Home Exercise vs PT for Reverse Total Shoulder Arthroplasty
- Conditions
- Rotator Cuff Tear ArthropathyShoulder Arthritis
- Interventions
- Other: Home TherapyOther: Physical Therapy
- Registration Number
- NCT03719859
- Lead Sponsor
- Rush University Medical Center
- Brief Summary
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.
- Detailed Description
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.
Recruitment & Eligibility
- Status
- ACTIVE_NOT_RECRUITING
- Sex
- All
- Target Recruitment
- 200
- Subjects who have RSA for cuff tear arthropathy, massive irreparable rotator cuff tear with pseudoparalysis, or primary osteoarthritis.
- 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)
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description Home Therapy (HT) Group Home Therapy Subjects will receive instruction from clinical staff regarding home therapy exercises after surgery. Physical Therapy (PT) Group Physical Therapy Subjects will attend formal physical therapy after surgery.
- Primary Outcome Measures
Name Time Method Range of motion up to two years postoperatively Clinician measure of function using active and passive forward elevation, external rotation with the arm at the side in adduction and at 90 degrees of abduction in the scapular plane, and active internal rotation measured by highest vertebral level reached with thumb
Postoperative Pain: Numerical Rating Scale up to 2 years postoperatively Pain measured using 0-10 Numeric Pain Rating Scale (NRS) with 0 being a better score
Patient-reported functional outcome- American Shoulder and Elbow Surgeons Score up to two years postoperatively American Shoulder and Elbow Surgeons (ASES). Survey is scored 0 to 100 with 0 being the lowest possible score indicating a poor outcome and 100 being the highest possible score and indicating a good outcome.
Patient-reported functional outcome- Single Assessment Numeric Evaluation score up to two years postoperatively Single Assessment Numeric Evaluation (SANE) score. Survey is scored 0 to 100 with 0 being the lowest possible score indicating a poor outcome and 100 being the highest possible score and indicating a good outcome.
- Secondary Outcome Measures
Name Time Method Complication rates up to 2 years postoperatively acromial stress fractures and shoulder dislocations monitored by patient report through phone calls, patient visits, clinical exams, and standard of care imaging. All complications will be combined as a composite measure.
Postoperative Pain Medication Prescription Refills up to two years postoperatively number of narcotic medication prescription refills as documented in the Illinois Prescription Monitoring Program (Illinois PMP) or equivalent monitoring program for non-Rush centers
Postoperative Pain Medication Use Duration up to two years postoperatively duration of narcotic medication usage as documented in the Illinois Prescription Monitoring Program (Illinois PMP) or equivalent monitoring program for non-Rush centers
Cost of Care up to 2 years after surgery reimbursement for therapy services, total number of therapy visits, estimated travel time per visit, and associated costs. These measures will be combined in a cost-effectiveness analysis with a decision tree model.
Quality adjusted life years: PROMIS-29 up to 2 years postoperatively assessed using Patient-Reported Outcomes Measurement Information System-29. PROMIS Profile instruments are a collection of short forms containing a fixed number of items from seven PROMIS domains (Depression, Anxiety, Physical Function, Pain Interference, Fatigue, Sleep Disturbance, and Ability to Participate in Social Roles and Activities).The PROMIS-29 assesses each of the 7 domains with 4 questions. Each of the 7 domains has a raw score range from 4 to 20 with 4 being the lowest score, indicating a poor outcome and 20 being the highest score, indicating a good outcome.(PROMIS-29) surveys
Trial Locations
- Locations (7)
Rush University Medical Center
🇺🇸Chicago, Illinois, United States
Western Orthopaedics
🇺🇸Denver, Colorado, United States
Medstar Georgetown University Hospital
🇺🇸Washington, District of Columbia, United States
Anderson Orthopedic Clinic
🇺🇸Arlington, Virginia, United States
University Hospitals Cleveland Medical Center
🇺🇸Cleveland, Ohio, United States
Centers for Advanced Orthopaedics
🇺🇸Leonardtown, Maryland, United States
New England Baptist Hospital
🇺🇸Dedham, Massachusetts, United States