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Rehabilitation following reverse shoulder arthroplasty

A work of the Rehabilitation Commission of the German Society of Shoulder and Elbow Surgery (DVSE) e. V. in collaboration with the German Association for Physiotherapy (ZVK) e. V., the Physical Therapy Association—Association for Physical Professions (VPT) e. V. and the Rehabilitation Section—Physical Therapy of the German Society for Orthopaedics and Trauma e. V. (DGOU)
  • S. BuchmannEmail author
  • C. Schoch
  • C. Grim
  • C. Jung
  • K. Beitzel
  • M. Klose
  • B. Mauch
  • F. Pfalzer
  • L. Tepohl
  • R. Tholen
  • T. Gottfried
  • H. Ortmann
  • M. Scheibel
  • F. Mauch
Open Access
Original Contribution

Abstract

Background

Reverse shoulder arthroplasty (RSA) shows a growing number of implantations and is a valuable option to improve shoulder function and decrease pain. However, there is no consensus concerning the rehabilitation protocol following surgery.

Objectives

To review and evaluate current rehabilitation contents and protocols after RSA by reviewing the existing scientific literature and providing an overview of the clinical practice of selected German Society of Shoulder and Elbow Surgery (Deutsche Vereinigung für Schulter- und Ellenbogenchirurgie e.V., DVSE) shoulder experts.

Materials and methods

A literature search for the years 1989–2016 was conducted in relevant databases and bibliographies including the Guidelines International Network, National Guidelines, PubMed, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and the Physiotherapy Evidence Database. In addition, 63 DVSE experts were contacted via an online questionnaire.

Results

Since no level I/II studies on postoperative protocols after RSA were found, the 856 hits were searched by the committee members and sorted according to the topics “rehabilitation”, “complications”, “clinical outcome studies”, “basic science”, “reviews” and “miscellaneous”. Additionally, survey results were analyzed and compared to the literature.

Discussion

The comparison between literature recommendation and expert survey showed agreement according principal aspects (e.g. brace/sling, immobilization, passive exercises). Based on the literature and the expert opinions obtained, a four-phase rehabilitation protocol could be developed.

Keywords

Reverse shoulder replacement Osteoarthritis Cuff tear arthropathy Physiotherapy 

Rehabilitation nach inverser Schulterprothetik

Eine Arbeit der Kommission Rehabilitation der Deutschen Vereinigung für Schulter- und Ellenbogenchirurgie (DVSE) e. V. in Zusammenarbeit mit dem Deutschen Verband für Physiotherapie (ZVK) e. V., dem Verband Physikalische Therapie – Vereinigung für die physiotherapeutischen Berufe (VPT) e. V. und der Sektion Rehabilitation – Physikalische Therapie der Deutschen Gesellschaft für Orthopädie und Unfallchirurgie (DGOU) e. V.

Zusammenfassung

Hintergrund

Bezüglich der inversen Schulterprothetik ist eine wachsende Anzahl von Implantationen zu verzeichnen. Sie ist eine wertvolle Option zur Verbesserung der Schulterfunktion und zur Schmerzlinderung. Das Rehabilitationsprotokoll nach der Operation ist jedoch noch wenig einheitlich.

Ziele

Überprüfung und Bewertung aktueller Rehabilitationsinhalte und -protokolle nach inverser Schulterprothetik durch Überprüfung der vorhandenen wissenschaftlichen Literatur und Bereitstellung eines Überblicks über die klinische Praxis ausgewählter Schulterexperten der Deutschen Vereinigung für Schulter- und Ellenbogenchirurgie e. V. (DVSE).

Material und Methoden

Eine Literaturrecherche für die Jahre 1989 bis 2016 wurde in einschlägigen Datenbanken und Bibliographien durchgeführt, einschließlich von Guidelines International Network, National Guidelines, PubMed, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews und Physiotherapy Evidence Database. Darüber hinaus wurden 63 DVSE-Experten über einen Online-Fragebogen kontaktiert.

Ergebnisse

Da keine Level-I/II-Studien zu postoperativen Protokollen nach inverser Schulterprothetik vorlagen, wurden die 856 Treffer von den Ausschussmitgliedern begutachtet und nach den Themen „Rehabilitation“, „Komplikationen“, „klinische Ergebnisse“, „Grundlagenforschung“, „Überblick“ und „Sonstiges“ eingeteilt und bewertet. Zusätzlich wurden die Umfrageergebnisse analysiert und mit der Literatur verglichen.

Diskussion

Der Vergleich zwischen Literaturempfehlung und Expertenbefragung zeigte Übereinstimmung unter den Hauptaspekten (z. B. Bandage/Schlinge, Immobilisierung, passive Übungen). Basierend auf der Literatur und den Expertenmeinungen konnte ein Vierphasenrehabilitationsprotokoll entwickelt werden.

Schlüsselwörter

Inverse Schulterprothetik Arthrose Rotatorenmanschettendefektarthropathie Physiotherapie 

Reverse shoulder arthroplasty (RSA) has become increasingly popular for the treatment of osteoarthritis (OA) in the case of rotator cuff insufficiency [6]. Due to its positive results, the indications for RSA have been widened to younger and more active patients. This could be explained by superior knowledge of biomechanics, the improvement of implants, growing revision numbers in primary anatomical shoulder arthroplasty (TSA) and additional indications, e. g. fracture treatment in the elderly patient [53]. Current studies have demonstrated a significant improvement in postoperative range of motion (ROM), activities of daily living (ADL) and strength.

To date, there is no general guideline or consensus on the postoperative treatment of RSA in general or even for special indications. The protocols mentioned in study descriptions vary significantly in all relevant parameters: time of immobilization, limitation of ROM and beginning of active ROM. The authors believe that postoperative treatment is important to achieve an optimal functional outcome and avoid postoperative complications. Therefore, the commission on rehabilitation of the German Society of Shoulder and Elbow Surgery (Deutsche Gesellschaft für Schulter- und Ellenbogenchirurgie e.V., DVSE) has studied this issue intensively. The aim of this paper was to:
  1. 1.

    Conduct an evidence-based evaluation of the most important aspects of rehabilitation after RSA, based on an extensive literature review

     
  2. 2.

    To close potential gaps in published research with best clinical practice consensus with the help of a survey among DVSE shoulder experts

     

Materials and methods

Literature review

The current literature search followed a hierarchical structure (best available evidence) based on postoperative treatment guidelines, health technology assessments (HTA), systematic reviews and clinical studies that investigated postoperative protocols after RSA.

The search of treatment guidelines was conducted in the databases of the “Guidelines International Network” (http://www.g-i-n.net/) and various other national guidelines: National Guideline Clearinghouse (NGC), German Association of Scientific Medical Societies (Arbeitsgemeinschaft der wissenschaftlichen medizinischen Fachgesellschaften, AWMF), Scottish Intercollegiate Guidelines Network (SIGN), National Institute for Health and Clinical Excellence (UK; NICE) and Health Technology Assessment (HTA), International Network of Agencies for Health Technology Assessment (INAHTA), Health Technology Assessment International (HTAi), European network for Health Technology Assessment (EUnetHTA), German Institute for Medical Documentation and Information (Deutsches Institut für Medizinische Dokumentation und Information, DIMDI), German Institute for Quality and Efficiency in Health Care (Institut für Qualität und Wirtschaflichkeit im Gesundheitswesen, IQWiG).

A search for meta-analyses, systematic reviews and primary studies was conducted using the electronic databases Medline via PubMed, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews and the Physiotherapy Evidence Database (PEDro) with the keywords “(reverse OR inverse) AND shoulder AND (arthroplasty OR replacement OR prosthesis)”.

The period between 01/1989 and 01/2016 was the period of reference. In addition, a manual search was conducted that included general internet research, a screening of the literature references listed in the collected articles and a renewed assessment of various journals. A manual search for relevant basic science and biomechanical studies was also performed.

The relevant publications were selected based on how relevant their content was to the issue, whether they were in English or German and whether the comparative studies enlisted at least 10 patients per group. The literature selection was planned to be based on the population, intervention, comparison and Outcomes (PICO) concept of the Cochrane Institute. The levels of evidence were interpreted based on the classifications of the Oxford Centre for Evidence-Based Medicine (OCEBM) 2009.

In addition to the PICO concept, the further evaluation by the PEDro scale (www.pedro.org.au) was planned. Due to the lack of search results for level 1 and 2 studies comparing postoperative protocols after RSA and guidelines, the planned analysis could not be performed. Therefore, the 856 studies were searched by the commission members and sorted by the topics “rehabilitation”, “complications”, “clinical outcome studies”, “basic science”, “reviews” and “miscellaneous” (Fig. 1).
Fig. 1

Systematic review search algorithm

Expert opinions

After evaluating the literature, the DVSE’s Rehabilitation Commission decided which topics additionally required the opinions of the DVSE experts. The individual topics were assigned to the following groups:
  1. 1.

    Physiotherapy, self-exercise and continuous passive motion (CPM), immobilization and arm positioning

     
  2. 2.

    Physical therapy (cryotherapy, electrotherapy, hydrotherapy)

     
  3. 3.

    Rehabilitation protocols

     
  4. 4.

    Differences between indications/techniques

     

The online tool Surveymonkey (www.surveymonkey.com) was used to survey 63 selected DVSE experts in RSA between 10/2017 and 12/2017. The experts were informed about the background of the survey via email. To increase the participation rate a friendly reminder was sent three times. The rate of participation was 63.5%.

Results

The guideline search resulted in no hits, as did the systematic and clinical study search. In the knowledge of the scarce level of evidence, the review was designed in the following way:
  1. 1.

    Summary of clinical studies with a description of a postoperative protocol and comparison to expert opinions

     
  2. 2.

    General aspects from clinical and basic science literature: functional outcome and reduction of complications

     
  3. 3.

    Individual case-dependent aspects

     
  4. 4.

    Phase-dependent rehabilitation protocol

     

1. Summary of rehabilitation protocols in clinical studies

Since there are no actual guidelines regarding a rehabilitation protocol after RSA, the following paragraph summarizes the published protocols in clinical studies after RSA implantation. Boudreau et al. published a proposal for a rehabilitation program based on scientific considerations and clinical experience [5]. No studies have been published on different treatment options and, despite a huge number of publications on RSA, the authors’ literature search found only 22 papers with a more or less clear description of the postoperative treatment protocol. An overview of the papers is shown in Table 1.
Table 1

Search results: rehabilitation protocols in clinical studies

Author

Year

Title

Level of evidence

Aims

Number of shoulders

Orthopaedic brace or sling

Brace or sling: timeframe

Passive ROM

Active ROM

Physiotherapy

Other treatments

Indication: CTA or fracture

Boudreau et al. [5]

2007

Rehabilitation following rTSA

Literature summary Level 5

The purpose of this paper was to review the indications for rTSA, focusing on underlying pathology and to outline a rehabilitation protocol founded on basic scientific principles and the authors’ experience working with patients following rTSA

7

Not mentioned

Not mentioned

Not mentioned

Not mentioned

Not mentioned

Not mentioned

Castricini et al. [7]

2013

HRQoL and functionality after RSA

Case series Level 4

The purpose of this study was to report the midterm survival rate, HRQoL, and functionality of the shoulder after RSA in a prospective series of patients with MRCTs, CTA, or primary glenohumeral OA and identify the possible predictors of clinical outcomes

80

Abduction pillow

3 Weeks

3 Weeks

3–8 Weeks

Not mentioned

Not mentioned

CTA

Cazeneuve et al. [8]

2009

Delta III RSA: radiologic outcome for acute complex fractures of the proximal humerus in elderly patients

Case series, treatment study Level 4

To investigate the radiological outcome of the reverse arthroplasty concept in this indication

41

Simple sling

4 Weeks

From 1st week p.o.

4 Weeks

Not mentioned

Not mentioned

Fracture

Cuff et al. [12]

2008

RSA for the treatment of rotator cuff deficiency

Case series Level 4

The purpose of this study was to perform a prospective outcomes study of RSA performed using 5.0-mm peripheral locking screws for baseplate fixation and a lateralized centre of rotation for the treatment of a rotator cuff deficiency

96

Immobilizer

6 Weeks

Pendulum exercises 1/day; ROM training after week 6

From week 6, from week 12 weights

Not mentioned

Not mentioned

CTA

De Biase et al. [3]

2012

rTSA: radiological and clinical result using an eccentric glenosphere

Case series Level 4

The objective of this retrospective study was to evaluate clinical and radiographic outcomes using the eccentric glenosphere and to determine whether this design might prevent inferior scapular notching

40

Abduction pillow

4 Weeks

4 Weeks

After 6 weeks, strengthening after 8 weeks

Not mentioned

Not mentioned

CTA

Frankle et al. [16]

2006

The reverse shoulder prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency. A minimum 2‑year follow-up study of 60 patients with regard to surgical technique

Case series, treatment study Level 4

The goal of this study was to retrospectively evaluate the short-term results of arthroplasty with use of the reverse shoulder prosthesis in the management of this problem

60

Shoulder immobilizer

6 Weeks

From 1st week p.o.

From week 6, from week 12 weights

Expected duration of therapy: 1 year

Not mentioned

CTA

Gillespie et al. [18]

2015

Surgical exposure for rTSA: differences in approaches and outcomes

Case series, treatment study Level 4

To describe the surgical approaches, discuss advantages and disadvantages of each approach, review the current literature and present data from the authors’ clinical experience

93

Simple sling

2 Weeks

Not mentioned

2–6 Weeks, after 6 weeks “free”

No formalised therapy setting

No

Mixed CTA and fracture

Kadum et al. [23]

2011

Results of TESS: a single-centre study of 56 consecutive patients

Case series Level 4

The purpose of the present study was to evaluate the authors’ short-term results and complications with TESS

56

Not mentioned

Not mentioned

Not mentioned

“Use as tolerated” after 6 weeks

Not mentioned

Not mentioned

CTA

Kalouche et al. [24]

2009

RSA: does reduced medialisation improve radiological and clinical results?

Case Series, Treatment Study Level 4

The purpose of this retrospective study was to assess the effect of the reduced medialisation of the ArrowR reverse shoulder prosthesis on short-term clinical and radiological results

96

Simple sling

4 Weeks

From 1st week p.o.

4 Weeks

Not mentioned

Not mentioned

CTA

Kempton et al. [25]

2011

A radiographic analysis of the effects of prosthesis design on scapular notching following rTSA

Retrospective case control study

Level 3

To clinically correlate these laboratory findings with a population of patients undergoing elective rTSA procedures

65

Abduction pillow

4 weeks

2 weeks

Not mentioned

PT wrist and elbow from 1st p.o. day

Not mentioned

CTA

Kempton et al.

2011

A radiographic analysis of the effects of glenosphere position on scapular notching following rTSA

Retrospective case control study

Level 3

The purpose of this study was to clinically determine the likelihood of scapular notching in a series of shoulders, with the glenospheres placed in neutral versus inferior tilt

71

Abduction pillow

4 Weeks

2 Weeks

Not mentioned

PT wrist and elbow from 1st p.o. day

Not mentioned

CTA

Klein et al. [30]

2008

Treatment of comminuted fractures of the proximal humerus in elderly patients with the Delta III reverse shoulder prosthesis

Case series

Level 4

To evaluate clinical and radiologic results after implantation of the Delta III reverse shoulder prosthesis in elderly patients with comminuted fractures of the proximal humerus

20

Abduction pillow

4 Weeks

From 1st week p.o. passive PT, CPM twice a day, ABD/FLEX 90°, rotation without limitation

From week 5

3-Week in-patient rehabilitation program (German system)

Not mentioned

Fracture

Leung et al. [34]

2012

Functional outcome of hemi-arthroplasty compared with rTSA in the treatment of rotator cuff tear arthropathy

Retrospective case-control series, treatment study

Level 3

The purpose of this study was to compare the authors’ outcomes for hemi-arthroplasty with those for rTSA

56

Sling

3 Weeks

After 3 weeks

After 6–8 weeks, strengthening after 12 weeks

Not mentioned

Not mentioned

CTA

Mizuno et al. [37]

2012

The clinical and radiographic results of rTSA with eccentric glenosphere

Prospective case series

Level 4

The purpose of this study was to evaluate the clinical and radiological results of rTSA with an eccentric glenosphere and compare the incidence and severity of scapular notching using a concentric glenosphere

57

Simple sling

4 Weeks

4 Weeks + simple ADL without lifting

After 4 weeks

Not mentioned

Not mentioned

CTA

Reitman et al. [38]

2011

RSA as treatment for comminuted proximal humeral fractures in elderly patients

Case series

Level 4

The present study examines the result of RSA as treatment for comminuted proximal humeral fractures in elderly patients

13

Simple sling

6 Weeks

1 Week pendulum exercises

For 6 weeks only isometric

Not mentioned

Not mentioned

Fracture

Rhee et al. [39]

2015

Effects of humeral component retroversion on functional outcomes in rTSA for cuff tear arthropathy

Retrospective cohort study

Level 3

To evaluate the effects of humeral component retroversion on the clinical and functional outcomes of rTSA for cuff tear arthropathy

62

Sling

4 Weeks

Immediately p.o. increasing to 2 weeks p.o.

After 4 weeks

3 Months

Not mentioned

CTA

Ross et al. [40]

2015

rTSA for the treatment of three-part and four-part proximal humeral fractures in the elderly

Retrospective cohort study

Level 3

The purpose of this study was to review survivorship and radiological and clinical outcomes of RSAused for the treatment of three-part and four-part proximal humeral fractures in the elderly

29

Simple sling

6 Weeks

After 1 week

After 6 weeks. Resisted activity and strengthening after 12 weeks

Not mentioned

Not mentioned

Fracture

Routman et al. [41]

2013

Indications, technique and pitfalls of rTSA for proximal humerus fractures

Literature summary Level 5

Sling or pillow

3–4 Weeks

4 Weeks

4–6 Weeks p.o.

Not mentioned

Not mentioned

Fracture

Sadoghi et al. [42]

2011

Impact of previous rotator cuff repair on the outcome of RSA

Case series

Level 4

To evaluate the outcome of the Delta reverse shoulder prosthesis in a consecutive series of 68 shoulders and perform a comparison of patients with and without previous shoulder arthroscopy for cuff tear reconstruction

68

Brace or sling not defined

6 Weeks

For 6 weeks CPM

From week 6 only 6 kg weight, from week 12 full weight

Not mentioned

Cryotherapy, lymphatic drain from week 1, from week 3 electrotherapy for muscle training, from week 5 PT in a swimming pool

CTA

Walch et al. [49]

2012

Do the indications, results and complications of RSA change with surgeon experience?

Retrospective case dontrol study, treatment study

Level 3

The goal of this study was to compare two consecutive series of 240 rTSA in order to evaluate whether the increase in surgeon experience modified the indications, clinical and radiographic results and rate of complications

240

Simple sling

4 Weeks

4 Weeks

Not mentioned

Not mentioned

Not mentioned

Mixed indications including fracture

Walker et al. [50]

2012

The use of the RSA for treatment of failed TSA

Case series, treatment study Level 4

To evaluated the outcomes of patients with failed TSA that were treated with conversion to RSA

24

Immobilizer

6 Weeks

For 6 weeks

After 6 weeks, strengthening after 12 weeks

Not mentioned

Not mentioned

Elective, failed TSA converted to RSA

Werner et al. [51]

2005

Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis

Case series, treatment study Level 4

The purpose was to evaluate the clinical and radiographic results of this arthroplasty in a consecutive series of shoulders with painful pseudoparesis due to irreversible loss of rotator cuff function

58

Sling

2 Weeks

From 1st week p.o.

Active ROM from week 2

Not mentioned

Hydrotherapy

CTA

ROM range of motion, rTSA reverse total shoulder arthroplasty, HRQoL health-related quality of life, RSA reverse shoulder arthroplasty, MRCTs massive rotator cuff tears, CTA cuff tear arthropathy, OA osteoarthritis, p.o. postoperatively, TESS Total Evolutive Shoulder System®, PT physiotherapy, CPM continuous passive motion, ABD/FLEX abduction/flexion, ADL activities of daily living, TSA total shoulder arthroplasty

2. General aspects from clinical and basic science literature

Functional outcome

The combination of physiotherapy and self-exercise was considered appropriate in the majority of cases in the expert survey (Table 2).
Table 2

DVSE experts survey: physiotherapy, self/home exercises and rehabilitation protocol (no. of responds n = 37)

Question 1:

Appropriate

Rather appropriate

Rather not appropriate

Not appropriate

The use of self/home exercises makes sense in the earlya post-operative phase after RSA.

I consider this statement to be:

57.5%

25%

12.5%

5.0%

Question 2:

Appropriate

Rather appropriate

Rather not appropriate

Not appropriate

I hand out a post-operative exercise plan to the patient.

I consider this statement to be:

50%

15.8%

15.8%

18.4%

Question 3:

Appropriate

Rather appropriate

Rather not appropriate

Not appropriate

The initial instruction of self/home exercises after RSA by a physiotherapist makes sense.

I consider this statement to be:

76.3%

13.2%

7.9%

2.6%

Question 4:

Appropriate

Rather appropriate

Rather not appropriate

Not appropriate

The visualization of self/home exercises (by photo/video) makes sense.

I consider this statement to be:

60.5%

23.7%

10.5%

5.3%

Question 5:

Appropriate

Rather appropriate

Rather not appropriate

Not appropriate

Self/home exercises supersede physiotherapy units after RSA.

I consider this statement to be:

2.6%

5.3%

34.2%

57.9%

RSA reverse shoulder arthroplasty

aStarting in the first post-operative week

Reduction of complications

A majority of the survey participants fears stiffening when the shoulder is immobilized for 4–6 weeks after surgery. The results of dislocation prevention and deltoid strengthening show no trend (Table 3).
Table 3

DVSE expert survey: prevention of complications (no. of responds n = 37)

Question 1:

Appropriate

Rather appropriate

Rather not appropriate

Not appropriate

I fear a relevant stiffening of the shoulder if it is completelya immobilized for the first 4–6 weeks after RSA.

I consider this statement to be:

43.2%

29.7%

29.7%

21.6%

Question 2:

Appropriate

Rather appropriate

Rather not appropriate

Not appropriate

I limit active and passive ROM after RSA in the first 4–6 weeks since I fear dislocation of the implant.

I consider this statement to be:

21.6%

24.3%

29.7%

24.3%

Question 3:

Appropriate

Rather appropriate

Rather not appropriate

Not appropriate

I allow strengthening exercises of the deltoid muscle from week 7 post-operatively.

I consider this statement to be:

37.8%

29.7%

2.7%

29.7%

aNo passive or active therapy. RSA reverse shoulder arthroplasty

3. Individual aspects from clinical and basic science literature

The data from the DVSE expert survey show that a majority of surgeons individualizes the treatment protocol for different indications. For example, individual treatment with and without subscapularis refixation was seen indifferently, with 29.7% participants changing their protocol for refixation and 32.4% not (Table 4).
Table 4

DVSE expert survey: individual factors (no. of responds n = 37)

 

Expert opinion

Question 1:

Appropriate

Rather appropriate

Rather not appropriate

Not appropriate

I define the start of active ROM individually according to pretensioning of the deltoid muscle and acromion morphology.

I consider this statement to be:

2.7%

24.3%

40.5%

32.4%

Question 2:

Appropriate

Rather appropriate

Rather not appropriate

Not appropriate

I define the duration of immobilization depending on subscapularis refixation or not.

I consider this statement to be:

29.7%

18.9%

18.9%

32.4%

Question 3:

Appropriate

Rather appropriate

Rather not appropriate

Not appropriate

I define the duration of immobilization differentiated between indications (e. g. fracture or cuff tear arthropathy).

I consider this statement to be:

43.2%

21.6%

13.5%

21.6%

ROM range of motion

The postoperative protocols of fracture and CTA indications are compared in Table 5. In conclusion, no relevant difference is seen.
Table 5

Comparison of rehabilitation protocols in the literature (fracture vs. CTA)

 

Fracture

Cuff tear arthropathy

Recommendation of orthopaedic brace or sling and if so, which one?

Used in all studies

Used in all but one study

63.6% Sling vs. 36.4% abduction pillow

42.9% Sling vs. 57.1% abduction pillow

Timeframe a brace/sling should be worn?

Min.: 2w–Max.: 6w; Ø: 4.2w; Median: 4w

Min.: 2w–Max.: 6w; Ø: 4.1w; Median: 4w

Passive mobilization should be started from:

Min.: 1w–Max.: 4w; Ø: 2.4w; Median: 2w

Min.: 1w–Max.: 6w; Ø: 2.4w; Median: 2w

Active shoulder exercises should be started from:

Min.: 4w–Max.: 6w; Ø: 5.2w; Median: 5w

Min.: 2w–Max.: 8w; Ø: 5.1w; Median: 6w

4. Phase-dependent rehabilitation protocol

The survey revealed strong support for the four-phase rehabilitation protocol with time- and criteria-based phase transitions (Table 6).
Table 6

DVSE expert survey: rehabilitation phases (no. of responds n = 37)

Question 1:

Appropriate

Rather appropriate

Rather not appropriate

Not appropriate

The rehabilitation protocol after reverse shoulder arthroplasty should have a progressive exercise set-up and can be divided into four phases.

I consider this statement to be:

62.2%

29.7%

8.1%

0%

Question 2:

Appropriate

Rather appropriate

Rather not appropriate

Not appropriate

The phase transitions and load increases should be time-based and criteria-based.

I consider this statement to be:

81.1%

16.2%

2.7%

0%

Discussion

1. Summary of rehabilitation protocols in clinical studies

The expectations of the patient and the general treatment expectations from the literature are essential in the planning of the rehabilitation process. Clinical studies show a significant reduction in pain and a gain in active anterior elevation and abduction of 50°–60° at 2–5 years. This reflects a postoperative relative age correlated constant score between 75%–80% depending on the indication [14, 51]. Nevertheless, the improvement of external rotation is postoperatively not significantly improved (a gain of around 5°–15° compared to preoperatively) and is significantly lower in comparison to anatomical TSA (53° vs. 38°) [27].

Compared to anatomical total shoulder arthroplasty (TSA), the expectation of postoperative internal rotation is also significantly lower. Triplet et al. showed that 67% of TSA patients achieved T12, whereas in the RSA group only 32% were able to achieve T12. In the subgroup analyses of the RSA group, revision arthroplasties showed significantly decreased internal rotation [46]. This aspect is especially important for managing toileting or washing of the back and needs to be considered in postoperative training and functional expectations.

Besides range of motion, strength plays an important role in ADL. Wiater et al. showed that the preoperative deltoid size and fatty infiltration correlates with postoperative functional scores and strength [52]. In terms of rehabilitation, this means that a reduction in postoperative deltoid atrophy could lead to improved function, but irreversible fatty infiltration of the deltoid may only allow functional improvement to a certain limit. Alta et al. compared isokinetic strength between TSA and RSA and revealed increased strength for TSA patients. In the RSA subgroup, weak external rotation torques correlated negatively with functional scores [1].

Scapulothoracic setting and strength is essential in RSA. Therefore, the influence of scapulothoracic muscle function provides highly interesting insights into the varying shoulder function compared to an anatomic shoulder. The upper trapezius and deltoid show significantly increased electromyography (EMG) activation during elevation and abduction. This reflects the findings of de Toledo et al. 2012 and their groups that the scapula contributed more to movement of the arm in RSA compared to healthy subjects [28, 32, 45]. From these findings one can conclude that the training of scapulothoracic setting and motion, as well as strengthening of the scapulothoracic muscle, may play an even more important role in the rehabilitation process than in shoulders with an anatomic joint.

Deltoid function is essential for shoulder function after RSA. Jobin et al. showed that intraoperative lengthening of the deltoid could achieve an improvement in active forward elevation [21]. How far specific training of the deltoid and especially the anterior segments could be effective has not been investigated as yet. The high load on the deltoid muscle over the years can lead to deltoid fatigue syndrome. A large clinical series by Favard et al. revealed a sudden functional loss at between 9 and 11 years postoperatively. The loss of deltoid function over time could be one explanation. Conversely, intensive deltoid training in the young RSA patient could be seen critically for survivorship [14].

Clinical results and, accordingly, the functional expectations of RSA differ between indications such as CTA, RA, revision arthroplasty and fracture cases. Whereas CTA and fracture sequelae show comparable results, revision arthroplasty reveals a lower American Shoulder and Elbow Surgeons (ASES) and constant score [4]. Rheumatoid arthritis (RA) patients also achieved comparable results to primary CTA cases, but had a higher risk of intraoperative fractures and loosening due to reduced bone quality [26, 54]. The treatment of humeral head fractures also achieved good functional results with a constant score between 60 and 70 points [30].

2. General aspects from clinical and basic science literature

Functional outcome

Directly following surgery, the question arises as to whether and to what extent the shoulder should be immobilized. Here the risk of early joint dislocation and structural ingrowth of the prosthesis components is weighed against re-educating deltoid function and regaining ROM. Biomechanically, it seems to be self-evident to give the prosthesis time for bony ingrowth and, clinically, consolidation of soft tissue should be awaited. There are no studies in the literature dealing with the type of immobilization or the length of immobilization. An abduction pillow was used postoperatively in eight of the 24 papers reviewed. Another 12 studies used what they called a “simple sling”. Four papers did not comment on the type of immobilization.

The duration of immobilization is given as 3–6 weeks after surgery; no study described direct postoperative mobilization without wearing any kind of immobilizer. The reviewed studies varied in indication for RSA and in duration of immobilization postoperatively, but not consistently, e. g. longer immobilization for fracture RSA.

A total of 21 studies described a protocol with the beginning of active ROM training at between 4 and 6 weeks. Only Werner et al. recommended faster active mobilization as early on as after 2 weeks [51].

The use of CPM is only mentioned in two studies, both conducted in Germany within the German health care system, which supports the use of CPM [30, 42].

Cryotherapy, electrotherapy and exercises in a pool are described methods of postoperative rehabilitation. There are no randomized controlled trials (RCT) on any of these modalities and only two studies mentioned these modalities for the standard rehabilitation protocol. The more recent study published by Sadoghi et al. mentioned the regular use of electrotherapy and cryotherapy [42]. Werner et al. described the use of a water pool after day 2 without any specific risk of failure in a descriptive level 4 case series [51].

Most of the papers support the principle of staged physiotherapy, starting with passive ROM training and pendulum exercises. Overall there are two different approaches: one group starts passive range of motion (PROM) at day 1, the other group starts after 2 weeks. Gerber et al. recommended active ROM directly after 2 weeks, while all other studies explained that active ROM training started after week 6. There are no special recommendations for the duration of physiotherapist-guided training. Table 7 shows a comparison between the literature and expert opinion. They generally agree on a 4- to 6‑week immobilization period in a sling or abduction brace. Passive mobilization also corresponds at a timepoint at around 2 weeks. The timepoint for active exercises appears to be earlier in the expert group (mean 3.8 vs. 5.1 weeks). This might be explained by some early studies in which the postoperative protocol was more restrictive [11, 16].
Table 7

Comparison of conclusions between the literature and the DVSE expert survey

 

Literature search (Table 1)

Experts’ opinion

Question 1:

Do you recommend any kind of orthopaedic brace or sling after RSA, and if so, which one?

Sling or abduction pillow in all studies where use is mentioned

No device

Sling

Brace (ABD:15–20°)

Brace (ABD:>20°)

54.5% Sling vs. 45.5% abduction pillow

0.0%

36.1%

58.3%

5.6%

Question 2:

 

Range

Ø

Median

What is the timeframe a brace/sling should be worn?

Min.: 2w–Max.: 6w; Ø: 4.3w; Median: 4w

Min.: 1w–Max.: 9w

3.8 w

4 w

Question 3:

 

Appropriate

Rather appropriate

Rather not appropriate

Not appropriate

After RSA, the operated shoulder should be immobilizeda for 2 weeks, i. e. neither treated passively nor actively.

I consider this statement to be:

Different groups: a group of studies starts PROM from day 1

Some groups later, week 2–4

5.4%

8.1%

21.6%

64.9%

Question 4:

 

Appropriate

Rather appropriate

Rather not appropriate

Not appropriate

I think earlyb passive exercise of the shoulder after RSA is beneficial.

I consider this statement to be:

A group of studies starts PROM from day 1

73.0%

16.2%

10.8%

0.0%

Question 5:

 

Range

Ø

Median

Active shoulder exercises after RSA should be started from:

Min.: 2w–Max.: 7w; Ø: 5.1w; Median: 5w

Min.: 1w–Max.: 8w

3.8 w

4 w

Question 6:

 

Appropriate

Rather appropriate

Rather not appropriate

Not appropriate

Self/home exercises supersede physiotherapy units after RSA.

I consider this statement to be:

Six studies mention physiotherapy

Therapy interval from 3 to 12 months is expected

2.6%

5.3%

34.2%

57.9%

Question 7:

 

Appropriate

Rather appropriate

Rather not appropriate

Not appropriate

Assisted active exercises as part of aquatic therapy (e. g. in a training pool) can improve active mobility after RSA.

I consider this statement to be:

Recommended in two studies

44.7%

29.0%

15.8%

10.5%

Question 8:

 

Appropriate

Rather appropriate

Rather not appropriate

Not appropriate

The use of a CPM device makes sense during the postoperative treatment of RSA.

I consider this statement to be:

Mentioned in one study

15.8%

7.9%

34.2%

42.1%

RSA reverse should arthroplasty, ABD abduction, PROM passive range of motion, CPM continuous passive motion

aNo passive or active therapy performed

bStarting in the first post-operative week

Reduction of complications

In addition to muscular function, the function of RSA depends on stable bony fixation of the implant. Since early humeral loosening is extremely rare, the focus needs to be placed on the glenoid side [29, 47]. In consideration of glenoid notching for postoperative treatment, extensive painful adduction exercises should be avoided especially in medialized implants. Further recommendations could not be drawn from clinical and biomechanical data.

The compression force, i.e. deltoid tension, is one of the main stabilizers of RSA [10].

In addition to intraoperative deltoid tensioning, a postoperative strengthening protocol could improve these forces. The optimal timepoint is discussed controversially between week 6 and 12 (Table 1 and 3). In contrast, there is a risk of acromial/scapular spine fracture. In high grade CTA with severe acetabularization (Hamada IVb) or patients with additional risk factors for acromion fracture (osteoporosis, excessive deltoid tension), delayed initiation of deltoid training might be indicated [48]. In fact, there is no correlation between acromion fracture and postoperative protocol mentioned in the literature.

Poor soft tissue status due to revision surgery or infection and an irreparable subscapularis tendon are correlated with a higher instability rate after RSA [13, 17]. Therefore, an extended immobilization period can be considered to risk stiffness and avoid instability in these high-risk patients (Table 4). Additionally in the case of subscapularis refixation, a slower rehabilitation protocol may protect the reconstruction.

A body mass index >35 cm/kg2 correlates with increased complication rates intra- and postoperatively. Whereas infection and medical complications are significantly higher, the rate of instability was only slightly increased, meaning that a delayed postoperative program for obese patients is not indicated [2, 19].

3. Individual aspects from clinical and basic science literature

Communication between the surgeon and the physiotherapist is essential to ensure appropriate patient rehabilitation following RSA. Besides the above-mentioned topics, individual factors may affect the course of rehabilitation. These can be divided into patient factors (e. g. preoperative shoulder function, previous surgery and indication) and surgical factors (e. g. type of implant, subscapularis refixation, surgical approach and implant fixation).

Within the DVSE expert survey, the influence of subscapularis refixation was rated conflictingly (Table 4). While 50% of experts increase the time of immobilization, the other 50% do not vary their rehabilitation protocol. Biologically, the time it takes for tendons to heal should be taken into account, as in rotator cuff repair. The time from the inflammatory phase through the proliferative phase to the maturation and remodelling phase is around 4–6 weeks [22]. As already mentioned, subscapularis refixation exhibits a protective effect on postoperative instability in RSA [9, 13, 17]. However, biomechanical studies revealed that subscapularis repair increases the force required by the deltoid and posterior rotator cuff and also significantly increases the joint reaction force [20]. This effect is explained by the stronger anterior force couple in relation to the mostly affected and weak posterior force couple. These aspects should be taken into consideration especially for strengthening exercises in the late phase in order to achieve sufficient muscle balance.

In general, two approaches to RSA are used: the delto-pectoral and the supero-lateral approaches (“Mackenzie”) [36]. In contrast to the atraumatic muscle sparing delto-pectoral approach, the supero-lateral approach uses a delta split. Alteration or insufficiency of the two anterior deltoid segments are described as risks [18, 33]. The loss of these segments correlates with significantly decreased abduction and flexion moments. In individual cases involving anterior deltoid refixation (e. g. revision cases), it is important to protect these deltoid parts during the early rehabilitation phases [43].

Particularly in the case of revision surgery, the individual soft and bony tissue status, as well as the neuromuscular function of the arm, needs to be analyzed in order to create tailored postoperative treatment. The individual rehabilitation concept in revision RSA is supported by the literature reporting a high rate of postoperative complications (loosening, instability) [15].

As the rate of humeral loosening is described as low, clinical studies made no difference in rehabilitation for cemented or uncemented stems [29, 35].

A comparison of rehabilitation protocols for fracture and CTA showed no relevant differences (Table 5). Nevertheless, postoperative treatment in individual primary RSA indications could differ in severe cases where extensive soft tissue trauma after the fracture or significantly reduced bone mineral density or bone stock in RA patients can be mentioned [44]. In conclusion, individual aspects need to be taken into consideration in order to adapt the postoperative protocol. Therefore, it is essential for the surgeon to communicate the individual changes to the patient, the treating physician and the physiotherapist. Written postoperative treatment schedules may improve communication in individual complex cases.

4. Rehabilitation phases

As is commonly accepted for rehabilitation following orthopaedic procedures, rehabilitation following RSA should be staged into different phases to allow a continuous progression with adequate protection of the implant and anatomic structures. Four phases based on the phases of soft tissue healing are usually used (Table 8). The progression should not only be time- but also criteria-based. In general, the criteria for progression need to be individually defined. The literature also lacks general and precisely defined criteria. However, the International Classification of Functioning, Disability and Health (ICF) is a good basis for identifying targets. Orientation criteria are assigned to each phase [22, 31].
Table 8

Rehabilitation phases

Phase

Contents

Phase and duration

Milestones before transition to next phase

ADL and core exercises

I

– Immobilization (as a form of protection) in 15°–45° ABD for 3–6 weeks

– ABD brace/sling can be removed during showers, while eating and for physiotherapy

– PROM training for 4 weeks, then gradual transition to AAROM [11, 51]

– Pendulum exercises

– Aquatic therapy if wounds are intact [51]

Week 1–6

– Symmetrical and pain-free movement compared to opposite side: PROM flexion 90°; PROM ABD with adjacent scapula 90°

– Pendulum exercise in elevation

– Elevation in closed chain: stand in front of a table and stretch out arms

– Isometric training of delta muscle and periscapular musculature

– Active movement of elbow, wrist and fingers

– Keeping posture erect and controlling scapula

– Isolated scapula depression and protraction and early training of scapulothoracic dynamic control

– At the end of the phase: aqua training

II

– Full AAROM transitioning to AROM against force of gravity

– Scar mobilization

– Aqua gymnastics/aquatic therapy

– CPM if favoured

– Training in closed chain to avoid shearing forces

– Training in open chain to strengthen muscles isolated

– Limitation: up to the pain threshold

– No resistance or strengthening exercises

Week 6–12

– Active achievement of all possible active range of movements

– No scapulothoracic dysfunction

– Sufficient glenohumeral and scapulothoracic functionality

– Back position: support affected side with non-affected side and move arm above the head (AAROM)

– Training of everyday movements: eating, combing hair, getting dressed etc.

– Stabilization in closed chain for proprioceptive training

– Proprioceptive training in an open chain

– Slow progression in specific strengthening of delta muscle and functional training in closed and open chain

III

– Building up strength—slowly starting to build up strength—low level

– Stretching

Week 12–16

– Free functional movement in a pain-free range

– ADL possible without pain—avoiding overhead exercises

– If enough strength in RC, phase 4 can start in order to carry out ADL cleanly and without pain

75% Of normal strength and endurance

– Light functional exercises

– Mobilization/building-up strength using a rope pull with low weights

– Push-ups against the wall

– Bicep and triceps training with low free weights

IV

– Stretching

– Intensifying functional training

Week >16

– Return to sports after 6 months

– Mobility and strength are symmetrical to the opposite side

– Scapulothoracic movement is present without significant side-to-side differences

– There is no pain at rest and during activity

– PNF against resistance

– Training in a specific sport in the pain-free range

ADL activities of daily living, ABD abduction, PROM passive range of motion, AAROM assistive-active range of motion, AROM active range of motion, CPM continuous passive motion, RC rotator cuff, PNF proprioceptive neuromuscular facilitation

First Phase (week 1–6): The main goals are to protect the implant (and reconstructions) and prevent stiffness. Parallel to this, the ingrowth of the implant and its connection to the bone should be supported. Mainly passive and assistive exercises are conducted during this time.

Second Phase (week 6–12): This period focuses on regaining function and returning to ADL. Therefore, more complex exercises related to daily life are performed. In addition, the development of strength is important in this phase.

Third Phase (week 12–16): Further strengthening and an increase in daily activities play an important role in this phase. Special emphasis is placed on proprioception and strength endurance.

Fourth phase (>16 weeks): This phase includes a return to full daily activities and/or sports.

Conclusions

RSA is an established option in shoulder replacement surgery. The postoperative functional gain is significantly faster compared to reconstructive shoulder surgery, but functional improvement can be achieved up to 1 year postoperatively with consequent training [16].

Therefore, the principle components and concepts of rehabilitation are applied in different ways and controversially discussed. The number of publications on the subject is relatively low and these provide limited evidence. Our search, starting in 1989, was unable to find one guideline, systematic review or level I/II study. Therefore, the article is based on clinical studies, biomechanical aspects and an expert survey; however, no clear recommendations can actually be derived.

Taking all the results of our survey together, a basic concept that was solid and valid could nevertheless be created, and which was summarized in a four-phase-model. The main aspects of this model were supported and supplemented for the first time through collected and pooled expert opinions from the DVSE expert society.

Notes

Acknowledgements

We cordially thank the following members of the “Rehabilitation” committee of the German Society of Shoulder and Elbow Surgery e. V. (DVSE) for their support and input: Active members: Frieder Mauch (Chairman), Christian Jung (Vice Chairman), Stefan Buchmann, Christian Schoch, Casper Grim, Knut Beitzel, Florian Pfalzer, Thomas Tischer, Michael Krifter, Florian Haasters, Wolfgang Pötzl. Guest members: Lena Tepohl, Reina Tholen, Thilo Kromer, Ferdinand Bergamo, Thomas Gottfried, Tobias Baierle, Hans Ortmann, Manuel Klose, Bettina Mauch.

Compliance with ethical guidelines

Conflict of interest

S. Buchmann, C. Schoch, C. Grim, C. Jung, K. Beitzel, M. Klose, B. Mauch, F. Pfalzer, L. Tepohl, R. Tholen, T. Gottfried, H. Ortmann, M. Scheibel and F. Mauch declare that they have no competing interests.

This article does not contain any studies with human participants or animals performed by any of the authors.

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Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Authors and Affiliations

  • S. Buchmann
    • 1
    • 2
    Email author
  • C. Schoch
    • 3
  • C. Grim
    • 4
  • C. Jung
    • 5
  • K. Beitzel
    • 2
  • M. Klose
    • 2
  • B. Mauch
    • 6
  • F. Pfalzer
    • 7
  • L. Tepohl
    • 8
  • R. Tholen
    • 9
  • T. Gottfried
    • 10
    • 11
  • H. Ortmann
    • 12
  • M. Scheibel
    • 5
    • 13
  • F. Mauch
    • 7
    • 14
  1. 1.Orthopädisches Fachzentrum (OFZ), Weilheim – Garmisch-Partenkirchen – Starnberg – PenzbergWeilheimGermany
  2. 2.Abteilung und Poliklinik für SportorthopädieKlinikum rechts der IsarMünchenGermany
  3. 3.St. Vinzenz AllgäuPfrontenGermany
  4. 4.Klinikum Osnabrück GmbHOsnabrückGermany
  5. 5.Obere ExtremitätenSchulthess Klinik ZürichZürichSwitzerland
  6. 6.Centrum 30/PraxisklinikFellbachGermany
  7. 7.Sportklinik StuttgartStuttgartGermany
  8. 8.Institut für Rehabilitationsmedizinische ForschungUniversität UlmBad BuchauGermany
  9. 9.Deutscher Verband für Physiotherapie (ZVK) e. V.KölnGermany
  10. 10.Klinik Höhenried gGmbHDeutsche Rentenversicherung Bayern SüdBernriedGermany
  11. 11.Sektion Rehabilitation, Physikalische TherapieDeutsche Gesellschaft für Orthopädie und Unfallchirurgie e. V. (DGOU)BernriedGermany
  12. 12.Verband Physikalische Therapie (VPT) e. V. Landesgruppe BayernMünchenGermany
  13. 13.Centrum für Muskuloskeletale ChirurgieCharité – UniversitätsmedizinBerlinGermany
  14. 14.Kommission RehabilitationDeutsche Vereinigung für Schulter- und Ellenbogenchirurgie e. V. (DVSE)StuttgartGermany

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