SUMMARY OF THE CONDITION
Reverse total shoulder arthroplasty is becoming a very popular surgical technique used to alleviate pain and dysfunction as a result of end stage rotator cuff arthropathy, complete rotator cuff tear, proximal humerus fracture, previous failed shoulder arthroplasty, tumor resection, as well as glenohumeral instability.1,2 Reverse total shoulder arthroplasty is a joint replacement procedure where the arthrokinematics of the glenohumeral joint are reversed: a metaglene ball is inserted into the glenoid fossa and a prosthetic component containing a polyethylene socket is inserted into the proximal humerus. Often patients requiring this procedure have a severely damaged or absent rotator cuff, therefore functional external rotation may be absent. Patient will present with pain, limited range of motion in surgical shoulder, and decreased strength in surgical shoulder.
GUIDE TO PT PRACTICE: PRACTICE PATTERN AND SUGGESTED MANAGEMENT
The Guide to PT Management was created to provide practicing physical therapists with general treatment guidelines for a myriad of clinical diagnoses.
Management of the reverse total shoulder arthroplasty is classified under Pattern 4H: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Joint Arthroplasty.3
The Guide to PT Practice indicates that patients in this pattern may receive treatment for 6 months, or 12-60 PT visits.
The goals of therapy for this population are to decrease pain, improve range of motion and improve strength. To accomplish these goals, the Guide states that treatment may include:
- Therapeutic Exercise: Balance, posture, flexibility, strength, aerobic, and endurance training
- Manual Therapy: Therapeutic massage, connective tissue massage, soft tissue mobilization
- Electrotherapeutic Modalities: Neuromuscular Electrical Stimulation (NMES), Transcutaneous Electrical Nerve Stimulation (TENS), Functional Electrical Stimulation (FES), Electrical Muscle Stimulation
- Functional Training: ADL training, adaptive equipment training, injury prevention
- Physical Agents and Mechanical Modalities: Cryotherapy, hydrotherapy, sound agents, thermotherapy, mechanical motion devices
RELIEVING PAIN
Patients with a reverse total shoulder arthroplasty will present with pain in the surgical shoulder and perhaps the surrounding area. The following modalities are are typically used in relieving pain:
Cryotherapy
Literature reports that cryotherapy, when used immediately post-op and throughout the recovery phase, significantly decreases the number of bouts and the severity of post-operative pain4. Patients with cryotherapy also report better sleep the night of the operation, and lesser need for pain medication than the control group who did not receive cryotherapy4.
Cryotherapy was also shown to decrease pain with shoulder movements during rehabilitation4. Cryotherapy can be used at the end of each PT session to decrease swelling and increase patient comfort. Cryotherapy is suggested 4-5 times a day for 20 minutes each session and can continue as long as needed for pain relief5.
Transcutaneous Electrical Nerve Stimulation (TENS)
There is no literature directly supporting the use of TENS for pain relief of post-operation reverse total shoulder arthroplasty. However, if TENS is approved by the surgeon, the following settings may be recommended6:
- Pulse width: 150 usec
- Pulse rate: 100Hz
- Intensity to a comfortable setting
INCREASING STRENGTH
Patients with a reverse total shoulder arthroplasty will typically present with decreased strength in the scapular, periscapular, shoulder, and elbow musculature. The weakness is attrituted to the incision site itself, the period of immobilization post-op, prior weakness or muscle atrophy and potentially an absent rotator cuff.
The strengthening phase of the rehabilitation protocol begins around week 6.
• For full protocol, refer to Boudreau5.
• No research has been done to determine the best practice rehabilitation protocol. There are a few clinical protocols in circulation.
Early Strengthening Phase
Week 6-8:
- Shoulder flexion, elevation, ER, IR Active and Active Assist ROM as necessary
- Manual resistance submaximal isometric IR and ER
- PNF scapulothoracic alternating isotonics in sidelying
- Anterior elevation & Posterior depression
- Anterior depression & Posterior elevation
- Rhythmic stabilization
- Isotonic, submaximal, pain-free exercises targeting scapular, periscapular, and deltoid musculature
- Anterior and middle deltoid
- Serratus anterior
- Rhomboids
- Upper, middle, lower trapezius
- Pectoralis major and minor
- Biceps and triceps brachii
- Wrist flexor/extensor
Week 9-12
- Continue and progress above exercises to include functional tasks
- Begin resisted AROM supine forward flexion and elevation in scapular plane using light weight (0.5lb -3lb)
- Progress to glenohumeral IR and ER isotonic strengthening exercises
- May use therabands or manual resistance
Moderate Strengthening Phase:
Weeks 12+
- Continue with previous exercise program, but progress weight and functionality of exercises
- Progress the gentle resisted shoulder flexion and elevation in standing as appropriate
- May use therabands or manual resistance
Home Exercise Phase:
Month 4+
- Home exercise plan should emphasize functional shoulder strength as appropriate
IMPROVING RANGE OF MOTION
**Full range of motion is not expected in the post-operative shoulder. However, functional ROM near the full ROM may be achievable in certain situations.
• For full protocol, refer to Boudreau5.
• No research has been done to determine the best practice rehabilitation protocol. There are a few clinical protocols in circulation
Early ROM Phase:
Days 1-21:
- Early PROM may begin as soon as interscalene block dissipates (in the acute care setting)
- Forward flexion and elevation in the scapular plane in supine to 90°
- ER in scapular plane in available range
- NO Internal rotation ROM due to dislocation risk and subscapularis tendon vulnerability
- AAROM and AROM of elbow, wrist, hand, and cervical spine
Week 3-6:
- Progress PROM to 120° of forward flexion and elevation in the scapular plane in supine
- ER in scapular plane to pain tolerance
- At weeks 6, IR PROM to tolerance but not to exceed 50°
Beyond 6 weeks PROM may still be utilized, but strengthening is the major focus. Continue PROM until max ROM is achieved for the patient
Weeks 6+:
- Continue progression of PROM. Full ROM is no the expectation, but it is achievable in certain patients.
DECREASING SWELLING
Cryotherapy:
Literature reports that cryotherapy, when used immediately post-op and for the following 10 days, significantly decreased swelling in the surgical shoulder when measured 10 days post-op4. Cryotherapy continues to control swelling throughout the recovery phase of rehabilitation when used. Cyrotherapy can be used at the end of each PT session to decrease swelling and increase patient comfort. Cryotherapy is suggested 4-5 times daily for 20 minutes each session. 5 This can be continued as long as needed for swelling and pain control.
FUNCTIONAL ACTIVITIES
Internal Rotation isotonic exercises and activities are a dislocation risk for the early stages (first 12 weeks) of the recovery phase. This limits functional activities such as:
- Tucking in shirt behind back
- Reaching for wallet in back pocket
- Washing the back
- Donning and doffing clothing
These activities may need to be limited until the internal rotation movement is no longer risky for the patient. At this point, the internal rotators need to be strengthened slowly to allow for these activities to be possible.
Postural training is very important for this population, since typically they have been living with a dysfunctional shoulder for a period of time. A rounded, elevated shoulder is a typical pre-surgical posture, which precipitates tight upper trapezius muscles, tight pectoralis minor, and lengthened and weak rhomboids. The pectoralis minor and upper traps may need to be stretched and the rhomboids may need to be strengthened, either through scapular PNF patterns or therabands or free weights.
Observation of movement is also very important in this population. Look for compensatory movements (i.e. shoulder shrug with forward flexion or abduction, trunk rotation with internal rotation or external rotation). The compensatory movements should be recognized and eliminated through proper strengthening and feedback from proper movement form.
HOME EXERCISE PROGRAMS
Weeks 1-6
| Exercise | Reps & Sets | # Times per Day |
|---|---|---|
| Ball squeezes with stress ball | 15 reps 3 sets | 3 |
| Wrist Curls (weight under 5 lbs) | 15 reps 3 sets | 3 |
| AROM or AAROM shoulder flexion to end range | 15 reps 3 sets | 1 |
Weeks 6-8
| Exercise | Reps & Sets | # Times per Day |
|---|---|---|
| Standing biceps curl with theraband (submax) | 12 reps 3 sets | 1 |
| Standing serratus anterior punches with theraband (submax) | 12 reps 3 sets | 1 |
| Standing external rotation with theraband (submax) | 15 reps 3 sets | 1 |
Weeks 9-12
| Exercise | Reps & Sets | # Times per Day |
|---|---|---|
| Standing biceps curl with theraband (submax) | 12 reps 3 sets | 1 |
| Standing rows with theraband | 20 reps 3 sets | 1 |
| Standing external rotation with theraband (submax) | 12 reps 3 sets | 1 |
Weeks 12-16+
| Exercise | Reps & Sets | # Times per Day |
|---|---|---|
| Standing external rotation with theraband | 8 reps 3 sets | 1 |
| Standing internal rotation with theraband (submax) | 14 reps 3 sets | 1 |
| Standing rows with theraband | 20 reps 3 sets | 1 |
MODALITY USE
Cryotherapy:
- As stated previously, used immediately post-op and at home cryotherapy is suggested 4-5 times daily for 20 minutes each session5.
TENS:
- As stated previously, TENS can be used at home. The following settings are recommended6:
- Pulse width: 150 usec
- Pulse rate: 100Hz
- Intensity to a comfortable setting
SPECIAL INSTRUCTIONS
Weeks 1-65:
- Sling is worn for 3-6 weeks
- Dislocation risk is shoulder extension, internal rotation, and adduction
- Only take sling off for bathing, home exercise, and therapy
- Patient should always be able to see the elbow when lying on their back (avoid shoulder extension)
- No shoulder AROM
- Avoid supporting body weight on surgical arm
- Keep incision dry. Follow surgeon’s orders on bathing
Weeks 6-125:
- Continue to avoid shoulder extension
- No lifting objects heavier than coffee mug
Weeks 12-165:
- No lifting of objects heavier than 6 pounds
- No sudden lifting or pulling motions with surgical shoulder
REFERENCES
1) Drake GN, O'Connor DP, Edwards TB. Indications for reverse total shoulder arthroplasty in rotator cuff disease.
Clin Orthop Relat Res. 2010;468(6):1526-1533. doi: 10.1007/s11999-009-1188-9.
2) McFarland, EG. Patient guide to “reverse” prosthesis. The Johns Hopkins University Department of Orthopedic
Surgery. http://www.hopkinsortho.org/Pt.%20Guide-reverse%20prosthesis_pks_01-23-06.pdf. Accessed
November 19, 2011.
3) Interactive guide to physical therapist practice. In: About physical therapists. American Physical Therapy Association; 2003.
4) Speer KP, Warren RF, Horowitz L. The efficacy of cryotherapy in the postoperative shoulder. J Shoulder Elbow Surg. 1996;5(1):62-68.
5) Boudreau S, Boudreau E, Canoa D, Higgins L, Wilcox WB. Reverse total shoulder arthroplasty protocol. Brigham and Women's Hospital. http://www.brighamandwomens.org/Patients_Visitors/pcs/RehabilitationServices/Physical%20Therapy%20Standards%20of%20Care%20and%20Protocols/Shoulder_Reverse_TSA_protocol.pdf. 2011. Accessed November 20, 2011.
6) KinexMedical.com. Post-operative TENS guidelines following shoulder surgery. http://www.kinexmedical.com/resources/ML%200139K%20Post-Operative%20TENS%20Guidelines%20Following%20Shoulder%20Surgery.pdf. Accessed 3/11/2012.
7) External rotation picture. WWW.Swimmingworldmagazine.com Accessed 3/11/2012
