Management of Glenohumeral Arthritis.

Last updated Wednesday, January 09, 2008

Figure 57

Figure 58

Figure 59

Figure 60

Figure 61

Figure 62

Figure 63

Figure 64

Figure 65

Figure 66

Postoperative rehabilitation

Continuous passive motion

Rehabilitation is started immediately following surgery in the recovery room with the initiation of slow and gentle continuous passive motion (see figure 57).

For patients who have had an interscalene block prior to surgery this early motion is pain free. Continuous passive motion (CPM) should be stopped and the wrist brace removed every two to three hours for approximately 15 - 20 minutes to relieve any skin and nerve compression. A sling is worn between exercise sessions until active muscle control is regained.

The patient-conducted rehabilitation program is started the day of surgery under the instruction of the surgeon or therapist. While the program may vary with the details of the surgery performed (see footnote 1), the following is a description of the basic program for shoulder arthroplasty. The stretching exercises include

1. elevation
2. external rotation limited to 40 degrees
3. internal rotation
4. cross body adduction
5. grip strengthening
6. elbow range of motion
7. external rotator isometrics, and
8. anterior, middle and posterior deltoid isometrics.

The patient is instructed to perform a total of five exercise sessions spread evenly throughout the day both while in the hospital as well as at home following discharge.

Charts are placed on the wall in full view from the patient's bed to graph the progress of external rotation and elevation (see figure 58) as measured by the surgeon or therapist. This provides positive feedback for rehabilitative progress.

For the routine arthroplasty, the range of motion goals to be achieved before discharge are 140 degrees of elevation, 40 degrees of external rotation, and functional internal rotation and cross body adduction. These goals may be modified according to the specific surgical procedure. Because the desired range has been achieved on the operating table, the patients' task is simplified, they have only to maintain this range during the post operative period.

Exercises

Elevation (overhead reach) is performed in the supine position (lying flat on the back), grasping the wrist or elbow of the operative shoulder with the hand of the unoperated arm, pulling up toward the ceiling and reaching overhead as high as possible to the goal of 140 degrees with the arm relaxed (see figure 59). A pulley or the forward lean (see figure 60) may also be useful in achieving elevation, especially if the opposite shoulder is involved.

External Rotation (rotation away from the body) is performed in the supine position (see figure 61), the operative side elbow held against or close to the side and flexed to 90 degrees. A stick is held in both hands so that the unaffected extremity pushes on the operative arm to externally rotate it to the goal of 40 degrees. Holding on to a door and turning away is another useful way to stretch external rotation (see figure 62).

Internal Rotation is performed by grasping the wrist of the relaxed involved arm with the non-operative side hand, the hands are lifted up the back as high as possible. A towel can also be used to assist with pulling the involved arm into internal rotation behind the back (see figure 63).

Cross Body Adduction is performed sitting or standing, grasping the elbow of the involved arm with the other hand. The involved arm is relaxed with the elbow extended and pulled across the body until a stretch is felt (see figure 64).

Active Elbow Motion is performed standing in order to allow unimpeded or unrestricted flexion/extension and supination/pronation.

Grip Strengthening is performed to maintain forearm tone and can be accomplished using a foam pad or tennis ball.

External Rotator Isometrics are performed with the forearm at neutral rotation. An attempt is made to move the wrist out to the side against the resistance of the other hand or a fixed object (see figure 65).

Deltoid Isometrics are also performed standing or sitting. The arm is held in a neutral position and pushed forward, to the side and to the back to exercise the anterior, middle, and posterior deltoid respectively.

Supine Presses are performed initially holding a cloth or stick between both hands with the hands held close together (see figure 66). From a starting position with the elbows bent and hands lying across the chest, the stick is pushed straight to the ceiling with both hands in a slow and controlled manner and then slowly lowered back to the resting position at the chest. The space between the two hands is progressively increased. As the shoulder becomes stronger, the hands are pushed to the ceiling in a slow and controlled manner independent of each other. With increasing strength, the exercise is conducted with a one pound weight which is held in the involved hand as it is pressed to the ceiling. When that is comfortable the incline is gradually increased to eventually reach the upright position. All presses should be performed in a slow and controlledmanner; they are progressed to the next level only when 20 repetitions can be performed comfortably.

The patient is instructed in all these exercises on three occasions:

1. Prior to surgery,
2. Immediately after surgery, and
3. Prior to leaving the hospital. Before discharge, the goals of assisted external rotation to 40 degrees and assisted elevation to 140 degrees must be accomplished.

The patient is placed in charge of their own rehabilitation and taught to progressively return to normal use of the shoulder. Typically, keyboarding and driving are achieved at two weeks, swimming is started at six weeks, golf or tennis are started at three-six month and chopping wood is precluded.

Footnotes

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