Reverse Total Shoulder Arthroplasty

• Initial recovery after shoulder surgery entails healing, controlling swelling and discomfort and regaining some shoulder motion. The following instructions are intended as a guide to help you achieve these goals until your 1^stpostoperative visit.

• COMFORT
  • Cold Therapy
    • If you elected to receive the circulating cooling device, this can be used continuously for the first 3 days, (while the initial post-op dressing is on). After 3 days, the cooling device should be applied 3 times a day for 20-30 minute intervals.
    • If you elected to receive the gel wrap, this may be applied for 20 minutes on, 20 minutes off as needed. You may apply this over the post-op dressing. Once the dressing is removed, be sure to place a barrier (shirt, towel, cloth, etc.) between your skin and the gel wrap.
    • If you elected to use regular ice, this may be applied for 20 minutes on, 20 minutes off as needed. You may apply this over the post-op dressing. Once the dressing is removed, be sure to place a barrier (shirt, towel, cloth, etc.) between your skin and the gel wrap.
  • Medication
    • Pain Medication-Take medications as prescribed, but only as often as necessary. Avoid alcohol and driving if you are taking pain medication.
      • You have been provided a narcotic prescription postoperatively. Use this medication sparingly for moderate to severe pain.
      • You are allowed two (2) refills of your narcotic prescription if necessary.
      • When refilling pain medication, weaning down to a lower potency or non-narcotic prescription is recommended as soon as possible.
      • Extra strength Tylenol may be used for mild pain.
      • Over the counter anti-inflammatories (Ibuprofen, Aleve, Motrin, etc.) shoulder be avoided for the first 4 weeks following surgery.
    • Anti-coagulation medication: A medication to prevent post-operative blood clots has been prescribed (Aspirin, Lovenox, etc.) This is the only medication that MUST be taken as prescribed until directed to stop by Dr. Forsythe.
    • Nausea Medication – Zofran (Odansetron) has been prescribed for nausea. You may take this as needed per the prescription instructions.
    • Constipation Medication -Colace has been prescribed for constipation. Both your pain medication and the anesthesia can cause constipation. Take this as needed.
  • Driving – Driving is NOT permitted as long as the sling is necessary.

• ACTIVITIES
  • You are immobilized with a sling and abductor pillow, full time, for approximately the first 6 weeks. Your doctor can tell you when you can discontinue use of the sling at your 1^stpostoperative visit. The sling may be removed for exercises.
  • Range-of-Motion Exercises –
    • While your sling is off you should flex and extend your elbow and wrist – (3x a day for 15 repetitions) to avoid elbow stiffness. You can also shrug your shoulders.
    • Ball squeezes should be done in the sling (3x a day for 15 squeezes).
    • You may NOT move your shoulder by yourself in certain directions. NO active flexion (lifting arm up) or abduction (lifting arm away from body) until Dr. Forsythe or your therapist gives permission. These exercises must be done under supervision of the therapist.
    • Physical therapy will begin approximately 2-3 weeks after surgery. Make an appointment with a therapist of your choice for this period of time. You have been given a prescription and instructions for therapy. Please take these with you to your first therapy visit.
    • Athletic activities such as throwing, lifting, swimming, bicycling, jogging, running, and stop-and-go sports should be avoided until cleared by Dr. Forsythe.

• WOUND CARE
  • Bathing - Tub bathing, swimming, and soaking of the shoulder should be avoideduntil allowed by your doctor - Usually 2-3 weeks after your surgery. Keep the dressing on, clean and dry for the first 3 days after surgery.
    • You may shower 3 days after surgery with a WATERPROOFbandage on. Apply a new dry dressing after showering.
  • Dressings - Remove the dressing 3 days after surgery. You may apply band-aids or dry sterile gauze to your incision.
  • Bathroom/Personal Hygiene – Placing your arm behind your back may predispose you to injuring your shoulder. Avoid tucking in your shirt or performing bathroom personal hygiene with the involved arm until you are cleared by Dr. Forsythe.

• EATING
  • Your first few meals, after surgery, should include light, easily digestible foods and plenty of liquids, since some people experience slight nausea as a temporary reaction to anesthesia

• CALL YOUR PHYSICIAN IF:
  • Pain in your shoulder persists or worsens in the first few days after surgery.
  • Excessive redness or drainage of cloudy or bloody material from the wounds (Clear red tinted fluid and some mild drainage should be expected). Drainage of any kind 5 days after surgery should be reported to the doctor.
  • You have a temperature elevation greater than 101°
  • You have pain, swelling or redness in your arm or hand.
  • You have numbness or weakness in your arm or hand.

• RETURN TO THE OFFICE
  • Your first return to our office should be within the first 1-2 weeks after your surgery. Call your physician’s office to make an appointment for this first post-operative visit.

REHABILITATION PROGRAM:

Reverse Total Shoulder Arthroplasty

NOTE: The following instructions are intended for your physical therapist and should be brought to your first physical therapy visit.

• General Information:
  • Reverse or Inverse Total Shoulder Arthroplasty (rTSA) is designed specifically for the treatment of glenohumeral (GH) arthritis when it is associated with irreparable rotator cuff damage, complex fractures as well as for a revision of a previously failed conventional Total Shoulder Arthroplasty (TSA) in which the rotator cuff tendons are deficient.
  • It was initially designed and used in Europe in the late 1980s by Grammont; and only received FDA approval for use in the United States in March of 2004.
  • The rotator cuff is either absent or minimally involved with the rTSA; therefore, the rehabilitation for a patient following the rTSA is different than the rehabilitation following a traditional TSA.
  • The surgeon, physical therapist and patient need to take this into consideration when establishing the postoperative treatment plan.

• Important rehabilitation management concepts to consider for a postoperative therapy rTSA program are:
  • Joint protection: There is a higher risk of shoulder dislocation following rTSA than a conventional TSA.
  • Avoidance of shoulder extension past neutral and the combination of shoulder adduction and internal rotation should be avoided for 12 weeks postoperatively.
  • Patients with rTSA don’t dislocate with the arm in abduction and external rotation. They typically dislocate with the arm in internal rotation and adduction in conjunction with extension. As such, Tucking in a shirt or performing bathroom / personnel hygiene with the operative arm is a particularly dangerous activity particularly in the immediate peri-operative phase.
  • Deltoid function: Stability and mobility of the shoulder joint is now dependent upon the deltoid and periscapular musculature. This concept becomes the foundation for the postoperative physical therapy management for a patient that has undergone rTSA.
  • Function: As usual, maximize overall upper extremity function, while respecting soft tissue constraints.
  • ROM: Expectation for range of motion gains should be set on a case-by-case basis depending upon underlying pathology. Normal/full active ROM of the shoulder joint following rTSA is not expected.

• Reverse Total Shoulder Arthroplasty Biomechanics
  • The rTSA prosthesis reverses the orientation of the shoulder joint by replacing the glenoid fossa with a glenoid base plate and glenosphere and the humeral head with a shaft and concave cup. This prosthesis design alters the center of rotation of the shoulder joint by moving it medially and inferiorly. This subsequently increases the deltoid moment arm and deltoid tension, which enhances both the torque produced by the deltoid as well as the line of pull/action of the deltoid. This enhanced mechanical advantage of the deltoid compensates for the deficient RC as the deltoid becomes the primary elevator of the shoulder joint. This results in an improvement of shoulder elevation and often individuals are able to raise their upper extremity overhead.

• Reverse Total Shoulder Arthroplasty Protocol
  • The intent of this protocol is to provide the physical therapist with a guideline/treatment protocol for the postoperative rehabilitation management for a patient who has undergone a Reverse Total Shoulder Arthroplasty (rTSA).
  • It is by no means intended to be a substitute for a physical therapist’s clinical decision making regarding the progression of a patient’s postoperative rehabilitation based on the individual patient’s physical exam/findings, progress, and/or the presence of postoperative complications.
  • If the physical therapist requires assistance in the progression of a postoperative patient who has had rTSA the therapist should consult with the referring surgeon.
  • The scapular plane is defined as the shoulder positioned in 30 degrees of abduction and forward flexion with neutral rotation. ROM performed in the scapular plane should enable appropriate shoulder joint alignment.

• Shoulder Dislocation Precautions:
  • No shoulder motion behind back. (NO combined shoulder adduction, internal rotation, and extension.)
  • No glenohumeral (GH) extension beyond neutral.
  • Precautions should be implemented for 12 weeks postoperatively unless surgeon specifically advises patient or therapist differently.

Phase I – Immediate Post Surgical Phase/Joint Protection (Day 1-6 weeks):

• Goals:
  • Patient and family independent with:
    • Joint protection
    • Passive range of motion (PROM)
    • Assisting with putting on/taking off sling and clothing
    • Assisting with home exercise program (HEP)
    • Cryotherapy
  • Promote healing of soft tissue / maintain the integrity of the replaced joint.
  • Enhance PROM.
  • Restore active range of motion (AROM) of elbow/wrist/hand.
  • Independent with activities of daily living (ADL’s) with modifications.
  • Independent with bed mobility, transfers and ambulation or as per pre-admission status.

• Phase I Precautions:
  • Sling is worn for 3-4 weeks postoperatively. The use of a sling often may be extended for a total of 6 weeks, if the current rTSA procedure is a revision surgery.
  • While lying supine, the distal humerus / elbow should be supported by a pillow or towel roll to avoid shoulder extension. Patients should be advised to “always be able to visualize their elbow while lying supine.”
  • No shoulder AROM.
  • No lifting of objects with operative extremity.
  • No supporting of body weight with involved extremity.

• Keep incision clean and dry (no soaking/wetting for 2 weeks); No whirlpool, Jacuzzi, ocean/lake wading for 4 weeks.

• Acute Care Therapy (Day 1 to 4):
  • Begin PROM in supine
    • Forward flexion and elevation in the scapular plane in supine to 90 degrees.
    • External rotation (ER) in scapular plane to available ROM as indicated by operative findings. Typically around 20-30 degrees.
    • No Internal Rotation (IR) range of motion (ROM).
    • Active/Active Assisted ROM (A/AAROM) of cervical spine, elbow, wrist, and hand.
    • Begin periscapular sub-maximal pain-free isometrics in the scapular plane.
  • Continuous cryotherapy for first 72 hours postoperatively, then frequent application (4-5 times a day for about 20 minutes).
  • Ensure patient is independent in bed mobility, transfers and ambulation
  • Ensure proper sling fit/alignment/ use.
  • Instruct patient in proper positioning, posture, initial home exercise program
  • Provide patient/ family with written home program including exercises and protocol information.

v Day 5 to 21:

• Continue all exercises as above.
• Begin sub-maximal pain-free deltoid isometrics in scapular plane (avoid shoulder extension when isolating posterior deltoid.)
• Frequent (4-5 times a day for about 20 minutes) cryotherapy.

v 3 Weeks to 6 Weeks:

• Progress exercises listed above.
• Progress PROM:
• Forward flexion and elevation in the scapular plane in supine to 120 degrees.
• ER in scapular plane to tolerance, respecting soft tissue constraints.
• Gentle resisted exercise of elbow, wrist, and hand.
• Continue frequent cryotherapy.

• Criteria for progression to the next phase (Phase II):
  • Tolerates shoulder PROM and isometrics; and, AROM- minimally resistive program for elbow, wrist, and hand.
  • Patient demonstrates the ability to isometrically activate all components of the deltoid and periscapular musculature in the scapular plane.

Phase II –Active Range of Motion / Early Strengthening Phase (Week 6 to 12):

• Goals:
  • Continue progression of PROM (full PROM is not expected).
  • Gradually restore AROM.
  • Control pain and inflammation.
  • Allow continued healing of soft tissue / do not overstress healing tissue.
  • Re-establish dynamic shoulder and scapular stability.
  • Continue to Avoid Shoulder Hyperextension

• Precautions:
  • In the presence of poor shoulder mechanics avoid repetitive shoulder AROM exercises/activity.
  • Restrict lifting of objects to no heavier than a coffee cup.
  • No supporting of body weight by involved upper extremity.

v 6 Weeks:

• Continue PROM program
• At 6 weeks post op start PROM IR to tolerance (not to exceed 50 degrees) in the scapular plane.
• Begin shoulder AA/AROM as appropriate.
  • Forward flexion and elevation in scapular plane in supine with progression to sitting/standing.
  • ER and IR in the scapular plane in supine with progression to sitting/standing.
• Begin gentle glenohumeral IR and ER sub-maximal pain free isometrics.
• Initiate gentle scapulothoracic rhythmic stabilization and alternating isometrics in supine as appropriate. Begin gentle periscapular and deltoid sub-maximal pain free isotonic strengthening exercises, typically toward the end of the 8^th
• Progress strengthening of elbow, wrist, and hand.
• Gentle glenohumeral and scapulothoracic joint mobilizations as indicated (Grade I and II).
• Continue use of cryotherapy as needed.
• Patient may begin to use hand of operative extremity for feeding and light activities of daily living including dressing, washing.

• 9 Weeks:
  • Continue with above exercises and functional activity progression
  • Begin AROM supine forward flexion and elevation in the plane of the scapula with light weights (1-3lbs. or .5-1.4 kg) at varying degrees of trunk elevation as appropriate. (i.e. supine lawn chair progression with progression to sitting/standing).
  • Progress to gentle glenohumeral IR and ER isotonic strengthening exercises in sidelying postion with light weight (1-3lbs or .5-1.4kg) and/or with light resistance resistive bands or sport cords.

• Criteria for progression to the next phase (Phase III):
  • Improving function of shoulder.
  • Patient demonstrates the ability to isotonically activate all components of the deltoid and periscapular musculature and is gaining strength.

Phase III – Moderate Strengthening Phase (Week 12 +):

• Goals:
  • Enhance functional use of operative extremity and advance functional activities.
  • Enhance shoulder mechanics, muscular strength and endurance.
• Precautions:
  • No lifting of objects heavier than 2.7 kg (6 lbs) with the operative upper extremity
  • No sudden lifting or pushing activities.

• Week 12 to Week 16
  • Continue with previous program as indicated
  • Progress to gentle resisted flexion, elevation in standing as appropriate.

Phase Iv – Continued Home Program (Typically 4+ months postop):

• Typically the patient is on a home exercise program at this stage to be performed 3-4 times per week with the focus on:
  • Continued strength gains
  • Continued progression toward a return to functional and recreational activities within limits as identified by progress made during rehabilitation and outlined by surgeon and physical therapist.

• Criteria for discharge from skilled therapy:
  • Patient is able to maintain pain free shoulder AROM demonstrating proper shoulder mechanics. (Typically 80 – 120 degrees of elevation with functional ER of about 30 degrees.)
  • Typically able to complete light household and work activities.