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REHABILITATION FOLLOWING INSTABILITY
SURGERYJulia Walton & Tanya Mackenzie
Clinical Specialist Shoulder Physiotherapists
AIMS
• Our approach to rehabilitating patients following instability surgery
• Rehab considerations through the phases
REHABILITATION PRINCIPLES
Analgesia/Education
Quality ROM
Muscle
Timing
Strength
Patient SpecificGoal
Control
REHABILITATION PRINCIPLES
Analgesia/Education
Quality ROM
Muscle
Timing
Strength
Patient SpecificGoal
Control
Avoid Deconditioning
REHABILITATION PRINCIPLES
Analgesia/Education
Quality ROM
Muscle
Timing
Strength
Patient SpecificGoal
Control
Avoid Deconditioning
ACCELERATED REHAB
• Higher patient satisfaction
• Lower post operative pain
• Earlier return to functionSlow Kim et al 2003
But…….
REHABILITATION• ac·cel·er·ate
1. to cause faster or greater activity, development, progress, advancement, etc., in: to accelerate economic growth.
2. to hasten the occurrence of: to accelerate the fall of a government.
3. Mechanics . to change the velocity of (a body) or the rate of (motion); cause to undergo acceleration.
4.to reduce the time required for (a course of study) by intensifying the work, eliminating detail, etc.
PRE-SURGERY
• Get started!
• Patient assessment
• Global conditioning/fitness
• Education
• Familiarisation of post op rehabilitation
POST-SURGERY
• Operation Note
• Immediately Available
• Repair Quality
• Associated Procedures / Findings
SAFE ZONE
• ROM determined Peri-Op
• Doesn’t put strain on repair
• Gives Confidence - clinician & patient
THE SCIENCE...
• Strict immobilisation results in functional instability with rotator cuff inhibition, muscular atrophy, and poor neuromuscular control.
• Get the balance right!
Killian et al 2012
WHAT ARE WE PROTECTING?
• The repair itself
• Sub-optimal muscle performance
• Poor neuromuscular control
EXERCISE CHOICES
• Consider the of the value of exercises
• ROM
• Proprioception
• Core
• Kinetic Chain
SUPRASPINATUS EMG
Uhl T. Dept of Rehabilitation Sciences. University of Kentucky, 2004
Exercise Mean % SD
Supine Passive ROM 1 6
Side-Lying Elevation 2 6
Prayer Position 2 2
Wash Cloth press-up hands close 3 7
Supine press-up 4 8
Scapular Protraction on Ball 5 9
Forward Bow (Pendular) 5 6
<10% - Trace activity/background noise, 10-20% - low activity
ANTERIOR INSTABILITY PROTOCOLDay 1 - 3 weeks Protection Phase
• Sling for 3 weeks • Teach axillary hygiene• Teach postural awareness and scapular setting• Core stability exercises as appropriate)• proprioceptive exercises (minimal weightbearing below 90 degrees)• Active assisted ROM as comfortable (in 'safe zone' )• Do not force or stretch• No combined abduction & external rotation
6 - 12 Weeks Progress to Functional Phase/End Stage • Regain scapula & glenohumeral stability working for
shoulder joint control rather than range• Gradually increase ROM• Strengthen• Increase proprioception through open & closed chain
exercise• Progress core stability exercises• Ensure and treat posterior tightness, if required• Incorporate sports-specific rehabilitation• Plyometrics and perturbation training
3 - 6 weeks Recovery Phase • Wean off sling• Progress active assisted to active ROM as comfortable• open chain gh joint ROM with RC graded strengthening through
painfree ROM • Do not force or stretch• No combined abduction & external rotation
PROTECTION PHASE
• Safe zone ROM
• Proprioception
• Re-enforcing good motor programming
• Kinetic chain involvement
THE BIGGER PICTURE…
• 50% power from tennis serve is generated from Lower quadrant
• Shoulder acts as a funnel to transfer energy
• Posterior oblique sling
Kibler 1995
WHAT DO WE NEED FOR SUCCESS?• Optimal biomechanics
• Flexibility
• Proprioception
• Strength
• Endurance
• Integrated into technique reproducible/learntSciascia & Cromwell (2013)
Throughout the kinetic chain
KINETIC CHAIN CONSIDERATIONS
• A step increases scapulothoracic recruitment by 10%
• Rotator cuff strength improves by 24% when scapula is retracted/stabilised
Tate et al 2008Kibler et al 2006