PHASE I Phase I consists of the immediate postsurgical time from post- surgery Day 1 to the end of the sixth postoperative week. The goals in this phase are to maintain the integrity of the replaced joint while restoring PROM. Family and caregiver involvement can help with joint protection. Patients who needed rTSA because of a failed conventional TSA will need to be managed on a case-by- case basis. These patients may require a longer immobilization period postsurgery to allow adequate soft tissue healing. It is rec- ommended that PROM be delayed for three to six weeks follow- ing surgery to ensure adequate bone integrity. When a surgical technique other than the traditional deltopec- toral approach is used, it is recommended that patients start the PROM program for three to four weeks postsurgery to ensure adequate deltoid healing. These patients should also delay the start of deltoid isometrics for at least four weeks postsurgery, with AROM in flexion beginning around 6 weeks and isotonic deltoid strengthening commencing at around 12 weeks postsurgery. This progression ensures adequate deltoid integrity following surgery. Close collaboration with the surgeon regarding the structural in- tegrity of the reconstructed shoulder is essential to determine the ideal time to begin shoulder ROM activities. During Phase I, all shoulder activity should be passive to mini- mize loads to the newly constructed joint. For patients who have a primary rTSA with a traditional deltopectoral approach, passive motion can begin after the effects of the interscalene block has resolved. This is to ensure proper deltoid function in addition to making certain the sensory feedback mechanisms are intact. Active and active-assisted elbow, wrist, and hand activity is ap- propriate during this phase as long as the shoulder joint remains statistically positioned. During the first four postoperative days, while the patient is typi- cally still in inpatient or acute care, PROM is limited to minimize strain on the shoulder and to allow the initial stage of tissue heal- ing. Flexion and elevation in the plane of the scapula should be gradually increased as tolerated to 90 degrees. Pure abduction should be avoided because it may place undue stress on the an- terior structures of the shoulder. Passive external rotation should be progressed to approximately 20 to 30 degrees while remaining in the scapular plane. If the subscapularis was repaired, external rotation range of motion parameters may need to be adjusted to avoid placing undue stress on the repair. It is recommended to collaborate with the referring surgeon to clarify if there should be any delay or ROM restrictions. IR range of motion should be avoided during the first six weeks because of the possibility of dislocation as the result of impaired shoul- der stability from a deficient rotator cuff. Submaximal pain-free deltoid isometrics and periscapular isometrics with the humerus protected in the scapular plane can begin around the fourth post- operative day. The deltoid and periscapular musculature are the primary dynamic restraints, stabilizers, and movers of the gleno- humeral joint because there is minimal to no intact rotator cuff following rTSA. It is important to avoid shoulder hyperextension while performing posterior deltoid isometrics to minimize the risk of dislocation. During weeks three through six following surgery, Phase I activi- ties progress based on clinical progression and presentation of the patient. The patient’s sensory feedback will improve as the initial soft tissue healing occurs. This allows a safer progression of passive forward flexion and elevation in the scapular plane to 120 degrees. After the sixth postoperative week, PROM in flexion and elevation in the scapular plane may be advanced per patient tolerance—typically up to 140 degrees. Based on the research, a patient following rTSA is expected to reach about 138 degrees of active elevation. Passive external rotation range of motion may gradually progress to 30 to 45 degrees while continuing to re- spect the soft tissue constraints of the subscapularis if repaired. Internal rotation may begin during the sixth week of the protocol and should be completed in a protected position of at least 60 degrees of abduction in the scapular plane to ensure avoidance
of internal rotation with adduction. Shoulder immobilization in an abduction-type sling, which supports the humerus in a position of the scapular plane, should occur for three to four weeks ex- cept during therapy, bathing, and home exercises. The patient will need to be aware of positioning and always remember not to reach across the abdomen or chest wall with the operative upper extremity, as this position involves combined internal rotation with adduction and increases the risk of dislocation. When the posterior cuff is repaired, the tendon quality is poor, and the posterior capsule tissue integrity may be compromised. In the case of a posterior cuff repair, an external rotation immobilizer like the DonJoy Ultrasling 15 degrees external rotation sling is routinely used. The positioning that an external rotation sling provides en- ables the head of the humerus to be in the position of a scapular plane with the added benefit of neutral to 15 degrees of external rotation. This positioning allows the posterior rotator cuff to heal as it promotes immobilization of the repaired posterior cuff in a relatively shortened position during the early postoperative healing phase. This also allows less external rotation stiffness and leads to better tolerance of external rotation passive motion. Cryotherapy is recommended to assist in the control of pain, minimize swelling and muscle spasm, and suppress inflammation. Speer and colleagues did a study with 50 participants following shoulder surgery. In this study, cryotherapy was used every 1 to 2 hours for the first 24 hours postsurgery and then decreased to 4 to 6 times per day or as needed until the time of reassessment on the 10th postoperative day. The individuals in the cryotherapy group had less pain over the first 24 hours with a better potential for sleep and less need for pain medication. Shoulder movement was also less painful during therapy by 10 days postsurgery, and these participants were generally able to better follow through with their rehabilitation. PHASE II Phase II is the AROM and early strengthening phase, which is usually from Weeks 6 to 12 of the rehabilitation protocol. Dur- ing Phase II, the patient progresses from PROM to active assisted range of motion (AAROM). AROM and gentle strengthening also begin with the primary focus of restoring dynamic shoulder stabil- ity and enhanced mechanics. Precautions should still be followed during this phase because of continued risk of dislocation. Soft tis- sue healing becomes adequate at around six weeks postsurgery, which allows AROM and AAROM to be safely initiated. When progressing from AAROM to AROM, the therapist must carefully monitor quality of movement patterns, motor control, and overall shoulder stability to ensure that the shoulder musculature is not inappropriately challenged. Abnormal movement patterns can lead to the development of poor mechanics, unnecessary pain, and compromised joint mechanics. Forward flexion and eleva- tion AAROM and AROM should be initiated in supine where the scapula is stabilized. These activities can then be progressed to more functional and dynamically challenged positions of sitting and standing. Close monitoring of patients is important to ensure that acromion displacement does not occur. AAROM and AROM of internal and external rotation are initiated and progressed during this phase, but rotational movements should be performed in a scapular plane. At eight weeks postsurgery, the initiation of internal and external rotation submaximal isometrics can begin when the soft tissue integrity of the teres minor and subscapularis improves. Typically, the infraspinatus is irreparable, although the teres mi- nor remains intact. Internal and external rotation isometrics be- gun earlier in the rehabilitation process can lead to retearing of the rotator cuff. If the rotator cuff was not surgically repaired, it is important to consult with the referring surgeon to establish if internal and external rotation isometrics can be initiated earlier than eight weeks postsurgery because the risk of a recurrent rota- tor cuff tear is not a risk. Between the sixth and eight week postsurgery, gentle periscapular and deltoid isometric activity should progress to isotonic activity. Patients will need to be educated to avoid shoulder extension past
Page 198
Book Code: PTCA2624
EliteLearning.com/ Physical-Therapy
Powered by FlippingBook