Presentation on theme: "Setting Specific Orthopedic Exercises"— Presentation transcript:
1Setting Specific Orthopedic Exercises Author: Jorit Wijnmaalen, DPT, MBA, MTC, CEAS Educator: Jorit Wijnmaalen (Dr. J) John van Ooyen, PT, MTC FPTA Approved for 9.5 CEU’s (2012)
2About this course: Setting Specific Orthopedic Exercises The Setting Specific Orthopedic Exercise Course is the new version of our Anatomy of Exercise course and now includes exercise protocols for most major Orthopedic and Spine Surgeries.We have added more material to the course and it has been submitted for FPTA approval for 9.5 CEU's. This course is required for the CORS certification, but if you have taken The Anatomy of Exercise in 2012 or 2011, you do not need to take this course to become eligible for the CORS certification.This hands-on exercise course will review in depth clinical protocols that are currently in place for the various, common orthopedic procedures including joint replacement, ligamentous and tendon repairs surgeries and many spine surgeries.This clinical review will include protocols as they are applied in the various rehab settings including Inpatient Acute Care, Subacute Rehab and Skilled Nursing settings, Homecare and Outpatient.
3Why do we need to know and understand the anatomy of muscle? SunCoast SeminarsSetting Specific Orthopedic ExercisesWhy do we need to know and understand the anatomy of muscle?This will allow the clinician to specify their exercise program geared towards the function of the muscle. Different muscles have different functions and these functions are in part defined by the anatomy of the muscle.There are approximately 639 skeletal muscles in the human body. There are different types of muscles, each with their distinct anatomy.Understanding the anatomy of the muscle will help the clinician understand how different (intrinsic and extrinsic) factors can impact muscles and exercising.We are looked upon as the experts when it comes to exercise therapy. Understanding the anatomy of muscles is an important part of being an exercise expert.
4Setting Specific Orthopedic Exercises Program Objectives:Reviewing muscular anatomy and physiologyThis will include a review of tissue healingDiscuss how extrinsic factors such as medication, progression, exercise objectives etc. may affect the exercise therapy programDiscuss how intrinsic factors including disease processes age, vital signs etc. may affect muscles and exercise programs.Discuss the basics of exercise therapyDiscuss common exercise principlesOpen chain vs. closed chainEccentricisometricconcentric
5SunCoast Seminars A few rules: Setting Specific Orthopedic Exercises We are in a hospital and should be aware of any codes that might be called.Bathrooms are right outside of this roomWe will break for lunch are around noonPlease turn off all cell phones.I would like to make this lecture as interactive as possible. Please feel free to ask questions, share your experiences, opinions etc. with the rest of the group.
6SunCoast Seminars About the educator: Background Education Setting Specific Orthopedic ExercisesAbout the educator:BackgroundEducationWork experienceHobbies
7About SunCoast Seminars Setting Specific Orthopedic Exercises5 educatorsDr. Brian HealyDr. Willem StegemanDr. Jorit WijnmaalenJohn Van Ooyen, PTDr. Nathan A. Possert, PT, DPT
8About SunCoast Seminars Setting Specific Orthopedic ExercisesMore courses:Orthopedic Joint Replacement course: 9.5 CEUComprehensive Management of back &neck pain: 9.5 CEUClinical Imaging for the Rehab Specialist, 9.5 CEUJoint Replacement, online: 7 CEUThoracic Outlet Syndrome: 6.0 CEU, OnlineHIV/Medical Errors/Abuse: 4 CEUThe Anatomy of Excercise: onlineAn Introduction to Manual Therapy : 9.5 CEUSetting Specific Orthopedic Exercises : 9.5 CEU’sCORS: 9.0 CEU’s
9Muscular anatomy and physiology SunCoast SeminarsSetting Specific Orthopedic ExercisesMuscular anatomy and physiologyMuscle Types:Smooth musclesCardiac musclesSkeletal muscles
10SunCoast Seminars Setting Specific Orthopedic Exercises Smooth muscles These muscles are very important in physiological regulation.Help to regulate the flow of blood.Help control BPThey control the movement of food through the digestive system.Control of the uterus during laborContraction of a smooth muscle cell is generated by a sliding mechanism of the myofilaments.Contraction is involuntary and may be initiated byNerve impulseHormones (i.e. cardiac function)Mechanical change to the muscle
11SunCoast Seminars Setting Specific Orthopedic Exercises Smooth Muscles :Crucial difference with skeletal muscles: nervous control is absolutely required for skeletal muscles, smooth muscles can, to a degree, work without nervous stimulation!Lastly, these muscles are not striated (the myofilaments are arranged into light and dark bands as in striated muscles).Striations are formed by alternating segments of thick and thin protein filaments, which are anchored by segments called T-lines
12SunCoast Seminars Setting Specific Orthopedic Exercises Cardiac Muscles :This muscle may look like a skeletal muscles (especially the contraction of it since they are striated as well) but it acts much like smooth muscle (it does not require nervous system input to function)The attachment site between cells is called an intercalated disc, which is present only in cardiac muscle cells and allows forces to be transmitted from one cell to the next.
13SunCoast Seminars Setting Specific Orthopedic Exercises Skeletal Muscles:Striated (banded) type. This distinctive banding pattern of striated muscle is an effect that comes from the alignment of sarcomeres in register across the myofibrilsSkeletal muscles are under voluntary control; no skeletal muscle works without “orders” from the nervous systemSkeletal muscles have elongated muscle cells (fibers) with multiple nuclei lying along the periphery of the cell. The sarcoplasm of each cell is contained by a sacrolemma (plasma membrane) and an external lamina.Each muscle contains many myofibrils and each myofibril contains thin actine and thick myosin myofilaments.These muscles normally make up the largest portion of a person's lean body mass
14SunCoast Seminars Setting Specific Orthopedic Exercises Skeletal MusclesThese are the muscles that are responsible for all voluntary movements (movements controlled by the central nervous system and which typically are directed at some sort of interaction with the environment)These muscles only contract in response to instructions from the central nervous system (with a few exceptions)In short, skeletal muscles have the following functions:provide joints with the forces necessary to produce movementto control movementto stabilize and protect joints when loads are applied to them.generating heat, maintaining normal body temperature, because they account for 40% of the body mass.
15Setting Specific Orthopedic Exercises Skeletal MusclesSkeletal muscles are a striated type of muscle with a rich blood supply, extensive afferent and efferent innervations and an extremely high metabolic capacity.Skeletal muscles have a tremendous adaptive capacity that allows them to hypertrophy, atrophy, increase in physiological length, decrease in physiological length and change metabolic capacities.Out of the three muscle types discussed, the skeletal muscle are the muscles that we will be most concerned within this course.
16Setting Specific Orthopedic Exercises Muscular anatomy and physiologyLet’s review!
17Setting Specific Orthopedic Exercises The Anatomy review of a skeletal muscleEach muscle cell is surrounded by a basal lamina and connective tissue.They are bound to each other and to surrounding tissues by connective tissue to form a gross "muscle". Skeletal muscle fibers are NOT joined by cell junctions.The endomysium consists of the basal lamina and thin connective tissue that surrounds individual muscle cells.The perimysium consists of sheets of connective tissue which separate the fibers into groups known as fascicles.The epimysium surrounds the groups of fasicles that comprise the “muscle”.
18Setting Specific Orthopedic Exercises Endomysium – delicate connective tissue sheeth that encloses each muscle fiberFasciculus – bundle of muscle fibers covered by perimysium (coarser fibrous membrane)Epimysium – covers bundle of fasciculi (entire muscle); blends into either:Tendon – cord of dense, fibrous tissue attaching a muscle to a boneAponeurosis – fibrous or membranous sheet connecting a muscle and the part is moves (usually found on torso)
20Setting Specific Orthopedic Exercises The Anatomy review of a skeletal muscleConnective tissue transmits the mechanical force of muscle. Tendons connect muscle to bone. The myotendinous junction occurs at the end of the muscle cell where the terminal actin filaments connect to the plasma membraneSkeletal muscle fibers are multi-nucleated cells that arise by fusion of mono-nucleate myoblasts.The many nuclei are located at the periphery of the cell.Mono-nucleate satellite cells, associate with the muscle fiber and reside within the muscle basal lamina. They promote limited regeneration of muscle in the adult.
21The muscle-tendon junction Setting Specific Orthopedic ExercisesThe Yellow line is corresponding to the tendon. How do we classify this Connective tissue? Dense Regular. The yellow arrows are pointing the nuclei of the fibroblasts making the collagen.The blue line is showing where the Striated Muscle is beginningThe muscle-tendon junction
22Setting Specific Orthopedic Exercises Innervation of a Skeletal MuscleSkeletal muscle is innervated and highly vascularized, due to its high energy requirements. It is penetrated of blood vessels into the epimysium with branches into the peri- and endomysium.
23Setting Specific Orthopedic Exercises Innervation of a Skeletal MuscleMotor end plates (neuromuscular junctions) are specialized sites at which a nerve contacts a muscle cell.The terminal branches of motor axons lie in the surface of the muscle cell, where the plasma membrane is highly folded.Muscle action begins at the motor end plate (or neuromuscular junction), which is analogous to a synapseAcetylcholine(ACh) binds to receptors localized in the muscle membrane at the motor end plate, resulting in local depolarization at the end plate.When this depolarization exceeds the threshold, it will result in an action potential
26Setting Specific Orthopedic Exercises Neuromuscular Junction or Motor End Plateaxon of Motor (Efferent) NeuronWhite arrow - Skeletal Muscle Fiber
27Setting Specific Orthopedic Exercises Innervation of a Skeletal MuscleAdditional proprioceptor endings (Golgi tendon organs) are located at the point where muscle fibers attach to tendonThese Golgi tendon organs (GTO) respond to tension (force) exerted by the muscle; activity in these axons inhibits muscle contraction (they are for instance stretched when a joint is swollen).
29Setting Specific Orthopedic Exercises Nerve ConductionBoth nerve cells and muscle cells are excitableTheir cell membrane can produce electrochemical impulses and conduct them along the membrane.In muscle cells, this electric phenomenon is also associated with the contraction of the cellThe origin of the membrane voltage is the same in nerve cells as in muscle cells. In both cell types, the membrane generates an impulse as a consequence of excitation.The long nerve fiber, the axon, transfers the signal from the cell body to another nerve or to a muscle cellThe axon may be covered with an insulating layer called the myelin sheath, which is formed by Schwann cells
30Setting Specific Orthopedic Exercises Nerve ConductionThis myelin sheath is not continuous but divided into sections, separated at regular intervals by the nodes of RanvierThe junction between an axon and the next cell with which it communicates is called the synapse.Information proceeds from the cell body uni-directionally over the synapse, first along the axon and then across the synapse to the next nerve or muscle cell (think about peripheral leasion)The part of the synapse that is on the side of the axon is called the pre-synaptic terminalThe part on the side of the adjacent cell is called the postsynaptic terminal. Between these terminals, there exists a gap.A chemical neurotransmitter, released from the pre-synaptic cell, is responsible for the impulse to transfer across the synapse.
33Setting Specific Orthopedic Exercises Nerve ConductionThis transmitter, when released, activates the postsynaptic terminal. The synapse between a motor nerve and the muscle it innervates is called the neuromuscular junction
34Setting Specific Orthopedic Exercises Nerve ConductionIf a nerve cell is stimulated, the trans-membrane voltage necessarily changes. The stimulation may beexcitatory (i.e., depolarizing; characterized by a decrease in the normally negative resting voltage) orinhibitory (i.e., hyperpolarizing, characterized by an increase in the magnitude of the membrane voltage).After stimulation the membrane voltage returns to its original resting valueIf the excitatory stimulus is strong enough, the trans-membrane potential reaches the threshold, and the membrane produces a characteristic electric impulse, the nerve impulse.Remember the Na+/K+ pump?
35Setting Specific Orthopedic Exercises Nerve ConductionMany factors may affect nerve conductivity but discussion of those factors would be outside the scope of this lecture.TemperatureProperties of the membraneSodium levelsAgeAnatomical changes because of disease (ALS)
36Setting Specific Orthopedic Exercises Nerve ConductionA myelinated axon (surrounded by the myelin sheath) can produce a nerve impulse only at the nodes of RanvierIn these axons the nerve impulse propagates from one node to anotherThe myelin sheath increases the conduction velocityThe conduction velocity of the myelinated axon is directly proportional to the diameter of the axon
37Setting Specific Orthopedic Exercises Nerve Conduction
39Setting Specific Orthopedic Exercises Types of Skeletal musclesNot all skeletal muscles are the same.Some cells are thicker than othersSome shorten fasterSome produce more tensionSome fatigue more rapidlyLooking at these different features, there appear to be three major types of skeletal muscles:
40Setting Specific Orthopedic Exercises Types of Skeletal musclesSlow TwitchFast Fatigue ResistantFast Twitch Fatigable
41Setting Specific Orthopedic Exercises Slow TwitchThese muscles produce the least amount of force. They actually produce less than half the force produced by fast twitch fatigue resistant fibers and are most resistant to fatigue.Slow twitch muscles use oxygen for power and have a predominance of aerobic enzymes.Slow twitch muscles are red, because they contain lots of blood vessels.These muscle fibers are "hit", or engorged with nitrogen-rich blood, during higher rep training, specifically in sets of 12 to 20 reps.Slow twitch muscles are used for holding posture
42Setting Specific Orthopedic Exercises Fast Twitch (Type II)Fast Twitch fibers use anaerobic metabolism to create fuel and so they are much better at generating short bursts of strength or speed than slow muscles.These types of muscles are best trained during sets of 2-5 repetitions.They fatigue more quickly.Fast twitch fibers generally produce the same amount of force per contraction as slow muscles, but they get their name because they are able to fire more rapidly.Having more fast twitch fibers can be an asset to a sprinter since she needs to quickly generate a lot of force (genetically determined, 50/50 on average; some research suggests that some fibers might be able to convert).
43Setting Specific Orthopedic Exercises Two Types:Type IIa Fibers / Fast Fatigue ResistantThese fast twitch muscle fibers are also known as intermediate fast-twitch fibers.They can use both aerobic and anaerobic metabolism almost equally to create energy.In this way, they are a combination of Type I and Type II muscle fibers.Produce forces greater than slow twitch fibers but less than fast twitch fatigable fiber.These fibers are more resistant to fatigue than fast fatigable but less fatigue resistant than slow twitch fibers.
44Setting Specific Orthopedic Exercises Type IIb FibersThese fast twitch fibers use anaerobic metabolism to create energy and are the "classic" fast twitch muscle fibers that excel at producing quick, powerful bursts of speed.This muscle fiber has the highest rate of contraction (rapid firing) of all the muscle fiber types, but it also has a much faster rate of fatigue and can't last as long before it needs rest.Produce the greatest amount of forceAre least resistant to fatigueForce produced is typically 2-3 times greater than fast twitch fatigue resistant fibers
46Setting Specific Orthopedic Exercises Low frequency stimulation of motor units of type II fibers transforms these fibers in type I fibers (endurance training, easier to accomplish)High frequency stimulation of motor units of type I fibers transforms these fibers in type II fibers (strength training, harder to accomplish)This is due to rest periods with low frequent stimulation of type II fibers, only metabolism and muscle fiber diameter stay increased.
47Conclusion Setting Specific Orthopedic Exercises So the lesson here is quite simple. As we are exercising our patients, we must keep in mind the main objective of our exercise program.In order to recruit the largest possible number of muscle fibers of both types during the exercise program, we must vary the repetition ranges .Keeping in mind that on average, there is a 50/50 split of these fibers so…Any therapist, who puts a patient on an exercise program that doesn't include a variation of repetition ranges might significantly limit the success of the exercise program.
48Skeletal Muscle Fiber Arrangement Setting Specific Orthopedic ExercisesSkeletal Muscle Fiber ArrangementIt is important to realize that there are different alignments of muscle fibers in the various skeletal muscles.These different fiber arrangements will have an effect on the length, mechanical properties and the number of muscle fibers of a muscle.Muscle fibers can be arranged in parallel or at angles to the tendon.Parallel fibered muscles are muscle composed of parallel aligned fibers. These muscles have long muscle fibers that can produce a large excursion on the tendon.FusiformTriangularSpiralPinnated fibers muscles are muscles composed of angled fibersUnipinnateBipinnateMultipinnate
50Setting Specific Orthopedic Exercises Structure & Function of a Skeletal muscle
51Setting Specific Orthopedic Exercises The cell comprises a series of striped or striated, thread-like myofibrils.Within each myofibril there are protein filaments that are anchored by dark Z line.The fiber is one long continuous thread-like structure.The smallest cross section of skeletal muscle is called a sarcomere which is the functional unit within the cell. It extends from one Z line to the next attached Z line. The individual sarcomere has alternating thick myosin and thin actin protein filaments.Myosin forms the center or middle of eache M line. Thinner actin filaments form a zig zag pattern along the anchor points or Z line.
52Setting Specific Orthopedic Exercises Muscle ContractionUpon stimulation by an action potential, skeletal muscles perform a coordinated contraction by shortening each sarcomere.The best proposed model for understanding contraction is the sliding filament model of muscle contraction.Actin and myosin fibers overlap in a contractile motion towards each other.ATP binds to the cross bridges between myosin heads and actin filaments. The release of energy powers the swiveling of the myosin headMyosin filaments have club-shaped heads that project toward the actin filaments.Larger structures along the myosin filament called myosin heads are used to provide attachment points on binding sites for the actin filaments.
53Setting Specific Orthopedic Exercises Muscle Contraction (cont.)The myosin heads move in a coordinated style, they swivel toward the center of the sarcomere, detach and then reattach to the nearest active site of the actin filament.This is called a rachet type drive system.This process consumes large amounts of adenosine triphosphate (ATP).Calcium ions are required for each cycle of the sarcomere.Calcium is released from the sarcoplasmic reticulum into the sarcomere when a muscle is stimulated to contract. This calcium uncovers the actin binding sites.When the muscle no longer needs to contract, the calcium ions are pumped from the sarcomere and back into storage in the sarcoplasmic reticulum
59Muscle contraction Setting Specific Orthopedic Exercises In rest the average human body uses as much energy as a 75W light bulb.During 24 hours of resting one still uses kcal (25 mile stroll)During extreme endurance sports the body is able to burn kcalMuscle tissue is a very effective power source:power versus weight for a jet motor is 1:5power versus weight for the biceps muscle is approx. 1:360
60Setting Specific Orthopedic Exercises Muscle contraction (cont.)ATP is the main source of energy for all muscle contraction.There are several chemical reactions that take place to produce ATP.When a muscle is used, a chemical reaction breaks down ATP to produce energy:ATP + Actin + Myosin Actomyosin + Phosphate + ADP + EnergyThis is the chemical reaction that produces energy, however, there is only enough ATP stored in the muscle cell for two or three slow twitch contractions, or one burst of power from a fast twitch contraction.Surprisingly muscles store very limited reserves of ATP 4-6 seconds worth at most, just enough to get you going.
61Setting Specific Orthopedic Exercises Muscle contraction (cont.)ATP is the only energy source used directly for contractile activities.It must be regenerated as fast as its broken down for continuation of the contraction.Fortunately, after ATP is hydrolyzed to ADP and inorganic phosphate in muscle fibers, it’s generated in a second by one or more of the three pathways,(1) direct phosphorylation of ADP by Creatine Phosphate(2) the anaerobic pathway called glycolysis, which converts glucose to lactic acid(3)Aerobic pathway, aerobic cellular respiration
62Setting Specific Orthopedic Exercises Muscle contraction (cont.)Direct phosphorylation of ADP by Creatine Phosphatea phosphate group transfers from CP to ADP, regenerating more ATP; CP supplies exhaust in about 20 secondsDuration of energy provision 15 seconds(2) Anaerobic glycolysis and lactic acid formationinitial steps of glucose breakdown occur via glycolysis which is anaerobic.Duration of energy provisionGlucose -> pyruvic acid with energy captured in ATP bonds (2ATP/ 1 glucose)
63Setting Specific Orthopedic Exercises (3) Aerobic respiration:provides 95% of ATP at rest and during lightExercise occurs in mitochondria & involves a series of metabolic pathways that use oxygencalled oxidative phosphorylationglucose is broken down into CO2 & H2Osome released energy is captured in ATP bonds (get 36ATP/1 glucose)There is also another way to look at those three steps, when we talk about the enzyme systems.There are three enzyme systems that can create more ATP. The enzyme system that is used depends on whether the type of muscle is fast twitch or slow twitch, and whether the muscle is used for strength, burst power, or endurance.
64Setting Specific Orthopedic Exercises Muscle Contraction (Cont.)The Strength Enzyme SystemWhen muscle strength is required, ATP is created quickly from the following chemical reaction.The enzyme creatine kinase mediates ATP production from the high energy molecule creatine phosphate by an anaerobic reaction:CP + ADP ATP + CreatineThe CP (Creatine Phosphate) is depleted in just a few seconds. This is the reason your maximum power can be maintained for only a few seconds. To continue producing high strength power, the speed enzyme system kicks in.
65Setting Specific Orthopedic Exercises Muscle Contraction (Cont.)The Burst Power Enzyme SystemThe enzymes required for this reaction are depleted in less than two minutes.This reaction is called Anaerobic Glycolysis because it uses glucose without oxygen.Glucose 2ATP + 2 LactateContinued muscle usage requires the aerobic system to kick in.The aerobic system uses oxygen and sugar for fuel.The ability to perform well after about two minutes of maximum exertion depends on the aerobic conditioning of the body which is trainable
66Setting Specific Orthopedic Exercises Muscle Contraction (Cont.)The Endurance Enzyme SystemThis system consists of three processes:Carbohydrate Metabolism: Carbohydrates metabolize most efficiently and are therefore used firstFat Metabolism: If no carbohydrates are available, the body metabolizes fat.Amino Acid Protein Metabolism: If no fat is available, the body metabolizes Amino Acids.The body stores glucose and fatty acids for these reactions. In addition, the cardiovascular system provides a continuous supply of oxygen.
67Setting Specific Orthopedic Exercises Muscle Contraction (Cont.)The Endurance Enzyme SystemThis system consists of three processes:Carbohydrate Metabolism: Carbohydrates metabolize most efficiently and are therefore used firstFat Metabolism: If no carbohydrates are available, the body metabolizes fat.Amino Acid Protein Metabolism: If no fat is available, the body metabolizes Amino Acids.The body stores glucose and fatty acids for these reactions. In addition, the cardiovascular system provides a continuous supply of oxygen.
68Setting Specific Orthopedic Exercises Muscle Contraction (Cont.)Cardiac muscle is adapted to be highly resistant to fatigue: it has a large number of mitochondria, enabling continuous aerobic respiration.The heart is so tuned to aerobic metabolism that it is unable to pump sufficiently in ischaemic conditions. (It has no back up system).At basal metabolic rates, about 1% of energy is derived from anaerobic metabolism. This can increase to 10% under moderately hypoxic conditions, but, under more severe hypoxic conditions, not enough energy can be liberated by lactate production to sustain ventricular contractions.Under basal aerobic conditions, 60% of energy comes from fat (free fatty acids and triglycerides), 35% from carbohydrates, and 5% from amino acids. However, these proportions vary widely according to nutritional state. For example, during starvation, lactate can be recycled by the heartnbvnvcn
69Setting Specific Orthopedic Exercises Muscle Contraction (Cont.)Glycogen is stored in the muscles and liver in sufficient quantities for about two hours of strenuous exercise.This timeframe can be extended by aerobic physical conditioning and high carbohydrate diet.After the glycogen stores are used up, the body obtains its energy from fatty acid metabolism and amino acid protein metabolism.These reactions are not efficient, which consequently causes your strength and endurance to drop drastically (hitting a brick wall or man with the hammer).
70Setting Specific Orthopedic Exercises Motor Units within a muscleA motor unit is defined as all of the muscle fibers supplied by a single motoneuron, and therefore, by a single axon and its branchesSkeletal muscles are organized into hundreds of motor units, each of which involves a motor neuron, attached by a series of thin finger-like structures called axon terminals.These attach to and control discrete bundles of muscle fibers. A coordinated and fine tuned response to a specific circumstance will involve controlling the precise number of motor units used.While individual muscle units contract as a unit, the entire muscle can contract on a predetermined basis due to the structure of the motor unit.Motor unit coordination, balance, and control frequently come under the direction of the cerebellum of the brain. This allows for complex muscular coordination with little conscious effort, such as when one drives a car without thinking about the process.jklhjkjk
71Setting Specific Orthopedic Exercises Motor Units within a muscleMuscles responsible for fine coordination have small motor units.Muscles responsible for gross movements have large motor units.The smaller motor units are more excitable than the larger ones, and are stimulated first when a weak signal is sent by the CNS to contract a muscleAs the strength of the signal increases, more motor units are excited in addition to larger ones, with the largest motor units having as much as 50 times the contractile strength as the smaller onesAs more and larger motor units are activated, the force of muscle contraction becomes progressively stronger. This concept is know as “the size principle”.
72Setting Specific Orthopedic Exercises Motor Units within a muscle: ConclusionAt low exercise intensities, like walking or slow running, slow twitch fibers are selectively utilized because they have the lowest threshold for recruitment.If suddenly the pace is increased to a sprint, the larger fast units will be recruited.In general, as the intensity of exercise increases in any muscle, the contribution of the fast fibers will increase.For the muscle, intensity translates to force per contraction and contraction frequency/minute.Motor unit recruitment is regulated by required force. In the unfatigued muscle, a sufficient number of motor units will be recruited to supply the desired force (wave contraction).
73Setting Specific Orthopedic Exercises Motor Units within a muscle: ConclusionInitially desired force may be accomplished with little or no involvement of fast motor units. However, as slow units become fatigued and fail to produce force, fast units will be recruited as the brain attempts to maintain desired force production by recruiting more motor units.Consequently, the same force production in fatigued muscle will require a greater number of motor units.This additional recruitment brings in fast, fatigable motor units.As a result, fatigue will be accelerated toward the end of long or severe bouts due to the increased lactate produced by the late recruitment of fast units. (Again, the man with the hammer)
74Setting Specific Orthopedic Exercises Contraction StrengthFor skeletal muscles, the force exerted by the muscle is controlled by varying the frequency at which action potentials are sent to muscle fibers.Action potentials do not arrive at muscles synchronously, and during a contraction some fraction of the fibers in the muscle will be firing at any given time.Typically when a human is exerting a muscle as hard as they are consciously able, roughly one-third of the fibers in that muscle will be firing at once, but various physiological and psychological factors (including Golgi tendon organs and Renshaw cells) can affect that.This 'low' level of contraction is a protective mechanism to prevent avulsion of the tendon - the force generated by a 95% contraction of all fibers is sufficient to damage the body.
75Setting Specific Orthopedic Exercises Contraction StrengthThe repetitive firing of a motor unit creates a train of impulses known as the motor unit action potential train (MUAPT).To sustain muscle contraction, the motor units must be repeatedly activated . As the firing rates of motor units active in a contraction increase, the twitches associated with each firing will eventually fuse to yield large forcesThe firing rates of earlier recruited motor units are greater than those of later recruited motor units at any given force valueThe control to the muscle is not designed to generate constant-force contractions.
76Setting Specific Orthopedic Exercises Maximal Voluntary Contraction (MVC)
77Setting Specific Orthopedic Exercises Contraction StrengthSo concluding, the strength of a muscular contraction can be influenced 2 factors:By increasing the number and size of contractile units simultaneously, called multiple fiber summation.By increasing the frequency at which action potentials are sent to muscle fibers, called frequency summation.
78Setting Specific Orthopedic Exercises Types of Muscle ContractionConcentric muscle contractionEccentric muscle contractionIsometric muscle contractionIsotonic muscle contraction
79Setting Specific Orthopedic Exercises Concentric muscle contractionMuscle contraction in which the muscles shorten while generating force. The insertion and origin of the muscle are moving toward eachother.During a concentric contraction muscle fibers slide across each other pulling the Z-lines togetherDuring a concentric contraction, a muscle is stimulated to contract according to the sliding filament mechanism.This occurs throughout the length of the muscle, generating force at the musculo-tendinous junction, causing the muscle to shorten and changing the angle of the joint.In relation to the elbow, a concentric contraction of the biceps would cause the arm to bend at the elbow.A concentric contraction of the triceps would change the angle of the joint in the opposite direction, straightening the arm.
80Setting Specific Orthopedic Exercises Eccentric Muscle ContractionDuring an eccentric contraction, the muscle elongates while under tension. The origin and the insertion of the muscle are moving away from eachother.The muscle acts to decelerate the joint at the end of a movement or otherwise control the repositioning of a load.This can occur involuntarily (when attempting to move a weight too heavy for the muscle to lift) or voluntarily (when the muscle is 'smoothing out' a movement).Over the short-term, strength training involving both eccentric and concentric contractions appear to increase muscular strength more than training with concentric contractions alone.During an eccentric contraction of the biceps muscle, the elbow starts the movement while bent and then straightens as the hand moves away from the shoulder. During an eccentric contraction of the triceps muscle, the elbow starts the movement straight and then bends as the hand moves towards the shoulder.
81Setting Specific Orthopedic Exercises Eccentric Muscle ContractionExercise featuring a heavy eccentric load can actually result in greater muscular damage and delayed onset muscle soreness one to two days after training.Exercise that incorporates both eccentric and concentric muscular contractions (i.e. involving a strong contraction and a controlled lowering of the weight) can produce greater gains in strength than concentric contractions alone.While unaccustomed heavy eccentric contractions can easily lead to overtraining, moderate training may confer protection against injury.
82Setting Specific Orthopedic Exercises Isometric Muscle Contraction.An isometric contraction of a muscle generates force without changing length.An example can be found in the muscles of the hand and forearm grip an object; the joints of the hand do not move but muscles generate sufficient force to prevent the object from being dropped.Isometrics are done in static positions, rather than being dynamic through a range of motion.The joint and muscle are either worked against an immovable force (overcoming isometric) or are held in a static position while opposed by resistance (yielding isometric).
83Setting Specific Orthopedic Exercises Eccentric Muscle ContractionMuscles are approximately 10% stronger during eccentric contractions than during concentric contractionsEccentric contractions are being researched for their ability to speed rehab of weak or injured tendons. Achilles tendinitis has been shown to benefit from high load eccentric contractions.During virtually any routine movement, eccentric contractions assist in keeping motions smooth.Muscles undergoing heavy eccentric loading suffer greater damage when overloaded (such as during muscle building or strength training exercise) as compared to concentric loading.During an eccentric contraction, the filaments slide past each other the opposite way, though the actual movement of the myosin heads during an eccentric contraction is not known.
84Setting Specific Orthopedic Exercises Isotonic Muscle ConcentrationIsotonic contractions occur when tension in the muscle remains constant despite a change in muscle length. This can occur only when a muscle's maximal force of contraction exceeds the total load on the muscle.
85Setting Specific Orthopedic Exercises A: Concentric/eccentricB: Isometric
86Setting Specific Orthopedic Exercises EXERCISING AND BUILDING MUSCLESMuscles change and develop with regular exercise but the effects differ, depending on whether you engage in strength, speed, or endurance training.Strength and burst training causes the muscle fibers to enlarge.Individual muscle fibers increase in diameter as a result of an increase in intracellular protein fibrils.Endurance training causes more blood vessel formation than does speed or strength training, which produces an increased capacity for aerobic metabolism within the muscle cell.This change is seen after a few weeks of training and is maximized in about three months. The aerobic enzymes that metabolize carbohydrates, fats, and proteins, double.It is important to develop your strength and speed systems, but if you want to continue past about two minutes of high intensity workouts, you need to have your aerobic systems developed
87Setting Specific Orthopedic Exercises EXERCISING AND BUILDING MUSCLESEffect of Exercise on Muscles:Aerobic or endurance exerciseExamples – biking, jogging, swimming lapsResults in stronger more flexible muscles with greater resistance to fatigueblood supply increasesindividual muscle cells form more mitochondria and store more oxygen (makes overall body metabolism more efficientImproves digestion and elimination of wastesEnhances neuromuscular coordinationMakes the skeleton strongerHeart enlargesFat deposits are cleared from blood vessel wallsLungs become more efficient at gas exchangeDoes NOT cause muscles to increase in size
88Setting Specific Orthopedic Exercises EXERCISING AND BUILDING MUSCLESEffects of Exercise on Muscles:Resistance or isometric exerciseExamples – weightlifting, theraband or medicine ball training, bodyweight exercises like push-ups or pull-ups, plyometricsKey is that muscles are being forced to contract with as much force as possible or as quickly as possibleMuscles increase in size and strengthDue to enlargement of individual muscle cells (more contractile filaments), not because more muscle fibers are madeSize of reinforcing connective tissue also increases to support increased muscle size
89Setting Specific Orthopedic Exercises Muscle FunctionsMuscle tissue has four main properties:Excitability or the ability to respond to stimuliContractibility or the ability to contractExtensibility or the ability of a muscle to be stretched without tearingElasticity or the ability to return to its normal shapeThrough contraction, the muscular system performs three important functions:Motion - walking, running etc.Heat production - maintain normal body temperatureMaintenance of posture - standing, sitting etc.
90Setting Specific Orthopedic Exercises Muscle FunctionsMuscles have two statesRelaxedContracted.
91Setting Specific Orthopedic Exercises Common Medications and their effect on ExerciseBlood thinners: Coumadin, Lovenox, Warfarin, PlavixAspirin: Watch the side effects. Do not take with NSAID’s (willnegate the blood thinning effect). Thinning of mucosa of thestomach wall, gastric ulceration, increased bleeding riskMuscle relaxors: Flexeril, Soma, Valium, SkelaxinFlexeril: Duration of action hourSkelaxin: Duration of action 4-6 hoursSide effects: Drowsiness, dizziness, vertigo, ataxia, dependencyParkinson's disease: Levodopa, Dopamine agonists, Anti cholinergicsSinemet/dopamine: arrhythmia's, postural hypotensionDiuretics: Bumex, Lasix, AldactoneHypokalemia, hyponatremia, fluid depletion, orthostatichypotension
92Setting Specific Orthopedic Exercises Common Medications and their effect on Exercise (continued)Cardiac function controlling medication: Beta blockers (Tenormin, Lopressor, Inderal, Betapace)Digitalis toxicity, dry cough, bradycardia, hypotensionBP controlling medication: Beta blockers, Alpha blockers (Cardura, Minipress)Broncho constriction, bradycardia, hypotensionHR controlling medication: Norpace, Beta blockers, Cordarone, CardizemIncrease of arrhythmia's, dizziness, hypotensionPulmonary function controlling medication: Albuterol, Epinephrine, Theo-Dur, Pulmicort, Decadron, Aerobid, CortefOsteoporosis, muscle wasting, skin breakdown, diabetes mellitis,hypertension
93Setting Specific Orthopedic Exercises The importance of a thorough evaluationThe concept is very simple here; without a complete and detailed evaluation, you cannot develop an appropriate exercise program.This evaluation is ongoing and does not stop after the “ initial evaluation” (there is a reason for that name…)Understanding the true dysfunction and understanding why that dysfunction exists will put the clinician in the position to address the dysfunction effectively.
94Setting Specific Orthopedic Exercises Different types of exercises with different objectivesObjectives/Goals of exercise:StrengthMuscular DystrophyCoordinationFiring PatternsEnduranceROMPROM vs. AROMEndfeel?PROM of the JointMuscle length (Muscle energy)Muscle toneDecrease of muscle toneIncrease of muscle tonePain control
95Setting Specific Orthopedic Exercises Components of an effective Exercise Program:Starts with a thorough and complete evaluation (evaluate the complete chain.Have clear outcome objectives.What are you looking to exerciseWhy are you exercising thatWhat outcome do you expectDepends on patient/age/function/other intrinsic and extrinsic factorsMeasure and document these objectives ongoingDon’t over exercise. Exercise to improve function not too complete a number of reps.When you feel or see the correct movement, continue to the next level.
96Setting Specific Orthopedic Exercises Components of an effective Exercise program:Get the buy-in from the patientDetailed documentationQuality of the movementSpeedCues given/neededStrengthShaky/TremorousCoordinationSensationIntensityActivity it is related to improve
97Setting Specific Orthopedic Exercises Progression/Regression of exerciseEstablish base point or midlinePoints of contact: Progress from larger base of support to smaller base of supportOpen chain vs. Closed chain# of repetitions or setsSpeed of the repsCues: tactile& VerbalLevel of resistancePoint of referenceeccentric Isometric concentricStabilize vs. destabilizeWeight shifting weight bearingSequence: Instruct correct movementrepeatchallenge add complexityput into a functional activityMethod of observation: visual, tactile, bio feed back
98Total Hip Arthroplasty Setting Specific Orthopedic ExercisesTotal Hip ArthroplastyBrief description of procedure:Hip replacement is a surgical procedure in which the hip joint is replaced by a prosthetic implant.Hip replacement surgery can be performed as a total replacement or a hemi (half) replacement. A total hip replacement (total hip arthroplasty) consists of replacing both the acetabulum and the femoral head while hemiarthroplasty generally only replaces the femoral head
99Setting Specific Orthopedic Exercises Variations: Hemi Arthroplasty, Revision, Hip, Resurfacing, ORIF. Muscles involved: Anterior approach: No muscles are cut other than the Piriformis which is transected 50% of the time Posterior approach:The piriformis muscle and the short external rotators (tendons) are taken off the femur Lateral approach: The hip abductors (gluteus medius and gluteus minimus) are elevated – not cut – to provide access to the joint
100Setting Specific Orthopedic Exercises When does Rehab start? For most elective orthopedic procedures, the patient can start strengthening prior to the surgery, as allowed by their pain and functional level. Unfortunately, this is typically not reimbursed by insurance companies, or it may take away from their post-op rehab visits. Precautions and time frames Total hip precautions; restricted Hip Adduction, ER and Flexion as per the surgeon. Avoid SIMULTANEOUS/COMBINATION movements of the operative hip. Patients are allowed to flex, extend, abduct, adduct, or rotate their operative hip in cardinal planes of motion with NO restriction to movement. Any combination of motion during the initial three (3) months, post operative period should be avoided.
101Surgical Hip Precautions Setting Specific Orthopedic ExercisesSurgical Hip PrecautionsWeight bearing: Typically WBAT unless there was a surgical complication, so ALWAYS read the operative report. ALWAYS FOLLOW WB INSTRUCTIONS
102Acute Care Protocol: Hip Setting Specific Orthopedic ExercisesAcute Care Protocol: HipDOS: Patient should get up with PT on the DOS, unless the patient had surgical complications, or had Total AnasthesiaPatient can get up on the surgical or non-surgical site and will use a walker to ambulate with the appropriate WB and may sit in a chair, maintaining the 90 degrees hip angle.Patient should also start Muscle Setting Exercises in bed .Day 1-4: Patient should get up with nursing as well for BRP and for short ambulation.Physical Therapy and Occupational Therapy will focus safe transfers, following WB directions, using a walker, focusing on posture as well. AAROM will be started today in all cardinal planes as well. Walking distance will steadily increase and precautions will be reviewed with the patient and their family.
103Setting Specific Orthopedic Exercises Ambulation Guidelines:Cemented Prosthesis: Weight bearing as tolerated (WBAT) ambulation. Patients are required to initially use a walker/crutches for a period of time, then are progressed to cane ambulation.The cane is discontinued when the patient is ambulating without a positive Trendelenberg test.Uncemented Prosthesis: Patients are required to ambulate using a walker/crutches and partial weight bearing for 6 post-operative weeks. Patients are progressed to WBAT over the following 2 weeks. When patients are able to ambulate without a positive Tredelenberg test, they may ambulate without any assistive devices.No running or involvement in sporting activities requiring running and/or jumpingfor 12 weeks.
104Acute Care Protocol: Hip Setting Specific Orthopedic ExercisesAcute Care Protocol: HipPOD #0:Begin isometric exercises and ankle pumps to leg. Encourage the patient to perform these exercises every two hours while awake.Begin assisted bed-to-chair transfers using an assistive device to a chair of appropriate height.Weight bearing status is dependent upon the type of prosthesis implanted.Patients may sit in an upright position if comfortable.Discuss post-operative dislocation precautions/restrictions.
105Setting Specific Orthopedic Exercises Post-Operative Day 1:Continue lower extremity isometrics and ankle pumps.Initiate upper extremity and contralateral limb strengthening exercises.Begin assisted ambulation on level surfaces using an assistive device, weightbearing status dependent upon prosthesis used.Begin discharge planning and home needs assessment.Review dislocation precautions/restrictions.
106Setting Specific Orthopedic Exercises Post Operative Day 2:Review lower extremity isometric and ankle pumping exercises.Begin supine lower extremity active assisted range of motion exercises to the operative extremity.Motions are to the patient’s tolerance and in cardinal planes.Continue assisted ambulation on level surfaces.Reinforce hip dislocation precautions/restrictions.
107Setting Specific Orthopedic Exercises Post Operative Day 3:Continue comprehensive exercise program with emphasis on increasing hip ROM and general muscle strength in the operative extremity.Begin sitting exercises.Refine gait pattern and instruct in stair climbing.Review home instructions/exercise program with emphasis on hipdislocation/precautions.Finalize discharge plans. All patients require an assistive device for ambulation, an elevated toilet seat, and follow-up physical therapy.
108Setting Specific Orthopedic Exercises Hip Surgery: Phase II: Days 3-10Goals:Achieve functional hip range of motion, within cardinal planes of movement.Muscle strengthening of the entire hip girdle of the operative extremity with emphasis on hip abductor and extensor muscle groups.Attention should also be directed toward any weakness present in the operative extremity as well as any generalized weakness in the upper extremities, trunk or contralateral lower extremity.Proprioceptive training to improve body/spatial awareness of the operative extremity in functional activities.Functional training to promote independence in activities of daily living and mobility.
109Setting Specific Orthopedic Exercises Hip Surgery: Phase II: Days 3-10Modalities for Pain Control and Edema Reduction:Moist Heat, IceTherapeutic Exercise:Gentle Passive, Active-Assisted, and active lower extremity range of motionStationary Biking - No resistance to motionBalance/Proprioception Training:Tandem Walking (line walking)Gait Training:Level SurfaceForward WalkingFunctional Training:Standing ActivitiesTransfer Activities
110Setting Specific Orthopedic Exercises Hip Surgery: Phase III 10 days to 6 weeks:Goals:Muscle strengthening of the entire hip girdle of the operative extremity with emphasis on hip abductor and extensor muscle groups.Attention should also be directed toward any weakness present in the operative extremity as well as any generalized weakness in the upper extremities, trunk or contralateral lower extremity.Proprioceptive training to improve body/spatial awareness of the operative extremity in functional activities.Endurance training to increase cardiovascular fitness.Functional training to promote independence in activities of daily living and mobility.Gait training: Assistive devices are discontinued when the patient is able to ambulate without a positive Trendelendberg test based upon the ambulationguidelines (usually 4-6 weeks).
111Setting Specific Orthopedic Exercises Hip: Phase III 10 days to 6 weeks:Modalities for Pain Control and Edema Reduction:Moist Heat, IceExercisesContinue previous exercisesLower Extremity Strengthening Exercises using TherabandAquatic Therapy/ActivitiesIliotibial Band Stretches-SupineScar Massage/Mobility-May be instituted after suture removal when the incision is clean and dry.Advance Passive, Active-Assisted, and active lower extremity range of motionClosed Kinetic Chain ActivitiesContinue stationary bike, progress resistance
112Setting Specific Orthopedic Exercises Hip: Phase III 10 days to 6 weeks:Balance/Proprioception Training:Weight-Shifting ActivitiesClosed Kinetic Chain ActivitiesLateral Stepping over/around objectsGait Training:Level SurfaceForward WalkingSidesteppingRetro WalkingUneven SurfacesFunctional TrainingLifting, CarryingPushing or Pulling, Squatting or CrouchingReturn-To-Work Tasks
113Setting Specific Orthopedic Exercises Phase IV 6-12 weeks:Exercises:Continue previous exercisesAdvance Passive, Active-Assisted, and active lower extremity range of motionNordic TrackStair-Step MachineIliotibial Band Stretches- standing at twelve (12) weeks post-operativelyDevelop walking programContinue pool and bike workEndurance Training:UBEAmbulation Activities
114Setting Specific Orthopedic Exercises Phase IV 6-12 weeks:Balance/Proprioception Training:Obstacle CourseFunctional TrainingLiftingCarryingPushing or PullingSquatting or CrouchingReturn to sport tasks
115Total Knee Arthroplasty Setting Specific Orthopedic ExercisesTotal Knee ArthroplastyBrief description of procedureThe normal knee joint functions as a complex hinge allowing primarily flexion and extension, but also rotation and gliding.The knee joint is made up of three compartments, the lateral, medial and patellofemoral.Damage to the cartilage of one or more compartments may be the result of osteoarthritis (idiopathic or post-traumatic), inflammatory arthritis (rheumatoid, psoriatic, etc.), avascular necrosis, tumors, or congenital deformities.Osteoarthritis and rheumatoid arthritis are the causes of the overwhelming majority of total joint arthroplasties
116Total Knee Arthroplasty Setting Specific Orthopedic ExercisesTotal Knee ArthroplastyBrief description of procedureModern total knee arthroplasty consists of resection of the diseased articular surfaces of the knee, followed by resurfacing with metal and polyethylene prosthetic components.For the properly selected patient, the procedure results in significant pain relief, improved function and quality of life
117Setting Specific Orthopedic Exercises Variations: Partial Knee Arthroplasty, Fixed Bearing device or Rotating Platform Device. Cemented or Compressed Fit; ACL/PCL sparing, Patella preservingWhen does Rehab start? For most elective orthopedic procedures, the patient can start strengthening prior to the surgery, as allowed by their pain and functional level. Unfortunately, this is typically not reimbursed by insurance companies, or it may take away from their post-op rehab visits.
118Setting Specific Orthopedic Exercises Precautions and time framesFollow WB directionsKneeling onto knee is typically not allowed/not recommended.Screen for blood clotsScreen for infectionAcute Care Phase: KneePhase IImmediate Postoperative Phase (Day 0 – 10)Goals:Active quad contractionSafe independent ambulation with walker or crutches as neededPassive knee extension to 0 degreesKnee flexion to 90 degrees or greaterControl of swelling, inflammation, bleeding
119Setting Specific Orthopedic Exercises Total Knee Surgery ProtocolDay 0-2:Weight bearing as tolerated with walker/2 crutches as needed starting on Day 0-1Cryotherapy immediately and continuously unless ambulatingROM of knee to begin immediately post opExercises, Ankle pumps, PROM/extension to 0 degreesSLRQuad setsKnee flexion to at least 90 degreesKnee extension to 0 degreesInstruct in gait training - safe transfers
120Setting Specific Orthopedic Exercises Total Knee Surgery ProtocolDay 3-10:Weight bearing as tolerated with walker/2 crutches as neededCryotherapyExercises: Ankle pumps, PROM knee extension to 0 degrees, SLR, Quad setsAAROM - Knee flexion to at least 90 degreesHip adduction/abductionInstruct in gait training – safe transfersStart stationary bike, low resistance
121Setting Specific Orthopedic Exercises Total Knee Surgery ProtocolPhase II: Motion Phase (Week 2-6)Goals: Improve ROMEnhance muscular strength, enduranceDynamic joint stabilityDiminish swelling/inflammationEstablish return to functional activitiesCriteria to enter Phase II:Leg control, able to perform SLRAROM 0-90 degreesMinimal pain/swellingIndependent ambulation/transfers
122Setting Specific Orthopedic Exercises Total Knee Surgery ProtocolWeeks 2 -4:WBAT with assistive device as needed. Wean from walker to cane or from 2 crutches to 1 by 2 weeks.Wean off all assistive devices by no later than 4 weeks.Exercises:Quad sets, SLR, VMO recruitment during quad sets and SLRKnee extension 90-0 degreesTerminal knee extension 45-0 degreesHip abduction/adductionHamstring curlsKnee flexion to at least 115 degrees
123Setting Specific Orthopedic Exercises Total Knee Surgery ProtocolStretching:HamstringsGastroc/soleusQuadsPassive knee extension stretchContinue stationary bike and advance resistance as toleratedContinue cryotherapyPatellofemoral mobilizationIncision mobilizationPatients may begin to drive if they are no longer using assistive devicesfor ambulation (about 2 weeks post op)
124Setting Specific Orthopedic Exercises Total Knee Surgery ProtocolWeeks 4-6:Exercises:Continue previous exercisesInitiate front and lateral step upsAdvance resistance on stationary bikeInitiate progressive walking programInitiate endurance pool program, swimming with flutter kickReturn to functional activitiesContinue compression, ice, elevation as needed for swellingPatients should be walking and driving independently at this point
125Setting Specific Orthopedic Exercises Total Knee Surgery ProtocolPhase III: Intermediate Phase (Weeks 7-12)Goals: Progression of ROM to greater than 115 degreesEnhancement of strength and enduranceEccentric/concentric control of limbCardiovascular fitnessFunctional activity performanceCriteria to enter Phase III:ROM degreesVoluntary quad controlIndependent ambulationMinimal pain
126Setting Specific Orthopedic Exercises Total Knee Surgery ProtocolWeeks 7-12:Exercises: Continue previous exercisesContinue pool activitiesContinue walkingContinue stationary bikeAggressive AROM degreesStrengthen quad/hamstrings
127Setting Specific Orthopedic Exercises Total Knee Surgery ProtocolPhase IV: Advanced Activity Phase (Weeks 12 and beyond)Goals: Allow patients to return to advanced level of function such as recreational sportsMaintain/improve strength and endurance of lower extremityReturn to normal life and routineCriteria to enter Phase IV:Full non painful ROM 0-115Strength 90% of contralateral limb (if contralateral limb is normal)Minimal pain and swellingSatisfactory clinical examination
128Setting Specific Orthopedic Exercises Total Knee Surgery ProtocolExercises:Quad sets, SLR, Hip abduction/adduction, Step ups, Knee extensionStationary bikeSwimmingWalkingStretching degreesReturn to pre op activities and develop HEP to maintain function of leg.NO SQUATS OR LUNGES AT ANY TIME!
129Setting Specific Orthopedic Exercises Partial Knee Surgery: Brief Description of the procedure.Unicompartmental knee replacement is an option for a small percentage of patients with osteoarthritis of the kneeIn a unicompartmental knee replacement, only the damaged compartment is replaced with metal and plasticPartial Knee Replacement can only be revised with a Total Knee Replacement
130Partial Knee Surgery Protocol Setting Specific Orthopedic ExercisesPartial Knee Surgery ProtocolGeneral Considerations: • All times are to be considered approximate, with actual progression based upon clinical presentation. • Patients are full weight bearing with the use of crutches, a walker, or a cane to assist walking until they are able to demonstrate good walking mechanics. • Early emphasis is on achieving full extension equal to the opposite leg as soon as able. • No passive or active flexion range of motion greater than 90° for the first two weeks. • No two-legged biking or flexion exercises for at least two weeks. Well-leg biking is fine. • Regular manual treatment should be conducted to the patella and all incisions so they remain mobile. • Early exercises should focus on recruitment of the vastus medialis obliquus (VMO). • No resisted leg extension machines (isotonic or isokinetic) at any point in the rehabilitation process.
131Setting Specific Orthopedic Exercises Partial Knee Surgery ProtocolHospital Stay is typically 24 hours and as soon as the sensation and motor control is back in the surgical leg and as soon as the patient is able to void, the patient will go home and start OP PT.Initial focus is on transfers, ambulation and AROM.90 % are done on the medial aspect of the kneeMay become OP procedure surgery soon
132Setting Specific Orthopedic Exercises Partial Knee Surgery ProtocolWeek 1: • Goal is to allow the medial arthrotomy to heal and decrease swelling. • MD visit on post-op Day 1 to change dressing and review home exercise program. • Icing, elevation, and aggressive edema control (i.e. circumferential massage, compression wraps). • Straight leg raise exercises (standing and seated), and passive and active ROM exercises. • OK to gently bend knee < 90° 1 - 2x per day. • Initiate quadricep/adduction/gluteal sets, gait training, balance/proprioception exercises. • Well-leg cycling and upper body conditioning. • Soft tissue treatments and gentle mobilization to the posterior musculature, patella, and incisions to avoid flexion or patella contracture.
133Setting Specific Orthopedic Exercises Partial Knee Surgery ProtocolWeeks 2 - 4: • Clinic visit at 14 days for suture removal and check-up. • Continue with home program, progress flexion range of motion, gait training, soft tissue treatments, and balance/proprioception exercises. • Incorporate functional exercises as able (i.e. seated/standing marching, hamstring carpet drags, hip/gluteal exercises, and core stabilization exercises). • Aerobic exercise as tolerated (i.e. bilateral stationary cycling as able, UBE, pool workouts once incisions are healed.)
134Setting Specific Orthopedic Exercises Partial Knee Surgery ProtocolWeeks 4 - 6: • MD visit at 4 weeks post-op. • Increase the intensity of functional exercises (i.e. progress to walking outside, introducing weight machines as able). • Continue balance/proprioception exercises (i.e. heel-to-toe walking, assisted single leg balance). Slow-to-normal walking without a limp.
135Setting Specific Orthopedic Exercises Partial Knee Surgery ProtocolWeeks 6 - 8: • Add lateral training exercises (i.e. lateral steps, lateral step-ups, step overs) as able. • Incorporate single leg exercises as able (eccentric focus early on). • Patients should be walking without a limp and range of motion should be <10° extension and >110° flexion.
136Setting Specific Orthopedic Exercises Partial Knee Surgery ProtocolWeeks : • Begin to incorporate activity-specific training (i.e. household chores, gardening, sporting activities). • Low-impact activities until after Week 12. • Patients should be weaned into a home/gym program with emphasis on their particular activity/sport.NOTE: All progressions are approximations and should be used as a guideline only. Progression will be based on individual patient presentation, which is assessed throughout the treatment process.
137Setting Specific Orthopedic Exercises Plyometrics (also known as "plyos" and "jumping") is a type of exercise training designed to produce fast, powerful movements, and improve the functions of the nervous system, generally for the purpose of improving performance in sports.Plyometric exercises may also be referred to as explosive exercises.Plyometric movements, in which a muscle is loaded and then contracted in rapid sequence, use the strength, elasticity and innervation of muscle and surrounding tissues to jump higher, run faster, throw farther, or hit harder, depending on the desired training goal.
138Setting Specific Orthopedic Exercises Plyometrics is used to increase the speed or force of muscular contractions, providing explosiveness for a variety of sport-specific activities. Plyometrics has been shown across the literature to be beneficial to a variety of athletes. Benefits range from injury prevention, power development and sprint performance amongst others
139Setting Specific Orthopedic Exercises Plyometric training involves and uses practicing plyometric movements to enhance tissues abilities and train nerve cells to stimulate a specific pattern of [muscle contraction] so the muscle generates as strong a contraction as possible in the shortest amount of time.A plyometric contraction involves first a rapid muscle lengthening movement (eccentric phase), followed by a short resting phase (amortization phase), then an explosive muscle shortening movement (concentric phase), which enables muscles to work together in doing the particular motion.Plyometric training engages the myotatic reflex, which is the automatic contraction of muscles when their stretch sensory receptors are stimulated (PNF).
140Setting Specific Orthopedic Exercises Knee Surgery Protocol : MeniscopyThe intent of this protocol is to provide the clinician with a guideline of the post-operative rehabilitation course of a patient that has undergone a meniscal repair.It is no means intended to be a substitute for one’s clinical decision making regarding the progression of a patient’s post-operative course based on their physical exam/findings, individual progress, and/or the presence of post-operative complications.If you require assistance in the progression of a post-operative patient you should consult with the referring Surgeon.
141Setting Specific Orthopedic Exercises Knee Surgery Protocol : MeniscectomyDescription of procedure:Removal of a part of one of the menisci of the knee or part thereof through an arthroscopic procedure, typically done at an ASC.General Considerations: • Weight-bearing as tolerated. Walk with crutches. • Surgical knee will be in a hinged rehab brace locked in FULL EXTENSION for 4 weeks post-op. • Regular assessment of gait to avoid compensatory patterns. • Regular manual mobilizations to surgical wounds and associated soft tissue to decrease the incidence of fibrosis. • No resisted leg extension machines (isotonic or isokinetic). • No high impact or cutting/twisting activities for at least 4 months post-op
142Setting Specific Orthopedic Exercises Knee Surgery Protocol : MeniscectomyGeneral Considerations: • Weight-bearing as tolerated. Walk with crutches. • Surgical knee will be in a hinged rehab brace locked in FULL EXTENSION for 4 weeks post-op. • Regular assessment of gait to avoid compensatory patterns. • Regular manual mobilizations to surgical wounds and associated soft tissue to decrease the incidence of fibrosis. • No resisted leg extension machines (isotonic or isokinetic). • No high impact or cutting/twisting activities for at least 4 months post-op
143Setting Specific Orthopedic Exercises Knee Surgery Protocol : MeniscectomyProgression to the next phase based on Clinical Criteria and/or Time Frames as Appropriate.Key Factors in determining progression of rehabilitation after Meniscal repair include:• Anatomic site of tear• Suture fixation (failure can be caused by too vigorous rehabilitation)• Location of tear (anterior or posterior)• Other pathology (ligamentous injury)
144Setting Specific Orthopedic Exercises Knee Surgery Protocol : MeniscectomyPhase I –Maximum Protection- Weeks 1-6:Goals:• Diminish inflammation and swelling• Restore ROM• Reestablish quadriceps muscle activityStage 1: Immediate Postoperative Day 1- Week 3• Ice, compression, elevation• Electrical muscle stimulation• Brace locked at 0 degrees• ROM 0-90
145Setting Specific Orthopedic Exercises Knee Surgery Protocol : MeniscectomyMeniscal Repair ProtocolMotion is limited for the first 7-21 days, depending on the development of scar tissue around the repair site.Gradual increase in flexion ROM is based on assessment of pain and site of repair (0-90 degrees).• Patellar mobilization• Scar tissue mobilization• Passive ROM
146Setting Specific Orthopedic Exercises Knee Surgery Protocol : MeniscectomyExercisesQuadriceps isometricsHamstring isometrics (if posterior horn repair, no hamstring exercises for 6 weeks)Hip abduction and adductionWeight-bearing as tolerated with crutches and brace locked at 0 degreesProprioception training with brace locked at 0 degrees
147Setting Specific Orthopedic Exercises Knee Surgery Protocol : MeniscectomyStage 2: Weeks 4-6• Progressive resistance exercises (PREs) 1-5 pounds.• Limited range knee extension (in range less likely to impinge or pull on repair)• Toe raises• Mini-squats (less than 90 degrees flexion)• Cycling (no resistance)• PNF with resistance• Unloaded flexibility exercises
148Setting Specific Orthopedic Exercises Knee Surgery Protocol : MeniscectomyPhase II: Moderate Protection- Weeks 6-10Criteria for progression to phase II:• ROM 0-90 degrees• No change in pain or effusion• Quadriceps control (MMT 4/5)Goals:• Increased strength, power, endurance• Normalize ROM of knee• Prepare patients for advanced exercises
149Setting Specific Orthopedic Exercises Knee Surgery Protocol : MeniscectomyExercises:• Strength- progression• Flexibility exercises• Lateral step-ups• Mini-squatsEndurance Program:• Swimming (no frog kick), pool running- if available• Cycling• Stair machineCoordination Program:• Balance board• Pool sprinting- if pool available• Backward walking• Plyometrics
150Setting Specific Orthopedic Exercises Knee Surgery Protocol : MeniscectomyPhase III: Advanced Phase- Weeks 11-15Criteria for progression to phase III:• Full, pain free ROM• No pain or tenderness• Satisfactory clinical examination• SLR without lag• Gait without device, brace unlockedGoals:• Increase power and endurance• Emphasize return to skill activities• Prepare for return to full unrestricted activities
151Setting Specific Orthopedic Exercises Knee Surgery Protocol : MeniscectomyExercises:• Continue all exercises• Increase plyometrics, pool program• Initiate running programReturn to Activity: Criteria• Full, pain free ROM• Satisfactory clinical examinationCriteria for discharge from skilled therapy:1) Non-antalgic gait2) Pain free /full ROM3) LE strength at least 4/54) Independent with home program5) Normal age appropriate balance and proprioception6) Resolved palpable edema
152Setting Specific Orthopedic Exercises Knee Surgery Protocol : Partial MeniscectomyRehabilitation after a partial meniscectomy may progress aggressively because there is noanatomic structure that requires protection.
153Setting Specific Orthopedic Exercises Knee Surgery Protocol : Partial MeniscectomyPhase I – Acute Phase:Goals:• Diminish pain, edema• Restore knee range of motion (goal 0-115, minimum of 0 degrees extension to 90degrees of flexion to progress to phase II)2• Reestablish quadriceps muscle activity/re-education (goal of no quad lag during SLR• Educate the patient regarding Weight bearing as tolerated, use of crutches, icing, elevation and the rehabilitation processWeight bearing:• Weight bearing as tolerated. Use two crutches initially progressing to weaning crutches as swelling and quadriceps status dictates.
154Setting Specific Orthopedic Exercises Knee Surgery Protocol : Partial MeniscectomyModalities:• Cryotherapy for 15 min 4 times a day 1• Electrical stimulation to quadriceps for functional retraining as appropriate• Electrical stimulation for edema control- high volt galvanic or interferentialstimulation as needed
155Setting Specific Orthopedic Exercises Knee Surgery Protocol : Partial MeniscectomyTherapeutic Exercise:• Quadriceps sets• SLR• Hip adduction, abduction and extension• Ankle pumps• Gluteal sets• Heel slides• ½ squats• Active-assisted ROM stretching, emphasizing full knee extension (flexion to tolerance)• Hamstring and gastroc/ soleus and quadriceps stretches• Use of compression wrap or brace• Bicycle for ROM when patient has sufficient knee ROM. May begin partial revolutions to recover motion if the patient does not have sufficient knee flexion
156Setting Specific Orthopedic Exercises Knee Surgery Protocol : Partial MeniscectomyPhase II: Internal Phase :Goals:• Restore and improve muscular strength and endurance• Reestablish full pain free ROM• Gradual return to functional activities• Restore normal gait without an assistive device• Improve balance and proprioceptionWeight bearing status:Patients may progress to full weight bearing as tolerated without antalgia.Patients may require one crutch or cane to normalize gait before ambulating without assistive device.
157Setting Specific Orthopedic Exercises Knee Surgery Protocol : Partial MeniscectomyTherapeutic exercise:• Continue all exercises as needed from phase one• Toe raises- calf raises• Hamstring curls• Continue bike for motion and endurance• Cardio equipment- stairmaster, elliptical trainer, treadmill and bike as above.• Lunges- lateral and front• Leg press• Lateral step ups, step downs, and front step ups• Knee extension degrees• Closed kinetic chain exercise terminal knee extension• Four way hip exercise in standing• Proprioceptive and balance training• Stretching exercises- as above, may need to add ITB and/or hip flexor stretches
158Setting Specific Orthopedic Exercises Knee Surgery Protocol : Partial MeniscectomyPhase III – Advanced activity phase:Goals:• Enhance muscular strength and endurance• Maintain full ROM• Return to sport/functional activities/work tasksTherapeutic Exercise:• Continue to emphasize closed-kinetic chain exercises• May begin plyometrics/ vertical jumping• Begin running program and agility drills (walk-jog) progression, forward andbackward running, cutting, figure of eight and carioca program• Sport specific drills
159Setting Specific Orthopedic Exercises Knee Surgery Protocol : Partial MeniscectomyCriteria for discharge from skilled therapy:1) Non-antalgic gait2) Pain free /full ROM3) LE strength at least 4+/54) Independent with home program5) Normal age appropriate balance and proprioception6) Resolved palpable edema
160Setting Specific Orthopedic Exercises Knee Surgery Protocol : ACL Reconstruction, Allograft (donor tissue)Brief description:Allograft is most commonly used in lower demand patients, or patients who are undergoing revision ACL surgery (when an ACL reconstruction fails).Biomechanical studies show that allograft (donor tissue from a cadaver) is not as strong as a patient's own tissue (autograft).For many patients, however, the strength of the reconstructed ACL using an allograft is sufficient for their demands.Therefore this may be an excellent option for patients not planning to participate in high-demand sports (e.g. soccer, basketball, etc.).
161Setting Specific Orthopedic Exercises Knee Surgery Protocol : AUTOGRAFT BONE-PATELLA TENDON-BONE and ALLOGRAFT PROTOCOLVariation: Autograft, ACL repair, Patello Tendon Autograft, Hamstring tendon Autograft.Phase I-Early Functional (Weeks 1-2)Goals:1. Educate re: the proper use of continuous passive motion (CPM) machine aHome exercise program (HEP).2. Decrease pain and effusion.3. Educate re: the importance of icing.4. Independent donning,doffing, adjusting hinges, and use of knee brace.5. Safe ambulation with assistant device and knee brace WEIGHTBEARING AS TOLERATED (WBAT) on the involved leg.6. Promote normal gait mechanics.7. Early balance control.8. Attain full extension and functional flexion of the involved knee.9. Obtain baseline values for the uninvolved limb (isokinetic testing).10. Initiate early neuromotor control of all muscle groups.
162Setting Specific Orthopedic Exercises Knee Surgery Protocol : ACL Reconstruction, AllograftPhase I-Early Functional (Weeks 1-2)Goals:1. Educate re: the proper use of continuous passive motion (CPM) machine aHome exercise program (HEP).2. Decrease pain and effusion.3. Educate re: the importance of icing.4. Independent donning,doffing, adjusting hinges, and use of knee brace.5. Safe ambulation with assistant device and knee brace WEIGHTBEARING AS TOLERATED (WBAT) on the involved leg.
163Setting Specific Orthopedic Exercises Knee Surgery Protocol : ACL Reconstruction, Allograft6. Promote normal gait mechanics.7. Early balance control.8. Attain full extension and functional flexion of the involved knee.9. Obtain baseline values for the uninvolved limb (isokinetic testing).10. Initiate early neuromotor control of all muscle groups.
164Setting Specific Orthopedic Exercises Knee Surgery Protocol : ACL Reconstruction, AllograftDay of Surgery:Ambulate WBAT with knee brace range from 0º to tolerated active flexion (maximum 60º) on level surfaces with axillary crutches. The brace will initially be set by the physical therapist.CPM will be set at 0º to 60º unless otherwise documented.Brace SHOULD NOT be worn while the operated limb is in the CPM.Brace is required only when ambulating and while performing straight leg raise (SLR) exercises outlined below.
165Setting Specific Orthopedic Exercises Knee Surgery Protocol : ACL Reconstruction, AllograftPost-Operative Day #1:- Ambulate as above on level surfaces and stairs.- CPM progression can be 10º – 20º daily but should not exceed 5 ºevery 3 hours.- Review of patient ACL ( PATELLA TENDON-BONE GRAFT) Home instructions.- KNEE BRACE MUST BE WORN WITH THE STRAIGHT LEGRAISE (SLR) EXERCISES LOCKED AT 0º.- ankle strengthening for all planes with theraband.- quad set with towel roll under the ankle to promote full extension.- heel slides.- hamstring sets.- seated hip flexion.- seated active assisted knee extension.- straight leg raises (SLR) in all 4 planes with BRACE LOCKED AT 0º.
166Setting Specific Orthopedic Exercises Knee Surgery Protocol : ACL Reconstruction, AllograftPost-operative Day #2-7:- Continue with above ambulation and exercise guidelines.- Increase knee brace setting with active knee motion.- Continue CPM until 90º active knee flexion is achieved. CPMprogression can be 10º – 20º daily but should not exceed 5º every 3hours.- BAPS- in sitting.- Stationary bicycle- start with a low, comfortable seat height topromote flexion, most force through non-operated limb-increase seatheight in subsequent sessions.- Supine wall slides- allow gravity to assist with knee flexion. DO NOT perform wall slides in the upright or stance position.- Home stretching – for quadriceps, hamstrings, and gastrocnemius.- Balance activities – begin with bilateral stance activities and progress to unilateral on the ground.
167Setting Specific Orthopedic Exercises Knee Surgery Protocol : ACL Reconstruction, AllograftBilateral standing modified knee bends (0-30º)-begin with bodyweight and then add light extrinsic weight accordingly.- Marching in place- begin in sitting and progress to standing.- Sidestepping- Multi hip – to involved lower limb. Be sure weight is applied proximal to the knee. (flexion, extension, abduction, adduction, terminal knee extension)- Retro walking – Begin with body weight then progress to pulling aweighted sled. Increase the load as tolerated.- Quadriceps isometrics – at varied degrees of knee flexion.- Active knee extension – of the involved knee (full) as tolerated.- Active knee flexion – full.- Rolling chair activity – active hamstring/quad activity by performing forward propulsion/retropulsion of rolling chair using alternating lower extremities (90º-0º).
168Setting Specific Orthopedic Exercises Knee Surgery Protocol : ACL Reconstruction, AllograftProprioceptive training: static stabilizing technique – at various degrees of knee flexion using therapeutic ball.Begin in supine with legs on the ball then progress to sitting on the ball (90º-0º).Heel raises – begin with bilateral lower limbs then progress to unilateral.
169Setting Specific Orthopedic Exercises Knee Surgery Protocol : ACL Reconstruction, Allograft** IN ALL CLOSED CHAIN KNEE EXERCISES, DO NOT ALLOW THEANTERIOR ASPECT OF THE KNEE TO PASS THE TOES.**BY THE END OF WEEK 1:AROM: PROM:0-80º 0-90º0-105º 0-120º0-120º 0-125º**DO NOT PUSH >125º WITH PASSIVE RANGE OF MOTION. CONTINUE TO CHECK RANGE OF MOTION PERIODICALLY TO MAKE SURE RANGE IS MAINTAINED.**
170Setting Specific Orthopedic Exercises Knee Surgery Protocol : ACL Reconstruction, AllograftPost-operative Day #8-14:- Continue as above.- Straight leg raises- without the brace if the patient demonstrates goodquad control, with resistance applied proximal to the knee. Use thebrace locked at 0º if an extension lag still exists.- Standing leg curl- begin in standing with no added weight. The patientmust demonstrate easy effort prior to adding weight.- Multi hip- to bilateral lower limbs. (Flexion, extension, abduction,adduction, terminal knee extension).- Leg press- begin using bilateral lower limbs (30º - 0º). Begin with lowextrinsic weight (10-50% maximum of the patient’s body weight) andprogress weight if the patient demonstrates good quad control duringterminal knee extension. The patient at this time may begin unilateralleg press (10-30% maximum of the patient’s body weight).- Balance activities – progress to bilateral activities on the disc theunilateral.- Discontinue crutches at POD #14 if proper gait mechanics are obtained.
171Setting Specific Orthopedic Exercises Knee Surgery Protocol : ACL Reconstruction, AllograftPhase II-Progressive Functional (Weeks 3-11)Goals:1. Decrease pain and effusion.2. Discontinue the postoperative brace when the patient demonstrates goodquad control.3. Continue the development of neuromotor control of all muscle groups.4. Retrain for proprioception and normalize responses to dynamicchallenges.
172Setting Specific Orthopedic Exercises Knee Surgery Protocol : ACL Reconstruction, AllograftWeeks 3 through 4:Continue as above.Cable column- should be performed once the patient is able to straightleg raise with resistance distal to the knee with good quad control.Begin with flexion and extension followed by abduction and adduction. Be more cautious with those patients who have meniscal, medial or lateral collateral involvement.Unilateral modified knee bends (0-30º)- Stand erect. Extend hip and flex the knee and place the dorsum of the foot on a bench or box behind you. With support to the upper limb, lower the torso, allowing your stance knee to flex to 45º. **DO NOT ALLOW THE ANTERIOR ASPECT OF THE KNEES TO PASS THE TOES.**Begin with body weight and progress with light extrinsic weight.Step ups- begin with body weight then add weights and step height gradually. Discontinue if the patient has any complaints of pain.Balance activities- incorporate multi task activities, i.e. unilateral modified knee bend while performing arm curls while balancing on a disc.
173Setting Specific Orthopedic Exercises Knee Surgery Protocol : ACL Reconstruction, AllograftClosed chain step machine (0-30º)- begin with low resistance and maintain short steps throughout.Swimming- the patient may perform side stroke or flutter kick initiating motion from the hip. No butterfly.
174Setting Specific Orthopedic Exercises Knee Surgery Protocol : ACL Reconstruction, AllograftWeeks 5 through 6:Continue as above.Progressive resisted knee extension- perform activity with a slow controlled motion.Begin with cuff weights for the involved leg and continue to do so until the patient can comfortably lift 20 lbs. Do not allow the activity to begin with >80º of knee flexion.Advanced hamstring activity – with the trunk flexed perform hip extension with upper extremity support, with the hip extended to midrange perform a hamstring curl, in the supine position perform bridging on the theraball with hip flexion, and relaxed knee dead lifts if there is no history of low back problems.Cross friction massage to scar.
175Setting Specific Orthopedic Exercises Knee Surgery Protocol : ACL Reconstruction, AllograftWeeks 7 through 8:Continue as above.Lateral activities – begin by increasing the speed with lateral stepping progressing to lateral shuffles, ski simulator, modified slide board activities (restricted distance slide board) to full range slide board.**WITH ALL OF THESE EXERCISES BE AWARE OF VALGUS STRESSES**Cable column simulated running – once the patient exhibits good control with single plane motion progress to multi joint motion.Crossover stepping –progress to cariocas as tolerated.BAPS – in standing. Beware of rotation occurring at the knee and valgus/varus stresses.
176Setting Specific Orthopedic Exercises Knee Surgery Protocol : ACL Reconstruction, AllograftWeeks 8 through 11:Continue as above.Standing bicycle- with high resistance, may progress to a bikespectrum.Plyometrics- begin with mini jumps on the leg press at approximately30% of body weight.
177Setting Specific Orthopedic Exercises Knee Surgery Protocol : ACL Reconstruction, AllograftWeeks 8 through 11:Continue as above.Standing bicycle- with high resistance, may progress to a bike spectrum.Plyometrics- begin with mini jumps on the leg press at approximately 30% of body weight.Phase III-Functional (Weeks 12-16)Goals:1. Master functional tasks of desired physical activity.2. Optimize force production and absorption with various activities.
178Setting Specific Orthopedic Exercises Knee Surgery Protocol : ACL Reconstruction, AllograftWeeks 12-15:Continue as above.Lateral shuffles weighted, Stop and Go.Slide board with the patient wearing a weighted vest (or holding a hand dumbbell) incorporating a ball toss.Begin Dynamic skills progression- (jumping, hopping, and leaping).Agility drillMay initiate light jogging program if the patient demonstrates good force production (i.e. jumping) and absorption (i.e. landing), especially when leaping from uninvolved to the involved limb.10RM testing as 12 weeks: begin heavy, moderate and light workout days according to strength assessment guidelines.
179Setting Specific Orthopedic Exercises Knee Surgery Protocol : ACL Reconstruction, AllograftWeeks 16+:Continue as above.May initiate running of the patient demonstrates good force production and absorption, especially when leaping from uninvolved to involved.The patient may return to activity without a derotation brace if:1. Pain free with ADL and rehab activities including agility and sport specific drills.2. No c/o stiffness during or after all above activities.3. No c/o giving way during all above activities.Objective:1. Full AROM and PROM (0-135º).
180Setting Specific Orthopedic Exercises Knee Surgery Protocol : PCL ReconstructionISOLATED AND COMBINED PCL RECONSTRUCTION POST-OP REHABILITATION PROTOCOLGENERAL PRINCIPLESNo open chain hamstring workAssume 8 weeks for graft to bone healing timeCaution against posterior tibial translation (gravity, muscle action)CPM 0°-60° to startPCL with posterolateral corner or LCL repair follows different post-op care, i.e.,crutches x 3 monthsSupervised physical therapy takes place for approximately 3-5 months post-op.
181Setting Specific Orthopedic Exercises Knee Surgery Protocol : PCL ReconstructionGENERAL PROGRSSION OF ACTIVITIES OF DAILY LIVING (ADLs)Patients may begin the following activities at the post-op dates listed (unless otherwise specified by the physician):Bathing/Showering without brace (surgical incisions should be healed before immersion in water) – 1 week post-opSleep without brace – 8 weeks post-opDriving – 6-8 weeks post-opFull weight bearing without assistive devices – 8 weeks post-op (with physician clearance)
182Setting Specific Orthopedic Exercises Knee Surgery Protocol : PCL ReconstructionPHYSICAL THERAPY ATTENDANCEThe following is an approximate schedule for supervised physical therapy visits:0 to 1 month: 1 x week1 to 3 months: 2-3 x week3 to 9 months: 2 x month9 to 12 months: 1 x month
183Setting Specific Orthopedic Exercises Knee Surgery Protocol : PCL ReconstructionREHABILITATION PROGRESSION0-1 WEEK POST-OPBrace: Locked at 0°-60° maximumWeight bearing Status: WBAT with crutches, with brace lockedSpecial Considerations: Pillow under proximal posterior tibia at rest to prevent posterior sagTherapy: Quad Sets Ankle PumpsSLR Hip AlphabetsHip AB/AD
184Setting Specific Orthopedic Exercises Knee Surgery Protocol : PCL Reconstruction7-28 DAYS POST-OPBrace: Locked except for protected range of motion performed by physical therapist.WB Status: WBAT with crutches, with brace lockedSpecial Considerations: Continue use of pillow under tibia at rest.
185Setting Specific Orthopedic Exercises Knee Surgery Protocol : PCL ReconstructionTherapy:PT Assisted knee flexionFor PCL only patients: Maintain anterior pressure on proximal tibia as knee is flexed.For combined PCL/ACL patients, maintain neutral position of proximal tibia as knee is flexed.It is important to prevent posterior tibial sagging at all times.Hamstring and Calf stretchingCalf press with TherabandStanding calf raises with full knee extensionStanding hip extension from neutral
186Setting Specific Orthopedic Exercises Knee Surgery Protocol : PCL Reconstruction4-8 WEEKSBrace: 4-8 weeks: Brace is unlocked for supervised gait training only (patients must be under the direct supervision of a PT)WB status: WBAT with crutchesTher. Ex: - When patient exhibits independent quad control, may begin open chain extension, if no flexion contracture exists.Wall slides (0° to 45°)Begin isometric, progress to active against body weight.Ambulation in pool (only while in physical therapy)Continue to maintain hamstring flexibility
187Setting Specific Orthopedic Exercises Knee Surgery Protocol : PCL Reconstruction8-12 WEEKSD/C Brace 8 weeksWB status: Wean off crutches at 8 weeks post-opMay D/C crutches if patient exhibits:No quad lag with SLRFull knee extensionKnee flexion 90°-100°Normal gait patternTherapy: Stationary bike: Foot forward on pedal (no toe clips), seat highBalance and proprioception, Seated calf raisesLeg press (within available range of motion)
188Setting Specific Orthopedic Exercises Knee Surgery Protocol : PCL Reconstruction12 WEEKS (3 MONTHS)Progress functional and symptomatically Therapy:Treadmill walkingJogging in pool withSwimming – no breaststroke emphasize flutter kick from hip (minimize active knee flexion)3-6 MONTHSReduce frequency of physical therapy sessions.Pt may continue therapy at gym club if released by physician.During this phase the patient should check in with the supervising physical therapist once every 2 weeks.
189Setting Specific Orthopedic Exercises Knee Surgery Protocol : PCL Reconstruction6-12 MONTHSReturn to full activity per MD release and testing shows surgical side quad strength at least 90% of unoperated side. (e.g. Return to work based on function capabilities)Sports specific functional progressionNordic TrackJog/Run progressionBackward running, CuttingJumping (Plyometrics)NO SQUATS OR LUNGES AT ANY TIME!
190Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : SLAP Lesion repair protocolBrief description procedure:A SLAP repair is a procedure performed for treatment of a SLAP tear.Surgical treatment of a SLAP tear is considered for patients who do not respond to more conservative treatmentsA SLAP repair is performed arthroscopically using sutures to reattach the torn labrum back to the boneA SLAP repair restores the normal anatomy of the shoulder by reattaching the labrum in its normal position.Once healed, the SLAP repair allows normal function of the previously damaged labrum and biceps attachment.
191Setting Specific Orthopedic Exercises Rehab after a SLAP repairRehabilitation varies depending on factors such as the strength of the SLAP repair, and the preference of the surgeon.Most often, a period of time of restricted motion is maintained for about six weeks following a SLAP repair.During this first phase of rehabilitation, some passive motion is allowed to prevent shoulder stiffness.In the first phase, the torn labrum is healing into its proper position.Once healed, patients enter the second phase of rehabilitation and can begin more motion at about six weeks.Physical therapy continues to help maintain motion and regain strength of the shoulder.The final phase of rehabilitation involves more active strengthening of the muscles that surround the shoulder joint, and full recovery is expected between 3 to 4 months.
192Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : SLAP Lesion repair protocolFor the first three weeks your sling must be worn in bed.Sleeping can be uncomfortable if you try and lie on the operated arm.It’s recommended that you lie on your back or on the opposite side.Pillows can be used to give you comfort and support.If you are lying on your side one pillow slightly folded under your neck gives enough support for most people.A pillow folded in half supports the arm in front and a pillow tucked along your back helps to prevent you rolling onto the operated shoulder during the night.If you are lying on your back, tie a pillow tightly in the middle (a "butterfly pillow") or use a folded pillow to support your neck. Place a folded pillow under the elbow of the operated arm to support that.
193Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : SLAP Lesion repair protocol
194Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : SLAP Lesion repair protocolSuperior Labral Tear Anterior to posterior (SLAP) are rare injuries and studies have suggested that magnetic resonance imaging (MRI) scans often produce false positives and that SLAP lesions are difficult to diagnose clinically.Numerous studies suggest that even experts disagree on how to define a type II SLAP tear and it was found that the rate of repair increased over time to peak at 10.1 percent in the final year of the study. Sports medicine specialists performed SLAP repairs at the highest rate—12.4 percent—compared to a rate of 9.2 percent among general orthopaedists
195Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : SLAP Lesion repair protocolThis rehabilitation protocol has been developed for the patient following a SLAP (Superior Labrum Anterior Posterior) repair.It is extremely important to protect the biceps/labral complex for 6 weeks post-operatively to allow appropriate healing.This protocol has been divided into phases. Each phase may vary slightly based on the individual patient and special circumstances.The overall goals of the surgical procedure and rehabilitation are to:Control pain and inflammationRegain normal upper extremity strength and enduranceRegain normal shoulder range of motionAchieve the level of function based on the orthopedic and patient goals
196Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : SLAP Lesion repair protocolEarly passive range of motion with noted limitations is highly beneficial to enhance circulation within the joint to promote healing.The physical therapy should be initiated within the first week following surgery.The supervised rehabilitation program is to be supplemented by a home fitness program where the patient performs the given exercises at home or at a gym facility.Important post-operative signs to monitor include:Swelling of the shoulder and surrounding soft tissueAbnormal pain response, hypersensitive-an increase in night painSevere range of motion limitationsWeakness in the upper extremity musculature
197Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : SLAP Lesion repair protocolReturn to activity requires both time and clinical evaluation.To safely and most efficiently return to normal or high level functional activity, the patient requires adequate strength, flexibility, and endurance.Functional evaluation including strength and range of motion testing is one method of evaluating a patient’s readiness to return to activity.Return to intense activities following a SLAP repair requires both a strenuous strengthening and range of motion program along with a period of time to allow for tissue healing.Symptoms such as pain, swelling, orinstability should be closely monitored by the patient.
198Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : SLAP Lesion repair protocolPhase 1: Week 1-3ROM :Gentle pendulum exercise onlySTRENGTH :No strengtheningBRACE Brace for 6 weeksBrace removed for exercises aboveMODALITIESE-stim as neededIce minutesGOALS OF PHASE:• Promote healing of tissue• Control pain and inflammation• Independent in HEP
199Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : SLAP Lesion repair protocolPhase 2: Week 3-6ROMGradual gentle passive range of motionFlexion/Elevation 0-60°Passive range of motion-scapular planeExternal Rotation 0-15°Internal Rotation as toleratedContinue pendulum exerciseSTRENGTHSubmaximal isometric activitiesShoulder shrugs with resistanceMODALITIESIce minutes
200Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : SLAP Lesion repair protocolGOALS OF PHASE:Control pain and inflammationEnhance upper extremity strengthGradual increase in ROM.
201Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : SLAP Lesion repair protocolPhase 3: Week 6-12ROMGentle passive range of motionFlexion/Elevation 0-145°Passive range of motion-scapular planeExternal Rotation 0-50°Internal Rotation Full ROMPosterior capsule stretchingTowel stretchingRope/Pulley activitiesWand exercisesManual stretching
202Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : SLAP Lesion repair protocolSTRENGTHContinue all strengthening from previous phases increasing resistance and repetitionInitiate supine rhythmic stabilization at 90° flexionInitiate IR/ER at neutral with tubingInitiate forward flexion, scaption, empty canInitiate sidelying ER and tricep strengtheningProne abduction with external rotationShoulder shrugs with resistanceSupine punches with resistanceShoulder retraction with resistanceInitiate UBE for endurance and Prone rowsInitiate light biceps curls at week 10Initiate plyotoss (overhead toss) chest pass and initiate PNF patterns with therabandInitiate IR/ER exercises at 90 ° abductionInitiate isokinetic IR/ER at neutral at wk 10-12
203Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : SLAP Lesion repair protocolMODALITIESIce minutesGOALS OF PHASE:Minimize pain and swellingReach full ROMImprove upper extremity strength and enduranceEnhance neuromuscular controlNormalize arthrokinematics.
204Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : SLAP Lesion repair protocolPhase 4: Week 12-24ROMContinue with all ROM activities from previous phases, goal full ROM in all planesPosterior capsule stretchingTowel stretchingJoint mob. as needed for full ROM
205Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : SLAP Lesion repair protocolSTRENGTHProgress strengthening program with increase in resistance and high speed repetitionProgress with eccentric strengthening of posterior cuff and scapular musculatureInitiate single arm plyotossProgress rhythmic stabilization activities to include standing PNF patterns with tubingUBE for strength and enduranceInitiate military press, bench press, lat pulldownInitiate sport specific drills and functional activitiesInitiate interval throwing program week 16Initiate light plyometric program week 12-16Progress isokinetics to 90 ° of abduction at high speeds
206Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : SLAP Lesion repair protocolMODALITIESIce minutesGOALS OF PHASE:Full ROMMaximize upper extremity strength and enduranceMaximize neuromuscular controlInitiate sports specific training/functional training
207Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : RTC Lesion repair protocolBrief Description of the procedure:There are a few options for repairing rotator cuff tears. Advancements in surgical techniques for rotator cuff repair include less invasive procedures.While each of the methods available has its own advantages and disadvantages, all have the same goal: getting the tendon to healThe type of repair performed depends on several factors, including your surgeon's experience and familiarity with a particular procedure, the size of your tear, your anatomy, and the quality of the tendon tissue and bone.
208Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : RTC Lesion repair protocolMany surgical repairs can be done on an outpatient basis and do not require you to stay overnight in the hospital.The orthopaedic surgeon will discuss the best procedure to meet the patients individual health needs.There may be other shoulder problems in addition to a rotator cuff tear, such as osteoarthritis, bone spurs, or other soft tissue tears which the surgeon may be able to take care of as well during the surgery.
209Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : RTC Lesion repair protocolThe three techniques most commonly used for rotator cuff repair include traditional open repair, arthroscopic repair, and mini-open repair.In the end, patients rate all three repair methods the same for pain relief, strength improvement, and overall satisfaction.
210Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : RTC Lesion repair protocolOpen RepairA traditional open surgical incision (several centimeters long) is often required if the tear is large or complex.The surgeon makes the incision over the shoulder and detaches the shoulder muscle (deltoid) to better see and gain access to the torn tendon.During an open repair, the surgeon typically removes bone spurs from the underside of the acromion (this procedure is called an acromioplasty).An open repair may be a good option if the tear is large or complex or if additional reconstruction, such as a tendon transfer, is indicated.Open repair was the first technique used for torn rotator cuffs. Over the years, new technology and improved surgeon experience has led to less invasive procedures.
211Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : RTC Lesion repair protocolAll-Arthroscopic RepairDuring arthroscopy, your surgeon inserts a small camera, called an arthroscope, into your shoulder joint. The camera displays pictures on a television screen, and your surgeon uses these images to guide miniature surgical instruments.Because the arthroscope and surgical instruments are thin, your surgeon can use very small incisions (cuts), rather than the larger incision needed for standard, open surgery.All-arthroscopic repair is usually an outpatient procedure and is the least invasive method to repair a torn rotator cuff.
212Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : RTC Lesion repair protocolMini-Open RepairThe mini-open repair uses newer technology and instruments to perform a repair through a small incision. The incision is typically 3 to 5 cm long.This technique uses arthroscopy to assess and treat damage to other structures within the joint. Bone spurs, for example, are often removed arthroscopically. This avoids the need to detach the deltoid muscle.Once the arthroscopic portion of the procedure is completed, the surgeon repairs the rotator cuff through the mini-open incision. During the tendon repair, the surgeon views the shoulder structures directly, rather than through the video monitor
213Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : RTC Lesion repair protocolROTATOR CUFF REPAIR PROTOCOLThis rehabilitation protocol has been developed for the patient following a rotator cuff surgical procedure.This protocol will vary in length and aggressivenessdepending on factors such as:Size and location of tearDegree of shoulder instability/laxity prior to surgeryAcute versus chronic conditionLength of time immobilizedStrength/pain/swelling/range of motion statusRehabilitation goals and expectations
214Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : RTC Lesion repair protocolROTATOR CUFF REPAIR PROTOCOLEarly passive range of motion is highly beneficial to enhance circulation within the joint to promote healing. The protocol is divided into phases. Each phase isadaptable based on the individual and special circumstances.The overall goals of the surgical procedure and rehabilitation are to:Control pain, inflammation, and effusionRegain normal upper extremity strength and enduranceRegain normal shoulder range of motionAchieve the level of function based on the orthopedic and patient goals
215Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : RTC Lesion repair protocolROTATOR CUFF REPAIR PROTOCOLPhysical therapy should be initiated within the first week post-op.The supervised rehabilitation program is to be supplemented by a home fitness program where the patient performs the given exercises at home or at a gym facility.Important post-op signs to monitor:Swelling of the shoulder and surrounding soft tissueAbnormal pain response, hypersensitive-an increase in night painSevere range of motion limitationsWeakness in the upper extremity musculature
216Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : RTC Lesion repair protocolROTATOR CUFF REPAIR PROTOCOLReturn to activity requires both time and clinical evaluation.To safely and most efficiently return to normal or high level functional activity, the patient requires adequate strength, flexibility, and endurance.Functional evaluation including strength and range of motion testing is one method of evaluating a patient’s readiness return to activity.Return to intense activities following a rotator cuff repair require both a strenuous strengthening and range of motion program along with a period of time to allow for tissue healing.Symptoms such as pain, swelling, or instability should be closely monitored by the patient.
217Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : RTC Lesion repair protocolROTATOR CUFF REPAIR PROTOCOLPhase 1: Week 1-6ROMPendulum exercisesElbow (flex/ext) range of motionSTRENGTHNO Active Shoulder flexion or abductionallowed in the first 6 weeksGrip strengthening with putty or ballBRACEBrace for 6 weeksBrace removed to perform exercises aboveMODALITIESE-stim as neededIce minutes
218Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : RTC Lesion repair protocolROTATOR CUFF REPAIR PROTOCOLGOALS OF PHASE:Promote healing of repaired rotator cuffControl pain and inflammationGradual increase of ROMIndependent in HEPDelay muscle atrophy
219Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : RTC Lesion repair protocolROTATOR CUFF REPAIR PROTOCOLPhase 2: Week 6-12ROMContinue all ROM from previous phasesInitiate gentle posterior capsule stretchingInitiate gentle IR stretchingInitiate rope/pulleyInitiate passive ER wand exerciseRope/Pulley (flex/abd/scaption)Wand activities in all planesPosterior capsule stretchingTowel stretching
220Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : RTC Lesion repair protocolROTATOR CUFF REPAIR PROTOCOLSTRENGTHContinue with all strengthening from previous phases increasing resistance and repetitionInitiate supine AROM exercises without resistanceInitiate UBE without resistanceInitiate scapular stabilizer strengthening-active assistedManual rhythmic stabilization exercises at 90 ° flexShoulder shrugs with resistanceShoulder retraction with resistanceSupine punches with resistanceProne shoulder extension
221Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : RTC Lesion repair protocolROTATOR CUFF REPAIR PROTOCOLProne rowingProne ER with abductionInitiate forward flexion, scaption, empty canSidelying ERUBE for endurance trainingInitiate plyotoss at chest then progress to overheadBicep/Tricep workIsokinetic ER/IR at neutral at week 10-12MODALITIESIce minutes
222Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : RTC Lesion repair protocolROTATOR CUFF REPAIR PROTOCOLGOALS OF PHASE:Minimize pain and swellingReach full ROMImprove upper extremity strength and enduranceEnhance neuromuscular controlNormalize arthrokinematics.
223Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : RTC Lesion repair protocolROTATOR CUFF REPAIR PROTOCOLPhase 4: Week 12-24ROMContinue with all ROM activities from previous phasesPosterior capsule stretchingTowel stretchingSTRENGTHProgress strengthening program with increase in resistance and high speed repetitionInitiate IR/ER exercises at 90 ° abductionProgress rhythmic stabilization activities to include standing PNF patterns with tubingInitiate single arm plyotoss
224Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : RTC Lesion repair protocolROTATOR CUFF REPAIR PROTOCOLInitiate military press, bench press, flys, lat pulldownsUBE for strength and enduranceInitiate sport specific drills and functional activitiesInitiate interval throwing program week 16-20Initiate light upper body plyometric program week 16-20Progress isokinetics to 90 ° abduction at high speeds
225Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : RTC Lesion repair protocolROTATOR CUFF REPAIR PROTOCOLMODALITIESIce minutesGOALS OF PHASE:Full painless ROMMaximize upper extremity strength and enduranceMaximize neuromuscular controlInitiate sports specific training/functional training
226Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Total Shoulder ReplacementBrief description of the procedure:Total shoulder joint replacement is an option given to patients who suffer from joint dysfunction.This is usually the result of osteoarthritis or rheumatoid arthritis, but more rarely for those who have sustained severe trauma from a shoulder fracture.Generally, all other modes of treatment are considered first, such as physical therapy and medication, but total shoulder replacement can provide pain relief and increased mobility for those who have not experienced relief.
227Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Total Shoulder Replacement
228Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Total Shoulder ReplacementWhen shoulder replacement surgery is performed, the ball is removed from the top of the humerus and replaced with a metal implant.This is shaped like a half-moon and attached to a stem inserted down the center of the arm bone.The socket portion of the joint is shaved clean and replaced with a plastic socket that is cemented into the scapula.Just like any joint replacement the success of the surgery depends on many factors including the advanced state of the arthritic joint at the time of surgery, the overall health of the patient and most importantly the dedication to the physical therapy required after the surgery.
229Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Total Shoulder Replacement
230Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Total Shoulder ReplacementVariations: Hemi Arthroplasty, Reverse Shoulder ReplacementThe intent of this protocol is to provide the clinician with a guideline of the postoperative rehabilitation course of a patient that has undergone a total shoulder arthroplasty (TSA) or hemi-arthroplasty (humeral head replacement, HHR).It is not intended to be a substitute for appropriate clinical decision-making regarding the progression of a patient’s postoperative course. The actual post surgical physical therapy management must be based on the surgical approach, physical exam/findings, individual progress, and/or the presence of postoperative complications. If a clinician requires assistance in the progression of a patient post-surgery, consult with the referring surgeon.
231Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Total Shoulder ReplacementPlease Note:Patients with a concomitant repair of a rotator cuff tear and/or a TSA/HHR secondary to fracture or cuff arthropathy should be progressed to the next phase based on meeting the clinical criteria (not based on the postoperative time frames) as appropriate in collaboration with the referring surgeon. The given time frames are an approximate guide for progression, achieving
232Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Total Shoulder ReplacementPassive Range of Motion (PROM): PROM for all patients having undergone a TSA should be defined as ROM that is provided by an external source (therapist, instructed family member, or other qualified personnel) with the intent to gain ROM without placing undue stress on either soft tissue structures and/or the surgical repair.PROM is not stretching!!!!!!!
233Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Total Shoulder ReplacementPhase I – Immediate Post Surgical Phase:Goals:Allow healing of soft tissueMaintain integrity of replaced jointGradually increase passive range of motion (PROM) of shoulder; restore active range of motion (AROM) of elbow/wrist/handReduce pain and inflammationReduce muscular inhibitionIndependent with activities of daily living (ADLs) withmodifications while maintaining the integrity of the replaced joint.
234Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Total Shoulder ReplacementPrecautions:Sling should be worn continuously for 3-4 weeksWhile lying supine, a small pillow or towel roll should be placed behind the elbow to avoid shoulder hyperextension / anterior capsule stretch / subscapularis stretch. (When lying supine patient should be instructed to always be able to visualize their elbow. This ensures they are not extending their shoulder past neutral.) – This should be maintained for 6-8 weeks post-surgically.Avoid shoulder AROM.
235Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Total Shoulder ReplacementNo lifting of objectsNo excessive shoulder motion behind back, especially into internal rotation (IR)No excessive stretching or sudden movements (particularly external rotation (ER))No supporting of body weight by hand on involved sideKeep incision clean and dry (no soaking for 2 weeks)No driving for 3 weeks
236Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Total Shoulder ReplacementPost-Operative Day (POD) #1 (in hospital):Passive forward flexion in supine to toleranceGentle ER in scapular plane to available PROM (as documented in operative note) – usually around 30°(Attention: DO NOT produce undue stress on the anterior joint capsule, particularly with shoulder in extension)Passive IR to chestActive distal extremity exercise (elbow, wrist, hand)Pendulum exercises
237Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Total Shoulder ReplacementFrequent cryotherapy for pain, swelling, and inflammation managementPatient education regarding proper positioning and joint protection techniquesEarly Phase I: (out of hospital)Continue above exercisesBegin scapula musculature isometrics / sets (primarily retraction)Continue active elbow ROMContinue cryotherapy as much as able for pain and inflammation management
238Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : RTC Lesion repair protocolLate Phase I:• Continue previous exercises• Continue to progress PROM as motion allows• Begin assisted flexion, elevation in the plane of the scapula, ER, IR in the scapular plane• Progress active distal extremity exercise to strengthening as appropriate
239Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Total Shoulder ReplacementCriteria for progression to the next phase (II):If the patient has not reached the below ROM, forceful stretching and mobilization/manipulation is not indicated. Continue gradual ROM and gentle mobilization (i.e. Grade I oscillations), while respecting soft tissue constraints.Tolerates PROM programHas achieved at least 90° PROM forward flexion and elevation in the scapular plane.Has achieved at least 45° PROM ER in plane of scapulaHas achieved at least 70° PROM IR in plane of scapula measured at 30° of abduction
240Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Total Shoulder ReplacementPhase II – Early Strengthening Phase(Not to begin before 4-6 Weeks post-surgery to allow for appropriate soft tissue healing):Goals:Restore full passive ROMGradually restore active motionControl pain and inflammationAllow continue healing of soft tissueDo not overstress healing tissueRe-establish dynamic shoulder stability
241Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Total Shoulder ReplacementPrecautions:Sling should only be used for sleeping and removed gradually over the course of the next 2 weeks, for periods throughout the day.While lying supine a small pillow or towel should be placed behind the elbow to avoid shoulder hyperextension / anterior capsule stretch.In the presence of poor shoulder mechanics avoid repetitive shoulder AROM exercises/activity against gravity in standing.No heavy lifting of objects (no heavier than coffee cup)No supporting of body weight by hand on involved sideNo sudden jerking motions
242Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Total Shoulder ReplacementEarly Phase II:Continue with PROM, active assisted range of motion (AAROM)Begin active flexion, IR, ER, elevation in the plane of the scapula pain free ROMAAROM pulleys (flexion and elevation in the plane of the scapula) – as long as greater than 90° of PROMBegin shoulder sub-maximal pain-free shoulder isometrics in neutralScapular strengthening exercises as appropriateBegin assisted horizontal adductionProgress distal extremity exercises with light resistance as appropriateGentle glenohumeral and scapulothoracic joint mobilizations as indicatedInitiate glenohumeral and scapulothoracic rhythmic stabilizationContinue use of cryotherapy for pain and inflammation.
243Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Total Shoulder ReplacementLate Phase II:Progress scapular strengthening exercisesCriteria for progression to the next phase (III):If the patient has not reached the below ROM, forceful stretching and mobilization/manipulation is not indicated. Continue gradual ROM and gentle mobilization (i.e. Grade I oscillations), while respecting soft tissue constraints.Tolerates P/AAROM, isometric programHas achieved at least 140° PROM forward flexion and elevation in the scapular plane.Has achieved at least 60+° PROM ER in plane of scapulaHas achieved at least 70° PROM IR in plane of scapula measured at 30° of abductionAble to actively elevate shoulder against gravity with good mechanics to 100°.
244Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Total Shoulder ReplacementPhase III – Moderate strengthening(Not to begin before 6 Weeks post-surgery to allow for appropriate soft tissue healing and to ensure adequate ROM):Goals:Gradual restoration of shoulder strength, power, and enduranceOptimize neuromuscular controlGradual return to functional activities with involved upper extremityPrecautions:No heavy lifting of objects (no heavier than 3 kg.)No sudden lifting or pushing activitiesNo sudden jerking motions
245Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Total Shoulder ReplacementEarly Phase III:Progress AROM exercise / activity as appropriateAdvance PROM to stretching as appropriateContinue PROM as needed to maintain ROMInitiate assisted shoulder IR behind back stretchResisted shoulder IR, ER in scapular planeBegin light functional activitiesWean from sling completelyBegin progressive supine active elevation strengthening (anterior deltoid) with light weights ( kg.) at variable degrees of elevation
246Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Total Shoulder ReplacementLate Phase III:Resisted flexion, elevation in the plane of the scapula, extension (therabands / sport cords)Continue progressing IR, ER strengtheningProgress IR stretch behind back from AAROM to AROM as ROM allows (Pay particular attention as to avoid stress on the anterior capsule.)
247Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Total Shoulder ReplacementCriteria for progression to the next phase (IV):If the patient has not reached the below ROM, forceful stretching and mobilization/manipulation is not indicated. Continue gradual ROM and gentle mobilization (i.e. Grade I oscillations), while respecting soft tissue constraints.Tolerates AA/AROM/strengtheningHas achieved at least 140° AROM forward flexion and elevation in the scapular plane supine.Has achieved at least 60+° AROM ER in plane of scapula supineHas achieved at least 70° AROM IR in plane of scapula supine in 30° of abductionAble to actively elevate shoulder against gravity with good mechanics to at least 120°.
248Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Total Shoulder Replacement(Not to begin before 12 Weeks to allow for appropriate soft tissue healing and to ensure adequate ROM, and initial strength):Goals:Maintain non-painful AROMEnhance functional use of upper extremityImprove muscular strength, power, and enduranceGradual return to more advanced functional activitiesProgress weight bearing exercises as appropriatePrecautions:• Avoid exercise and functional activities that put stress on the anterior capsule and surrounding structures. (Example: no combined ER and abduction above 80° of abduction.)• Ensure gradual progression of strengthening
249Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Total Shoulder ReplacementEarly Phase IV:• Typically patient is on a home exercise program by this point to be performed 3-4 times per week.• Gradually progress strengthening program• Gradual return to moderately challenging functional activities.Late Phase IV (Typically 4-6 months post-op): Return to recreational hobbies, gardening, sports, golf, doubles tennisCriteria for discharge from skilled therapy:• Patient able to maintain non-painful AROM• Maximized functional use of upper extremity• Maximized muscular strength, power, and endurance• Patient has returned to advanced functional activities
250Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Reverse Shoulder ReplacementBrief description of the procedure:The reverse total shoulder replacement arthroplasty enables experienced shoulder surgeons to treat patients with conditions that previously had no solution.These conditions include rotator cuff tear arthroplasty, instability with anterosuperior escape, pseudoparalysis, and failures of surgery for arthritis and facture management.In the normal shoulder, the rotator cuff muscles, including the supraspinatus, help balance the ball of the arm bone (humeral head) in the socket against the upward pull of the deltoid muscle
251Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Reverse Shoulder ReplacementIn the normal shoulder, the rotator cuff muscles, including the supraspinatus, help balance the ball of the arm bone (humeral head) in the socket against the upward pull of the deltoid muscle.The goal of reverse total shoulder replacement is to restore some function to the joint destroyed as a result of cuff tear arthropathy by providing stability and a fulcrum against which the deltoid muscle can help elevate the shoulder to a level where basic shoulder functions can be performed without the risk of dislocating the shoulder
252Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Reverse Shoulder ReplacementWith the Reverse Shoulder Prosthesis, the anatomy, or structure, of the healthy shoulder is reversed. The implant is designed so that the ball portion is attached to the scapula and the socket is placed at the upper end of the humerus.The Reverse Shoulder Prosthesis is mainly used for older patients with rotator cuff tear arthropathyPatients see a drastic difference in their range of mobility, and their ability to perform daily activities, such as eating, drinking, combing their hair, etc.Patients who have had the procedure go from having severe shoulder dysfunction to 90 to 100 degrees full elevation.
253Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Reverse Shoulder Replacement Protocol:Shoulder Dislocation PrecautionsThis rehabilitation protocol has been developed for the patient following a Reverse Total Shoulder Arthroplasty.Precautions should be implemented for the first 16 weeks postoperatively unless surgeon specifically advises patient or therapist differently.This protocol has been divided into phases. Each phase may vary slightly based on the individual patient and special circumstances.Progression to the next phase based on clinical criteria and time frames as appropriate.
254Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Reverse Shoulder ReplacementPhase 1: Immediate Postsurgical Phase, Joint Protection (Day 1 to Week 6)Goals:Patient and family independent withJoint protectionPassive range of motion (PROM) after 2 weeksAssisting with putting on/taking off sling and clothingAssisting with home exercise program (HEP)CryotherapyPromote healing of soft tissue/maintain the integrity of the replaced jointEnhance PROM after two weeks
255Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Reverse Shoulder ReplacementRestore active range of motion (AROM) of elbow/wrist/handIndependent with activities of daily living (ADLs) with modifications
256Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Reverse Shoulder ReplacementPrecautions:Sling is worn for 2-3 weeks postoperatively.While lying supine, the distal humerus/elbow should be supported by a pillow or towel roll to avoid shoulder extension. Patients should be advised to “always be able to visualize their elbow while laying supine”No shoulder AROMNo lifting of objects with operative extremityNo supporting of body weight with involved extremityKeep incision clean and dry (no soaking/wetting for 2 weeks); no whirlpool, Jacuzzi, ocean/lake wading for 4 weeks minimum.
257Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Reverse Shoulder ReplacementDay 14(acute care therapy)Begin PROM in supineForward flexion and elevation in the scapular plane in supine to 90°External rotation (ER) in scapular plane to available ROM as indicated by operative findings, typically around 20° - 30°No IR range of motion (ROM)AROM/active assisted ROM of cervical spine, elbow, wrist, and handBegin periscapular submaximal pain-free isometrics in the scapular planeContinuous cryotherapy for first 72 hrs postoperatively, then frequent application (4-5 times a day for about 20 minutes) cryotherapy
258Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Reverse Shoulder ReplacementDays 15 to 21Continue all exercises as aboveBegin submaximal pain-free deltoid isometrics in scapular plane(avoid shoulder extension when isolating posterior deltoid)Frequent (4-5 times a day for about 20 minutes) cryotherapy
259Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Reverse Shoulder ReplacementWeeks 3 to 6Progress exercises listed aboveProgress PROMForward flexion and elevation in the scapular plane in supine to 120°ER in scapular plane to tolerance, respecting soft tissue constraintsAt 6 weeks postoperatively start PROM IR to tolerance (not to exceed 50°) in the scapular planeGentle resisted exercise of elbow, wrist, and handContinue frequent cryotherapy
260Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Reverse Shoulder ReplacementCriteria for progression to the next phase (phase II)Patient tolerates shoulder PROM and AROM program for elbow, wrist, and handPatient demonstrates the ability to isometrically activate all components of the deltoid and periscapular musculature in the scapular plane
261Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Reverse Shoulder ReplacementPhase II: ARAOM, Early Strengthening Phase (Weeks 6 to 12)Goals:Continue progression of PROM (full PROM is not expected)Gradually restore AROMControl pain and inflammationAllow continued healing of soft tissue/do not overstress healing tissueRe-establish dynamic shoulder stability
262Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Reverse Shoulder ReplacementPrecautions:Continue to avoid shoulder hyperextensionIn the presence of poor shoulder mechanics avoid repetitive shoulder AROM exercises/activityRestrict Lifting of objects to no heavier than a coffee cupNo supporting of body weight by involved upper extremity
263Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Reverse Shoulder ReplacementWeeks 6 to 8Continue with PROM programBegin shoulder active assisted ROM/AROM as appropriateForward flexion and elevation in scapular plane in supine with progression to sitting/standingER in IR in the scapular plane in supine with progression to sitting/standingBegin gentle GH IR and ER submaximal pain-free isometricsInitiate gentle scapulothoracic rhythmic stabilization and alternating isometrics in supine as appropriate. Begin gentle periscapular and deltoid submaximal pain-free isotonic strengthening exercises, typically toward the end of the eighth weekProgress strengthening of elbow, wrist, and hand
264Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Reverse Shoulder ReplacementGentle GH and scapulothoracic joint mobilizations as indicated (grades I and II)Continue use of cryotherapy as neededPatient may begin to use hand of operative extremity for feeding and light ADLs
265Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Reverse Shoulder ReplacementWeeks 9 to 12Continue with above exercises and functional activity progressionBegin AROM supine forward flexion and elevation in the plane of the scapula with light weights of 0.5 to 1.4 kg (1 to 3 lb) at varying degrees of trunk elevation as appropriate (ie, supine lawn chair progression with progression to sitting/standing)Progress to gentle GH IR and ER isotonic strengthening exercises
266Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Reverse Shoulder ReplacementCriteria for progression to the next phase (phase III)Improving function of shoulderPatient demonstrates the ability to isotonically activate all components of the deltoid and periscapular musculature and is gaining strength
267Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Reverse Shoulder ReplacementPhase III: Moderate Strengthening (Week 12+)Goals:Enhance functional use of operative extremity and advance functional activitiesEnhance shoulder mechanics, muscular strength, power and endurancePrecautionsNo lifting of objects heavier than 2.7 kg (6lb) with the operative upper extremityNo sudden lifting or pushing activities
268Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Reverse Shoulder ReplacementWeeks 12 to 16Continue with previous program as indicatedProgress to gentle resisted flexion, elevation in standing as appropriate
269Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Reverse Shoulder ReplacementPhase IV: Continued Home Program (Typically 4+ Months Postoperative)Typically the patient is on a HEP at this stage, to be performed 3-4 times per week, with the focus onContinued strength gainsContinued progression toward a return to functional and recreational activities within limits, as identified by progress made during rehabilitation and outlined by surgeon and physical therapistCriteria for discharge from skilled therapyPatient is able to maintain pain-free shoulder AROM, demonstrating proper shoulder mechanics (typically 80° - 120° of elevation, with functional ER of about 30°)
270Setting Specific Orthopedic Exercises Shoulder Surgery Protocol : Reverse Shoulder ReplacementACDFTLIFALIFPLIFXLIF
271Setting Specific Orthopedic Exercises References:Berne RM, Levy MN (1993): Physiology, 3rd ed., 1091 pp. C. V. Mosby, St. Louis.
272Setting Specific Orthopedic Exercises Bullock TH (1959): Neuron doctrine and electrophysiology. Science 129:(3355)Davis LJ, Lorente de Nó R (1947): Contributions to the mathematical theory of the electrotonus. Stud. Rockefeller Inst. Med. Res. 131:Elsberg CA (1931): The Edwin Smith surgical papyrus. Ann. Med. Hist. 3:Ganong WF (1991): Review of Medical Physiology, 15th ed., Appleton & Lange, Norwalk, Conn.Guyton AC (1992): Human Physiology and Mechanisms of Disease, 5th ed., 690 pp. Saunders, Philadelphia.Hermann L (1872): Grundriss der Physiologie, 4th ed., (Quoted in L Hermann (1899): Zur Theorie der Erregungsleitung und der elektrischen Erregung. Pflüger Arch. ges. Physiol. 75: )Hermann L (1905): Lehrbuch der Physiologie, 13th ed., 762 pp. August Hirschwald, Berlin.Kandel ER, Schwartz JH (1985): Principles of Neural Science, Elsevier Publishing, New York.Lorente de Nó R (1947): A Study of Nerve Physiology, 293 pp. Rockefeller Institute for Medical Research, New York.Muler AL, Markin VS (1978): Electrical properties of anisotropic nerve-muscle syncytia - II. Spread of flat front of excitation. Biophys. 22:Nunez PL (1981): Electric Fields of the Brain: The Neurophysics of EEG, 484 pp. Oxford University Press, New York.
273Setting Specific Orthopedic Exercises Patton HD, Fuchs AF, Hille B, Scher AM, Steiner R (eds.) (1989): Textbook of Physiology, 21st ed., 1596 pp. W. B. Saunders, Philadelphia.Ruch TC, Patton HD (eds.) (1982): Physiology and Biophysics, 20th ed., 1242 pp. W. B. Saunders, Philadelphia.Schadé JP, Ford DH (1973): Basic Neurology, 2nd ed., 269 pp. Elsevier Scientific Publishing, Amsterdam.Thompson CF (1985): The Brain - An Introduction to Neuroscience, 363 pp. W. H. Freeman, New York.