Saturday, March 28, 2015

Rehabilitation after shoulder joint replacement replacement - Cliff Notes



Diligent rehabilitation exercises are a very large part of the success of a shoulder joint replacement.

An example program is described below, but the specifics of the program for each shoulder are determined by the surgeon based on the findings at surgery and the details of the procedure. Note that this type of program is not used after a reverse total shoulder or after a shoulder replacement for fracture.

During the first six weeks after surgery, five stretching exercise sessions per day are needed. The primary goal of these stretching exercises is to gain motion in forward elevation – that is the ability for the arm to move up above your head.

While the muscles of the operated shoulder will not be able to power this motion weeks after surgery, using the other arm for assistance will assure that the necessary stretching takes place. Three methods of forward elevation stretching are shown in these links: Supine Stretch, Forward Lean, and The Pulley. One of these stretches needs to be performed with five repetitions five times spread out through the day. The fifth stretch of each session should be held at the maximal comfortable position for a full two minutes. This allows the muscles to relax so that the tissues around the shoulder can be stretched. This investment is less than one hour per day for optimizing the recovery of your shoulder. The goal is to attain at least 150 degrees of forward elevation; for easy reference, that is a position in which your arm is alongside your ear.

Once 150 degrees of forward elevation is achieved, other exercises can be added such as the Abduction Stretch and the Sleeper Stretch and Reaching Up the Back

At six weeks we usually start gentle strengthening using the Supine Press the Lat Pull and Rowing.

If there are any questions and especially if these exercises cause substantial discomfort, contact your surgical team promptly.

A word of caution about protecting the subscapularis and  exercises to avoid.

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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

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To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Sunday, March 8, 2015

Shoulder joint replacement arthroplasty - types and revisions


These authors analyzed 6336 shoulder arthroplasties entered into the Kaiser Permanente registry between January 2005 and June 2013. Median follow-up time for all primaries was 3.3 years; 461 cases were lost to follow-up by ending of health plan membership. Primary cases were predominantly female (56%) and white (81%), with an average age of 70 years. The most common reason for surgery was osteoarthritis in 60% of cases, followed by acute fracture (17%) and rotator cuff tear arthropathy (15%). In elective shoulder arthroplasty procedures, 200 all-cause revisions (4%) were reported, with glenoid wear being the most common reason.

Revisions were defined as any procedure after the registered index arthroplasty involving the addition, removal or replacement of at least 1 implanted component, so that soft tissue procedures would not be included.

Much of the story can be told by the numbers:






Comment: This is a most impressive overview of a large case series with a very low rate of cases lost to followup.

In interpreting these data it is important to understand that this is NOT a pure comparison of procedures, rather it is a comparison of surgeons electing to perform certain procedures on certain patients with certain diagnoses. We must wonder why surgeons chose to do 818 hemiarthroplasties and 130 resurfacings on patients with osteoarthritis - was it because they were not comfortable with their ability to do a total shoulder in these cases, because the patient did not want a glenoid, or because the surgeon thought the patient had involvement of the humeral side of the joint only (a rarity in glenohumeral arthritis). In any event, we must conclude that there was something different about these cases from those receiving total shoulder arthroplasty. This may explain why there was such a high revision rate for "glenoid wear" following hemiarthroplasty or resurfacing (27% of all revisions). Among elective hemiarthroplasties, the revision rate was 6% with glenoid wear as the reason for revision in 52% of cases, while the revision rate following TSA in particular was only 2%. It is of note that resurfacing arthroplasties had by far the highest revision rate.

So...these investigators have a wonderful opportunity to explore the "4P" factors associated with the need for revision: (1) the problem (diagnosis, the preoperative pathoanatomy of the shoulder), (2) the physician (surgeon identity, training, age), (3) the patient (age, gender of the patient, co-morbidities), and (4) the prosthesis used. In addition, as the authors were careful to point out that implant survival alone fails to capture patients with under performing shoulder arthroplasties who simply decline revision surgery. Thus it is possible that older individuals would be less likely to elect revision even if the outcome of their surgery was unsatisfactory. 





Tuesday, March 3, 2015

How do revised shoulders that are culture positive for Propionibacterium differ from those that are not?

This article presents the investigation of 132 shoulders undergoing surgical revision of a prior shoulder arthroplasty, comparing the 66 that were culture positive for Propionibacterium to the 66 that did not culture out this organism.

The authors' goal was to identify preoperative and intraoperative characteristics that may alert surgeons to an increased likelihood of positive cultures. This is important because while many shoulder arthroplasties revised for pain, stiffness, or component loosening are culture positive for Propionibacterium, the results of these cultures remain unknown until days or weeks after surgery - too late to inform intraoperative surgical decisions and immediate postsurgical antibiotic treatment. 

The authors found that Propionibacterium-positive and Propionibacterium negative shoulders were similar with respect to many characteristics; however, Propionibacterium negative shoulders were revised sooner after the index procedure and were significantly more likely to be female, to have sustained a fall, to have instability, and to have rotator cuff deficiency. Propionibacterium-positive shoulders demonstrated more glenoid erosions, glenoid osteolysis, glenoid loosening, and a higher incidence of a soft tissue membrane between the humeral component and humeral endosteum. Shoulders culture positive for Propionibacterium were more likely to be culture positive for another bacteria, such as coagulase negative Staphylococcus.

A characteristic picture of Propionibacterium  infection is the onset of stiffness, pain, loosening and / or osteolysis after a 'honeymoon' of good function following a shoulder arthroplasty, especially in a male patient. Such shoulders may merit multiple deep cultures at the time of revision surgery and consideration of aggressive surgical and medical treatment.

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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

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To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Monday, March 2, 2015

Ream and run: rehabilitation tips from the super stars #18, #19 and #20

We've invited some of the folks who have done a great job of their rehabilitation after a ream and run to share their tips. There are many many more, but we'll conclude for now with these three. We hope these descriptions are helpful in conveying on one had the dedication involved in the recovery from the ream and run and on the other hand the great results that this dedication can produce.

Here's #18

Thank you for the Ream & Run procedure. I'm doing everything I want to and most importantly, doing the activities pain free. Although I'm 71 , I'm extremely active - road biking, handball, backpacking, swimming and still functioning as a pediatric dentist . The three words that best describe why I'm where I'm are patience, discipline and dedication. The healing process is long and you need to be patient and not become discouraged during the recovery. It requires lots of discipline to perform all the exercises when you sometimes don't think you're improving whatsoever. There are numerous plateaus in the total recovery process. Finally, you have to be dedicated and commit to a lifetime of exercises to maintain strength and range of motion to insure continual health of the shoulder. I know looking back it was worth it. I'm living life on my terms at least in regards to my shoulder.

JS
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Here's #19

Upon returning home from UW we followed the Physical Therapist instructions. My  raised my arm to 180 degrees at least twice daily. After a month or two I was able to do it by myself. Every morning after breakfast I would lay on my back & raise my arm to 180 degrees. As I gained strength I added weight. I kept this up for 2 years & now am able to do anything especially golf & work with no pain even to this day. My advice to anyone considering this surgery is to do the therapy religiously for best results.

RB

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Here's #20

First and most importantly was the incredible skill and surgical experience that ha been brought to the mechanics of the operation. Without that, whatever I did would have had a lesser outcome or no significant improvement of my greatly deteriorated shoulder. The skill of the repair was tantamount to the success because it created the platform for what I could do to build on that perfect foundation and rehab the shoulder.

Pain management was also a crucial component. Aggressive management of the initial trauma enabled me to meet the immediate movement protocols. I was not prepared to begin rehab within an hour from being moved out of recovery, but pain management gave me the confidence to embrace what was requested and stay with that protocol throughout my stay at the hospital. Same for my recovery and rebuild at home- not pain free, but manageable so I could engage all the exercises- initially using the cable raise, then self-assisted movement to about 150+ degrees overhead. By the way, that was a move that had caused partial dislocation prior to surgery and a position that required no small of measure of mental "bracing" to engage in.

The single element that allowed me to succeed in this replacement is simply this: I believed I had the best surgical team available; I followed every direction and completed all rehab instructions and religiously logged completion of every exercise and the time of exercise provided by the world-class physical therapy team at the medical center. Believe, Trust and Do. When it hurts- push through. It was amazing to me, that the initial prescription for oxycodone appeared to me running out before my followup exam, so I called for a refill, which arrived in the mail (paper Rx) just three days before my return to the office. I still had a couple doses left, so I filled that Rx on my visit. Because the recovery had caught up with the pain threshold, I no longer needed the oxy and could manage on the Tylenol alone. That prescription remained sealed with the red tape until I flushed it a couple of months later. The rehab protocol had taken me from surgical recovery to pain free, not even tylenol needed, by mid-November (merely 60 days). From my perspective, that's nothing less than amazing and it has changed my life. I am most thankful and appreciate everything you and your team have done to give me a pain-free life back.

RO

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Again, this is a small sample of the rehabilitation tips we have received from the many superstars. Hopefully these experiences expressed in the words of the patients is informative.


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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

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To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Sunday, March 1, 2015

Ream and run: rehabilitation tips from the super stars #16 and 17

We've invited some of the folks who have done a great job of their rehabilitation after a ream and run to share their tips.

Here's #16:

The success for me in being able to use my shoulders without restrictions is due to many factors. The following are my opinions on what makes for success:

-The surgeon in charge of the procedure
-The team (dedicated and motivated to make the surgery successful)
-Beginning physical therapy while coming out of anesthesia
-The motivation and determination of the patient
-The team's analysis of the situation before the event to determine if the patient is up to the challenge to do what it takes to make the procedure successful
- For me, I had to endure discomfort and to know that was part of the process; -My belief in what I needed to do and my desire to make that happen was a motivating factor to keep going -- I knew there would be a silver lining.
- Consistency and repetition. Every day keep the body parts going and religiously go through the therapy and exercises and never stop.
-I feel when you take this surgery on, fitness, movement and the motivation to use your shoulders without pain means to do what it takes to keep that going for as long as you live. This is not a short time commitment. In order to make that happen, I was more than willing to practice my shoulder therapy exercises every day - which I continue to do and believe is what has helped make this successful.
- To this day, I keep pushing the envelope because I feel stronger and my shoulders are handling the load. I always ask on my return visits if I'm doing too much and how far can I go.
- I do practice some levels of scrutiny regarding how much weight I am lifting.
- I just keep doing the fundamental therapy every day, and stay active working out. My saying "monotonous repetition of fundamental skills makes champions of us all."
- I am constantly thankful for the life this procedure has given back to me.
- Bottom line is the incredible team inspiring confidence in the patient, believing in the surgeon, and having a strong desire to make it work.

BH

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and #17

I didn't know if you or any fellow ream and runners might find helpful a few personal rehabilitation observations.

ICE...To reduce inflammation and discomfort, I kept 4-5 small reusable ice packs (5/9in) in the freezer, at all times.
For the first three months they were used for pain, after stretching, and when going to bed. After that, they were used after strengthening routines as well as after visiting the physical therapist.

ROPES VS FLOOR FOR STRETCHING....Initially, I found it very beneficial to do both. After I had pretty decent range of motion, with the ropes I found it difficult to improve without creating a pulling motion. At this point, I switched entirely to the floor. After floor stretching, my shoulder was less sore and recovered quicker.

ROTATOR CUFF PRECAUTIONS.....What I've learned about rotator cuff muscles has come at the expense of an injury during rehabilitation. Before surgery, I had routinely done bar dips in the weight room. At 15 months, my shoulder was doing great and it felt pretty much 'bullet proof'......or so I thought. Unfortunately, all it took was one simple bar dip to change things. Although not a complete tear, it was a major setback. If one looks at the recovery time chart (http://shoulderarthritis.blogspot.com/2011/03/sst-in-tracking-recovery-after-shoulder.html), it is very understandable why -  from disuse and surgery -  the cuff muscles are the last muscles to become strong again. Maximum recovery is not reached until the 30th month or 2 1/2 years. I didn't believe it then, but I do now. Be aware of exercises prone to cause rotator cuff injury: 
   1. With cuff muscles, it is also important for many months not to make any quick movements. The affected arm is weak and it is easy to drop something, accidentally. Don't instinctively reach to catch anything or you'll know it in a hurry.
2. Be careful too, getting in and out of cars. Wearing the sling is a good idea for the first 6 weeks.
3. FALLS...Be careful walking, jogging, going out after dark, climbing stairs, etc. At 4 months, I was looking for a workout and was slowly running stairs for exercise. I slipped and automatically started to catch myself on the steps. For a brief moment my shoulder lit up like 4th of July. End of workout. I dodged a bullet...just barely.

All of us feel a great debt of gratitude for this procedure. The surgery has helped us regain our active and pain free lifestyles. We all know the importance of daily stretching and maintenance. With all the time and effort that we have invested, it is our responsibility to keep our shoulders healthy. With this in mind, and with a good physical therapist, it is imperative to develop a personal maintenance program that one can stick with for the rest of our lives and most importantly, injury free. It's a small price to pay. During rehabilitation it's often hard to be patient, but now I've learned that it's not a race, either.

TF

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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

Click here to see the new Rotator Cuff Book

To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'




Saturday, February 28, 2015

Ream and run: rehabilitation tips from the super stars #15

We've invited some of the folks who have done a great job of their rehabilitation after a ream and run to share their tips.

Here's #15:

For months 0-3, I did the exercises you gave me religiously. I would do the shoulder stretch using a table and then the rope and pulley stretches 6 times a day. Sleeping was a little rough but not bad. There were times where I would wake up with pain and just go do my stretches. Please warn future patients that each time you do your stretches it feels like you have never done them before. It can seem like your shoulder will never get better and that the painful stretches you just went through 2-3 hours earlier had no benefit. But day by day, things slowly get better. One thing that really helped me was doing exercises in the pool. The water gives you both support and resistance. I was able to do things in the pool with my shoulder that I could not do outside the pool. It served both to steadily strengthen my shoulder in many different planes of movement and to provide encouragement in knowing that one day I would have the same functionality outside the pool. At one month, I was finally seeing significant improvement. On the exact 3 month anniversary of my shoulder surgery, I was able to lift my arm completely vertical over my head for the first time.


Months 3-6 were also pretty difficult but I think I was pushing too hard. My goal was to be back to 90% by 6 months but since my range of motion had been so limited for so long, I think I should have been more patient. As a result, I had a couple of set-backs with rotator cuff muscle strains but the joint has never had an issue. At that point I had a couple of appointments with different physical therapist down here in So CA. I learned from both of them to be more patient with my progress. The soft tissue in my shoulder had atrophied significantly over the past 15 years and even though some of the stronger muscles of the shoulder were ready to go, I really had to focus on doing the rotator cuff muscles exercises (doing the colored rubber band stuff) and rotator cuff stretches.


I also would like you to re-enforce to prospective patients that they have to commit 100% to rehab. You actually have to like it and must be persistent! Interesting that many of your survey questions ask about depression since I can see going through rehab does have its ups and down, but if you keep a long term focus, the progress you make can definitely put a bounce in your step. Rehab can actually give one a purpose and a break from life’s sometime same old routine. I think it is helpful to set goals (3 month, 6 month, 12 month goals) and have a final picture in your mind of how you want things to be. Also, try to measure your progress through a journal or even a video journal.

The key is to be both patient and persistent! And “YES” it was well worth it for me. One of the best decisions in my life.

SS
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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

Click here to see the new Rotator Cuff Book

To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Friday, February 27, 2015

Ream and run: rehabilitation tips from the super stars #13 and 14

We've invited some of the folks who have done a great job of their rehabilitation after a ream and run to share their tips.

Here's #13

In terms of various shoulder replacement choices, like automobiles... I tend to think of Ream and Run as the premium, heavy-duty, long lasting, high performance model. As I look back now, coming for Ream and Run was one of the best decisions I've ever made. After initial surgery the outcome is very much dependent upon the patient. Any potential candidate must have the proper mindset ahead of time. You really have to 'earn' a successful result. An excellent recovery is not a given, nor is it fast and easy. For anyone considering Ream and Run, rehabilitation takes a stern commitment, dogged perseverance, and enormous patience. Stretch, stretch, and stretch some more. Latch on to a really good physical therapist. Strengthen gradually but prudently and then stay on a conscientious maintenance program. Fortunately, these days whether playing handball, body surfing, doing push-ups, or starting to do pull-ups again....it's all been well worth it.

TF
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and #14

Happy to send along a few thoughts on outcome of my shoulder(ream and run) surgery. Throughout the process I was struck with the notion that I was being cared for by a team of providers that worked closely with each other and communicated frequently about my surgery and recovery. I was diligent about the physical therapy and was impressed with the two therapist that I meet with twice weekly. What helped me through the process(aside from being a bit compulsive) was the post op physical therapy routine. One can't imagine how difficult it is to hold a position for a three minute stretch for 3 to 6 reps only to find out that you have more than one stretch to do at each session(recommended three times daily). What finally really worked for me was to take the pain meds 30 minutes before each stretching session. While the sessions were still painful( and I think I have a fairly high pain tolerance) the meds allowed me to push myself farther than I would have without the pain medication. This and the discovery that my new phone had a timer i could set and watch as the seconds slowly approached the 3 minute mark.

I with be forever thankful for the improvement in my quality of sleep and enjoyment of physical activities.

GE

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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

Click here to see the new Rotator Cuff Book

To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'