Precautions ● Avoid exercise and functional activities that put stress on the anterior capsule and surrounding structures—no combined ER and abduction above 80 degrees of abduction. ● Ensure gradual progression of strengthening. Early Phase IV ● Typically, patient is on a home exercise program by this point to be performed three or four times per week. ● Gradually progress strengthening program. ● Gradual return to moderately challenging functional situations. for a patient following this procedure is different than the rehabilitation following the traditional TSA. The biomechanics of the prosthesis are different. There is inherent potential for instability because of the design, which makes the precautions for rTSA unique and different from those of TSA and a hemiarthroplasty. The surgeon, physical therapist, and patient need to consider these factors when developing a postoperative treatment plan. The surgical approach also needs to be considered when developing the postoperative protocol. Traditionally, an rTSA procedure is performed via a deltopectoral approach, which minimizes surgical trauma to the anterior deltoid. But some surgeons use a superior approach that retracts the anterior deltoid from the anterior lateral one-third of the clavicle. This technique allows superior exposure to the glenohumeral joint between the retracted anterior deltoid and the clavicle. The anterior deltoid is sutured back to its anatomical position during surgical closure; in these cases, early deltoid activity is contraindicated. Collaboration between the surgeon and the physical therapist is essential to ensure appropriate rehabilitation following rTSA. A number of factors can affect rehabilitation, including the patient’s preoperative shoulder status, type of implant used, the glenoid and humeral bone quality, the integrity of the remaining rotator cuff, concomitant rotator cuff repair or tendon transferred, and the overall component stability at the time of the surgical reconstruction. There is variability in functional and ROM outcomes following rTSA, and patients need to be reminded that their shoulder mechanics and function will have some limitations when compared to the other shoulder. Patients who live a more active lifestyle typically require greater education in regards to their restrictions to ensure proper longevity of their new prosthesis and to decrease the risk of dislocation. Key postoperative rehabilitation concepts need to be considered when outlining the care for a patient following rTSA, including joint protection, deltoid function, and establishing appropriate functional and ROM expectations. Joint protection is important for initial postoperative positioning and initial activity. There is a higher risk of shoulder dislocation following rTSA than with the conventional TSA. Patients who undergo rTSA can dislocate with the surgical arm in internal rotation and adduction in conjunction with extension. This high-risk position allows the prosthesis to escape anteriorly and inferiorly, which is the position of greatest vulnerability for rTSA. Certain functional activities should be avoided. Tucking in a shirt and reaching behind one’s hip and lower back with the operative upper extremity are dangerous activities, especially during the immediate postoperative phase, and should be the major postoperative precautions for no less than the first 12 weeks. Deltoid function is also important following rTSA. Enhancement of deltoid function in the absence of the rotator cuff following rTSA is the most important concept of the postoperative strengthening phase of recovery. Stability and mobility of the shoulder joint largely depend on the deltoid and periscapular musculature.
Late Phase IV (Typically, four to six months postsurgery.) ● Return to recreational hobbies, gardening, sports, golf, doubles tennis. Criteria for discharge from skilled physical therapy ● Patient is able to maintain nonpainful AROM. ● Maximized functional use of upper extremity. ● Maximized muscular strength, power, and endurance. ● Patient has returned to advanced functional activities. The rehabilitation program and selection of exercises need to progressively emphasize the deltoid and periscapular musculature. Patients may experience great difficulty in recruiting the deltoid to become the primary mover for shoulder elevation. Biofeedback can be used to assist patients in learning recruitment strategies. Therapists can use biofeedback techniques to help improve deltoid recruitment, including verbal and tactile cues, surface electromyography, and rehabilitation ultrasound imaging. Clinicians will find that the operative upper extremity will demonstrate much higher deltoid recruitment than the uninvolved shoulder following a successful rehabilitation program. Range of motion and functional expectations are set on a case-by-case basis. Any return of active shoulder rotation will depend on the postoperative condition of the teres minor. The expectations depend on the underlying pathology, the status of the external rotators, and the extent to which the deltoid and periscapular musculature can be rehabilitated. Patients who have a negative ER lag sign during the initial strengthening phase of rehabilitation progress quicker in terms of strength gains and functional progression. They have a tendency to demonstrate higher active elevation ROM at the time of discharge from physical therapy. Normal full active elevation of the shoulder is not expected following rTSA, but functional active elevation of at least 105 degrees should be anticipated. The status of the posterior cuff is critical to achieve shoulder elevation. Significant external rotation weakness presurgery may mean that the surgeon will consider a concomitant latissimus dorsi transfer. Active forward flexion without external rotation may create a dysfunctional upper extremity and lead to poor patient satisfaction regardless of the intensity and effort of the patient and physical therapist following surgery. The postoperative protocol for the rTSA physical therapy rehabilitation program is divided into four phases. Each phase is based upon postoperative timelines that respect the healing process and soft tissue parameters. Progression through each phase should depend on an evaluation-based method in conjunction with healing time frames to progress a patient through the protocol based on intraoperative and postoperative findings, clinical presentation, and achievement of clinical goals and milestones. 1. Phase I is the immediate postsurgical, joint protection phase. 2. Phase II is the active range of motion and early strengthening phase. 3. Phase III is the moderate strengthening phase. 4. Phase IV is the independent, progressive home program phase. PHASE I Phase I consists of the immediate postsurgical time from postsurgery 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 recommended that PROM be delayed for
Specifics of physical therapy rehabilitation following reverse TSA Because of the rotator cuff being absent or minimally functional following a reverse total shoulder replacement, the rehabilitation
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