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

Mar 26, 2015

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Page 1: 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

Page 2: Evidence Based Algorithm for Rehabilitation after RC Repair Michael A. Shaffer PT, ATC, OCS.

Instability Guidelines NOT THIS TALK!!!

JOSPT March 2010

Page 3: Evidence Based Algorithm for Rehabilitation after RC Repair Michael A. Shaffer PT, ATC, OCS.
Page 4: Evidence Based Algorithm for Rehabilitation after RC Repair Michael A. Shaffer PT, ATC, OCS.
Page 5: Evidence Based Algorithm for Rehabilitation after RC Repair Michael A. Shaffer PT, ATC, OCS.

‘Well if you think you

can do better,

go ahead and try.’(paraphrasing)

Page 6: Evidence Based Algorithm for Rehabilitation after RC Repair Michael A. Shaffer PT, ATC, OCS.

“Patients completed a standard physical therapy program”

“S/P RCR- MOON Protocol”

Page 7: Evidence Based Algorithm for Rehabilitation after RC Repair Michael A. Shaffer PT, ATC, OCS.

Standard PT Program

0-2 Weeks Pendulums Elbow AROM Grip Isometrics

2-6 Weeks PROM/ AAROM

> 6 Weeks “Strengthening”

Page 8: Evidence Based Algorithm for Rehabilitation after RC Repair Michael A. Shaffer PT, ATC, OCS.

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

Page 9: Evidence Based Algorithm for Rehabilitation after RC Repair Michael A. Shaffer PT, ATC, OCS.

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

Page 10: Evidence Based Algorithm for Rehabilitation after RC Repair Michael A. Shaffer PT, ATC, OCS.

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”

Page 11: Evidence Based Algorithm for Rehabilitation after RC Repair Michael A. Shaffer PT, ATC, OCS.

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

Page 12: Evidence Based Algorithm for Rehabilitation after RC Repair Michael A. Shaffer PT, ATC, OCS.

“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°

Page 13: Evidence Based Algorithm for Rehabilitation after RC Repair Michael A. Shaffer PT, ATC, OCS.

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

Page 14: Evidence Based Algorithm for Rehabilitation after RC Repair Michael A. Shaffer PT, ATC, OCS.

Avoid Painful – Stiff Train Wreck

Page 15: Evidence Based Algorithm for Rehabilitation after RC Repair Michael A. Shaffer PT, ATC, OCS.

Avoid Painful-Stiff

0-2 weeks

Start correct exercises Identify problems early

Comprehension Pain ROM

Page 16: Evidence Based Algorithm for Rehabilitation after RC Repair Michael A. Shaffer PT, ATC, OCS.

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

Page 17: Evidence Based Algorithm for Rehabilitation after RC Repair Michael A. Shaffer PT, ATC, OCS.

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

Page 18: Evidence Based Algorithm for Rehabilitation after RC Repair Michael A. Shaffer PT, ATC, OCS.

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

Page 19: Evidence Based Algorithm for Rehabilitation after RC Repair Michael A. Shaffer PT, ATC, OCS.

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

Page 20: Evidence Based Algorithm for Rehabilitation after RC Repair Michael A. Shaffer PT, ATC, OCS.

Persistent problems

3-4 weeks Still struggling

(< 80° PFE/ <10° Gain) Comprehension

OH Pulleys Pain

∆ Ex. Program/ MD ROM

Start 2-3x week PROM

Page 21: Evidence Based Algorithm for Rehabilitation after RC Repair Michael A. Shaffer PT, ATC, OCS.

Avoid Painful- Stiff ~ 4 Weeks

What predominates? Pain

Pendulums only Stiffness

Continue PROM Increase HEP

Frequency End range hold time

Page 22: Evidence Based Algorithm for Rehabilitation after RC Repair Michael A. Shaffer PT, ATC, OCS.

What Predominates?

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

Stiffness Pain after end range

Page 23: Evidence Based Algorithm for Rehabilitation after RC Repair Michael A. Shaffer PT, ATC, OCS.

Strengthening Progression

Typical protocol = 6 weeks Clinically?

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

Page 24: Evidence Based Algorithm for Rehabilitation after RC Repair Michael A. Shaffer PT, ATC, OCS.

ROM is the Gate to Strengthening

Page 25: Evidence Based Algorithm for Rehabilitation after RC Repair Michael A. Shaffer PT, ATC, OCS.

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.

Page 26: Evidence Based Algorithm for Rehabilitation after RC Repair Michael A. Shaffer PT, ATC, OCS.

Other components

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

Guide for… Scapular hiking Limited active elevation

Return to work, sport criteria

Page 27: Evidence Based Algorithm for Rehabilitation after RC Repair Michael A. Shaffer PT, ATC, OCS.

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 ______”

Page 28: Evidence Based Algorithm for Rehabilitation after RC Repair Michael A. Shaffer PT, ATC, OCS.

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

Chuck Thigpen PhD, PT, ATC

Reg. Wilcox PT, DPT, MS, OCS