Background, Rationale and significance - ANZCTR



Research Plan: Exercise rehabilitation and functional recovery following reverse total shoulder arthroplastyBackground, Rationale and significance Reverse total shoulder arthroplasty (RSA) is an end-stage surgical treatment option for patients with rotator cuff arthropathy and/or massive rotator cuff tears with who have significant difficulty in moving their shoulder and undertaking daily activities. RSA has demonstrated good success at relieving pain, improving range of motion, functional capacity and overall satisfaction, ADDIN PAPERS2_CITATIONS <citation><uuid>D2DF5735-1091-4A63-80C4-489E5433A6ED</uuid><priority>0</priority><publications><publication><uuid>B93985B7-38D4-46C4-BB63-58750F48D6CB</uuid><volume>468</volume><doi>10.1007/s11999-009-1188-9</doi><startpage>1526</startpage><publication_date>99201006001200000000220000</publication_date><url> for reverse total shoulder arthroplasty in rotator cuff disease.</title><institution>Core Orthopedics and Sports Medicine, 555 Biesterfield Road, Elk Grove Village, IL 60007, USA. gregdrake@</institution><number>6</number><subtype>400</subtype><endpage>1533</endpage><bundle><publication><title>Clinical orthopaedics and related research</title><type>-100</type><subtype>-100</subtype><uuid>3AEBFF8F-B957-4335-936C-184B9F9BF06B</uuid></publication></bundle><authors><author><firstName>Gregory</firstName><middleNames>N</middleNames><lastName>Drake</lastName></author><author><firstName>Daniel</firstName><middleNames>P</middleNames><lastName>O'Connor</lastName></author><author><firstName>T</firstName><middleNames>Bradley</middleNames><lastName>Edwards</lastName></author></authors></publication><publication><uuid>9D38ADE7-0EB8-4859-98CB-B7CBDC9F1E59</uuid><volume>93</volume><doi>10.1302/0301-620X.93B1.24218</doi><startpage>57</startpage><publication_date>99201101001200000000220000</publication_date><url> Delta III reverse shoulder replacement for cuff tear arthropathy: a single-centre study of 50 consecutive procedures.</title><institution>Princess Elizabeth Orthopaedic Centre, Exeter, United Kingdom.</institution><number>1</number><subtype>400</subtype><endpage>61</endpage><bundle><publication><title>The Journal of bone and joint surgery. British volume</title><type>-100</type><subtype>-100</subtype><uuid>E86ED82D-154C-47C2-B97D-F89ACE4A1163</uuid></publication></bundle><authors><author><firstName>M</firstName><middleNames>A</middleNames><lastName>Naveed</lastName></author><author><firstName>J</firstName><lastName>Kitson</lastName></author><author><firstName>T</firstName><middleNames>D</middleNames><lastName>Bunker</lastName></author></authors></publication></publications><cites></cites></citation>1,2 and with expanding indications and successful midterm outcomes, it is now being performed in a wider patient demographic, including younger patients. ADDIN PAPERS2_CITATIONS <citation><uuid>68E7350C-00C2-422E-A82D-F7116FEDF9B2</uuid><priority>1</priority><publications><publication><uuid>A0541DE5-5371-479B-8238-9699A03C33F4</uuid><volume>92</volume><doi>10.2106/JBJS.I.00912</doi><startpage>2544</startpage><publication_date>99201011031200000000222000</publication_date><url> shoulder arthroplasty for the treatment of irreparable rotator cuff tear without glenohumeral arthritis.</title><institution>Florida Orthopaedic Institute, 13020 North Telecom Parkway, Tampa, FL 33637, USA.</institution><number>15</number><subtype>400</subtype><endpage>2556</endpage><bundle><publication><title>The Journal of bone and joint surgery. American volume</title><type>-100</type><subtype>-100</subtype><uuid>5FDCD024-1BC8-40A2-A5C6-237D3213B57D</uuid></publication></bundle><authors><author><firstName>Philip</firstName><lastName>Mulieri</lastName></author><author><firstName>Page</firstName><lastName>Dunning</lastName></author><author><firstName>Steven</firstName><lastName>Klein</lastName></author><author><firstName>Derek</firstName><lastName>Pupello</lastName></author><author><firstName>Mark</firstName><lastName>Frankle</lastName></author></authors></publication><publication><uuid>03BD5EE4-4729-4BE9-8BE9-FD889CE1D98D</uuid><volume>43</volume><doi>10.1177/0363546515597673</doi><startpage>2816</startpage><publication_date>99201511001200000000220000</publication_date><url> Activity Levels After Reverse Total Shoulder Arthroplasty: What Are Patients Doing?</title><institution>Hospital for Special Surgery, New York, New York, USA GarciaGr@hss.edu.</institution><number>11</number><subtype>400</subtype><endpage>2821</endpage><bundle><publication><title>The American journal of sports medicine</title><type>-100</type><subtype>-100</subtype><uuid>B35FB05F-66F1-4D5E-B63C-202703C9B1DD</uuid></publication></bundle><authors><author><firstName>Grant</firstName><middleNames>H</middleNames><lastName>Garcia</lastName></author><author><firstName>Samuel</firstName><middleNames>A</middleNames><lastName>Taylor</lastName></author><author><firstName>Brian</firstName><middleNames>J</middleNames><lastName>DePalma</lastName></author><author><firstName>Gregory</firstName><middleNames>T</middleNames><lastName>Mahony</lastName></author><author><firstName>Brian</firstName><middleNames>M</middleNames><lastName>Grawe</lastName></author><author><firstName>Joseph</firstName><lastName>Nguyen</lastName></author><author><firstName>Joshua</firstName><middleNames>S</middleNames><lastName>Dines</lastName></author><author><firstName>David</firstName><middleNames>M</middleNames><lastName>Dines</lastName></author><author><firstName>Russell</firstName><middleNames>F</middleNames><lastName>Warren</lastName></author><author><firstName>Edward</firstName><middleNames>V</middleNames><lastName>Craig</lastName></author><author><firstName>Lawrence</firstName><middleNames>V</middleNames><lastName>Gulotta</lastName></author></authors></publication></publications><cites></cites></citation>3,4 Return to sports and physical activity is increasingly being evaluated as a factor in judging orthopaedic surgical outcomes. An increase in patient activity intensity post-surgery may reflect greater function associated with clinical improvements in range of motion, strength, pain and / or overall physical function. Conversely, patients avoiding high intensity activities may represent deteriorating function associated with clinical impairments. ADDIN PAPERS2_CITATIONS <citation><uuid>CA8E3B06-0E63-42B0-A61C-271AB5D65FE4</uuid><priority>2</priority><publications><publication><uuid>68DC6665-020F-4F74-BB99-0215E52B84D4</uuid><volume>23</volume><accepted_date>99201303201200000000222000</accepted_date><doi>10.1016/j.jelekin.2013.03.010</doi><startpage>924</startpage><revision_date>99201303201200000000222000</revision_date><publication_date>99201308001200000000220000</publication_date><url> accelerometer analysis techniques for evaluating functional use of the extremities.</title><submission_date>99201207031200000000222000</submission_date><number>4</number><institution>Department of Orthopedic Surgery, Division of Orthopedic Research, Mayo Clinic, Rochester, MN 55902, USA. hurd.wendy@mayo.edu</institution><subtype>400</subtype><endpage>929</endpage><bundle><publication><title>Journal of electromyography and kinesiology : official journal of the International Society of Electrophysiological Kinesiology</title><type>-100</type><subtype>-100</subtype><uuid>97423DE7-4A97-41F8-ACA1-0EF18597E911</uuid></publication></bundle><authors><author><firstName>Wendy</firstName><middleNames>J</middleNames><lastName>Hurd</lastName></author><author><firstName>Melissa</firstName><middleNames>M</middleNames><lastName>Morrow</lastName></author><author><firstName>Kenton</firstName><middleNames>R</middleNames><lastName>Kaufman</lastName></author></authors></publication></publications><cites></cites></citation>5 A variety of different methods are routinely employed to assess patient function after RSA, such as self-reported questionnaires. Previous studies have demonstrated relationships between strength and self-reported activity and functional outcomes, ADDIN PAPERS2_CITATIONS <citation><uuid>99C5E78D-37E3-4220-8C5D-32C3AC26EC7E</uuid><priority>3</priority><publications><publication><volume>2013</volume><publication_date>99201301111200000000222000</publication_date><number>jan11 1</number><doi>10.1136/bcr-2012-007899</doi><startpage>bcr2012007899</startpage><title>Autologous tenocyte implantation, a novel treatment for partial-thickness rotator cuff tear and tendinopathy in an elite athlete</title><uuid>D9ACABCB-043B-4A6D-9DB7-7FC0518341C1</uuid><subtype>400</subtype><endpage>bcr2012007899</endpage><type>400</type><url> Reports</title><type>-100</type><subtype>-100</subtype><uuid>B08F14AE-52AD-4C4D-91B7-9727102E6A85</uuid></publication></bundle><authors><author><firstName>A</firstName><middleNames>W</middleNames><lastName>Wang</lastName></author><author><firstName>S</firstName><lastName>Bauer</lastName></author><author><firstName>M</firstName><lastName>Goonatillake</lastName></author><author><firstName>W</firstName><lastName>Breidahl</lastName></author><author><firstName>M</firstName><middleNames>H</middleNames><lastName>Zheng</lastName></author></authors></publication><publication><uuid>F158D6B0-81DA-47A8-A526-AA6D29E9AE76</uuid><volume>29</volume><accepted_date>99201408181200000000222000</accepted_date><doi>10.1016/j.clinbiomech.2014.08.018</doi><startpage>965</startpage><revision_date>99201408181200000000222000</revision_date><publication_date>99201411001200000000220000</publication_date><url> strength differences between patients with primary reverse and total shoulder prostheses: muscle strength quantified with a dynamometer.</title><submission_date>99201401291200000000222000</submission_date><number>9</number><institution>Department of Orthopaedic Surgery and Traumatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands; Amsterdam Rehabilitation Research Center, Reade, Amsterdam, The Netherlands. Electronic address: tdw.alta@.</institution><subtype>400</subtype><endpage>970</endpage><bundle><publication><title>Clinical biomechanics (Bristol, Avon)</title><type>-100</type><subtype>-100</subtype><uuid>B7C7F417-2ECA-4C1F-9A62-DE8B84111B5D</uuid></publication></bundle><authors><author><firstName>Tjarco</firstName><middleNames>D W</middleNames><lastName>Alta</lastName></author><author><firstName>DirkJan</firstName><middleNames>H E J</middleNames><lastName>Veeger</lastName></author><author><lastName>Toledo</lastName><nonDroppingParticle>de</nonDroppingParticle><firstName>Joelly</firstName><middleNames>M</middleNames></author><author><firstName>Thomas</firstName><middleNames>W J</middleNames><lastName>Janssen</lastName></author><author><firstName>W</firstName><middleNames>Jaap</middleNames><lastName>Willems</lastName></author></authors></publication><publication><uuid>60D7F5A0-C3AC-479D-881F-87A57906962A</uuid><volume>27</volume><accepted_date>99201204251200000000222000</accepted_date><doi>10.1016/j.clinbiomech.2012.04.009</doi><startpage>793</startpage><revision_date>99201204241200000000222000</revision_date><publication_date>99201210001200000000220000</publication_date><url> evaluation of patients with total and reverse shoulder arthroplasty during rehabilitation exercises with different loads.</title><submission_date>99201201261200000000222000</submission_date><number>8</number><institution>Physical Education School, Exercise Research Laboratory, Federal University of Rio Grande do Sul, Porto Alegre, Brazil. joellytoledo@</institution><subtype>400</subtype><endpage>800</endpage><bundle><publication><title>Clinical biomechanics (Bristol, Avon)</title><type>-100</type><subtype>-100</subtype><uuid>B7C7F417-2ECA-4C1F-9A62-DE8B84111B5D</uuid></publication></bundle><authors><author><lastName>Toledo</lastName><nonDroppingParticle>de</nonDroppingParticle><firstName>Joelly</firstName><middleNames>Mahnic</middleNames></author><author><firstName>Jefferson</firstName><middleNames>Fagundes</middleNames><lastName>Loss</lastName></author><author><firstName>Thomas</firstName><middleNames>W</middleNames><lastName>Janssen</lastName></author><author><lastName>Scheer</lastName><nonDroppingParticle>van der</nonDroppingParticle><firstName>Jan</firstName><middleNames>W</middleNames></author><author><firstName>Tjarco</firstName><middleNames>D</middleNames><lastName>Alta</lastName></author><author><firstName>W</firstName><middleNames>Jaap</middleNames><lastName>Willems</lastName></author><author><firstName>DirkJan</firstName><middleNames>H E J</middleNames><lastName>Veeger</lastName></author></authors></publication></publications><cites></cites></citation>6-8 however self-reported outcome evaluations are dependent on patient recall and perception of activity performance which do not inherently capture detailed functional movement data. Furthermore, within-clinic assessments fail to capture an accurate representation of upper limb function during activities of daily living in a patient’s natural living environment. The use of activity monitors in measuring function and limb use after injury to assess the impact of disease on movement, and the effectiveness of intervention in normalising limb use has grown to involve the upper extremity, including those scheduled for RSA. ADDIN PAPERS2_CITATIONS <citation><uuid>61FB6F23-FB1D-4ADF-BE95-582EDFD48CBA</uuid><priority>4</priority><publications><publication><uuid>B70AD7D7-A75F-4484-8E8D-0F297478E608</uuid><volume>23</volume><accepted_date>99201402101200000000222000</accepted_date><doi>10.1016/j.jse.2014.02.008</doi><startpage>e251</startpage><revision_date>99201402041200000000222000</revision_date><publication_date>99201410001200000000220000</publication_date><url> approaches to objectively assess shoulder function.</title><submission_date>99201310301200000000222000</submission_date><number>10</number><institution>Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA. Electronic address: hurd.wendy@mayo.edu.</institution><subtype>400</subtype><endpage>5</endpage><bundle><publication><publisher>Graduate School of Health Sciences, Sapporo Medical University, Sapporo, Japan.</publisher><title>Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.]</title><type>-100</type><subtype>-100</subtype><uuid>BEDF5255-D33C-4355-A49B-F398CD0D012E</uuid></publication></bundle><authors><author><firstName>Wendy</firstName><middleNames>J</middleNames><lastName>Hurd</lastName></author><author><firstName>Melissa</firstName><middleNames>M</middleNames><lastName>Morrow</lastName></author><author><firstName>Emily</firstName><middleNames>J</middleNames><lastName>Miller</lastName></author><author><firstName>Robert</firstName><middleNames>A</middleNames><lastName>Adams</lastName></author><author><firstName>John</firstName><middleNames>W</middleNames><lastName>Sperling</lastName></author><author><firstName>Kenton</firstName><middleNames>R</middleNames><lastName>Kaufman</lastName></author></authors></publication></publications><cites></cites></citation>9 Using activity monitors in the upper extremity as an alternative method for evaluating patient function post-surgery, may allow for a more objective measurement of the frequency, duration, and intensity of shoulder function in patients after RSA.Patient satisfaction is closely correlated with resumption of regular activities, and in the case of RSA, it has been shown that those who return to their pre-surgery physical activity and recreational sports after RSA, report greater levels of satisfaction post-surgery. ADDIN PAPERS2_CITATIONS <citation><uuid>0E94923F-FE0B-42AF-ACB4-3E416CEA889C</uuid><priority>5</priority><publications><publication><uuid>03BD5EE4-4729-4BE9-8BE9-FD889CE1D98D</uuid><volume>43</volume><doi>10.1177/0363546515597673</doi><startpage>2816</startpage><publication_date>99201511001200000000220000</publication_date><url> Activity Levels After Reverse Total Shoulder Arthroplasty: What Are Patients Doing?</title><institution>Hospital for Special Surgery, New York, New York, USA GarciaGr@hss.edu.</institution><number>11</number><subtype>400</subtype><endpage>2821</endpage><bundle><publication><title>The American journal of sports medicine</title><type>-100</type><subtype>-100</subtype><uuid>B35FB05F-66F1-4D5E-B63C-202703C9B1DD</uuid></publication></bundle><authors><author><firstName>Grant</firstName><middleNames>H</middleNames><lastName>Garcia</lastName></author><author><firstName>Samuel</firstName><middleNames>A</middleNames><lastName>Taylor</lastName></author><author><firstName>Brian</firstName><middleNames>J</middleNames><lastName>DePalma</lastName></author><author><firstName>Gregory</firstName><middleNames>T</middleNames><lastName>Mahony</lastName></author><author><firstName>Brian</firstName><middleNames>M</middleNames><lastName>Grawe</lastName></author><author><firstName>Joseph</firstName><lastName>Nguyen</lastName></author><author><firstName>Joshua</firstName><middleNames>S</middleNames><lastName>Dines</lastName></author><author><firstName>David</firstName><middleNames>M</middleNames><lastName>Dines</lastName></author><author><firstName>Russell</firstName><middleNames>F</middleNames><lastName>Warren</lastName></author><author><firstName>Edward</firstName><middleNames>V</middleNames><lastName>Craig</lastName></author><author><firstName>Lawrence</firstName><middleNames>V</middleNames><lastName>Gulotta</lastName></author></authors></publication></publications><cites></cites></citation>4 Following RSA, patients with greater isokinetic shoulder strength participate in higher demand recreational or sports activity and report fewer difficulties with activities of daily living, ADDIN PAPERS2_CITATIONS <citation><uuid>7500B27B-889C-4C91-A358-7FAEBAB45DDB</uuid><priority>0</priority><publications><publication><publication_date>99201604081200000000222000</publication_date><doi>10.1016/j.jse.2016.01.025</doi><institution>Department of Orthopaedic Surgery, The University of Western Australia, Nedlands, WA, Australia; St John of God Hospital, Murdoch, WA, Australia; Sir Charles Gairdner Hospital, Nedlands, WA, Australia. Electronic address: allanwang@.au.</institution><accepted_date>99201601221200000000222000</accepted_date><title>Isokinetic shoulder strength correlates with level of sports participation and functional activity after reverse total shoulder arthroplasty.</title><revision_date>99201601171200000000222000</revision_date><subtype>400</subtype><uuid>84B9DB78-58E3-497C-8ED1-40EE3F1C245F</uuid><type>400</type><submission_date>99201507051200000000222000</submission_date><url> School of Health Sciences, Sapporo Medical University, Sapporo, Japan.</publisher><title>Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.]</title><type>-100</type><subtype>-100</subtype><uuid>BEDF5255-D33C-4355-A49B-F398CD0D012E</uuid></publication></bundle><authors><author><firstName>Allan</firstName><lastName>Wang</lastName></author><author><firstName>Timothy</firstName><lastName>Doyle</lastName></author><author><firstName>Gregory</firstName><lastName>Cunningham</lastName></author><author><firstName>Michael</firstName><lastName>Brutty</lastName></author><author><firstName>Peter</firstName><lastName>Campbell</lastName></author><author><firstName>Chrianna</firstName><lastName>Bharat</lastName></author><author><firstName>Timothy</firstName><lastName>Ackland</lastName></author></authors></publication></publications><cites></cites></citation>10 and conversely, lower isokinetic shoulder strength is known to be a major factor in reduced range of motion (ROM), ADDIN PAPERS2_CITATIONS <citation><uuid>05E83EA5-F487-4E7B-A07A-0D5B9E8A5952</uuid><priority>6</priority><publications><publication><uuid>F158D6B0-81DA-47A8-A526-AA6D29E9AE76</uuid><volume>29</volume><accepted_date>99201408181200000000222000</accepted_date><doi>10.1016/j.clinbiomech.2014.08.018</doi><startpage>965</startpage><revision_date>99201408181200000000222000</revision_date><publication_date>99201411001200000000220000</publication_date><url> strength differences between patients with primary reverse and total shoulder prostheses: muscle strength quantified with a dynamometer.</title><submission_date>99201401291200000000222000</submission_date><number>9</number><institution>Department of Orthopaedic Surgery and Traumatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands; Amsterdam Rehabilitation Research Center, Reade, Amsterdam, The Netherlands. Electronic address: tdw.alta@.</institution><subtype>400</subtype><endpage>970</endpage><bundle><publication><title>Clinical biomechanics (Bristol, Avon)</title><type>-100</type><subtype>-100</subtype><uuid>B7C7F417-2ECA-4C1F-9A62-DE8B84111B5D</uuid></publication></bundle><authors><author><firstName>Tjarco</firstName><middleNames>D W</middleNames><lastName>Alta</lastName></author><author><firstName>DirkJan</firstName><middleNames>H E J</middleNames><lastName>Veeger</lastName></author><author><lastName>Toledo</lastName><nonDroppingParticle>de</nonDroppingParticle><firstName>Joelly</firstName><middleNames>M</middleNames></author><author><firstName>Thomas</firstName><middleNames>W J</middleNames><lastName>Janssen</lastName></author><author><firstName>W</firstName><middleNames>Jaap</middleNames><lastName>Willems</lastName></author></authors></publication></publications><cites></cites></citation>7 and is also associated with inferior clinical outcomes following RSA. ADDIN PAPERS2_CITATIONS <citation><uuid>0ACF03A6-96E4-49FF-A11C-11C18B2B90DB</uuid><priority>7</priority><publications><publication><uuid>F158D6B0-81DA-47A8-A526-AA6D29E9AE76</uuid><volume>29</volume><accepted_date>99201408181200000000222000</accepted_date><doi>10.1016/j.clinbiomech.2014.08.018</doi><startpage>965</startpage><revision_date>99201408181200000000222000</revision_date><publication_date>99201411001200000000220000</publication_date><url> strength differences between patients with primary reverse and total shoulder prostheses: muscle strength quantified with a dynamometer.</title><submission_date>99201401291200000000222000</submission_date><number>9</number><institution>Department of Orthopaedic Surgery and Traumatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands; Amsterdam Rehabilitation Research Center, Reade, Amsterdam, The Netherlands. Electronic address: tdw.alta@.</institution><subtype>400</subtype><endpage>970</endpage><bundle><publication><title>Clinical biomechanics (Bristol, Avon)</title><type>-100</type><subtype>-100</subtype><uuid>B7C7F417-2ECA-4C1F-9A62-DE8B84111B5D</uuid></publication></bundle><authors><author><firstName>Tjarco</firstName><middleNames>D W</middleNames><lastName>Alta</lastName></author><author><firstName>DirkJan</firstName><middleNames>H E J</middleNames><lastName>Veeger</lastName></author><author><lastName>Toledo</lastName><nonDroppingParticle>de</nonDroppingParticle><firstName>Joelly</firstName><middleNames>M</middleNames></author><author><firstName>Thomas</firstName><middleNames>W J</middleNames><lastName>Janssen</lastName></author><author><firstName>W</firstName><middleNames>Jaap</middleNames><lastName>Willems</lastName></author></authors></publication></publications><cites></cites></citation>7 Therefore a well-planned postoperative rehabilitation program, in combination with a correctly performed surgical procedure, is essential in optimising patient outcomes. ADDIN PAPERS2_CITATIONS <citation><uuid>595B71CC-D963-47D0-A356-64E62C46D242</uuid><priority>8</priority><publications><publication><uuid>60D7F5A0-C3AC-479D-881F-87A57906962A</uuid><volume>27</volume><accepted_date>99201204251200000000222000</accepted_date><doi>10.1016/j.clinbiomech.2012.04.009</doi><startpage>793</startpage><revision_date>99201204241200000000222000</revision_date><publication_date>99201210001200000000220000</publication_date><url> evaluation of patients with total and reverse shoulder arthroplasty during rehabilitation exercises with different loads.</title><submission_date>99201201261200000000222000</submission_date><number>8</number><institution>Physical Education School, Exercise Research Laboratory, Federal University of Rio Grande do Sul, Porto Alegre, Brazil. joellytoledo@</institution><subtype>400</subtype><endpage>800</endpage><bundle><publication><title>Clinical biomechanics (Bristol, Avon)</title><type>-100</type><subtype>-100</subtype><uuid>B7C7F417-2ECA-4C1F-9A62-DE8B84111B5D</uuid></publication></bundle><authors><author><lastName>Toledo</lastName><nonDroppingParticle>de</nonDroppingParticle><firstName>Joelly</firstName><middleNames>Mahnic</middleNames></author><author><firstName>Jefferson</firstName><middleNames>Fagundes</middleNames><lastName>Loss</lastName></author><author><firstName>Thomas</firstName><middleNames>W</middleNames><lastName>Janssen</lastName></author><author><lastName>Scheer</lastName><nonDroppingParticle>van der</nonDroppingParticle><firstName>Jan</firstName><middleNames>W</middleNames></author><author><firstName>Tjarco</firstName><middleNames>D</middleNames><lastName>Alta</lastName></author><author><firstName>W</firstName><middleNames>Jaap</middleNames><lastName>Willems</lastName></author><author><firstName>DirkJan</firstName><middleNames>H E J</middleNames><lastName>Veeger</lastName></author></authors></publication></publications><cites></cites></citation>8 While rehabilitation is generally recommended following RSA, these recommendations are based on expert opinion only, ADDIN PAPERS2_CITATIONS <citation><uuid>43318ED8-D91E-4583-B0AF-94AEEE752CC7</uuid><priority>9</priority><publications><publication><uuid>533272E9-AB27-45D6-857B-D578454E43C5</uuid><volume>37</volume><doi>10.2519/jospt.2007.2562</doi><startpage>734</startpage><publication_date>99200712001200000000220000</publication_date><url> following reverse total shoulder arthroplasty.</title><institution>Department of Rehabilitation Services, Brigham and Women's Hospital, Boston, MA 02115, USA.</institution><number>12</number><subtype>400</subtype><endpage>743</endpage><bundle><publication><publisher>Kaiser Permanente Panorama City Orthopaedic Physical Therapy Residency Program, Panorama City, CA.</publisher><title>The Journal of orthopaedic and sports physical therapy</title><type>-100</type><subtype>-100</subtype><uuid>F7783C23-7EDB-48CE-A44D-4CE8FDA5E40F</uuid></publication></bundle><authors><author><firstName>Stephanie</firstName><lastName>Boudreau</lastName></author><author><firstName>E</firstName><middleNames>D</middleNames><lastName>Boudreau</lastName></author><author><firstName>Laurence</firstName><middleNames>D</middleNames><lastName>Higgins</lastName></author><author><firstName>Reg</firstName><middleNames>B</middleNames><lastName>Wilcox</lastName></author></authors></publication></publications><cites></cites></citation>11 with no studies having investigated the effect of structured postoperative rehabilitation at an evidence level of 1 or 2. Furthermore, no study to date has evaluated the effect of a pre-operative strengthening program in patients with massive rotator cuff tears scheduled for shoulder surgery, in particular, RSA. Exercise rehabilitation has previously been shown to be effective in improving pain, strength and quality of life scores in patients living with massive rotator cuff tears, ADDIN PAPERS2_CITATIONS <citation><uuid>BE6EE74D-7DBE-47DD-BCC2-DACE86D51386</uuid><priority>10</priority><publications><publication><uuid>B015D2A6-CCE5-4B0B-99FB-DD5B19FD79F0</uuid><volume>4</volume><doi>10.1002/msc.85</doi><startpage>140</startpage><publication_date>99200609001200000000220000</publication_date><url> rehabilitation in patients with massive, irreparable rotator cuff tears.</title><institution>Physiotherapy Department, Torbay Hospital, Torquay, UK. roberta.ainsworth@</institution><number>3</number><subtype>400</subtype><endpage>151</endpage><bundle><publication><publisher>Tvaaker Primary Health Care Centre, Varberg, Sweden. pia.nilsson@lthalland.se</publisher><title>Musculoskeletal care</title><type>-100</type><subtype>-100</subtype><uuid>7563167C-ACB4-470E-9450-0FC8CC2957A3</uuid></publication></bundle><authors><author><firstName>Roberta</firstName><lastName>Ainsworth</lastName></author></authors></publication><publication><uuid>C6A757B9-ADF2-4B27-A50F-353549AF0E36</uuid><volume>41</volume><doi>10.1136/bjsm.2006.032524</doi><startpage>200</startpage><publication_date>99200704001200000000220000</publication_date><url> therapy for the conservative management of full thickness tears of the rotator cuff: a systematic review.</title><institution>South Devon NHS Healthcare Trust, Torbay Hospital, Torquay, UK.</institution><number>4</number><subtype>400</subtype><endpage>210</endpage><bundle><publication><publisher>School of Health and Human Sciences, Faculty of Health, Leeds Metropolitan University, Leeds LS1 3HE, UK. d_stasinopoulos@yahoo.gr</publisher><title>British journal of sports medicine</title><type>-100</type><subtype>-100</subtype><uuid>2157892B-FE0E-49AD-BC17-4BCE7BD96CDC</uuid></publication></bundle><authors><author><firstName>Roberta</firstName><lastName>Ainsworth</lastName></author><author><firstName>Jeremy</firstName><middleNames>S</middleNames><lastName>Lewis</lastName></author></authors></publication><publication><type>400</type><publication_date>99200900001200000000200000</publication_date><title>A prospective randomized placebo controlled clinical trial of a rehabilitation programme for patients with a diagnosis of massive rotator cuff tears of the shoulder</title><url> &amp; Elbow</title><type>-100</type><subtype>-100</subtype><uuid>4020041F-8081-4B54-83DF-E7035BCD8837</uuid></publication></bundle><authors><author><firstName>R</firstName><lastName>Ainsworth</lastName></author><author><firstName>J</firstName><lastName>Lewis</lastName></author><author><firstName>V</firstName><lastName>Conboy</lastName></author></authors></publication><publication><uuid>39FA63B6-4CC5-41D0-9577-6464D99BE186</uuid><volume>17</volume><accepted_date>99200804091200000000222000</accepted_date><doi>10.1016/j.jse.2008.04.005</doi><startpage>863</startpage><revision_date>99200803191200000000222000</revision_date><publication_date>99200811001200000000220000</publication_date><url> role of anterior deltoid reeducation in patients with massive irreparable degenerative rotator cuff tears.</title><submission_date>99200608131200000000222000</submission_date><number>6</number><institution>Reading Shoulder Unit, Royal Berkshire Hospital, Reading, United Kingdom. oferlevy@</institution><subtype>400</subtype><endpage>870</endpage><bundle><publication><publisher>Graduate School of Health Sciences, Sapporo Medical University, Sapporo, Japan.</publisher><title>Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.]</title><type>-100</type><subtype>-100</subtype><uuid>BEDF5255-D33C-4355-A49B-F398CD0D012E</uuid></publication></bundle><authors><author><firstName>Ofer</firstName><lastName>Levy</lastName></author><author><firstName>Hannan</firstName><lastName>Mullett</lastName></author><author><firstName>Sarah</firstName><lastName>Roberts</lastName></author><author><firstName>Stephen</firstName><lastName>Copeland</lastName></author></authors></publication><publication><uuid>059B7290-C2BF-4A1A-B3CB-6A0D2657DC5C</uuid><volume>22</volume><accepted_date>99201301301200000000222000</accepted_date><doi>10.1016/j.jse.2013.01.026</doi><startpage>1371</startpage><revision_date>99201301211200000000222000</revision_date><publication_date>99201310001200000000220000</publication_date><url> of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study.</title><submission_date>99201209151200000000222000</submission_date><number>10</number><institution>MOON Shoulder Group, Nashville, TN, USA. Electronic address: j.kuhn@vanderbilt.edu.</institution><subtype>400</subtype><endpage>1379</endpage><bundle><publication><publisher>Graduate School of Health Sciences, Sapporo Medical University, Sapporo, Japan.</publisher><title>Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.]</title><type>-100</type><subtype>-100</subtype><uuid>BEDF5255-D33C-4355-A49B-F398CD0D012E</uuid></publication></bundle><authors><author><firstName>John</firstName><middleNames>E</middleNames><lastName>Kuhn</lastName></author><author><firstName>Warren</firstName><middleNames>R</middleNames><lastName>Dunn</lastName></author><author><firstName>Rosemary</firstName><lastName>Sanders</lastName></author><author><firstName>Qi</firstName><lastName>An</lastName></author><author><firstName>Keith</firstName><middleNames>M</middleNames><lastName>Baumgarten</lastName></author><author><firstName>Julie</firstName><middleNames>Y</middleNames><lastName>Bishop</lastName></author><author><firstName>Robert</firstName><middleNames>H</middleNames><lastName>Brophy</lastName></author><author><firstName>James</firstName><middleNames>L</middleNames><lastName>Carey</lastName></author><author><firstName>Brian</firstName><middleNames>G</middleNames><lastName>Holloway</lastName></author><author><firstName>Grant</firstName><middleNames>L</middleNames><lastName>Jones</lastName></author><author><firstName>C</firstName><middleNames>Benjamin</middleNames><lastName>Ma</lastName></author><author><firstName>Robert</firstName><middleNames>G</middleNames><lastName>Marx</lastName></author><author><firstName>Eric</firstName><middleNames>C</middleNames><lastName>McCarty</lastName></author><author><firstName>Sourav</firstName><middleNames>K</middleNames><lastName>Poddar</lastName></author><author><firstName>Matthew</firstName><middleNames>V</middleNames><lastName>Smith</lastName></author><author><firstName>Edwin</firstName><middleNames>E</middleNames><lastName>Spencer</lastName></author><author><firstName>Armando</firstName><middleNames>F</middleNames><lastName>Vidal</lastName></author><author><firstName>Brian</firstName><middleNames>R</middleNames><lastName>Wolf</lastName></author><author><firstName>Rick</firstName><middleNames>W</middleNames><lastName>Wright</lastName></author><author><lastName>MOON Shoulder Group</lastName></author></authors></publication></publications><cites></cites></citation>12-16 and a larger preoperative deltoid size has been shown to correlate with an improvement in outcomes after RSA. ADDIN PAPERS2_CITATIONS <citation><uuid>3D310120-EFD9-4F63-848F-47559E300749</uuid><priority>11</priority><publications><publication><uuid>F7BA51E4-3AD9-4EDD-8539-BD5BE8664DBF</uuid><volume>473</volume><accepted_date>99201410291200000000222000</accepted_date><doi>10.1007/s11999-014-4047-2</doi><startpage>663</startpage><publication_date>99201502001200000000220000</publication_date><url> deltoid size and fatty infiltration of the deltoid and rotator cuff correlate to outcomes after reverse total shoulder arthroplasty.</title><submission_date>99201403281200000000222000</submission_date><number>2</number><institution>Department of Orthopaedic Surgery, Beaumont Health System, 3601 W 13 Mile Road, Royal Oak, MI, 48073, USA.</institution><subtype>400</subtype><endpage>673</endpage><bundle><publication><title>Clinical orthopaedics and related research</title><type>-100</type><subtype>-100</subtype><uuid>3AEBFF8F-B957-4335-936C-184B9F9BF06B</uuid></publication></bundle><authors><author><firstName>Brett</firstName><middleNames>P</middleNames><lastName>Wiater</lastName></author><author><firstName>Denise</firstName><middleNames>M</middleNames><lastName>Koueiter</lastName></author><author><firstName>Tristan</firstName><lastName>Maerz</lastName></author><author><firstName>James</firstName><middleNames>E</middleNames><lastName>Moravek</lastName></author><author><firstName>Samuel</firstName><lastName>Yonan</lastName></author><author><firstName>David</firstName><middleNames>R</middleNames><lastName>Marcantonio</lastName></author><author><firstName>J</firstName><middleNames>Michael</middleNames><lastName>Wiater</lastName></author></authors></publication></publications><cites></cites></citation>17 Therefore, an individually tailored exercise program before and after surgery may accelerate a patient’s return to normal activity, improve their postoperative outcome, and result in a higher level of postoperative satisfaction. Therefore, this research aims to investigate the benefit of a structured, peri-operative exercise program in patients scheduled for RSA, compared with control subjects who receive the usual conservative course of management. Furthermore, this study will also investigate the effectiveness of using upper limb activity monitors to objectively capture upper extremity function in patients following RSA.2. Statement of the Purpose and Aims of the ProjectThis research will comprise of two primary studies. The first part of this research is a prospective RCT investigating the benefit of a structured pre- and post-operativeperi-operative exercise rehabilitation program in patients undergoing RSA. The purpose of this study is to investigate the capacity in which structured pre-surgery and post-surgery exercise programs can improve patient strength, active range of motion (AROM) and early functional recovery after RSA, compared with control subjects who receive the usual course of care. Specifically, this study will examine:The extent to which patients with massive rotator cuff tears tolerate an exercise intervention prior to surgery.The value of exercise rehabilitationa structured, peri-operative exercise program on the patient’s rate of improvement in strength, AROM and functional rehabilitation after surgery.The value of exercise rehabilitation on the participant’s rate of improvement in upper extremity function and other aspects related to quality of life after surgeryThe influence of exercise rehabilitation on patient satisfaction after surgeryThe following research hypotheses will be tested:A four-week, individually tailored clinic plus home-based exercise program will be well tolerated by patients with massive rotator cuff tears who have been scheduled for RSAParticipants in the exercise group will demonstrate improved pre-operative strength, AROM and upper extremity function following the preoperative exercise programThe pain levels of patients who undertake the preoperative exercise program will remain either the same, or decrease pre-surgery.Patients in the exercise EM group will demonstrate improved independence and higher quality of life scores immediately prior to reverse TSA (though after the pre-operative exercise intervention), and at 3, 6 and 12 months post-surgery, compared to the control group. Patients in the exercise EM group will report higher levels of post-operative satisfaction at 3, 6 and 12 months post-surgery, compared to the control group.The second part of this research will seek to evaluate the effectiveness of using upper limb accelerometers to objectively capture upper extremity function in patients after reverse shoulder arthroplasty and to a.) compare activity data between the operated and non-operated limb, b.) compare activity data between a surgical cohort and a control cohort, and c.) correlate this data with self-reported functional scores from common clinical questionnaires and satisfaction surveys across the postoperative timeline.The specific aims of this study include:Evaluating upper limb function in patients with isolated massive rotator cuff tears scheduled for RSA using activity monitors worn on the upper limb, and comparing them to their uninvolved limb, as well as a separate healthy control group.Evaluating upper limb function in patients at 3-, 6- and 12 months’ post-RSA using activity monitors worn on the involved limb and comparing them to their uninvolved limb, as well as a separate healthy control group.Determining whether the level of activity, including volume and intensity, correlates with self-reported, perceived function post-RSA and subsequent rehabilitation.The following research hypotheses will be tested:Overall functional limb use will be greater for the uninvolved limb compared to the involved limb in patients with rotator cuff tearsOverall functional limb use will be greater in healthy controls compared to patients with massive rotator cuff tearsOverall functional limb use will significantly improve in patients undergoing reverse shoulder replacement, from baseline to 3-, 6-, and 12 months’ post-surgerySignificant limb asymmetries will exist between the involved and uninvolved sides of patients with massive rotator cuff tears, as well as healthy controls.Limb symmetry will progressively improve in patients undergoing reverse shoulder replacement from baseline to 3-, 6- and 12 months’ post-surgeryGreater overall functional limb use / activity will correlate with greater self-reported physical activity and functional scores 3. MethodsStudy 13.2.1Study population, informed consent and recruitmentThis is a prospective RCT investigating two different peri-operative management regimens in patients undergoing reverse TSR and, therefore, patients scheduled for reverse TSA that fit the below inclusion study criteria will be invited to participate in this trial. Participants will be invited to be part of the study after consultation with their surgeon having confirmed a massive, full-thickness tear of the rotator cuff via clinical examination and magnetic resonance imaging (MRI), and being scheduled for surgery. At this time, the Patient Information Sheet (Appendix 1) and a verbal summary of the study and patient expectations, with particular reference to the two different rehabilitation pathways, will be presented to the patients. Patients willing to participate will then complete the Patient Consent Form (Appendix 1), and will then be randomized to one of the two rehabilitation arms of the study: usual management (UM) group or the exercise management (EM) group. Ethical approval will be obtained from the St John of God (SJOG) Research Ethics Committee and the written, informed consent from each patient will be collected prior to surgery.Patients meeting the following criteria will be eligible for inclusion in this study:Male or female, between 55 and 80 years and local to the Perth metropolitan areaPatients with a massive rotator cuff tear, with or without arthropathy, subsequently scheduled for RSA Pseduoparalysis of the affected shoulder, including forward elevation <90 degreesPatients with the following criteria will be excluded from participation:Require a revision shoulder arthroplastyRecent or previous fractures of the shoulder complex?Previous shoulder surgery on the affected side or bothAdhesive capsulitisPresent with pre-existing conditions associated with upper extremity pain, including ongoing infection, carpal tunnel syndrome, cervical neuropathy or other nerve pathologyClinically verified polyarthritis, rheumatoid arthritis and/or fibromyalgia?Failed medical clearance to participate in exerciseAre likely to have problems with follow-up (i.e. patients with no fixed address, report a plan to move out of town, or intellectually challenged patients without adequate support network)Do not read and speak EnglishThe individual is unable or unwilling to follow the designated pre- and/or post-operative rehabilitation protocolWithdrawal CriteriaAs outlined on the Patient Consent Form, patients will be free to withdraw from the study without prejudice or altered post-operative care.Ethical approval will be obtained from St John of God Human Research Ethics Committee and the written, informed consent from each patient will be collected prior to surgery.Sample Size CalculationA power analysis using G power software ADDIN PAPERS2_CITATIONS <citation><uuid>45114702-4F3F-41AE-A789-955DC443AC2A</uuid><priority>12</priority><publications><publication><volume>39</volume><publication_date>99200705001200000000220000</publication_date><number>2</number><institution>Institut für Psychologie, Christian-Albrechts-Universit?t Kiel, Kiel, Germany. ffaul@psychologie.uni-kiel.de</institution><startpage>175</startpage><title>G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences.</title><uuid>72B17A5C-5D63-4663-A957-D460E94DD983</uuid><subtype>400</subtype><endpage>191</endpage><type>400</type><url> research methods</title><type>-100</type><subtype>-100</subtype><uuid>A0AA5C64-9945-48FC-87B0-EEA103FD3536</uuid></publication></bundle><authors><author><firstName>Franz</firstName><lastName>Faul</lastName></author><author><firstName>Edgar</firstName><lastName>Erdfelder</lastName></author><author><firstName>Albert-Georg</firstName><lastName>Lang</lastName></author><author><firstName>Axel</firstName><lastName>Buchner</lastName></author></authors></publication></publications><cites></cites></citation>18 was performed to calculate the sample size required for this study. Assuming a 5% significance level, a power of 0.8 a sample of 31 patients in each group was required to detect a 10-point difference in ASES scores ADDIN PAPERS2_CITATIONS <citation><uuid>1C254D3A-6018-4662-B2EB-C941885F2F47</uuid><priority>13</priority><publications><publication><uuid>BAD8EF69-6052-4493-9AFF-A6C25F5F6943</uuid><volume>19</volume><accepted_date>99200907121200000000222000</accepted_date><doi>10.1016/j.jse.2009.07.012</doi><startpage>570</startpage><revision_date>99200906091200000000222000</revision_date><publication_date>99201006001200000000220000</publication_date><url> a formal physical therapy program necessary after total shoulder arthroplasty for osteoarthritis?</title><submission_date>99200903101200000000222000</submission_date><number>4</number><institution>Shoulder &amp; Elbow Division, Florida Orthopaedic Institute, Tampa, FL, USA.</institution><subtype>400</subtype><endpage>579</endpage><bundle><publication><publisher>Graduate School of Health Sciences, Sapporo Medical University, Sapporo, Japan.</publisher><title>Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.]</title><type>-100</type><subtype>-100</subtype><uuid>BEDF5255-D33C-4355-A49B-F398CD0D012E</uuid></publication></bundle><authors><author><firstName>Philip</firstName><middleNames>J</middleNames><lastName>Mulieri</lastName></author><author><firstName>Jason</firstName><middleNames>O</middleNames><lastName>Holcomb</lastName></author><author><firstName>Page</firstName><lastName>Dunning</lastName></author><author><firstName>Michele</firstName><lastName>Pliner</lastName></author><author><firstName>R</firstName><middleNames>Kent</middleNames><lastName>Bogle</lastName></author><author><firstName>Derek</firstName><lastName>Pupello</lastName></author><author><firstName>Mark</firstName><middleNames>A</middleNames><lastName>Frankle</lastName></author></authors></publication></publications><cites></cites></citation>19, To account for a 5% drop out rate, a total of 66 patients (33 in each group) has been proposed., a minimal clinical important difference (MCID) of 10.4 points between groups on the Constant Score ADDIN PAPERS2_CITATIONS <citation><uuid>ADE05E32-14F2-4687-87D7-CB561DF9075F</uuid><priority>15</priority><publications><publication><uuid>BE8A80FB-6E38-4047-BFAF-BA3F03271DB0</uuid><volume>22</volume><accepted_date>99201305021200000000222000</accepted_date><doi>10.1016/j.jse.2013.05.002</doi><startpage>1650</startpage><revision_date>99201304211200000000222000</revision_date><publication_date>99201312001200000000220000</publication_date><url> minimal clinically important difference for Constant score in patients undergoing rotator cuff surgery.</title><submission_date>99201212201200000000222000</submission_date><number>12</number><institution>Department of Orthopaedics and Traumatology, Turku University Hospital, Turku, Finland. Electronic address: jupeku@utu.fi.</institution><subtype>400</subtype><endpage>1655</endpage><bundle><publication><publisher>Graduate School of Health Sciences, Sapporo Medical University, Sapporo, Japan.</publisher><title>Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.]</title><type>-100</type><subtype>-100</subtype><uuid>BEDF5255-D33C-4355-A49B-F398CD0D012E</uuid></publication></bundle><authors><author><firstName>Juha</firstName><lastName>Kukkonen</lastName></author><author><firstName>Tommi</firstName><lastName>Kauko</lastName></author><author><firstName>Tero</firstName><lastName>Vahlberg</lastName></author><author><firstName>Antti</firstName><lastName>Joukainen</lastName></author><author><firstName>Ville</firstName><lastName>A?rimaa</lastName></author></authors></publication></publications><cites></cites></citation>22 and standard deviations from previous study ADDIN PAPERS2_CITATIONS <citation><uuid>ABD6AD89-32F6-47D4-9B26-CBE3BBB9DE4A</uuid><priority>16</priority><publications><publication><uuid>07588FC8-CB47-4D33-B3FC-C711B869ADBD</uuid><volume>96</volume><doi>10.2106/JBJS.M.00034</doi><startpage>11</startpage><publication_date>99201401011200000000222000</publication_date><url> following arthroscopic rotator cuff repair: a prospective randomized trial of immobilization compared with early motion.</title><institution>Shoulder and Elbow Service, Department of Orthopaedic Surgery, Washington University, CB #8233, St. Louis, MO 63110. E-mail address for J.D. Keener: keenerj@wustl.edu.</institution><number>1</number><subtype>400</subtype><endpage>19</endpage><bundle><publication><title>The Journal of bone and joint surgery. American volume</title><type>-100</type><subtype>-100</subtype><uuid>5FDCD024-1BC8-40A2-A5C6-237D3213B57D</uuid></publication></bundle><authors><author><firstName>Jay</firstName><middleNames>D</middleNames><lastName>Keener</lastName></author><author><firstName>Leesa</firstName><middleNames>M</middleNames><lastName>Galatz</lastName></author><author><firstName>Georgia</firstName><lastName>Stobbs-Cucchi</lastName></author><author><firstName>Rebecca</firstName><lastName>Patton</lastName></author><author><firstName>Ken</firstName><lastName>Yamaguchi</lastName></author></authors></publication></publications><cites></cites></citation>23, a sample size of 72 patients (36 per group) has been proposed. 3.1.2Procedures:As outlined above, patients will first be seen at the private practice of Mr Allan Wang. Patients being offered reverse TSA that meet the inclusion criteria for this study will be invited to participate in the trial. The Patient Information Sheet and a verbal summary of the study and the expected participation will be presented to the patients. Those patients willing to participate will then complete the Patient Consent Form (Appendix 1) and will be randomized to either the EM or UM groups.Once patient consent has been obtained as outlined above, enrolled patients will be referred to the adjoining clinical rehabilitation room in the rooms of Mr Wang at St John of God Hospital at least 4 weeks prior to their scheduled surgery for an initial assessment to record baseline data as well as introductory questions pertaining to previous injuries, medical history and demographics. For those randomised to the exercise group, familiarisation of the home-based exercise program and an education session will also take place. All patients will be assessed clinically using validated subjective and functional assessment measures (detailed below). A summary of the study design is outlined in Figure 1.Figure 1. Study flow chartPre-surgery Exercise Rehabilitation Patients assigned to the exercise group will be required to participate in a 4-week pre-surgery exercise program, scheduled following the baseline assessment and familiarisation session. The pre-surgery intervention program will consist of an individually tailored exercise program undertaken with an Exercise Physiologist twice per week, consisting of strengthening exercises addressing the deltoid for active elevation, active internal and external rotation and the scapula stabilisers, interspersed with moderate intensity cardiovascular exercise. On the days outside of supervised exercise, an individualised home-based exercise program will be required to be undertaken at least three times per week. Each participant will be provided with a training kit consisting of TheraBands as well as everyday objects useful for rehabilitation exercise. Written guidelines will be set out by the Exercise Physiologist will be provided to patients to use as a reference. Additionally, competency and ongoing instruction in undertaking home exercises will be ensured by developing a digital home exercise reference using Physitrack, which involves video-based demonstrations of exercise technique and dosage, and allows the therapist to monitor daily adherence and patient-reported pain. A brief overview of goals and exercises and guidelines for the EM group is demonstrated in Table 1.Table 1. Proposed pre-operative rehabilitation focus for the Exercise Management (EM) group. ADDIN PAPERS2_CITATIONS <citation><uuid>9A0705E4-ACC1-4681-B9D5-EBEF14E3DB2C</uuid><priority>14</priority><publications><publication><volume>11</volume><publication_date>99201604001200000000220000</publication_date><number>2</number><institution>School of Sport Science, Exercise and Health, the University of Western Australia, Perth, Australia.</institution><startpage>279</startpage><title>EXERCISE REHABILITATION IN THE NON-OPERATIVE MANAGEMENT OF ROTATOR CUFF TEARS: A REVIEW OF THE LITERATURE.</title><uuid>93269F2C-2F26-4960-A6C2-F35406F38070</uuid><subtype>400</subtype><endpage>301</endpage><type>400</type><url> journal of sports physical therapy</title><type>-100</type><subtype>-100</subtype><uuid>F2A2E079-68B8-4636-BC6E-041472D96EDA</uuid></publication></bundle><authors><author><firstName>Peter</firstName><lastName>Edwards</lastName></author><author><firstName>Jay</firstName><lastName>Ebert</lastName></author><author><firstName>Brendan</firstName><lastName>Joss</lastName></author><author><firstName>Gev</firstName><lastName>Bhabra</lastName></author><author><firstName>Tim</firstName><lastName>Ackland</lastName></author><author><firstName>Allan</firstName><lastName>Wang</lastName></author></authors></publication></publications><cites></cites></citation>20GoalsExercise GuidelinesRange of Motion (ROM)Improve glenohumeral motion (forward flexion, abduction & external rotation), improve shoulder and thoracic posturePassive ROM (PROM)Forward flexion, internal / external rotationPendulum exercisePosture Shoulder shrugs Shoulder retractionActive-assisted ROM (AAROM)Wand exercises (elevation, abduction, adduction, internal / external rotation)Pulley exercises (elevation)Active ROMSpider crawl, wall slidesFlexibilityImprove flexibility and reduce tightness of anterior and posterior capsuleAnterior capsule stretchPosterior capsule stretchTrapezius stretchStrengtheningImprove strength and conditioning of the anterior deltoid for shoulder elevationImprove active external rotation strengthImprove strength of the scapular stabilizing muscles and dynamic scapular controlAnterior deltoid strengthening e.g. supine seated standing shoulder flexionExternal Rotation e.g. supine seated standing, 0 abduction (elastic resistance), side lying (dumbbell)Scapula exercises e.g. prone scapula retractions seated rows standing rows; supine scapula protractions wall protractions wall push ups standing pressesROM = range of motion; CKC = closed kinetic chain exercises; The Surgical TechniqueAll patients will undergo RSA under general anesthesia in a semi–beach chair position with routine antibiotic prophylaxis. A deltopectoral approach will be used in all cases. The subscapularis tendon will be tagged and mobilised. A limited tenotomy of the superior edge of the pectoralis major tendon will be performed for mobilization of the proximal humerus and to improve exposure of the glenoid. RSA will be performed using the uncemented SMR Modular Shoulder System (Lima Corporate, Udine, Italy) in all cases. A 36-, 40-, or 44-mm glenosphere will be implanted as judged necessary to achieve satisfactory soft tissue tension and stability. All glenospheres will be eccentric in design. The humeral component will be implanted routinely in neutral version. In closure, the subscapularis tendon will be repaired as possible with No. 5 Ti-Cron (Ethicon, Somerville, NJ, USA) horizontal mattress sutures. Post-operative Exercise RehabilitationInitially, all patients?will be placed in an immobilisation sling for six weeks and instructed to adhere strictly to the activity restrictions outlined in Table 2, which has been developed based on current clinical practice and the reported literature. All patients will be educated on optimal management for reducing pain and/or swelling, as well as safely removing and fitting of the sling and clothing, and all contraindications and precautions. In-patient exercises will focus on safe passive range of motion (PROM) of the shoulder, as well as AROM of the hand, wrist and elbow. As mentioned above, these exercises will also be developed into a home exercise program (HEP) for patients to continue with in the comfort of their home, assisted by Physitrack which involves video-based demonstrations of exercise technique and dosage, and allows the therapist to monitor daily adherence and patient-reported pain.Following hospital discharge, all patients will return to the SJOG Hospital 2 weeks post-surgery to consult with their surgeon to attend to the surgical wound, and then again at 6 weeks post-surgery for follow-up. Patients randomised to the UM group will have their immobilisation sling removed and continue without intervention, whereas patients assigned to the EM group will be referred to the SJOG clinical rehabilitation room for education and to advance their HEP and to remove the immobilisation sling. The new exercises will focus on progressing the current ROM exercises to more active exercises to restore full, pain-free AROM. Isometric strengthening of the anterior and posterior deltoid, and remaining posterior cuff muscles will also be initiated to advance active elevation and rotatory movement. Patients will be required to complete these home-exercises daily for a further 6 weeks with ongoing surveillance monitored via a phone call at 9 weeks to follow up on the exercises and progress further if needed. Patients will be asked to make reference to a “post-surgery home exercise guide” for instruction and guidelines, as well as Physitrack. At 12-weeks, patients randomised to the EM group will again attend the SJOG hospital clinical rehabilitation room for further education as well as the first supervised exercise session. From 12 weeks, patients will undertake intensified strength and conditioning aimed at advancing deltoid and external rotator strength to improve functional elevation & active rotation, scapula stability training and cardiovascular exercise under the supervision of an Exercise Physiologist twice per week for 6 weeks. Patients will also be required to complete daily home exercises, which will again be referenced in the “post-surgery home exercise guide” as well as via Physitrack. Patients will be provided with a “training kit” consisting of Therabands and other simple equipment found in most homes to complete the prescribed exercises. A brief overview of goals, exercises and guidelines for the EM group is demonstrated in Table 2.Table 2. Proposed post-surgery rehabilitation protocol for the Exercise Management (EM) group.PhaseGoalsTreatment GuidelinesPhase 1: Early Passive ROM (Week 0 – 6)Education, joint protection, passive ROM exercises, assistance putting on / taking of sling / clothingEducationShoulder anatomyOperative procedurePatient and therapist expectationsSling immobilization for 4 weeksPrecautions:CryotherapyNo shoulder AROMNo lifting objectsNo internal rotation, adduction or extension beyond neutralSelf-managed home exercisesSupine flexion / elevation in scapular plane to 90Pain-free deltoid isometrics in scapular planeTherapist-guided passive ROM: 'cradle the arm' and 'rock the baby',Codman’s pendulum exercise, Internal/external rotation ('open the gate')Periscapular exercises, cervical ROM, elbow/hand ROM grip strengthening exercises, Phase 2: AROM & Early Strengthening(week 6 – 12)Restore full, pain-free active ROM, restore normal scapula control / kinematicsCompleted self-managed at home, 3 x per dayActive-assisted ROM using uninvolved arm, overhead pulleys, wand/cane exercises, & TheraBands.Active ROM: Spider crawl exercise (elevation/depression of hand up wall), elevation, fitball clocks, supine forward elevation / abduction standing.Scapular retractions, cervical ROM, elbow/hand ROM grip strengthening exercisesIsometric rotator cuff exercisesPhase 3: Advanced strengthening (week 12+) Advanced deltoid strengthening & active rotation, scapula strengthening. Progress functional tasks and ADLsSupervised rehabilitation twice per week & self-managed at home alternate days, 3 x per dayIsometric ER / IR Active ER / IR using TheraBands, dumbbellsIsotonic scapula exercises, e.g. scapula retractions / protractions / shrugs using TheraBands, dumbbellsCKC stability exercises e.g. wall pushups, quadrupedPatient EvaluationThe following measures will be undertaken following surgery at the designated time points.Patient-reported Outcome (PRO) AssessmentsPatients in both the EM and UM groups will be required to attend follow-up clinical assessments at 6 weeks, as well as 3, 6, and 12 months post-surgery. Five validated PROs will be employed to evaluate post-treatment outcomes. These will include:The Oxford Shoulder ScoreThe Oxford Shoulder Score (OSS); American Shoulder and Elbow Surgeons Questionnaire (ASES)The Simple Shoulder Test (SST); The Short Form (36) Health Survey (SF-36), andThe Shoulder Activity Scale (SAS). Functional Patient AssessmentPatients’ bilateral AROM will be measured in all planes (abduction, flexion, internal and external rotation) using a fluid inclinometer at 3-, 6- and 12 months post-surgery. AROM will be measured within the patients’ pain tolerance to minimize any risk of injury or discomfort. The Constant Score will also be evaluated, which is a shoulder-specific tool using a combination of subjective and objective components to assess shoulder function. The maximum score of 100 points consists of 35 points based on subjective assessments of pain and activities of daily living and 65 points based on examiner-derived measurements of shoulder strength and ROM. The higher the score, the higher is the quality of function. Strength in abduction will be measured via a strain gauge with the patient in a standing position with the arm in the scapular plane and 90° of elevation, with the hand and forearm pronated. The measurement should be pain-free and the highest value out of three is used.All participants at 12 months post-surgery undergo evaluation of isokinetic shoulder strength using a Biodex System 3 Pro dynamometer (Biodex Medical Systems, New York, NY , USA). Three protocols of shoulder movement will be tested: internal and external rotation, abduction and adduction, and forward flexion and extension. For each protocol, patients will be tested within a locked range of motion predetermined by their limit of comfort. The isokinetic testing was performed with the dynamometer velocity set to 60°/s. Each protocol will consist of 1 practice motion to ensure comfort and technique. After 2 minutes of rest, 3 consecutive repetitions of the movement at maximum power will be performed and measurements will be recorded. C.Activity Data AssessmentFunctional limb activity will be measured using five ActiGraph GT9X+ Link (ActiGraph, Pensacola, FL) activity monitors secured bilaterally to the upper arms at the mid-biceps, the lower arms at the wrist, and on the waist of each participant, as per previous recommendations ADDIN PAPERS2_CITATIONS <citation><uuid>8521C42F-8ED1-4ECC-8049-6C9052715D5B</uuid><priority>15</priority><publications><publication><uuid>B70AD7D7-A75F-4484-8E8D-0F297478E608</uuid><volume>23</volume><accepted_date>99201402101200000000222000</accepted_date><doi>10.1016/j.jse.2014.02.008</doi><startpage>e251</startpage><revision_date>99201402041200000000222000</revision_date><publication_date>99201410001200000000220000</publication_date><url> approaches to objectively assess shoulder function.</title><submission_date>99201310301200000000222000</submission_date><number>10</number><institution>Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA. Electronic address: hurd.wendy@mayo.edu.</institution><subtype>400</subtype><endpage>5</endpage><bundle><publication><publisher>Graduate School of Health Sciences, Sapporo Medical University, Sapporo, Japan.</publisher><title>Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.]</title><type>-100</type><subtype>-100</subtype><uuid>BEDF5255-D33C-4355-A49B-F398CD0D012E</uuid></publication></bundle><authors><author><firstName>Wendy</firstName><middleNames>J</middleNames><lastName>Hurd</lastName></author><author><firstName>Melissa</firstName><middleNames>M</middleNames><lastName>Morrow</lastName></author><author><firstName>Emily</firstName><middleNames>J</middleNames><lastName>Miller</lastName></author><author><firstName>Robert</firstName><middleNames>A</middleNames><lastName>Adams</lastName></author><author><firstName>John</firstName><middleNames>W</middleNames><lastName>Sperling</lastName></author><author><firstName>Kenton</firstName><middleNames>R</middleNames><lastName>Kaufman</lastName></author></authors></publication></publications><cites></cites></citation>9. Activity data will be collected over three consecutive days preoperatively and at 3-, 6- and 12 months’ post-surgery in patients’ natural living environment, but not including time spent sleeping. The accelerometer sampling rate will be set at 30 Hz (as recommended by the manufacturer). The vector magnitude (VM) physical of activity counts from each accelerometer will be calculated with ActiLife software (ActiGraph, Pensacola, FL). The ActiLife VM physical activity counts will be exported to an Excel spreadsheet using 1-second epochs for every second during the entire data collection. The average activity for each limb segment will be determined each day by calculating the arithmetic mean of the epoch activity value within 1 day for each subject. A within-subject average activity value will subsequently be calculated for each limb segment over the 3 days of collection. Novel techniques used to determine limb asymmetries and activity intensities will also be applied. ADDIN PAPERS2_CITATIONS <citation><uuid>D6965C9E-D8A5-47B6-9734-54F067D69BA4</uuid><priority>16</priority><publications><publication><uuid>68DC6665-020F-4F74-BB99-0215E52B84D4</uuid><volume>23</volume><accepted_date>99201303201200000000222000</accepted_date><doi>10.1016/j.jelekin.2013.03.010</doi><startpage>924</startpage><revision_date>99201303201200000000222000</revision_date><publication_date>99201308001200000000220000</publication_date><url> accelerometer analysis techniques for evaluating functional use of the extremities.</title><submission_date>99201207031200000000222000</submission_date><number>4</number><institution>Department of Orthopedic Surgery, Division of Orthopedic Research, Mayo Clinic, Rochester, MN 55902, USA. hurd.wendy@mayo.edu</institution><subtype>400</subtype><endpage>929</endpage><bundle><publication><title>Journal of electromyography and kinesiology : official journal of the International Society of Electrophysiological Kinesiology</title><type>-100</type><subtype>-100</subtype><uuid>97423DE7-4A97-41F8-ACA1-0EF18597E911</uuid></publication></bundle><authors><author><firstName>Wendy</firstName><middleNames>J</middleNames><lastName>Hurd</lastName></author><author><firstName>Melissa</firstName><middleNames>M</middleNames><lastName>Morrow</lastName></author><author><firstName>Kenton</firstName><middleNames>R</middleNames><lastName>Kaufman</lastName></author></authors></publication><publication><uuid>B70AD7D7-A75F-4484-8E8D-0F297478E608</uuid><volume>23</volume><accepted_date>99201402101200000000222000</accepted_date><doi>10.1016/j.jse.2014.02.008</doi><startpage>e251</startpage><revision_date>99201402041200000000222000</revision_date><publication_date>99201410001200000000220000</publication_date><url> approaches to objectively assess shoulder function.</title><submission_date>99201310301200000000222000</submission_date><number>10</number><institution>Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA. Electronic address: hurd.wendy@mayo.edu.</institution><subtype>400</subtype><endpage>5</endpage><bundle><publication><publisher>Graduate School of Health Sciences, Sapporo Medical University, Sapporo, Japan.</publisher><title>Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.]</title><type>-100</type><subtype>-100</subtype><uuid>BEDF5255-D33C-4355-A49B-F398CD0D012E</uuid></publication></bundle><authors><author><firstName>Wendy</firstName><middleNames>J</middleNames><lastName>Hurd</lastName></author><author><firstName>Melissa</firstName><middleNames>M</middleNames><lastName>Morrow</lastName></author><author><firstName>Emily</firstName><middleNames>J</middleNames><lastName>Miller</lastName></author><author><firstName>Robert</firstName><middleNames>A</middleNames><lastName>Adams</lastName></author><author><firstName>John</firstName><middleNames>W</middleNames><lastName>Sperling</lastName></author><author><firstName>Kenton</firstName><middleNames>R</middleNames><lastName>Kaufman</lastName></author></authors></publication></publications><cites></cites></citation>5,93.1.3 Data handling, statistical analysis and reporting of resultsPaper records will be kept under lock and key in a metal filing cabinet in the SJOG Hospital. Computer records will be stored in the assessor database and will be password protected. The patients consulting surgeon and the study investigators will only have access to hand written and electronic records. Records will be kept for 15 years after which, paper records will be shredded and computer records will be permanently deleted including back-up copies. The result of the research will be made available through medical journals or meetings, but all patient information will be de-identified and no private information will be identified outside the investigator office.Statistical analysis will be performed using SPSS software (SPSS, Version 11.5, SPSS Inc., USA). A series of repeated measures analysis of variance (ANOVA) will be used to investigate primary and secondary clinical outcome measures between the two rehabilitation groups at baseline, and at 6 weeks and 3, 6, and 12 months’ post-surgery. Where a significant interaction effect is found, post-hoc independent t-tests will be used to determine time-points at which the two groups differ. Statistical significance will be determined at p ≤ 0.05.At baseline, a series of one-way analyses of variance (ANOVA) will be performed to determine if initial differences exist between the two patient groups. To determine the efficacy of a pre-surgery exercise program, a series of one-way analysis of variance (ANOVA) will be performed in conjunction with post-hoc paired t-tests in the results obtained between the pre-intervention and pre-operative time points, and then again at 3-, 6-, and 12 months’ post-surgery. When comparing the effectiveness of the surgery plus the exercise intervention, against the surgery plus usual care, a series of two-factor ANOVAs (group and time) will be taken at pre-surgery, 3-, 6-, and 12 months’ post-surgery. Study 23.2.1Study population, informed consent and recruitmentThirty patients from the same RSA cohort as described above will be recruited for this study, as well as a control group consisting of thirty “apparently healthy” participants. All control group participants are required to have no upper extremity injury at the time of testing, no symptoms in either upper extremity, and no history of shoulder surgery to either arm. Individuals who did not meet all participation criteria will not be eligible for study enrollment. Ethical approval will be obtained from St John of God Human Research Ethics Committee and the written, informed consent from each patient will be collected prior to surgery3.2.2Procedures:Functional limb activity will be measured using five ActiGraph GT9X+ Link (ActiGraph, Pensacola, FL) activity monitors secured bilaterally to the upper arms at the mid-biceps, the lower arms at the wrist, and on the waist of each participant, as per previous recommendations. ADDIN PAPERS2_CITATIONS <citation><uuid>B00C0C10-26FE-4127-99BA-446285600EEB</uuid><priority>17</priority><publications><publication><uuid>B70AD7D7-A75F-4484-8E8D-0F297478E608</uuid><volume>23</volume><accepted_date>99201402101200000000222000</accepted_date><doi>10.1016/j.jse.2014.02.008</doi><startpage>e251</startpage><revision_date>99201402041200000000222000</revision_date><publication_date>99201410001200000000220000</publication_date><url> approaches to objectively assess shoulder function.</title><submission_date>99201310301200000000222000</submission_date><number>10</number><institution>Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA. Electronic address: hurd.wendy@mayo.edu.</institution><subtype>400</subtype><endpage>5</endpage><bundle><publication><publisher>Graduate School of Health Sciences, Sapporo Medical University, Sapporo, Japan.</publisher><title>Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.]</title><type>-100</type><subtype>-100</subtype><uuid>BEDF5255-D33C-4355-A49B-F398CD0D012E</uuid></publication></bundle><authors><author><firstName>Wendy</firstName><middleNames>J</middleNames><lastName>Hurd</lastName></author><author><firstName>Melissa</firstName><middleNames>M</middleNames><lastName>Morrow</lastName></author><author><firstName>Emily</firstName><middleNames>J</middleNames><lastName>Miller</lastName></author><author><firstName>Robert</firstName><middleNames>A</middleNames><lastName>Adams</lastName></author><author><firstName>John</firstName><middleNames>W</middleNames><lastName>Sperling</lastName></author><author><firstName>Kenton</firstName><middleNames>R</middleNames><lastName>Kaufman</lastName></author></authors></publication></publications><cites></cites></citation>9 Activity data will be collected over three consecutive days preoperatively and at 3-, 6- and 12 months’ post-surgery in patients’ natural living environment, but not including time spent sleeping. After activity data collection, patients will complete the Oxford Shoulder Score (OSS), the Simple Shoulder Test (SST), and the American Shoulder and Elbow Surgeons evaluation form (ASES). An activity participation questionnaire and a patient satisfaction questionnaire used in previous studies will be employed, as well and a Global Rating Scale for Perceived Function.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EaSBTdGFzaTwvQXV0aG9yPjxZZWFyPjIwMTM8L1llYXI+

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ADDIN EN.CITE.DATA 24,26 Mean, minimum and maximum daily physical activity counts will be evaluated for the lower and upper arm between the patient group and the control group over the three days. Limb asymmetries and activity intensities assessing the amount of time participants are inactive, and engaged in low-intensity and high-intensity activity using previously described algorithms ADDIN PAPERS2_CITATIONS <citation><uuid>04D02EC7-BC74-49A7-AB63-6D0BFECE1A61</uuid><priority>18</priority><publications><publication><uuid>68DC6665-020F-4F74-BB99-0215E52B84D4</uuid><volume>23</volume><accepted_date>99201303201200000000222000</accepted_date><doi>10.1016/j.jelekin.2013.03.010</doi><startpage>924</startpage><revision_date>99201303201200000000222000</revision_date><publication_date>99201308001200000000220000</publication_date><url> accelerometer analysis techniques for evaluating functional use of the extremities.</title><submission_date>99201207031200000000222000</submission_date><number>4</number><institution>Department of Orthopedic Surgery, Division of Orthopedic Research, Mayo Clinic, Rochester, MN 55902, USA. hurd.wendy@mayo.edu</institution><subtype>400</subtype><endpage>929</endpage><bundle><publication><title>Journal of electromyography and kinesiology : official journal of the International Society of Electrophysiological Kinesiology</title><type>-100</type><subtype>-100</subtype><uuid>97423DE7-4A97-41F8-ACA1-0EF18597E911</uuid></publication></bundle><authors><author><firstName>Wendy</firstName><middleNames>J</middleNames><lastName>Hurd</lastName></author><author><firstName>Melissa</firstName><middleNames>M</middleNames><lastName>Morrow</lastName></author><author><firstName>Kenton</firstName><middleNames>R</middleNames><lastName>Kaufman</lastName></author></authors></publication><publication><uuid>B70AD7D7-A75F-4484-8E8D-0F297478E608</uuid><volume>23</volume><accepted_date>99201402101200000000222000</accepted_date><doi>10.1016/j.jse.2014.02.008</doi><startpage>e251</startpage><revision_date>99201402041200000000222000</revision_date><publication_date>99201410001200000000220000</publication_date><url> approaches to objectively assess shoulder function.</title><submission_date>99201310301200000000222000</submission_date><number>10</number><institution>Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA. Electronic address: hurd.wendy@mayo.edu.</institution><subtype>400</subtype><endpage>5</endpage><bundle><publication><publisher>Graduate School of Health Sciences, Sapporo Medical University, Sapporo, Japan.</publisher><title>Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.]</title><type>-100</type><subtype>-100</subtype><uuid>BEDF5255-D33C-4355-A49B-F398CD0D012E</uuid></publication></bundle><authors><author><firstName>Wendy</firstName><middleNames>J</middleNames><lastName>Hurd</lastName></author><author><firstName>Melissa</firstName><middleNames>M</middleNames><lastName>Morrow</lastName></author><author><firstName>Emily</firstName><middleNames>J</middleNames><lastName>Miller</lastName></author><author><firstName>Robert</firstName><middleNames>A</middleNames><lastName>Adams</lastName></author><author><firstName>John</firstName><middleNames>W</middleNames><lastName>Sperling</lastName></author><author><firstName>Kenton</firstName><middleNames>R</middleNames><lastName>Kaufman</lastName></author></authors></publication></publications><cites></cites></citation>5,9 will be compared between the control and patient groups.3.2.3 Data handling, statistical analysis and reporting of results Between group differences will be evaluated for the lower and upper arm for minimum, mean, and maximum activity counts with a univariate ANOVA.?A?paired samples t-test will be applied to the asymmetry indices results to compare between the control and patient groups for the lower and upper arm separately. Between group differences were also evaluated for the time spent across activity bins. When statistical significance was achieved, post hoc testing will be performed using independent samples t-test to determine where differences were occurring. For all measures alpha will be set a priori at p≤0.05. Pearson correlation coefficients will be computed between patient-reported outcome scores and the accelerometer scores.4. References ADDIN PAPERS2_CITATIONS <papers2_bibliography/>1.Drake GN, O'Connor DP, Edwards TB. Indications for reverse total shoulder arthroplasty in rotator cuff disease. Clin Orthop Relat Res. 2010;468(6):1526–1533. 2.Naveed MA, Kitson J, Bunker TD. The Delta III reverse shoulder replacement for cuff tear arthropathy: a single-centre study of 50 consecutive procedures. J Bone Joint Surg Br. 2011;93(1):57–61. 3.Mulieri P, Dunning P, Klein S, Pupello D, Frankle M. Reverse shoulder arthroplasty for the treatment of irreparable rotator cuff tear without glenohumeral arthritis. J Bone Joint Surg Am. 2010;92(15):2544–2556. 4.Garcia GH, Taylor SA, DePalma BJ, et al. Patient Activity Levels After Reverse Total Shoulder Arthroplasty: What Are Patients Doing? Am J Sports Med. 2015;43(11):2816–2821. 5.Hurd WJ, Morrow MM, Kaufman KR. Tri-axial accelerometer analysis techniques for evaluating functional use of the extremities. J Electromyogr Kinesiol. 2013;23(4):924–929. 6.Wang AW, Bauer S, Goonatillake M, Breidahl W, Zheng MH. Autologous tenocyte implantation, a novel treatment for partial-thickness rotator cuff tear and tendinopathy in an elite athlete. Case Reports. 2013;2013(jan11 1):bcr2012007899–bcr2012007899. 7.Alta TDW, Veeger DHEJ, de Toledo JM, Janssen TWJ, Willems WJ. Isokinetic strength differences between patients with primary reverse and total shoulder prostheses: muscle strength quantified with a dynamometer. Clin Biomech (Bristol, Avon). 2014;29(9):965–970. 8.de Toledo JM, Loss JF, Janssen TW, et al. Kinematic evaluation of patients with total and reverse shoulder arthroplasty during rehabilitation exercises with different loads. Clin Biomech (Bristol, Avon). 2012;27(8):793–800. 9.Hurd WJ, Morrow MM, Miller EJ, Adams RA, Sperling JW, Kaufman KR. Novel approaches to objectively assess shoulder function. J Shoulder Elbow Surg. 2014;23(10):e251–e255. 10.Wang A, Doyle T, Cunningham G, et al. Isokinetic shoulder strength correlates with level of sports participation and functional activity after reverse total shoulder arthroplasty. J Shoulder Elbow Surg. April 2016. 11.Boudreau S, Boudreau ED, Higgins LD, Wilcox RB. Rehabilitation following reverse total shoulder arthroplasty. J Orthop Sports Phys Ther. 2007;37(12):734–743. 12.Ainsworth R. Physiotherapy rehabilitation in patients with massive, irreparable rotator cuff tears. Musculoskelet care. 2006;4(3):140–151. 13.Ainsworth R, Lewis JS. Exercise therapy for the conservative management of full thickness tears of the rotator cuff: a systematic review. BJSM online. 2007;41(4):200–210. 14.Ainsworth R, Lewis J, Conboy V. A prospective randomized placebo controlled clinical trial of a rehabilitation programme for patients with a diagnosis of massive rotator cuff tears of the shoulder. Shoulder & Elbow. 2009.15.Levy O, Mullett H, Roberts S, Copeland S. The role of anterior deltoid reeducation in patients with massive irreparable degenerative rotator cuff tears. J Shoulder Elbow Surg. 2008;17(6):863–870. 16.Kuhn JE, Dunn WR, Sanders R, et al. Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study. J Shoulder Elbow Surg. 2013;22(10):1371–1379. 17.Wiater BP, Koueiter DM, Maerz T, et al. Preoperative deltoid size and fatty infiltration of the deltoid and rotator cuff correlate to outcomes after reverse total shoulder arthroplasty. Clin Orthop Relat Res. 2015;473(2):663–673. 18.Faul F, Erdfelder E, Lang A-G, Buchner A. G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods. 2007;39(2):175–191.19.Mulieri PJ, Holcomb JO, Dunning P, et al. Is a formal physical therapy program necessary after total shoulder arthroplasty for osteoarthritis? J Shoulder Elbow Surg. 2010;19(4):570–579. 20.Edwards P, Ebert J, Joss B, Bhabra G, Ackland T, Wang A. EXERCISE REHABILITATION IN THE NON-OPERATIVE MANAGEMENT OF ROTATOR CUFF TEARS: A REVIEW OF THE LITERATURE. Int J Sports Phys Ther. 2016;11(2):279–301. ................
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