Summary

Fast rehabilitation protocols after reverse shoulder arthroplasty are as safe as the delayed ones, while mobilising the shoulder sooner.

Abstract

Background

Reverse shoulder arthroplasty (RSA) cases have been increasing worldwide as this operation had been established as a valuable option to improve shoulder function and decrease pain. However, there is no consensus concerning the rehabilitation protocol following surgery. Many patients undergoing RSA, are expecting to be able to do daily activities or even participate in recreational activities or sports after the operation.

Methods

This review was designed as an intervention systematic review with narrative analysis. Authors searched English literature in PubMed and Embase databases from 1/1/1989 until July 2020. Controlled studies comparing different rehabilitation protocols for patients undergoing RSA were included, apart from cases were the initial diagnosis was infection, revision of reverse arthroplasty, or the former combined with tendon transfers, and from case reports. Data quality was examined with the Cochrane risk of bias assessment tool for randomized trials, the Methodological Index for Non-Randomized studies (MINORS) tool, as well as the Grading of Recommendations Assessment Development and Evaluation (GRADE) approach. Narrative synthesis was undertaken.

Results

From the 619 articles primarily identified, three were finally included in the review process. On estimating the effect of early vs delayed rehabilitation, 12 months post-op, very low quality evidence existed of no statistically significant difference in any clinical or patient reported outcome, pain or range of movement. At three months post-op, forward flexion was noted by one study to be significantly higher in the early rehabilitation group (140.5, 95% confidence intervals (CI) 135.10- 145.89; the delayed rehabilitation group mean was 131.24, 95% CI 125.73- 136.74; p= 0.019) . There was low quality evidence of no significant difference between early or delayed rehabilitation on peak isometric shoulder strength. In one study, more complications were reported in the 6 weeks (delayed) rehabilitation group.

Conclusion

Past rehabilitation protocols included an immobilization period of 2-6 weeks to allow for shoulder and remaining cuff recovery. Newer protocols have been more aggressive on mobilizing the shoulder girdle from the first postoperative days, since subscapularis repair in lateralized models is not deemed necessary. Their results, compared to delayed therapy regimes, so far show at least non-inferiority on clinical outcomes and fewer complications. However, the quality of this evidence is either conflicting or low/very low. There are occasions where a RSA will need immobilization during the first 3-6 weeks, as increased deltoid length, low bone mineral mass and revision surgery are risk factors for an acromial fracture.