TOTAL SHOULDER REPLACEMENT : ACTIVE OE PASSIVE ROM!!!

The number of Total shoulder replacement surgery is being increased every year .  Over the years, the surgical technique for a total shoulder replacement has improved. I’m not sure our rehabilitation approach has also improved.  Rehabilitation program should adjust according to patient`s goal.

Rehabilitation Following Total Shoulder Replacement

A conservative approach was appropriate for many patients. It was acceptable to have a moderate loss of range of motion in exchange for less pain in their shoulder. It is true that one of the primary goals of the postoperative rehabilitation is to protect the subscapularis.  During surgical procedure, surgeon the subscapularis muscle is taken down to some extent. Overall outcome is depending on subscapularis integrity. Other motions, such as behind the back and shoulder extension are disadvantageous position. These position can lead to dislocation of the joint. However, I concetrate on of early range of motion, especially if you respect restrictions.

Passive ROM & Active ROM

A recent report was recently published in Journal of Shoulder and Elbow Surgery that may actually be causing some confusion on when to start range of motion.

In this study patient were divided into two group. 1) Immediate mobilization 2) Delay ROM at 4 weeks. The author reported that group 1 regain more ROM and showed earlier functional outcome scores..

However, 96% of the patients that delayed range of motion showed healing of the lesser tuberosity osteotomy, while only 82% of the immediate range of motion group showed healing.  There was similar functional outcome measure between two groups at 3 months and 1 year after surgery.

When you deep dive into the methods, the authors chose to use the rope and pulley and stick for elevation range of motion exercises.  As we all know, these are active assisted range of motion exercises not passive exercise.

There’s a big difference between passive and active range of motion exercises. Previous EMG studies have shown the rotator cuff 18-25% active and the deltoid 21-43% active during these exercises.  Not very passive.  Conversely, passive range of motion exercises only 3-10% active.

Its a big difference. I believe that initial stage of rehabilitation passive range of motion is appropriate. You respect the restrictions on restoring external rotation to protect the subscapularis and avoid IR to protect the replacement. Immediate Range of Motion Restores Function Faster than delay ROM. Since we all work with these patients after surgery, we know that they are always happier when they restore their motion.

By focusing on this, I believe our patients will have much better outcomes.

Summary:

Start Passive ROM in supine

Focus on pure GH motion

Isometric exercise

focus on functional goal