REVERSE TOTAL SHOULDER REPLACEMENT REHABILITATION PROTOCOL

Key Terms

AAROM =active assisted range of motion

ADL =activity of daily living

AROM =Active range of motion

ER  =external rotation

IR =internal rotation

PROM =passive range of motion

ROM =range of motion

 

Phase I: early postoperative phase “protected mobilisation”

Goals

  • Patient independent with
    • Sling and dressing management
    • Sleep and resting position in scapular flexion
    • Glenohumeral AAROM exercise programme
    • Cryotherapy as necessary
    • Activities of daily living (ADL) with or without assistance of carer/family
    • Joint protection precautions

Day 1 to 5 (acute inpatient care)

  • Commence glenohumeral AAROM exercise programme
    • Forward flexion to 90° supine
    • Supine external rotation up to 30°
    • Standing shoulder rolls
    • Educate sling use, resting and sleeping positions,  and facilitate early ADL practice

 

Day 6 to 14

  • Patient continues the above rehabilitation at home until first physiotherapy outpatient appointment
  • First post operation appointment with Dr Haber.
  • Supine active assisted flexion progression with stick
  • Supine 90° glenohumeral static joint holds
  • Supine 90° glenohumeral joint static control exercise (base test)

 

Criteria to progress to next phase (phase II)

  • Pain controlled
  • No clinical signs of instability

 

  • Phase II: intermediate active control phase “movement control”

Goals

  • Gradually restore glenohumeral AROM
  • Scapular control with movement
  • Optimise movement pattern

Precautions

  • Avoid supporting body weight with involved limb
  • Limit lifting to cup of tea/coffee or plate
  • Care with glenohumeral extension and hand behind back movements

 

 

Week 2 to 6

  • Continue with AAROM exercises from phase I and sleep/resting position advice
  • Sling use for busy outdoor environments
  • Glenohumeral AROM
    • Active supine glenohumeral flexion to 90°
    • Gentle supine rhythmic stabilisations at 90° glenohumeral flexion
    • Active external rotation to 30° (supine to side lying as able)
    • Active glenohumeral flexion from supine to sitting at 10° incline intervals (from short lever to long lever)
    • Glenohumeral extension and hand behind back progressions from four weeks if base test achieved
    • Supine external and internal rotation isometrics with stick
    • Scapular movement control and re-education as necessary

 

Criteria to progress to next phase (phase III)

  • Pain controlled
  • No clinical signs of instability
  • Acceptable movement pattern
  • Complete loaded base test (0.5kg)

 

Goals

  • Gradually restore glenohumeral AROM
  • Scapular control with movement
  • Optimise movement pattern

 

Precautions

  • Avoid supporting body weight with involved limb
  • Limit lifting to cup of tea/coffee or plate
  • Care with glenohumeral extension and hand behind back movements

 

Week 2 to 6

  • Continue with AAROM exercises from phase I and sleep/resting position advice
  • Sling use for 4 to 6 weeks
  • Glenohumeral AROM
    • Active supine glenohumeral flexion to 90°
    • Gentle supine rhythmic stabilisations at 90° glenohumeral flexion
    • Active external rotation to 30° (supine to side lying as able)
    • Active glenohumeral flexion from supine to sitting at 10° incline intervals (from short lever to long lever)
    • Glenohumeral extension and hand behind back progressions from four weeks if base test achieved
    • Supine external and internal rotation isometrics with stick
    • Scapular movement control and re-education as necessary

 

Criteria to progress to next phase (phase III)

  • Pain controlled
  • No clinical signs of instability
  • Acceptable movement pattern
  • Complete loaded base test (0.5kg)

 

 

Phase III: dynamic strengthening phase “functional rehabilitation”

 

Goals

  • Develop functional use of upper limb
  • Develop dynamic scapular and glenohumeral strength and endurance
  • Continue to develop movement pattern control

Precautions

  • Avoid weight-bearing through the upper extremity
  • Avoid sudden lifting and pushing of loads
  • Progress loading as deemed relevant and necessary for the individual patient

 

Week 6 to 12

  • Continue AAROM and AROM from phase II
  • Glenohumeral strengthening exercises
    • Loaded glenohumeral flexion from supine (short lever)
    • Loaded glenohumeral flexion progressions from supine to sitting through 10° inclines (short lever to long lever)
    • Standing glenohumeral external and internal rotation with resistance tubing as patient ability allows
    • Resisted belly press as patient ability allows
    • Standing glenohumeral flexion and extension with resistance tubing (through controlled range avoiding hyperextension)
    • Resistance tubing pulldowns in sitting or standing
    • Standing lateral raises in scapular plane as tolerated

 

Week 12-26

  • Progress AROM and strengthening work
    • vary repetitions from 10 to 30 to improve strength and/or endurance
    • increase resistance as appropriate for the individual patient in line with their expected clinical outcome and goals
    • Educate patient with regard to their appropriate functional ability and promote independence with rehabilitation programme
    • Clarify patient expectations and ongoing upper limb use before physiotherapy discharge

 

Adjustments for poor functional patient outcomes

 

  • Where patients are unable to perform the base test they should continue with the exercise prescription from phase I.
  • In patients unable to progress to the base test, phase II can be initiated however caution does need to be exercised. Patients unable to perform the base test usually indicate a poor functional outcome. Phase II exercises can be incorporated however where deltoid control is poor glenohumeral extension and internal rotation should be progressed carefully so as not to increase the risk of instability. Patient education on potential positions of instability should also be further highlighted.
  • Phase III exercises also need to be tailored for these patients so they incorporate work at a lower level that reflects the reduced functional ability. This would usually mean using the resistance exercises at a lower level and avoiding exercises that are too demanding such as the lateral raises and adjusting the patient expectations and emphasising some functional adaptations that can be utilised where function is poor, as discussed in the main text.