I. Purpose of shoulder arthroplasty and rehabilitation requirements
The main purpose of shoulder arthroplasty is to relieve shoulder joint pain, restore shoulder joint function and stabilize the joint. The goal of rehabilitation after shoulder arthroplasty is to restore the joint mobility of the shoulder joint, the muscle strength around the shoulder, and the stability and coordination of the shoulder joint as soon as possible. Compared to other surgeries, total shoulder arthroplasty relies more on postoperative rehabilitation to achieve good joint mobility. Swelling of the shoulder muscles and blood accumulation in the joint generally occur after total shoulder arthroplasty. Without timely rehabilitation, muscle fibrosis and adhesions can occur, which can affect joint movement. Early functional training is an effective measure to prevent muscle fibrosis and adhesions, which may ensure a certain level of joint movement without affecting the healing of soft tissues. However, overly conservative rehabilitation can lead to joint stiffness, while being too aggressive can impair the healing of the joint capsule and rotator cuff, thus affecting the stability of the shoulder joint and joint function. The ideal range of motion after shoulder arthroplasty should be 140° of shoulder supination, 40° of external rotation, 90° of abduction, 70° of internal rotation, and 50° of posterior extension.
Commonly used rehabilitation training methods
Early rehabilitation training after total shoulder arthroplasty directly affects the outcome of the surgery and is a key step in obtaining satisfactory function of the shoulder joint after total shoulder arthroplasty, so we must pay full attention to it. Common rehabilitation training methods are as follows.
1.”Swing” exercise
If there is no obvious pain, then swing in the left and right lateral direction, and finally increase the ring (drawing circle) movement, 20-30 times/group in each direction. If the pain is obvious, swing under the protection of the triangular towel or the healthy hand.
2.Supine shoulder forward bending
Lie on your back, hold the affected elbow with the healthy hand, and passively flex the affected shoulder forward until you feel pain and stop for 2-3 minutes. When the angle is larger, you can also borrow a treatment stick to complete a larger angle exercise.
3.Sitting shoulder abduction
In a sitting position, hold the affected elbow with the hand on the healthy side and passively abduct the affected shoulder until you feel pain and stop for 2-3 minutes, then gradually increase the angle after the pain is relieved. When the angle is larger, you can also borrow a treatment stick to complete a larger angle exercise.
4.Supine shoulder external rotation
Lie on your back, keep your upper arm close to your torso, bend your elbow at 90°, hold the affected wrist with your healthy hand, passively rotate the affected shoulder externally, stop for 2-3 minutes until you feel pain, and continue to increase the angle after the pain is relieved. When the angle is larger, you can also borrow the treatment stick to complete a larger angle exercise.
5.Supine shoulder internal rotation
Lie on your back, keep your upper arm close to your torso, bend your elbow 90°, hold the affected wrist with your healthy hand and passively rotate the affected shoulder internally until you feel pain, stop for 2-3 minutes and continue to increase the angle after the pain subsides.
6.Supine shoulder extension
Lie on your back, bend your elbow at 90°, hold the affected wrist with your healthy hand, passively extend the affected shoulder backward until you feel pain, stop for 2-3 minutes, and continue to increase the angle after the pain is relieved. When the angle is larger, you can also borrow a treatment stick to complete a larger angle exercise.
7.Supine external booth external rotation
Lie on your back, abduct the shoulder joint at 90°, flex the elbow at 90°, hold the affected wrist with the healthy hand, passively externally rotate the affected shoulder, stop for 2-3 minutes until you feel pain, and continue to increase the angle after the pain is relieved. When the angle is larger, you can also borrow the treatment stick to complete a larger angle exercise.
8.Supine external booth internal rotation
Lie on your back, abduct the shoulder joint at 90°, flex the elbow at 90°, hold the affected wrist with the healthy hand, passively rotate the affected shoulder internally, stop for 2-3 minutes until you feel pain, and continue to increase the angle after the pain is relieved. When the angle is larger, you can also borrow a treatment stick to complete the exercise at a larger angle.
9.Horizontal internal rotation
Sitting or lying on your back, hold the affected elbow with your healthy hand and passively internally rotate the affected shoulder until you feel pain, stop for 2-3 minutes, then continue to increase the angle after the pain is relieved.
III. Development of rehabilitation plan
Functional rehabilitation after total shoulder arthroplasty should be developed according to the patient’s condition.
1.Phase 1 passive functional exercise
The main objective is to increase the range of motion and reduce soft tissue adhesions such as joint capsule and ligaments, so that the patient can lie in a supine position and perform forward flexion, external rotation and abduction exercises under the guidance of a physician, as well as pendulum-like exercises for 4-6 weeks.
Postoperative day 1-2: Perform gentle joint exercises, fist clenching and fist loosening exercises to promote blood circulation and functional recovery of the fingers. The affected shoulder is fixed in a neutral position at rest to reduce rotator cuff tension.
Postoperative day 3: Perform passive and active extension and flexion exercises of the upper limb joints (hand, wrist and elbow) and isometric contraction of the shoulder muscles for about 10 minutes each time, 3-5 times a day, to promote early recovery of the distal muscle strength of the upper limb and wrist joint function.
Postoperative day 5-7: The healthy limb assisted in elbow extension and flexion exercises, external rotation and supination exercises in the supine position, external rotation exercises with 90° flexion of the elbow and holding the wrist over the shoulder with the healthy hand and touching the forehead with the healthy hand, gradually over the head, 4 times a day for about 10 minutes each time.
Postoperative day 7-14: increase the “swing” exercise, bend the affected arm down, hold a wooden stick, draw circles on the ground in internal or external rotation, and gradually increase the radius of the circle. The torso is bent forward during the exercise, which can reduce the burden of overcoming gravity on the patient’s muscles and further relax the shoulder muscles.
2.Stage 2 start active functional exercise
However, passive activities must still be assisted to increase the shoulder joint mobility.
Postoperative week 3: The operated limb does active activity exercise. During the period of functional exercise, use physical therapy to eliminate fatigue, relieve pain and promote healing. Begin to increase isometric functional exercises by flexing the elbow at 90°, using the healthy hand, wall, etc. as resistance, and then isometric contraction of the internal and external rotation muscle groups.
Postoperative week 6: The trauma of deltoid and rotator cuff was basically healed, and the active exercises of deltoid and infraspinatus muscles were started gradually. The above exercises were repeated 5 times a day for about 5 minutes each time, performing active forward flexion, back extension, internal rotation and external rotation activities. Gradually increase the muscle strength and range of motion of the shoulder joint.
3. Stage 3 increases the range of motion and strengthens strength exercises.
Encourage the patient to use the operated limb as early as possible to complete daily activities, while prohibiting vigorous activities, lifting or dragging heavy objects and throwing or swinging the arm to avoid dislocation of the replacement joint, loosening or even fracture of the prosthetic stem.
As time passes, gradually transition to resistance exercises, resumption of daily activities and non-confrontational physical exercise, generally about 18 weeks after surgery to complete rehabilitation training.
IV. Precautions
1.Post-operative functional training must be carried out under the strict guidance of therapists, avoiding early active rotation of the affected limb to prevent re-rupture or tearing of the muscle.
2.Patients are instructed to gradually increase the intensity of training in the rehabilitation treatment 3 weeks after surgery; 3 months after surgery, they can carry out some large and slightly resistant movements such as lifting and belting; strenuous activities are prohibited, and lifting or dragging heavy objects or waving arms with force are not recommended to avoid dislocation, loosening or even fracture of joint prosthesis.
3.Guide the patient to effectively use the home environment and conditions, planned and purposeful rehabilitation training, until the function is fully restored.