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SHOULDER ARTHROPLASTY/HEMIARTHROPLASTY
PHYSIOTHERAPY LED POST OPERATIVE SHOULDER CLINIC COMPILED BY: TENDAYI MUTSOPOTSI BSc. HPT (Hons) MSc. ORTHO-MED MCSP MSOM APPROVED BY: MR ANDREW SANKEY ORTHOPAEDIC CONSULTANT SURGEON

Total Shoulder Arthrosplasty Protocol 2010: Tendayi Mutsopotsi (Specialist Shoulder Therapist)

Total Shoulder Arthroplasty/Hemiarthroplasty Protocol


The purpose of this protocol is to provide the physiotherapist with a guideline for the post- operative rehabilitation course of a patient that has undergone a Total Shoulder Arthroplasty (TSA) or Hemiarthroplasty (Humeral Head Replacement, HHR). It is not intended to be a substitute for appropriate clinical decisionmaking regarding the progression of a patients post-operative course. The actual post surgical physiotherapy management must be based on the surgical approach, physical examination/findings, individual progress, and/or the presence of post-operative complications. If a physiotherapist requires assistance in the progression of a post-operative patient they should consult with Mr. Andrew Sankey (Shoulder Consultant) or Mr. Tendayi Mutsopotsi (Specialist Shoulder Therapist). Please Note: Those patients with a concomitant repair of a rotator cuff tear and/or a TSA/HHR secondary to fracture should be progressed to the next phase based on meeting the Clinical Criteria (not based on the post-op time frames) as appropriate in collaboration with Mr. Andrew Sankey.

Phase I Immediate Post Surgical (0-4 weeks):


Goals: Allow healing of soft tissue Maintain integrity of replaced joint Gradually increase passive range of motion (PROM) of shoulder; restore active range of motion (AROM) of Elbow/Wrist/Hand Diminish pain and inflammation Prevent muscular inhibition Independent with activities of daily living (dressing, bathing, etc.) with modifications while maintaining the integrity of the replaced joint.

Precautions: Sling should be worn for 3 weeks for comfort Sling should be used for sleeping and removed gradually over the course of the four weeks, for periods throughout the day. While lying supine a small pillow or towel roll should be placed behind the elbow to avoid shoulder hyperextension / anterior capsule / subscapularis stretch. Avoid Shoulder active range of motion. No lifting of objects No excessive shoulder motion behind back No excessive stretching or sudden movements (particularly external rotation) No supporting of body weight by hand on involved side

Total Shoulder Arthrosplasty Protocol 2010: Tendayi Mutsopotsi (Specialist Shoulder Therapist)

Keep incision clean and dry (no soaking for 2 weeks) No driving for 3 weeks

Criteria for progression to the next phase: Tolerates PROM program at least 90 degrees PROM flexion At least 90 degrees PROM abduction. At least 45 degrees PROM ER in plane of scapula At least 70 degrees PROM IR in plane of scapula Be able to biometrically activate all shoulder, RC, and upper back musculature

Postoperative Day 1 (in hospital): Passive Forward Flexion in supine to tolerance ER in scapular plane to available gentle PROM (as documented in Operative Note) usually around 30 degrees. (Attention: DO NOT produce undue stress on the anterior joint capsule and subscapularis particularly with shoulder in extension) Passive internal rotation to chest Active distal extremity exercise (Elbow, Wrist, Hand) Pendulums Frequent cryotherapy for pain, swelling and inflammation management Patient education regarding proper positioning & joint protection techniques

Postoperative Days 2-10 (out of hospital) Continue above exercises Assisted flexion and abduction in the scapular plane Assisted external rotation Begin sub-maximal, pain-free shoulder isometrics in neutral Begin scapula musculature isometrics / sets Begin active assisted Elbow ROM Pulleys (flexion and abduction) as long as greater than 90 degrees of PROM Continue Cryotherapy as much as able for pain and inflammation management

Postoperative Days 10-21: Continue previous exercises Continue to progress PROM as motion allows Gradually progress to AAROM in pain free ROM Progress active distal extremity exercise to strengthening as appropriate Restore active elbow ROM

Total Shoulder Arthrosplasty Protocol 2010: Tendayi Mutsopotsi (Specialist Shoulder Therapist)

Phase II Early Strengthening (Weeks 3-6):


Goals: Continue PROM progression/ gradually restore full passive ROM Gradually restore Active motion Control Pain and Inflammation Allow continue healing of soft tissue Do not overstress healing tissue Re-establish dynamic shoulder stability Precautions: Sling should be used as needed for sleeping and removed gradually over the course of the next two weeks, for periods throughout the day. While lying supine a small pillow role or towel should be placed behind the elbow to avoid shoulder hyperextension / anterior capsule stretch. Begin shoulder AROM against gravity. No heavy lifting of objects (no heavier than coffee cup) No supporting of body weight by hands and arms No sudden jerking motions

Criteria for progression to next phase: Tolerates P/AAROM, isometric program Has achieved at least 140 degrees PROM flexion Has achieved at least 120 degrees PROM abduction Has achieved at least 60+ degrees PROM ER in plane of Scapula Has achieved at least 70 degrees PROM IR in plane of Scapula Be able to actively elevate shoulder against gravity with good mechanics to 100 degrees. Week 3: Continue with PROM, AAROM, Isometrics Scapular Strengthening Begin Assisted Horizontal adduction Progress Distal Extremity Exercises with light resistance as appropriate Gentle Joint Mobilizations as indicated Initiate Rhythmic stabilization Continue use of cryotherapy for pain and inflammation. Week 4: Begin Active forward flexion, internal rotation, external rotation, and abduction in supine position, in pain free ROM Progress scapular strengthening exercises Wean from Sling completely Begin isometrics of rotator cuff and peri-scapular muscles

Total Shoulder Arthrosplasty Protocol 2010: Tendayi Mutsopotsi (Specialist Shoulder Therapist)

Phase III Moderate strengthening (week 6-12):


Goals: Gradual restoration of shoulder strength, power, and endurance Optimize neuromuscular control Gradual return to functional activities with involved upper extremity

Precautions: No heavy lifting of objects (no heavier than 5 lbs.) No sudden lifting or pushing activities No sudden jerking motions

Criteria for progression to the next phase (IV): Tolerates AA/AROM Has achieved at least 140 degrees AROM flexion supine Has achieved at least 120 degrees AROM abduction supine. Has achieved at least 60+ degrees AROM ER in plane of Scapula supine Has achieved at least 70 degrees AROM IR in plane of Scapula supine Be able to actively elevate shoulder against gravity with good mechanics to least 120 degrees.

WEEK 6:

Increase anti-gravity forward flexion, abduction as appropriate Active internal rotation and external rotation in scapular plane Advance PROM as tolerated, begin light stretching as appropriate Continue PROM as need to maintain ROM Initiate assisted IR behind back Begin light functional activities

WEEK 8 Begin progressive supine active elevation (anterior deltoid strengthening) with light weights (1-3 lbs) and variable degrees of elevation. WEEK 10-12: Begin resisted flexion, Abduction, External rotation (therabands/sport cords) Continue progressing internal and external strengthening Progress internal rotation behind back from AAROM to AROM as ROM allows (pay particular attention as to avoid stress on the anterior capsule.)
Total Shoulder Arthrosplasty Protocol 2010: Tendayi Mutsopotsi (Specialist Shoulder Therapist)

Phase IV Advanced strengthening (weeks 12 to 6 months):


Goals: Maintain full non-painful active ROM Enhance functional use of UE Improve muscular strength, power, and endurance Gradual return to more advanced functional activities Progress closed chain exercises as appropriate. Precautions: Avoid exercise and functional activities that put stress on the anterior capsule and surrounding structures. (Example: no combined ER and abduction above 80 degrees of abduction.) Ensure gradual progression of strengthening.

Criteria for discharge from skilled therapy: Patient able to maintain full non-painful active ROM Maximized functional use of upper extremity Maximized muscular strength, power, and endurance Patient has returned to more advanced functional activities

WEEK 12+: Typically patient is on just a home exercise program by this point 3-4x per week. Gradually progress strengthening program Gradual return to moderately challenging functional activities.

4-6 months Return to recreational hobbies, gardening, sports, golf, and doubles tennis Return to functional activities Driving from 4 weeks Swimming Breaststroke: 6weeks, Freestyle: 12 weeks Golf from 3/12 Lifting Light lifting from 3 weeks. Avoid heavy lifting for 6/12 Work Sedentary job: 6weeks Manual job: as guided by Surgeon

Total Shoulder Arthrosplasty Protocol 2010: Tendayi Mutsopotsi (Specialist Shoulder Therapist)

Milestones Week 3: 50% of pre-op active ROM Week 6: PROM to at least pre-op level Week 12: AROM to at least pre-op level
Milestone driven These are milestone driven guidelines designed to provide an equitable rehabilitation service to all of our patients. They will also limit unnecessary visits to the outpatient clinic here at Chelsea & Westminster by helping the patient and therapist to identify when specialist review is required. If patients are progressing satisfactorily and meeting milestones, there is no need for them to attend clinic routinely. Failure to progress or variations from the norm should be the main reason for clinic attendance. Both patients and therapists can book clinic visits by contacting the numbers given further on in this document. Clinic follow-up schedule post-op: 2, 6, 12, 16-24 weeks (only if necessary) Failure to meet milestones: 1. Refer to/discuss with Shoulder and Elbow Unit 2. Consider possible reasons for failure to progress and act accordingly 3. Continue with outpatient physiotherapy while patient is still making progress
Total Shoulder Arthrosplasty Protocol 2010: Tendayi Mutsopotsi (Specialist Shoulder Therapist)

Failure to progress If a patient is failing to progress, then consider the following: Possible problem Pain inhibition Action Adequate analgesia Keep exercises pain-free Return to passive ROM if necessary until pain controlled Progressing too quickly hold back If severe night pain/resting pain refer to Shoulder Unit Patient exercising too vigorously Increase or reduce physiotherapy/ Patient not doing home exercise (HEP) (max 2-4x/day) for few programme (HEP) regularly enough days/weeks and assess difference Ensure HEP focuses on key exercises and link to function Returned to activities too soon Decrease activity intensity Cervical/thoracic pain referral Assess and treat accordingly Unable to gain strength Passive ROM may need improving Altered neuropathodynamics Assess and treat accordingly Poor rotator cuff control Ensure passive range gained first Consider isometrics through range Rotation dissociation through range with decreasing support and increasing resistance Ensure not progressing through Therabands too quickly Poor scapula control Work on scapula stability through range without fixing with pec major/lat dorsi Poor core stability Work on improving core stability Secondary frozen shoulder Maintain passive ROM as able Use physiological and accessory mobilisations, taking into account end feel and tissue healing times

THE SHOULDER UNIT TEAM Shoulder Consultant: Mr. Andrew Sankey 0208 746 8545 Shoulder Therapist: Mr. Tendayi Mutsopotsi 0208 746 8404 Secretary: 0208 746 8545

Total Shoulder Arthrosplasty Protocol 2010: Tendayi Mutsopotsi (Specialist Shoulder Therapist)

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