No differences in outcomes found with early vs delayed rehabilitation after TSA
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Results from a systematic review showed no differences in patient-reported or clinician-reported outcomes between early and delayed rehabilitation at 12 months after total shoulder replacement.
Researchers performed a comprehensive literature search of key databases from inception until July 29, 2021, for randomized controlled trials that compared early vs. delayed rehabilitation following primary anatomic, primary reverse or revision total shoulder replacement. To evaluate the quality of evidence, researchers used a revised Cochrane risk of bias assessment tool for randomized controlled trials, as well as the Grading of Recommendations Assessment, Development and Evaluation approach.
Among the three eligible randomized controlled trials with 230 patients included in the review, researchers found low-quality evidence of no statistically significant difference in pain, shoulder function, health-related quality of life or lesser tuberosity osteotomy healing at 12 months between early and delayed rehabilitation. Results also showed the trials had conflicting and low-quality evidence of a difference between the effect of early and delayed rehabilitation on shoulder range of movement.
In the early postoperative period, early rehabilitation after anatomic total shoulder replacement had limited, low quality-evidence of statistically significantly improved pain and function, according to researchers.
“Future research should focus on the uncertainties surrounding the optimal time point at which to begin mobilization of the shoulder following surgery and how long the postoperative sling should be worn,” the authors wrote. “Understanding patients’ perspectives on early post-surgical recovery through further qualitative research would also be useful in helping to prioritize patient-important outcomes in the early postoperative period.”
Perspective
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Rehabilitation following anatomic and reverse shoulder arthroplasty aims to optimize mobility and strength postoperatively and can be initiated immediately or following an initial period of immobilization. The authors make a valiant attempt at a systematic review evaluating the effectiveness of early vs. delayed rehabilitation following shoulder arthroplasty. Only three studies were included, highlighting the dearth of high-quality evidence to guide decision-making. The authors note that non-healing following lesser tuberosity osteotomy in one anatomic shoulder arthroplasty study was fivefold greater with early compared with delayed rehabilitation. However, stiffness resulting from excessive delay is also problematic, and a principal mode of patient dissatisfaction following shoulder arthroplasty. Physical therapy effectiveness also depends on execution and strategy, whether supervised, physician-directed, remote through telerehabilitation or combinations thereof. Additionally, it is important to recognize that many other factors contribute to outcome, including patient factors, such as health, resiliency and other psychosocial factors, as well as anatomic factors, such as rotator cuff integrity and bony anatomy, and implant factors, such as glenosphere size.
The surgeon is the method, according to Frederick A. Matsen III, MD, and physical therapy alone cannot offset poor patient selection or deficient surgical technique. The review underscores that large-scale, high-level studies are needed to critically evaluate various rehabilitation strategies following shoulder arthroplasty before any recommendations can be made.
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