Transcript Slide 1

Evidence Based Algorithm for
Rehabilitation after RC Repair
Michael A. Shaffer
PT, ATC, OCS
Instability Guidelines
NOT THIS TALK!!!
JOSPT March 2010
‘Well if you think you
can do better,
go ahead and try.’
(paraphrasing)
“Patients completed a standard
physical therapy program”
“S/P RCR- MOON Protocol”
Standard PT Program
 0-2 Weeks
 Pendulums
 Elbow AROM
 Grip Isometrics
 2-6 Weeks
 PROM/ AAROM
 > 6 Weeks
 “Strengthening”
Shari Shaffer’s Grandmother’s
Recipe for Homemade Bread
Step 1“Put 2 scoops of flour
into the green bowl”
Step 2Keep buying bread at
the store
Normal Rockwell
Freedom from Want
What’s the goal?
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Dissect the black box of exercise prescription
Supplement the ASSET RC Guidelines
Spur discussion among “seasoned” clinicians
Serve as a guide for novice clinicians
Integral Features of an Algorithm
 “Delayed” and Standard on same algorithm
 ROM Progression Detailed
 PROM, AROM
 ROM “gate” to strengthening
 Strengthening Progression Detailed
 Dosing
 Staged elevation program
 End Point for Supervised Rehab
 “Maintenance program”
A million ways to fold them…
But only two ways to use them
 Avoid getting lost…
 Prevent the most common
problems
 Or after you’re lost….
 Fix the problems to get
back on track
“Typical Patient”
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63 y.o. male
Full thickness 3-5 cm2 SS and IS
s/p arthroscopic RCR
Immob. in standard sling or ultrasling
2 week follow up visit
 Pain = 4/10 at rest. Difficulty sleeping.
 PFE = 0-95°; PER = 0-10°
What are the rehab goals after RC Repair?
 Pain controlled
 Functional ROM
 > 115° AFE
 > 140° PFE
 > 75° PER at 90°
AFE = Active Forward Elevation
PFE = Passive Forward Elevation
PER = Passive External Rotation
 Functional strength
 Able to complete 1) ADL’s, 2) Work, 3) Hobbies
 Healed repair (?)
Avoid Painful – Stiff
Train Wreck
Avoid Painful-Stiff
0-2 weeks
 Start correct exercises
 Identify problems early
 Comprehension
 Pain
 ROM
ROM Progression
 Start 0-14 days
 Exercises
 Pendulums
 Supine PFE w/ opp. hand
 Supine PER
** Exercise Prescription
Exercise Series = 2 - 4x/ day
ROM Exercises = 5 - 10x each w/ 10 sec hold
ROM Progression
 ROM Check
 > 80° PFE
 > 10° PFE Gain
 If Yes
 Return in 2 weeks
 If No
 Instruct in Table Step Backs
 Return within 2 days
Back on Track?
3-4 Weeks
 ROM Check
 110° PFE
 25° PER
 20° PAbd.
 If Yes
 Remove sling as per MD
 Return in 2 weeks
 If No
 Add OH Pulleys
 Supervised Rehab 1-2x/week
 PROM
What’s the goal of the algorithm?
Assistance out of a rough spot
Persistent problems
3-4 weeks
 Still struggling
(< 80° PFE/ <10° Gain)
 Comprehension
 OH Pulleys
 Pain
 ∆ Ex. Program/ MD
 ROM
 Start 2-3x week PROM
Avoid Painful- Stiff
~ 4 Weeks
 What predominates?
 Pain
 Pendulums only
 Stiffness
 Continue PROM
 Increase HEP
 Frequency
 End range hold time
What Predominates?
 Pain
 Resting pain
 Pain before end range (empty end feel)
 Stiffness
 Pain after end range
Strengthening Progression
 Typical protocol = 6 weeks
 Clinically?
 6 weeks if……..x,y,z
 ROM is the gate to strengthening
ROM is the Gate to Strengthening
ROM is the Gate to Strengthening
 6 Weeks
 Elastic Resistance
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IR
ER
Extension* (unilateral)
Rowing* (bilateral)
* to neutral
*THERABAND INSTRUCTION: (For each exercise/motion)
-Start with yellow Theraband (1x10 reps)
-When patient “can complete the exercise without difficulty”, then progress to 2x10 reps
-Eventually progress to 3x10 reps
-Advance to next resistance level (color) and begin with 1x10 reps
Expected recovery - Approximately 1 week/ color.
Other components
 Strengthening progressions
 9 Weeks
 12 Weeks
 “Advanced strengthening” (athletes, laborers)
 Guide for…
 Scapular hiking
 Limited active elevation
 Return to work, sport criteria
What we need to move forward
Your Feedback, but…..
(Keeping in algorithmic format)
 NO
 “I do ______ with my patients after RC surgery.”
 YES
 “I do ______ with my patients after RC surgery
when/ if they present like ______”
Thank You.
Brian G. Leggin PT, DPT, OCS
Chuck Thigpen PhD, PT, ATC
Reg. Wilcox PT, DPT, MS, OCS