2025 Neer Award Part 1 - The SHORT Trial: Multicenter, Randomized, Controlled Trial of Surgeon-Directed Home Therapy vs. Outpatient Rehabilitation by Physical Therapists for Reverse Total Shoulder Arthroplasty

Abstract

Background: Reverse total shoulder arthroplasty (rTSA) has experienced exponential growth in popularity, although the optimal rehabilitation strategy remains unclear. The primary purpose of the SHORT multi-center randomized controlled trial was to compare patient-reported outcomes (PROs) and range of motion (ROM) after rTSA when rehabilitation is directed by outpatient, clinic-based physical therapists (PT group) versus home therapy, instructed by the patient's surgeon at post-operative appointments (HT group). Secondary aims include comparisons of complications, cost of care, and quality of life between the two groups.

Methods: Seven sites with nine shoulder and elbow fellowship-trained, high-volume arthroplasty surgeons randomized 222 shoulders in 216 consecutive, consented patients. There were 117 shoulders in the PT group and 105 shoulders in the HT group. Data was gathered pre-operatively and at 2, 6, and 12 weeks, 6 months, 1 year, and 2 years following surgery. Active and passive ROM, PROs, complications, and costs were collected.

Results: At our primary endpoint of one year, we had 93% (174/187) follow-up, at two years we had 88% (161/183). There was no statistically significant difference between the two groups at any time point with respect to active and passive ROM: scaption, external rotation at 90 degrees abduction (ER90), ER at 0 degrees abduction (ER0), and internal rotation (IR) at 1 year and 2 years. Similarly, there were no differences with regards to PROs, including pain level, the Single Assessment Numeric Evaluation (SANE) score, the American Shoulder and Elbow Surgeons (ASES) score, and quality of life (measured by PROMIS 29 v.2.0). There was no difference in the complication or revision rate. Crossovers were anticipated and statistical significance was not reached whether analyzed with intention-to-treat including patients who crossed over or per-protocol, truncated to the time patients crossed over. HT group showed decreased 1-year care cycle costs with a statistically significant economic value benefit on incremental cost-effectiveness ratio analysis [PT=$17,837.48 (SD=2,687.34) and HT= $11,284.97 (SD=1,578.08)], p<.01).

Conclusion: On average, surgeon-directed home therapy after rTSA offers a better value proposition than formal PT, by providing equivalent clinical benefit at a reduced cost.

Level of evidence: Level I; Randomized Controlled Trial; Treatment Study.

Keywords: home therapy; patient reported outcomes; physical therapy; range of motion; reverse total shoulder; shoulder arthroplasty; surgeon-directed.