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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)

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Presentation on theme: "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)"— Presentation transcript:

1 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)

2 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. About this course:

3 SunCoast Seminars Why 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.

4 Program Objectives: Reviewing muscular anatomy and physiology This will include a review of tissue healing Discuss how extrinsic factors such as medication, progression, exercise objectives etc. may affect the exercise therapy program Discuss how intrinsic factors including disease processes age, vital signs etc. may affect muscles and exercise programs. Discuss the basics of exercise therapy Discuss common exercise principles Open chain vs. closed chain Eccentric  isometric  concentric

5 A few rules: We are in a hospital and should be aware of any codes that might be called. Bathrooms are right outside of this room We will break for lunch are around noon Please 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. SunCoast Seminars

6 About the educator: Background Education Work experience Hobbies SunCoast Seminars

7 5 educators – Dr. Brian Healy – Dr. Willem Stegeman – Dr. Jorit Wijnmaalen – John Van Ooyen, PT – Dr. Nathan A. Possert, PT, DPT About SunCoast Seminars

8 More courses: Orthopedic Joint Replacement course: 9.5 CEU Comprehensive Management of back & neck pain: 9.5 CEU Clinical Imaging for the Rehab Specialist, 9.5 CEU Joint Replacement, online: 7 CEU  Thoracic Outlet Syndrome: 6.0 CEU, Online  HIV/Medical Errors/Abuse: 4 CEU  The Anatomy of Excercise: online  An Introduction to Manual Therapy : 9.5 CEU  Setting Specific Orthopedic Exercises : 9.5 CEU’s  CORS: 9.0 CEU’s About SunCoast Seminars

9 Muscular anatomy and physiology Muscle Types: Smooth muscles Cardiac muscles Skeletal muscles SunCoast Seminars

10 Smooth muscles These muscles are very important in physiological regulation. Help to regulate the flow of blood. Help control BP They control the movement of food through the digestive system. Control of the uterus during labor Contraction of a smooth muscle cell is generated by a sliding mechanism of the myofilaments. Contraction is involuntary and may be initiated by Nerve impulse Hormones (i.e. cardiac function) Mechanical change to the muscle

11 SunCoast Seminars 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

12 SunCoast Seminars 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.

13 SunCoast Seminars 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 myofibrils Skeletal muscles are under voluntary control; no skeletal muscle works without “orders” from the nervous system Skeletal 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

14 SunCoast Seminars Skeletal Muscles These 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 movement to control movement to 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.

15 Skeletal Muscles Skeletal 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.

16 Muscular anatomy and physiology Let’s review!

17 The Anatomy review of a skeletal muscle Each 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”.

18 Endomysium – delicate connective tissue sheeth that encloses each muscle fiber Fasciculus – 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 bone – Aponeurosis – fibrous or membranous sheet connecting a muscle and the part is moves (usually found on torso)

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20 The Anatomy review of a skeletal muscle Connective 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 membrane Skeletal 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.

21 The muscle-tendon junction The 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 beginning

22 Innervation of a Skeletal Muscle Skeletal 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.

23 Innervation of a Skeletal Muscle Motor 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 synapse Acetylcholine(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

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26 Neuromuscular Junction or Motor End Plate axon of Motor (Efferent) Neuron White arrow - Skeletal Muscle Fiber

27 Innervation of a Skeletal Muscle Additional proprioceptor endings (Golgi tendon organs) are located at the point where muscle fibers attach to tendon These 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).

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29 Nerve Conduction Both nerve cells and muscle cells are excitable Their 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 cell The 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 cell The axon may be covered with an insulating layer called the myelin sheath, which is formed by Schwann cells

30 Nerve Conduction This myelin sheath is not continuous but divided into sections, separated at regular intervals by the nodes of Ranvier The 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 terminal The 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.

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33 Nerve Conduction This transmitter, when released, activates the postsynaptic terminal. The synapse between a motor nerve and the muscle it innervates is called the neuromuscular junction

34 Nerve Conduction If a nerve cell is stimulated, the trans-membrane voltage necessarily changes. The stimulation may be excitatory (i.e., depolarizing; characterized by a decrease in the normally negative resting voltage) or inhibitory (i.e., hyperpolarizing, characterized by an increase in the magnitude of the membrane voltage). After stimulation the membrane voltage returns to its original resting value If 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?

35 Nerve Conduction Many factors may affect nerve conductivity but discussion of those factors would be outside the scope of this lecture. Temperature Properties of the membrane Sodium levels Age Anatomical changes because of disease (ALS)

36 Nerve Conduction A myelinated axon (surrounded by the myelin sheath) can produce a nerve impulse only at the nodes of Ranvier In these axons the nerve impulse propagates from one node to another The myelin sheath increases the conduction velocity The conduction velocity of the myelinated axon is directly proportional to the diameter of the axon

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39 Types of Skeletal muscles Not all skeletal muscles are the same. Some cells are thicker than others Some shorten faster Some produce more tension Some fatigue more rapidly Looking at these different features, there appear to be three major types of skeletal muscles:

40 Types of Skeletal muscles Slow Twitch Fast Fatigue Resistant Fast Twitch Fatigable

41 Slow Twitch These 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

42 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).

43 Two Types: Type IIa Fibers / Fast Fatigue Resistant These 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.

44 Type IIb Fibers These 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 force Are least resistant to fatigue Force produced is typically 2-3 times greater than fast twitch fatigue resistant fibers

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46 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.

47 Conclusion 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.

48 Skeletal Muscle Fiber Arrangement It 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. Fusiform Triangular Spiral Pinnated fibers muscles are muscles composed of angled fibers Unipinnate Bipinnate Multipinnate

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50 Structure & Function of a Skeletal muscle

51 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.

52 Muscle Contraction Upon 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 head Myosin 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.

53 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

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57 Images from Purves et al., Life: The Science of Biology, 4th Edition, by Sinauer Associates (www.sinauer.com) and WH Freeman (www.whfreeman.com)www.sinauer.comwww.whfreeman.com

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59 Muscle contraction -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 kcal -Muscle tissue is a very effective power source: power versus weight for a jet motor is 1:5 power versus weight for the biceps muscle is approx. 1:360

60 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 + Energy This 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.

61 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 Muscle contraction (cont.)

62 (1)Direct phosphorylation of ADP by Creatine Phosphate  a phosphate group transfers from CP to ADP, regenerating more ATP; CP supplies exhaust in about 20 seconds  Duration of energy provision 15 seconds (2) Anaerobic glycolysis and lactic acid formation initial steps of glucose breakdown occur via glycolysis which is anaerobic. Duration of energy provision  Glucose -> pyruvic acid with energy captured in ATP bonds (2ATP/ 1 glucose)

63 (3) Aerobic respiration: provides 95% of ATP at rest and during light Exercise occurs in mitochondria & involves a series of metabolic pathways that use oxygen called oxidative phosphorylation glucose is broken down into CO2 & H2O some 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.

64 Muscle Contraction (Cont.) The Strength Enzyme System When 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 + Creatine The 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.

65 Muscle Contraction (Cont.) The Burst Power Enzyme System The 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 Lactate Continued 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

66 Muscle Contraction (Cont.) The Endurance Enzyme System This system consists of three processes: 1.Carbohydrate Metabolism: Carbohydrates metabolize most efficiently and are therefore used first 2.Fat Metabolism: If no carbohydrates are available, the body metabolizes fat. 3.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.

67 Muscle Contraction (Cont.) The Endurance Enzyme System This system consists of three processes: 1.Carbohydrate Metabolism: Carbohydrates metabolize most efficiently and are therefore used first 2.Fat Metabolism: If no carbohydrates are available, the body metabolizes fat. 3.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.

68 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 heart

69 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).

70 Motor Units within a muscle A motor unit is defined as all of the muscle fibers supplied by a single motoneuron, and therefore, by a single axon and its branches Skeletal 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.

71 Motor Units within a muscle Muscles 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 muscle As 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 ones As more and larger motor units are activated, the force of muscle contraction becomes progressively stronger. This concept is know as “the size principle”.

72 Motor Units within a muscle: Conclusion At 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).

73 Motor Units within a muscle: Conclusion Initially 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)

74 Contraction Strength For 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.

75 Contraction Strength The 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 forces The firing rates of earlier recruited motor units are greater than those of later recruited motor units at any given force value The control to the muscle is not designed to generate constant- force contractions.

76 Maximal Voluntary Contraction (MVC)

77 Contraction Strength So concluding, the strength of a muscular contraction can be influenced 2 factors: 1.By increasing the number and size of contractile units simultaneously, called multiple fiber summation. 2.By increasing the frequency at which action potentials are sent to muscle fibers, called frequency summation.

78 Types of Muscle Contraction 1.Concentric muscle contraction 2.Eccentric muscle contraction 3.Isometric muscle contraction 4.Isotonic muscle contraction

79 Concentric muscle contraction Muscle 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 together During 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.

80 Eccentric Muscle Contraction During 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.

81 Eccentric Muscle Contraction Exercise 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.

82 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).

83 Eccentric Muscle Contraction Muscles are approximately 10% stronger during eccentric contractions than during concentric contractions Eccentric 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.

84 Isotonic Muscle Concentration Isotonic 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.

85 A: Concentric/eccentric B: Isometric

86 EXERCISING AND BUILDING MUSCLES Muscles 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

87 EXERCISING AND BUILDING MUSCLES Effect of Exercise on Muscles: Aerobic or endurance exercise  Examples – biking, jogging, swimming laps  Results in stronger more flexible muscles with greater resistance to fatigue  blood supply increases  individual muscle cells form more mitochondria and store more oxygen (makes overall body metabolism more efficient  Improves digestion and elimination of wastes  Enhances neuromuscular coordination  Makes the skeleton stronger  Heart enlarges  Fat deposits are cleared from blood vessel walls  Lungs become more efficient at gas exchange  Does NOT cause muscles to increase in size

88 EXERCISING AND BUILDING MUSCLES Effects of Exercise on Muscles: Resistance or isometric exercise Examples – weightlifting, theraband or medicine ball training, bodyweight exercises like push-ups or pull-ups, plyometrics Key is that muscles are being forced to contract with as much force as possible or as quickly as possible Muscles increase in size and strength Due to enlargement of individual muscle cells (more contractile filaments), not because more muscle fibers are made Size of reinforcing connective tissue also increases to support increased muscle size

89 Muscle Functions Muscle tissue has four main properties: Excitability or the ability to respond to stimuli Contractibility or the ability to contract Extensibility or the ability of a muscle to be stretched without tearing Elasticity or the ability to return to its normal shape Through contraction, the muscular system performs three important functions: Motion - walking, running etc. Heat production - maintain normal body temperature Maintenance of posture - standing, sitting etc.

90 Muscle Functions Muscles have two states Relaxed Contracted.

91 Common Medications and their effect on Exercise Blood thinners: Coumadin, Lovenox, Warfarin, Plavix Aspirin: Watch the side effects. Do not take with NSAID’s (will negate the blood thinning effect). Thinning of mucosa of the stomach wall, gastric ulceration, increased bleeding risk Muscle relaxors: Flexeril, Soma, Valium, Skelaxin Flexeril: Duration of action hour Skelaxin: Duration of action 4-6 hours Side effects: Drowsiness, dizziness, vertigo, ataxia, dependency Parkinson's disease: Levodopa, Dopamine agonists, Anti cholinergics Sinemet/dopamine: arrhythmia's, postural hypotension Diuretics: Bumex, Lasix, Aldactone Hypokalemia, hyponatremia, fluid depletion, orthostatic hypotension

92 Common Medications and their effect on Exercise (continued) Cardiac function controlling medication: Beta blockers (Tenormin, Lopressor, Inderal, Betapace) Digitalis toxicity, dry cough, bradycardia, hypotension BP controlling medication: Beta blockers, Alpha blockers (Cardura, Minipress) Broncho constriction, bradycardia, hypotension HR controlling medication: Norpace, Beta blockers, Cordarone, Cardizem Increase of arrhythmia's, dizziness, hypotension Pulmonary function controlling medication: Albuterol, Epinephrine, Theo-Dur, Pulmicort, Decadron, Aerobid, Cortef Osteoporosis, muscle wasting, skin breakdown, diabetes mellitis, hypertension

93 The importance of a thorough evaluation The 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.

94 Different types of exercises with different objectives Objectives/Goals of exercise: Strength Muscular Dystrophy Coordination Firing Patterns Endurance ROM PROM vs. AROM Endfeel? PROM of the Joint Muscle length (Muscle energy) Muscle tone Decrease of muscle tone Increase of muscle tone Pain control

95 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 exercise Why are you exercising that What outcome do you expect Depends on patient/age/function/other intrinsic and extrinsic factors Measure and document these objectives ongoing Don’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.

96 Components of an effective Exercise program: Get the buy-in from the patient Detailed documentation Quality of the movement Speed Cues given/needed Strength Shaky/Tremorous Coordination Sensation Intensity Activity it is related to improve

97 Progression/Regression of exercise Establish base point or midline Points of contact: Progress from larger base of support to smaller base of support Open chain vs. Closed chain # of repetitions or sets Speed of the reps Cues: tactile& Verbal Level of resistance Point of reference eccentric  Isometric  concentric Stabilize vs. destabilize Weight shifting  weight bearing Sequence: Instruct correct movement  repeat  challenge  add complexity  put into a functional activity Method of observation: visual, tactile, bio feed back

98 Total Hip Arthroplasty Brief 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

99 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

100 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.

101 Weight bearing: Typically WBAT unless there was a surgical complication, so ALWAYS read the operative report. ALWAYS FOLLOW WB INSTRUCTIONS Surgical Hip Precautions

102 Acute Care Protocol: Hip DOS: Patient should get up with PT on the DOS, unless the patient had surgical complications, or had Total Anasthesia Patient 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.

103 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.

104 POD #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. Acute Care Protocol: Hip

105 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, weight bearing status dependent upon prosthesis used. Begin discharge planning and home needs assessment. Review dislocation precautions/restrictions.

106 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.

107 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.

108 Hip Surgery: Phase II: Days 3-10 Goals: 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.

109 Hip Surgery: Phase II: Days 3-10 Modalities for Pain Control and Edema Reduction: Moist Heat, Ice Therapeutic Exercise: Gentle Passive, Active-Assisted, and active lower extremity range of motion Stationary Biking - No resistance to motion Balance/Proprioception Training: Tandem Walking (line walking) Gait Training: Level Surface Forward Walking Functional Training: Standing Activities Transfer Activities

110 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 ambulation guidelines (usually 4-6 weeks).

111 Hip: Phase III 10 days to 6 weeks: Modalities for Pain Control and Edema Reduction: Moist Heat, Ice Exercises Continue previous exercises Lower Extremity Strengthening Exercises using Theraband Aquatic Therapy/Activities Iliotibial Band Stretches-Supine Scar 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 motion Closed Kinetic Chain Activities Continue stationary bike, progress resistance

112 Hip: Phase III 10 days to 6 weeks: Balance/Proprioception Training: Weight-Shifting Activities Closed Kinetic Chain Activities Lateral Stepping over/around objects Gait Training: Level Surface Forward Walking Sidestepping Retro Walking Uneven Surfaces Functional Training Lifting, Carrying Pushing or Pulling, Squatting or Crouching Return-To-Work Tasks

113 Phase IV 6-12 weeks: Exercises: Continue previous exercises Advance Passive, Active-Assisted, and active lower extremity range of motion Nordic Track Stair-Step Machine Iliotibial Band Stretches- standing at twelve (12) weeks post-operatively Develop walking program Continue pool and bike work Endurance Training: UBE Ambulation Activities

114 Phase IV 6-12 weeks: Balance/Proprioception Training: Obstacle Course Functional Training Lifting Carrying Pushing or Pulling Squatting or Crouching Return to sport tasks

115 Total Knee Arthroplasty Brief description of procedure The 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

116 Total Knee Arthroplasty Brief description of procedure Modern 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

117 Variations: Partial Knee Arthroplasty, Fixed Bearing device or Rotating Platform Device. Cemented or Compressed Fit; ACL/PCL sparing, Patella preserving 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.

118 Precautions and time frames Follow WB directions Kneeling onto knee is typically not allowed/not recommended. Screen for blood clots Screen for infection Acute Care Phase: Knee Phase I Immediate Postoperative Phase (Day 0 – 10) Goals: Active quad contraction Safe independent ambulation with walker or crutches as needed Passive knee extension to 0 degrees Knee flexion to 90 degrees or greater Control of swelling, inflammation, bleeding

119 Total Knee Surgery Protocol Day 0-2: Weight bearing as tolerated with walker/2 crutches as needed starting on Day 0-1 Cryotherapy immediately and continuously unless ambulating ROM of knee to begin immediately post op Exercises, Ankle pumps, PROM/extension to 0 degrees SLR Quad sets Knee flexion to at least 90 degrees Knee extension to 0 degrees Instruct in gait training - safe transfers

120 Total Knee Surgery Protocol Day 3-10: Weight bearing as tolerated with walker/2 crutches as needed Cryotherapy Exercises: Ankle pumps, PROM knee extension to 0 degrees, SLR, Quad sets AAROM - Knee flexion to at least 90 degrees Hip adduction/abduction Instruct in gait training – safe transfers Start stationary bike, low resistance

121 Total Knee Surgery Protocol Phase II: Motion Phase (Week 2-6) Goals: Improve ROM Enhance muscular strength, endurance Dynamic joint stability Diminish swelling/inflammation Establish return to functional activities Criteria to enter Phase II: Leg control, able to perform SLR AROM 0-90 degrees Minimal pain/swelling Independent ambulation/transfers

122 Total Knee Surgery Protocol Weeks 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 SLR Knee extension 90-0 degrees Terminal knee extension 45-0 degrees Hip abduction/adduction Hamstring curls Knee flexion to at least 115 degrees

123 Total Knee Surgery Protocol Stretching: Hamstrings Gastroc/soleus Quads Passive knee extension stretch Continue stationary bike and advance resistance as tolerated Continue cryotherapy Patellofemoral mobilization Incision mobilization Patients may begin to drive if they are no longer using assistive devices for ambulation (about 2 weeks post op)

124 Total Knee Surgery Protocol Weeks 4-6: Exercises: Continue previous exercises Initiate front and lateral step ups Advance resistance on stationary bike Initiate progressive walking program Initiate endurance pool program, swimming with flutter kick Return to functional activities Continue compression, ice, elevation as needed for swelling Patients should be walking and driving independently at this point

125 Total Knee Surgery Protocol Phase III: Intermediate Phase (Weeks 7-12) Goals: Progression of ROM to greater than 115 degrees Enhancement of strength and endurance Eccentric/concentric control of limb Cardiovascular fitness Functional activity performance Criteria to enter Phase III: ROM degrees Voluntary quad control Independent ambulation Minimal pain

126 Total Knee Surgery Protocol Weeks 7-12: Exercises: Continue previous exercises Continue pool activities Continue walking Continue stationary bike Aggressive AROM degrees Strengthen quad/hamstrings

127 Total Knee Surgery Protocol Phase IV: Advanced Activity Phase (Weeks 12 and beyond) Goals: Allow patients to return to advanced level of function such as recreational sports Maintain/improve strength and endurance of lower extremity Return to normal life and routine Criteria to enter Phase IV: Full non painful ROM Strength 90% of contralateral limb (if contralateral limb is normal) Minimal pain and swelling Satisfactory clinical examination

128 Total Knee Surgery Protocol Exercises: Quad sets, SLR, Hip abduction/adduction, Step ups, Knee extension Stationary bike Swimming Walking Stretching degrees Return to pre op activities and develop HEP to maintain function of leg. NO SQUATS OR LUNGES AT ANY TIME!

129 Partial Knee Surgery: Brief Description of the procedure. Unicompartmental knee replacement is an option for a small percentage of patients with osteoarthritis of the knee In a unicompartmental knee replacement, only the damaged compartment is replaced with metal and plastic Partial Knee Replacement can only be revised with a Total Knee Replacement

130 Partial Knee Surgery Protocol General 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.

131 Partial Knee Surgery Protocol Hospital 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 knee May become OP procedure surgery soon

132 Partial Knee Surgery Protocol Week 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.

133 Partial Knee Surgery Protocol Weeks 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.)

134 Partial Knee Surgery Protocol Weeks 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.

135 Partial Knee Surgery Protocol Weeks 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 110° flexion.

136 Partial Knee Surgery Protocol Weeks : 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.

137 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.

138 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

139 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).

140 Knee Surgery Protocol : Meniscopy The 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.

141 Knee Surgery Protocol : Meniscectomy Description 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

142 Knee Surgery Protocol : Meniscectomy 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

143 Knee Surgery Protocol : Meniscectomy Progression 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)

144 Knee Surgery Protocol : Meniscectomy Phase I –Maximum Protection- Weeks 1-6: Goals: Diminish inflammation and swelling Restore ROM Reestablish quadriceps muscle activity Stage 1: Immediate Postoperative Day 1- Week 3 Ice, compression, elevation Electrical muscle stimulation Brace locked at 0 degrees ROM 0-90

145 Knee Surgery Protocol : Meniscectomy Meniscal Repair Protocol Motion 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

146 Knee Surgery Protocol : Meniscectomy Exercises Quadriceps isometrics Hamstring isometrics (if posterior horn repair, no hamstring exercises for 6 weeks) Hip abduction and adduction Weight-bearing as tolerated with crutches and brace locked at 0 degrees Proprioception training with brace locked at 0 degrees

147 Knee Surgery Protocol : Meniscectomy Stage 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

148 Knee Surgery Protocol : Meniscectomy Phase II: Moderate Protection- Weeks 6-10 Criteria 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

149 Knee Surgery Protocol : Meniscectomy Exercises: Strength- progression Flexibility exercises Lateral step-ups Mini-squats Endurance Program: Swimming (no frog kick), pool running- if available Cycling Stair machine Coordination Program: Balance board Pool sprinting- if pool available Backward walking Plyometrics

150 Knee Surgery Protocol : Meniscectomy Phase III: Advanced Phase- Weeks Criteria for progression to phase III: Full, pain free ROM No pain or tenderness Satisfactory clinical examination SLR without lag Gait without device, brace unlocked Goals: Increase power and endurance Emphasize return to skill activities Prepare for return to full unrestricted activities

151 Knee Surgery Protocol : Meniscectomy Exercises: Continue all exercises Increase plyometrics, pool program Initiate running program Return to Activity: Criteria Full, pain free ROM Satisfactory clinical examination Criteria for discharge from skilled therapy: 1) Non-antalgic gait 2) Pain free /full ROM 3) LE strength at least 4/5 4) Independent with home program 5) Normal age appropriate balance and proprioception 6) Resolved palpable edema

152 Knee Surgery Protocol : Partial Meniscectomy Rehabilitation after a partial meniscectomy may progress aggressively because there is no anatomic structure that requires protection.

153 Knee Surgery Protocol : Partial Meniscectomy Phase I – Acute Phase: Goals: Diminish pain, edema Restore knee range of motion (goal 0-115, minimum of 0 degrees extension to 90 degrees 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 process Weight bearing: Weight bearing as tolerated. Use two crutches initially progressing to weaning crutches as swelling and quadriceps status dictates.

154 Knee Surgery Protocol : Partial Meniscectomy Modalities: 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 interferential stimulation as needed

155 Knee Surgery Protocol : Partial Meniscectomy Therapeutic 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

156 Knee Surgery Protocol : Partial Meniscectomy Phase 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 proprioception Weight 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.

157 Knee Surgery Protocol : Partial Meniscectomy Therapeutic 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

158 Knee Surgery Protocol : Partial Meniscectomy Phase III – Advanced activity phase: Goals: Enhance muscular strength and endurance Maintain full ROM Return to sport/functional activities/work tasks Therapeutic Exercise: Continue to emphasize closed-kinetic chain exercises May begin plyometrics/ vertical jumping Begin running program and agility drills (walk-jog) progression, forward and backward running, cutting, figure of eight and carioca program Sport specific drills

159 Knee Surgery Protocol : Partial Meniscectomy Criteria for discharge from skilled therapy: 1) Non-antalgic gait 2) Pain free /full ROM 3) LE strength at least 4+/5 4) Independent with home program 5) Normal age appropriate balance and proprioception 6) Resolved palpable edema

160 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.).

161 Knee Surgery Protocol : AUTOGRAFT BONE-PATELLA TENDON-BONE and ALLOGRAFT PROTOCOL Variation: 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 a Home 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 WEIGHT BEARING 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.

162 Knee Surgery Protocol : ACL Reconstruction, Allograft Phase I-Early Functional (Weeks 1-2) Goals: 1. Educate re: the proper use of continuous passive motion (CPM) machine a Home 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 WEIGHT BEARING AS TOLERATED (WBAT) on the involved leg.

163 Knee Surgery Protocol : ACL Reconstruction, Allograft 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.

164 Knee Surgery Protocol : ACL Reconstruction, Allograft Day 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.

165 Knee Surgery Protocol : ACL Reconstruction, Allograft Post-Operative Day #1: - Ambulate as above on level surfaces and stairs. - CPM progression can be 10º – 20º daily but should not exceed 5 º every 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.

166 Knee Surgery Protocol : ACL Reconstruction, Allograft Post-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. CPM progression can be 10º – 20º daily but should not exceed 5º every 3 hours. - BAPS- in sitting. - Stationary bicycle- start with a low, comfortable seat height to promote 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.

167 Knee Surgery Protocol : ACL Reconstruction, Allograft Bilateral standing modified knee bends (0-30º)-begin with body weight 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 a weighted 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).

168 Knee Surgery Protocol : ACL Reconstruction, Allograft Proprioceptive 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.

169 Knee Surgery Protocol : ACL Reconstruction, Allograft ** IN ALL CLOSED CHAIN KNEE EXERCISES, DO NOT ALLOW THE ANTERIOR ASPECT OF THE KNEE TO PASS THE TOES.** BY THE END OF WEEK 1: AROM: PROM: 0-80º 0-90º 0-105º 0-120º 0-120º 0-125º **DO NOT PUSH >125º WITH PASSIVE RANGE OF MOTION. CONTINUE TO CHECK RANGE OF MOTION PERIODICALLY TO MAKE SURE RANGE IS MAINTAINED.**

170 Knee Surgery Protocol : ACL Reconstruction, Allograft Post-operative Day #8-14: - Continue as above. - Straight leg raises- without the brace if the patient demonstrates good quad control, with resistance applied proximal to the knee. Use the brace locked at 0º if an extension lag still exists. - Standing leg curl- begin in standing with no added weight. The patient must 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 low extrinsic weight (10-50% maximum of the patient’s body weight) and progress weight if the patient demonstrates good quad control during terminal knee extension. The patient at this time may begin unilateral leg press (10-30% maximum of the patient’s body weight). - Balance activities – progress to bilateral activities on the disc the unilateral. - Discontinue crutches at POD #14 if proper gait mechanics are obtained.

171 Knee Surgery Protocol : ACL Reconstruction, Allograft Phase II-Progressive Functional (Weeks 3-11) Goals: 1. Decrease pain and effusion. 2. Discontinue the postoperative brace when the patient demonstrates good quad control. 3. Continue the development of neuromotor control of all muscle groups. 4. Retrain for proprioception and normalize responses to dynamic challenges.

172 Knee Surgery Protocol : ACL Reconstruction, Allograft Weeks 3 through 4: Continue as above. Cable column- should be performed once the patient is able to straight leg 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.

173 Knee Surgery Protocol : ACL Reconstruction, Allograft Closed 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.

174 Knee Surgery Protocol : ACL Reconstruction, Allograft Weeks 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.

175 Knee Surgery Protocol : ACL Reconstruction, Allograft Weeks 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.

176 Knee Surgery Protocol : ACL Reconstruction, Allograft Weeks 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.

177 Knee Surgery Protocol : ACL Reconstruction, Allograft Weeks 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.

178 Knee Surgery Protocol : ACL Reconstruction, Allograft Weeks 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 drill May 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.

179 Knee Surgery Protocol : ACL Reconstruction, Allograft Weeks 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).

180 Knee Surgery Protocol : PCL Reconstruction ISOLATED AND COMBINED PCL RECONSTRUCTION POST- OP REHABILITATION PROTOCOL GENERAL PRINCIPLES No open chain hamstring work Assume 8 weeks for graft to bone healing time Caution against posterior tibial translation (gravity, muscle action) CPM 0°-60° to start PCL with posterolateral corner or LCL repair follows different post-op care, i.e., crutches x 3 months Supervised physical therapy takes place for approximately 3-5 months post-op.

181 Knee Surgery Protocol : PCL Reconstruction GENERAL 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-op Sleep without brace – 8 weeks post-op Driving – 6-8 weeks post-op Full weight bearing without assistive devices – 8 weeks post-op (with physician clearance)

182 Knee Surgery Protocol : PCL Reconstruction PHYSICAL THERAPY ATTENDANCE The following is an approximate schedule for supervised physical therapy visits: 0 to 1 month: 1 x week 1 to 3 months: 2-3 x week 3 to 9 months: 2 x month 9 to 12 months: 1 x month

183 Knee Surgery Protocol : PCL Reconstruction REHABILITATION PROGRESSION 0-1 WEEK POST-OP Brace: Locked at 0°-60° maximum Weight bearing Status: WBAT with crutches, with brace locked Special Considerations: Pillow under proximal posterior tibia at rest to prevent posterior sag Therapy: Quad Sets Ankle Pumps SLR Hip Alphabets Hip AB/AD

184 Knee Surgery Protocol : PCL Reconstruction 7-28 DAYS POST-OP Brace: Locked except for protected range of motion performed by physical therapist. WB Status: WBAT with crutches, with brace locked Special Considerations: Continue use of pillow under tibia at rest.

185 Knee Surgery Protocol : PCL Reconstruction Therapy: PT Assisted knee flexion For 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 stretching Calf press with Theraband Standing calf raises with full knee extension Standing hip extension from neutral

186 Knee Surgery Protocol : PCL Reconstruction 4-8 WEEKS Brace: 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 crutches Ther. 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

187 Knee Surgery Protocol : PCL Reconstruction 8-12 WEEKS D/C Brace 8 weeks WB status: Wean off crutches at 8 weeks post- op May D/C crutches if patient exhibits: No quad lag with SLR Full knee extension Knee flexion 90°-100° Normal gait pattern Therapy: Stationary bike: Foot forward on pedal (no toe clips), seat high Balance and proprioception, Seated calf raises Leg press (within available range of motion)

188 Knee Surgery Protocol : PCL Reconstruction 12 WEEKS (3 MONTHS) Progress functional and symptomatically Therapy: Treadmill walking Jogging in pool with Swimming – no breaststroke emphasize flutter kick from hip (minimize active knee flexion) 3-6 MONTHS Reduce 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.

189 Knee Surgery Protocol : PCL Reconstruction 6-12 MONTHS Return 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 progression Nordic Track Jog/Run progression Backward running, Cutting Jumping (Plyometrics) NO SQUATS OR LUNGES AT ANY TIME!

190 Shoulder Surgery Protocol : SLAP Lesion repair protocol Brief 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 treatments A SLAP repair is performed arthroscopically using sutures to reattach the torn labrum back to the bone A 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.

191 Rehab after a SLAP repair Rehabilitation 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.

192 Shoulder Surgery Protocol : SLAP Lesion repair protocol For 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.

193 Shoulder Surgery Protocol : SLAP Lesion repair protocol

194 Superior 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

195 Shoulder Surgery Protocol : SLAP Lesion repair protocol This 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 inflammation Regain normal upper extremity strength and endurance Regain normal shoulder range of motion Achieve the level of function based on the orthopedic and patient goals

196 Shoulder Surgery Protocol : SLAP Lesion repair protocol Early 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 tissue Abnormal pain response, hypersensitive-an increase in night pain Severe range of motion limitations Weakness in the upper extremity musculature

197 Shoulder Surgery Protocol : SLAP Lesion repair protocol Return 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, or instability should be closely monitored by the patient.

198 Shoulder Surgery Protocol : SLAP Lesion repair protocol Phase 1: Week 1-3 ROM :Gentle pendulum exercise only STRENGTH :No strengthening BRACE Brace for 6 weeks Brace removed for exercises above MODALITIES E-stim as needed Ice minutes GOALS OF PHASE: Promote healing of tissue Control pain and inflammation Independent in HEP

199 Shoulder Surgery Protocol : SLAP Lesion repair protocol Phase 2: Week 3-6 ROM Gradual gentle passive range of motion Flexion/Elevation 0-60° Passive range of motion-scapular plane External Rotation 0-15° Internal Rotation as tolerated Continue pendulum exercise STRENGTH Submaximal isometric activities Shoulder shrugs with resistance MODALITIES Ice minutes

200 Shoulder Surgery Protocol : SLAP Lesion repair protocol GOALS OF PHASE: Control pain and inflammation Enhance upper extremity strength Gradual increase in ROM.

201 Shoulder Surgery Protocol : SLAP Lesion repair protocol Phase 3: Week 6-12 ROM Gentle passive range of motion Flexion/Elevation 0-145° Passive range of motion-scapular plane External Rotation 0-50° Internal Rotation Full ROM Posterior capsule stretching Towel stretching Rope/Pulley activities Wand exercises Manual stretching

202 Shoulder Surgery Protocol : SLAP Lesion repair protocol STRENGTH Continue all strengthening from previous phases increasing resistance and repetition Initiate supine rhythmic stabilization at 90° flexion Initiate IR/ER at neutral with tubing Initiate forward flexion, scaption, empty can Initiate sidelying ER and tricep strengthening Prone abduction with external rotation Shoulder shrugs with resistance Supine punches with resistance Shoulder retraction with resistance Initiate UBE for endurance and Prone rows Initiate light biceps curls at week 10 Initiate plyotoss (overhead toss) chest pass and initiate PNF patterns with theraband Initiate IR/ER exercises at 90 ° abduction Initiate isokinetic IR/ER at neutral at wk 10-12

203 Shoulder Surgery Protocol : SLAP Lesion repair protocol MODALITIES Ice minutes GOALS OF PHASE: Minimize pain and swelling Reach full ROM Improve upper extremity strength and endurance Enhance neuromuscular control Normalize arthrokinematics.

204 Shoulder Surgery Protocol : SLAP Lesion repair protocol Phase 4: Week ROM Continue with all ROM activities from previous phases, goal full ROM in all planes Posterior capsule stretching Towel stretching Joint mob. as needed for full ROM

205 Shoulder Surgery Protocol : SLAP Lesion repair protocol STRENGTH Progress strengthening program with increase in resistance and high speed repetition Progress with eccentric strengthening of posterior cuff and scapular musculature Initiate single arm plyotoss Progress rhythmic stabilization activities to include standing PNF patterns with tubing UBE for strength and endurance Initiate military press, bench press, lat pulldown Initiate sport specific drills and functional activities Initiate interval throwing program week 16 Initiate light plyometric program week Progress isokinetics to 90 ° of abduction at high speeds

206 Shoulder Surgery Protocol : SLAP Lesion repair protocol MODALITIES Ice minutes GOALS OF PHASE: Full ROM Maximize upper extremity strength and endurance Maximize neuromuscular control Initiate sports specific training/functional training

207 Shoulder Surgery Protocol : RTC Lesion repair protocol Brief 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 heal The 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.

208 Shoulder Surgery Protocol : RTC Lesion repair protocol Many 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.

209 Shoulder Surgery Protocol : RTC Lesion repair protocol The 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.

210 Shoulder Surgery Protocol : RTC Lesion repair protocol Open Repair A 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.

211 Shoulder Surgery Protocol : RTC Lesion repair protocol All-Arthroscopic Repair During 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.

212 Shoulder Surgery Protocol : RTC Lesion repair protocol Mini-Open Repair The 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

213 Shoulder Surgery Protocol : RTC Lesion repair protocol ROTATOR CUFF REPAIR PROTOCOL This rehabilitation protocol has been developed for the patient following a rotator cuff surgical procedure. This protocol will vary in length and aggressiveness depending on factors such as: Size and location of tear Degree of shoulder instability/laxity prior to surgery Acute versus chronic condition Length of time immobilized Strength/pain/swelling/range of motion status Rehabilitation goals and expectations

214 Shoulder Surgery Protocol : RTC Lesion repair protocol ROTATOR CUFF REPAIR PROTOCOL Early passive range of motion is highly beneficial to enhance circulation within the joint to promote healing. The protocol is divided into phases. Each phase is adaptable based on the individual and special circumstances. The overall goals of the surgical procedure and rehabilitation are to: Control pain, inflammation, and effusion Regain normal upper extremity strength and endurance Regain normal shoulder range of motion Achieve the level of function based on the orthopedic and patient goals

215 Shoulder Surgery Protocol : RTC Lesion repair protocol ROTATOR CUFF REPAIR PROTOCOL Physical 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 tissue Abnormal pain response, hypersensitive-an increase in night pain Severe range of motion limitations Weakness in the upper extremity musculature

216 Shoulder Surgery Protocol : RTC Lesion repair protocol ROTATOR CUFF REPAIR PROTOCOL Return 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.

217 Shoulder Surgery Protocol : RTC Lesion repair protocol ROTATOR CUFF REPAIR PROTOCOL Phase 1: Week 1-6 ROM Pendulum exercises Elbow (flex/ext) range of motion STRENGTH NO Active Shoulder flexion or abduction allowed in the first 6 weeks Grip strengthening with putty or ball BRACE Brace for 6 weeks Brace removed to perform exercises above MODALITIES E-stim as needed Ice minutes

218 Shoulder Surgery Protocol : RTC Lesion repair protocol ROTATOR CUFF REPAIR PROTOCOL GOALS OF PHASE: Promote healing of repaired rotator cuff Control pain and inflammation Gradual increase of ROM Independent in HEP Delay muscle atrophy

219 Shoulder Surgery Protocol : RTC Lesion repair protocol ROTATOR CUFF REPAIR PROTOCOL Phase 2: Week 6-12 ROM Continue all ROM from previous phases Initiate gentle posterior capsule stretching Initiate gentle IR stretching Initiate rope/pulley Initiate passive ER wand exercise Rope/Pulley (flex/abd/scaption) Wand activities in all planes Posterior capsule stretching Towel stretching

220 Shoulder Surgery Protocol : RTC Lesion repair protocol ROTATOR CUFF REPAIR PROTOCOL STRENGTH Continue with all strengthening from previous phases increasing resistance and repetition Initiate supine AROM exercises without resistance Initiate UBE without resistance Initiate scapular stabilizer strengthening-active assisted Manual rhythmic stabilization exercises at 90 ° flex Shoulder shrugs with resistance Shoulder retraction with resistance Supine punches with resistance Prone shoulder extension

221 Shoulder Surgery Protocol : RTC Lesion repair protocol ROTATOR CUFF REPAIR PROTOCOL Prone rowing Prone ER with abduction Initiate forward flexion, scaption, empty can Sidelying ER UBE for endurance training Initiate plyotoss at chest then progress to overhead Bicep/Tricep work Isokinetic ER/IR at neutral at week MODALITIES Ice minutes

222 Shoulder Surgery Protocol : RTC Lesion repair protocol ROTATOR CUFF REPAIR PROTOCOL GOALS OF PHASE: Minimize pain and swelling Reach full ROM Improve upper extremity strength and endurance Enhance neuromuscular control Normalize arthrokinematics.

223 Shoulder Surgery Protocol : RTC Lesion repair protocol ROTATOR CUFF REPAIR PROTOCOL Phase 4: Week ROM Continue with all ROM activities from previous phases Posterior capsule stretching Towel stretching STRENGTH Progress strengthening program with increase in resistance and high speed repetition Initiate IR/ER exercises at 90 ° abduction Progress rhythmic stabilization activities to include standing PNF patterns with tubing Initiate single arm plyotoss

224 Shoulder Surgery Protocol : RTC Lesion repair protocol ROTATOR CUFF REPAIR PROTOCOL Initiate military press, bench press, flys, lat pulldowns UBE for strength and endurance Initiate sport specific drills and functional activities Initiate interval throwing program week Initiate light upper body plyometric program week Progress isokinetics to 90 ° abduction at high speeds

225 Shoulder Surgery Protocol : RTC Lesion repair protocol ROTATOR CUFF REPAIR PROTOCOL MODALITIES Ice minutes GOALS OF PHASE: Full painless ROM Maximize upper extremity strength and endurance Maximize neuromuscular control Initiate sports specific training/functional training

226 Shoulder Surgery Protocol : Total Shoulder Replacement Brief 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.

227 Shoulder Surgery Protocol : Total Shoulder Replacement

228 When 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.

229 Shoulder Surgery Protocol : Total Shoulder Replacement

230 Variations: Hemi Arthroplasty, Reverse Shoulder Replacement The 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.

231 Shoulder Surgery Protocol : Total Shoulder Replacement Please 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

232 Shoulder Surgery Protocol : Total Shoulder Replacement Passive 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!!!!!!!

233 Shoulder Surgery Protocol : Total Shoulder Replacement Phase I – Immediate Post Surgical Phase: Goals: Allow healing of soft tissue Maintain integrity of replaced joint Gradually increase passive range of motion (PROM) of shoulder; restore active range of motion (AROM) of elbow/wrist/hand Reduce pain and inflammation Reduce muscular inhibition Independent with activities of daily living (ADLs) with modifications while maintaining the integrity of the replaced joint.

234 Shoulder Surgery Protocol : Total Shoulder Replacement Precautions: Sling should be worn continuously for 3-4 weeks While 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.

235 Shoulder Surgery Protocol : Total Shoulder Replacement No lifting of objects No 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 side Keep incision clean and dry (no soaking for 2 weeks) No driving for 3 weeks

236 Shoulder Surgery Protocol : Total Shoulder Replacement Post-Operative Day (POD) #1 (in hospital): Passive forward flexion in supine to tolerance Gentle 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 chest Active distal extremity exercise (elbow, wrist, hand) Pendulum exercises

237 Shoulder Surgery Protocol : Total Shoulder Replacement Frequent cryotherapy for pain, swelling, and inflammation management Patient education regarding proper positioning and joint protection techniques Early Phase I: (out of hospital) Continue above exercises Begin scapula musculature isometrics / sets (primarily retraction) Continue active elbow ROM Continue cryotherapy as much as able for pain and inflammation management

238 Shoulder Surgery Protocol : RTC Lesion repair protocol Late 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

239 Shoulder Surgery Protocol : Total Shoulder Replacement Criteria 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 program Has achieved at least 90° PROM forward flexion and elevation in the scapular plane. Has achieved at least 45° PROM ER in plane of scapula Has achieved at least 70° PROM IR in plane of scapula measured at 30° of abduction

240 Shoulder Surgery Protocol : Total Shoulder Replacement Phase II – Early Strengthening Phase (Not to begin before 4-6 Weeks post-surgery to allow for appropriate soft tissue healing): Goals: Restore full passive ROM Gradually restore active motion Control pain and inflammation Allow continue healing of soft tissue Do not overstress healing tissue Re-establish dynamic shoulder stability

241 Shoulder Surgery Protocol : Total Shoulder Replacement Precautions: 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 side No sudden jerking motions

242 Shoulder Surgery Protocol : Total Shoulder Replacement Early 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 ROM AAROM pulleys (flexion and elevation in the plane of the scapula) – as long as greater than 90° of PROM Begin shoulder sub-maximal pain-free shoulder isometrics in neutral Scapular strengthening exercises as appropriate Begin assisted horizontal adduction Progress distal extremity exercises with light resistance as appropriate Gentle glenohumeral and scapulothoracic joint mobilizations as indicated Initiate glenohumeral and scapulothoracic rhythmic stabilization Continue use of cryotherapy for pain and inflammation.

243 Shoulder Surgery Protocol : Total Shoulder Replacement Late Phase II: Progress scapular strengthening exercises Criteria 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 program Has achieved at least 140° PROM forward flexion and elevation in the scapular plane. Has achieved at least 60+° PROM ER in plane of scapula Has achieved at least 70° PROM IR in plane of scapula measured at 30° of abduction Able to actively elevate shoulder against gravity with good mechanics to 100°.

244 Shoulder Surgery Protocol : Total Shoulder Replacement Phase 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 endurance Optimize neuromuscular control Gradual return to functional activities with involved upper extremity Precautions: No heavy lifting of objects (no heavier than 3 kg.) No sudden lifting or pushing activities No sudden jerking motions

245 Shoulder Surgery Protocol : Total Shoulder Replacement Early Phase III: Progress AROM exercise / activity as appropriate Advance PROM to stretching as appropriate Continue PROM as needed to maintain ROM Initiate assisted shoulder IR behind back stretch Resisted shoulder IR, ER in scapular plane Begin light functional activities Wean from sling completely Begin progressive supine active elevation strengthening (anterior deltoid) with light weights ( kg.) at variable degrees of elevation

246 Shoulder Surgery Protocol : Total Shoulder Replacement Late Phase III: Resisted flexion, elevation in the plane of the scapula, extension (therabands / sport cords) Continue progressing IR, ER strengthening Progress IR stretch behind back from AAROM to AROM as ROM allows (Pay particular attention as to avoid stress on the anterior capsule.)

247 Shoulder Surgery Protocol : Total Shoulder Replacement Criteria 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/strengthening Has 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 supine Has achieved at least 70° AROM IR in plane of scapula supine in 30° of abduction Able to actively elevate shoulder against gravity with good mechanics to at least 120°.

248 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 AROM Enhance functional use of upper extremity Improve muscular strength, power, and endurance Gradual return to more advanced functional activities Progress weight bearing exercises as appropriate Precautions: 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

249 Shoulder Surgery Protocol : Total Shoulder Replacement Early 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 tennis Criteria 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

250 Shoulder Surgery Protocol : Reverse Shoulder Replacement Brief 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

251 Shoulder Surgery Protocol : Reverse Shoulder Replacement 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. 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

252 Shoulder Surgery Protocol : Reverse Shoulder Replacement With 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 arthropathy Patients 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.

253 Shoulder Surgery Protocol : Reverse Shoulder Replacement Protocol: Shoulder Dislocation Precautions This 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.

254 Shoulder Surgery Protocol : Reverse Shoulder Replacement Phase 1: Immediate Postsurgical Phase, Joint Protection (Day 1 to Week 6) Goals: Patient and family independent with Joint protection Passive range of motion (PROM) after 2 weeks Assisting with putting on/taking off sling and clothing Assisting with home exercise program (HEP) Cryotherapy Promote healing of soft tissue/maintain the integrity of the replaced joint Enhance PROM after two weeks

255 Shoulder Surgery Protocol : Reverse Shoulder Replacement Restore active range of motion (AROM) of elbow/wrist/hand Independent with activities of daily living (ADLs) with modifications

256 Shoulder Surgery Protocol : Reverse Shoulder Replacement Precautions: 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 AROM No lifting of objects with operative extremity No supporting of body weight with involved extremity Keep incision clean and dry (no soaking/wetting for 2 weeks); no whirlpool, Jacuzzi, ocean/lake wading for 4 weeks minimum.

257 Shoulder Surgery Protocol : Reverse Shoulder Replacement Day 14(acute care therapy) Begin PROM in supine Forward 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 hand Begin periscapular submaximal pain-free isometrics in the scapular plane Continuous cryotherapy for first 72 hrs postoperatively, then frequent application (4-5 times a day for about 20 minutes) cryotherapy

258 Shoulder Surgery Protocol : Reverse Shoulder Replacement Days 15 to 21 Continue all exercises as above Begin 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

259 Shoulder Surgery Protocol : Reverse Shoulder Replacement Weeks 3 to 6 Progress exercises listed above Progress PROM Forward flexion and elevation in the scapular plane in supine to 120° ER in scapular plane to tolerance, respecting soft tissue constraints At 6 weeks postoperatively start PROM IR to tolerance (not to exceed 50°) in the scapular plane Gentle resisted exercise of elbow, wrist, and hand Continue frequent cryotherapy

260 Shoulder Surgery Protocol : Reverse Shoulder Replacement Criteria for progression to the next phase (phase II) Patient tolerates shoulder PROM and AROM program for elbow, wrist, and hand Patient demonstrates the ability to isometrically activate all components of the deltoid and periscapular musculature in the scapular plane

261 Shoulder Surgery Protocol : Reverse Shoulder Replacement Phase II: ARAOM, Early Strengthening Phase (Weeks 6 to 12) Goals: Continue progression of PROM (full PROM is not expected) Gradually restore AROM Control pain and inflammation Allow continued healing of soft tissue/do not overstress healing tissue Re-establish dynamic shoulder stability

262 Shoulder Surgery Protocol : Reverse Shoulder Replacement Precautions: Continue to avoid shoulder hyperextension In the presence of poor shoulder mechanics avoid repetitive shoulder AROM exercises/activity Restrict Lifting of objects to no heavier than a coffee cup No supporting of body weight by involved upper extremity

263 Shoulder Surgery Protocol : Reverse Shoulder Replacement Weeks 6 to 8 Continue with PROM program Begin shoulder active assisted ROM/AROM as appropriate Forward flexion and elevation in scapular plane in supine with progression to sitting/standing ER in IR in the scapular plane in supine with progression to sitting/standing Begin gentle GH IR and ER submaximal pain-free isometrics Initiate 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 week Progress strengthening of elbow, wrist, and hand

264 Shoulder Surgery Protocol : Reverse Shoulder Replacement Gentle GH and scapulothoracic joint mobilizations as indicated (grades I and II) Continue use of cryotherapy as needed Patient may begin to use hand of operative extremity for feeding and light ADLs

265 Shoulder Surgery Protocol : Reverse Shoulder Replacement Weeks 9 to 12 Continue with above exercises and functional activity progression Begin 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

266 Shoulder Surgery Protocol : Reverse Shoulder Replacement Criteria for progression to the next phase (phase III) Improving function of shoulder Patient demonstrates the ability to isotonically activate all components of the deltoid and periscapular musculature and is gaining strength

267 Shoulder Surgery Protocol : Reverse Shoulder Replacement Phase III: Moderate Strengthening (Week 12+) Goals: Enhance functional use of operative extremity and advance functional activities Enhance shoulder mechanics, muscular strength, power and endurance Precautions No lifting of objects heavier than 2.7 kg (6lb) with the operative upper extremity No sudden lifting or pushing activities

268 Shoulder Surgery Protocol : Reverse Shoulder Replacement Weeks 12 to 16 Continue with previous program as indicated Progress to gentle resisted flexion, elevation in standing as appropriate

269 Shoulder Surgery Protocol : Reverse Shoulder Replacement Phase 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 on Continued strength gains Continued progression toward a return to functional and recreational activities within limits, as identified by progress made during rehabilitation and outlined by surgeon and physical therapist Criteria for discharge from skilled therapy Patient is able to maintain pain-free shoulder AROM, demonstrating proper shoulder mechanics (typically 80° - 120° of elevation, with functional ER of about 30°)

270 Shoulder Surgery Protocol : Reverse Shoulder Replacement ACDF TLIF ALIF PLIF XLIF

271 References: cid=201 cid= hy.html hy.html Berne RM, Levy MN (1993): Physiology, 3rd ed., 1091 pp. C. V. Mosby, St. Louis.

272 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.

273 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.


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