Sunday, May 31, 2015

Shoulder joint replacement - postoperative rehabilitation

It is helpful for patients and for the entire care team to standardize the postoperative program as much as possible. While variations may be needed for special circumstances, we describe the program we usually use for hemiarthroplasties, CTA prostheses, ream and run procedure and total shoulder arthroplasties. Our philosophy is early ambulation, early shoulder motion and early transition to oral analgesics. A sling is used only for comfort or support when necessary. The patient is encouraged to use the arm for gentle activities, such as eating, keyboarding, and squeezing a foam ball.

The rehabilitation goal is 150 degree range of assisted elevation prior to hospital discharge. We emphasize that the patient must accept responsibility for the success of the rehabilitation program. Patients are given access to a website with videos of the key exercises. The exercise program is started immediately after surgery in the recovery room with the initiation of slow and gentle continuous passive motion for 30 minutes each hour.

CPM is avoided in arms that are large and heavy, when there is concern about the strength of the subscapularis repair, or when there is concern for aggravating a carpal tunnel syndrome by the pressure from the gauntlet. The patient-conducted rehabilitation program is started on the day of surgery under instructions given by the surgeon or therapist. Elevation stretching is performed in the supine position (lying flat on the back) by grasping the wrist or elbow of the relaxed operative shoulder with the hand of the unoperated arm, pulling up toward the ceiling, and then reaching overhead as high as possible towards the goal of 150 degrees. The stretch is most effective if the patient relaxes the shoulder muscular while holding the position for two minutes. The pulley and the forward lean are also very useful, particularly if the opposite upper extremity is not healthy. Passive external rotation stretching is restricted to zero degrees initially. Daily range of elevation as measured by the surgeon or therapist is displayed on a wall chart in full view of the patient, staff and visitors to provide the patient with feedback on their rehabilitation progress. Because the desired range was achieved while the patient was on the operating table, the patient’s task is simplified: the achieved range has only to be maintained during the postoperative period. It is important to warn the patient that the arm may swell during the first week after surgery (as shown below) but this usually subsides by the second week and should not deter the performance of the range of motion exercises.

The exercises are to be performed five times a day both while the patient is in the hospital and at home after discharge.

At six weeks after surgery while the assisted elevation program is continued, we add stretching in abduction,  the sleeper stretch, cross body adduction, internal rotation up the back and gentle external rotation .

Strengthening exercises are also started at 6 weeks. The most important of which is the two-hand supine press series which is progressed to the press plus with a one pound weight, starting in the supine position and progressing to increasingly vertical positions, adding the ‘press plus’ at the top of each exercise. This exercise along with the shoulder shrug helps develop the scapular musculature. We indicate that these strengthening exercises should be repeatable 20 times comfortably before advancing to more weight or a more upright position. Slow, steady progression is the goal. In most cases we avoid strengthening exercises that isolate the cuff muscles to minimize the risk of delayed cuff failure. Activities are added progressively. We allow driving and gentle water exercises at 6 weeks. Golf and tennis may be started at 3 to 6 months if the shoulder is comfortable, flexible, and strong. Impact activities, such as chopping wood, are precluded for total shoulders but are permitted for the ream and run once the patient has achieved a good range of motion, comfort, and strength.

Because a successful rehabilitation is critical to the outcome of shoulder arthroplasty, we encourage patients to give us regular progress reports and to feel welcome to contact us by email if there are questions or concerns. A most effective way to monitor range of motion progress is to ask the patient to email a lateral photograph with the arm in maximal elevation.

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