10/1/2007. Philosophy. Pune Shoulder Rehabilitation Programme (PSRP) 9 th Annual TRAC meeting, Budapest. Principles -I. Design. Study-I.

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1 Dr. Ashish Babhulkar D.Orth., DNB(Orth.), MCh.Orth.(Liverpool,UK.),FRCS(Tr. & Orth.) Shoulder & Joint Replacement Surgeon Pune, India Pune Shoulder Rehabilitation Programme (PSRP) Philosophy Design an accelerated rehab programme Predictable time frame Sans NSAIDs / Modality / Steroid injections For Conservative Rx & Post Operation Patients Restoring Biomechanics Success due to clinical skills in id key factors & recruitment of correct patients 9 th Annual TRAC meeting, Budapest Define the causal pathway PSRP is designed to ensure complete patient compliance and simultaneously, provide optimal rehabilitation in the minimum time interval Design Inclusion All ages Shoulder pain & Stiffness Without structural tear 2 weeks Phase I 4 weeks Home Progr. No Modalities SOS NSAIDs No Steroids Exclusion Diabetes Rheumatoid Arthritis Cervical Myelopathy or radiculopathy Principles -I Scapular strengthening Cuff Strengthening Posture Correction All CKCE, Eccentric strengthening, Low resistance, high h repetition subimpingement i range Stretches Ant/Post/Inf capsule In 90/90 Proprioception Core strengthening Dynamic Functional movement patterns Methods Study-I Phase I 2 weeks supervised Trained Shoulder Physiotherapist About Half an Hour session Occasionally twice a day for 10 days UCLA scores before & after phase I Phase II 4 week Home Programme UCLA score 6 weeks Sports at 6 weeks if (for non surgical Pts.) UCLA 32/35 Cuff strong O'Brien Neg 90/90 IR equal to opp. side >800 patients in study over 4 years Prospectively studied UCLA scores Before & after Detailed data on all patients Potential Daily 60 patients over two weeks at three centres 1

Steroid injections For Conservative Rx & Post Operation Patients Restoring Biomechanics Success due to clinical skills in id key factors & recruitment of correct patients 9 th Annual TRAC meeting,

2 Sample of Last 50 patients No.s Ave UCLA UCLA score Day Zero Six weeks Patient Satisfaction Will you repeat PSRP? 2% 8% 90% Yes No Maybe Limitations & Variables Diverse conditions Varied time of presentation Degree of pain Degree of stiffness Co morbid factors Cuff status (DM) CRPS Core strength Assoc. Tennis Elbow, Cx Spond, LBA Compliance (2% poor compliance) Scapular Muscle strengthening Serratus & Rhomboids Also Lower Traps, Levator Scapulo-Thoracic Rhythm Proprioception/Dissociation techniques Why Scapula? Stable base Optimal position of glenoid Lateralized position - anterior instability If rotation reduced impingement Maintains length-tension relationship DiGiovine 1992,Wilk 1999 Scapular Theraband Workout Rotator Cuff Theraband Technique 2

Tennis Elbow, Cx Spond, LBA Compliance (2% poor compliance) Scapular Muscle strengthening Serratus & Rhomboids Also Lower Traps, Levator Scapulo-Thoracic Rhythm Proprioception/Dissociation techniques

3 Dynamic Functional Therabands Stretching: 1) Anterior Capsule To improve external rotation. 2) Inferior Capsule In forward flexion and abduction. 3) Posterior Capsule In forward flexion adduction across the body; Adduction internal rotation behind the back. Posture Correction Pec Minor stretches 3

3) Posterior Capsule In forward flexion adduction across the body;

4 Theraband Advantage Strengthening Exercises Advantage of Closed Kinetic Chain Exercises: Minimize joint shear force. Reduce humeral head translation. Increase true compressive force (approximation). Increase proprioceptive and afferent stimulation. Facilitate multiple joint co-contraction muscle activation pattern. Wilk 1996 J Sport rehab Adjunct Severe cuff tendinoses Full Can active assisted GIRD vis-à-vis SLAP & Internal Impingement IR stretches 90/90 Address Subscap fatigue Krishnan & Hawkins, Bigliani, Brown 1988, Johnson 1992, Wilk 1993 MDI Dissociation, scapular setting Acute Calcific Tendinopathy USG guided Needling PSRP principally believes that theraband training must begin after improved scapular control and recruitment of scapular muscles Complete supervision is of the utmost importance as compensation manoeuvres common Eccentric strengthening is also emphasized during rehabilitation, i.e., controlling return movement Red Flags Renewed or Increased pain ROM > Strength Strength > ROM Strength ISQ or deterioration in ROM No response to Physio in 1 week Operative / Non-op Core Stability Abdominals Back Extensors Hips Where e COG is Int. & Ext. Obliques Primary Trunk Stabiliser Transversus Lumbo Pelvis & Spine 4

Wilk 1996 J Sport rehab Adjunct Severe cuff tendinoses Full Can active assisted GIRD vis-à-vis SLAP & Internal Impingement IR stretches 90/90 Address Subscap fatigue Krishnan & Hawkins, Bigliani,

5 Core stability-before & After 2 wks What you search for could be where you least expect it MDI Poor proprioception Blasier 1994, Allegrucci 1995 Dynamic Stabilisation (Davies 1993)& Neuromuscular control Scapulothoracic stability Cocontraction of cuff NS 18yr Student Post injury 13mths Scapular Stabilizing Programme: (Scapular Proprioception Restoration/Scapular Setting) There are three main components of scapular stabilizing programme 1) Setting in Neutral. 2) Assisted Setting with Passive Control. 3) Dynamic Control/Dissociation. 5

com NS 18yr Student Post injury 13mths Scapular Stabilizing Programme: (Scapular Proprioception Restoration/Scapular Setting) There are

6 NS Post Rehab Conservative PSRP 44 year old Severe stiffness after throwing A stone at a dog After weeks of Only Physiotherapy 6

7 38 yr Colonel General Surgeon,Assam, Tennis Player 15 xs Dislocated Rt sho Post surgery Examples Arthroscopic Bankart Repair 4mths Post Arthroscopic Bankart Repair No immobilization Avoid heavy weights All ADLs except combing hair Rotator Cuff Repair Edith (Swede) 6 weeks Post Op No Immobilisation Avoid >90 deg Avoid ER >40 SLAP Repair 7

No immobilization Avoid heavy weights All ADLs except combing hair Rotator Cuff

8 62 year Italian 1 year of pain & suffering 3 months after surgery Shoulder Replacement 62 yr 100kg Diabetic Comminuted Posterior Fracture Dislocation 3 mths Post Op 8

9 6 Part Prox Humerus # 110kg Diabetic 10 wks Post op Start Rehab on 10 th post-op. day No restrictions CHL Release 48 yr Businessman - 5 yrs of stiff shoulder Research PSRP in Calcific Tendinoses after USG guided needling PSRP in Rx of Diabetic Stiff Shoulders PSRP results in Post op Cuff repair & Bankarts MDI & PSRP STUDY II 10 weeks post-op >250 patients Define causal pathways Metabolic profile combined with the PSRP Theraband programme 9

Tendinoses after USG guided needling PSRP in Rx of Diabetic Stiff Shoulders PSRP results in Post op Cuff

10 Conclusion No Absolutes in Rx Shoulder problems. Reliable, Reproducible Protocol Predictable recovery time frame Nil Modality / Expensive Equipment Can avoid Sx in MDI & subacromial decompression Can t have a magic recipe for success Good Clinical assessment Thank You! 10

Modality / Expensive Equipment Can avoid Sx in MDI & subacromial

Rehabilitation Guidelines for Anterior Shoulder Reconstruction with Arthroscopic Bankart Repair

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