REHABILITATION FOLLOWING INSTABILITY

SURGERYJulia Walton & Tanya Mackenzie

Clinical Specialist Shoulder Physiotherapists

AIMS

• Our approach to rehabilitating patients following instability surgery

• Rehab considerations through the phases

POST SURGERY REHAB SIMPLY......

• Immobilisation

• Range of Motion

• Strengthening

• Return to ADLs

REHABILITATION PRINCIPLES

Analgesia/Education

Quality ROM

Muscle

Timing

Strength

Patient SpecificGoal

Control

REHABILITATION PRINCIPLES

Analgesia/Education

Quality ROM

Muscle

Timing

Strength

Patient SpecificGoal

Control

Avoid Deconditioning

REHABILITATION PRINCIPLES

Analgesia/Education

Quality ROM

Muscle

Timing

Strength

Patient SpecificGoal

Control

Avoid Deconditioning

REHABILITATION REGIMES

Slow

Accelerated

ACCELERATED REHAB

• Higher patient satisfaction

• Lower post operative pain

• Earlier return to functionSlow Kim et al 2003

But…….

REHABILITATION• ac·cel·er·ate

1. to cause faster or greater activity, development, progress, advancement, etc., in: to accelerate economic growth.

2. to hasten the occurrence of: to accelerate the fall of a government.

3. Mechanics . to change the velocity of (a body) or the rate of (motion); cause to undergo acceleration.

4.to reduce the time required for (a course of study) by intensifying the work, eliminating detail, etc.

REHABILITATION

• What We Do...

• EARLY

• CONTROLLED

• SAFE

• HOLISTIC

PRE-SURGERY

• Get started!

• Patient assessment

• Global conditioning/fitness

• Education

• Familiarisation of post op rehabilitation

POST-SURGERY

• Operation Note

• Immediately Available

• Repair Quality

• Associated Procedures / Findings

SAFE ZONE

• ROM determined Peri-Op

• Doesn’t put strain on repair

• Gives Confidence - clinician & patient

THE SCIENCE...

• Strict immobilisation results in functional instability with rotator cuff inhibition, muscular atrophy, and poor neuromuscular control.

• Get the balance right!

Killian et al 2012

WHAT ARE WE PROTECTING?

• The repair itself

• Sub-optimal muscle performance

• Poor neuromuscular control

EXERCISE CHOICES

• Consider the of the value of exercises

• ROM

• Proprioception

• Core

• Kinetic Chain

SUPRASPINATUS EMG

Uhl T. Dept of Rehabilitation Sciences. University of Kentucky, 2004

Exercise Mean % SD

Supine Passive ROM 1 6

Side-Lying Elevation 2 6

Prayer Position 2 2

Wash Cloth press-up hands close 3 7

Supine press-up 4 8

Scapular Protraction on Ball 5 9

Forward Bow (Pendular) 5 6

<10% - Trace activity/background noise, 10-20% - low activity

ANTERIOR INSTABILITY PROTOCOLDay 1 - 3 weeks Protection Phase

• Sling for 3 weeks • Teach axillary hygiene• Teach postural awareness and scapular setting• Core stability exercises as appropriate)• proprioceptive exercises (minimal weightbearing below 90 degrees)• Active assisted ROM as comfortable (in 'safe zone' )• Do not force or stretch• No combined abduction & external rotation

6 - 12 Weeks Progress to Functional Phase/End Stage • Regain scapula & glenohumeral stability working for

shoulder joint control rather than range• Gradually increase ROM• Strengthen• Increase proprioception through open & closed chain

exercise• Progress core stability exercises• Ensure and treat posterior tightness, if required• Incorporate sports-specific rehabilitation• Plyometrics and perturbation training

3 - 6 weeks Recovery Phase • Wean off sling• Progress active assisted to active ROM as comfortable• open chain gh joint ROM with RC graded strengthening through

painfree ROM • Do not force or stretch• No combined abduction & external rotation

PROTECTION PHASE

• Safe zone ROM

• Proprioception

• Re-enforcing good motor programming

• Kinetic chain involvement

THE BIGGER PICTURE…

• 50% power from tennis serve is generated from Lower quadrant

• Shoulder acts as a funnel to transfer energy

• Posterior oblique sling

Kibler 1995

WHAT DO WE NEED FOR SUCCESS?• Optimal biomechanics

• Flexibility

• Proprioception

• Strength

• Endurance

• Integrated into technique reproducible/learntSciascia & Cromwell (2013)

Throughout the kinetic chain

IF NOT…….

• Leads to increase in load/stress at the Shoulder

• Resulting in dysfunction and injury

KINETIC CHAIN CONSIDERATIONS

• A step increases scapulothoracic recruitment by 10%

• Rotator cuff strength improves by 24% when scapula is retracted/stabilised

Tate et al 2008Kibler et al 2006

KINETIC CHAIN CONSIDERATIONS

• Hip stiffness or weakness found in 49% of post/superior labral tears

Sciascia et al 2012