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Evidence review for inpatient shoulder postoperative rehabilitation
Evidence review Q
NICE Guideline, No. 157
National Guideline Centre (UK).
1. Post-operative rehabilitation
1.1. Review question: In adults who have undergone primary elective shoulder replacement, what is the most clinical and cost-effective timing and duration for inpatient rehabilitation?
1.2. Introduction
Although the number of shoulder replacements are increasing year on year there is still a lack of consensus on the rehabilitation guidance immediately following shoulder replacement surgery. Most people may only be an in-patient for 24 hours following their surgery and priority is therefore focused on safe ambulation and instruction on self-care. People following these operations may experience a number of post-operative complications including nausea, hypotension, pain, delirium and confusion. The role of the multidisciplinary team in this post-operative stage of the inpatient recovery is to minimise these complications to promote early function, with the overall aim on facilitating a safe hospital discharge.
Core interventions in current postoperative inpatient rehabilitation include, advice with regard to sling management, instructions on preventing stiffness in the neck, hand and elbow regions, specific advice on what degree of exercise can be performed at the shoulder (this is dependent on surgeon preference and type of shoulder replacement) and functional-based tasks including washing, dressing and other activities of daily living. These are led by the physiotherapy and occupational therapy team but supported by the whole multidisciplinary team during the individual’s hospital stay. Postoperative inpatient rehabilitation also frequently includes an assessment of further, post-discharge rehabilitation needs, which may lead to referral to community physiotherapy or occupational therapy services or to social services or third sector organisations for ongoing support if indicated.
There is inconsistency with the timing and type of postoperative inpatient rehabilitation patients should receive following shoulder replacement surgery. There is uncertainty as to what should be included in the postoperative inpatient rehabilitation programme especially with regards to periods of immobilisation in a sling and degree of movement allowed at the shoulder to help maintain muscle and joint function and periods for these restrictions.
This review seeks to find out what the most clinical and cost effective inpatient rehabilitation intervention is for people who have undergone shoulder replacement, and particularly on when this rehabilitation begins.
1.3. PICO table
For full details, see the review protocol in Appendix A:
Table 1
PICO characteristics of review question.
1.4. Clinical evidence
1.4.1. Included studies
After searches for both RCTs and observational studies were conducted, no relevant clinical studies comparing the timing of beginning inpatient rehabilitation after shoulder replacement surgery were identified.
1.4.2. Excluded studies
1.5. Economic evidence
1.5.1. Included studies
No relevant health economic studies were identified for this review. However, evidence from the inpatient rehabilitation for hip and knee replacement review (Evidence review P) was used to support a recommendation.
1.5.2. Excluded studies
No health economic studies that were relevant to this question were excluded due to assessment of limited applicability or methodological limitations.
See also the health economic study selection flow chart in Appendix G:
1.5.3. Unit costs
Some potentially relevant unit costs are provided below to aid consideration of cost effectiveness.
Table 2
Cost per hour of a hospital based physiotherapy or occupational therapy teams by Band.
The weighted average of the HRG codes for primary elective shoulder replacements in Table 3 are based upon the average length of stay and average cost of an excess bed day
Table 3
Weighted average unit cost for hip and knee HRG codes.
1.6. Evidence statements
1.6.1. Clinical evidence statements
No relevant published evidence was identified.
1.6.2. Health economic evidence statements
No relevant economic evaluations were identified.
1.7. The committee’s discussion of the evidence
1.7.1. Interpreting the evidence
1.7.1.1. The outcomes that matter most
The critical outcomes were agreed to be quality of life (QOL) within 6 weeks, Patient Reported Outcome Measures (PROMs) within 6 weeks, time until joint replacements were revised and reoperation within 6 weeks. PROMs measure health gain in patients undergoing joint replacement. They vary in terms of content and can cover a range of clinical measures such as QOL, pain, stiffness, and function. Reoperation within 6 weeks was chosen to pick up negative rehabilitation outcomes including dislocation.
Important outcomes were infection, hospital readmissions within 30 days, and length of stay. It was agreed to utilise function or pain as outcomes if they were reported and not included in a PROM.
The follow up timescales for QOL, PROMs, reoperation, infection, pain and function were within 6 weeks to pick up the meaningful benefits of inpatient rehabilitation. The longer-term benefits are explored in the outpatient rehabilitation evidence review. The timing of the hospital readmission timescale was 30 days to match how it is normally reported and this is a short-term timescale that could be influenced by inpatient rehabilitation.
The 30-day mortality after joint arthroplasty is a rare event usually due to pre-existing cardiovascular and/or pulmonary disease and the GC did not consider this to be altered by varying inpatient rehabilitation.
No clinical evidence was found for this question.
1.7.1.2. The quality of the evidence
No clinical evidence was found for this question.
1.7.1.3. Benefits and harms
There is currently great variability between orthopaedic teams in terms of immediate postoperative rehabilitation. Some large centre teams use a sling for 6 weeks and some use a sling for 10 days. There is also variability compared to hip or knee joint replacement because walking is often not limited by shoulder replacement. Walking is often possible and can be enabled through effective pain control. This allows for hospital discharge within 24 hours and there are moves to utilise a day case model.
Increased speed of discharge may promote people to be given early rehabilitation, consisting of advice on self-care, assessment and directions from a physiotherapist. Physiotherapists and/or occupational therapists can advise on how to manage activities of daily living out of hospital with only one usable arm. The physiotherapist interactions include assessment of safe zones as well as mobilisation of the parts of the shoulder and arm that can be done safely. Some physiotherapist intervention could happen before surgery but assessment of safe zones is required after the surgery. A further aspect of this role is to insure people don’t get secondary stiffness in the wrist or hand of the affected joint.
The committee stated that ambulation after shoulder replacement surgery is part of the person’s progress to hospital discharge and fast discharge was and agreed by all of the committee to be important for a person’s wellbeing after joint replacement. However, the committee were clear that a person’s specific clinical situation at initial assessment would be considered in care as it currently stands. Signs that the inpatient rehabilitation program, and consequently ambulation, should be slowed or delayed would be made at the initial assessment after surgery by the orthopaedic team. For example, ambulation and discharge within 24 hours would not be actioned if the team finds a detectable limiting factor such as bleeding. The committee agreed that continuing this assessment of each person to ensure they are not contraindicated for rehabilitation within 24 hours after surgery reduces possible adverse effects of an early inpatient rehabilitation program. The committee noted that while it is preferable for rehabilitation to occur on the day of surgery there may be barriers that could prevent this, such as operations at later time-points in the day.
Therefore, the committee decided to make a consensus recommendation with extrapolation from the hip and knee surgery evidence to offer therapy led rehabilitation including mobilisation within 24 hours for people having primary shoulder replacement surgery not due to immediate trauma.
The committee consensus was that there were no harms associated with this recommendation as people’s specific clinical situation at initial assessment would be considered and rehabilitation delayed if indicated. The committee did not have evidence or consensus to recommend when the shoulder should be mobilised and were keen that this decision should be taken by the orthopaedic team.
The committee also agreed that two research recommendations were important to fill this gap in the evidence. One research recommendation would directly answer the question posed by this evidence review. Is early inpatient rehabilitation including ambulation within 24 hours of shoulder replacement surgery clinically and cost effective compared to later inpatient rehabilitation including ambulation. The second question not answered by the current evidence base is whether early shoulder mobilisation within 24 hours of shoulder replacement surgery clinically and cost effective compared to later shoulder mobilisation? The committee mentioned that the specifics of the surgery that mean a sling might be used for an extended period. Therefore the surgery technique affects whether it is possible to have early shoulder mobility and then early shoulder mobilisation.
The committee discussed the type of exercises to prescribe. They agreed that these should be tailored to the person’s needs and circumstances, taking into account their activities of daily living.
1.7.2. Cost effectiveness and resource use
No economic evaluations were found for early rehabilitation in shoulder replacement. However, two studies included in the inpatient hip and knee rehabilitation review were used to support a recommendation. One study found a cost saving associated with early mobilisation in a total knee replacement. The study also reported improved health outcomes (a reduced length of stay of 0.44 days and greater odds of achieving at least 90 degrees of knee flexion) in the early ambulation group. The other found cost savings associated with 7-day physiotherapy for hip and knee replacement patients compared with weekday-only physiotherapy. The study also reported improved health outcomes (quicker time to mobilise with two sticks for hip and knee, and a trend towards earlier discharge) in the weekend physiotherapy group.
The committee decided to recommend rehabilitation on the day of surgery or within 24 hours of surgery by extrapolating the evidence for hip and knee replacement patients. In the committee’s experience, the benefits of inpatient postoperative rehabilitation are similar for shoulder replacements as those seen after hip or knee replacements. All patients who receive a shoulder replacement (5,500 operations in 2017/18 according to Hospital Episode Statistic data) receive some form of physiotherapy and rehabilitation during their inpatient stay as part of current practice. This may be assessing the patient from the bed, assistance in mobilising from the bed and provision of exercises. Inpatient rehabilitation would usually be a 30–45 minute initial session for the majority of patients, from reading the notes to seeing the patient to finishing recording in the notes. For any surgery conducted on Monday, Tuesday, Wednesday or Thursday, the recommendation will not have a substantial resource impact as inpatient rehabilitation within 24 hours of surgery will take place on a weekday when physiotherapists and occupational therapists would be readily available as part of current practice. There was suggestion by the committee that more elective procedures would occur on weekdays, as opposed to weekends, due to greater accident and emergency pressures on the weekend.
All services currently offer a reduced provision of weekend physiotherapists/occupational therapists. However, these staff may not necessarily be seeing this group of patients as part of current practice. This therefore has a resource implication as it means that they would either have to see these patients and not others, or increase services to see these patients. The hourly unit costs for hospital based physiotherapy and occupational therapy team staff is £32–78 (Bands 4–8b), although the weekend costs may be more than those included. Registered physiotherapists and occupational therapists start at Band 5. Staff may also be on Band 3, however costs for this Band are not provided by the Personal Social Services Research Unit (PSSRU). There was discussion that it is important that an appropriately qualified physiotherapist or occupational therapist is available to give the first assessment. However, there are instances where staff on lower Bands who are well supported by members of the rehabilitation team can undertake subsequent inpatient care.
The economic evidence suggests that increasing weekend staff capacity and their associated costs will be at least partially offset by a reduction in length of stay due to faster recovery. The cost of an excess bed day for a primary elective shoulder replacement is £456. The committee believed the recommendation would result in an overall cost saving.
References
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- Curtis LA, Burns A. Unit costs of health and social care 2018. Project report. Kent. University of Kent, 2018. Available from: https://kar
.kent.ac.uk /70995/1/Unit%20Costs %202018%20-%20FINAL %20with%20bookmarks %20and%20covers%20%282%29.pdf - 2.
- Hultenheim Klintberg I, Gunnarsson AC, Styf J, Karlsson J. Early activation or a more protective regime after arthroscopic subacromial decompression-a description of clinical changes with two different physiotherapy treatment protocols-a prospective, randomized pilot study with a two-year follow-up. Clinical Rehabilitation. 2008; 22(10–11):951–65 [PubMed: 18955427]
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- Kluczynski MA, Isenburg MM, Marzo JM, Bisson LJ. Does early versus delayed active range of motion affect rotator cuff healing after surgical repair? A systematic review and meta-analysis. American Journal of Sports Medicine. 2016; 44(3):785–91 [PubMed: 25943112]
- 4.
- National Institute for Health and Care Excellence. Developing NICE guidelines: the manual [updated 2018]. London. National Institute for Health and Care Excellence, 2014. Available from: http://www
.nice.org.uk /article/PMG20/chapter /1%20Introduction%20and%20overview [PubMed: 26677490] - 5.
- Saltzman BM, Zuke WA, Go B, Mascarenhas R, Verma NN, Cole BJ et al. Does early motion lead to a higher failure rate or better outcomes after arthroscopic rotator cuff repair? A systematic review of overlapping meta-analyses. Journal of Shoulder and Elbow Surgery. 2017; 26(9):1681–1691 [PubMed: 28619382]
Appendices
Appendix A. Review protocols
Table 4. Review protocol: inpatient rehabilitation after shoulder replacement (PDF, 202K)
Appendix B. Literature search strategies
The literature searches for this review are detailed below and complied with the methodology outlined in Developing NICE guidelines: the manual.4
For more detailed information, please see the Methodology Review.
B.1. Clinical search literature search strategy
Searches were constructed using a PICO framework where population (P) terms were combined with Intervention (I) and in some cases Comparison (C) terms. Outcomes (O) are rarely used in search strategies for interventions as these concepts may not be well described in title, abstract or indexes and therefore difficult to retrieve. Search filters were applied to the searches where appropriate.
B.2. Health Economics literature search strategy
Health economic evidence was identified by conducting a broad search relating to the joint replacement population in NHS Economic Evaluation Database (NHS EED – this ceased to be updated after March 2015) and the Health Technology Assessment database (HTA) with no date restrictions. NHS EED and HTA databases are hosted by the Centre for Research and Dissemination (CRD). Additional health economic searches were run in Medline and Embase.
Appendix C. Clinical evidence selection
Appendix D. Clinical evidence tables
No studies were identified.
Appendix E. Forest plots
No studies were identified.
Appendix F. GRADE tables
No studies were identified.
Appendix G. Health economic evidence selection
Figure 2. Flow chart of health economic study selection for the guideline
Appendix H. Health economic evidence tables
No studies were identified.
Appendix I. Excluded studies
I.1. Excluded clinical studies
I.2. Excluded health economic studies
None.
Appendix J. Research recommendations
J.1. Early shoulder mobilisation
Research question: Is early mobilisation of the shoulder after primary elective shoulder replacement surgery more effective than delayed mobilisation in restoring rapid return of function and pain relief?
Why this is important:
Shoulder replacement surgery including both anatomic and reverse replacements is on the increase. Post operative physiotherapy is considered routine practice following this surgery however there is a lack of high quality trials and clinical consensus on when movement of the shoulder should be encouraged following surgery. Restoring range of motion and strength following shoulder replacement is considered important to obtain good outcomes. Given the rise of this procedure there is an urgent need for high quality well powered RCTs to determine effective post operative rehabilitation programmes.
| PICO question | Population: People undergoing primary elective shoulder replacement Intervention(s): Mobilisation of the shoulder within 24 hours of surgery Comparison: Delayed mobilisation of the shoulder (up to 3 weeks) Outcome(s): Pain, function, health related quality of life, adverse events, health economic measures (direct and indirect costs), return to work, rate of recovery |
|---|---|
| Importance to patients or the population | The sooner the shoulder can be mobilised the sooner formal shoulder rehabilitation can begin. Getting back to a more normal functional existence is very important to people who have undergone surgery. |
| Relevance to NICE guidance | This could lead to a recommendation when this recommendation is updated in the future. |
| Relevance to the NHS | Earlier return of function may allow people to be discharged from orthopaedic care earlier. |
| National priorities | Not linked to any national priorities |
| Current evidence base | There are currently no randomised controlled trials for the timing of mobilisation of the shoulder after shoulder replacement surgery |
| Equality | There are no equality issues identified for this research recommendation. However the likely effect on people with neurocognitive decline or co-morbidities should be considered when the results of the trial are acted upon. |
| Study design | Randomised controlled trial |
| Feasibility | It is considered feasible and will either not change or reduce costs associated with rehabilitation. |
| Other comments | |
| Importance |
|
Final
Intervention evidence review underpinning recommendation 1.10.1 and the research recommendation in the NICE guideline
This evidence review was developed by the National Guideline Centre, hosted by the Royal College of Physicians
Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and, where appropriate, their carer or guardian.
Local commissioners and providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.
NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.
- PubMedLinks to PubMed
- Review Evidence review for inpatient hip and knee postoperative rehabilitation: Joint replacement (primary): hip, knee and shoulder: Evidence review P[ 2020]Review Evidence review for inpatient hip and knee postoperative rehabilitation: Joint replacement (primary): hip, knee and shoulder: Evidence review PNational Guideline Centre (UK). 2020 Jun
- Physiotherapy rehabilitation after total knee or hip replacement: an evidence-based analysis.[Ont Health Technol Assess Ser....]Physiotherapy rehabilitation after total knee or hip replacement: an evidence-based analysis.Medical Advisory Secretariat. Ont Health Technol Assess Ser. 2005; 5(8):1-91. Epub 2005 Jun 1.
- Review Evidence review for outpatient rehabilitation after shoulder replacement: Joint replacement (primary): hip, knee and shoulder: Evidence review S[ 2020]Review Evidence review for outpatient rehabilitation after shoulder replacement: Joint replacement (primary): hip, knee and shoulder: Evidence review SNational Guideline Centre (UK). 2020 Jun
- An extended stroke rehabilitation service for people who have had a stroke: the EXTRAS RCT.[Health Technol Assess. 2020]An extended stroke rehabilitation service for people who have had a stroke: the EXTRAS RCT.Shaw L, Bhattarai N, Cant R, Drummond A, Ford GA, Forster A, Francis R, Hills K, Howel D, Laverty AM, et al. Health Technol Assess. 2020 May; 24(24):1-202.
- Conservative management following closed reduction of traumatic anterior dislocation of the shoulder.[Cochrane Database Syst Rev. 2019]Conservative management following closed reduction of traumatic anterior dislocation of the shoulder.Braun C, McRobert CJ. Cochrane Database Syst Rev. 2019 May 10; 5(5):CD004962. Epub 2019 May 10.
- Evidence review for inpatient shoulder postoperative rehabilitationEvidence review for inpatient shoulder postoperative rehabilitation
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