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REHABILITATION OF THE
UPPER EXTREMITY:
COMMON CONDITIONS
& THERAPEUTIC INTERVENTIONS
BY: DANIELLE LAWS
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Pathophysiology & Etiology
Purpose of RC stabilizes humeral headinthe glenohumeral joint
4 Muscles & their tendons: X Supraspinatus
Y Infraspinatus
Z Teres Minor
[ Subscapularis
Overall Etiology:
RCtendontensilestresstolerance = up to 100N/mm (1)
Compressive & shearforces- overloadssupraspinatus tendon
Chronic= tinytearsthat progressovertime
Extrinsic Factors:
ImpingementTheory(2)
Demographic Variables
Intrinsic Factors:
Degenerative-Microtrauma Model(5)(6)
Rotator Cuff Injury
2009 Blum et al.
Acromion Morphology % Tea rs % Tx Response
Type I flat 17 89
Type II curved 43 73Type III - hooked 39 58
(3) (4)
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Signs/Symptoms & Evaluation
Pain:
- rarelybelowelbow,oftenalong insertionofdeltiod
Weakness:
- painonly = potentiallytendonitis
- pain + weakness=RC
tearDecreased Shoulder ROM:
- AROM, particularly ERandabduction
- PROMtypically pain-free, unlesscomorbidities exist (i.e. OA)
Crepitus:
- humeralrotation
- significant = osteophytes and/or FTtears
Positive Impingement/RC Tests:
(seenextslide)
Rotator Cuff Injury
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Rotator Cuff Injury
Test Procedure Positive Results
Quick FT Screen * Position: shouldersneutral & elbowsflexed 90
- Resist @ dorsum ofhandwhile pt. ERshoulders
Shoulderadd & IR = FTRCtear
(supraspinatus & infraspinatusCross-body
adduction test
- passivelyadductedarm acrossbodytoopposite
shoulder.
Pain= ACjointdamage
Drop-Arm Test
(Codmans Test)
* Position: Shoulderabductedto 160
- instructtolowerarm slowly.
RCdamage= arm drops quickly
duetonocontrol
Hawkins-Kennedy
Impingement Test
* Position: shoulder & elbowflexed 90.
- stabilizeshoulder & IRshoulder
Pain= impingementand/orRC
tear
Neer Impingement
Test
- stabilizescapula & passively pronate during maximal
passiveshoulderflexion & IR
Pain = subacromial impingement
Patte Test * Position: shoulder & elbowflexed 90
- stabilizeelbow & resist @ wristwhile pt. ERshoulder
Weaknessor pain= infraspinatus
damage
Gerber Liftoff Test * Position: shoulderextendedwith dorsum ofhand
resting oniliaccrest
- resist @ wristwhile pt.raises hand 2-5 in.from back
Painorinabilityto hold position=
subscapularis damage
Speeds Test * Position: elbowextended,forearm supinated,
shoulderflexed 90
- palpatebicepts tendon & resist @ wristwhile pt.
flexesshoulder 60
Painortenderness = long head
ofthebiceps
Jobe Test
(EmptyCan Test)
* Position: (B) shouldersabducted 90 & IR
-applydownward pressuredistallywhile patientresists
Asym.weaknessorinabilityto
hold position= supraspinatusdamage
Signs/Symptoms & Evaluation: Provocative Tests (7)
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Therapeutic Intervention: Management & Rehab (8)Rotator Cuff Injury
Initial Phase: X Supervisedtx atleast 2-3x/wk
YManualtx
Z Establishmentofhome program
- Criteria forprogressing to maintenance phase:
a.) nolongerrequire manualtx
b.) safe, proficient, & (I) atestablished home program
Maintenance Phase: X Home program only:
* ROM & Flexibility daily
* Strengthening 3x/wk
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Rotator Cuff Injury
INTERVENTIONS RECOMMENDATIONS INSTRUCTIONS
Manual Tx Softtissue &joint mobilization
Modalities Heat,Cold,orboth US shouldnotbe used
ROM Posturalexercises x Shrugs & Scap.retraction
GH motion- progressascomfortallows
pendulum AAROM AROM
xAAROM- can use: cane,pulleys, otherarm
xAROM- preventothershoulderfrom hiking
with: mirror,other handontrapezius
Flexibility(Stretching)
Ant. Shoulder - corner/doorjamb Post. Shoulder- crossedbodyadd.
xHold30 seceach
x rep x 5
x 10 secrestbetweeneach
Strengthening TheraBand:
- IRwith arm adductedatside
- scaption (ifno pain)
Scap. Stabilizer:- chair press
- push up plus
- uprightrowswith elasticband
Combostrengthening while standing:
- forwardelevation
- extension
x3setsx 10 reps
x increaseelasticresistanceasstrength
improves
Therapeutic Intervention: Management & Rehab (8)
* NOTE: illustrations
provided
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Therapeutic Intervention: Non-conservative/SurgicalRotator Cuff Injury
Indications: (9)
X NoresponsetoconservativeapproachesY Profoundweakness/debility
Z AcuteTrauma
Size > 3cm
Procedures:
Open Openincision
RCaccess & acromioplasty viadissectionofdeltoid
Mini-Open Smallopenincision (3-5 cm)
RCaccess & acromioplasty viaarthroscopy
Arthroscopic 3-4smallarthroscopy portals
RCaccess & acromioplasty viaarthroscopy
Post-op Rehabilitation: Routinelyinvolves phases
~Protocols Vary WIDELY depending onthe procedureandthesurgeons
technique/preferences
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Therapeutic Intervention: Post-op Rehabilitation (General)Rotator Cuff Injury
Precautions: (10)
X Donotactively movearm awayfrom body (~4-6 wks)Y Donotlifting ANYTHING,evenifonly moving elbow
Z Initially Donotreach behindback (extend)
Donot push up/offstructures (~6wks)
Depending onsurgeon checkforrotation precautions (IR/ER)
Insupine rolledtowel underelbow
Activity & Environmental Adaptation/Accommodation:
Codmans positiontoaccess underarms
Extended handles
One-handed ADL techniques
AE: (justtonameafew..)
reachers button & zipper hooks curlyshoelaces
brella bag plate guards/scoop dishes furniture hoists/pulleys
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Therapeutic Intervention: Post-op Rehabilitation (General)Rotator Cuff Injury
PHASE FOCUS PRECAUTIONS THERAPY
Phase I
(wk 1-wk 6)
Protect
repaired
tissues
Gain motion
Prevent
adhesions
No AROM
No pushing/pulling up
Noaggressive/painful
stretching
Sling/Immobilizer offfor
bathing & therapyonly
~4wks: startweaning fromimmobilization
Codmansexercises
Activeexerciseofother UE
jointswith arm add.atside
~elbow dependsonbiceps
involvement
ModalitiesPRN
Scar management
Safetyeducation
Phase II
(wk6-12)
Normalize
motion
Normalize
ADLs
Nolifting or ROMbeyond
comfort nothing heavier
thencup ofwater
Nosupporting bodyweightNobehindback movements
Nojerky/sudden motions
Active functional useduring
ADLs
ModalitiesPRN
Cont.safetyedu.Gradually progress:
PROMAAROMAROM
AROM
- Lighttheraband
- Low-levelclosedchain
- Scapula
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Therapeutic Intervention: Post-op Rehabilitation (General)Rotator Cuff Injury
PHASE FOCUS PRECAUTIONS THERAPY
Phase III
(wk 12 -16)
Strength
PLOF - motion,
endurance
returnto
normal ADLs,
work, and
modifiedrecreation
Nostraightarm lateralraise
Nolifting > 5 lbs
Nojerky/uncontrolled motion
Noarm raiseswith thumb
down (emptycan) keep
thumbs up
Free weights 1-4lbs
Progresstheraband resist.
ModalitiesPRN
moreaggressivestretching
Open-chainkinesthetic
awarenessdrills
Progressclosedchainactivities
Safetyeducation
Phase IV
(wk 16-24)
ROM
PLOF strength
& recreation
Home
program
Nolifting > 10lbs
Nosuddenlifting or pushing
Noactivitiesbeyondcurrent
ROMorstrength
Dailystretching
Progressive strengthening &
endurance
Phase V
(wk24 +)
Returntofull
PLOF
Criteria For FullReturntoPLOF:
1.) M.D. Clearance 3.) min 0 c/o pain
2.) ROM WFL forallregular ADLs 4.) regularHEPcompletion
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Pathophysiology & EtiologyArthritis
Osteoarthritis (OA) Rheumatoid Arthritis (RA)
Gradual, progressivebreakdownofarticular
cartilage & otherjointtissuesduetowear
andtear leading toovergrowth ofbone(11)
- wearing down & repair processaltered
- H2O & protein
- deterioration:
superficial deep= lesions= tears
- enzymes:thins= wearsaway
- osteophytes = triggering
- synovitis = decreasedsyn.fluid
Etiology: (16)
1.) Primary OA: unkown cause/factor
2.) Secondary OA: knowncause/factor
x Genetics/history x Obesity
x Trauma/infection x ChronicRCtear
x Cong. malformation x Radiation
x Alcohol/drugs x CS therapy
x Chronicdislocation x Sicklecell
Chronic,autoimmuneresponse/disease
markedbyinflammationofconnectivetissues
(synovial membrane) (11)
- thickenedsynoviallining
- formationofgranulationtissue
- destroysjointtissue & weakenscapsule
- adhesions deformity
Etiology: genetics + environment
Increased Risk: (12-15)
x F sex x Silicateexposure
x Family history x Smoking
x > 3CupsCoffee/Day (Decaf)
Decreased Risk: (14-15)
x Vit D intake x Tea
xOralContraception
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Arthritis
2008 Medicenet, Inc.
2008
2008
RA vs. OA
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Signs/Symptoms & Evaluation
Arthritis
Osteoarthritis (OA) Rheumatoid Arthritis (RA) Age x Morecommonwith age x Anyage
Gender x F=M x F>M
Distribution x Asymmetrical Symmetrical
x O
ftenlimitedto 1 setofjointshands/fingersorlarge WB joints
x Symmetrical
x
Small & largejoints
Typesof
Symptoms
x Limitedtoorthopedicsymptoms x Orthopedic,cardiac,respiratory,
fatigue, generalillness,ect.
Joint
Symptoms
x Mayacheandbestiff,but
limited swelling
x Painful,stiff,swelling
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ArthritisTherapeutic Intervention: Management & Rehab (17)
Condition Pathology Physical Findings Therapy
Rheumatoid
arthritis
x
Synovitis
x Vasculitis
x Onset:
earlyorlate
(>55 years)
x Bilateral & symmetrical
jointinvolvement
x Joint pain &
inflammationx Jointstiffness
x Contractures maybe
present
x Crepitus
x Fatigueoften
underappreciated
x Muscleweaknessx Enlargements- nodes
Acute exacerbation:- AROMexercises 2 reps/joint/day
- Frequentrestforfatigue
- Orthoses andsplintsforsupportive &
neutraljoint position
- Isometricexercises: 6-s hold,4reps
Subacute:- AROMexercises: 8-10 repetitions/joint/day
- Isometricexercises: 4-6 contractions
- Lightresistancedynamicexercises:
avoidifjointsare unstable, presenceof
tense
popliteal cystsorinternaljointderangement
- Aerobicexercise (aquatic/land): 15-20 min(3x/wk).
- Cardiaceval recommended: Establish HR
parameters & use perceivedROE scale
Stable disease:
- Asabove,butincreaseaerobicactivities
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ArthritisTherapeutic Intervention: Management & Rehab (17)
Condition Pathology Physical Findings Therapy
Osteoarthritis
x Cartilage
degeneration
xOnset:
Gradual &
progressive
x Stiffness & pain-
predominantlyinlarge,weight-bearingjoints
x Little-no Inflammation
x Joint malalignment
x Weakness
xJoint
instability/hypermobility
Mild disease:
- AROMexerciseswith dailyactivities:3-5 repsofflexibilityexercise & 8-10 repsof
staticexercises,each of6-sduration
- Dynamicexercises: 8-10 reps
- Low-impactaerobicactivities (aquatic & bikes):
20 min,3x/wk
- Balanceactivities (BAPS andtiltboard):
single-limbstanceModerate:
- Staticanddynamicexercises: reduceto 5 reps,
3-5 repsofflexibilityexercises
- Low-impactaerobicexercises (aquatic & bikes):
20 min,3x/week
-balance & proprioception activities- bilateral
Severe disease:- Low- tono-impactaerobicexercises (aquatic)
x Note: advisefunctionalactivitiestokeep
moving,fewtonorepsofdynamicexercises;
patienteducationisveryimportant
x Note: in patientswith ligamentous laxity &
malalignment, usecautionwith strengthening
exercises;orthoses,crutchesorwalker
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Introduction (9)Total Shoulder Arthroplasty (TSA)
7 Common Conditions:
OA RA AN
Post-traumaticarthritis Failed previousTSA Humeralfractures
RCrepair
4 Contraindications to TSA:
X Infectioninshoulderand/orsurrounding regions
Y Paralysisofdeltoid & RC
Z Neuropathicjoints
Bonyinsufficienciesthatcannotbeadequatelyreconstructed
Description:
In general,TSA involvestheremovalofanynecrotic/nonviabletissueafterwhich the
surfaceofthe glenoid anda portionofthe humeral headareremoved & replacedwith an
artificialimplantcalleda prosthesis.
*Keep In Mind: RCMuscles & Tissues
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ShoulderProstheses (9)Total Shoulder Arthroplasty (TSA)
2 Main Components:
X GlenoidComponent- replacesjointsocket
- durable, plasticinsertwith cuppedsurfaceon
onesideandfixation pegsontheother
Y HumeralComponent replaces humeral headanda portionoftheshaft- long metalstem thatfitsinto humeralcanal & a
half-sphereshaped, metal head
- head mountedontop ofstem & art.with glenoid
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Therapeutic Intervention: Post-op Rehabilitation (18-19)Total Shoulder Arthroplasty (TSA)
Phase I: Week 0-4
Goals: 1.) IncreasePROM
2.) DecreasePain3.) Retard Atrophy
Precautions:
x~3 Wks: nodriving
x 3-4 Wks: Sling atalltimesforcomfort & avoiding AROM
x 6-8 weeks: Supine- small pillowortowelrollshouldbe placedbehindelbowtoavoid
shoulder hyperextension/ant.capsule/subscapularis stretch (alwaysabletoseelbow)
x Avoidshoulder AROM
x Nolifting orsupporting bodyweight
Therapy:
x Cryotherapy
x CPM
x PROM: - Flexion = 0-90
- ER (at30 abduction) = 0-20 - IR (at30 abduction) = 0-30
x Pendulum
x Elbow/Wrist/HandROM & Grip Strength
x Rope & Pulley (wk #2)
x AAROM whencomfortallows
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Therapeutic Intervention: Post-op Rehabilitation (18-19)Total Shoulder Arthroplasty (TSA)
Phase II: Not Before Week #4
Goals: 1.) Increase Strength 3.) DecreasePain/Inflammation
2.) IncreaseROM 4.) Increase Functional Activities Precautions:
x Sling- onlyduring sleep & graduallyremovedovernext 2 wks
x 6-8 weeks: Supine- small pillowortowelrollshouldbe placedbehindelbowtoavoid
shoulder hyperextension/ant.capsule/subscapularis stretch (alwaysabletoseelbow)
x Poorshoulder mechanics- avoidshoulder AROMinstanding
x Nolifting heavierthancoffeecup orsupporting weightwith involvedside
x Nosuddenjerky motions
Therapy:
x Cont.Cryotherapy
x Cont.PROM: - Flexion = 0-90
- ER (at30 abduction) = 0-20
- IR (at30 abduction) = 0-30
- Assisted hor.adductionx Greaterthan 90 PROM AAROM pulleys (flexion & elevation)
x Begin AROM (painfree) : flexion & elevation
x Isometrics: - Abductors
- IR/ER
x Progressdistalexerciseswith lightresist.astolerated
x Scap.strengthening astolerated
x GentleGH & STjoint mob.
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Therapeutic Intervention: Post-op Rehabilitation (18-19)Total Shoulder Arthroplasty (TSA)
Phase III: Not BeforeWeek #6
Goals: 1.) GraduallyRestore Strength,Power, & Endurance
2.) Increase NMControl2.) Gradually Increase Functional Activities
Precautions:
x No heavylifting
x Nosuddenlifing/pushing/jerking
Therapy: Early Phase III
x Eliminatesling
x Progress AROM/activityastolerated
x AdvancePROM & stretching astolerated cont.PRN to maintainROM
x Initiate AAROM- IRbehindbackstretch
x Resisted- IR, ERinscap plane
x Isometrics: - Abductors
- IR/ER
x Beginlightfunctionalactivities Therapy: LaterPhase III
x Resistedflexion,elevationin planeofscap.,extension (therabands)
x Cont. progressing IR & ERstrengthening
x Progress IRstretch behindbackfrom AAROMto AROMastolerated
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Therapeutic Intervention: Post-op Rehabilitation (18-19)Total Shoulder Arthroplasty (TSA)
Phase IV: Not Before Week #12
Goals: 1.) Maintain pain-free AROM
2.) Increase Functional Activities Precautions:
x Noexercise/funct. Activitiesthat p stressonant.capsule & surrounding structures
(example combined ER & abductionabove 80 ofabduction)
x Ensure progressionofstrengthening is gradual
Therapy: Early Phase IV:
~OnHEP3-4x/wk
x Gradually progressstrengthening
x Graduallyreturnto mod.functionalactivity
Therapy: Late Phase IV:
x Returntorecreational hobbies & occupations
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Therapeutic Intervention: Post-op Rehabilitation (18-19)Total Shoulder Arthroplasty (TSA)
Occupation-Based Intervention Schedule
Phase 1:
Days 1-10ADL: Wash facewith affectedextremityindependently.
CPMortherapisttoassistinPROM
Cryotherapy
Days 10-21
ADL: Donanddoffshirt using hemidressing techniqueswith assist.
Sub maximalisometricexercisesagainstadoorwayorwall.
ContinuecryotherapyPhase 2:
ADL: Useaffectedextremitytobrush teeth
ADL: Eating using affectedextremity.
Lightstrength training using dumbbells (1-3lbs)
Continuecryotherapy
Phase 3:
ADL: Folding clothesLayinsupinewhilelifting dowelrodover head.
Internalandexternalrotationexercises using theraband.
Phase 4:
ADL: Driving- Practice putting onseatbeltandturning thesteering wheelwith affected
extremity (simulatedorreal)
Continuetheraband exercises
Light- moderate UE strength training orastolerated.
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THE END
Ron Leishman
Illustrationsof.com
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17.) Iversen M., Finckh, A., Liang,M. (2005). Exercise prescriptionsforthe majorinflammatoryandnon-inflammatoryarthritides. In W. Frontera, D.
Dawson, & D. Slovik (Eds).Exercise In Rehabilitation Medicine.Champaign, IL: Human Kinetics,Champaign.
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19.) UAB Highlands. (n.d). Total shoulderreplacement post-operative rehabilitation program: Tissue deficientrehab. Group. Birmingham, Alabama: Author.
References
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