Pain-Free Equals a Home Run

Post-op and Beyond

Gall summarized the Brigham and Women’s Hospital (BWH) Department of Rehabilitation TSA protocol, which was developed in concert with surgeon Lawrence Higgins of BWH and the Boston Shoulder Institute. (See “Online Resources for Professionals” on p. 62 for a link to the protocol.) The four-phase, approximately 12-week program includes specific range-of-motion goals that must be met before the muscle strengthening begins. Rehabilitation protocols vary, but they “are only guides,” Gall reminded her audience. The most important concept is to tailor the protocol to individual patients’ progress and tolerance, she noted.

Cryotherapy, or ice, is started immediately after surgery and applied for one to two hours for the first 24 hours. Patients will be in a shoulder immobilizer, which is not sufficient to prevent shoulder extension in the supine position. A folded blanket, thicker pillow or rolled towel in between the arm and chest can maintain neutral shoulder alignment. Gall stressed communication with nursing staff on all shifts to make them aware of these positioning issues. “There’s nothing worse,” she said, “than having a person in agony the next morning because their arm was in extension and not protecting the anterior structure.”

Inpatient physical therapy usually includes passive forward flexion in the supine position (to tolerance), gentle external rotation in the scapular plane to around 30°, active exercises for distal extremities, and pendulum exercises done in the seated position. Patients will be released home or to a skilled nursing facility, depending on the amount of assistance they need. Before discharge, patients receive precautions: no driving, no lifting of heavy objects, no excessive stretching or sudden movements, and no active range of motion or motions behind the back. Gall also believes involvement of occupational therapists is very valuable to help patients negotiate their activities of daily living when they return home.