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OCS prep > Shoulder APTA (3) > Flashcards

Shoulder APTA (3) Flashcards

1
Q

The GH joint is the ___ most affected large joint by OA.

A
  • 3rd, behind hip and knee
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2
Q

What are 3 broad categories of arthritis?

A
  • osteoarthritis
  • inflammatory arthritis
  • other artritides
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3
Q

What are 2 types of OA?

A
  • primary (idiopathic)

- secondary (post traumatic, e.g., fx, or post surgical)

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4
Q

What are 3 types of inflammatory arthritides?

A
  • RA
  • ankylosing spondylitis
  • psoriatic arthritis
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5
Q

What is an example of an “other” arthritide?

A
  • atraumatic or avascular osteonecrosis

- RC arthropathy (as a result of end stage RC disease)

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6
Q

What are the primary shoulder replacement surgeries that are used for GH arthritis?

A
  • total shoulder arthroplasty (TSA)
  • hemiarthroplasty (HA)
  • reverse shoulder arthroplasty (RSA)
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7
Q

What muscles are typically directly affected by a shoulder arthroplasty?

A
  • deltopectoral incision to gain initial entry.
  • subscapularis is typically released to expose the joint
  • LH biceps tendon may be tenodesed (reattached) or a tenotomy (not reattached) may be performed
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8
Q

What is the state of the literature regarding post-op shoulder arthroplasty rehab?

A
  • crap.
  • basically follow the surgeon’s guidelines. May be variable for how much ER is limited initially to protect the subscap repair
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9
Q

What is probably the most important factor that guides rehabilitation and expectation for improvement following shoulder arthroplasty?

A
  • underlying pathology
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10
Q

What is a consideration for a pt following shoulder arthroplasty due to RA?

A
  • progress will be slower, as they will likely have less robust RC tissue compared to OA.
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11
Q

Which of the following has the best prognosis for shoulder arthroplasty:

  • OA
  • RA
  • post traumatic arthritis
  • RC arthropathy
A
  • OA; less soft tissue involvement, better osseous alignment, etc
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12
Q

What ROM for shoulder elevation should be expected for shoulder replacement for OA?

A
  • probably ~140 or a bit more. Studies have ranging averages, some up to the upper 140s
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13
Q

Does shoulder arthroplasty typically improve function and pain for pts w/ OA?

A
  • yes; usually it helps
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14
Q

What is usually a better procedure for OA. TSA or HA?

A
  • TSA has better outcomes; strong evidence supports this
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15
Q

What % of pts w/ primary OA going in for shoulder arthroplasty have RC tears?

A
  • 9%; usually just the supraspinatus
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16
Q

What % of pts w/ RA that are getting a shoulder replacement have full thickness RC tears?

A
  • 24-30%
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17
Q

What is the most likely arthroplasty option for pts w/ later stage RA?

A
  • HA or RSA

- due to significant bone loss, or significant humeral migration due to RC dysfunction

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18
Q

What are the advantages of TSA over HA?

A
  • typically better pain relief and ROM
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19
Q

How much elevation ROM return can be expected w/ pts undergoing shoulder arthroplasty for RA?

A
  • between 103-119*; so definitely lower than TSA
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20
Q

What is the expectation for pain relief following SA for RA?

A
  • it’s good. 96% of pts report good pain relief
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21
Q

What replacement surgery is typically used for acute post fx? Why?

A
  • usually HA, since the glenoid is typically spared in the trauma
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22
Q

What is a concern for SA rehab for acute fx pts that doesn’t exist for RA or OA?

A
  • these fxs typically have 3-4 breaks, with the greater tuberosity needing to be fixated. Typically, it is advised to avoid AAROM for the first 4-5 days post-op, but that advice is more currently challenged, advocating for longer periods without RC activation to avoid tuberosity migration.
  • likely need to be more conservative with elderly pts as well (>70 yo)
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23
Q

If a pt that had an HA following a 4-part fx is having a bad outcome, should I feel like it’s my fault?

A
  • probably not.
  • the surgeries are really complex. There is a high rate of malpositioned/aligned tuberosity and/or components
  • a significant proportion of pts are unsatisfied after the surgery (~40% per one study…but there’s not a ton on this subject)
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24
Q

What is the expectation for average shoulder elevation ROM following shoulder arthroplasty for acute fx w/ HA?

A
  • ~103*

- 70% had less than 120*

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25
Q

Is there potential to mess up an HA following acute humeral fx?

A
  • yup. Can create iatrogenic injury if pt is pushed too far. Be conservative.
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26
Q

How much ER may be too much for PROM for an HA following acute humeral fx>? What ER is expected?

A
  • 50*. Keep it less than that.

- typical ranges for ER are 15-24* with IR from L4-L1

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27
Q

What % of pts with HA following acute humeral fx can be expected to return to performing above shoulder activities?

A
  • 50%
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28
Q

What % of patients with proximal humeral fx have nerve injuries? Which is most commonly affected?

A
  • 67% will have nerve involvement

- most often axillary nerve is involved, but combinations of nerve lesions are associated with PHF (proximal humeral fx)

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29
Q

Pts classified as having post traumatic arthritis most often have what associated dx/hx?

A
  • previous proximal humeral fx w/ or w/o surgical fixation
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30
Q

What kind of active elevation ROM can be expected for pts w/ SA for post traumatic arthritis?

A
  • ~100*
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31
Q

For pts w/ SA for post traumatic arthritis, what are the timeframes for starting strengthening and AROM?

A
  • depends on whether the greater tuberosity was osteotomized
  • w/o osteotomy, can expect AROM at ~6 weeks, and strengthing around 12 weeks.
  • w/ osteotomy, these may be restricted until 12 weeks
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32
Q

Does osteonecrosis begin at the level of cartilage or subchondral bone?

A
  • subchondral bone
33
Q

What are the two classifications of osteonecrosis?

A
  • traumatic: related to fx of the proximal humerus

- atraumatic: related to disease px, e.g., chronic steroid use, chronic alcoholism, Cushing’s disease

34
Q

Which is more likely to have a favorable outcome? SA for osteonecrosis following fx, or steroid use?

A
  • steroid use
35
Q

What is capsulorraphy arthropathy?

A
  • considered a type of post traumatic arthritis

- instability that results in arthritis following surgical intervention

36
Q

What are some considerations for treating pts post SA for capsulorraphy arthritis?

A
  • will have to be more conservative with stretching, as the condition is associated with instability. Likely keep things in the plane of the scapula
  • strengthening may be delayed to 12 weeks depending on the specifics of the procedure
37
Q

What is the concern with doing a TSA for a primary dx of RC arthropathy?

A
  • may eventually result in glenoid component loosening

- used to be primarily HA for surgical management, however RSA is becoming the more popular for this

38
Q

An HA for RC arthropathy will likely have positive effects for _____.

A
  • pain and function
39
Q

What is expected for elevation ROM for HA for RC arthopathy?

A
  • ~86*

- the RC soft tissue damage is irreparable when arthropathy becomes the option…ROM will be limited

40
Q

What defines someone who might be in a “limited goals” group following SA?

A
  • instability
  • RC/deltoid deficiency due to:
    • denervation
    • tuberosity malplacement
    • poor tendinous tissue
41
Q

What are the expectations for active elevation and ER ROM for the “limited goals” SA group?

A
  • less than 90* active elevation

- ~20* of ER

42
Q

Are there clear benefits to supervised therapy when compared to HEP for shoulder arthroplasty?

A
  • probably depends on how far out you look.

- but no, at 3 years, there didn’t seem to be a difference based on one study

43
Q

How many phases are there in the standard framework for TSA and HA rehab? What are their expected timeframes?

A
  • Phase I: 0-3 weeks
  • Phase II: 3-8 weeks
  • Phase III: 8-16 weeks
  • Phase IV: >16 weeks
44
Q

What are the goals for Phase I of TSA/HA rehab?

A
  • patient education
  • allow healing of subscapularis
  • control pain/inflammation
  • initiate ROM exercises
  • PROM: elevation (90-120) and ER (20-30)
45
Q

What are the goals for Phase II of TSA/HA rehab?

A
  • decreased pain and inflammation
  • increase ADLs
  • PROM: elevation (120), ER (30)
  • initiate strengthening therex
46
Q

What are the goals for Phase III of TSA/HA rehab?

A
  • PROM: elevation (140), ER (30-40)
  • AROM: elevation (120-140*)
  • increase functional activities
  • increase strength of scapular stabilizers
47
Q

A pt is 2 weeks post-op TSA. Is it ok for them to use their affected arm to eat?

A
  • yes. Can bring the hand to the mouth and use the arm for waist level activities
  • however, should not be lifting, pushing, pulling, or leaning on the arm
48
Q

A pt is 2 weeks post-op TSA. They have not done pendulums or any other PROM therex. They said they are supposed to wait until they are 3 weeks out before it can be moved. Is this correct?

A
  • generally no. PROM is usually started 1-2 days post-op, or within the first week with standard TSA/HA
49
Q

What are 3 standard initial PROM exercises to begin with for TSA?

A
  • pendulums
  • supine passive forward elevation
  • ER to 30* as tolerated
50
Q

The pt is doing their PROM exercises in Phase I of TSA rehab 10x/day with reps of 5-10. Is this too much? Too little?

A
  • meh, it’s a bit off

- standard practice would be 4-6x/day with reps of 10-20. 5-10 second holds for stretches as tolerated.

51
Q

T or F;

The therapist initiated scapular adduction therex at week 5 following a standard TSA. This is within normal protocol guidelines.

A
  • F

- can start in the first week or two

52
Q

T or F;

Heat may precede ROM therex, or be applied during stretches in Phase I of TSA rehab.

A
  • T
53
Q

What is the positioning for ER exercises in phase I of TSA rehab?

A
  • supine, with pillows under the elbow to bring the GH into the scapular plane. ~6-8 inches between arm and body. No >20-30* ER to maintain integrity of subscapularis repair.
54
Q

What is a modification for supine passive elevation in early TSA rehab for pts w/ a hx of contralateral shoulder issues?

A
  • put the arm on a chair and then bend forward/walk backward to get the passive stretch
55
Q

Is there a concern with TSA for a therapist causing anterior dislocation or subscapularis rupture?

A
  • yup. One study found that 5 of 7 instances of anterior dislocation or subscap failure were due to being too aggressive in PT.
56
Q

A TSA patient is 5 weeks out and has 50* ER. Is this concerning?

A
  • yes. that’s a lot more than expected, as most guidelines are still in the 20-30* for ER through the first 6-8 weeks. May be indicative of subscap tendon failure.
57
Q

A pt with TSA due to RA is 5 weeks out. Can they begin ER in sidelying?

A
  • AROM against gravity is not recommended for RA, postacute fx, or greater tuberosity osteotomy until 6 weeks or later.
  • however, gravity eliminated or supported movements are likely ok
58
Q

T or F;

During post-operative/injury phase of rehab, strengthening therex should focus on maximizing targeted muscle activity within tolerance.

A
  • F-ish
  • as the structure is healing, lower intensity, supported movements are optimal
  • e.g., shorter lever arms through use of ball, slant board, etc
59
Q

What is “gatching”?

A
  • changing the pt’s body position to allow for lower intensity muscle activation in an otherwise difficult to achieve alignment.
  • e.g., HOBE to 30* to allow for elevation >90* against gravity with less torque
60
Q

What change distally can be added to increase IR activation during an early shoulder elevation exercise?

A
  • squeezing something in the hand
61
Q

A TSA pt has been started on submax isometrics at 2 weeks post op. Is this appropriate?

A
  • not really. Standard guidelines would wait until week 3-4.
62
Q

When is it ok to start doing AAROM with a TSA pt?

A
  • no earlier than week 3.
63
Q

When is it ok to start doing strengthening against resistance with a TSA pt?

A
  • in Phase II, around the 6-8 week mark.
  • however, only for ER, IR, and extension
  • IR is likely deferred to 8 weeks
64
Q

When is it ok to start pulley therex with a TSA pt?

A
  • 4-6 weeks; Phase II
65
Q

When is it ok to start doing strengthening therex against resistance for abduction/flexion?

A
  • Phase III: at least 8 weeks
66
Q

A pt with RA who had a TSA is starting strengthening with resistance at 12 weeks. Is this appropriate?

A
  • yes, typically all dxs are appropriate to begin strengthening at 12 weeks.
67
Q

A pt with TSA really wants to get back to running, golf, and swimming. When is it likely ok to do these things?

A
  • typically no earlier than 4-6 months post-op
68
Q

How long is recovery considered to take following TSA?

A
  • at least a year
69
Q

What are the standard 3 indications for RSA over other arthroplasties?

A
  • massive or irreparable RC damage
  • PHF resulting in deficient RC
  • revision of previous arthroplasty that results in a RC deficiency
  • however is starting to be used as an alternative to TSA for dx that are less likely to be successful
70
Q

What must be intact for a person to be a candidate for a RSA?

A
  • intact deltoid function

- enough glenoid to be able to fixate the components

71
Q

What is the prognostic difference between a deltopectoral vs a deltoid splitting approach for an RSA?

A
  • higher incidence of dislocation with deltopectoral approach
  • with deltoid splitting, will have to protect the deltoid; more conservative in the earlier stages
72
Q

How long do pts typically use a sling following RSA?

A
  • 4-6 weeks
73
Q

Is there a lot of consensus on appropriate rehab following RSA?

A
  • nope
74
Q

What are some precautions for ROM following RSA?

A
  • avoid functional IR to mitigate risk of dislocation

- avoid ER in coronal plane abduction due to potential instability

75
Q

A pt following RSA has been using their arm for waist level activities at 3 weeks. Is this ok?

A
  • yes, as long as they have good deltoid function
76
Q

When do pts w/ RSA begin PROM exercises? What exercises are ok?

A
  • within the first 7-10 days
  • supine passive flexion
  • ER to 30*
  • that’s it
77
Q

An RSA pt is 5 weeks out and has been using their arm during gait. Is that appropriate?

A
  • not really; it should be avoided
78
Q

When does strengthening typically begin for an RSA?

A
  • 12 weeks

- there are some protocols that will begin it earlier with isometric/isotonic beginning at 6-8 weeks

OCS prep (25 decks)

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