SHOULDER ARTHROPLASTY REHABILITATION

Purpose:

To guide patients through the pre-operative, acute and sub-acute phases rehabilitation associated with the Shoulder Arthroplasty (SA), in an effort to assists the patient in becoming functionally independent following surgery.

Indications:

Patients who are considering or who have undergone Shoulder Arthroplasty.

Contraindications:

Any medical, surgical or post-operative complication as stated by the attending physician.

Physical Therapy Goals:

Pre-Operatively:

Explanation of the role of physical therapy in SA rehabilitation.
Discussion/Agreement on physical therapy goals following SA.
Instruction and demonstration of post-operative physical therapy procedures/treatments (i.e. dislocation precautions, functional limitations, exercise regimen)

Acute:

Early range of motion of the shoulder with progression toward functional range of motion, (per surgeon’s restrictions), limited only by the prosthetic design and the patient’s potential.
Maintenance/Improvement of muscle tone in the operative shoulder.
Muscle strengthening of the shoulder girdle, as possible.

Sub-Acute (Post-Discharge):

Achieve maximal functional shoulder range of motion, as allowed by the prosthetic design and limited only by the patient’s potential.
Muscle strengthening of the shoulder girdle on the operative extremity. Attention should also be directed toward any weakness present in the upper quadrant of the operative extremity.

Proprioceptive training to improve body/spatial awareness of the operative extremity in functional activities.
Endurance training to increase cardiovascular fitness.
Functional training to promote independence in Activities of Daily Living.

Physical Therapy Rehabilitation Guidelines:

Milestones for patient Progression:

Patients are discharged from the hospital wearing an arm sling on the operative extremity at all times except during therapy sessions. Patients are encouraged to gradually decrease the amount of time wearing the arm sling over the first 2 weeks post-discharge unless stated otherwise by their therapist or physician.
Discharge from the acute care setting approximately 2 days post-operative.
Discharge from the sub-acute care physical therapy program to independent home exercise program when the patient achieves “functional” range of motion in the operative shoulder.

Restrictions:

· External rotation limitations of the operative shoulder per surgeon.
Dr. Limbird – shoulder ER to neutral only for 6 weeks.
Dr. McCarty – shoulder ER to 20° initial 6 weeks.
Dr. Obremskey – shoulder ER allowed to limit of subscapularis repair, as ordered by surgeon; generally 40° ER allowed first 6 weeks.

· No use of free weights on the operative shoulder for six (6) weeks.

· No weight bearing on the operative extremity for 6 weeks post-operatively.

· No lifting of any objects weighting more than ½ to l pound using only the operative arm for six (6) weeks; afterwards, never lift objects weighing more than 5-10 pounds using only the operative extremity.

Treatment Parameters:

Forward Elevation/Flexion of the shoulder is always performed in the plane of the scapula (~30 – 40 degrees of Abduction).

Pre-Operative:

Participation in educational class on Shoulder Arthroplasty. Material covered in this class includes discussion of normal abnormal shoulder joint anatomy, components of shoulder prosthesis, intra-operative complications and preventive measures, admission procedures for Vanderbilt Medical Center, post-operative rehabilitation, and discharge needs.
Pre-operative physical therapy assessment at time of educational class. This session includes a baseline assessment of joint range of motion, muscle strength, mobility and functional status in Activities of Daily Living.
Discharge planning initiated regarding physical therapy after hospital discharge and home care needs.

Acute Care (In Hospital):

Treatment protocols instituted day of surgery with efforts to achieve discharge 2 days after surgery.

Day of Surgery:

Check shoulder positioning, the operative extremity will be placed in a specialty shoulder sling.
Initiate ipsilateral hand and wrist active exercises in the sling. Encourage the patient to perform these exercises every two (2) hours while awake.
Begin assisted bed-to-chair transfers, supporting the operative extremity/sling on pillows while sitting bedside with nursing staff assistance.

Post-Operative Day 1:

Check shoulder positioning in sling; this sling is to be worn at all times when upright, removed for therapy sessions.
Continue ipsilateral hand and wrist exercises.
Initiate CPM to the operative shoulder if appropriate, based upon discussion with the attending surgeon. The CPM is to be used during daylight hours only 2-3 hours/day.
Initiate Codman and Pendulum exercises of the operative shoulder
Begin supine active-assisted range of motion exercises to the operative shoulder/extremity within specific surgeon restrictions of ER. Initiate humeral head depression shoulder shrugging, and scapular retraction exercises. Ice/cold therapy should be applied to the shoulder after exercise session.
Ambulate ad-lib as tolerated.
Review precautions and functional restrictions.

Post-Operative Day 2 – Discharge:

Continue comprehensive exercise program with emphasis on increasing shoulder range of motion in the operative extremity.
Initiate isometric exercise to the operative shoulder girdle. These may be performed in supine or standing.
Begin supine cane/wand exercises.
Review home instructions/exercise program.
Finalize discharge plans/ all patient’s require follow-up physical therapy (preferably outpatient visits).

Sub-Acute Care:

Patients who have acutely undergone Shoulder Arthroplasty are strongly encouraged to receive follow-up physical therapy services in an outpatient clinic setting. However, due to transportation limitations, support services and/or functional limitations, this may not be a feasible option. In these situations, the multidisciplinary team will, prior to discharge from the acute care setting, make arrangements for the patient to receive physical therapy services either in the home, extended care facility, or sub-acute facility. Within each of these settings, a comprehensive treatment program should be implemented based upon each patient’s individual needs and within established therapy restrictions. Suggested physical therapy treatment/activities are listed below:

Modalities for Pain Control, Edema Reduction, Etc.:

Moist Heat
Galvanic Stimulation
TENS
Interferential
FES
Ice

Therapeutic Exercise:

Passive, Active-Assisted, Active shoulder/upper extremity range of motion - some patients may be limited to no External Rotation of the operative shoulder for six (6) weeks post-op
Contract/Relax exercises
Joint Mobilization to the shoulder girdle.
Closed Kinetic Chain Activities – maybe initiated at six (6) weeks post-operatively
PNF (upper extremity patterns) – with and without manual resistance
Upper extremity strengthening exercises using theraband
Shoulder pulley- flexion and abduction movements
Wand/Cane exercises
Codman’s/Pendulum exercises
Aquatic therapy/Activities
Upper Extremity Restorator
Activities of daily Living Training/Activities
Reverse Codman’s Exercises

Endurance:

UBE
Upper and/or Lower Extremity Restorator
Treadmill
Ambulation Activities
Stationary Biking
Aquatic Therapy

Proprioception Training:

Closed Change Exercises/Activities – 6 weeks post-op
Ball Activities
Upper Extremity Weight Shifting Activities – 6 weeks post-op

Functional Training:

Basic Intermediate ADL
Reaching
Lifting
Carrying
Pushing
Return- to-Work Tasks
Sport Tasks

Revised: 3/2/03