Shoulder APTA (3) Flashcards
The GH joint is the ___ most affected large joint by OA.
- 3rd, behind hip and knee
What are 3 broad categories of arthritis?
- osteoarthritis
- inflammatory arthritis
- other artritides
What are 2 types of OA?
- primary (idiopathic)
- secondary (post traumatic, e.g., fx, or post surgical)
What are 3 types of inflammatory arthritides?
- RA
- ankylosing spondylitis
- psoriatic arthritis
What is an example of an “other” arthritide?
- atraumatic or avascular osteonecrosis
- RC arthropathy (as a result of end stage RC disease)
What are the primary shoulder replacement surgeries that are used for GH arthritis?
- total shoulder arthroplasty (TSA)
- hemiarthroplasty (HA)
- reverse shoulder arthroplasty (RSA)
What muscles are typically directly affected by a shoulder arthroplasty?
- 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
What is the state of the literature regarding post-op shoulder arthroplasty rehab?
- crap.
- basically follow the surgeon’s guidelines. May be variable for how much ER is limited initially to protect the subscap repair
What is probably the most important factor that guides rehabilitation and expectation for improvement following shoulder arthroplasty?
- underlying pathology
What is a consideration for a pt following shoulder arthroplasty due to RA?
- progress will be slower, as they will likely have less robust RC tissue compared to OA.
Which of the following has the best prognosis for shoulder arthroplasty:
- OA
- RA
- post traumatic arthritis
- RC arthropathy
- OA; less soft tissue involvement, better osseous alignment, etc
What ROM for shoulder elevation should be expected for shoulder replacement for OA?
- probably ~140 or a bit more. Studies have ranging averages, some up to the upper 140s
Does shoulder arthroplasty typically improve function and pain for pts w/ OA?
- yes; usually it helps
What is usually a better procedure for OA. TSA or HA?
- TSA has better outcomes; strong evidence supports this
What % of pts w/ primary OA going in for shoulder arthroplasty have RC tears?
- 9%; usually just the supraspinatus
What % of pts w/ RA that are getting a shoulder replacement have full thickness RC tears?
- 24-30%
What is the most likely arthroplasty option for pts w/ later stage RA?
- HA or RSA
- due to significant bone loss, or significant humeral migration due to RC dysfunction
What are the advantages of TSA over HA?
- typically better pain relief and ROM
How much elevation ROM return can be expected w/ pts undergoing shoulder arthroplasty for RA?
- between 103-119*; so definitely lower than TSA
What is the expectation for pain relief following SA for RA?
- it’s good. 96% of pts report good pain relief
What replacement surgery is typically used for acute post fx? Why?
- usually HA, since the glenoid is typically spared in the trauma
What is a concern for SA rehab for acute fx pts that doesn’t exist for RA or OA?
- 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)
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?
- 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)
What is the expectation for average shoulder elevation ROM following shoulder arthroplasty for acute fx w/ HA?
- ~103*
- 70% had less than 120*
Is there potential to mess up an HA following acute humeral fx?
- yup. Can create iatrogenic injury if pt is pushed too far. Be conservative.
How much ER may be too much for PROM for an HA following acute humeral fx>? What ER is expected?
- 50*. Keep it less than that.
- typical ranges for ER are 15-24* with IR from L4-L1
What % of pts with HA following acute humeral fx can be expected to return to performing above shoulder activities?
- 50%
What % of patients with proximal humeral fx have nerve injuries? Which is most commonly affected?
- 67% will have nerve involvement
- most often axillary nerve is involved, but combinations of nerve lesions are associated with PHF (proximal humeral fx)
Pts classified as having post traumatic arthritis most often have what associated dx/hx?
- previous proximal humeral fx w/ or w/o surgical fixation
What kind of active elevation ROM can be expected for pts w/ SA for post traumatic arthritis?
- ~100*
For pts w/ SA for post traumatic arthritis, what are the timeframes for starting strengthening and AROM?
- 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
Does osteonecrosis begin at the level of cartilage or subchondral bone?
- subchondral bone
What are the two classifications of osteonecrosis?
- traumatic: related to fx of the proximal humerus
- atraumatic: related to disease px, e.g., chronic steroid use, chronic alcoholism, Cushing’s disease
Which is more likely to have a favorable outcome? SA for osteonecrosis following fx, or steroid use?
- steroid use
What is capsulorraphy arthropathy?
- considered a type of post traumatic arthritis
- instability that results in arthritis following surgical intervention
What are some considerations for treating pts post SA for capsulorraphy arthritis?
- 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
What is the concern with doing a TSA for a primary dx of RC arthropathy?
- may eventually result in glenoid component loosening
- used to be primarily HA for surgical management, however RSA is becoming the more popular for this
An HA for RC arthropathy will likely have positive effects for _____.
- pain and function
What is expected for elevation ROM for HA for RC arthopathy?
- ~86*
- the RC soft tissue damage is irreparable when arthropathy becomes the option…ROM will be limited
What defines someone who might be in a “limited goals” group following SA?
- instability
- RC/deltoid deficiency due to:
- denervation
- tuberosity malplacement
- poor tendinous tissue
What are the expectations for active elevation and ER ROM for the “limited goals” SA group?
- less than 90* active elevation
- ~20* of ER
Are there clear benefits to supervised therapy when compared to HEP for shoulder arthroplasty?
- 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
How many phases are there in the standard framework for TSA and HA rehab? What are their expected timeframes?
- Phase I: 0-3 weeks
- Phase II: 3-8 weeks
- Phase III: 8-16 weeks
- Phase IV: >16 weeks
What are the goals for Phase I of TSA/HA rehab?
- patient education
- allow healing of subscapularis
- control pain/inflammation
- initiate ROM exercises
- PROM: elevation (90-120) and ER (20-30)
What are the goals for Phase II of TSA/HA rehab?
- decreased pain and inflammation
- increase ADLs
- PROM: elevation (120), ER (30)
- initiate strengthening therex
What are the goals for Phase III of TSA/HA rehab?
- PROM: elevation (140), ER (30-40)
- AROM: elevation (120-140*)
- increase functional activities
- increase strength of scapular stabilizers
A pt is 2 weeks post-op TSA. Is it ok for them to use their affected arm to eat?
- 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
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?
- generally no. PROM is usually started 1-2 days post-op, or within the first week with standard TSA/HA
What are 3 standard initial PROM exercises to begin with for TSA?
- pendulums
- supine passive forward elevation
- ER to 30* as tolerated
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?
- 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.
T or F;
The therapist initiated scapular adduction therex at week 5 following a standard TSA. This is within normal protocol guidelines.
- F
- can start in the first week or two
T or F;
Heat may precede ROM therex, or be applied during stretches in Phase I of TSA rehab.
- T
What is the positioning for ER exercises in phase I of TSA rehab?
- 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.
What is a modification for supine passive elevation in early TSA rehab for pts w/ a hx of contralateral shoulder issues?
- put the arm on a chair and then bend forward/walk backward to get the passive stretch
Is there a concern with TSA for a therapist causing anterior dislocation or subscapularis rupture?
- yup. One study found that 5 of 7 instances of anterior dislocation or subscap failure were due to being too aggressive in PT.
A TSA patient is 5 weeks out and has 50* ER. Is this concerning?
- 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.
A pt with TSA due to RA is 5 weeks out. Can they begin ER in sidelying?
- 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
T or F;
During post-operative/injury phase of rehab, strengthening therex should focus on maximizing targeted muscle activity within tolerance.
- 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
What is “gatching”?
- 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
What change distally can be added to increase IR activation during an early shoulder elevation exercise?
- squeezing something in the hand
A TSA pt has been started on submax isometrics at 2 weeks post op. Is this appropriate?
- not really. Standard guidelines would wait until week 3-4.
When is it ok to start doing AAROM with a TSA pt?
- no earlier than week 3.
When is it ok to start doing strengthening against resistance with a TSA pt?
- in Phase II, around the 6-8 week mark.
- however, only for ER, IR, and extension
- IR is likely deferred to 8 weeks
When is it ok to start pulley therex with a TSA pt?
- 4-6 weeks; Phase II
When is it ok to start doing strengthening therex against resistance for abduction/flexion?
- Phase III: at least 8 weeks
A pt with RA who had a TSA is starting strengthening with resistance at 12 weeks. Is this appropriate?
- yes, typically all dxs are appropriate to begin strengthening at 12 weeks.
A pt with TSA really wants to get back to running, golf, and swimming. When is it likely ok to do these things?
- typically no earlier than 4-6 months post-op
How long is recovery considered to take following TSA?
- at least a year
What are the standard 3 indications for RSA over other arthroplasties?
- 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
What must be intact for a person to be a candidate for a RSA?
- intact deltoid function
- enough glenoid to be able to fixate the components
What is the prognostic difference between a deltopectoral vs a deltoid splitting approach for an RSA?
- higher incidence of dislocation with deltopectoral approach
- with deltoid splitting, will have to protect the deltoid; more conservative in the earlier stages
How long do pts typically use a sling following RSA?
- 4-6 weeks
Is there a lot of consensus on appropriate rehab following RSA?
- nope
What are some precautions for ROM following RSA?
- avoid functional IR to mitigate risk of dislocation
- avoid ER in coronal plane abduction due to potential instability
A pt following RSA has been using their arm for waist level activities at 3 weeks. Is this ok?
- yes, as long as they have good deltoid function
When do pts w/ RSA begin PROM exercises? What exercises are ok?
- within the first 7-10 days
- supine passive flexion
- ER to 30*
- that’s it
An RSA pt is 5 weeks out and has been using their arm during gait. Is that appropriate?
- not really; it should be avoided
When does strengthening typically begin for an RSA?
- 12 weeks
- there are some protocols that will begin it earlier with isometric/isotonic beginning at 6-8 weeks
