Rehabilitation after Shoulder Arthroplasty.
Last updated Thursday, February 10, 2005
Figure 1 - Continuous passive motion machine: motor-driven adjustable cam and pulley system Figure 2 - Motivation chart displays progress toward the discharge goals Figure 3 - Assisted forward flexion in the supine position Figure 4 - Progressive forward lean Figure 5 - External rotation while lying on back Figure 6 - External rotation by holding onto a fixed object Figure 7 - Internal rotation: Grasping a towel behind the back with both hands Figure 8 - Cross-body movement Figure 9 - Progressive supine press Figure 10 - Bench press plus Figure 11 - Shoulder shrug About the rehabilitation program
This is the information which might be shared with patients after a
shoulder arthroplasty. Before it can be applied to a specific clinical
situation, however, it needs to be tailored to the patient, the surgery
and the surgeon.Goal of treatment The goal of shoulder arthroplasty is to restore function to an
impaired shoulder. Good shoulder function requires motion, stability,
strength, and smoothness. During the operation your doctor seeks to
optimize your shoulder's motion and stability by balancing the soft
tissues around your joint and releasing adhesions and contractures.
The smoothness of your joint is improved by the implantation of
highly polished artificial joint surfaces. The stage is now set for you
to continue the improvement in motion and stability and to develop some
strength in your reconstructed shoulder with a simple, but vitally
important series of exercises.
Persistence and progressive improvement The goal is to teach you how to successfully rehabilitate your
shoulder. This requires the early gaining of excellent range of motion
and the slow but progressive addition of strength, coordination, and
endurance. Frequent, gentle exercises have been proven much more
effective than irregular forceful efforts. The goal is a smooth
progression in activities without any episodes of soreness from
overdoing it. Make sure that each stage of exercises can be performed
comfortably and with the required number of repetitions before
advancing to the next stage. If soreness does develop, strengthening
exercises are stopped, but the range of motion exercises must be
continued so that stiffness does not result. Nothing must interfere
with the regular five-times-a-day conduct of the range of motion
program.
Many years of shoulder disability cannot be reversed without
persistent work over time on range of motion, strength, and
coordination. The shoulder requires two years of rehabilitative
exercises to reach maximal function after a shoulder replacement. If
you are willing to commit to such a rehabilitative effort, you will
achieve maximum benefit from your shoulder arthroplasty. If you have
any questions about this program, please be sure to ask your doctor.
Since primary goals of arthroplasty surgery are to provide motion
and smoothness, immediate postoperative passive motion is important.
The immediate postoperative program is essentially the same as that
used after the open release of a frozen shoulder. We use a simple
motor-driven adjustable cam and pulley system which puts the shoulder
through a 90 degree arc of flexion and a 45 degree arc of rotation.
This is used for at least 24 of the first 48 postoperative hours. The
patient is taught to use the opposite arm for assisted elevation and
external rotation. A "motivation" chart is maintained on the wall of
the patient's hospital room displaying progress toward the discharge
goals of 140 degrees of elevation and 40 degrees of rotation. Grip and
external rotation isometrics are started immediately. Unless a rotator
cuff repair has been performed, the patient is encouraged to use the
shoulder as comfort permits for active elevation and activities of
daily living. If rotator cuff repairs or osteotomies have been
performed, active motion and isometric cuff strengthening are delayed
until healing has occurred. Early motion Early on after your operation the highest priority is maintaining
the gains in motion achieved by your surgery. Because the muscles in
the operated shoulder are expected to be weak after surgery, one has to
depend on other means to maintain the motion during the first critical
weeks. We often use a passive motion machine immediately after surgery
to move the arm gently through an arch of motion even while you are
recovering from your anesthetic.
You will maintain and improve your shoulder reach using a routine which includes three basic maneuvers.
- 1. The Warm-Up
-
Bend over, letting the operated arm dangle comfortably in front of you
and move it in gentle circles in a clockwise and counterclockwise
direction with your hand pointing forward and with your hand pointing
back. This is predominantly to loosen up the shoulder and to relax it.
- 2. Assisted Forward Flexion in the Supine Position
- Forward flexion is lifting your stiff arm up as high as it will go.
To stretch your forward flexion, lie flat on your back, relax, and
grasp the wrist of the tight shoulder with your opposite hand. Here's a video of this exercise.
Using the power in your opposite arm, bring the stiff arm up as far as
it is comfortable. Start holding it for 10 seconds and then work up to
where you can hold it for a count of 100. Breathe slowly and deeply
while the arm is moved. Repeat this stretch three times, trying to help
the arm up a little higher each time.
An alternative method of stretching to forward flexion is to use
the "progressive forward lean." Here you sit beside a table, shelf,
armchair back or other fixed object with your arm in a comfortable
amount of elevation in Forward flexion. Then, by leaning forward, allow
the fixed object to apply a gentle, upward-directed force on the arm
for a count of 100. The advantage of this method is that it does not
require the help of the other arm and it can be sustained for a longer
period of time.
- 3. The Pulley
-
A pulley is mounted on a door with handles for both hands. Sit in a
chair facing the door. Place one handle in the hand of the operated
shoulder while it is relaxed at your side. Using the unoperated hand to
pull down on the other handle, gently raise the operated shoulder to a
horizontal and then toward a vertical position. Again, this exercise is
performed with total relaxation of the operated arm. When the arm
appears to stop because of stiffness, you should concentrate on
relaxing the operated arm, trying to get even greater degrees of
elevation. When you finally reach the apparent maximum in elevation,
hold it for a count of twenty while optimizing the relaxation.
It is essential that these range-of-motion exercises be performed at
least five times a day. Maintaining the range of motion gained at
surgery is one of the essential ingredients in restoring the function
to your shoulder. There is no one more qualified to do that than you.
Devise a system for registering your progress in these motion
exercises. For example, mark a spot on the bedpost that you can reach
while lying on your back or mark the height on the door that you can
reach with the pulley. Keeping track of your progress on a daily basis
will make sure that you are moving forward and provide you with
well-deserved positive feedback. Your doctor will help you keep track
of your progress.
Other motion exercises are important to your rehabilitation. Your doctor will indicate the exercises you should do.
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External rotation External rotation is turning the arm out to the side while your
elbow stays close to your body. External rotation is best stretched
while you are lying on your back. Hold a cane, yardstick, broom handle,
or dowel in both hands. Bend both elbows to a right angle. Use steady,
gentle force from your normal arm to rotate the hand of the stiff
shoulder out away from your body. Continue the rotation as far as it
will go comfortably. Work up to holding it there for a count of 100.
Repeat this exercise three times. Here's a video of this exercise.
An alternative method of stretching in external rotation is to hold
onto a fixed object and gently turn your body away while holding your
elbow at the side. The advantage of this method is that it does not
require the help of the other arm and it can be sustained for a longer
period of time.
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Internal rotation Internal rotation is the motion of reaching up the back. Grasp a
towel behind your back in both hands. To stretch in internal rotation,
gently pull the hand of the stiff shoulder up your back. Work up to
holding the maximum comfortable stretch for a count of 100. Repeat the
exercise three times. Here's a video of this exercise.
An alternative method of stretching in internal rotation is to hold
onto a fixed object behind you with your hand as high up your back as
it will easily reach. Then by bending your knees, a gentle stretching
force can be applied and sustained for a count of 100.
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Cross-body movement Cross body reach is reaching across your chest so that your elbow
approaches your opposite shoulder. To stretch cross the body, grasp the
elbow of the stiff shoulder in your opposite hand and pull it toward
the opposite shoulder. Work up to holding the maximum comfortable
stretch for 100 seconds. Repeat the exercise three times. Here's a video of this exercise.
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Water exercises Water exercises are often very well tolerated by the shoulder after
arthroplasty. Gentle movements of the arm in shoulder-deep water,
progressing slowly to swimming the breast stroke and then the crawl are
very helpful in restoring strength, coordination, and endurance to the
shoulder.
Comfortable activities with the operated arm are encouraged after
surgery. Your doctor will determine which activites are appropriate for
you at this time.Determining appropriate activities Your doctor will determine which of these activites are appropriate for you at this time:
- Working on your grip by squeezing play putty, foam, or a tennis ball
- Raising your hand to your face to eat and wash
- Writing, keyboarding, sewing, answering the telephone
- Swinging the arm in a relaxed way at your side while walking
Fitness Regular fitness exercise helps keep your joints supple. This
"lubricating" effect is optimized if you perform a half-hour of aerobic
exercise each day. This exercise may take a variety of forms including
brisk walking, jogging, riding a stationary or mobile bicycle, rowing,
climbing stairs, or using a crosscountry skiing simulator. If you have
concerns about your ability to carry out such an exercise program, you
should consult your general physician. It is not important that these
exercises be carried out vigorously; it is only important that in
addition to the stretching program, a half hour of your day be devoted
toward some form of aerobic exercise. Overall conditioning will have a
direct positive effect on the recovery of your shoulder.Driving Driving is not advised after shoulder replacement until two conditions are met:
- it has been at least six weeks after the operation, and
- the shoulder is comfortable enough and strong enough so that when
you are standing you can raise it to the horizontal position straight
out in front of you twenty times.
Using these criteria, you can avoid placing the shoulder,
passengers, other drivers, and pedestrians at risk from a shoulder that
cannot perform under emergency circumstances.
Strengthening of the shoulder after arthroplasty is a vital step in the
restoration of function. However, strengthening exercises early after
the operation are not nearly as important as establishing motion.
Therefore, your doctor is likely to institute strengthening exercises
only after you can achieve excellent motion and shoulder comfort.Shoulders require good muscle strength and posture After your prolonged shoulder arthritis and your shoulder
replacement, your muscles are expected to be weak and sore. In many
cases a period of time for muscle healing is required before
strengthening can be started. Please be sure that you do not do any
strengthening exercises that are painful: this is NOT a "no pain, no
gain" situation. If you have any questions about the advisability of
these strengthening exercises, wait until you have checked with your
doctor.
As you gain strength and coordination, try to carry out
progressively more of your usual activities, concentrating on using
smooth motions. Try to avoid actions that make your shoulder pop, snap,
or catch. Swimming, rowing, and using cross country ski simulators are
all good exercises for developing strength, coordination, and
endurance. They also have the advantage of exercising both shoulders at
the same time.
In general, activities of the shoulder can be increased as the
comfort, range of motion, and strength of the motion allow. It is
essential that these activities be added gradually and progressively so
that there is no risk of straining your muscles. A sudden increase in
activity or abrupt jerky or forceful activities will jeopardize the
comfort and function of your shoulder. Progressive supine press An important exercise is the progressive supine press. It is most
effective for helping you regain the ability to use your arm in an
elevated position. The nice thing about this exercise is that you can
do it by yourself and can adjust your rate of progress according to
what is most comfortable for you.
The exercise proceeds in small steps. Start by lying on your back,
grasping a washcloth with both hands together. Push the cloth straight
up toward the ceiling. At the end of each push, lift your entire
shoulder off the bed or floor. When you can do this 20 times easily,
separate your hands an inch or so when you push the cloth toward the
ceiling. This places slightly more of the load on the muscles of your
weaker shoulder. As the exercise gets easier, separate your hands more
on the washcloth until you can push your hand toward the ceiling
without any assistance from the opposite arm.
Practice this exercise with nothing in your hand until you are able
to repeat it 20 times. Then take an empty pint container and perform
the same movement, pushing it toward the ceiling. Add water to increase
the resistance slowly. When the container is full of water, the weight
is about one pound. Be sure that you can perform the movement
comfortably 20 times at each stage before advancing to the next stage.
When you can press one pound toward the ceiling 20 times, the next step
is to perform the exercise with your back propped up slightly on
pillows or by using a recliner or garden chair. When 20 comfortable
repetitions are possible, increase the degree to which your back is
propped up.
At each level, push the shoulder all the way up. Continue this
process until you are able to push the one pound weight 20 times toward
the ceiling in a sitting position. Work for smooth, slow, controlled
motions. Rotator cuff muscles The rotator cuff muscles are important shoulder muscles. They hold
the ball properly aligned in the socket. They are strengthened by
working against resistance in rotation internally (toward the body) and
externally (away from the body). It is important that your shoulder
have both strength and endurance of internal and external rotation.
This means that you need to carry out at least five exercise sessions
each day, each taking only about five minutes. The muscles of the
rotator cuff are strengthened by exercises in internal rotation and
external rotation. Internal rotation (video) is strengthened by holding
the elbow close to the side and trying to rotate the arm inward against
resistance. This resistance can be isometric (unmoving), such as the
opposite hand, a wall, or another fixed object. You can also use
dynamic exercises against rubber tubing, weights and pulleys, or free
weights while you lie on your side. External rotation (video) is
strengthened by holding the elbow at the side and trying to rotate the
arm outward against either isometric or dynamic resistance.
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Trapezius and scapular muscles A second important group of muscles, the scapular muscles, are those
that control the posture of your shoulder blade on the chest wall. The
purpose of these exercises is to strengthen these scapular muscles and
to eliminate bad habits or posture that your shoulder may have
developed. The largest and most important muscle groups are those which
move your shoulder blade forward (the serratus and pectoralis) and
those which lift the shoulder blade (the trapezius, levator scapulae,
and rhomboids). The first group of muscles are strengthened by a bench
press-type exercise performed while you lie on your back holding the
bar with your hands about a meter (yard) apart. At first only the bar
is used while you concentrate on powering the shoulder blade upward.
When you lift your shoulder blade off the bed or table, we call this
the "press plus." The "plus" is important for training the shoulder
blade muscles. Once you can control the bar alone for 20 repetitions,
add weight to the bar progressively up to about half your body weight.
Never use a weight greater than what you can control for 20
repetitions. Once you feel confident in the shoulder, you can start
doing a one hand press using a 1 lb weight and building up to 20
percent of your body weight.
The second muscle group helps strengthen your shoulder during
lifting at the side. Start with simple shoulder shrugs carried out with
the arms holding some weight at the side, lifting the point of your
shoulders as high as they will go 20 times. It is important that both
shoulders be exercised concurrently. Once the shoulder shrug becomes
easy, add weight 1 lb at a time to each hand, keeping the number of
repetitions at 20. With each shrug, concentrate on lifting the tip of
the shoulder.
The trapezius can also be strengthened by pulling against resistance.
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