evidence based algorithm for rehabilitation after rc repair michael a. shaffer pt, atc, ocs
TRANSCRIPT
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’sRecipe for Homemade Bread
Step 1-
“Put 2 scoops of flour
into the green bowl”
Step 2-
Keep buying bread at
the store Normal Rockwell
Freedom from Want
What’s the goal?
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”
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°
Functional strength Able to complete 1) ADL’s, 2) Work, 3) Hobbies
Healed repair (?)
AFE = Active Forward Elevation
PFE = Passive Forward Elevation
PER = Passive External Rotation
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 PrescriptionExercise Series = 2 - 4x/ dayROM 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
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 forwardYour 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