthroplasty" suggests that physician directed video-based rehabilitation may be
 just as effective as formal physical therapy. The author points out the need for randomized
 controlled trials to determine the need for physical therapy following a variety of shoulder
 surgeries. Clarifying the impact of formal clinic based PT intervention following RSA is
 important in determining the best plan of care for this population following surgery, while
 ensuring that there is not an increase in complications associated with the therapy.
Inclusion Criteria:

 -  Subjects who have RSA for cuff tear arthropathy, massive irreparable rotator cuff tear
 with pseudoparalysis, or primary osteoarthritis.

 Exclusion Criteria:

 -  Subjects who have a non-reverse total shoulder arthroplasty, RSA for fracture, tendon
 transfers as part of RSA, and revision RSA

 -  Subjects who had RSA and require discharge to skilled nursing facility, in-patient
 rehabilitation placement, or use of home health therapy prior to progressing in
 recovery

 -  Subjects who cannot speak, read, or write the English language

 -  Subjects who have cognitive deficits limiting ability to follow directions

 -  Subjects who have inability to attend physical therapy (i.e. transportation or
 financial limitations)