Evidence Based Algorithm for Rehabilitation after RC Repair Michael A. Shaffer PT, ATC, OCS.

Evidence Based Algorithm for Rehabilitation after RC Repair

Michael A. Shaffer

PT, ATC, OCS

Instability Guidelines NOT THIS TALK!!!

JOSPT March 2010

‘Well if you think you

can do better,

go ahead and try.’(paraphrasing)

“Patients completed a standard physical therapy program”

“S/P RCR- MOON Protocol”

Standard PT Program

0-2 Weeks Pendulums Elbow AROM Grip Isometrics

2-6 Weeks PROM/ AAROM

> 6 Weeks “Strengthening”

Shari Shaffer’s Grandmother’sRecipe for Homemade Bread

Step 1-

“Put 2 scoops of flour

into the green bowl”

Step 2-

Keep buying bread at

the store Normal Rockwell

Freedom from Want

What’s the goal?

Dissect the black box of exercise prescription Supplement the ASSET RC Guidelines Spur discussion among “seasoned” clinicians Serve as a guide for novice clinicians

Integral Features of an Algorithm “Delayed” and Standard on same algorithm ROM Progression Detailed

PROM, AROM ROM “gate” to strengthening

Strengthening Progression Detailed Dosing Staged elevation program

End Point for Supervised Rehab “Maintenance program”

A million ways to fold them…But only two ways to use them

Avoid getting lost… Prevent the most common

problems

Or after you’re lost…. Fix the problems to get

back on track

“Typical Patient”

63 y.o. male Full thickness 3-5 cm2 SS and IS s/p arthroscopic RCR Immob. in standard sling or ultrasling 2 week follow up visit

Pain = 4/10 at rest. Difficulty sleeping. PFE = 0-95°; PER = 0-10°

What are the rehab goals after RC Repair? Pain controlled Functional ROM

> 115° AFE > 140° PFE > 75° PER at 90°

Functional strength Able to complete 1) ADL’s, 2) Work, 3) Hobbies

Healed repair (?)

AFE = Active Forward Elevation

PFE = Passive Forward Elevation

PER = Passive External Rotation

Avoid Painful – Stiff Train Wreck

Avoid Painful-Stiff

0-2 weeks

Start correct exercises Identify problems early

Comprehension Pain ROM

ROM Progression Start 0-14 days Exercises

Pendulums Supine PFE w/ opp. hand Supine PER

** Exercise PrescriptionExercise Series = 2 - 4x/ dayROM Exercises = 5 - 10x each w/ 10 sec hold

ROM Progression

ROM Check > 80° PFE > 10° PFE Gain

If Yes Return in 2 weeks

If No Instruct in Table Step Backs Return within 2 days

Back on Track?3-4 Weeks

ROM Check 110° PFE 25° PER 20° PAbd.

If Yes Remove sling as per MD Return in 2 weeks

If No Add OH Pulleys Supervised Rehab 1-2x/week PROM

What’s the goal of the algorithm?Assistance out of a rough spot

Persistent problems

3-4 weeks Still struggling

(< 80° PFE/ <10° Gain) Comprehension

OH Pulleys Pain

∆ Ex. Program/ MD ROM

Start 2-3x week PROM

Avoid Painful- Stiff ~ 4 Weeks

What predominates? Pain

Pendulums only Stiffness

Continue PROM Increase HEP

Frequency End range hold time

What Predominates?

Pain Resting pain Pain before end range (empty end feel)

Stiffness Pain after end range

Strengthening Progression

Typical protocol = 6 weeks Clinically?

6 weeks if……..x,y,z ROM is the gate to strengthening

ROM is the Gate to Strengthening

ROM is the Gate to Strengthening 6 Weeks Elastic Resistance

IR ER Extension* (unilateral) Rowing* (bilateral)

* to neutral

*THERABAND INSTRUCTION: (For each exercise/motion)

-Start with yellow Theraband (1x10 reps)-When patient “can complete the exercise without difficulty”, then progress to 2x10 reps-Eventually progress to 3x10 reps-Advance to next resistance level (color) and begin with 1x10 reps

Expected recovery - Approximately 1 week/ color.

Other components

Strengthening progressions 9 Weeks 12 Weeks “Advanced strengthening” (athletes, laborers)

Guide for… Scapular hiking Limited active elevation

Return to work, sport criteria

What we need to move forwardYour Feedback, but…..(Keeping in algorithmic format)

NO “I do ______ with my patients after RC surgery.”

YES “I do ______ with my patients after RC surgery

when/ if they present like ______”

Thank You. Brian G. Leggin PT, DPT, OCS

Chuck Thigpen PhD, PT, ATC

Reg. Wilcox PT, DPT, MS, OCS