Reverse Total Shoulder Arthroplasty Rehabilitation Protocol

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1 Andrew McNamara, MD Hand and Upper Extremity Surgery The Orthpaedic and Fracture Clinic 1431 Premier Drive Mankat, MN ph call 24/7 Reverse Ttal Shulder Arthrplasty Rehabilitatin Prtcl Patient Name: Date: Diagnsis: Surgery: Surgery Date: Phase I (0-6 weeks pst p; 2 PT visits) Pstp educatin: 0-7 days Use Ice pack up t 6-8x/day Stay in sling at all times, except fr hygiene and t cme ut f sling fr shrt perids fr elbw, wrist and hand range f mtin Sleeping: reclined may be the mst cmfrtable with a small pillw r twel rll under the elbw and upper arm but nt under the shulder itself The patient is encuraged t perfrm scapular elevatin, depressin, retractin and prtractin (clck exercises) frequently thrughut the day. Review safety and ADLs fr life in a sling. Emphasize dnning/dffing f shirts Review pstperative precautins with patient and care-partner. Avid shulder AROM. N lifting f bjects When reclining r lying supine, the patient is encuraged t keep a pillw r blanket behind their elbw, preventing extensin thrugh the shulder, t reduce stress n the anterir repair site. As a rule f thumb, the patient shuld always be able t see their elbw. N excessive shulder mtin beynd side pcket, especially int internal rtatin N excessive stretching r sudden mvements (particularly external rtatin (ER)) N supprting f bdy weight by hand r elbw n invlved side May shwer at 1 days pstp, letting water run ver the skin and patting dry with a clean twel. N standing in a pl fr 3 weeks. N swimming fr 10 weeks. N driving fr 3 weeks Allw healing f sft tissue Gradually increase shulder passive range f mtin, restre elbw/wrist/ hand active range f mtin Reduce pain and inflammatin Reduce muscle inhibitin 1

2 Independent with activities f daily living (ADLs) while maintaining integrity f replaced jint Precautins: Sling shuld be wrn fr the first 7-10 days and then wrn as needed fr cmfrt While lying supine, a small pillw r twel rll shuld be place behind the elbw t avid shulder hyperextensin, anterir capsule stretch, r subscapularis stretch. N lifting f bjects N internal rtatin (IR) behind the back r resisted internal rtatin N supprting f bdy weight by hand n the invlved side. N pushing up frm bed r chair with the surgical arm/hand. N excessive stretching r sudden mvements (especially int external rtatin) Because the subscapularis is divided and repaired, the patient is cautined against active internal rtatin and passive external rtatin beynd 30. PROM in all ther planes is permitted. Avid shulder AROM int abductin r flexin past 90. Active frward flexin and abductin are als permitted if the arm is held in internal rtatin thrughut the arc. Again, because f the subscapularis repair, the patient shuld be cautined against resistive internal rtatin as a strng cntractin might stress the repair. Active and passive mtin is permitted fr the elbw, frearm, wrist and hand. Pst-perative PT Visit #1: Typically 8-10 days pst-peratively 1. Dressing left intact, tegaderm may be reinfrced 2. Supine passive frward flexin t 90 (Hand t tp f head) 3. Passive lr t chest 4. Active distal extremity exercises (elbw/wrist/hand) 5. Pendulums 6. Scapular sub-max ismetrics (primarily retractin) 7. Frequent crytherapy fr pain, swelling, and inflammatin management, cnventinal highrate TENS may be used 8. Patient educatin regarding prper psitining and jint prtectin techniques. Pst-perative PT Visit #2: Typically 2-3 weeks pstperatively 1. Dressing is remved 2. 3-view XR f perative shulder 3. Cntinue previus exercises 4. Passive ER t neutral with arm by side. 5. Active-assisted exercises int flexin as tlerated -table slides t wall slides/walks 6. Begin sub-maximal deltid and periscapular ismetrics in neutral (avid IR) 7. Cntinue distal extremity AROM 8. Cntinue PROM 9. Cntinue crytherapy as much as able fr pain and inflammatin management Tlerates PROM prgram Achieves at least 90 f flexin Achieves at least 0 f external rtatin 2 Phase I Hme prgram exercises: (Starting at wk 2) Pendulums/Cdmans Passive ER Passive Flexin Shulder Shrugs Elbw and Hand ROM

3 Achieves at least 70 f internal rtatin measured at 30 abductin Patient demnstrates the ability t ismetrically activate all cmpnents f the deltid and periscapular musculature in the scapular plane Phase II: Active ROM (typically frm 6-12 weeks pst p, 2-3x per week) Restre full shulder PROM Gradually restre shulder AROM Cntrl pain and inflammatin Allw cntinued healing f sft tissue Re-establish dynamic shulder stability Precautins While lying supine, a small pillw r twel rll shuld be place behind the elbw t avid shulder hyperextensin, anterir capsule stretch, r subscapularis stretch. In presence f pr shulder mechanics, avid repetitius shulder AROM exercises/activity against gravity in standing. N lifting f heavy bjects bjects (heavier than a cffee cup) N supprting f bdy weight by hand n the invlved side N sudden jerking mvements Early Phase II: (typically frm weeks 6-8) Cntinue with PROM/AAROM (slw prgressin f PROM int external rtatin and abductin with arm externally rtated) AAROM pulleys flexin and abductin (as lng as PROM >90 ) Begin assisted hrizntal adductin Initiate gentle glenhumeral and scapulhumeral mbilizatins Strengthening: Scapular strengthening Submaximal shulder ismetrics in neutral Initiate glenhumeral and scapulhumeral rhythmic stabilizatin Cntinue crytherapy as much as able fr pain and inflammatin management Late Phase II: (typically 8-12 weeks) Begin active flexin, internal rtatin, external rtatin, abductin in pain-free range f mtin Prgress scapular strengthening Cntinue crytherapy as much as able fr pain and inflammatin management Tlerates PROM/AROM/ismetric prgram 3 Phase II Hme prgram exercises: (added t phase I) Cane Exercises Overhead Cane External Rtatin Cane Punches Internal/External Rtatin at side Shulder Flexin t 90 Shulder Abductin t 90 Bicep Curls Pulleys

4 Achieves at least 140 f flexin PROM Achieves at least 120 f abductin PROM Achieves at least 60 f external rtatin PROM in plane f scapula Achieves at least 70 f internal rtatin PROM measured in plan f scapula at 30 abductin Able t actively elevate the arm t 90 with gd mechanics in supine Phase III: strengthening phase (typically 12+ weeks, 2-3x per week) Restre shulder AROM Optimize neurmuscular cntrl Gradual return t functinal activities with invlved extremity Precautins: All exercises shuld be perfrmed pain-free OK t lift, push, pull Early Phase lll: (typically weeks) Cntinue PROM as needed t maintain ROM Advance PROM t stretching as apprpriate (wand) Prgress AROM exercises/activity as apprpriate Initiate assisted shulder internal rtatin behind the back stretch Strengthening Begin prgressive supine active elevatin strengthening (ant deltid) with light weights (1-2lb) as tlerated Supine shulder elevatin strengthening at prgressive inclines Cntinued distal upper extremity strengthening and scapular strengthening Begin light functinal training Late Phase Ill: (typically 14+ weeks) Resisted shulder internal and external rtatin in scapular plane Prgress t resisted flexin, abductin, extensin (weights/theraband) in standing and/r prne Cntinue prgressing internal and external rtatin strengthening Tlerates PROM/AROM/strengthening Achieves at least 120 f flexin AROM Achieves at least 120 f abductin AROM Achieves at least 60 f external rtatin AROM in plane f scapula Achieves at least 70 f internal rtatin AROM measured in plan f scapula at 30 abductin Nte: In patients that are rtatr cuff deficient, gals and criteria must be mre functinally-based. Flexin and abductin shuld ideally be near 90 with 30 f ER and 70 f IR. Patient shuld be able 4 Phase III Hme prgram exercises: (Added t phase II) Wall pushups Sitting weight shift Theraband exercises Arm raise with up t 1lb weight (scaptin)

5 t reach their hand t the tp f their head t perfrm persnal hygiene Phase IV: Advanced Strengthening Phase: Typically 4+ mnths t MMI: 1x per week Maintain nn-painful AROM Enhance functinal use f the upper extremity Imprve muscular strength, pwer, endurance Gradual return t mre advanced functinal activities Prgress clsed chain exercises as apprpriate Precautins Avid exercises that puts excessive stretch n anterir capsule (90-90 psitin) Ensure gradual strengthening Typically patients are n a hme exercise prgram perfrmed 3-4 days per week with PT prgressin 1 visit per week Cntinue AROM stretching exercises as indicated Strengthening Gradually prgressing strengthening prgram with increasing resistance and decreasing repetitins Functinal Prgressin Gradual return t mderately challenging functinal activities Return t recreatinal hbbies including gardening, sprts, glf, tennis Criteria fr discharge: Maintain nn-painful AROM Maximized functinal use f the upper extremity Maximum strength, pwer, endurance Return t activities/wrk Mdeled after Budreau et al. Rehabilitatin fllwing reverse ttal shulder arthrplasty. Jurnal f Orthpaedic & Sprts Physical Therapy, 2007 Vlume:37 Issue:12 Pages: DOI: /jspt

Total Shoulder Arthroplasty/Hemiarthroplasty Rehabilitation Protocol

Total Shoulder Arthroplasty/Hemiarthroplasty Rehabilitation Protocol Andrew McNamara, MD The Orthpaedic and Fracture Clinic 1431 Premier Drive Mankat, MN 56001 507-386-6600 Ttal Shulder Arthrplasty/Hemiarthrplasty Rehabilitatin Prtcl Patient Name: Date: Diagnsis: Surgery: