Page 26 - ISAKOS 2019 Newsletter Volume 1

CURRENT CONCEPTS
Rehabilitation After Arthroscopic Shoulder Surgery
During this phase, the shoulder is immobilized with a sling or orthotic device in order to protect the repair, and therapy is focused on preserving joint range of motion as much as possible without compromising the repair. In addition, muscular contractures in the neck, scapula, upper thorax, and arm are treated and scapular exercises are started.
The second phase, which can last up to 3 months after surgery, is characterized by the recovery of motion and function. During this phase, the goal is to restore full passive and active motion of the glenohumeral and adjacent joints while strengthening and balancing the periscapular and dynamic stabilizer muscles.
The third phase, which usually lasts tillr 6 to 12 months after surgery, focuses on strengthening as well as on specific sports and/or occupational retraining. During this phase, the patient recovers strength and neuromuscular coordination throughout the entire kinetic chain and may return to sports or labor.
Scapular Stabilization
In order to achieve maximum functional recovery of the shoulder girdle, we also need to understand the role of scapular stabilization. Every movement that the upper limb performs occurs as a kinetic chain of sequential movements that proceed from proximal to distal. The initial transmission of energy from the core to the arm starts at the core, with lower extremity and trunk muscle activation. Then, scapular stabilizers hold the scapula in position for the energy to be transmitted through the glenohumeral joint and its associated structures and into the arm.
With this in mind, it is essential to start functional recovery of the shoulder by strengthening the scapular stabilizers, thereby increasing the efficiency of movement and minimizing energy consumption through incorrect activation and motion of periscapular muscles. Even in the setting of shoulder stiffness, this step is essential because of the need to retrain muscles that have become movers rather than stabilizers.
Rehabilitation After Specific Injuries
Rotator Cuff Injuries (Box 2)
It is commonly accepted that a period of immobilization of 4 to 6 weeks allows for tendon healing after an arthroscopic rotator cuff repair. However, immobilization itself leads to stiffness, muscular atrophy, and loss of function. There is no consensus on the optimal time after surgery to initiate physical therapy, and different protocols with different criteria have been described. So far, systematic reviews have shown that there is no statistically significant difference between early, accelerated-motion protocols and more conservative, protected-motion protocols.
A recent systematic review of systematic reviews1 showed that there was no statistically significant difference between early and conservative therapy in terms of pain, function range of motion, and the retear rate; however, it should be noted there was great heterogeneity among the published studies. Some authors have suggested that smaller tears might be more amenable to earlier physical therapy than large or massive repairs2. To avoid stiffness, the 3 to 4-week period is an acceptable time to start therapy; during that period, collagen fibers start to arrange their microarchitecture and therefore movement can help to avoid adhesions. Still, the quality of evidence is not great, and further high-quality studies may be necessary to further clarify this issue.
Shoulder Instability (Box 3)
In 2012, the American Society of Shoulder and Elbow Therapists published a consensus guideline regarding therapy after arthroscopic anterior capsulolabral repair3; to date, there is still a paucity of studies and protocols related to this issue. The principles that guide this consensus include protecting the repaired structures while selectively and progressively stressing neighboring, and also to progress motion and strengthening while protecting tissue healing. In the first phase (0 to 6 weeks), passive and active-assisted motion are initiated without exceeding stated external rotation goals. Initiating scapular strengthening has also begun. Range of motion should never be forced in this stage. In the second stage (6 to 12 weeks post-op), active exercises are initiated and neuromuscular control of the rotator cuff and scapular muscles is initiated, ending in full motion (except for 90° external rotation). In the third and final phase, the focus is on strengthening and neuromuscular balance, with the goal of achieving normal function. A recent systematic review indicated that there is no difference between early and conservative therapy programs in terms of recurrence rates and functional results4.
Shoulder Stiffness
Although physical therapy is the most widely used strategy for the treatment of primary frozen shoulder, current recommendations5 acknowledge there is no consensus regarding the effect, durability, and type of therapy.
Box 2
Key Points of Rehabilitation Following Rotator Cuff Repair
• Protect repair for 4 weeks on average
• Start passive motion/scapular exercises as soon
as possible
• Progress to active-assisted and active motion according to tear size
• Start strengthening after full range of motion is achieved
24 ISAKOS NEWSLETTER 2019: VOLUME I