Original Manuscript Geriatric Orthopaedic Surgery & Rehabilitation Patient Satisfaction Using a Home-Based Volume 12: 1–8 © The Author(s) 2021 Rehabilitation Protocol for the Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/21514593211040293 Non-Surgical Treatment of Proximal journals.sagepub.com/home/gos Humeral Fractures: A Prospective Longitudinal Cohort Study Héctor J. Aguado, MD, PhD1 , Paula S. Ventura-Wichner, MD, PhD2, Laura Perez-Hickman, MD3, Isabel Polo-Pérez, MD1, Juan A. Alonso-Olmo, MD, PhD1, Marı́a Bragado, MD1, Adela Pereda-Manso, CRA1, Mario Martı́nez-Zarzuela, PhD4 , Virginia Garcı́a-Virto, MD1 , Clarisa Simón-Pérez, MD, PhD1, Emilio J. Barajas, MD, PhD3, and Miguel A. Martı́n-Ferrero, MD, PhD1 Abstract Supervised, center-based, daily physiotherapy presents limitations: transport, need for an accompanying person, or risk of infection. Home-based rehabilitation protocols (HBRP) can be effective alternatives. We use a HBRP for the non- surgically treated proximal humeral fractures (PHF) in older patients. Objectives: To assess patient satisfaction and preferences of using a booklet, videos, or an app to guide physiotherapy. Patients and methods: Prospective, single-center observational study of patients ≥55 years old who sustained a non- surgically treated PHF. The HBRP consisted of immediate mobilization, followed by 5 physiotherapist-guided, weekly sessions of rehabilitation and standard physiotherapy after 3 months, if needed. A booklet with images, videos, or a smartphone application were offered to guide the patients. Results: Mean degree of satisfaction (1-5) was 4.66 ± .9: 84 patients (82.4%) were very satisfied, 11 patients (10.8%) were satisfied, and 5 patients (4.9%) were not satisfied at all. Mean Oxford Shoulder Score achieved was 40.5 ± 6.6. 59.8% patients preferred the booklet and 29.4% the videos. Exercise compliance was considered very high in 87.3% of patients, while 4% hardly never followed the HBRP. Only 17.7% patients needed center-based physiotherapy after the HBRP. Discussion: Reasons for satisfaction were good final functional outcome, no need for transportation, being away from hospital, immediate rehabilitation availability and being capable of maintaining independence. Adherence is a major concern. Videos are more didactic explaining the exercises. Conclusion: If standard physiotherapy is not available, the HBRP can be a valid treatment option for PHF management in older patients, with a high degree of patient satisfaction. Older patients preferred the booklet to guide physiotherapy. Keywords fragility, proximal humeral fracture, immediate mobilization, telerehabilitation, lifestyle, autonomy, independency Introduction care survivors, urinary incontinence, fibromyalgia, or rheumatoid arthritis.1-8 Lately, HBRPs are also used with Home-based rehabilitation protocols (HBRPs) or tele- good results for patients with degenerative knee and hip rehabilitation is used in different clinical scenarios: neu- pathology, back pain, rotator cuff tears, or distal radius and rological and cardiovascular diseases, sarcopenia, critical hip fractures.9-17 The demand for physical therapy exceeds Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 Geriatric Orthopaedic Surgery & Rehabilitation 0(0) physiotherapy resources. This situation delays the start of Patients and Methods physiotherapy. Trauma surgeons are using these methods as alternatives to standard physiotherapy after initial We conducted a prospective clinical observational study fracture treatment.14,18 including patients 55 years old or older suffering a low- On the other hand, supervised, center-based, daily energy PHF between June 2017 and February 2019 in one physiotherapy–guided rehabilitation might not be wel- single center who underwent non-surgical treatment fol- come under certain circumstances: transport can be ex- lowed by early mobilization HBRP independent of the in- hausting or difficult for older patients, patients living far dication (type of fracture, health condition, no consent for away or in places with bad weather conditions,6,8 and also surgical treatment, etc.). The study was approved by the some patients may need the help of accompanying rela- institution´s ethics committee (PI 20-1685). All patients gave tives during their working hours. There is also lack of their written informed consent for participation in this study. resources and skillful professionals in rural or remote The inclusion criteria were patients 55 years of age or older areas.6 Recently, the lockdown and readjustment of re- presenting with a low-energy PHF treated non-surgically sources during the SARS-CoV-2 pandemic has left patients with minimum 1 year follow-up and available for a phone without standard physiotherapy. Patients suffering frac- call interview and willing to provide all the answers. The tures in overwhelmed hospitals have serious difficulties exclusion criteria were diagnosis of dementia at the time of restoring their pre-fracture function. Under these cir- the PHF, cognitive impairment preventing a telephone in- cumstances, a HBRP can be very useful and it could be an terview, and lost for follow-up before fracture healing. alternative to formal physiotherapy,3,4,6,9,10,12,13,16,17,19 if clinic-based physiotherapy is not available or possible for Home-Based Rehabilitation Protocol the patient. The advantages of telerehabilitation are physical We had already used immediate mobilization with early functioning20 and psychological benefits,13 exercises can exercises for the non-surgical treatment of PHF. At that time start immediately with faster recovery,1,15,18,21,22 and (January 2015), patients did not receive any document earlier independence for basic activities of daily living explaining the exercises, except for verbal explanations, and (BADL). Telerehabilitation provides the comfort and all patients received standard physiotherapy. Because the safety of a home environment,7,23,24 with no time wasted results of that study were promising,29 we took a step on transportation, no need to involve an accompanying forward to improve this treatment. We produced an early relative, and lower need of clinic-based physiotherapy.12 mobilization HBRP with specific documental tools. Since Telerehabilitation empowers patients as it provides a better June 2017, we have implemented this early mobilization context for individualized care plans.25 The main disad- HBRP for the non-surgical treatment of PHF in older pa- vantages are low-intensity training, poor patient tients. The protocol consists of (1) exercise program for compliance,20,23,26,27 low adherence to the program,28 early mobilization starting from day 1 after the fracture and unfeasible for cognitive impaired patients,1 and manual allowing BADL so that patients remain as independent as treatment limitations.25 possible, (2) weekly monitored sessions with a physio- The use of media-based tools to guide physiotherapy therapist, for education, home exercise supervision, and has not been formally assessed. We aimed to evaluate the physical activity advice, starting after 2/3 weeks follow-up; use of innovative media-based tools to guide physio- and (3) standard physiotherapy at 3 months follow-up if therapy for non-surgically treated proximal humeral there is unsatisfactory progression: the patient has diffi- fractures (PHF) in older patients. culties for exercising, shoulder movements are painful, there is room for improving shoulder range of motion, there is a low or no increase of range of motion, or pain is not de- 1 Trauma & Orthopaedic Surgery Department, Hospital Clı́nico creasing or under control measured with VAS. During in- Universitario, Valladolid, Spain person follow-up visits at 1 week, 2 weeks, 1 month, 3 and 2 HM Hospitales, Barcelona, Spain 3 6 months, and 1 year, patients were checked upon pain, Rehabilitation Department, Hospital Clı́nico Universitario, Valladolid, Spain independency for BADL, range of movement, and problem 4 Telecoms Engineering School, Valladolid, Spain understanding and performing the exercises. The instruc- Submitted January 2, 2021. Revised July 12, 2021. Accepted August 1, tions for the exercise program are provided, at diagnosis, 2021 with 3 tools: videos, application for smartphone (app), and booklet with pictures. New exercises are added on weekly Corresponding Author: basis. The videos explain how to perform the exercises and Héctor J Aguado, MD, PhD, Trauma & Orthopaedic Surgery Department, Hospital Clı́nico Universitario de Valladolid, Av. Ramón y Cajal, are grouped in a YouTube playlist (first author´s channel: Valladolid 47007, Spain. https://youtube.com/playlist?list=PLBTmM5Q0_zaMcpi- Email: hjaguado@gmail.com TyFUkwe9grYF5DVZjR). The free app shows the same Aguado et al. 3 videos, a voice over guides the exercise performance, and analysis, a P ≤ .05 (2 tailed) was considered statistically allows adjusting number of repetitions and speed (https:// significant. play.google.com/store/apps/details?id=com.gti.maria. physiotherapyapp&hl=es_419). The booklet shows Results snapshots from the video recording sessions and text explaining the exercises. Patients can freely use any of the A total of 133 patients fulfilled the inclusion criteria and 3 tools, or a combination of them. were eligible to take the survey: 5 patients refused to Our main objective was to assess the degree of satis- participate in the survey or did not answer all the questions; faction of older patients using these innovative tools for the 19 patients could not be contacted; and 7 patients had non-surgical treatment of PHF. Secondary objectives were already died. In total, 102 patients answered the complete to find out whether patients preferred the booklet, videos or survey. Epidemiologic data from these patients, their app to guide HBRP, evaluate the degree of compliance fractures, treatment, clinical results, degree of satisfaction, with HBRP, and assess the subjective degree of shoulder and preferences are reported in Table 1. Mean follow-up function recovery. time was 1.86 ± 1.14 years. Mean degree of satisfaction with the HBRP was 4.66 ± .9: 84 patients (82.4%) were very satisfied with the treatment regime, 11 patients Measures (10.8%) were satisfied, and 5 patients (4.9%) were not Type of fracture according to Neer´s classification,30 age at satisfied at all. diagnosis, and patients´ center-based physiotherapy Thirty patients (29.4%) did not attend any treatment regime (either monitored sessions or standard physiotherapist-supervised session. For those patients who physiotherapy) were registered. Patients were reached by were supervised, the mean number of monitored sessions telephone during the second half of March 2020 to was 4.58 ± 1.26. After these monitored sessions, 18 evaluate their degree of satisfaction (1–5), subjective de- (17.7%) of all the patients needed further standard phys- gree of exercise compliance (1–5), degree of difficulty iotherapy. The mean OSS for those patients who did not using the different guide tools (1–5), preferred guiding tool (booklet, videos, or app), degree of recommendation for the protocol (1–5), internet accessibility, Oxford Shoulder Table 1. Epidemiologic Data from the Patients, their Fractures, Score (OSS),31 and subjective recovered range of motion as Well as for the Treatment, Clinical Results, Degree of (ROM) (1–5), that is, subjective perception of shoulder Satisfaction, and Preferences. ROM recovery compared to pre-fracture shoulder ROM. Age 70.6 ± 9.5 yo Subjective scales were produced according to Likert´s model.32 Example of the question regarding satisfaction: “I Sex: Female 80 (78.4%) was satisfied with the treatment I have received for the Male 22 (21.6%) management of my proximal humeral fracture; I would like PHF classification: 1-Part 27 (26.5%) to be treated with this same protocol again: (1) Strongly 2-part 31 (30.4%) 3-part 30 (29.4%) disagree; (2) Disagree; (3) Neither agree nor disagree; (4) 4-part 11 (10.8%) Agree; and (5) Strongly agree.” Articular 3 (2.9%) Internet access: Yes 58 (56.9%) Data Analysis No 44 (43.1%) Treatment: Only HBRP 30 (29.4%) Data were analyzed using SPSS 23.0 software (IBM, Monitored sessions without physio 54 (52.9%) Armonk, NY, USA). Continuous variables are described Monitored sessions with physio 18 (17.7%) using mean ± standard deviation. Categorical variables Number of sessions 4.58 ± 1.26 are presented with absolute and relative frequencies. OSS 40.5 ± 6.6 Continuous variables were explored for normal distri- Degree of satisfaction* 4.66 ± 0.9 bution according to histograms and the Shapiro–Wilk Degree of recommendation* 4.66 ± 0.9 test. The comparison of quantitative variables between 2 Subjective degree of exercise compliance* 4.75 ± 1 groups was done using the Student’s t-test for normally Subjective ROM recovery* 4.15 ± 1.1 distributed variables and the Mann–Whitney U test for Preferred tool: Booklet 61 (59.8%) non-normally distributed variables. The ANOVA test was Videos 30 (29.4%) used to compare quantitative variables between 3 groups. App 11 (10.8%) The chi-square test was used to compare categorical PHF: Proximal humeral fracture; HBRP: home-based rehabilitation variables. Pearson’s correlation coefficient was used to protocols; OSS: Oxford Shoulder Score; ROM: Range of movement. assess association between quantitative variables. For all *Degree in a 1-5 scale. 4 Geriatric Orthopaedic Surgery & Rehabilitation 0(0) attend standard physiotherapy was 41.22 ± 5.99 vs 37.94 ± According to the subjective self-assessment home- 7.58 (P = .054) for those who received standard physio- based exercise compliance, 89 (87.3%) patients fol- therapy after the monitored sessions. lowed the home exercise program with one of the tools as According to the availability of internet, patients with support and 4% did not do any exercise at all or hardly internet access were younger, more satisfied with the ever. The subjective exercise compliance was not related to HBRP, and had better OSS than those without internet the age of the patient. Patients who reported good exercise connection. There were no differences in the number of accomplishment presented better OSS (P = .038). At the monitored sessions or in the number of patients attending end of follow-up, 83 patients (81.4%) perceived complete standard physiotherapy (Table 2). Degree of satisfaction or almost complete shoulder ROM recovery and 3 patients and recommendation of the HBRP were inversely corre- (3%) perceived worse ROM than before the fracture. 84 lated with age (r = .275) (P = .005) (both), and positively (82,4%) patients strongly recommend the exercise pro- correlated with the final OSS (r = .428) (P < .001) (both), gram and 5 patients (4.9%) would not recommend the the self-assessment exercise compliance (r = .459) (P < HBRP and preferred standard physiotherapy. Six patients .001) (both), and the subjective shoulder ROM recovery (r (5.9%) experienced difficulties with the exercise tools, thus = .415) (P < .001) (both). reducing the use of the HBRP and the chances for func- According to the treatment regime, there were no dif- tional recovery. ferences in age, access to internet, degree of satisfaction, recommendation, subjective exercise compliance, or final OSS. But those needing further standard physiotherapy Discussion attended to less monitored sessions (Table 3). More pa- The use of the HBRP for PHF reported a high degree of tients preferred the booklet even though they had internet satisfaction in our patients, similar to the 95% reported by access. This group of patients was older and presented a Johansson et al. after first-time lumbar disc surgery.12 worse OSS than those preferring the videos or the app. No Reasons for satisfaction among our patients were no matter which tool the patients preferred, there were no need for travelling or bothering relatives, initiation of differences in degree of satisfaction or treatment regime rehabilitation without a waiting list, increased indepen- (Table 4). dence, and ability to keep on with BADL. Table 2. Answers to the Items in the Survey According to the Internet Access. OSS: Oxford Shoulder Score. Age Satisfaction OSS # Monitored sessions Received Standard physio Internet access n P > .001 P = .032 P = .002 P = .158 P = .959 Yes 58 (56.9%) 66 ± 8 4.8 ± 0.1 42 ± 5 3.6 ± 2.4 10 (59%) No 44 (43.1%) 76 ± 7 4.5 ± 1.1 38 ± 8 2.8 ± 2.2 7 (41%) Table 3. Answers to the Items in the Survey According to the Rehabilitation Treatment Regime. HBRP: home-based rehabilitation protocols, OSS: Oxford Shoulder Score. Age Internet Compliance Satisfaction Recommend OSS # sessions Treatment n P = .925 P = .795, % P = .511 P = 0. 613 P = .613 P = .207 P < .001 Only HBRP 30 29.4% 70 ± 10 53 4.5 ± 1.2 4.3 ± 1.5 4.3 ± 1.5 39 ± 7 0 Monitored 54 52.9% 71 ± 9 61 4.8 ± 1 4.8 ± 0.7 4.8 ± 0.7 42 ± 6 4.7 ± 1.3 sessions With physio 18 17.7% 72 ± 9 60 4.7 ± 0.8 4.6 ± 0.8 4.6 ± 0.8 39 ± 7 3.2 ± 3 Table 4. Answers to the Items in the Survey According to the Preferred Tool. OSS: Oxford Shoulder Score. Preferred Age Satisfaction # Monitored sessions Received Standard physio Internet access tool n P = .002 P = .139 OSS P = .037 P = .002 P = .147 P = .002 Booklet 61 (59.8%) 73 ± 9 4.5 ± 1.1 39 ± 7 2.6 ± 0.3 13 (78%) 26 (44%) Videos 30 (29.4%) 68 ± 9 4.8 ± 0.8 43 ± 4 3.8 ± 1.5 2 (11%) 23 (40%) App 11 (10.8%) 64 ± 8 5±0 42 ± 6 4.9 ± 0.5 2 (11%) 9 (16%) Aguado et al. 5 Adherence is one of the biggest concerns when pre- static. More sophisticated technologies might work better scribing HBRP.8,10,23,27,28 Reasons mentioned most often in younger patients. Although Hong et al. showed positive for nonadherence are vacation and work,10 the same as for effects on sarcopenia using more advanced tools like video in-hospital physiotherapy. Greater independence, self- conference–based supervised resistance,3 Wijnen et al. motivation, social support, motivation, and previous ad- used a tablet app and mobility monitoring devices for total herence to physical therapies predict higher adherence to hip arthroplasty. Adherence was good, patient experience HBRPs.28 Adherence to HBRP is low after hip was positive, and the novel technology was well ac- fractures,3,20,26 as patients have a great decrease in global cepted.17 Recent technological developments such as physical function and autonomy.14 It might be a problem in wearable sensors and tablets with a mobile internet con- pathologies with higher incidence in older adults, when nection hold promise for providing electronic health home- interventions do not fit patients’ limitations and goals. But based programs with remote coaching for patients.10,17 this is not the case for this HBRP for PHF as its goal is to When designing a HBRP, the tool must be adequate to the restore independence and autonomy. And we know from a target population. previous study that early mobilization does not displace Reduction of hospital visits provides comfort and PHF.29 This HBRP does not prescribe a certain number of minimizes the risk of infection.34 HBRP involves patients repetitions, or timing, or number of training sessions: we in their own recovery treatment, minimizing the use of encourage to exercise daily in multiple short sessions, with hospital resources. The sooner rehabilitation starts, the less only 1 longer exercise session per day, and keep as in- amount of physiotherapy the patients need.21 In the present dependent as possible for BADL from the first day. Be- study, the HBRP starts right after the PHF diagnosis, thus sides, the tools are not “fancy”: easy content with simple 29% of the patients did not need any physiotherapy su- instructions in plain language. That is why age was not pervision at all, and a reduced number of patients (17.7%) related to the subjective self-assessment exercise com- needed standard physiotherapy at 3 months follow-up. pliance in our study. Thus, older and more dependent This is important for older patients for whom recovering patients were also stimulated to do the exercise program. their independence and remain living in their home is Adherence can be facilitated by increasing the attrac- paramount. Patients needing standard physiotherapy re- tiveness of the programs: new technologies meet these ceived less monitored sessions: if these patients had re- challenges but are not a substitute for the personal rela- ceived 2 to 4 more monitored sessions, maybe they would tionship between patients and care providers.4,23 have not needed standard physiotherapy. Physiotherapist-supervised sessions provide this per- More recently, in spite of the elective activity cease sonal relationship to the HBRP and help improving ad- during the SARS-CoV-2 pandemic lockdown, we still had herence factors. Although Bruder et al. found that therapist to treat patients with PHF, while physiotherapy and re- supervision might not be necessary in conservatively habilitation services were closed. We kept doing the same managed distal radius fractures or PHF,18 an in-home treatment management except for the weekly visits to the setting helps physical therapists co-create patient- physiotherapist. Instead, we did telephone follow-ups and centered care plans with exercises that are more relevant asked about doubts with the exercises. In a lockdown to a patient’s immediate environment.25 We supervised our scenario, these home-based tools are definitively better patients during follow-up visits, but supervision can be than the alternative, which is no rehabilitation treatment at done by telephone follow-up calls,5,33 by physiothera- all. With this work we encourage trauma surgeons to carry pists,12 or by video conference-based supervision.3 But out HBRPs together with their rehabilitation teams, and be regarding the degree satisfaction, our patients preferred prepared for future lockdowns due to the SARS-CoV-2 some kind of supervision rather than only HBRP, and still pandemic: we have to be more pro-active in our patients’ some degree of independency as those attending standard rehabilitation process, as minimal function recovery will physiotherapy weren´t more satisfied, but no statistical provide great autonomy. Self-explanatory short videos difference was found. and/or a booklet with exercises might help in the recovery Proximal humeral fracture is a fragility fracture, thus of fractures or other joint disorders. one of the major concerns are patient´s ability to deal with The ideal home-based (tele)rehabilitation should be new technologies, and also limited internet access. These easy to follow and to comply with, effective, and with high are the reasons why older patients without external help adherence rates. We must consider that older patients can preferred the booklet. Although according to the mean age struggle with apps, but almost anyone with a smartphone of our patients, in 5 years’ time, the great majority of can watch videos from YouTube. Also, videos are easy to patients presenting a PHF should have internet connection. record, but apps are difficult to build. A booklet with Exercises in the videos might be better explained than in images and explanations will always be helpful. The the booklet: videos are easier to follow and guide the protocols should include exercises similar to in-hospital movement in each exercise, while images in the booklet are therapy. Start with illustrative booklets and videos with 6 Geriatric Orthopaedic Surgery & Rehabilitation 0(0) clear instructions. Once the HBRP is effective, more so- Mario Martı́nez-Zarzuela  https://orcid.org/0000-0002-6866- phisticated technological tools (apps, sensors, tablets, …) 3316 can be introduced. Virginia Garcı́a-Virto  https://orcid.org/0000-0002-7609-7991 To our knowledge, this is the first article presenting a HBRP for a fragility fracture with the clinical objective of References restoring global function and independence. Our study has 1. Flynn A, Allen NE, Dennis S, Canning CG, Preston E. several limitations: As there is no control group, we cannot Home-based prescribed exercise improves balance-related compare the degree of satisfaction nor effectiveness with activities in people with Parkinson’s disease and has standard physiotherapy for PHF. At our institution, stan- benefits similar to centre-based exercise: a systematic re- dard physiotherapy starts 3 months after the PHF, which in view. 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