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 2-6 Weeks > 6 Weeks Pendulums Elbow AROM Grip Isometrics 2-6 Weeks PROM/ AAROM > 6 Weeks “Strengthening”

Shari Shaffer’s Grandmother’s Recipe 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 Avoid Painful-Stiff 0-2 weeks

** Exercise Prescription ROM Progression Start 0-14 days Exercises Pendulums Supine PFE w/ opp. hand Supine PER ** Exercise Prescription Exercise Series = 2 - 4x/ day ROM Exercises = 5 - 10x each w/ 10 sec hold

ROM Progression ROM Check If Yes If No > 80° PFE > 10° PFE Gain Return in 2 weeks If No Instruct in Table Step Backs Return within 2 days

Back on Track? 3-4 Weeks ROM Check If Yes If No 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 Stiffness 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 Guide for… 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 forward Your Feedback, but… What we need to move forward Your 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