Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
COMPILED
BY:
TENDAYI
MUTSOPOTSI
BSc.
HPT
(Hons)
MSc.
ORTHO-MED
MCSP
MSOM
APPROVED
BY:
MR
ANDREW
SANKEY
ORTHOPAEDIC
CONSULTANT
SURGEON
Anterior Stabilisation Protocol: Tendayi Mutsopotsi (Specialist Shoulder Therapist)
PHASE
I:
(0-2
WEEKS)
Immediate
Post
Surgical
Phase:
(Day
1
to
2
weeks)
Goals:
Patient
Education
Immobilization
to
protect
repair
Diminish
pain
and
inflammation
Precautions:
Remain
in
body
belt
(2-3
weeks),
only
removing
for
showering
and
elbow/wrist
ROM
No
PROM/
AROM
of
shoulder.
Can
do
ER
to
neutral
up
to
4
weeks
No
lifting
of
objects
with
operative
shoulder
and
Keep
incisions
clean
and
dry
Week
1-3
Body
belt
at
all
times
PROM/AROM
elbow
and
wrist
only
+
Ball
squeezes
Sleep
with
body
belt
supporting
operative
shoulder
Shower
with
arm
held
at
your
side
Cryotherapy
for
pain
and
inflammation
Patient
education:
posture,
joint
protection,
positioning,
hygiene,
etc.
Begin
isometrics
week
3
PHASE
II:
(2-6
WEEKS)
Protection
Phase/PROM
(Week
4
and
5)
Goals:
Gradually
restore
PROM
of
shoulder
Do
not
overstress
healing
tissue
Precautions:
Follow
surgeons
specific
PROM
restrictions-
primarily
for
external
rotation
No
lifting
and
No
PROM/stretching
of
the
anterior
capsule
in
the
90/90
positions.
Criteria
for
progression
to
the
next
phase:
Full
flexion
and
internal
rotation
PROM
PROM
30
degrees
of
external
rotation
at
the
side
Anterior Stabilisation Protocol: Tendayi Mutsopotsi (Specialist Shoulder Therapist)
Week
4-5
Continue
use
of
sling
and
Pendulum
exercises
PROM:
Full
flexion,
Full
Internal
rotation,
and
External
rotation
to
30
Continue
cryotherapy
as
needed
Continue
all
precautions
and
joint
protection
PHASE
III:
(6-12
Weeks)
Intermediate
phase/AROM
(Week
6
and
7)
Goals:
Continue
to
increase
external
rotation
PROM
gradually
Full
AROM
and
Independence
with
ADLs
Precautions:
Wean
from
Sling
and
No
lifting
with
affected
arm
Can
begin
gentle
external
rotation
stretching
in
the
90/90
(8
weeks)
Week
6
and
7
AROM
of
shoulder
and
Progress
to
full
AROM
against
gravity
Begin
incorporating
more
aggressive
posterior
capsular
stretching
Cross
arm
stretch
and
Side
lying
internal
rotation
stretch
Posterior/inferior
gleno-humeral
joint
mobilization
Begin
gentle
rhythmic
stabilization
techniques
for
rotator
cuff
musculature
strength.
Week
8
Week
12
(Strengthening
Phase)
Goals:
Continue
to
increase
external
rotation
PROM
gradually
Maintain
full
non-painful
AROM
Improve
muscular
strength,
stability
and
endurance
Gradual
return
to
full
functional
activities
Precautions:
Be
sure
not
to
stress
the
anterior
capsule
with
aggressive
overhead
strengthening
Avoid
contact
sports/activities
Week
8-10
Continue
stretching
and
PROM
and
Initiate
strengthening
program
(elastic
resistance)
ER/IR
with
elbow
at
the
side
of
the
body,
Forward
punch,
Seated
row
Rhythmic
stabilization
exercises
Initiate
strengthening
program
(elastic
resistance)
Shoulder
shrug,
Seated
row,
Bicep
curls,
Lat
pulls,
Triceps
extensions,
Push-up
plus
Anterior Stabilisation Protocol: Tendayi Mutsopotsi (Specialist Shoulder Therapist)
Week
10-12
Continue
all
exercises
listed
above
including
Continue
stretching
and
PROM
Begin
gentle
strengthening
overhead,
avoiding
excessive
anterior
capsule
stress
ER/IR
in
the
90/90
positions,
D1/D2
flexion
and
extension
diagonals
PHASE
IV:
Return
to
activity
phase
(12-20
WEEKS)
Goal:
Increase
strength,
endurance
and
ROM
to
the
functional
level
required
by
the
patient.
Gradual
return
to
strenuous
work
activities
Gradual
return
to
recreational
activities
Gradual
return
to
sports
activities
Precautions:
Do
not
begin
throwing,
or
overhead
athletic
moves
until
4
months
post-op
No
exercises/activities
that
increase
pain,
cause
apprehension
or
reinforce
abnormal
muscle
patterning.
With
weight
lifting:
Avoid
wide
grip
bench
press
and
No
military
press
or
lat
pulls
behind
the
head.
Be
sure
to
always
see
your
elbows
Treatment
Patient
education:
Encourage
paced
return
to
normal
activities
and
lifting;
encourage
normal
movement
patterns
during
functional
activities;
advise
patients
of
ongoing
improvements
for
up
to
one
year.
Exercises:
Full
ROM
with
controlled
stretching
to
achieve
functional
range
if
necessary.
Advanced
scapula
stabiliser
and
rotator
cuff
rehabilitation
through
range
-
include
speed
and
ballistic
work
as
appropriate.
Kinetic
chain/balance
work
incorporating
core
stability
and
lower
limbs
as
needed.
Advanced
proprioceptive
work
include
PNF
to
regain
rotation
control
through
range
Functional
activities
review
functional
goals;
refer
to
Occupational
Therapy
if
needed.
Ensure
sports
specific/work
specific
activities
retrained.
May
need
to
consider
graduated
throwing
programme.
Can
begin
golf,
tennis
(no
serves
until
4
mo.),
etc.
Can
begin
weight
lifting
with
low
weight,
and
high
repetitions,
being
sure
to
follow
weight
lifting
precautions.
Activities:
Return
to
moderate
heavy
work.
May
need
to
modify
duties
if
requires
heavy
overhead
work
(anterior
stabilisation)
or
heavy
pushing,
upper
limb
weight
bearing
(posterior
stabilisation).
Anterior Stabilisation Protocol: Tendayi Mutsopotsi (Specialist Shoulder Therapist)
Week
16-20
May
initiate
interval
sports
program
if
appropriate
Swimming
all
strokes.
Return
to
sports
e.g.
football,
golf,
racquet
sports,
and
martial
arts
at
6-8
months.
Returning to functional activities
Returning to work Driving Swimming Golf Lifting Contact Sport Sedentary job: as tolerated Manual job: 3 months About 6-8 weeks Breaststroke: 6 weeks Freestyle: 12 weeks At least 3 Months Light lifting can be started at 3 weeks. Avoid lifting heavy objects for 3 months. Such as football, racket sports, rock climbing etc: 3 months
Milestone
driven
These
are
milestone
driven
guidelines
designed
to
provide
an
equitable
rehabilitation
service
to
all
of
our
patients.
They
will
also
limit
unnecessary
visits
to
the
outpatient
clinic
here
at
Chelsea
&
Westminster
by
helping
the
patient
and
therapist
to
identify
when
specialist
review
is
required.
If
patients
are
progressing
satisfactorily
and
meeting
milestones,
there
is
no
need
for
them
to
attend
clinic
routinely.
Failure
to
progress
or
variations
from
the
norm
should
be
the
main
reason
for
clinic
attendance.
Both
patients
and
therapists
can
book
clinic
visits
by
contacting
the
numbers
given
further
on
in
this
document.
Milestones
for
discharge:
1. Achieved
time
and
patient
specific
functional
goals.
2. Achieved
90-100%
of
contralateral
shoulder
active
ROM.
3. Patient
has
a
negative
lag
sign
(i.e.
active
equals
passive
range)
with
dynamic
rotation
control
at
0
abd,
45
abd,
90
abd.
4. Patient
has
no
apprehension
with
specific
movements
and
activities.
Failure
to
meet
milestones:
Anterior Stabilisation Protocol: Tendayi Mutsopotsi (Specialist Shoulder Therapist)
1. Refer to/discuss with Shoulder and Elbow Unit 2. Consider possible reasons for failure to progress and act accordingly (see below). 3. Continue with outpatient physiotherapy while patient is still making progress. Clinic follow-up schedule: 2, 6, 12, and 16-24 weeks (only if necessary) Failure to progress If a patient is failing to progress, then consider the following: Possible problem Pain inhibition Action Adequate analgesia Keep exercises pain-free Return to passive ROM if necessary until pain controlled Progressing too quickly hold back If severe night pain/resting pain refer to Shoulder Unit Increase or reduce physiotherapy/ (HEP) (max 2-4x/day) for few days/weeks and assess difference Ensure HEP focuses on key exercises and link to function Decrease activity intensity Assess and treat accordingly Passive ROM may need improving Assess and treat accordingly Ensure passive range gained first Consider isometrics through range Rotation dissociation through range with decreasing support and increasing resistance Ensure not progressing through Therabands too quickly Work on scapula stability through range without fixing with pec major/lat dorsi Work on improving core stability Maintain passive ROM as able Use physiological and accessory mobilisations, taking into account end feel and tissue healing times
Patient exercising too vigorously Patient not doing home exercise programme (HEP) regularly enough
Returned to activities too soon Cervical/thoracic pain referral Unable to gain strength Altered neuropathodynamics Poor rotator cuff control
THE SHOULDER UNIT TEAM Shoulder Consultant: Mr. Andrew Sankey 0208 746 8545 Shoulder Therapist: Mr. Tendayi Mutsopotsi 0208 746 8404 Secretary: 0208 746 8545