Postoperative Care and Rehabilitation
James Koo, PT, DPT
Laura Vasquez-Welsh, MS, OT/L, CHT
INTRODUCTION
Anatomic total shoulder arthroplasty (ATSA) has been well recognized as an excellent method of providing pain relief and improved function for glenohumeral (GH) osteoarthritis, inflammatory arthritis (eg, rheumatoid arthritis), and other arthropathies (eg, osteonecrosis).
The utilization of postoperative rehabilitation is often thought to be an important factor in the successful outcome of shoulder arthroplasty.1,2,3,4 The physical or occupational therapists, in conjunction with input from the surgeon and patient, develop an individualized rehabilitation program consisting of a sequence of interventions to improve soft-tissue and joint mobility, dynamic GH joint stability, and strength around the shoulder complex.
The purpose of this chapter is to describe a phased progression of postoperative rehabilitation following ATSA to maximize the patient’s ability to perform functional activities, and return to work (RTW), and recreational activities.
GENERAL REHABILITATION PRINCIPLES
While a consensus on general rehabilitation principles based on shoulder biomechanics, tissue healing times, and exercise loading strategies exists, there are several variations in the published protocols.4,5,6,7,8,9,10,11 Ultimately, the goal of the rehabilitation process is to facilitate the patient’s ability to return to full activities of daily living (ADLs), work and recreational activities, in a timely and safe manner. However, literature to support superior clinical outcomes of one rehabilitation protocol over another is limited. Therefore, the physical or occupational therapist must use the existing protocols as a general guide and work to individualize the rehabilitation progression to the patient.
The rehabilitation program involves a multiphased approach that progresses sequentially according to the principles of biological tissue healing, the surgical technique, and potential strain on the involved tissues. The protocol can be divided into five distinct phases, each with its own goals and objective criterion to progress to the next phase. Phase I focuses on the protection of the arthroplasty and initiation of passive range of motion (PROM). During this initial stage, the rehabilitation professional prioritizes the reduction of pain and inflammation along with the progressive restoration of PROM. Phase II advances the range of motion (ROM) from passive (PROM), to active-assisted (AAROM), to active (AROM) movements to allow for the gradual introduction of stress to the healing tissues. Treatment interventions focus on muscle activation, endurance, and neuromuscular control. When the patient can perform functional movement without compensation, the patient is ready to progress to the next phase. Improvements in AROM and function are contingent on improving the strength and control of the scapular muscles as well as the GH joint muscles. Phase III progresses periscapular and GH muscle strength by integrating resistance equipment such as dumbbells, elastic bands and cords, and manual resistance. Electromyography (EMG) studies have been used to identify exercises most appropriate for this phase of the rehabilitation. Once the patient achieves the necessary ROM and strength, advanced strengthening and activity-specific movements are performed to prepare the patients who plan to return to an occupation, activity, or sport with higher demands. Phase IV prepares the patient for return to their athletic activity or occupational demands by addressing deficits in power, agility, and speed. Phase V focuses on returning the athlete to preinjury sporting levels in a systematic method.
As the patient progresses through each phase, the exercises become more challenging and the stresses applied to the GH joint and shoulder complex are greater. The patient is reassessed at each therapy session to determine their response to the exercise progression, and when needed, the program is modified based on the patient’s progress.
The time frames of each phase may vary depending on the patient’s rate of progression. It is essential to manage expectations appropriately and continually involve the patient and their support team in decision-making to ensure high levels of motivation and engagement throughout the process.12,13,14 Early in the rehabilitation process, physical or occupational therapists must educate patients on realistic time frames for improved function and return to work and sport. Steinhaus et al15
reported that in 447 nonretired patients, approximately two-thirds (63.6%) of patients undergoing shoulder arthroplasty were able to RTW postoperatively. Patients returned at an average of 2.3 months postoperatively, with a wide range of 0.3 to 24 months. RTW was lower for patients with heavy-intensity occupations versus all intensity types (61.7% vs 67.6%). There was no significant difference in RTW among patients with ATSA (63.4%) and hemiarthroplasty (66.1%) or reverse total shoulder arthroplasty (61.5%).
reported that in 447 nonretired patients, approximately two-thirds (63.6%) of patients undergoing shoulder arthroplasty were able to RTW postoperatively. Patients returned at an average of 2.3 months postoperatively, with a wide range of 0.3 to 24 months. RTW was lower for patients with heavy-intensity occupations versus all intensity types (61.7% vs 67.6%). There was no significant difference in RTW among patients with ATSA (63.4%) and hemiarthroplasty (66.1%) or reverse total shoulder arthroplasty (61.5%).
If the patient is progressing slower than expected, the rehabilitation specialist should consider potential postoperative complications and be prepared to manage these problems swiftly should they arise. Westermann et al16 reported that in a study of 2779 patients undergoing shoulder arthroplasty, 74 (2.66%) patients required unplanned readmissions within 30 days of surgery. The most common surgical causes for unplanned readmission were surgical site infections (18.6%), dislocations (16.3%), and venous thromboembolism (14.0%). Medical causes for readmission were responsible for 51% of unplanned readmissions. Therapists must continue to monitor for any signs and symptoms that may necessitate a referral back to the surgeon or primary care physician.16,17
POSTSURGICAL CONSIDERATIONS
An appropriate rehabilitation program accounts for the type of prothesis, surgical technique, and the information the surgeon provides regarding the intraoperative findings (eg, tissue status and ROM). This process is facilitated by an open line of communication between the surgeon and the rehabilitation professional. In addition, the surgeon and rehabilitation clinician should discuss any concomitant surgeries that may alter the standard protocol (eg, rotator cuff repair, biceps tenodesis) as well as any precautions before initiating treatment.
The therapist should be familiar with the referring surgeon’s operative technique for shoulder arthroplasty, particularly as it pertains to gaining access to the GH joint. As described in previous chapters, surgeons generally use a deltopectoral approach and enter the GH joint through the subscapularis musculotendinous complex.18,19,20 There are four common subscapularis management options: tenotomy, tendon peel, lesser tuberosity osteotomy, and subscapularis-sparing approaches.18,19,20 When the subscapularis tendon or lesser tuberosity is involved, the therapist must take precautions to protect these structures during the postoperative rehabilitation process. To reduce stress on the healing tissues, the patient wears a sling to support the arm throughout the day. The clinician limits the external rotation (ER) ROM to a range based on what the surgeon determines to be safe based upon intraoperative assessment (typically less than 30°-40°). Internal rotation (IR) resistance exercises are avoided to minimize undue stress on the healing subscapularis.2,4,5 Unfortunately, a potential negative outcome of approaches that detach and reattach the subscapularis is the potential for it not to heal.21 Because the subscapularis has the largest force generating capacity of all the rotator cuff muscles, contributing to 53% of the cuff moment,22 a compromised subscapularis will often result in decreased function. Common signs and symptoms of a compromised subscapularis include pain, IR weakness, and/or anterior GH instability.23,24,25,26
Lafosse et al27 described a novel shoulder arthroplasty technique that preserves the subscapularis tendon by performing the procedure entirely through the rotator interval. Although more technically challenging, this subscapularis-sparing technique allows for the patient to initiate early AROM in all planes without restrictions.
Therefore, communication with the surgeon regarding the specific arthroplasty technique is essential to prescribe an individualized rehabilitation program.
EXAMINATION
The rehabilitation process typically begins on the day of surgery or the first postoperative day. The clinical examination begins with a thorough chart review of the patient’s medical and surgical history. The clinician gathers any pertinent information that may affect the rehabilitation process and overall clinical outcome such as duration of impairments before surgery, preoperative quality of the rotator cuff, and the pre- and postoperative ROM of the shoulder. If unclear, it is important for the therapist to communicate with the surgeon to clarify their preferred time frames for progression and to understand if there are any precautions or ROM restrictions unique to the patient.
Upon meeting the patient, the therapist performs a thorough subjective history, including the events leading up to the surgery, their preoperative function, and their current pain and functional status. A standard upper quarter postoperative examination including observation, palpation, neurological status, ROM, joint mobility, flexibility, and strength of the proximal and distal joints should be performed. Patient-reported outcome measures provide insights into their perceived functional capacity. These baseline measures are captured at this visit and measured throughout the rehabilitation process. These outcome measures are described further in Chapter 21.
Throughout this interaction, the therapist also seeks to develop a therapeutic alliance to foster open communication and cooperation during the rehabilitation process.28,29,30,31 The patient and their support team must be engaged as active participants in the rehabilitation process to ensure the best possible outcome.14 The utilization of a biopsychosocial model allows the clinician to assess the patient holistically and further patient-centered care and outcomes.31,32
Page et al33 described several themes that patients with shoulder pain experience: pain, physical function/activity limitations (eg, difficulties performing ADLs), participation restriction (eg, work disruption, limited recreation), sleep disruption (eg, difficulty falling and staying asleep, sleep positions), cognitive dysfunction (eg, poor concentration and memory), emotional distress (eg, frustration, anxiety, and depression), and impairment in musculoskeletal and movement-related functions (eg, loss of muscle strength). There can be many interactions between these themes, with certain experiences impacting on others (eg, pain leading to reduced activities and sleep disruption). Clinicians must seek to identify these themes in the context of the patient’s specific experience and formulate strategies to address them.
Part of the initial discussion should also capture the patient’s understanding of the rehabilitation process, expectations, and goals so that the therapist can clarify important points and align their rehabilitation program toward the achievement of the patient’s goals.12 Henn et al,34 reported that preoperative patient expectations often included relief of daytime pain, relief of nighttime pain, and improvement in shoulder ROM. These themes were very important to 86%, 82%, and 84% of the patients, respectively. Younger patients had greater expectations for relief of nighttime pain, for an improved ability to interact with others, and for an improved ability to exercise or participate in sports. Reduced improvements in pain, function, and ROM increased the risk of dissatisfaction in patients 2 to 5 years after ATSA.35
The therapist then synthesizes all the findings and educates the patient on the rehabilitation plan of care, precautions, and expectations.
PHASES OF REHABILITATION
Phase I: Joint Protection and Early Passive Range of Motion (Table 15.1)
Phase I is initiated on postoperative day 0 or day 1. The goals of Phase I are to protect the integrity of the surgical reconstruction by minimizing inappropriate stress, decrease pain and inflammation, restore PROM to the shoulder to minimize stiffness, and initiate neuromuscular control exercises for the periscapular muscles.
To protect the healing tissues from excessive stress, the patient is instructed on supporting the surgical arm with a sling for the first 4 to 6 weeks. The patient is to immobilize the shoulder throughout the day and night, except during the therapy session, bathing, and home exercises.
Following ATSA and shoulder surgery in general, finding a position to sleep may be challenging for the patient. The patient may not sleep on the side of the affected shoulder, so the therapist must educate the patient on alternative positions of comfort and safety. If the patient prefers to sleep supine, the humerus should
be supported using pillows, so that the arm is not in the extended position relative to the midline of the body. It is the author’s clinical experience that patients are often most comfortable sleeping in a recliner or a semireclined position created by a wedge behind the thorax. The importance of protecting the healing tissues from excessive stress is emphasized to the patient throughout Phase I to ensure adherence.
be supported using pillows, so that the arm is not in the extended position relative to the midline of the body. It is the author’s clinical experience that patients are often most comfortable sleeping in a recliner or a semireclined position created by a wedge behind the thorax. The importance of protecting the healing tissues from excessive stress is emphasized to the patient throughout Phase I to ensure adherence.
TABLE 15.1 Phase I: Joint Protection and Range of Motion | ||||||||
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To help manage pain that may limit the progression of therapy, it is recommended that patients utilize their prescribed analgesics half an hour to 1 hour before the start of therapy. Cryotherapy should be used following exercise and throughout the day to control pain and muscle spasm, suppress the inflammatory response, reduce swelling, and improve sleep patterns in the immediate postoperative period.36,37,38,39 If excessive pain is limiting the progression of rehabilitation, the therapist should communicate these findings to the physician for further assessment and potential changes in the pain management program.
If excessive edema is noted, the patient is encouraged to elevate the arm throughout the day. The sling may need to be readjusted to minimize the dependent position of the hand relative to the elbow. The patient is encouraged to squeeze a ball to encourage forearm muscle contraction and improved circulation. Manual therapy techniques, such as retrograde lymphatic drainage, can be added with light compression bandages, sleeves, or gloves. If swelling persists or worsens or appears in conjunction with signs that may suggest infection, the therapist should communicate these findings with the physician as soon as possible.
Initiating PROM for the GH joint in the immediate postoperative period has remained a central principle in total shoulder arthroplasty rehabilitation protocols for many years.3,7,40,41 Immediate motion helps minimize joint stiffness, assists in collagen synthesis and organization, and may promote a more rapid return of function compared to a protocol with a delayed initiation of ROM.41,42,43,44 PROM exercises for the GH joint are performed in the scapular plane with limits of motion according to the referring physician’s protocol (eg, 90° of shoulder flexion, 30° of ER in the scapular plane, and IR to the body). When performing the ROM exercises in the supine position, a rolled-up towel is placed under the humerus to raise it to the scapular plane, minimizing stress to the anterior tissues.
Active scapular movement (protraction, retraction, elevation, and depression) helps to facilitate early neuromuscular control. The side-lying scapular clock exercise is performed and then progressed to sitting or standing. Submaximal isometric contractions of the periscapular muscles, particularly into retraction and depression, are initiated to bridge the transition to Phase II.
To maintain the gains achieved in therapy, therapists should educate the patient on performing a daily home exercise program comprising AROM for the elbow, wrist, and hand; scapular clocks and isometric contractions; pendulum exercises; supine passive forward elevation; and passive ER within the range recommended by the surgeon.
Aerobic activity has been shown to improve overall health and fitness, psychological well-being, and quality of life in adults.45,46,47,48,49 The American College of Sports Medicine recommends 150 minute of moderate-intensity aerobic activity per week or the amount of physical activity that one’s abilities and conditions allow.46 Therefore, in the latter part of Phase I, safe aerobic activities such as the stationary recumbent bicycle while wearing the sling are recommended.50 Other forms of aerobic activity should be delayed until later phases to allow for sufficient tissue healing..
Phase II: ROM Progression and Neuromuscular Control (Table 15.2)
The goal of Phase II is to successfully advance the patient’s PROM to AAROM and then to AROM. This is achieved by focusing on neuromuscular retraining to enhance muscle activation and endurance. By the end of this phase, the patient needs to demonstrate not only functional PROM but also functional AROM in the involved extremity without compensatory movements (eg, shoulder shrug).
TABLE 15.2 Phase II: Range of motion (ROM) and Neuromuscular Control | ||||||||||||
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