FREQUENCY: 2 to 3 times per week.

Transcription

1 Frisbie Memorial Hospital Marsh Brook Rehabilitation Services Wentworth-Douglass Hospital AQUATIC/LAND CLINICAL PROTOCOL FOR ANTERIOR SHOULDER RECONSTRUCTION (INCLUDES CAPSULAR SHIFT AND/OR BANKART REPAIR) FREQUENCY: 2 to 3 times per week. DURATION: 3-4 months based on Physical Therapy evaluation findings. Continued formal treatment beyond meeting Self-Management Criteria will be allowed when patient out of work or to hasten return to work full duty. DOCUMENTATION: Progress Note to physician at each follow-up appointment. Follow treatment calendar for daily requirements. Discharge Summary within two weeks of discharge. POST-OPERATIVE EVALUATION (WEEKS 0 TO 6) 1. Evaluation to assess: Posture Shoulder active assistive/passive range of motion Cervical/Elbow/Wrist active range of motion Pain/Inflammation Incisional integrity 2. Postural education. 3. Initiate home exercise program to include active assisted range of motion for pendulum exercises, pulleys, and cane exercises for range of motion. 4. Instruction regarding weaning from immobilizer. 5. Patient oriented to aquatic program as well as given information packet. Initiate formal rehabilitation two to three times per week until self-management criteria has been met. Frequency of weekly appointments will depend on patient's availability, working status, choice/interest. When patient presents with the following SELF-MANAGEMENT CRITERIA (estimated at 3-4 months post-operatively): Normal cervical/elbow/forearm/wrist active range of motion. Passive range of motion symmetrical to uninvolved shoulder. Minimal to no capsular restrictions. Involved shoulder active range of motion within degrees of uninvolved shoulder. Minimal compensatory shoulder/scapular movement with elevation. 4/5 to 4+/5 strength in rotator cuff and deltoid. Minimal winging of scapula with wall push with hands below waist. No incisional hypersensitivity/adherence. Can perform basic ADL with the exception of heavy lifting and work tasks with moderate to minimal pain with pain level continuing to decrease. No evidence of instability. Progressing toward returning to work or has returned to work with modification of duties. Demonstrates good understanding of normal posture. Demonstrates good understanding and compliance with independent home exercise program and self-pain management techniques. then patient can be instructed in either home exercise program or program to be performed at a local health club with follow-up appointments every 2-4 weeks until discharge criteria has been met. Please refer to Anterior Shoulder Reconstruction Home Exercise Program Progression. 7 Marsh Brook Drive, Suite 101, Somersworth, NH Tel:(603) Fax:(603)

2 DISCHARGE CRITERIA (4 TO 6 MONTHS) Full range of motion without compensatory movement of shoulder or scapula. No evidence of instability. No capsular restrictions. 4+/5 to 5/5 strength of deltoid/rotator cuff/biceps/triceps. Minimal to no winging of scapula with repetitive elevation with Theraband. Return to work full duty. Independent with and understands importance of continuing with home exercise program. Failure to progress. Failure to comply. 2 --TREATMENT GUIDELINES-- POST-OPERATIVE WEEKS 4 TO 6 (To be met at least at end of time frame.) 1. Minimal to no pain at rest. 2. The following active range of motion: Full elevation, full abduction, full extension, hand in small of back, external rotation to 45 at 90 abduction. 3. Independent with incision mobilization/desensitization techniques. WEEKS 0 TO 2 LAND ONLY: 1. Begin early range of motion. 2. Decrease pain. 3. Decrease inflammation. 4. Increase stability. Immobilizer to be worn X four weeks and no overhead movement X six to eight weeks. Cervical/Elbow range of motion exercises. Pendulum exercises, pulley exercises, shoulder flexion to 90, shoulder elevation in scapular plane to 60, cane exercises external rotation to 15 with arms abducted to 30, no shoulder abduction or elevation combination. Isometrics for flexion/extension/external rotation/internal rotation/adduction. WEEKS 2 TO 4: 1. Increase range of motion. 2. Increase/Normalize joint mobility. 3. Increase strength. 4. Decrease pain. 5. Decrease inflammation. 6. Add water component. Continue pulley exercises. Continue cane exercises for internal/external rotation at 30 in scapular plane, shoulder flexion to 115. Joint mobilization of ST joint, glenohumeral joint, and STC joint. Strengthening isometrics of shoulder musculature in rhythmic stabilization. Modalities as needed to decrease inflammation.

3 3 WEEKS 2 TO 4 (continued) Shallow Water: Warm-up Walking forward/backward/sideways being careful to perform gentle abduction with sideways walking if tolerated by patient. Start mobility exercises in sitting/standing for active assisted range of motion using foam cube or dumbbell for increased buoyancy to facilitate motion. Pendulum exercises with face in or out of water, may add waterproof wrist weights to gently increase joint traction on the shoulder also providing additional momentum. Gentle rhythmic stabilization exercises with no equipment. Isometric strengthening, shallow water walking forward/sideways/backward holding arms still against the resistance of the water add webbed glove for increased resistance. Perform cardiovascular strengthening with wet vest or ski belt. POST-OPERATIVE WEEKS 4 TO 6 (To be met at least at end of time frame.) 1. Minimal to no pain at rest. 2. The following active range of motion: Full elevation, full abduction, full extension, hand in small of back, external rotation to 45 at 90 abduction. 3. Independent with incision mobilization/desensitization techniques. Wean from immobilizer within three to four weeks post-op. Modalities as indicated to control and decrease pain/inflammation/muscle guarding. If indicated, incision mobilization/desensitization techniques. Joint mobilization of glenohumeral joint, AC joint, and scapulothoracic junction if indicated. Initiate gentle oscillations Grade I and II and progress as dictated by patient's tolerance. Initiate pain-free active range of motion exercises and home exercise program to include cervical/elbow/wrist active range of motion and flexibility exercises. PNF with rhythmic stabilization exercises. Shallow Water: Warm-up Walking forward/backward/sideways with semi-squats with modified arm movement to tolerance. (If able to lift arms past horizontal without difficulty during sideways walking, may add increased buoyancy for increased range of motion.) Continue mobility exercises in sitting/standing for active assisted range of motion using foam cube or dumbbell for increased buoyancy to facilitate motion. Continue pendulum exercises with face in or out of water, may add waterproof wrist weights to gently increase joint traction on the shoulder also providing additional momentum. Continue isometric strengthening, shallow water walking forward/sideways/backward holding arms still against the resistance of the water add webbed glove for increased resistance. Initiate strengthening for biceps/triceps using webbed glove or buoyancy for added resistance. Begin rhythmic stabilization exercises with kickboard or ball.

4 4 POST-OPERATIVE WEEKS 4 TO 6 (continued) Progress to prone (mask and snorkel) using D1/D2 patterns, if tolerated. Cardiovascular conditioning in deep water using wet vest as not to stress shoulder. POST-OPERATIVE WEEKS 6 TO 8 (To be met at least at end of time frame.) 1. Minimal to no discomfort with use of upper extremity to 90 elevation. 2. External rotation to within 25 of contralateral shoulder. 3. No incisional hypersensitivity/adherence. Continue with use of Cryocuff if indicated. Continue with joint mobilization if indicated. Can progress to Grades III and IV. Progress home exercise program to include gentle self-capsular stretches and a comprehensive flexibility program. Isotonic dumbbell program emphasizing rotator cuff. No deltoid strengthening as yet. Continue rhythmic stabilization. Shallow Water: Continue warm-up walking exercises. May add increased resistance/buoyancy for increased range of motion and strength. Increased buoyancy for range of motion if needed. The patient to use wall to stretch for shoulder external rotation or use railing in deep end. Initiate resistive exercises with the use of web glove or additional buoyancy as patient tolerates. Exercises to include: Prone mask and snorkel with kickboard serratus punches, flexion/extension, horizontal abduction/adduction. Standing with buoyancy flexion/extension, abduction/adduction, internal rotation/external rotation, horizontal abduction/adduction. Chair press-ups sitting on large kickboard. Continue rhythmic stabilization exercises with kickboard or ball increasing buoyancy and size of ball if needed. The patient should be progressed to prone mask and snorkel at this phase. Deep water bobbing for flexion/abduction. Initiate rhythmic stabilization by using rapid movements starting in neutral adding buoyancy (kickboard) as patient tolerates. Progress to prone with single arm buoyancy (single arm cuff) for more challenging resistance. Progress cardiovascular activities to incorporate shoulder, such as deep water cross country skiing and running (may add buoyancy to wrists and ankles for increased resistance). Can use wet vest or incorporate barbells/dumbbells for upper extremity motion. POST-OPERATIVE WEEKS 9 TO 12 (To be met at least at end of time frame.) 1. 4/5 to 4+/5 strength of all muscle groups. 2. Full non-painful range of motion.

5 5 POST-OPERATIVE WEEKS 9 TO 12 (continued) Continue with joint mobilization as indicated. Progress home program as indicated. Please refer to Anterior Shoulder Reconstruction Home Exercise Program handout. Continue with previous treatments as indicated for water. May progress to the deep water exercises listed below: Continue with range of motion exercises. Add buoyancy or 180/360 turns to bobbing if tolerated. Continue with prone stabilization, changing buoyancy (wrist cuffs, kickboard/dumbbells, etc.) to challenge patient. Initiate swimming. Continue to progress cardiovascular activities by increasing buoyancy/speed and duration. The patient should be completely transitioned to land after Week #12. POST-OPERATIVE WEEKS 13 TO DISCHARGE GOAL: Meet Discharge Criteria. Continue with isotonic/theraband/dumbbell strengthening program. Continue with manual joint mobilization and stretching as indicated. Initiate functional upper extremity proprioception/functional progression activities. Please refer protocol. For throwing athlete, if dominant arm, initiate short/long toss program with tennis ball progressing to full throwing for both distances and speed. Please refer to Interval Throwing Program. At discharge, the patient should be independent with and understand the importance of continuing with a comprehensive flexibility and strengthening program at home or at a local health club. For advanced exercises, please refer to Advanced Upper Extremity Aquatic Exercise Protocols. RM/aoc 11/99, Rev. 3/00, Rev. 1/04

6 6 ADDENDUM Anterior Shoulder Reconstruction patients are being referred to Physical Therapy earlier than the usual 3-4 weeks post-op. Some of these patients have had a capsular repair with microwave laser. Our current Protocol initiates evaluation at three weeks and post-op treatment at 4-6 weeks. Patients seen prior to that have the following treatment guidelines: 1. Wearing of immobilizer/sling at all times except to shower. 2. Passive range of motion to shoulder: Flexion to 90 degrees Abduction to 90 degrees Full internal rotation External rotation at 45 degrees abduction in plane of scapula to neutral only. 3. Passive range of motion to elbow, wrist, and hand. 4. Incision mobilization/desensitization techniques. ADDENDUM FOR THERMAL ASSISTED CAPSULORRHAPHY WEEKS 0 TO 2: Begin early motion of elbow/wrist/hand. PRECAUTIONS: 1. Wear immobilizer/sling at all times except when showering for at least 14 days. 2. No overhead motion for 12 weeks. 3. Avoid abduction, flexion/external rotation combination. Exercises: Gripping exercises Elbow flexion/extension/pronation/supination Active range of motion of cervical spine After 10 days, active abduction but not exceeding 90 WEEKS 2 TO 4: 1. Increase range of motion. 2. Increase arthrokinematics. 3. Increase strength. Pulley/Cane exercises for flexion/abduction to 90, external rotation to 45 at 0 and 90 of abduction, extension to 0. Strengthening isometrics all planes Scapular strengthening Elbow/Wrist strengthening After four weeks, follow Anterior Shoulder Reconstruction Protocol starting at 4 to 6 weeks. RM/aoc 1/04, 2009