Rehabilitation in Total Shoulder Arthroplasty
Paolo Paladini, Giuseppe Porcellini, Fabrizio Campi
Total shoulder arthroplasty (TSA) has become the treatment of choice for most glenohumeral arthritis. Results are variable and depend on many factors, including normal and prosthetic anatomy and biomechanics, surgical technique, rotator-cuff integrity, bone deficiency, and postoperative rehabilitation (Cameron et al. 2001). Although the prosthetic design represents an important factor in the success of glenohumeral arthroplasty, the surgical reconstruction of the soft tissues to recreate the normal soft tissue balance as well as postoperative rehabilitation (Heers et al 2001) determine the functional outcome. Boardman (et al. 2001) studied TSAs at a minimum of 2 years' follow-up, with specific focus on the maintenance of motion and the development of soft tissue healing problems. Patients with a diagnosis of rheumatoid arthritis, traumatic arthritis, and osteonecrosis were identified as being at risk for failure to regain motion and for tendon healing complications. We know for previous studies (Neer & Kirby 1982) that every different shoulder disease can reach a goal that can be limited by the nature of the pathology, so we must decide before the implantation of a shoulder prosthesis, communicating it to the patients, if we are trying to reach a standard goal or a limited goal. All these pathologies and shoulder fracture (Movin et al 1998) need different surgical approaches using a variety of shoulder prostheses: total arthroplasty, hemiarthroplasty, reverse and bipolar (Swanson et al. 1989, Worland et al. 1997, Worland & Arredondo 1998, Alund et al. 2000, Hattrup 1998, Waldman & Figgie 1998, Delloye et al. 2002). The goals that the patients can reach are limited by the pathology and the choose of the right shoulder replacement device is mandatory for a good result. When performed without appropriate indications, exacting technique, and a tailored rehabilitation program, however, complications often result (Brown & Bigliani 2000). Similar to other procedures, TSA relies on postoperative physical therapy to maintain the motion that has been gained intraoperatively. Postoperative rehabilitation requires the therapist to know the basics of the surgical technique so that safe and effective therapeutic intervention can be made. A successful outcome depends on effective communication and interaction among the physician, therapist and patient and on a well-designed and a well-executed physical therapy program (Brown & Friedman 1998). Each "team" member has a defined role in rehabilitation, and all three must feel their responsibilities for the desired outcome to be achieved (Kelley & Ramsey 2000). Such programs typically involve a progression from passive to active motion, later incorporating progressive stretching and strengthening. This design attempts to balance the need to obtain and maintain motion with the need to allow for adequate soft tissue healing. Overly protective rehabilitation could result in stiffness, whereas overly aggressive therapy could compromise healing of the subscapularis and cuff musculature and shoulder stability and function (Boardman et al. 2001). In rare cases can be necessary to proceed to arthroscopic revision of the shoulder implant to relieve pain and stiffness residual. Subscapularis seems to be essential in recovery shoulder motion and function and different technique have been described to detach this tendon from bone or with bone of lesser tuberosity, to better visualize eventuality of malunion of the time necessary to let the tendon heal (Gerber 2001). We think that transosseous suture stitches can be enough to close the tendon to bone not to compromise good healing. We observed, particularly in last years, with old prosthetic designs, a painful LHB that can compromise regular course of the rehabilitation program. We actually decide to preserve the LHB only if there is not degeneration, fraying or impingement on the prosthetic humeral head. It’s important for the patients to undergo to shoulder replacement with the better range of motion possible, so it can be easier to reach, in the postoperative time, the better possible motion. For maximal benefit, the program is usually initiated immediately after surgery and follows a logical pattern of joint mobilization followed by muscle strengthening. The process proceeds through a series of well-defined phases. The patient must see himself or herself as the active agent in the program, a concept that is enhanced by a discussion and demonstration of the therapy goals before surgery. Because of a unique understanding of the therapy requirements, the surgeon should remain intimately involved with the patient and therapist, frequently evaluating progress and outcomes of the exercises. When a well-performed surgical procedure is supplemented with a well-designed and frequently monitored therapy program, an excellent outcome of shoulder replacement should be expected (Brems 1994). In general this program consists of 3 phases:
Phase I
- During the first 4 weeks after surgery, the shoulder is usually immobilized with a sling, During this time, the therapist will move the shoulder through passive range of motion exercises to prevent stiffness. This will allow the patient to maintain functional motion in the shoulder while protecting the soft tissue repair. Boileau (et al. 1999) suggests complete immobilization for 6 weeks in case of bone repair for shoulder fracture. Passive motion is permitted with the help of a Continuous Passive Motion (CPM) machine if available, pulleys and sticks.
Phase II
- After the soft tissues are adequately healed (about 5 weeks) an active range of motion exercise program can begin in water pool only in scapular plane and internal rotation with particular care to proprioception and to resume the correct position of the arm in the space. Pool is an ideal rehabilitation site for improving shoulder mobility since the glenohumeral joint is assisted by buoyancy. Improving muscle performance can also be done in the pool with exercises such as stretching the internal rotators with pool weights and stretching the external rotators with a pool noodle. cardiovascular training and core body strengthening can also be done. After 6 or 7 weeks we let the patient begin active motion in pool for external rotation and stretching of the subscapularis tendon.
Phase III
- Soon after adequate active range of motion is achieved (8-10 weeks), a strengthening program begins, concentrating on the rotator cuff muscles and those that stabilize the scapula with tension band. Before the patient goes away from our care we let him perform an isometric strength test, with an our developed machine collaborating with Technogym ®, to assess an eventual altered balance between internal and external rotators and the recovery of strength in every plane.
Phase IV
- Once appropriate levels of motion and strength are reached, a maintenance program of shoulder exercises, as part of a whole-body fitness regimen, is recommended. Return to full activity is highly variable among patients. Generally, complete recovery takes 4-6 months even if in patients who undergo shoulder arthroplasty and play sport frequently we recommend a hemiarthroplasty because of concern about future glenoid problems in sports (Jensen & Rockwood 1998).
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