high repetition to enhance shoulder endurance and decrease the risk of injury and dislocation. During this phase, sudden lifting, pushing, and jerking motions should be avoided indefinitely to minimize the risk of injury and dislocation. PHASE IV Phase IV is the continued home program phase, which typically occurs four months or longer postsurgery. Phase IV begins when the patient has been discharged from skilled physical therapy and is continuing with a home exercise program. To enter this last phase of rehabilitation, the patient should be able to demon- strate functional pain-free shoulder AROM and be independent with an appropriate strengthening program. The ultimate postop- erative shoulder ROM is typically 80 to 120 degrees of elevation, with function external rotation up to 30 degrees. Functional use of the operative shoulder should be demonstrated by a return to light household work and leisure activities as recommended by the surgeon and physical therapist. Typically, a 10- to 15-pound bilateral lifting limit should be followed indefinitely to ensure that the operative shoulder is not strained beyond functional integrity. ● Continuous cryotherapy for first 72 hours postsurgery then frequent application, four or five times per day for about 20 minutes. Days 5 to 21 ● Continue all previous exercises. ● Begin submaximal pain-free deltoid isometrics in a scapular plane; avoid shoulder extension when isolating posterior del- toid. ● Frequent cryotherapy, four or five times per day for about 20 minutes. Weeks 3 to 6 ● Progress previous exercises. ● Progress PROM. ○ Forward flexion and elevation in the scapular plane in su- pine to 120 degrees. ○ ER in scapular plane to tolerance, respecting soft tissue constraints. ● At six weeks postsurgery, start PROM IR to tolerance—not to exceed 50 degrees in the scapular plane. ● Gentle resisted exercise of elbow, wrist, and hand. ● Continue frequent cryotherapy. Criteria for progression to phase II ● Patient tolerates shoulder PROM and AROM program for el- bow, wrist, and hand. ● Patient demonstrates the ability to isometrically active all components of the deltoid and periscapular musculature in the scapular plane. PHASE II AROM, EARLY STRENGTHENING PHASE (weeks 6 to 12) Goals ● Continue progression of PROM; full PROM in not expected at this point. ● Gradually restore AROM. ● Control pain and inflammation. ● Allow continued healing of soft tissue; do not overstress heal- ing tissue. ● Re-establish dynamic shoulder stability. Precautions ● Continue to avoid shoulder hyperextension. ● In the presence of poor shoulder mechanics, avoid repetitive shoulder AROM exercises and activity. ● Restrict lifting of objects no heavier than a coffee cup. ● No supporting of body weight by the involved upper extrem- ity.
neutral to limit the stress placed on the anterior tissues when isolat - ing the posterior deltoid. Initiation of isotonic strengthening should begin only once adequate mechanics and acceptable AROM of the glenohumeral and scapulothoracic joints are present. It is recom- mended that when starting isotonic strengthening to begin with low weight and high repetitions. PHASE III Phase III, also known as the moderate strengthening phase, begins around 12 weeks postsurgery. Phase III activities can be initiated when the patient has appropriate PROM, AAROM, and AROM and is able to isotonically activate each portion of the deltoid and periscapular musculature while demonstrating the appropriate shoulder mechanics. The patient should also be able to tolerate gentle resistance strengthening of the elbow, wrist, and hand of the operative upper extremity. The primary goals of this phase are to advance strengthening and increase functional independence and to maintain appropri - ate pain-free shoulder mechanics. Dislocation precautions should continue for all static and dynamic activities. All strengthening activities should be based on the principles of low weight and shoulder adduction, internal rotation, and extension. ● No glenohumeral joint extension beyond neutral. PHASE I: IMMEDIATE POSTSURGICAL PHASE, JOINT PROTECTION (day 1 to week 6) Goals ● Patient and family independent with: ○ Joint protection. ○ Passive range of motion. ○ Assisting with putting on, taking off sling and clothing. ○ Assisting with home exercise program (HEP). ● Promote healing of soft tissue; maintain the integrity of the replaced joint. ● Enhance PROM. ● Sling is worn for three to four weeks postsurgery. Use of sling may be extended for a total of six weeks, often if it is a revi- sion surgery. ● While patient is supine, the distal humerus and elbow should be supported by a pillow or towel roll to avoid shoulder exten- sion. Patient should be advised to always visualize his or her elbow while supine. ● No shoulder AROM. ● No lifting objects with involved upper extremity. ● No supporting of body weight on the involved upper extrem- ity. ● Keep incision clean and dry; no soaking or wetting for two weeks; no whirlpool, Jacuzzi, ocean, or lake wading for four weeks. Days 1 to 4 (acute care therapy) ● Begin PROM in supine after complete resolution of intersca- lene block. ○ Forward flexion and elevation in the scapular plane in su- pine to 90 degrees. ○ External rotation in scapular plane to available ROM as in- dicated by operative findings but typically around 20 to 30 degrees. ○ No IR ROM. ● Restore AROM of elbow, wrist, and hand. ● Independent with ADLs with modifications. Precautions ● AROM and AAROM of cervical spine, elbow, wrist, and hand. ● Begin periscapular submaximal pain-free isometrics in the scapular plane.
Reverse total shoulder arthroplasty protocol (Boudreau et al., 2007) Shoulder dislocation precautions Precautions should be implemented for the first 12 weeks postsurgery unless the surgeon specifically advises the patient or therapist differently. ● No shoulder motion behind lower back and hip; no combined
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