Etiology and Weslca! Management Donde atecrer wet te teeter Sa ee ee SS eae Sahimcn stem amermconte Hocyeciedinemesonmaecs ates pean, Fegan inca seseecipeeet 1858 [Selita ws earaternry nl pcm nS afr SE iron antiogpe eet st Fearne lon easyer ‘Special Considerations for Shoulder Joint Replacements oor poten fects cepts epee ihe Seca ee nets ae 1859sree eter eh centages ‘ih the upper cre ton (with the humeral Read approximated in the leno foray [prteipte in ay restive acfiiies in infernal or extemal rotator, When sleeping pillow or {evel rll should be placed under the scapula or elbow ax needed for comfort to enaute thatthe shoulder in support in the font ofthe Bod ana n adherence to the preautions (Box 403) Box 40.3 Total Shoulder Replacement Precautions No weight bearing rough surgical upper extremity ‘No litg more han 102s wih surgical upper extreaity ‘Avoid shoulder entension past mera ‘Avoid shoulder abduction pat 5 degree Avold shoulder estemal rotation past 30 dagress ‘Avoid intel rotation past 60 degrees Limit shoulder PROM in exion to approximately 90 10 degreesEvaluation and Intervention Following the occupational profile, an assessment of the motor, cognitive, social, and emotional factors is recommended, specifically as they relate to occupational performance. Upper extremity. assistive range of motion (AROM) and muscle strength can be tested in joints of the elbow, wrist, ‘and hand. However, movement, weight bearing, and resistance precautions must be observed in the shoulder in the postoperative phase. Only gentle, controlled passive range of motion (PROM) should be conducted in all shoulder movements: Sensory function and coordination aze assessed distally as well, although analgesics inserted through joint or epidural catheters may mask sensory abilities for a few days after surgery. Mental functions such aé memory, problem solving, and ‘sequencing must be considered in light of precautions, safety awareness, and performance of ‘occupations. Activities of daily living and other relevant occupations should be evaluated through standardized assessments, direct observation, or interview as the context and client condition allow. Social or emotional concerns may include feat of participation in appropriate therapeutic exercise, hesitation to resume normal activities, or concerns about surgical healing, OT intervention planning will focus on the following two primary areas: (I)appropriat® therapeutic exercise and resuming normal occupations and (2) primarily routines involving activities of daily living and instrumental activities of daily living. Therapeutic exercise must be designed to promote controlled movement within precautions so that eventual return of full upper extremity function is possible, ‘Occupations may need to be ‘modified during healing to promote the client's active participation while advancing shoulder use appropriately. Performance in both of these areas will be used to determine discharge planning and ‘consideration of inpatient rehabilitation or home and outpatient care. Therapeutic Exercise Considerations Total Shoulder Replacement In the immediate postoperative phase, patients are permitted to perform active assistive range of ‘motion (AAROM) and PROM only of the shoulder in protected ranges. Passive range of motion is typically limited to 90 degrees of shoulder flexion, 45 degrees of shoulder abduction, and extension, ‘nly to neutral Specific surgical precautions should be followed related to internal and external rotation, but clients are typically permitted to lay the hand across the abdomen in internal rotation, toabout'30 degrees of external rotation. Codman's pendulum exercises may be initiated on the first postoperative day. After removal of the sling, the lient is instructed to bend forward by flexing at the hips, allowing up to 90 degrees of passive shoulder flexion, with the arm hanging perpendicular to the floor. The nonoperated upper extremity should rest on a counter or tabletop surface, and a ‘wide base of support with the feet should be maintained to avoid a risk of falls. By shifting the Body? ‘weight, the arm may passively move in anterior-posterior motions lateral motions, small clockwise ‘ices, and small counter-clockwise circles (Fig. 40.16) Depending on the surgeon's preference, distal AROM should also be performed several times daily t avoid distal edema and to promote 1861functional hand use. Over the next? to weeks, larger PROM ranges may be initiated at the shoulder. These may include table slides, in which the client sits next to a table with the operated UE supported on the table, and he or she slowly leans forward and allows the shoulder to passively flex. Some physicians allow dowel exercises (the client holds a wooden dowel with both hands) so’ that the nonoperated UE can be used to assist movement of the operated UE. FIG 40.16 Codmar's (pendulum) exercises: Approximately 4 to 6 weeks following the surgery, and if PROM is gradually increasing and normal movement pattems are observed, precautions related to movement may be relaxed. Greater PROM is expected, but weight bearing and lifting are still restricted, Active-assisted therapeutic exercise and carefully executed overhead pulley exercises may be initiated. The therapist should assess glenchumeral and scapula-thoracic mobility to ensure normal movement patterns. Light strengthening can be initiated in the elbow, wrist, and hand joints in preparation for greater functional use. Some physicians will allow for a light weight to be added to Codman’s pendulum exercises. Shoulder strengthening and full movement through all planes is typically initiated 6 weeks postoperative. Monitored therapeutic exercise to ensure return to full AROM and strength may continue from the 6 weeks through several months as indicated.“Specific Training Techniques for Participation in Occupations “The occupational therapist ean encourage Ine pabent {ouse the hand onthe side ofthe operated shoulder asa stabilizer o assist for light Bctivites that do not require weight bearing or strength (eg, holding toothpaste, buttoning lower butions, stabilizing paper for welling or haldinga washdloth while soaping it up withthe other hand, Sleeping Positions and Bed Mobility er. Core and lower extremity strength and positorung may support movement to and from the bed, bout for clients who do not have this evel of strength, care must be taken that clients do not se the {Bee Chapter 10 Foradditional ADL and [ADL Wacane was required prior to the surgery, it should be used with the nonoperated UE only Physical therapy practitioners typically address balance, ambulation, and gait with the client a cane # needed, the orespational therapist should ensure tafe se during homemaking asks ‘other intrumenal actviies of daily Living. Use of the operated UE should slo be avoided during transters to avoid weightbeazing. Upper-Body Dressing and Bathing Clothing should he chosen fo ease of dressing and with consideration of sling wear. this sleeve is pulled ento the upper extremity and the client returns to siting upright, he or she can ‘each around the back to pull the shit o the other side and to each toslide the nonoperated arm into the oer sleeve. ‘oceupaticnal therapist should also ensure thatthe clients aware of how to put the alg on and off over the clothing, Additional adaplations to othing or technique ray be ‘nctded for the client who alo has limited shoulder mation on the nonoperated side as there ‘ypiealy is bilateral join involvement with esteoathrts For biting the sing is removed and a sponge bath can be completed when the clint is seated. A) waterproo! dressing