Fig. 1 Mean active forward elevation over time in patients undergoing reverse total shoulder arthroplasty who underwent either a home exercise program (gray) or supervised physical therapy program (white).
Courtesy of Peter Chalmers, MD

AAOS Now

Published 12/20/2023
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Rebecca Araujo

Home Exercise Program Shows Similar 1-year Improvements after Reverse TSA as Physical Therapy Regimen

The results of a randomized clinical trial, presented at the AAOS 2023 Annual Meeting, found that a home-based rehabilitation program provided similar benefits to supervised physical therapy (PT) after reverse total shoulder arthroplasty (RTSA). AAOS Now Editor-in-chief Robert M. Orfaly, MD, MBA, FAAOS, spoke with the presenting author, Peter Chalmers, MD, associate professor at the University of Utah, about the study findings and how they will impact clinical practice.

Dr. Chalmers highlighted the main takeaway: “For the average primary reverse, either for glenohumeral osteoarthritis or rotator cuff tear arthropathy, physical therapy may not be necessary to achieve the same outcome you can achieve with a home exercise program (HEP). I think this really speaks to the reverse in general and how it’s a very overall resilient procedure.”

He added the caveat, “Our findings don’t apply to every reverse, and certainly if it’s a revision reverse or a reverse done for fracture, then those may be different, and certainly those were excluded from our study.”


Patients and methods

The study recruited patients undergoing primary RTSA, who were then randomized to HEP or supervised PT. Eighty-nine patients were enrolled, with 43 in the PT group and 46 in the HEP group. The primary outcomes were range of motion (ROM) and patient-reported outcomes (PROs) up to 1 year postoperatively. PROs included American Shoulder and Elbow Surgeons scores, Western Ontario Osteoarthritis Scores (WOOS), and visual analog scale (VAS) scores. PROs and ROM were measured at baseline and at 6 weeks, 3 months, and 1 year postoperatively.

To capture ROM, the researchers videotaped patients and asked them to maximally forward elevate, abduct, externally rotate in adduction, and internally rotate in adduction. Blinded observers measured ROM, and ROM measurements were found to be reliable, with intraclass correlation coefficients of >0.923 and kappa values of >0.6.

ROM and pain outcomes
Eighty-three patients (93%) completed 1-year follow-up PROs, and 73 patients (82%) completed 1-year follow-up ROM measurements. Twenty percent of patients (n = 9) crossed over from HEP to PT.

Thirteen percent of HEP patients and 17 percent of PT patients experienced complications, respectively, which was not a statistically significant difference (P = 0.629). Reports of instability were also similar between the HEP and PT groups (9 percent versus 7 percent, respectively; P = 1.000).

Regarding primary outcomes, the intent-to-treat analysis found no significant differences in PROs or ROM between the two rehabilitation programs at any postoperative timepoint (Fig. 1). In the as-treated analysis, the HEP group reported significantly better VAS scores (P = 0.012) and WOOS (P = 0.006), as well as better abduction (P = 0.042).

Clinical takeaways
HEP offers many benefits to patients and the healthcare system more broadly, Dr. Chalmers noted. “It’s less travel, it’s less cost, it’s more convenient for the patient,” he said. “If we can achieve the same outcome with less input from the patient, from the surgeon, and from our medical system, that’s a desirable outcome.” Some patients may still require or prefer PT, though Dr. Chalmers stated that the study sample size was not large enough to perform a subgroup analysis to identify predictive factors for which patients needed PT over HEP.

Dr. Chalmers touched on some deficiencies in recovery after RTSA among participants, such as patients not recovering full internal and external rotation postoperatively. Some of that can be explained by changes in practice over the course of the study period, he said.

“I started this study 7 years ago. These were all Grammont prostheses. None of them was preoperatively planned. There are advances we’ve made in our clinical practice since we started this study,” Dr. Chalmers acknowledged. “Obviously, we standardized things for the study, and I do think some of those advances probably can improve motion. One of the things we’re doing now is to try and look at a more granular level. Are there changes in implant position you can make to improve rotation? That’s hopefully something that will be our next step for this study.”

Dr. Chalmers’ coauthors of “Physical Therapy Does Not Improve Outcomes after Reverse Total Shoulder Arthroplasty: A Multi-center, Assessor-blinded Randomized Clinical Trial” are Robert Zaray Tashjian, MD; Jay D. Keener, MD, FAAOS; Julianne A. Sefko, MPH; Adrik Zuriel Da Silva; Caellagh Dell Catley; and Aaron Mark Chamberlain, MD, MBA, MSc, FAAOS.

Rebecca Araujo is the managing editor of AAOS Now. She can be reached at raraujo@aaos.org.