Thursday, January 30, 2020

Ream and Run - the rehab program

The ream and run procedure creates a partnership between the surgeon and the patient. The surgeon's job is to replace the arthritic joint with a prosthetic one that is smooth and stable. The patient's job is to rehabilitate a joint that has been stiff and painful for years prior to the surgery.  As in all partnerships, open-ended communication between the surgeon and patient is essential, in that each person's pattern of recovery is different. Our practice is to provide our patients with a personal email address and to invite them to contact us anytime with questions or with progress reports. These days communication using photos or videos is really helpful in allowing the surgeon to see how things are progressing.

For example, here's a video of a patient one week after his left ream and run
And here is a video of the same patient 10 months after surgery. He did a fantastic job of working up to this gradually with smooth, controlled movements, which is the key to success

Our standard rehabilitation program depends heavily on patient-conducted exercises at home or in the gym. Working with a physical therapist can be helpful, but is often not necessary as long as the shoulder progresses satisfactorily. If you do work with a physical therapist, it continues to be very important that you stay in regular communication with your surgeon. When you email messages/questions to your surgeon, it’s a good idea to include that physical therapist’s email, too.

First 6 weeks

The goal for the first six weeks is to attain this degree of flexion:
Note that progress toward this goal is easily documented by a cell phone photo from the side.If possible, please have someone take a photo like this of you on a weekly basis and email it to your surgeon. It is very helpful in gauging your progress and how things are going with you and your shoulder.

For the first 6 weeks, we recommend five stretching sessions a day lasting 12 minutes each (click on the links for each exercise). That equals one hour per day investment in a solid recovery. The standard program is shown below.

One minute warm up with Forward Elevation: Over Door Pulley
Three minutes of Forward Elevation: Forward Lean
Three minutes of Abduction stretching - the sideways lean
Three minutes of Forward Elevation: Supine
Two minutes of Internal Rotation Lying On Your Side  Please check with your surgeon before implementing this stretch.

We note that some patients really do best with, and prefer, the over door pulley for the stretching, in addition to the ones with a problematic shoulder on the opposite side. Some patients decide to alternate between the 3 methods because they feel somewhat different kinds of stretching from each of them. 

The key to these exercises is muscle relaxation. If the muscles are relaxed, the joint can be stretched effectively.

During the first 6 weeks we encourage daily safe aerobic exercises, such as walking, stair climber, stationary bike, elliptical, and treadmill. If you tend to sweat a lot, you should hold off on vigorous exercises until two weeks after surgery. The bandage needs to be kept clean and dry.

If a full range of motion is not achieved at 6 weeks, we consider a manipulation under anesthesia  with complete muscle relaxation. This is an outpatient procedure which we perform in the recovery  room. The patient is given a two-minute anesthetic during which the surgeon moves the shoulder through a complete range of motion to break up any adhesions that may be restricting motion. Immediately after that, that same day, the 5 sessions of stretching program is restarted. And patients find it much easier to move their shoulders further. There is some soreness from this, but the relief of being much easier to move most always supersedes it. 

Here are some videos of these exercises (see this link).

Second 6 weeks

Stretching exercises do continue on. If it’s been pretty easy to maintain the full motion you’ve gained since surgery, it’s OK to decrease from 5 to 4 sessions per day for a few days. If you find that you are still keeping that great motion with 4 sessions per day, then OK to try decreasing to 3 sessions per day, and so on. However, if when you decrease you find your shoulder feeling stiffer, it’s best to go back to the last higher number of times per day. Some shoulders just take longer to keep their flexibility with less stretching.  Never quit stretching entirely – stretch at least once a day into each direction – just as a check to know that your full motion is still there. Your shoulder has been stiff for a LONG time, so takes some time to help it stay looser.
Assuming the patient has achieved a full range of passive motion, we start gentle progressive strengthening exercises at  6 weeks from the date of surgery.

The key to strengthening is slow, steady progression, making sure that any discomfort from the exercise disappears within 10 minutes after the exercise sessions. In general, any strengthening should not be painful, except for the kind of muscular soreness we have all felt after starting any other kind of strengthening exercise for another body part.

The strengthening exercises are done twice a day. During this time, it is important to do enough stretching exercises to maintain the full range of motion.

Each strengthening exercises should be done with a resistance that allows 20 comfortable repetitions. Once 20 reps are achieved at one level, a bit more resistance can be added.

The most important exercises is five minutes of  Supine Press with Progressive Incline 

This is a good time to add the Rowing Machine Exercise and the Pull Down Bar Exercise 

Water exercises, such as moving the arm gently against the resistance of the water, kicking with the arms on a kick board, and breast stroke can be started at this time.

Keep in mind that while the joint itself is solid, the soft tissues, especially the rotator cuff, are at risk from sudden, heavy or jerky motions. This why gentle steady progression is the key.  !A word of caution about exercises to avoid is shown here.

Three months

At this time, the patient can progress gradually into activities such as swimming, paddling, climbing, and gym workouts.

Gentle throwing can be started at this time.

Here are some additional rehab tips from ream and run superstars 

With persistent effort, some patients have been able to achieve extraordinary levels of function

Bottom line
Remember that the ream and run is a partnership. Ask your surgeon all your questions. If you are concerned about pain, weakness, stiffness, shifting, clicking, popping or what to do next, let the surgeon know. Each patient and each shoulder is unique, so that modifications to this program may be necessary. 

You might enjoy this post on a man's personalized rehab program leading to a highly successful outcome (see this link).

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link)
Shoulder arthritis - x-ray appearance (see this link)
The smooth and move for irreparable cuff tears (see this link)
The total shoulder arthroplasty (see this link).
The ream and run technique is shown in this link.
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).

Shoulder rehabilitation exercises (see this link).

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Note that author has no financial relationships with any orthopaedic companies.