Continuing Education Bits for PTs & PTAs

Two quick paragraphs as a prelude to the next steps in the Case:

  1.  Once again, I have to start off by saying how impressed I am with your thought processes and professionalism.  I’ve received many private emails from PTs who are learning from all of you who comment (as a matter of fact, the over 2,000 page views within the first 24 hours of posting indicates people are really interested in what you have to say!)
  2. I’m going to interject a wee bit about myself here:  while I am very comfortable with the shoulder (especially with sports and biomechanics) I am BY NO MEANS an expert in the kind of case presented here.  This case was purposefully selected so the YOU have a place to educate all of us.  So, Thanks, on behalf of all of us PTs!

Now, back to the Case:

As many of you wrote, the MRI indicated a need for referral to an orthopaedic surgeon who performs rTSAs.  The reverse total shoulder is a ‘last chance’ procedure for folks without much rotator cuff.  And, Mr. G. clearly was lacking in the rotator cuff department.  Candidates for the rTSA need to be medically sound and have demonstrated precise follow-through to instructions/limitations post surgery.  Because if something happens to the rTSA, there is no re-do —- there is no second chance with it.

The rTSA entails the ‘ball’ of the socket to be inserted into the scapula and the ‘dish’ of the joint into the humerus (you can see that in the x-ray above – and some of the references below give even clearer pictures).

This is a relatively new procedure and Mr. G. was encouraged to interview multiple surgeons, ask about the number of rTSA procedures each surgeon performs and the outcomes.   Fortunately for Mr. G., one of the surgeons is a leader in the field of rTSA, a member of the American Shoulder and Elbow Surgeons, has performed research, does over 160 rTSA’s/year and has excellent outcomes.  Dr. Itamura is an Associate Professor of Clinical Orthopaedic Surgery at the University of Southern California  School of Medicine, Department of Orthopaedics.  Operating room staff and therapy staff also recommended Dr. Itamura without reservation.

Here is a word from his surgeon, Dr. John Itamura:

Mr. G. was an ideal candidate for the rTSA.  First of all, he is medically sound.  This is a difficult procedure and if he had had medical co-morbidities, I would not have done the procedure on him.  Secondly, his lack of rotator cuff make the rTSA the most viable procedure.  Third, he has had other total joint replacements, so he knows what it will take to get back on the road.  He is aware that it will take a year before we know exactly how far he will progress.  Fourth, he listens.  I believe he will be very conservative and careful with his reconstruction.  Even though he is basically an over-achiever with exercise, the consequences of that have been explained to him and he agrees not to overdo things.  He knows there is no second chance at this point. 

I’m not a big proponent of PT for the rTSA, since conservatism is the route I go. And if the patient does receive PT, it HAS to be slow, easy and the patient must listen carefully to the therapist – so, we’d need to all be on the same page. I have my patients perform the Anterior Deltoid Exercises for Patients with Massive Rotator Cuff Tears 5 times a day (the reference for that is below). Yet, I know other excellent surgeons are more aggressive. Boudreau et al 2007, JOSPT (which is not research, but a Clinical Commentary) is much more aggressive than I choose to be at this point, and there are surgeons who go that route.  But, give me some evidence, and I’m happy to reconsider — I may do some research on the rehab myself!

For four weeks post-op, Mr. G. wore an abduction splint (image above), even at night.  After 4 weeks in the splint, here is the resting position of his arm (image below).  At 6 weeks post op, his arm had naturally dropped to < 10 degrees of abduction.

physical therapy continuing education shoulder deltoid shortening

Now, as a member of American Shoulder and Elbow Surgeons myself, I see a huge difference in rehab opinions even among this specialized group of orthopaedic surgeons.  However, in my simple opinion, I’d still like to do some work on Mr. G.’s scapular stabilization.  So, once again, armed with literature, Dr. Itamura and I are scheduled to meet the end of this month.  We will discuss scapular mechanics, the effect of lack of scapular stabilization (Dr. Jacquelin Perry calls it a ‘floating scapula’) on the axis of rotation (and how that may affect the longevity of the prosthesis as well as the success of the outcomes), the probable fact that Mr. G. has been using his anterior deltoid (hence ‘retraining’) in place of his rotator cuff for years (thus some questionability about the ‘anterior deltoid’ retraining as seen in www.readingshoulderunit.com) and the potential for precise, practical, low risk scapular exercises for Mr. G. – and all folks receiving a rTSA.  Dr. Itamura and I may actually do some research on this since I suspect Mr. G. is not alone – that most rTSA candidates have been ‘re-educating’ their deltoids for awhile and I’d hypothesize that a large percentage of these patients have a ‘floating scapula’ (i.e. not enough scapular stabilization to allow for precision in the axis of rotation with humeral motion.)

So, we will see where that goes!

Here are some articles available for you regarding the rTSA. Unfortunately, there is very limited evidence based information out there (probably because the procedure is relatively new – it was performed in Europe for about 20 years before it was approved by the FDA in the United States). These articles are available for free as part of the physical therapy continuing education resources at EDUCATA’s library. You will need to log in, but membership is free too.

  1. Consequences of scapular anatomy for reversed total shoulder arthroplasty
    By: Middernacht B, De Roo PJ, Van Maele G, De Wilde LF.
    Clin Orthop Relat Res. 2008 Jun;466(6):1410-8.
  2. Contribution of the reverse endoprosthesis to glenohumeral kinematics
    By: Bergmann JH, de Leeuw M, Janssen TW, Veeger DH, Willems WJ.
    Clin Orthop Relat Res. 2008 Mar;466(3):594-8.
  3. Evolution of the reverse total shoulder prosthesis
    By: Jazayeri R, Kwon YW.
    Bull NYU Hosp Jt Dis. 2011;69(1):50-5.
  4. Reverse shoulder arthroplasty
    By: Smithers CJ, Young AA, Walch G.
    Curr Rev Musculoskelet Med. 2011 Dec;4(4):183-90.
  5. Rotator cuff deficient arthritis of the glenohumeral joint
    By: Macaulay AA, Greiwe RM, Bigliani LU.
    Clin Orthop Surg. 2010 Dec;2(4):196-202.
  6. Total shoulder arthroplasty
    By: Sanchez-Sotelo J.
    Open Orthop J. 2011 Mar 16;5:106-14.
  7. What is a successful outcome following reverse total shoulder arthroplasty?
    By: Roy JS, Macdermid JC, Goel D, Faber KJ, Athwal GS, Drosdowech DS.
    Open Orthop J. 2010 Apr 23;4:157-63.

Additional resources include the following two articles as well as the exercises that Dr. Itamura utilizes.

http://www.jshoulderelbow.org/article/S1058-2746(08)00429-1/abstract

Boudreau, S, Boudreau E, Higgins LD, Wilcox RB 3rd: Rehabilitation Following Reverse Total Shoulder Arthroplasty.  JOSPT, 37(12), 2007, 734-743

www.readingshoulderunit.com which is out of England and I think the exercises are there under  Physiotherapy.

All right – it’s YOUR TURN again!  I love reading your posts! What do you think should be done next?

Marilyn

Coming next week: Mr. G. discusses the outcome of his treatments and present condition

Comments on: "So… off to a Reverse Total Shoulder (rTSA)" (15)

  1. Douglas Rosario, PT said:

    It is interesting to note that the operating surgeon does not utilize physical therapy much if at all for this procedure. Our natural inclination as physicl therapists is to question this and to say that PT is warranted. However, I would postulate that if you compared the cohort of rTSA given PT post-surgically and those that did not receive PT and at the end of one year compared the two using a DASH protocol that there would be little difference in the two groups.

    It is well documented in the treatment of low back pain or frozen shoulder not everyone receives or should receive PT and the long term outcomes are good for those not receiving PT. We can choose to do certain exercises for this group of patients and use cogent reasons why they are correct, however at the end of one year it would not make any difference. So where would our time and expertise make a difference? Our goal is not to have him throw a ninety mile an hour fastball, but rather to be as functional as he can be. I believe we can accomplish this by teaching the patient how to use what they have. Develop strategies for them “to work smarter not harder.” To instruct them and utilize problem solving strategies to alleviate the pitfalls of inactivity. It sounds that this man will listen well and do well whatever our strategies are.

    • Matthew Himsey, PT, DPT, SCS said:

      Totally agree, Doug! I would also think that just because outcomes at one-year are similar doesn’t mean outcomes are similarr at 3, 6, and 9 months. Perhaps, with physical therapy, they could reach their one year achievement levels even earlier!

    • Alan Goodman said:

      Hi Douglas:

      My surgeon told me I will never be able to go rock climbing (I never wanted to anyway).
      I completely agree with your comments.

      Thanks,

      Alan G

    • Marilyn Pink. said:

      What a great research idea you two! Use the DASH to compare outcomes in this population with and w/o PT at 3, 6, 9, 12 and 24 months!! Run with it!

      I am proceeding with a study on scapular symmetry/asymmetry pre op in rTSA’s and TSA’s — your idea would be a terrific complement to our profession.

      Another question I have is what is ‘normal’ for scapula motion in the population of rTSAs??? As you will see in next week’s post (Alan at 10 weeks post-op) there is a video — take a look at his scapula motion. I wonder what ‘normal’ should be for him.

      I also noticed that since the surgery, his scapular asymmetry is not quite as pronounced – but your opinion on that would be appreciated as well.

      AND, it is obvious on his Left side (non-op side) he also has some scapular winging — and probably some less obvious rc problems there.

      Thoughts?
      Marilyn

  2. Matthew Himsey, PT, DPT, SCS said:

    I just started reading through the case study. I’m not sure whether or not it’ll continue, but I’d love to get involved with everyone. Thanks for all the information on rTSA’s. I’ve worked with only a couple over my short career. Looking forward to more interaction!

  3. Suzi Johnson PT, MPT, OCS said:

    I see inverse TSA and start them with aquatic PT. They tend to do very well and the environment is controlled and ideal to start working on scapualar stabilization since the arm is supported.I have seen Dr. Itamura’s TSA and other surgeries in the pool as well.

    • Hi Suzi:

      I’m obviously very interested in aquatic PT for rTSA rehab that you
      mentioned in your blog response. Do you have any info., references,
      procedures etc. that I might take a look at?
      Thx for your comments.

      Alan G

  4. Spondylogenic causes of muscle weakness can be a facilitated segment (chronic segmental irritation, for example hypermobility) and patterned inhibition (forward head posture or acquired segmental instability). e.g., fusion or laminectomy?
    These will cause weakness in the spinal and limb musculature.
    Spinal muscle weakness of a facilitated segment is segmental and unilateral.
    Segmental instability is initially segmental and bilateral effecting the deepest muscle layers, multisegmental and regional.
    In the limbs a facilitated segment initially the key muscles become hypertonic and strong resisting stretch then, eventually hypertonic, weak and wasted. Rotator cuff tear?
    The segmental instability usually starts bilaterally and rapidly spreads from regional to global muscle inhibition involving abdominal and pelvic weakness.LBP?
    Bottomline: core strengthening of neck and pelvis. The Stabilizer, pressure bio-feedback works well with the deep cervical flexors. I have been dry needling the mutifidus and following up using the needle as an electrode for intramusculature stimulation for neck and lumbar. Good luck.

  5. David Poulter PT said:

    Thanks for another opportunity to comment on this case.

    I am lucky to work with two great surgeons who perform this surgery on a regular basis.

    Here is a link to Dr Freehill and Dr McCarty’s post op protocol.

    http://www.sportsandortho.com/_dnld/Reverse%20Total%20Shoulder%20Replacement.pdf

    I have had great success with all the Total reverse shoulders patients from these surgeons.(12-15 over the last two years) Patients normally regain 120-140 deg of forward elevation, 120-130 of abducton.
    The main limitation is ER due to lack of a cuff, playing the piano can be difficult. IR behind the back is always functional for dressing.

    Scapula retraction can be started at 6 weeks post op in a safe manner by getting the patient to clasp their hands under or on their belly, this prevents them using their shoulder joint (ER humerus) to drive scapula retraction. With the hands clasped patients have to use their scap retractors, to sqeeze their shoulder bades together and down. I offer gentle facilitation to the movement, and tap the retractors gently to facilitate contraction. I instruct the patients to imgine they are trying to squeeze thier shoudler blades together and down into their back pockets

    Gentle codmans are initiated at 5 weeks post op, and AAROm with a cane in Flexion, ab, ad ER to neutral at 6 weeks. (see protocol above)

    For those interested in viewing the reverse total shoulder procedure here is a link to a youtube video showing the full surgery : http://www.youtube.com/watch?v=QqjR54pBNrg

    Kind regards,

    David Poulter PT Minnesota.

    • Marilyn Pink said:

      Thanks for the link to the Rehab Protocal, David! That is super. Can you help us out by giving us a description of what Scapular stabilization exercises #1 – 7 are???

      Thanks Again!
      Marilyn

  6. Leon Richard said:

    My experience with the procedure is somewhat limited and I appreciate the exposure here.

  7. Excellent Information!

  8. Marilyn Pink said:

    Hey Paule –

    Thanks again for your your great input in so many areas!

    Just wanted to let you know that as a member of EDUCATA, which you are, you CAN get those articles. Just login at http://www.educata.com and go to the library — those 7 articles are there for you (free – you don’t have to go hunt them down).

    humm – neuropaediatrics – that is interesting —— I’m noodling on that!

    Marilyn

    • Ms Pink,

      My apologies for the delay in answering your comment.
      Thank you for the link to the EDUCATA library which I have finally consulted and yet not have the time to read the many interesting articles written by other healthcare professionals. I have also noticed that you have contributed several times to the healthcare litterature. You may tend to consider quite correctly so that your experitize is in sport (you certainly do know your expertize much better than I), yet what I am trying to write is this. If I refer to your “swimming” article in athlete and the excellent details given about biomechanics, I could also write without a doubt that the article mentioned is also an excellent reference for all areas of healthcare as the biomechanics of the shoulder remains. There may be many other professions in which the shoulder movements use similar AROM and therefore are at risk of similar lesions. For example, construction building workers or even farmers do use similar range of motions, not only as the swimmers more so, those do not work in a gravity assist (in water) environment as would the swimmers.
      In Belgium, there is a name reference for shoulder treatments, whether those injuries are consequences of sport or average repetitive movements or accidental. The name reference is “Mr Sohier” who developped a system of motions which is often used in shoulder rehabilitation as to avoid the friction of tendons sub acromial. There are many courses for PTs or OTs and if I am correct the “Sohier” system of mobilisation was described and established several years before the expansion of other manipulative courses such as Mc Kenzie and al, for the shoulder, each with their own emphasis and specificities. In the same way as Bobath’s Neurodevelopmental treatment apporach gave rise to other in depth NDT approaches, whether these be Peto or Ms Jean Ayres which have become well established approaches around the world and for excellent reasons and with maybe more specific emphasis on particular sub areas within NDT. Often times, in treatment and no matter how well trained, educated and aware the therapists are, they use more than one specific approach. I have often seen this and practiced when appropriate a integrated approach, it is for the patients benefits anyway.

      Thank you again, for this blog and a complex shoulder case. Thank you for the link to the library to EDUCATA.
      Excellent day and week to you.

      Paule Morbois

  9. Honestly, my own practical knowledge is in neuropaediatrics. So if I were the PT for this particular patient with the knowledge of anatomy and the surgery this patient has received, here is what I would PROFESSIONALLY do:

    Consult other PTs and OTs about their own knowledge of such clinical case and share my own thoughts on the treatment I would provide.
    Being honest about the PT’s own limitations (knowledge of practice) is an excellent place to begin with, mine in this case.
    Then there are the articles provided by you Ms Pink, which I would in real life try to find and read. Other PTs and OTs expertise and results is another great place to know.

    As all treatments begin there would be ASSESSMENT of PROM and AROM of the upper limbs (the involved UE and the non involved UE).
    General assessment of the patient stance as well as gait pattern (look for coping mechanisms in the overall body).
    Passive mobilisation of involved UE
    Active mobilisation of involved UE
    Hydrotherapy in the very early PT sessions might help mobilisation (actively assisted)
    Exercises which will gradually improve shoulder stability and mobility.
    Consider keeping a sling to support the shoulder joint between the PT session so as not impose stress on the shoulder joint where muscles are still too weak unless grade 3 on muscle chart is already present.
    Provide advices on resting positioning of UE involved.
    Ask the patient how he comes to the PT sessions and discourage him from driving until the shoulder involved is more functionel.
    Ask the patient when he goes back for check up with his surgeon.

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