Abstract
With much enthusiasm, we have read the article by Gómez et al. titled, ‘Functional results and return to sports on recurrent anterior glenohumeral instability. Influence of the COVID-19 pandemic; Comparative retrospective study and short-term results.’ 1 This research article regarding the difference between home-based and in-person rehabilitation models after Laterjet or arthroscopic Bankary surgery proved to pique the interest of this letter’s authors. Thus, we would like to comment on this work and guide future research on this topic.
Gómez et al. 1 compared the functional results in patients that underwent surgery for recurrent anterior shoulder instability (RAGHI) during the COVID-19 pandemic with in-person and home-based rehabilitation methods. The researchers concluded that the follow-up and different rehabilitation methods did not significantly differ in the patients return to function or athletics. While this shows hope for the home-based rehabilitation method, further research and consideration should be given to these methods. This letter will comment on the use of objective shoulder evaluation and uniform rehabilitation scheduling.
To begin, the Western Ontario Shoulder Instability Index (WOSI) and subjective shoulder value (SSV) assessment methods have shown to be reliable indicators of post-operative quality of life and mobility. However, these measurements are self-reported by the patient and, hence, subjective based on patient outlook. Even for the at home protocol, we would recommend using more objective measures for evaluating anterior shoulder instability. In addition, these scores were only determined after the procedure, whereas we would recommend this information to be collected pre- and post-operatively to determine a significant difference. We believe that a more objective test for anterior shoulder instability is needed to assess recovery success. Tests such as the apprehension test, anterior release, or surprise test demonstrate the best sensitivity and specificity for clinically diagnosing anterior shoulder instability. The combination of history and performing apprehension, relocation, release or surprise, anterior load, and anterior drawer exam maneuvers optimize sensitivity and specificity for accurately diagnosing anterior shoulder instability in clinical practice. 2 While these tests cannot be performed by the patient alone, it can still be used to assess the efficacy of in-person versus at-home rehabilitation with brief and necessary appointments with an Orthopaedic surgeon.
Another point about the subjectivity of WOSI and SSV tests regards the timing of test application. The home-based rehabilitation group self-reported these results during the COVID-19 lockdowns. During this time the prevalence of mental health issues increased significantly, 3 which may deem these self-reports sub-reliable. Although this may be a stretch in reasoning, reports of stress, anxiety, depression, and poor sleep quality rose dramatically during the time the patients were reporting, especially among those in the age range of this study. 4 These reporting conditions may have led to differences in disclosure. While an unavoidable reality of subjective patient measures during this time, we think it is necessary for this to be made evident to readers.
Lastly, we would recommend a more uniform rehabilitation schedule between the home-based and in-person groups. Standardizing the duration and phases of rehabilitation is an important aspect for post-operative health and returning to sports, however, we believe scheduling of rehab is just as important to consider. Although obtaining complete uniformity is nearly impossible between in-person and home-based rehabilitation, we would recommend the groups receive uniform scheduling and programming. The in-person group performed rehabilitation in a specialized center 3 times per week for 24 weeks with a physiotherapist in addition to an at-home program that was personally instructed and controlled. The home-based group performed telerehabilitation with a physiotherapist one time per week and daily self-administered rehabilitation. We would recommend rehabilitation to be as uniform as possible, despite the limitations due to the COVID-19 pandemic, to maintain data integrity.
The authors showed an impressive ability to pivot previously standard protocols into effective and sufficient rehabilitation, while maintaining efficacious results for the patients. Future research should consider alternative measurements for anterior shoulder instability and uniformity in physiotherapy between home-based and in-person rehabilitation.
