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.