FYSIOTHERAPIE EN DE

REVERSE SCHOUDERPROTHESE

RYCHARD H. GERYSZEWSKI FYSIOTHERAPEUT

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Basismusculoskeletaal

Modulatieneurologisch

Biomechanischstatiek dynamiek

Onderhoudhart long stofw.

Afwijkendneurologisch of radiologisch

functioneel beperkt

herhaald specifieke-gewrichtsbeweging

-houding

beperkingen van componenten of

interacties

bewegings- beperkingen

syndromen van bewegings-beperkingen

Het kinesiopathologisch model van Shirley A. Sahrmann

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OPERATIEVE INTERVENTIE

Voor patinten met gewrichtspathologie n aanhoudend pijn n functieverlies ondanks conservatief beleid.

glenohumerale artrose, reumatode artritis, rotator cuff arthropathie, osteonecrose, humeruskop fracturen

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(REVERSE) PROTHESE

ter vervanging schoudergewricht bij GH artrose en definitieve RC schade, complexe fracturen, of revisie totale schouder waarbij RC afwezig is.

peer- reviewed beschrijvingen van post-operatieve behandeling niet ruim voorhanden

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in 1975.52 Because a clear description of the protocolis not published, it would be difficult to reproducetheir results. It appears from their very brief descrip-tion of the postoperative program that patients pri-marily participated in an unspecified home exerciseprogram and periodically had physical therapy visits,which appear to have consisted of learning their newexercises for the next phase of rehabilitation. TheirROM values are quite good compared to many otheroutcome studies. However, solely looking at ROMdoes not allow a comprehensive assessment of howwell a patient did postoperatively or how effective therehabilitation program was. There is no report of thequality of the patients movement, what the pain levelwas, and what the functional outcomes were.

It is standard practice for patients to begin early (afew hours postoperatively in the hospital) passiveROM following a TSA. This has been established inliterature from Brems,14,15 Brown,17 and Cameron.18

However, other than consensus regarding early ROM,progression varies considerably. There are severalpublished protocols14,15,17,18 regarding the postopera-tive rehabilitation following TSA and, according toBrems,15 this is an indication that there has not beenone program established as most effective.

Typical protocols are not structured to accommo-date for, and address, underlying pathology. Individu-als who have been treated with a TSA, with orwithout rotator cuff pathology, will need to progressat a much different pace. As previously discussed,patients with severe RA, or who had a delayed orprimary humerus fracture or cuff arthropathy as theirunderlying pathology, may have had a TSA for paincontrol with low expectations for ROM and/or func-tion. Therefore, the protocol they follow should bedifferent than that for the young patient withosteonecrosis who has a healthy rotator cuff and ahigh expectation to return to a high functional level.

We suggest that those patients with a concurrentrepair of a rotator cuff tear and/or a TSA secondaryto RA, a delayed or nonunion of a fracture, or cuffarthropathy should be progressed to the next phaseof rehabilitation based on specified clinical criteriaand not on typical postoperative time frames. Also,any postoperative rehabilitation program should beestablished with strong collaboration between thephysical therapist and referring surgeon. The achieve-ment of specific clinical criteria enable the surgeon,physical therapist, and patient to customize the post-operative course based on how the individual isprogressing postoperatively, taking into considerationunderlying pathology and possible comorbidities.Time frames on such protocols should be identifiedmerely as an approximate guide for progression andnot the progression criteria itself. Timelines shouldonly be used to ensure that a clinician and patientare progressing to activities that are appropriatelygeared to the current postoperative state of healing.

The 3 protocols15,17,18 previously mentioned in thisreview are broken down into 3 or 4 phases ofrecovery and use timelines for progression to thenext phase. These phases are identified and de-scribed as passive ROM, active ROM, and strengthen-ing phases. However, patients do not always progressclinically at the same rate delineated by the 3 or 4phases of the protocol. In addition, none of theseprotocols include early scapular musculature stabilizerexercises. It is our opinion that early scapular stabilitywork is crucial to the rehabilitation of a patient whohas undergone a TSA. Both Brems14,15 and Brown17

agree that maximizing passive motion is the firstmajor goal of therapy, followed by regaining strength,as the ability to restore strength is directly dependenton the available passive ROM.

In our clinic, we have chosen to use the SST andthe American Shoulder and Elbow Surgeons Shoul-der Evaluation Short Form9 because they have beenfound to have good reliability and fairly high respon-siveness, as compared to other shoulder outcometools.8 They are very simple and quick for the subjectand therapist to fill out. The SST has been demon-strated to be sensitive for various shoulder conditionsas well as sensitive in detecting changes in shoulderfunction over time.73 In addition, the SST has beenfound to correlate well with the University of Califor-nia at Los Angeles Shoulder Score1 and the Constantscore.92

SUMMARY

There are multiple underlying pathologies that aremost effectively managed with TSA. Clinical practicesuggests that these different patient populations havevastly different outcomes in terms of pain relief,ROM, and, most importantly, function. This differ-ence in underlying pathologies in conjunction withtissue-healing time frames should be the basis of anyprotocol or standard of care following TSA. Suchconsideration should provide an effective postopera-tive plan of care, which should allow patients to reachtheir maximum functional recovery. It is proposedthat a standard of care that is tailored to each specificpatient by considering the underlying pathology, witha focus on meeting specific impairment and func-tional criteria before progressing to the next stage ofrehabilitation, will promote maximal functional recov-ery (Appendices 1 and 2).

ACKNOWLEDGEMENTS

The primary author (RBW) would like to thank,his wife, Kristin M. Wilcox, PT for her support andassistance during the writing of this paper.

828 J Orthop Sports Phys Ther Volume 35 Number 12 December 2005

Rehabilitation Following Total ShoulderArthroplastyReg B. Wilcox III, PT, DPT, MS1

Linda E. Arslanian, PT, DPT, MS2

Peter J. Millett, MD, MSc3

Total shoulder arthroplasty (TSA) is a standard operative treatment for a variety of disorders of theglenohumeral joint. Patients, who have continued shoulder pain and loss of function in thepresence of advanced joint pathology, despite conservative management, are often managed byundergoing a TSA. The overall outcomes that are reported after surgical intervention are quitegood and appear to be primarily determined by the underlying pathology and the tissue quality ofthe rotator cuff. The current Neer protocol for postoperative TSA rehabilitation is widely used andbased on tradition and the basic science of soft tissue and bone healing. The purpose of this paperis to review the indications for TSA, focusing on the underlying pathologies, and to describe thevariables that impact the rehabilitation program of individuals who have had a TSA. Apostoperative TSA rehabilitation protocol and algorithm, founded on basic science principles andtailored toward the specific clinical condition, are presented. J Orthop Sports Phys Ther2005;35:821-836.

Key Words: physical therapy, protocols, shoulder rehabilitation

The first total shoulder arthroplasty (TSA) was performed byJules Emile Pean in 1893 for the purpose of treatingtuberculous arthritis of the shoulder.68 Neer81 developed ahumeral prosthesis for the treatment of 4-part fractures in1955, and in the mid-1970s he refined his prosthesis for thetreatment of the degenerative humeral head.82 TSA is a standardtreatment intervention for patients with underlying advanced jointpathology who have persistent pain and loss of function despiteconservative management. These pathologies include osteoarthritis(OA),7,13,30,32,39,41,43,44,64,71,74,82,86,88,89,100,101 rheumatoid arthritis(RA),6,34,35,38,52,61,64,76,91,102,106 cuff tear arthropathy,5,33,64,94,95,107,111

osteonecrosis,26,48,49,64,70,79 and fractures of the humeralhead.2,3,6,21,42,62,69,85,90,93 Over the last 25 years, surgical techniques andprostheses have advanced greatly. However, there is still considerablevariability in surgical techniques, particularly the use of cement forfixation and the type of prosthesis. Despite these significant variations,the overall reported outcomes for patients that have undergone TSA aregood.31,49,64,99,104 Self-assessed health status reports of individuals whohave undergone TSA are comparable to those of individuals who haveundergone a total hip arthroplasty or coronary artery bypass graft.11

1 Clinical Supervisor, Outpatient Services, Department of Rehabilitation Services, Brigham and WomensHospital, Boston, MA; Fellow, Center for Evidence-Based Imaging, Department of Radiology, Brigham andWomens Hospital, Boston, MA.2 Director, Department of Rehabilitation Services, Brigham and Womens Hospital, Boston, MA.3 Associate Surgeon, Director of Shoulder Surgery, Steadman Hawkins Clinic, 181 West Meadow Drive,Vail, CO.Address correspondence to Reg B. Wilcox III, Department of Rehabilitation Services, Brigham andWomens Hospital, 75 Francis Street, Boston, MA 02115. E-mail: rwilcox@partners.org

In the early 1990s approximately5000 TSAs were performed in theUnited States annually.108 The suc-cess of a TSA procedure is predi-cated on several factors, includingprosthetic design, etiology and se-verity of the underlying pathology,surgical technique, and postopera-tive rehabilitation.34 Many factorshave an impact on the outcome ofpatients who have had a TSA; theyinclude preoperative health status,preoperative shoulder function,age, gender, and social environ-ment.22,32,37 To ensure optimal re-lief of pain and restoration offunction, it is imperative to inte-grate preoperative, intraoperative,and postoperative factors whenplanning rehabilitation after TSA.Unfortunately, many of the pub-lished studies on TSA focus onsurgical complications and havenot specifically assessed functionaloutcomes or described in detailpostoperative rehabilitation.

The purpose of this paper is tooutline how underlying patholo-gies impact the rehabilitation pro-gram following TSA, with theintent to optimize functional out-come. Maybach and Schlegel75

support the notion that the rate ofprogression for a patient followingTSA should be based on underly-ing pathology in conjunction withthe type of surgical technique usedand the patients overall toleranceto exercise and activity. A betterunderstanding of these factorsshould enable the physical thera-

Journal of Orthopaedic & Sports Physical Therapy 821

CL

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TA

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CUFF ARTHROPATHIE

massieve ruptuur RC

verandering GH biomechanica

kop kan craniaalwaarts

schade lig. coraco-aromiale en AC.

degeneratie kraakbeen, aantasting bot kwaliteit en vormverlies caput.

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BIOMECHANICA VAN REVERSE PROTHESE

kop concaaf, kom bolvorm

rotatiepunt mediaal inferieur

deltoideus > moment arm

deltoideus > spanning

deltoideus compenseert RC

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(reverse) prothese kent een andere biomechanica

kans op instabiliteit afhankelijk van ontwerp

veiligheidsmaatregelen

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AANDACHT VOOR

informeren van de patint

gevolgen afwezigheid RC

type (reverse) prothese

hoe post - operatief te handelen

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FACTOREN OK

botkwaliteit

bij revisie is bot kwaliteit slechter na verwijderen eerdere prothese

delto-pectoriale entree gunstig voor behouden ant. deltoideus.

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SUCCES FACTOREN REVALIDATIE

samenwerking ortho - fysio

voorlichting en informatie patint

status pre-operatieve schouder

type implantaat

bot kwaliteit

integriteit RC

eerdere interventie RC

stabiliteit tijdens OK

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PATINT

risico luxeren

mechanica is veranderd !!

restbeperking onvermijdelijk

leefstijl bepaalt levensduur

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UITKOMSTEN PRIMAIRE REVERSE

betere actieve elevatie > 105

rotatie niet beter

belang intacte teres minor 15

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POST-OP KERNPUNTEN

bescherming prothese post-ok

spierfunctie deltodeus

verwachting functie en ROM

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BESCHERMING

luxatie risico termijn - type

endorotatie en adductie

bv shirt in broek, portemonnee, jeuk op rug

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DELTOIDEUS

functie deltoideus belangrijk

bepaalt stabiliteit en mobiliteit

nadruk deltodeus en thoraco -scapulaire musculatuur

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ROM EN FUNCTIE verwachtingspatroon;

onderliggende pathologie en status exorotatoren, belang teres minor!!

pre-operatief bepalen exo

re-activeren deltoideus en scapula setting, normaliseren ruststand scapula

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FASE 1 POST - OKDislocatie dreiginga) soms tm week 12b) hand niet achter rug heupc) RF 0 graden maximaal

Thuisa) familie + pt + protectieb) Passief ROMc) thuis oefenprogramd) ingroei beschermene) houdingf ) Actief ROM elleboog-handg) geleidelijk zelfstandig

Voorzorgena) abd kussen 4 weken post -okb) ruglig jantje steunt elleboogc) geen Actieve ROMd) niet tillen, steunen, leunen, dragene) wondhygine

Acute fasea) lig, elevatie in scapulaire vlakb) Exo in scapulaire vlak 0c) GEEN Endod) Arom nek+ elleboog+ hande) periscapulair isom. pijnvrij

Week 1 - 4a) continueer pendel oefeningenb) low load training deltoideusc) cave refixatie subscapularis

Door naar fase II patint heeft goede PROM schouder en AROM elleboog hand. patint kan isometrisch deltoideus en peri-scapulaire spieren aanspannen.

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FASE I1 AROMDislocatie dreiginga) geldt tm week 12b) hand niet achter rug heupc) RF 0 graden maximaal

Doelena) continueer progressie PROMb) herstel geleidelijk AROMc) ontzie herstellend weefseld) herstel dynamische stabiliteit

Voorzorgena) slechte actieve functie ? => kort repeterend belasten.b) tillen maximaal beker theec) niet steunen / opduwen

Week 4 - 8a) voortzetten PROMb) start met geleid AROMc) indien geleid actief te pijnlijk is kortdurend terug naar passief

Week 8 - 12a) continueer oefeningenb) elevatie scapulair vlak van lig/ zit/standd) idem exo en endoe) exo/endo isometrisch pijnvrijf) ruglig AROM; AF 1.5 kg max progressie naar zit naar stand.

Week 12 - verdera) continueer oefeningenb) PROM naar 120 c) Exo binnen pijngrensd) 6 wkn Endo tot 50 graden in scapulaire vlake) weerstand elleboog hand

Door naar fase III als de schouderfunctie verbetert en kracht toeneemt. patint kan isotoon de deltoideus en peri-scapulaire spieren aanspannen.

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FASE III MAAND 4+ EN VERDER Doelena) stimuleer functioneel gebruikb) verbeter de kracht tbv gelimiteerd functioneel en recreatief gebruik afhankelijk van doorgemaakte progressie, overleg specialist en fysio.

Criteria voor ontslaga) patent kan AROM pijnvrij onderhoudenb) Beschikt over 80 - 120 graden motorische functie richting elevatie en een 30 graden functionele exorotatie.

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Dank voor jullie aandacht

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