Total Shoulder Arthroplasty Rehabilitation Guidelines s1

Department of Rehabilitation Services 1 ( ) Rehabilitation GuidelinesDepartment of Rehabilitation ServicesArthroscopic Rotator Cuff Repair Rehabilitation GuidelinesPostoperative Rehabilitation: Phase I: 0-6 Weeks Post-opTREATMENT GOALS: 1. Patient education2. Pain and swelling control3. Protect anatomic repair4. Prevent negative effects of immobilization5. Initiate PROM exercises per tolerance except IR. No AROM a. 0-120 degrees flexion, 0-45 degrees external rotation by 3 weeks post-op, gaining 10 degrees per motion per week. b. Symmetrical ROM to contra-lateral shoulder by 6 weeks post-opTREATMENT GUIDELINES: 0-2 Weeks Post-Op:  Patient education o Wear shoulder sling and swathe 23 hours per day including sleeping o Safe donning and doffing of shoulder sling o No active use of the involved shoulder o Appropriate sleeping positions o Postural education o Skin careRevised 01/2010 Department of Rehabilitation Services 2 ( ) Rehabilitation Guidelines Pain and swelling management o Ice to shoulder after exercises and as needed for pain relief. o Skin temperature to return to normal prior to starting another session of icing. o Appropriate use of prescribed pain and anti-inflammatory medications to allow full participation in therapy Initiate HEP (PROM 2x/day, pendlums and other 4-6 x/day) o Multiplanar pendulum exercises o Elbow/wrist/finger AROM o Passive shoulder flexion and external rotation with shoulder at 45 degrees of abduction,(in the scapular plane to minimize strain to the supraspinatus) providing instruction to family as needed o GH mobilizations grade I/II for pain or muscle spasm o Thoracic Spine mobilizations as needed seated2-6 Weeks Post-Op:  Continue patient education as above o Slow wean from shoulder sling beginning 3 weeks post-operatively, with goal to be out completely by 6 weeks Continue pain and swelling management  Progress HEP o Initiate active scapular retraction, elevation, depression and clock exercises in neutral position (not performed with subscapularis repair) o Initiate assisted flexion (scaption) to tolerance with self help of opposite hand 1. Supine long lever flexion2. Sitting short lever flexion3. Sitting short lever scaption o Initiate supine active assisted ER stretch with wand, arm supported and shoulder at 45 degrees. Progress to multiple angles as tolerated.Revised 01/2010 Department of Rehabilitation Services 3 ( ) Rehabilitation Guidelines o Initiate Kibler scapular exercises1. Low Row2. Inferior Glide3. Lawn Mower4. Robbery Physical performance test: PROM symmetrical to contra lateral side Phase II: 6-12 weeks Post-opTREATMENT GOALS: 1. Pain and inflammation control2. Advance to shoulder AAROM/AROM exercises3. Initiate scapular stability exercises4. Increase ADL function5. Symmetrical AROM to contra lateral shoulder by 12 weeks without premature scapular elevation. Patient must be able to elevate arm without scapular hiking before initiating isotonics.6. Preserve the integrity of the surgical repairTREATMENT GUIDELINES Patient education Review/continue current HEP Initiate AAROM/AROM stretching exercise with emphasis on quality of movement o Progressive active assistive UBE o Butterfly stretch o Posterior capsule stretching o Standing IR behind the back stretch (horizontal adduction with the other hand or belt)Revised 01/2010 Department of Rehabilitation Services 4 ( ) Rehabilitation Guidelines o Thoracic mobilization o GH mobilizations Advance scapular stability exercise o Cervical and scapular retraction o Isometrics for flexion, abduction, extension, internal and external rotation in neutral in standing o Scapula stabilization exercises (start with the weight of the extremity)1. Prone I, Y, or T’s and side lying external rotation with axillary towel roll. If patient substitutes with upper trapizius during any elevation, substitute side lying flexion for Y and/or add W for T’s. If substitues in prone, may start with arm hanging off edge and perform extension or shorten arm with elbow flexed 90 degrees. 2 times/day without weight, once weight is added 1 time/day. Physical performance test: Functional independence with ADLs; Symmetrical multiplane reaching (overhead reach, cross the body, behind the head, behind the back, out to side)Phase III: 12-16 weeks post-opTREATMENT GOALS: 1. Full, pain-free AROM2. Independence with ADLs3. Increase strength of scapular stabilizers4. Increase rotator cuff strength5. Initiate functional activity specific strengthening TREATMENT GUIDELINES:  Patient education Continue Phase II stretching exercises Continue/progress scapular stability exercises Revised 01/2010 Department of Rehabilitation Services 5 ( ) Rehabilitation Guidelines Initiate rotator cuff strengthening exercises o Isotonic exercise: 1x/day 4-5 days/wk Physical Performance test: Upper extremity stability test (Push-up Plus in feet-elevated position)Phase IV: 16-20 weeks post opTREATMENT GOALS: 1. Power phase 1x/day 4 days/wk with 3 day recovery i.e. M, W, Th, S…2. Progress to activity specific tasks/duties, i.e. throwing, construction tasks, etc.TREATMENT GUIDELINES: Patient education and ice Continue/progress strengthening exercises Work or sport-specific training Modification suggestions for work, sport or functional activitiesREFERENCES1. Borstad J. Measurement of Pectoralis Minor Muscle Length: Validation and Clinical Application, J Ortho Sports Phys Ther, 2008; 38:169-174.2. Borstad J. Resting Position Variables at the Shoulder: Evidence to Support a Posture-Impairment Association, Physical Therapy, 2006; 86:549-557.3. Borstad J, Ludewig P. The Effect of Long Versus Short Pectoralis Minor Resting Length on Scapular Kinematics in Health Individuals, J Ortho Sports Phys Ther, 2005;35:227-238.Revised 01/2010 Department of Rehabilitation Services 6 ( ) Rehabilitation Guidelines4. Borstad JD, Ludewig PM, The Effect of Pectoralis Minor Length on Scapular Kinematics in Subjects without Shoulder Pathology (abstract), J Ortho Sports Phys Ther, 2004;34: A16.5. Bressel ME, Bressel E, et al, Lower Trapezius Activity during Supported and Unsupported Scapular Retraction Exercise, Phys Ther Sport, 2001;2:175-185.6. Ellenbecker, T.S., Davies, G.S., Reinold, M.M., (2009). Rehabilitation principles following rotator cuff and superior labral repair. In Orthopedic knowledge update: Sports medicine (4th ed., pp. 217-227). Rosemount, IL: AAOS.7. Cools AM, de Mey K, et al, Scapular Rehabilitation Exercises: What’s the Influence of the Kinetic Chain? J Ortho Sports Phys Ther, 2009; 39; A13.8. Cools AM, Dewitte V, et al, Rehabilitation of Scapula Muscle Balance: Which Exercises to Prescribe? Am J Sports Med, 2007; 35:1744-1751.9. Lear LJ, Gross MT, et al, An Electromyographic Analysis of the Scapular Stabilizing Synergists during a Push-Up Progression, J Orthop Sports Phys Ther, 1998;28:146-157.10. Maenhout A, Van Praet K, et al, Electromyographic Analysis of Knee Push-Up Plus Variations: the Influence of the Kinetic Chain on Scapular Muscle Activity, Br J Sports Med, 2009.11. McCann PD, Wootten ME, et al, A Kinematic and Electromyographic Study of Shoulder RehabilitationExercises, Clin Orthop Relat Res, 1993; 179-188.12. Moseley JB, Jobe FW, et al, EMG Analysis of the Scapular Muscles during a Shoulder RehabilitationProgram, Am J Sports Med, 1992;20;128-134.13. Smith J, Dahm DL, EMG Activity in the Immobilized Shoulder Girdle Musculature duringScapulothoracic Exercises, Arch Phys Med Rehabil, 2006; 87 923-927.14 .Townsend H, Jobe FW, et al, EMG Analysis of the Glenohumeral Muscles during a BaseballRehabilitation Rogram, Am J Sports Med, 1991; 19: 264-272.15. Tyler TF, Nichols SJ, et al, Quantification of Posterior Capsule Tightness and Motion Loss in Patients with Shoulder Impingement, Am J Sports Med, 2000; 28: 668-673.Revised 01/2010 Department of Rehabilitation Services 7 ( ) Rehabilitation GuidelinesRevised 01/2010

Total Shoulder Arthroplasty Rehabilitation Guidelines s1

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