Pain-Free Equals a Home Run

ATLANTA—Advances in shoulder arthroplasty have extended what surgeons can offer patients suffering from shoulder pain. Those advances have, in turn, driven refinements in rehabilitation protocols. In a session titled, “Total Shoulder Arthroplasty and Reverse Total Shoulder Arthroplasty: Surgery and Rehabilitation,” here at the 2010 ACR/ARHP Annual Scientific Meeting, an orthopedic shoulder specialist and a physical therapist partnered to discuss the integrated approach to shoulder repair and rehabilitation. [Editor’s note: This session was recorded and is available via ACR SessionSelect at www.rheumatology.org.] Clear communication between surgeon, patient, and physical therapist is key for successful outcomes following shoulder joint replacement, said the two presenters.

Conventional Total Shoulder Arthroplasty

Although shoulder replacements are done for a variety of reasons (including avascular necrosis, fracture, and dislocation), the most common indication is osteoarthritis, said Scott D. Pennington, MD, an orthopedic surgeon in private practice at Peachtree Orthopaedic Clinic in Atlanta. Total shoulder arthroplasty (TSA), “has a really good track record for OA, with 90% good to excellent results,” he remarked. Surgery is usually considered after a patient fails a course of conservative management, consisting of corticosteroid injections, antiinflammatories, and physical therapy. Evaluation includes a physical exam, X-rays, assessment of function, and range of motion.

In their conversations with patients, surgeons should discuss realistic outcomes, Dr. Pennington noted. “The main and best reason for total shoulder arthroplasty is to eliminate the patient’s pain. Functional results are somewhat variable, and patients need to know that they’re not going to get 170° of forward flexion. Their days of changing light bulbs may be over. But, if they can touch the top of their heads, eat by themselves, and are pain free, that’s a home run.” Patients with rheumatoid arthritis can expect to achieve 75 to 100° of forward flexion (as opposed to 130–145° of forward flexion for OA patients). Their results may deteriorate over time because of the systemic nature of their disease. Still, TSA “is still a very good pain-relieving operation” for this population as well, according to Dr. Pennington.

Dr. Pennington then outlined the procedure. Surgeons typically use a deltopectoral surgical approach under an interscalene block. The third-generation TSA prosthetics allow surgeons to restore the patient’s normal shoulder anatomy. Dr. Pennington emphasized the importance of dictating the operative note, which details the type of surgical approach and the expected range of motion limits. This ensures that the physical therapist will not “try to take the patient beyond the [range of motion] allowed.”

Educate Patients

Successful postoperative rehab involves patient buy-in, said Victoria Gall, PT, MEd, in practice at New England Baptist Hospital in Boston. “They need to understand what they are committing to by having this shoulder surgery.”

Patients report the value of preoperative classes and education, which include information about rehab protocols, trying on the shoulder immobilizers, and accessing patient education websites. (See “Online Resources for Patients” on p. 62 for a list of these sites). She does caution her patients about commercial sites that are biased because they do not discuss any of the disadvantages of the surgery.

Post-op and Beyond

Gall summarized the Brigham and Women’s Hospital (BWH) Department of Rehabilitation TSA protocol, which was developed in concert with surgeon Lawrence Higgins of BWH and the Boston Shoulder Institute. (See “Online Resources for Professionals” on p. 62 for a link to the protocol.) The four-phase, approximately 12-week program includes specific range-of-motion goals that must be met before the muscle strengthening begins. Rehabilitation protocols vary, but they “are only guides,” Gall reminded her audience. The most important concept is to tailor the protocol to individual patients’ progress and tolerance, she noted.

Cryotherapy, or ice, is started immediately after surgery and applied for one to two hours for the first 24 hours. Patients will be in a shoulder immobilizer, which is not sufficient to prevent shoulder extension in the supine position. A folded blanket, thicker pillow or rolled towel in between the arm and chest can maintain neutral shoulder alignment. Gall stressed communication with nursing staff on all shifts to make them aware of these positioning issues. “There’s nothing worse,” she said, “than having a person in agony the next morning because their arm was in extension and not protecting the anterior structure.”

Inpatient physical therapy usually includes passive forward flexion in the supine position (to tolerance), gentle external rotation in the scapular plane to around 30°, active exercises for distal extremities, and pendulum exercises done in the seated position. Patients will be released home or to a skilled nursing facility, depending on the amount of assistance they need. Before discharge, patients receive precautions: no driving, no lifting of heavy objects, no excessive stretching or sudden movements, and no active range of motion or motions behind the back. Gall also believes involvement of occupational therapists is very valuable to help patients negotiate their activities of daily living when they return home.

Patients are usually referred to outpatient therapy after the two-week surgical follow-up visit. As outlined in the BWH protocol, progression to each subsequent phase can happen only if the patient is able to achieve—without pain—specific range-of-motion (ROM) goals. For example, patients progress to early Phase II only if they tolerate the passive ROM (PROM) program; have achieved at least 90° PROM forward flexion and elevation in the scapular plane; 45° PROM external rotation in the scapular plane; and at least 70° PROM internal rotation in the scapular plane measured at 30° of abduction.

Careful progression through each of the early and late portions of each phase hopefully leads to the advanced strengthening phase, which begins after 12 weeks to allow for soft tissue healing, adequate ROM and initial strength. Some patients, such as those with RA, may never reach Phase IV and may need to concentrate on functional activities between “the thighs and the eyes,” said Gall.

The Game-Changer

The final portion of the session focused on reverse total shoulder arthroplasty (rTSA), which Dr. Pennington called “a complete game changer.” Before its Food and Drug Administration approval in 2006, surgeons could offer little beyond injections to temporarily relieve pain in patients with glenohumeral arthritis associated with irreparable rotator cuff damage. Pioneered by Paul Grammont, the prosthesis reverses the orientation of the shoulder joint, placing a socket where there was a ball and a ball where there was a socket. The joint’s center of the rotation is moved medially and inferiorally; its stability and mobility become dependent upon the deltoid and periscapular muscles. “You can raise your arm with just your deltoid: it’s fantastic,” said Dr. Pennington.

However, the procedure comes with a price. Complication rates are twice those of conventional TSA. Because it alters anatomy, rTSA puts additional forces on the scapula and humerus and is not a stable construct. Infection rates are also higher. Its limited lifespan (six to 11 years at present) means that it should only be offered to those 65 and over, said Dr. Pennington.

The procedure introduces additional precautions into the rehabilitation protocol, added Gall. Although the protocol still follows a four-phase design, the therapy has “a slower start and a slower progression,” she said. Patient and family education regarding positioning and patient activity are necessary for a successful outcome. Some of the differences from the conventional TSA protocol include longer use of the immobilizer; avoiding internal rotation, or hands behind the back; introducing periscapular and deltoid isometrics to regain upper back and shoulder girdle strength; using biofeedback to help recruit scapula or deltoid muscles; and paying special attention to customizing the protocol to each individual. In addition, therapists should be alert to possible acromion fracture, symptoms of which include insidious pain, tenderness and pain over the superior aspect of the acromion, pain with deltoid activity, and sudden loss of motion. Prognosis can still be good, although it may take three or more months for such a fracture to heal, she said.

Greater progression and better outcomes for both procedures are based on underlying pathology, the surgeon’s technique and patients’ tolerance for exercise, Gall summarized. “All good rehab programs depend on communication between the surgeon, inpatient nursing staff, and all of the therapists.” While it is the surgeon’s responsibility to discuss outcome and expectations with patients well before surgery, she said, “it’s really important to integrate pre-op, intra-op, and post-op factors into the rehab progression.”

Gretchen Henkel is a medical journalist based in California.