Frisbie Memorial Hospital Marsh Brook Rehabilitation Services Wentworth-Douglass Hospital AQUATIC/LAND CLINICAL PROTOCOL FOR LESS THAN 5cm ROTATOR CUFF REPAIR REHABILITATION (See Attached ADDENDUM at end of Protocol for Greater than 5cm Rotator Cuff Repair Rehabilitation) FREQUENCY: 2 to 3 times per week. DURATION: 8-20 weeks 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. PRE-OP EVALUATION Pre-operative evaluation and patient education. POST-OPERATIVE EVALUATION (5 TO 7 DAYS POST-OP) GOALS: 1. Evaluation to assess: Posture. Cervical/Elbow/Wrist active range of motion. Passive range of motion of involved shoulder. Pain/Inflammation. Incisional integrity. 2. Postural education. 3. Review home exercise program/edema reduction techniques. 4. Education regarding sling, immobilizer, and precautions. 5. Patient oriented to aquatic program as well as given Information Packet. Initiate formal rehabilitation 2-3 times per week until SELF-MANAGEMENT CRITERIA has been met. Frequency of weekly appointments will depend on patient's availability, working status, and choice/interest. 7 Marsh Brook Drive, Suite 101, Somersworth, NH 03878 Tel:(603) 749-6686 Fax:(603) 749-9270
2 POST-OPERATIVE EVALUATION (5 TO 7 DAYS POST-OP continued) When patient presents with the following SELF-MANAGEMENT CRITERIA (estimated at 8-16 weeks post-operatively): Normal cervical, elbow, wrist active range of motion. Passive range of motion symmetrical to uninvolved shoulder. Minimal to no capsular restrictions. Active range of motion within 10-15 of uninvolved shoulder. Minimal compensatory shoulder and 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 or adherence. Can perform basic ADL with exception of heavy lifting and work tasks with moderate to minimal pain with pain level continuing to decrease. Progressing toward return 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. the patient can then 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. DISCHARGE CRITERIA (12-20 WEEKS) Active range of motion symmetrical to uninvolved shoulder. No capsular restrictions. Normal elevation of shoulder with minimal to no pain and without compensatory movement of shoulder or scapula. Normal scapulothoracic rhythm. 4+/5 to 5/5 strength of deltoid, rotator cuff, biceps, and triceps. 85% strength of internal rotators/external rotators as compared to uninvolved shoulder if throwing athlete according to isokinetic evaluation. Minimal to no winging of scapula with repetitive elevation with Theraband. Return to work. Independent with and understands the importance of continuing with home exercise program. Failure to progress. Failure to comply. --TREATMENT GUIDELINES-- POST-OP WEEKS 1 TO 3 GOALS (To be met at least at end of time frame): 1. The patient demonstrates good understanding of home exercise program, proper posture, and precautions to be followed. 2. Independent with incision mobilization/desensitization techniques. 3. Passive range of motion as follows: Flexion: 90-125 Abduction: 90 Internal Rotation: 45 with arm abducted to 45 External Rotation: 45 with arm abducted to 45
3 POST-OP WEEKS 1 TO 3 (continued) LAND COMPONENT: Sling/Immobilizer duration determined by physician. Modalities as indicated to control and decrease pain, inflammation, and muscle guarding. When incision adequately healed, perform incisional mobilization/desensitization techniques, if indicated. Home exercise program to include cervical, elbow, and wrist active range of motion/flexibility exercises. Initiate active assisted range of motion exercises to include pendulum exercises as well as cane exercises emphasizing shoulder flexion to 125, internal/external rotation with 45 abduction, pulley exercises for shoulder flexion. Initiate submaximal isometrics for shoulder flexors/abductors/internal and external rotators/elbow flexors. Once incision is healed, begin water component, if indicated. WATER COMPONENT: Shallow Water: Warm-up walking forward/backward/sideways with semi-squats with modified arm movement to tolerance (can add foam cube or dumbbell for increased buoyancy to facilitate range of motion). Pendulum exercises with face in and out of water. May add wrist weights to gently increase joint traction of shoulder, also providing additional momentum. Active assisted range of motion exercises in sitting/standing/modified position using foam cube or dumbbell for increased buoyancy to facilitate motion. For internal/external rotation, shoulder should be placed in 45-60 of abduction. D1/D2 patterns if tolerated with shoulder submerged. Cervical, elbow, and wrist active range of motion/flexibility exercises. Initiate submaximal isometric strengthening with shallow water walking forward/backward/ sideways holding arms still against resistance of water (may add webbed glove for increased resistance). Internal/External rotation to be performed in modified neutral position. WEEKS 4 TO 6 GOALS (To be met at least at end of time frame): 1. Prevent development of adhesive capsulitis. 2. Independent with home exercise program progression. 3. No incisional hypersensitivity/adherence. 4. Pain level continuing to decrease. 5. Passive range of motion as follows: Elevation: At least 160 Adduction: Within normal limits Internal Rotation: 60 with arm abducted to 90 External Rotation: 60 with arm abducted to 90
4 WEEKS 4 TO 6 (continued) LAND COMPONENT: Discontinue immobilizer/sling. Continue with cryotherapy as needed. Continue with incisional techniques as indicated. Joint mobilization of glenohumeral joint and scapulothoracic junction. Can progress to Grades III/IV as dictated by patient's tolerance. Initiate isotonic Theraband strengthening for internal/external rotation in the plane of the scapula and initiate parascapular strengthening, i.e. serratus punches, prone row, prone extension, and internal/external rotation in sidelying position in plane of scapula. Progress home exercise program as Weeks 1-3. Begin active range of motion exercises. Isotonic Theraband strengthening can be initiated with internal/external rotation in plane of the scapula. WATER COMPONENT: Shallow Water: Continue with warm-up walking forward/backward/sideways with semi-squats with foam cube or dumbbell for increased buoyancy to facilitate range of motion. Continue with active assisted and active range of motion exercises in sitting/standing/supine/ prone with increased buoyancy to increase range of motion. (Shoulder may be in 90 of abduction for internal/external rotation). Initiate isotonic strengthening in standing with kickboard/dumbbells/webbed gloves with shoulders submerged: flexion/extension, abduction/adduction, internal/external rotation, horizontal abduction/adduction, supraspinatus strengthening with thumb up to 70-80 of flexion. Continue with D1/D2 pattern shallow water or with mask and snorkel in deep water. Deep Water: Begin mask and snorkel at this phase initiating active range of motion exercises with foam/ kickboard. (Elevation in range of motion where there is no scapular or shoulder compensatory movement. Care must be taken not to foster aberrant movement patterns.) Deep water bobbing for flexion/abduction. Progress cardiovascular activities to incorporate shoulder such as deep water cross country skiing and/or running, jumping jacks, and pectorals. (May add upper extremity/lower extremity buoyancy for increased resistance.) Can use wet vest/ski belt to decrease shoulder elevation. WEEKS 7 TO 10 GOALS (To be met at least at end of time frame): 1. Passive range of motion symmetrical to uninvolved shoulder. 2. Minimal to no capsular restrictions. 3. Pain level continuing to decrease. 4. Active elevation to at least 140 without compensatory movement of shoulder or scapula. 5. 4/5 to 4+/5 strength of rotator cuff, deltoid, and parascapular musculature.
5 WEEKS 7 TO 10 (continued) LAND COMPONENT: Continue with joint mobilization as indicated. Initiate functional upper extremity proprioception and functional progression activities. Continue isotonic strengthening using Theraband with emphasis on internal/external rotation with arm at side. Initiate dumbbell exercises for deltoid, supraspinatus, scapular musculature, elbow flexion/ extension. Progress home exercise program to include comprehensive flexibility program. WATER COMPONENT: Shallow Water: Continue with water walking forward/backward/sideways with semi-squats with foam/dumbbell, dumbbells submerged to increase resistance. With 1-3 kg medicine ball: Perform ball toss/chest pass/ball push one (two) handed to increase stabilization/proprioception. Continue isotonic strengthening in standing with kickboard/dumbbells/web gloves with shoulders submerged; flexion/extension, abduction/adduction, internal rotation/external rotation, horizontal abduction/adduction, supraspinatus strengthening with thumb up to 70-80 flexion. Chair press-ups on large kickboard for scapula musculature strengthening. Deep Water: Continue mask and snorkel exercises with kickboard/dumbbells for parascapular strengthening, i.e. serratus punches, flexion/extension, horizontal abduction/adduction, rowing, and supraspinatus strengthening with thumb up (can perform previous exercises with both arms or single arm when appropriate and tolerated). Rhythmic stabilization with kickboard/ball using rapid movement starting in neutral and adding increased movement and speed as patient tolerates (See Advanced Upper Extremity Protocol for further exercises). Bobbing adding 180 and 360 turns to tolerance with/without buoyancy. Initiate swimming paying particularly attention not to foster adherent movements. Incorporate sport specific exercises if appropriate. Continue to progress cardiovascular activities by increasing buoyancy/speed/duration. For advanced exercises, please refer to Advanced Upper Extremity Aquatic Exercise Protocols. The patient should be completely transitioned to land after Week 10.
6 WEEK 11 TO DISCHARGE GOAL (To be met at least at end of time frame): Meet discharge criteria. Continue with formal treatment as outlined below until SELF-MANAGEMENT CRITERIA has been met. When SELF-MANAGEMENT CRITERIA is met, then patient will continue with independent program with follow-up appointments every 2-4 weeks until discharge criteria has been met. UBE forward/backward for an active warm-up and muscular endurance. Continue with manual joint mobilization and stretching as indicated. Continue with comprehensive isotonic/theraband strengthening program. Program should include all major muscle groups of upper extremity with emphasis on deltoid, rotator cuff, parascapular musculature, triceps, and biceps. Progress rotator cuff strengthening exercises to 90 abduction and deltoid and supraspinatus above shoulder height if can be accomplished pain-free and without compensatory hiking of scapula or shoulder. Progress home exercise program to include self-joint mobilization exercises if capsular restrictions noted/remain. 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. ADDENDUM FOR ROTATOR CUFF REPAIR GREATER THAN 5cm When treating rotator cuff repair greater than 5cm, treatment progression is similar, only no inferior glides on land and active assisted range of motion may begin 1-2 weeks later. However, this is client specific and dependent upon physician. At days 5-20, no flexion isometrics initially. However, emphasis should be placed on abduction, internal/ external rotation, and elbow flexion. At weeks 4-6, flexion only to 100, not 160, and internal/external rotation at 40 at 45 abduction. For advanced exercises, please refer to Advanced Upper Extremity Aquatic Exercise Protocols. RM/aoc 3/00, Rev. 1/04, 2009