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Reverse Total Shoulder Arthroplasty: A Post-operation Protocol Using Therapeutic Exercises for Elderly PatientsBy: Nicole WahlinIntroduction:Reverse total shoulder arthroplasty (RTSA) has developed into a successful treatment for patients with a rotator cuff deficiency, pain, and poor function. “It was initially designed and performed in Europe in the late 1980s by Grammont and recently received approval from the FDA to be used in the United States in March of 2004.” ("Reverse total shoulder ")With a RTSA, the rotator cuff is either absent or minimally functional and therefore the rehabilitation of a patient following a RTSA is different than a patient who had the conventional TSA. The prosthesis reverses the orientation of the shoulder joint by “replacing the glenoid base plate and the glenosphere and the humeral head with a shaft and concave cup.” The design modifies the center of rotation of the shoulder joint by moving it medially and inferiorly. By doing so, “both the torque of the deltoid and line of pull of the deltoid is enhanced. The enhancement of the deltoid compensates for the deficient rotator cuff; the deltoid becomes the primary elevator of the shoulder joint.” ("Reverse total shoulder")Studies have outlined that the indications for a RTSA are permanent rotator cuff damage, complex fractures, or a previously failed conventional total shoulder arthroplasty (TSA). (Boudreau, Boudreau, Higgins & Wilcox, 2007) A contraindication of this procedure would be an absence or severe impairment of deltoid contraction. (Drake, O'Connor & Edwards, 2010) When outlining a treatment plan for a patient following a RTSA, it is essential to consider these three concepts; joint protection, deltoid function, and establishing appropriate functional and ROM expectations. (Rehabilitation following a RTSA, 736) In physical therapy, it is essential to consider these concepts as well as the specific precautions and protocol of the surgery when creating a successful treatment plan. Case Description:Patient:The patient was a 72 year old male who had recently undergone a reverse total shoulder arthroplasty on his left shoulder on October 16, 2013 and began inpatient physical therapy services the following day. The patient was retired and lived at home with his spouse and grandson. It was noted that the grandson would be the primary caregiver during the patient’s rehabilitation. The patient’s home consisted of one flight of stairs with one handrail. The handrail was on the patient’s left during descent and on the right during an ascent of the stairs. The patient reported he was independent in most of his activities of daily living and did not previously use an assistive device. The patient reported that he would like to return home following his stay at the hospital. His past medical history included high blood pressure, degenerative arthritis, gastroesophageal reflux disease and urinary frequency. The patient is non-weight bearing on his left upper extremity and must wear the sling at all times as per the surgeon as well as therapeutic exercises according to the protocol prescribed by the surgeon.Examination:The following examination was performed by the physical therapist upon admission to the inpatient care unit; the same day the surgery was performed. PostureNo deficits notedSitting BalanceBoth static and dynamic balance within functional limitsStanding BalanceRequires use of single point cane on right upper extremity for stabilization and balance. Range of MotionNA StrengthNAGaitPatient able to ambulate 50 feet using a single point cane with his right upper extremity. Pt was contact guard assist with multiple verbal cues and demonstration for safe and correct use of assistive device. Activity ToleranceLimited endurance noted with activity, specifically with ambulation. SensationIntact at this time, no deficitsPain6/10 at time of examinationIntegumentary StatusSurgical incision is covered with a clean, dry dressingCognitionPatient is awake and oriented. Pt exhibits decreased safety awareness; specifically with gait. Mobility Skills/TransfersThe patient requires contact guard assist for out of bed transfers with verbal cues and transferring from sitting to standing with verbal cues as well.Interventions:After examining the patient, the patient and physical therapist discussed therapy and patient goals. The following short-term and long-term goals were set and agreed upon by both the therapist and patient.Short-Term Goals: Bed mobility, supervisoryFunctional transfers, supervisory The patient able to walk 150 feet with use of single point cane with right upper extremity, contact-guard assist.Therapeutic activities per reverse total shoulder protocol 10 repetitions each; 4-6 times per day. Discharge/Long-Term Goals: Bed mobility, independentFunctional transfers demonstrated independentlyGait training of 200 feet with use of single point cane with right upper extremity, contact guard assist. The patient will be able to negotiate 12 steps with use of handrail on right on ascent and use of a single point cane with right upper extremity as well as under supervision of caregiver.Patient will be safe in performing bed mobility, stairs and transfers in order to return home under supervision of caregiver. The patient was admitted to the inpatient care unit immediately following surgery. The plan was for the patient to remain in the inpatient care unit for 2 days following surgery; with 2 physical therapy sessions twice daily for 20 to 30 minutes each. The initial plan of treatment set by the physical therapist consisted of gait training, transfer training, bed mobility training, therapeutic exercises, stair training with assistive device, proper positioning, and patient/caregiver education specifically for safety training as well as precautions per protocol. Gait Training:Gait training was performed with a single point cane with right upper extremity. Patient was allowed standing rest breaks as required. Gait training distance began at 50 feet, with contact-guard assist. Verbal cues as well as demonstration were given for safe and correct use of single point cane. As patient’s activity tolerance improved, gait distance was increased and fewer rest breaks were taken. On day 2, patient’s distance ambulated was increased to 200 feet with supervisory. Transfer Training:Transfer training involved supine-to-sit and sit-to-stand transfers. The patient initially required contact guard assist for transfers. Sequencing and safety was taught to the patient; this was followed by demonstration and verbal cueing. The training was progressed to decreased assistance by physical therapist. Bed mobility Training: Bed mobility training was accomplished through multiple verbal cues for correct hand placement and sequencing. The patient initially required contact guard assist for transfers. The training was progressed to decreased assistance by physical therapist. Therapeutic ExerciseExercises were demonstrated by therapist prior to patient initiation and verbal cues for correct execution were given as the patient performed the exercises. The following table delineates what therapeutic exercises were performed, how many repetitions and how often.Day 0: Day 1: Day 2: PROM of elbow flexion; 10 repetitionsPROM of elbow flexion; 10 repetitionsPROM of elbow flexion; 10 repetitionsBall squeezes; 10 repetitionsBall squeezes; 10 repetitionsBall squeezes; 10 repetitionsAlternating wrist flexion and extension; 10 repetitionsAlternating wrist flexion and extension; 10 repetitionsAlternating wrist flexion and extension; 10 repetitionsAbduction and adduction of digits; 10 repetitionsAbduction and adduction of digits; 10 repetitionsAbduction and adduction of digits; 10 repetitionsStair Training:The patient was instructed to ascend stairs using handrail on right and descend stairs using single point cane on left with contact guard assist to supervisory from caregiver. The following sequence was used for stair training:Ascend/descend two 6” steps with no handrail; using single point cane for support and stability for both ascent and descent as well as contact guard assist from physical therapist. Ascend/descend a flight of stairs, twelve 6” steps, with a handrail on the right for ascent and the use of a single point cane on the descent as well as contact guard assist to supervisory from physical therapist. Proper Positioning:The patient was instructed to wear sling at all times and was demonstrated to place pillows underneath the arm while lying in bed for support as well as comfort.Patient/Caregiver Education:The patient as well as the primary caregiver was instructed in the precautions related to his specific surgery. Which were, no active range of motion of left shoulder, wear sling at all times and non-weight bearing on left shoulder. The patient and caregiver were also instructed in safety awareness during gait and ambulation of stairs. Caregiver was specifically educated in proper guarding techniques when assisting patient in ambulating stairs. Education was given through demonstration and verbal cueing. Training was progressed to decreased assistance from physical therapist. Outcomes:PostureNo deficits notedSitting BalanceBoth static and dynamic balance within functional limitsStanding BalanceRequires use of single point cane on right upper extremity for stabilization and balance. Range of MotionNA StrengthNAGaitPatient able to ambulate 200 feet using a single point cane with his right upper extremity. Pt was contact guard assist to supervisory with minimal verbal cues for safe and correct use of assistive device. Activity TolerancePt can ascend/descend 12 stairs with a single point cane on the right upper extremity on descent and a handrail for the ascent on the right upper extremity; contact guard assist to supervisory. SensationIntact at this time, no deficitsPain3/10Integumentary StatusSurgical incision is covered with a clean, dry dressingCognitionPatient is awake and oriented. Mobility Skills/TransfersThe patient is supervisory for out of bed transfers and transferring from sitting to standing with minimal verbal cues.Discussion:The main focus and primary goals during physical therapy are to promote joint protection through patient and caregiver education; appropriate techniques for donning and doffing sling as well as clothing in order to ensure joint protection. Therapists must also promote healing of the soft tissue through following the appropriate protocol and progressing the patient’s exercise plan from passive range of motion, to active assistive and then active range of motion. The therapist must ensure the patient is independent with all activities of daily living, bed mobility, transfers and ambulation upon discharge from physical therapy. ("Reverse total shoulder")Patients will remain immobilized in a sling for the first 49-72 hours. “After 3 days the sling may be removed for light activity, as long as the patient is awake and the patient’s hand remains in front of their body.” After 4 weeks the patients only need to wear their sling at night until 6 weeks postoperative. ("Reverse total shoulder rehabilitation") However, another study advised patients to continually wear their sling for 3-4 weeks; especially during therapy treatments. (Boudreau, Boudreau, Higgins & Wilcox, 2007)The first postoperative visit should mainly consist of patient education. Therapists must educate their patients on the appropriate precautions and motions to avoid to prevent dislocation and disruption of the prosthesis. Research has shown that abduction with external rotation and abduction with internal rotation should be avoided. ("Reverse total shoulder rehabilitation") “Functional activities such as tucking in a shirt, reaching behind one’s hip and lower back” with the involved upper extremity can lead to a dislocation of the shoulder joint; these precautions should be followed for no less than the first 12 weeks postoperative. (Boudreau, Boudreau, Higgins & Wilcox, 2007)Phase one, 1-6 weeks, consists of increasing shoulder passive range of motion (PROM), promoting healing of soft tissue, maintaining integrity of replaced joint, and restore active range of motion of the elbow joint. ("Reverse total shoulder") Pendulum exercises are performed by the patient, without weight; clockwise, counterclockwise, side to side and front and back. ("Reverse total shoulder rehabilitation") Physical therapists may begin performing PROM of the shoulder joint with the patient positioned in supine; forward flexion up to 90 degrees, external rotation up to 20-30 degrees and no internal rotation. Active or active assisted range of motion of the elbow, wrist and hand can be performed. ("Reverse total shoulder") Exercises such as ball squeezes and wrist curls may also be performed. ("Physical therapy management") During weeks 3-6, initial soft tissue healing and sensory feedback has improved to the point where it is safe to progress the patient to 120 degrees of forward flexion. At week 4, the initiation of deltoid and periscapular isometrics are performed. (Boudreau, Boudreau, Higgins & Wilcox, 2007) During phase one it is also appropriate to ensure the patient is independent in bed mobility, transfers and ambulation as well as independent in activities of daily living with modifications. ("Reverse total shoulder")Phase two, 6-12 weeks, consists of the progression from PROM to active range of motion (AROM) and early strengthening exercises. “The primary focus of this phase is restoring dynamic shoulder stability and enhancing shoulder mechanics.” (Boudreau, Boudreau, Higgins & Wilcox, 2007) At 6 weeks it is appropriate to begin PROM of internal rotation of the shoulder joint; no more than 50 degrees. At this time the patient should be performing active assistive and or active range of motion in supine, where the scapula is stabilized and can be further progressed to sitting and standing per patient tolerance. (Boudreau, Boudreau, Higgins & Wilcox, 2007) Gentle periscapular and deltoid isometrics may be progressed to isotonic activity during weeks 6-8. At weeks 9-12, patients may begin gentle glenohumeral internal and external rotation isotonic strengthening exercises in side-lying with either light resistive bands or 1-3 pound weights. ("Reverse total shoulder") At this time, patients may begin using their hand of the involved upper extremity for feeding, dressing, washing and other light activities. ("Reverse total shoulder")Phase three begins at weeks 12+ or when “the patient demonstrates appropriate PROM/AAROM/AROM and is able to isotonically activate each portion of the deltoid.” This phase consists of advancing strengthening and increase functional independence. (Boudreau, Boudreau, Higgins & Wilcox, 2007) In this phase all strengthening exercises follow the low weight and high repetition rule in order to increase shoulder endurance and decrease the risk of shoulder dislocation. (Boudreau, Boudreau, Higgins & Wilcox, 2007) Exercises performed may be standing external rotation, standing internal rotation and standing rows; all exercises performed with theraband. ("Physical therapy management")Phase four is initiated when the patient is able to demonstrate functional pain-free shoulder AROM and can independently perform their home exercise program. During this stage, when patients are able to maintain pain free shoulder AROM and are able to perform light household and work activities, pain free, they may be discharged from physical therapy. ("Reverse total shoulder")At the time of discharge it was noted by a recent study that the majority of their participants “demonstrated reliable pain relief and functional improvements in older patients.” (Lenarz, McCrum, Shishani, Nowinski, Edwards & Gobezie, 2011) Another study supported that claim and also noted a low complication rate. This study noted of the 67 patients 23% resulted with complications postoperative, however, only 17% were related to the shoulder. (Nolan, 2011) One study noted that of 484 patients who were followed for 52 months postoperatively, documented that patients demonstrated increased improvements in pain relief and shoulder elevation from 71 degrees to 130 degrees. (Nam, Kepler, Neviaser, Jones, Wright, Craig & Warren, 2010) Another study found that of their 94 patients, “the patients with a primary rotator cuff deficiency had significantly better average postoperative scores than those who had a failed arthroplasty.” (Cluff, Pupello, Virani, Levy, & Frankle, 2008) In this same study it was also noted that the most common complication during postoperative rehabilitation was dislocation secondary to falls. (Cluff, Pupello, Virani, Levy, & Frankle, 2008) In most elderly patients’, falls are due to poor balance and poor balance is a result of vestibular, somatosensory and or visual disturbances. Many patients would benefit from an initial outpatient or home health evaluation that includes a thorough balance assessment. This information can be critical when designing a treatment protocol for an elderly patient. It assists the therapist in knowing their patient’s limitations and ensuring they are given the proper support, caregiver assistance, assistive devices and treatment to improve their balance. This will help to decrease the risk of falls and therefore decrease the risk of dislocation or disruption of the prosthesis. Through proper education and assessment, therapists can create the appropriate treatment for their patients that is specific to them and will ensure the security of the prosthesis and ensure the safety of their patients. At the time of discharge from the inpatient setting, 3 days postoperative, this specific patient validated these studies with noting decreased pain after the surgery. The patient demonstrated independence in bed mobility, transfers and ambulation with use of a single point cane. The patient planned on participating in home health in order to continue therapy and follow the specific protocol previously outlined in order to ensure a successful recovery. Conclusion:Reverse total shoulder arthroplasties, however still new, have become a reliable surgery known to decrease pain and improve function of the shoulder joint. For elderly individuals, studies have shown that reverse total shoulder arthroplasties provide successful outcomes with minimal complications. If therapists educate their patients on the appropriate precautions and follow the appropriate protocol as well as prescribe the proper exercises, studies have shown that patients will have a successful outcome. References:Drake, G., O'Connor, D., & Edwards, T. B. (2010). Inications for reverse total shoulder arthroplasty. Clinical Orthopedics and Related Research, 468(6), 1530.Nam, D., Kepler, C. K., Neviaser, A. S., Jones, K. J., Wright, T. M., Craig, E. V., & Warren, R. F. (2010). Reverse total shoulder arthroplasty: Current concepts, results and component wear analysis. The Journal of Bone and Joint Surgery, 92, 29.Cluff, D., Pupello, D., Virani, N., Levy, J., Frankle, M. , & , (2008). Reverse shoulder arthroplasty for the treatment of rotator cuff deficiency. The Journal of Bone and Joint Surgery, 90, 1247-1248.Nolan, B. M. (2011). Reverse total shoulder arthroplasty improves function in cuff tear arthroplasty. Clinical Orthopedics and Related Research, 469(9), 3330.Lenarz, C., McCrum, C., Shishani, Y., Nowinski, R., Edwards, T. B., & Gobezie, R. (2011). Is reverse shoulder arthroplasty appropriate for the treatment of fractures in the older patient?. Clinical Orthopedics and Related Research, 469(12), 3330.Boudreau, S., Boudreau, E., Higgins, L., & Wilcox, R. B. (2007). Rehabilitation following reverse total shoulder arthroplasty. Journal of Orthopaedic and Sports Physical Therapy, 37(12), 737-739.Physical therapy management of reverse total shoulder arthro. (n.d.). Retrieved from (n.d.). Reverse total shoulder arthroplasty protocol. Brigham and Women's Hospital, 5-8. Retrieved from therapy standards of care and protocols/shoulder_reverse_tsa_protocol.pdf(n.d.). Reverse total shoulder rehabilitation protocol. Sports Medicine & Shoulder Surgery, Retrieved from Medicine/Rehab Protocols/Shoulder Arthroplasty protocol.ashx ................
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