Reverse Total Shoulder Arthroplasty Protocol: 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. 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 physical therapy rTSA program
are: 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 / persona hygiene with the operative arm is an especially 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.
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:
Surgical Considerations: The surgical approach needs to be considered when devising the postoperative plan of care.
Progression to the next phase based on Clinical Criteria and Time Frames as Appropriate. Phase I – Immediate Post Surgical Phase/Joint Protection (Day 1-6 weeks):Goals:
o Joint protection
Phase I Precautions:
once able. The use of a sling often may be extended for a total of 6 weeks, if the current rTSA procedure is a revision surgery.
roll to avoid shoulder extension. Patients should be advised to “always be able to visualize their elbow while lying supine.”
Acute Care Therapy (Day 1 to 4):
Day 5 to 21:
3 Weeks to 6 Weeks:
Criteria for progression to the next phase (Phase II):
Phase II –Active Range of Motion / Early Strengthening Phase (Week 6 to 12):Goals:
Precautions:
Week 6 to Week 8:
Week 9 to Week 12:
Criteria for progression to the next phase (Phase III):
Phase III – Moderate strengthening (Week 12 +)Goals:
Precautions:
Week 12 to Week 16:
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:
Criteria for discharge from physio therapy:
How long do you do physical therapy after reverse shoulder replacement?Most people who have an uncomplicated total shoulder replacement can expect to spend about six to eight weeks in physical therapy. Some people sail through rehab and reach their goals more quickly, while others take a bit more time. Most often, people are back to normal about 12 to 16 weeks after surgery.
When do you start physical therapy after reverse shoulder surgery?Light strengthening exercises begin 6 to 8 weeks after your surgery. Again, the focus is on improving the strength of your deltoid muscle and the muscles that attach to your shoulder blade. Strengthening exercise are performed once daily 3 to 5 times per week.
What is reverse total shoulder arthroplasty protocol?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 ...
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