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. Author manuscript; available in PMC: 2019 Jul 1.
Published in final edited form as: J Geriatr Phys Ther. 2018 Jul-Sep;41(3):126–133. doi: 10.1519/JPT.0000000000000112

Patient-Reported and Objectively Measured Function Before and After Reverse Shoulder Arthroplasty

Wendy J Hurd a, Melissa M Morrow a, Emily J Miller a, Robert A Adams a, John W Sperling a, Kenton R Kaufman a
PMCID: PMC5498280  NIHMSID: NIHMS820509  PMID: 28060054

Abstract

Background and Purpose

Documenting functional outcomes after reverse shoulder arthroplasty (RSA) is critical to advancing patient care. The interplay been self-reported and objectively measured outcome measures has not been widely described. The utilization of wearable devices to document upper extremity limb activity is a new approach for objectively measuring outcomes. Therefore the purpose of this study was to evaluate changes in pain, and self-reported function and objectively measured limb activity after RSA. We also assessed the influence of pain on self-reported function and objectively measured limb activity to determine the impact of pain on outcomes after RSA.

Materials

This study implemented a prospective, repeated measures design. Fourteen patients undergoing RSA underwent testing before surgery, and 2 and 12 months after surgery. Patient-report instruments included pain, DASH, and physical component summary (PCS) of the SF-36. Objective limb activity (mean activity value (m/s2/minute epoch), inactive time (%), low activity (%) and high activity (%)) was captured with tri-axial accelerometers worn on the upper and lower arm. A repeated measures ANOVA tested for differences across time. Spearman's rank-order correlation was calculated to evaluate the influence of pain on DASH, PCS scores, and mean limb activity.

Results

Patient-reported measures improved after surgery (Pain, P < 0.01; DASH, P < 0.01; PCS, P = 0.01). There was no change in limb activity at one year compared to pre-operative values for mean (Forearm, P=1.00; Arm, P=0.36), inactivity (Forearm, P = 0.33; Arm, P = 0.22) low (Forearm, P = 0.77; Arm, P=0.11) or high (Forearm, P = 1.00; Arm, P = 0.20) activity. There was a relationship between pain and DASH scores one year after surgery (P = 0.04) but not before surgery (P = 0.16), or 2 months after surgery (P=0.30). There was no relationship between pain and PCS scores at any time point (pre-operative, P=0.97; 2 months, P=0.21; one year, P=0.08) nor pain and limb activity (Forearm: pre-operative, P = 0.36; 2 months, P = 0.67; one year, P=0.16; Arm: pre-operative, P = 0.97; 2 months, P=0.59; one year, P = 0.51).

Conclusions

RSA reduced pain and enhanced patient perceived function. Objectively measured upper extremity limb activity is not different one year after surgery compared to pre-operative levels.

Keywords: Shoulder, Arthroplasty, Function

INTRODUCTION

Growth of shoulder arthroplasty (SA) procedures being performed each year is greater than for any other joint, with a 2.5 fold increase in the number of procedures performed between 2000 and 2008.1 Implementation of the reverse shoulder arthroplasty (RSA) procedure has been identified as the causative factor behind a steep increase in the number of SA surgeries performed.1 Reverse shoulder arthroplasty includes reversal of the physiological ball and socket configuration of the humerus and glenoid. This results in medialisation and distalisation of the center of rotation of the shoulder joint and increases the deltoid muscle moment arm.2 The change in anatomical alignment facilitates recruitment of more deltoid fibers for elevation and abduction.2 This feature is unique to the RSA, and valuable 3, particularly for treatment of rotator cuff tear arthropathy, 4-6 massive irreparable rotator cuff tears without osteoarthritis and failed hemiarthroplasty with irreparable rotator cuff tearing.7 The expanding list of indications for RSA is contributing to the exponentially increasing number of procedures performed each year. Factoring in the growing population of older adults in the United States, 8 the target demographic for joint arthroplasty, it is clear that maximizing outcomes for this patient population is an imperative.

Functional improvements after RSA are significant.9-14 Improvements in function are routinely documented using a combination of patient self-report questionnaires and clinician measured of range of motion and strength. Self-reported function provides useful information related to patients’ perceptions of qualitative physical function.15 Questionnaires are also inexpensive, easy to administer, and require minimal time to complete.15 Self-reported function must be interpreted with caution, however, as responses are dependent on the patient's recall and bias related to activity performance.16,17 Clinical measures do not inherently capture function. There is consequently a significant void in previous efforts to objectively document shoulder function after RSA.

Tri-axial accelerometer– based activity monitors have been implemented on a broad scale among researchers who are interested in measuring the volume of physical activity. In these instances the activity monitor is worn at the waist or around an ankle to capture activity level or step counts. Activity monitors may also be utilized to capture discrete movements of specific body segments, including the upper extremity activity.18-21 Furthermore, they may be worn for an extended period of time in a patient's natural living environment. In this paradigm activity monitors may provide insight to upper extremity use in the home environment. Previous work established the effectiveness of activity monitors in discriminating between involved and uninvolved limbs in patients who were scheduled to undergo RSA.21 Objective data regarding limb use captured outside of the laboratory provides unique insight to upper extremity activity. We are unaware, however, of previous reports documenting outcomes after RSA using tri-axial accelerometer based activity monitors.

Documenting functional outcomes after RSA is critical to advancing patient care. Patient perceived function and objectively captured upper extremity limb activity are both important outcome measures. Therefore the purpose of this study was to evaluate changes in pain, self-reported function and objectively measured limb activity after RSA. We hypothesized all measures of interest would be significantly improved one year after surgery compared to pre-operative values. Understanding the impact of pain on outcomes has not been well documented after RSA. Therefore we also assessed the influence of pain on both self-reported and objectively measured function. We hypothesized pain would have a significant impact on both self-reported and objectively measured limb activity.

MATERIALS AND METHODS

Study Design

This study incorporated a prospective, repeated measures cohort study design. The cohort was comprised of patients who underwent testing before surgery, 2 months after surgery, and 1 year after surgery. To maximize subject recruitment and retention, testing intervals coincided with physician-scheduled clinical follow ups. At each testing interval all self-report and objective measures were captured. Before initiating testing procedures, informed consent was obtained from study participants.

Participants

Fifteen individuals with glenohumeral OA and rotator cuff insufficiency scheduled to undergo RSA were recruited for study participation. One individual was unable to complete the 1 year testing session secondary to transportation issues, thus the final sample size included 14 participants. Individuals were required to be between 50-85 years of age, be independent ambulators, and have no neurological disease that impacted mobility or cognitive function. Individuals who did not meet all inclusion requirements were not eligible for participation. Average age for the group was 73 years (SD ± 6), and included 7 males and 7 females. Thirteen individuals reported upper extremity dominance for the right limb, and one for the left limb. The right upper extremity was the involved limb for 9 subjects; the left upper extremity was the involved limb for 5 subjects. All study participants were recruited from the practice of a single orthopedic surgeon, and followed the same post-operative rehabilitation protocol (Table 1). Informed consent approved by Mayo Clinic Institutional Review Board was obtained prior to initiating study procedures.

Table 1.

Post-operative rehabilitation guidelines

Weeks 0-6: *Sling
*Passive range of motion
Weeks 6-12 *Discharge sling
*Active range of motion
*Isometric strengthening
Weeks 12 + *Isotonic strengthening
*No lifting > 6lb
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Self-Reported Function

Disabilities of Arm, Shoulder and Hands (DASH)

The Disabilities of Arm, Shoulder and Hands (DASH) is a 30-item self-report questionnaire designed to capture upper extremity symptoms and function. A Likert-scale is utilized to document an individual's symptom severity and ability to perform a variety of daily activities. The DASH may be used for patients with any condition of any joint of the upper extremity and effectively detect changes of disability over time after surgery in patients with upper extremity musculoskeletal disorders.22 The minimum clinically important difference (MCID) for the DASH has been estimated as 12 points of change.23

Short Form-36 Health Questionnaire (SF-36)

The physical component summary (PCS) of the Medical Outcomes Survey Short Form-36 (SF-36) was utilized to assess overall perceived function. The SF-36 is a generic health measure questionnaire that includes 8 scales of differing domains of health including physical functioning, bodily pain, role-physical, general health, vitality, role-emotional, social functioning, and mental health. Each scale is scored on a scale of 0-100, with higher values representing higher levels of function. The SF-36 has been documented as a reliable instrument with good internal consistency.24 The PCS represents a composite score for the respective physical scales of the questionnaire. These scores are standardized normative scores based on the general population's score with an average of 50 and a standard deviation of 10.25 The SF-36 PCS was reported because it is a composite of all scales to represent the physical aspects of health. The MCID for the PCS has been estimated as 4 points of change.26

Pain

Pain intensity was assessed using a numeric rating scale (0-10). Subjects were asked to record a number representing their mean level of pain for their involved shoulder over the week preceding testing. The range of the scale uses whole numbers from 0 to 10, with 0 representing no pain and 10 representing the worst pain imaginable. The numeric rating scale has been shown to have good test-retest reliability, construct validity, and responsiveness for measuring shoulder pain.27,28 The MCID for the numeric pain rating scale has been estimated as 2 points of change.29-31

Objective Limb Activity

Limb activity was assessed over a three day period at each testing interval, subsequent to physician office visits. Objective limb activity was measured using triaxial accelerometry based activity monitors (ActiGraph, Pensacola, FL, USA, Model GT3XP-BTLE). The accelerometers captured individual forearm and arm segment movements relative to the external environment. Monitors were issued to subjects to take home at the conclusion of laboratory testing. Instruction was provided regarding application, removal, and wear time. Monitors were secured at the wrist and mid-biceps level of the arm with Velcro straps. Each day, participants placed the monitors on themselves or with assistance from someone in their home. Sleep was not included in the data collection period of interest, and participants were instructed to remove the monitors prior to sleep.

Each activity monitor contained a triaxial accelerometer and captured data within a range of ±6g at a rate of 100 Hz. Analyses were performed independently for each segment using custom Matlab programs (MathWorks, Natick, MA). The raw signals output from the activity monitor were high-pass filtered using a 4th order Butterworth digital design at 0.1 Hz to remove the gravitational component.32 Filtered signals were parsed into 60-s (1 min) epochs For each epoch a single activity value was calculated by summing the vector magnitude from the three orthogonal acceleration axes for each of the 100 samples across the minute epoch.33 The mean activity value (m/s2/minute epoch) was calculated for each segment for the three-day period of interest.

In addition to the mean activity value, the activity frequency was calculated using a novel technique that places each 1 minute epoch activity value into bins.21 The activity frequency bins were defined for the amount of time patients were inactive, and the time spent performing activities categorized as low and high frequency. Inactive limb use time was calculated as a percentage of the total wear time wherein the activity value was less than 110 m/s2/epoch (inactivity= activity value < 110 m/s2/epoch).33 A normalization method was performed wherein the activity value epoch data was divided into low and high activity bins based on the percentage of maximum activity (MA) determined from a control group.20 The data obtained from the control group in a previous investigation consisted of an age and sex-matched cohort with no upper limb orthopedic pain or pathology. The control group members were matched to patients undergoing shoulder arthroplasty. The activity frequency bins were determined by the following equations:18

Lowactivity:110m∕s2∕minute epoch≤Activity valuet≤33%of MA
Highactivity:Activity valuet>33%of MA

The epochs in each bin were summed to determine the percentage of each day spent at the different activity levels, and the total percent time spent in each bin was averaged across days for analysis. There is currently no data available to establish the MCID for limb activity captured by triaxial accelerometers.

Statistics

Self-reported function variables of interest included the PCS score from the SF-36, DASH score, and mean pain. Objectively measured limb activity variables of interest included mean activity (m/s2/minute epoch), percentage inactive time, percentage of time spent performing low frequency activities, and percentage of time spent performing high frequency activities for the surgical extremity. Changes in self-reported scores and objectively measured limb activity were evaluated with a repeated measures ANOVA with time as the independent variable. Data distribution was evaluated for normality of distribution using Mauchly's Test of Sphericity. When statistical significance was reached (α≤0.05) post-hoc analysis was performed with a Bonferroni Test to determine the level at which differences were occurring. Secondary to the sample size, the non-parametric Spearman's rank-order correlation was calculated to evaluate the relationship between pain and DASH scores, PCS scores and mean activity level at each time point.

RESULTS

Self-Reported Function

There was a significant difference across time for DASH scores (Table 2) (P < 0.001). At the 2 month interval there was no change in scores compared to pre-operative values (P=1.000). There were significant improvements in scores 12 months post-operatively compared to both pre-operative (P=0.001) and 2 month post-operative (P<0.001) time points.

TABLE 2.

Repeated measures ANOVA results evaluating differences over time for self-reported pain and function scores.

Pre-Operative 2 Months 12 Months P-Value F Value
DASH 42 (14) 45 (15) 17 (12) < 0.01*† 19.61
PCS 37 (5) 40 (7) 44 (10) P=0.01 5.52
Pain 4 (2) 2 (2) 1 (1) < 0.01*†‡ 15.81
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Results (Mean, SD), P-values and F values for the Disabilities of Arm, Shoulder and Hands (DASH), physical component summary (PCS) of the Medical Outcomes Survey Short Form-36, and Pain.

*

Denotes statistically significant differences between two and twelve month time intervals

†

Denotes statistically significant differences between pre-operative and twelve month time intervals

‡

Denotes statistically significant differences between pre-operative and two month time intervals

α ≤0.05

There was a significant difference across time for SF-36 PCS scores (Table 1) (P=0.014). There was no change between 2 month and pre-operative scores (P=0.369), or 2 and 12 month post-operative scores (P=0.219). The improvement between 12 month and pre-operative scores approached statistical significance (P=0.068).

Pain

There was a significant reduction in pain across time (Table 2) (P<0.001). Pain scores were significantly lower at the 2 month interval compared to pre-operative scores (P=0.003), and scores at 1 year were significantly lower compared to both the 2 month interval (P=0.003) and pre-operative (P < 0.001) scores.

Objective Limb Activity

Mean activity for the forearm (P=0.02, F=4.390) and arm (P<0.01, F=6.721) were significantly different across time. Activity for the forearm at 2 months after surgery approached statistical significance compared to pre-operative levels (P=0.07). There was no difference for the arm at 2 months compared to pre-operative activity levels (P=0.22). Limb activity at 1 year was significantly greater than 2 month values (Forearm, P=0.02; Arm, P=0.01), but not when compared to pre-operative activity (Forearm, P=1.00; Arm, P=0.36) (Table 3). The percentage of inactive time was not different across time for either the forearm (P=0.33, F=1.166) or arm (P=0.22, F=1.589) (Table 3).

TABLE 3.

Repeated measures ANOVA results evaluating limb activity (Mean (SD)) over time.

Pre-Operative Two Months Twelve Months P Value F Value
Forearm Mean Activity Value (m/s2/minute epoch) 940 (256) 841 (270) 1010 (352) P=0.02* F=4.390
Inactive (%) 13 (8) 16 (10) 15 (8) P=0.33 F=1.166
Low Activity (%) 55 (14) 58 (12) 51 (11) P=0.04* F=3.608
High Activity (%) 31 (14) 26 (14) 34 (16) P=0.02* F=5.036
Arm Mean Activity Value (m/s2/minute epoch) 546 (150) 488 (164) 626 (223) P<0.01* F=6.721
Inactive (%) 21 (13) 26 (15) 21 (11) P=0.22 F=1.589
Low Activity (%) 54 (13) 53 (11) 47 (8) P=0.03 F=3.909
High Activity (%) 25 (11) 21 (11) 31 (15) P<0.01* F=8.612
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*

Denotes statistically significant differences between two and twelve month time intervals

α ≤0.05

The percentage of time spent performing low frequency activities was significantly different across time for both the forearm (P=0.04, F=3.608) and arm (P=0.03, F=3.909) (Table 3). There was no difference in the amount of time spent performing low frequency activities for either limb segment at 2 months compared to pre-operative values (Forearm, P=0.48; Arm, P=1.00). At 1 year there was less time spent performing low frequency activities compared to 2 months after surgery for the forearm (P=0.04) but not the arm (P=0.13). Differences in percentage of time spent performing low frequency activities 1 year after surgery compared to pre-operative values were not significantly different for either the forearm (P=0.77) or arm (P=0.11).

There was a significant difference across time spent performing high frequency activities for the forearm (P=0.02, F=5.036) and arm (P<0.01, F=8.612) (Table 3). For the forearm the percentage of time spent performing high frequency activities at 2 months compared to pre-operative values approached statistical significance (P=0.06). There was no difference at the 2 month interval compared to pre-operative values for the arm (P=0.25). At 1 year the percentage of time spent performing high frequency activities was significantly greater for both arm segments compared to 2 month values (Forearm, P<0.01; Arm, P<0.01) but not when compared to pre-operative values (Forearm, P=1.00; Arm, P=0.20).

Correlation Between Pain and Limb Activity

There was a significant association between pain and DASH scores 1 year after surgery (rs= 0.566, P=0.04) but not before (rs= 0.395, P=0.16), or 2 months after surgery (rs= 0.299, P=0.30) (Figure 1). Pain was not associated with PCS scores pre-operatively (rs= −0.011, P=0.97; 2 months, rs= −0.359, P=0.21; 1 year, rs= −0.499, P=0.08). There was no association between pain and objectively measured limb activity for the forearm (pre-operative, rs= −0.267, P=0.36; 2 months, rs=0.130, P=0.67; 1 year, rs= 0.411, P=0.16) or the arm (pre-operative, rs=−0.009, P=0.97; 2 months, rs=0.157, P=0.59; 1 year, rs= 0.199, P=0.51) at any time point.

Figure 1.

Figure 1

Figure 1

Figure 1

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Relationship between pain and DASH before surgery (A), 2 months (B) and 12 months (C) after surgery. α ≤ 0.05.

DISCUSSION

Our hypotheses were partially supported by the results. As we predicted, there were improvements in DASH scores and a reduction in pain after surgery compared to pre-operative values. There was also a significant association between pain and DASH scores after surgery. In contrast to our hypotheses, there were no significant changes in PCS scores or objectively measured limb activity 1 year after surgery compared to pre-operative values. There were also no significant relationships between pain and objectively measured limb activity, or pain and PCS scores.

Multiple investigators have reported significant improvements in patient pain level and self-reported function after RSA. Improvements in pain and function have been reported for time intervals ranging from 1 to 5 years after RSA for rotator cuff arthropathy, and a variety of self-report instruments including the Simple Shoulder Test, American Shoulder and Elbow Surgeons score, Constant-Murley score, Oxford score, and Single Assessment Numeric Evaluation score have been utilized to capture functional improvements in this patient population.9,11-14,34 It was therefore not surprising that subjects in this study also exhibited improvements in pain and DASH scores at the 1 year post-operative interval compared to pre-operative values.

There were patterns in the magnitude and changes in self-reported function and pain after surgery. Group averages for self-reported function and pain measures exceeded the MCID at one year after surgery compared to pre-operative values. Thus, improvement in the patient's perception of function after RSA is clinically meaningful. There was an immediate and significant reduction in pain at the 2 month interval. The reduction in pain levels continued at 1 year but this was a less pronounced change as pain had been mostly resolved before this time. PCS scores were significantly different across time, with scores 1 year after surgery 8 points better compared to pre-operative values. DASH scores were unchanged 2 months after surgery. The absence of change was likely a consequence of the 6 week immobilization period after surgery enforced to promote healing, control pain, and minimize the risk of glenohumeral dislocation. After the 6 week mark, however, the rehabilitation program did not limit arm activities or use. Subsequently, DASH scores improved from 45% at the 2 month interval to 17% at 1 year after surgery (lower scores representing higher levels of function). The DASH is a regional instrument that captures self-reported function and is not disease specific.22 The PCS is a measure of global physical function and a measure of overall physical performance.25 Factors other than shoulder disease may impact PCS scores, particularly among an aging population among whom co-morbidities are common. The modest PCS score changes versus large changes in DASH scores reflect the difference between global and regional functional questionnaires when assessing a population with musculoskeletal injury. Improvements in PCS scores that exceed MCID levels do suggest, however, that shoulder disability had a meaningful impact on this patient population and their overall physical functioning.

There was no meaningful change in objectively measured upper extremity activity 1 year after surgery. The pattern of limb activity paralleled DASH scores: at 2 months there was a slight decrease in mean arm use and the percentage of time spent performing high frequency activities. This was observed in conjunction with a slight increase in the percentage of time performing low frequency activities. One year after surgery there was an increase in mean and high frequency activity for the involved limb, and less time spent performing low frequency activities. Thus, significant changes were observed between the 12 and 2 month testing intervals. In contrast to DASH scores, however, none of these changes in objectively measured limb activity were statistically significant compared to pre-operative levels. The discord between patient self-reported function and objective clinical measures among individuals undergoing joint arthroplasty has been documented. Harreld et al14 evaluated the relationship between subjective and objective measures in 171 patients who had undergone shoulder arthroplasty including 93 total and 81 reverse shoulder arthroplasties. Self-report instruments included the American Shoulder and Elbow Surgeons (ASES), Simple Shoulder Test and SF-36 while objective shoulder measures consisted of strength as measured with a clinical dynamometer and visually assessed range of motion. The authors reported little correlation between how patients perceive their function and how well they performed in regard to objectively measured strength and motion.14

Parallel findings have been reported in studies of patients who have undergone total knee arthroplasty (TKA). Mizner et al15 reported outcomes for 100 patients who had undergone TKA. Self-report outcome measures included the SF-36, Knee Outcome Survey Activities of Daily Living, and Global Rating of knee function. Performance-based measures of activity included the timed up and go, stair climbing and 6 minute walk tests. Mizner et al15 reported that all measures improved at the one-year mark. Improvements captured with the self-report instruments were twice as large, however, as improvements in the performance tests. Our results are similar to those of Mizner et al,15 as patients in this study had remarkable improvement in self-reported upper extremity function after RSA, and minimal changes in objectively measured limb activity.

An emerging question after joint arthroplasty is “what is our goal?” Historically the primary objective has been to control pain and facilitate performance of basic activities of daily living. The overwhelming majority of patient-reported outcome instruments are consistent with this goal. The DASH, ASES, Constant-Murley, and Oxford score all emphasize the ease or difficulty an individual has when performing discrete activities of daily living. In this study, the association between pain and DASH scores was weak (rs=0.395; P > 0.05) before surgery, suggesting additional factors were impacting how patients perceived their upper extremity function in the presence of glenohumeral arthritis and rotator cuff insufficiency. One year after surgery, however, there was a stronger (rs=0.566; moderate; P < 0.05) association with pain and DASH scores, indicating the decrease in pain was meaningful as patients’ perceived improvements in their function. Although there was no significant increase in limb activity after surgery, the patient-reported outcomes indicate RSA effectively enhanced the quality of ADL performance.

Pain is an inherent component of the DASH questionnaire. Very few questions across instruments however capture limitations in the range of tasks an individual is able to perform. The current generation of aging adults has expectations beyond performance of daily tasks after arthroplasty. Schumann et al35 reported outcomes for 100 consecutive patients who underwent total shoulder arthroplasty. The authors reported that, for the 55 patients who took part in sports before having shoulder disease, 89% were able to resume participation after surgery.35 This included 11 patients who had stopped participation before surgery. If one of the goals of RSA is to expand the functional envelope for patients, we must be more discerning in methodologies when objectively evaluating function beyond traditional questionnaires and clinical tests. Additionally, post-operative rehabilitation must be enhanced to expand function. Using a traditional post-operative management program, patients in this study exhibited no significant changes in limb activity 1 year after surgery. The activity level was not impacted by pain. Future studies will be necessary to determine if rehabilitation that enhances range of motion, strength, or developing new neuromuscular movement strategies may positively impact a patient's ability to increase their range of functional abilities.

Triaxial accelerometers present a novel means by which to capture upper extremity use in an individual's natural living environment. Among patients in this study, both upper and lower arm segment activity was classified as either inactive or engaged in low frequency activity approximately 66% of the time at all testing intervals. We hypothesize this may be in part a protective mechanism to minimize arm use and avoid painful limb movements that was initiated before surgery. If arm activity among patients who undergo RSA is related to habitual use, it would in part explain the lack of significant changes in arm activity 1 year after surgery compared to pre-operative levels. Further insight regarding normal arm activity across ages and pathologies will be gained as future studies incorporate activity monitors in their study methodology. There are limitations associated with data obtained with triaxial accelerometer based activity monitors. Neither the magnitude of range of motion nor plane of motion is measured. At this time it is also not possible to define the specific tasks that have been performed. Rather, the monitors simply capture when a limb segment has moved relative to the external environment. This simplistic information does, however, provide valuable insight to an individual's arm use in a real-world setting. These data, combined with additional metrics including EMG, three-dimensional motion analysis, clinical measures, and functional activities analyses, will contribute to a broader understanding of objective outcomes after RSA.

This study is not without limitations. All patients came from the practice of a single surgeon. This approach facilitated greater homogeneity relative to surgical technique and postoperative management. Larger studies that include patients from the practice of multiple surgeons will be necessary to determine if the results from the current investigation are generalizable across surgical techniques and post-operative management strategies. There are multiple self-report questionnaires to capture patient function. We selected the DASH specifically because it is not disease specific and outcomes may be compared across pathologies. Additionally, the DASH has good reliability and validity.22 Although the use of alternative questionnaires may be justified, we do not believe this would have impacted the results of this study. Similar improvements in patient-reported function after RSA have been reported across instruments.9,11,13,14 Another limitation of this study is the time of testing after surgery. There was a substantial gap between the 2 and 12 month testing intervals during which substantial changes in function may have occurred. Improvements in function may continue beyond 1 year. Consequently this study does not shed insight to the timing of recovery. The rationale for the timing of patient testing was that these intervals coincided with their standard physician follow-up appointments. Many of the patients had to travel a significant distance to participate in the study. To minimize drop-out, we coordinated research testing with clinical care. Future studies will be necessary to determine if function continues to improve beyond the 1 year interval.

CONCLUSIONS

This study supports RSA for treatment of rotator cuff arthropathy as an effective intervention for reducing pain and enhancing patient perception of shoulder and global physical function. Reduction in pain has a significant impact on patient perceived function, which is reflective of the nature of patient self-report instruments. There was not, however, an improvement in upper extremity activity 1 year after surgery when using a novel approach to objectively assess limb use. These data indicate the impact of RSA on patient outcomes is in the enhancement of the quality of ADL performance.

ACKNOWLEDGEMENTS

The body-worn motion detection and recording units from Mayo Clinic were provided by Dr. Barry K. Gilbert, James E. Bublitz, Kevin J. Buchs, Charles A. Burfield, Christopher L. Felton, Dr. Clifton R. Haider, Michael J. Lorsung, Shaun M. Schreiber, Steven J. Schuster, and Daniel J. Schwab from the Special Purpose Processor and Development Group at Mayo Clinic.

Funding Sources: Project funding and salary support (Dr. Hurd) provided by the Arthritis Foundation; salary support (Dr. Morrow) provided by the National Institutes of Health (NIH K12HD065987)

Footnotes

Disclaimers: Dr. Sperling, Biomet-Royalties

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