oah reverse total shoulder arthroplasty protocol
TRANSCRIPT
Chris Lena MD, James Alvarez PAC
Arthroscopic and Reconstructive Surgery of the Shoulder and Knee Sports Medicine MEA’s Karen Smith, Jackie Zuidema, Annmarie Fiore
Tel: (860) 549-8249 - FAX: (860) 244-8813 www.oahct.com
ReverseTotalShoulderArthroplastyProtocol
GeneralInformation:ReverseorInverseTotalShoulderArthroplasty(rTSA)isdesignedspecificallyforthetreatmentofglenohumeral(GH)arthritiswhenitisassociatedwithirreparablerotatorcuffdamage,complexfracturesaswellasforarevisionofapreviouslyfailedconventionalTotalShoulderArthroplasty(TSA)inwhichtherotatorcufftendonsaredeficient.ItwasinitiallydesignedandusedinEuropeinthelate1980sbyGrammont;andonlyreceivedFDAapprovalforuseintheUnitedStatesinMarchof2004.TherotatorcuffiseitherabsentorminimallyinvolvedwiththerTSA;therefore,therehabilitationforapatientfollowingtherTSAisdifferentthantherehabilitationfollowingatraditionalTSA.Importantrehabilitationmanagementconceptstoconsiderare:
•Jointprotection:ThereisahigherriskofshoulderdislocationfollowingrTSAthanaconventionalTSA.oAvoidanceofshoulderextensionpastneutralandthecombinationofshoulderadductionandinternalrotationshouldbeavoidedfor12weekspostoperatively.oPatientswithrTSAdon’tdislocatewiththearminabductionandexternalrotation.Theytypicallydislocatewiththearmininternalrotationandadductioninconjunctionwithextension.Assuch,Tuckinginashirtorperformingbathroom/personnelhygienewiththeoperativearmisaparticularlydangerousactivityparticularlyintheimmediateperi-operativephase.
•Deltoidfunction:Stabilityandmobilityoftheshoulderjointisnowdependentuponthedeltoidand
periscapularmusculature.ThisconceptbecomesthefoundationforthepostoperativephysicaltherapymanagementforapatientthathasundergonerTSA
•Function:AswithaconventionalTSA,maximizeoverallupperextremityfunction,whilerespectingsoft
tissueconstraints.
•ROM:Expectationforrangeofmotiongainsshouldbesetonacase-by-casebasisdependinguponunderlyingpathology.Normal/fullactiverangeofmotionoftheshoulderjointfollowingrTSAisnotexpected.
ReverseTotalShoulderArthroplastyBiomechanicsTherTSAprosthesisreversestheorientationoftheshoulderjointbyreplacingtheglenoidfossawithaglenoidbaseplateandglenosphereandthehumeralheadwithashaftandconcavecup.Thisprosthesisdesignaltersthecenterofrotationoftheshoulderjointbymovingitmediallyandinferiorly.Thissubsequentlyincreasesthedeltoidmomentarmanddeltoidtension,whichenhancesboththetorqueproducedbythedeltoidaswellasthelineofpull/actionofthedeltoid.ThisenhancedmechanicaladvantageofthedeltoidcompensatesforthedeficientRCasthedeltoidbecomestheprimaryelevatoroftheshoulderjoint.Thisresultsinanimprovementofshoulderelevationandoftenindividualsareabletoraisetheirupperextremityoverhead.
ReverseTotalShoulderArthroplastyProtocol:Theintentofthisprotocolistoprovidethephysicaltherapistwithaguideline/treatmentprotocolforthepostoperativerehabilitationmanagementforapatientwhohasundergoneaReverseTotalShoulderArthroplasty(rTSA).Itisbynomeansintendedtobeasubstituteforaphysicaltherapist’sclinicaldecisionmakingregardingtheprogressionofapatient’spostoperativerehabilitationbasedontheindividualpatient’sphysicalexam/findings,progress,and/orthepresenceofpostoperativecomplications.IfthephysicaltherapistrequiresassistanceintheprogressionofapostoperativepatientwhohashadrTSAthetherapistshouldconsultwiththereferringsurgeon.Thescapularplaneisdefinedastheshoulderpositionedin30degreesofabductionandforwardflexionwithneutralrotation.ROMperformedinthescapularplaneshouldenableappropriateshoulderjointalignment.ShoulderDislocationPrecautions:
•Noshouldermotionbehindback.(NOcombinedshoulderadduction,internalrotation,andextension.)•Noglenohumeral(GH)extensionbeyondneutral.
*Precautionsshouldbeimplementedfor12weekspostoperativelyunlesssurgeonspecificallyadvisespatientor
therapistdifferently.SurgicalConsiderations:Thesurgicalapproachneedstobeconsideredwhendevisingthepostoperativeplanofcare.•TraditionallyrTSAprocedureisdoneviaatypicaldeltopectoralapproach,whichminimizessurgicaltraumato
theanteriordeltoid.ProgressiontothenextphasebasedonClinicalCriteriaandTimeFramesasAppropriate.PhaseI–ImmediatePostSurgicalPhase/JointProtection(Day1-6weeks):Goals:
•Patientandfamilyindependentwith:oJointprotectionoPassiverangeofmotion(PROM)oAssistingwithputtingon/takingoffslingandclothingoAssistingwithhomeexerciseprogram(HEP)oCryotherapy
•Promotehealingofsofttissue/maintaintheintegrityofthereplacedjoint. •EnhancePROM. •Restoreactiverangeofmotion(AROM)ofelbow/wrist/hand. •Independentwithactivitiesofdailyliving(ADL’s)withmodifications. •Independentwithbedmobility,transfersandambulationorasperpre-admissionstatus.PhaseIPrecautions: •Slingiswornfor3-4weekspostoperatively.Theuseofaslingoftenmaybeextendedforatotalof6weeks,
ifthecurrentrTSAprocedureisarevisionsurgery. •Whilelyingsupine,thedistalhumerus/elbowshouldbesupportedbyapillowortowelrolltoavoid
shoulderextension.Patientsshouldbeadvisedto“alwaysbeabletovisualizetheirelbowwhilelyingsupine.” •NoshoulderAROM. •Noliftingofobjectswithoperativeextremity. •Nosupportingofbodyweightwithinvolvedextremity. •Keepincisioncleananddry(nosoaking/wettingfor2weeks);Nowhirlpool,Jacuzzi,ocean/lakewadingfor4
weeks.
AcuteCareTherapy(Day1to4):•BeginPROMinsupineaftercompleteresolutionofinterscaleneblock.
oForwardflexionandelevationinthescapularplaneinsupineto90degrees.oExternalrotation(ER)inscapularplanetoavailableROMasindicatedbyoperativefindings.Typicallyaround20-30degrees.
oNoInternalRotation(IR)rangeofmotion(ROM). •Active/ActiveAssistedROM(A/AAROM)ofcervicalspine,elbow,wrist,andhand. •Beginperiscapularsub-maximalpain-freeisometricsinthescapularplane. •Continuouscryotherapyforfirst72hourspostoperatively,thenfrequentapplication(4-5timesadayfor
about20minutes). •Insurepatientisindependentinbedmobility,transfersandambulation •Insureproperslingfit/alignment/use. •Instructpatientinproperpositioning,posture,initialhomeexerciseprogram •Providepatient/familywithwrittenhomeprogramincludingexercisesandprotocolinformation.
Day5to21:•Continueallexercisesasabove. •Beginsub-maximalpain-freedeltoidisometricsinscapularplane(avoidshoulderextensionwhenisolating
posteriordeltoid.) •Frequent(4-5timesadayforabout20minutes)cryotherapy.
3Weeksto6Weeks: •Progressexerciseslistedabove. •ProgressPROM:oForwardflexionandelevationinthescapularplaneinsupineto120degrees.oERinscapularplanetotolerance,respectingsofttissueconstraints. •Gentleresistedexerciseofelbow,wrist,andhand. •Continuefrequentcryotherapy.Criteriaforprogressiontothenextphase(PhaseII): •ToleratesshoulderPROMandisometrics;and,AROM-minimallyresistiveprogramforelbow,wrist,and
hand. •Patientdemonstratestheabilitytoisometricallyactivateallcomponentsofthedeltoidandperiscapular
musculatureinthescapularplane.PhaseII–ActiveRangeofMotion/EarlyStrengtheningPhase(Week6to12):Goals: •ContinueprogressionofPROM(fullPROMisnotexpected). •GraduallyrestoreAROM. •Controlpainandinflammation. •Allowcontinuedhealingofsofttissue/donotoverstresshealingtissue. •Re-establishdynamicshoulderandscapularstability.Precautions: •Continuetoavoidshoulderhyperextension. •InthepresenceofpoorshouldermechanicsavoidrepetitiveshoulderAROMexercises/activity. •Restrictliftingofobjectstonoheavierthanacoffeecup. •Nosupportingofbodyweightbyinvolvedupperextremity.
Week6toWeek8: •ContinuewithPROMprogram. •At6weekspostopstartPROMIRtotolerance(nottoexceed50degrees)inthescapularplane. •BeginshoulderAA/AROMasappropriate.oForwardflexionandelevationinscapularplaneinsupinewithprogressiontositting/standing.oERandIRinthescapularplaneinsupinewithprogressiontositting/standing. •BegingentleglenohumeralIRandERsub-maximalpainfreeisometrics. •Initiategentlescapulothoracicrhythmicstabilizationandalternatingisometricsinsupineasappropriate.Begingentleperiscapularanddeltoidsub-maximalpainfreeisotonicstrengtheningexercises,typicallytowardtheendofthe8
thweek.
•Progressstrengtheningofelbow,wrist,andhand. •Gentleglenohumeralandscapulothoracicjointmobilizationsasindicated(GradeIandII). •Continueuseofcryotherapyasneeded. •Patientmaybegintousehandofoperativeextremityforfeedingandlightactivitiesofdailylivingincluding
dressing,washing.Week9toWeek12: •Continuewithaboveexercisesandfunctionalactivityprogression. •BeginAROMsupineforwardflexionandelevationintheplaneofthescapulawithlightweights(1-3lbs.or
.5-1.4kg)atvaryingdegreesoftrunkelevationasappropriate.(i.e.supinelawnchairprogressionwithprogressiontositting/standing).
•ProgresstogentleglenohumeralIRandERisotonicstrengtheningexercisesinsidelyingpositionwithlightweight(1-3lbsor.5-1.4kg)and/orwithlightresistanceresistivebandsorsportcords.
Criteriaforprogressiontothenextphase(PhaseIII): •Improvingfunctionofshoulder. •Patientdemonstratestheabilitytoisotonicallyactivateallcomponentsofthedeltoidandperiscapular
musculatureandisgainingstrength.PhaseIII–Moderatestrengthening(Week12+)Goals: •Enhancefunctionaluseofoperativeextremityandadvancefunctionalactivities. •Enhanceshouldermechanics,muscularstrengthandendurance.Precautions: •Noliftingofobjectsheavierthan2.7kg(6lbs)withtheoperativeupperextremity •Nosuddenliftingorpushingactivities.Week12toWeek16: •Continuewiththepreviousprogramasindicated. •Progresstogentleresistedflexion,elevationinstandingasappropriate.PhaseIV–ContinuedHomeProgram(Typically4+monthspostop):•Typicallythepatientisonahomeexerciseprogramatthisstagetobeperformed3-4timesperweekwith
thefocuson:o Continuedstrengthgainso Continuedprogressiontowardareturntofunctionalandrecreationalactivitieswithinlimitsasidentifiedby
progressmadeduringrehabilitationandoutlinedbysurgeonandphysicaltherapist.Criteriafordischargefromskilledtherapy: •PatientisabletomaintainpainfreeshoulderAROMdemonstratingpropershouldermechanics.(Typically
80–120degreesofelevationwithfunctionalERofabout30degrees.) •Typicallyabletocompletelighthouseholdandworkactivities.