Kate Dunn
DPT 751
July 12, 2010
- To understand the surgical procedure of a
rTSA
-To apply current evidence in the
development of an POC for rTSA
-To describe the overall physical therapy
management of a patient who underwent a
rTSA
-To incorporate complex impairments of an
individual with a rTSA that has PD
-TSA: for patients with
advanced GH joint
pathology (OA, RA, RCA)
-Hemiarthroplasty: for
patients with either
severe cuff pathology or
irreparable cuff1
-persistent pain and loss of
function despite
conservative
management1
-replacement of humeral
head
-Approved by the FDA in 20041
-Reverses the orientation of the
shoulder girdle
-Glenoid fossa > glenoid base plate & glenosphere
-Humeral head > humeral shaft & concave cup
- Increases deltoid moment arm to enhance the torque
- Enhanced mechanical advantage of deltoid compensates
for deficient RC
Drake GN, O’Connor DP, Edwards TB. Indications for reverse total shoulder arthroplasty in rotator cuff disease.
Clin Orthop Relat Res. 2010;468:1526-1533.
Indications1,3
Contraindications3
-GH joint arthritis
associated with
irreparable RCT
-Complex humeral
fracture
-Revision of failed
traditional TSA
-Absent RC
-Over the age of 70yrs
-Advanced glenoid
destruction
-Severe lesions of deltoid
-Axillary nerve palsy
-Patient with expectation
of high functional return
-Post-op complications3
-Hardware instability or dislocation (abd with ER)
-Nerve damage
-Infection
-Hematoma
-Intra-operative fracture
-Complication rates are 2-68%1
-What are some indications for a rTSA?
-GH joint arthritis with irreparable RC
-Revision of failed TSA or hemiarthroplasty
-Over the age of 70 years
-Who is not appropriate for a rTSA procedure?
-Glenoid destruction
-Deltoid that is not intact
-Patient wanting high functional return
-What is the most common surgical complication?
-hardware instability or dislocation
-76y/o female
-Referred to PT s/p right rTSA (05/14/10)
-Previous injury: fall 07/16/09
-Previous sx: RCR Sept 2009
-PMHx: Parkinson’s Disease (1997), CVA (1996), PAD,
breast cancer (R mastectomy), memory loss
-Social hx: retired, does not drive
-Parkinson’s
Disease: progressive degeneration of
dopamine cells & imbalance of neurotransmitters
in basal ganglia
-Body impairments: tremors, rigidity, akinesia, postural instability
-FORCE CONTROL (impaired amplitude of movement)
-Rotator Cuff Repair
-Sept 2009
-Repaired supraspinatus & infraspinatus
-Repair sites failed
-Arthritic changes of the humeral head
-Significant retraction of cuff musculature
Impression: irreparable pathology without
replacement
-General anesthesia with an interscalene block
-Subscapularis released
-No supraspinatus, biceps tendon, infraspinatus
attachments found
-Capsule released, labrum debrided circumferentially
-Completed 2.5wks post-op
-Subjective: right shoulder, elbow & hand pain
(5/10), N & T into fingers
-PIP’s: difficulty washing & combing hair, difficulty
with household chores, shoulder pain
-Patient goals: get back to doing basic household
chores, be able to move arm without pain
*On 1L of O2 at night
-Observation
-PROM
90° flex
-Rounded shoulders
60 ° abd
-FHP
11° ER
-Increased thoracic kyphosis
-5° elbow ext
-Reverse scapular rhythm
-Palpation
-Scar mildly adhered
-Tender over anterolateral
-Neuro Screen
incision & mid belly of
biceps
-Intact to LT bilaterally
-Quick DASH: 72%
-Postural instability
(0-100%, higher score
-B UE “pill rolling tremor”
indicates more disability)
-Jaw tremor
-Decreased facial
expressions
-Initial Hypothesis: Patient presents with decreased
ability to perform ADL’s and functional activities
secondary to decreased right shoulder ROM &
strength, increased shoulder pain, postural instability,
and bilateral UE rigidity & tone.
-APTA Guide Patterns
-4H: impaired joint mobility, motor function, muscle
performance, and ROM associated with joint
arthroplasty
-5E: impaired motor function & sensory integrity
associated with progressive disorders of the CNS
-Good to fair prognosis for return to (I)
functioning
-Progress may be limited by:
-Severity of PD (rigidity, tremors, postural
instability, akinesia)
-Previous shoulder surgery
-Age of patient @ time of current surgery
-Cognitive functioning
-Compliance with POC/ HEP
-Frequency: 3x/wk for 6 weeks to date (3x/wk for 10wks)
1- Pt education: precautions, sling use
2- Transfer & gait training
3- Joint/ soft tissue mobilizations
4- Ther-ex for ROM
5- Ther-ex for strengthening
6- Modalities for pain & edema management
-Things to remember:
-Only deltoid & teres minor are intact
-High risk for anterior/inferior subluxation
-Patient has difficulty with movement initiation &
amplitude of movement
-Avoid dual tasks (BG controls one, attention on the other)
-TSA: convex humeral head
moving on concave glenoid
fossa (opposite direction)
*superior rotation, inferior glide
-rTSA: concave humeral cup
moving on convex glenosphere
(same direction)
*superior rotation, superior glide
Boudreau S, et al. JOSPT 2007;37:734-743.
- Shoulder mechanics & function will have some
limitations when compared to unaffected
shoulder
- Establish appropriate functional & ROM
expectations
-Sling 4 weeks
-Potential for instability due to design
-No active IR or extension for 6 weeks1
-Pt must be able to visualize elbow while lying supine
(no hyperextension)
-No resisted IR or extension for 12 weeks
-No IR, adduction, extension (tucking in shirt) for 12 weeks
-STG: 5 weeks
1-MinA with
established HEP
2- Decrease in pain
by 50%
-LTG: 10 weeks
1- Able to wash &
comb hair with R UE
independently
2- R UE AROM within
75% of L UE AROM
3- Decreased QuickDASH by 50%
-Dislocation precautions for 12 weeks post-op
-no combined add/IR/ext (tucking in shirt)
-no GH joint extension beyond neutral
-Phase 1: Joint Protection
(day 1 to week 6)
-joint protection, PROM, edema/pain management
-PROM: flex 120°, ER to tolerance, IR <50°
-AROM & resisted exercises of involved elbow/wrist/hand
-Criteria to move to next phase:
-Pt tolerate PROM of shoulder
-Pt is able to isometrically activate each component of the
deltoid & scapular muscles
-Phase 2: AROM, Early Strength
(weeks 6-12)
-Gradual AROM, control pain & inflammation, re-establish
dynamic stability
-Begin AROM when gleno-humeral rhythm is restored
-Flex, abd, ER isotonic strengthening
-Criteria to move to next phase:
-Improving functional ability
-Pt is able to isotonically activate each component of the
deltoid & scapular muscles
-Phase 3: Moderate Strengthening (weeks 12-16)
-Enhance functional use, increase strength/power/
endurance
-Begin gentle resisted flexion/abduction (5+lbs) in
standing
-Phase 4: Independent HEP
(months 4+)
-3-4x/wk
-strength gains, return to functional/recreational activities
-Criteria for discharge:
-Pt is able to maintain pain-free AROM with proper
shoulder mechanics
-ROM: 80-120° of flexion, 30° of ER
140
130
120
110
100
90
80
70
60
50
40
30
20
10
0
Initial
4 weeks
6 weeks
Flex
Abd
ER
Pain (x/10)
-PIP’s
1- Difficulty washing & combing hair
2- Difficulty with household chores
3- Shoulder pain
-Non- PIP’s
1- Swinging arms during gait
2- Right arm strength
-STG: 5 weeks
1-MinA with established HEP
2- Decrease in pain by 50%
-LTG: 10 weeks
1- Able to wash & comb hair with R UE independently
2- R UE AROM within 75% of L UE AROM
3- Decreased Quick-DASH by 50%
(MCID=15pts)5
MET
MET
MET
?
?
72% > 52%
-Improvement in passive range of motion, pain scores, and functional
outcome scores
-Pt has met all STG, progressing towards LTG
-Pt is progressing consistently, but may reach plateau due to
comorbidities
-Primary focus needs to be on patient education and precautions, high
functional return is unlikely
-No setbacks in POC, compliance with HEP is questionable
-60 pts (mean age 70yrs) with glenohumeral arthritis associated with severe RC
deficiency treated with rTSA, followed for minimum of 2 yrs
-2 groups: previous RC repair, no previous surgery
-Intervention: PROM started day 2, sling worn for 4 weeks, AAROM began @
4wks, AROM started @ 8wks, resisted exercises @ 12wks
-All measures improved significantly (p<0.001)
-ASES increased 33.9pts
-VAS decreased 4.1pts
-ROM: flexion increased 50°, abduction 60°, ER 29°
-No significant difference between 2 groups in terms of demographic data,
preoperative scores, post-op VAS scores, ROM
-Device failed in 7 pts, requiring revision @ average of 21.4 months (insuffient
bone density, glenoid loosening)
-Results suggest that arthroplasty with rTSA may be a viable treatment for pts w/
GH arthritis & a massive RC tear, future studies need to determine the
longevity of the implant
-45 pts w/ rTSA
-21 massive & irreparable RCT associated with arthritis treated
-5 complex humeral fracture with arthritis
-19 failure of revision arthroplasty
-Mean follow-up was 40 months
-Outcomes: ROM , VAS pain scale, Constant functional score
-Intervention: sling for 6 weeks, pendulum exercises started day 2,
physical therapy @ wk 3, no abd @ 90° with ER
-Results: all groups showed significant increase in flexion by 66°, no
significant change in ER or IR
-rTSA can improve function and restore active flexion in patients with
cuff-deficient shoulders
-rTSA should not be offered to a young individual who wants a normal
shoulder or who will demand more out of the prosthesis that it was
designed to do
-15 TSA in patient’s with PD
-Mean follow-up: 5.3yrs
-Results: significant improvement
-Pain
-Poor functional results
-Duration of PD, rigidity, arm swing & rapid alternating movement scores
were not found to be significant predictive factors
-Increased failure rates of TSA in PD- increased muscle tone, severity of
tremor, increased mortality rate of 1.6 to 3x that of general population
-Increase in subluxation rates & associated complication- result of
increased tone of shoulder girdle musculature, difficulties w/ rehab,
stretching of RC-capsule arthrotomy site
-Similar results found by Kryzak, et al in 2009
-Enhance deltoid function in absence of RC
-Biofeedback: to assist pts in learning recruitment
strategies1
-PT started @ day 2 or 3rd week, no significant
difference in LT outcome
-LTG may be limited by severity of PD (tone,
rigidity, akinesia, dementia)
-Use rhythmic cues to increase cadence of activity
-Amplitude of movements: think BIG concept9
-HEP compliance issue: suggest 5x/wk for 20min1
THANK YOU!
1. Boudreau S, Boudreau E, Higgins LD, Wilcox RG. Rehabilitation following reverse total shoulder
arthroplasty. JOSPT 2007;37:734-743.
2. Drake GN, O’Connor DP, Edwards TB. Indications for reverse total shoulder arthroplasty in
rotator cuff disease. Clin Orthop Relat Res. 2010;468:1526-1533.
3. Volpe S, Craig JA. Postoperative physical therapy management of a reverse total shoulder
arthroplasty (rTSA). Ortho Practice. 2007;21:11-17.
4. Boileau P, Watkinson D, Hatz AM, Hovorka I. Neer Award 2005: The Grammont reverse shoulder
prosthesis: Results in cuff tear arthritis, fracture sequelae, and revision arthroplasty. J Shoulder
Elbow Surg. 2006;15:527-540.
5. Beaton DE, Katz JN, Fossell AH, et al. Measuring the whole or the parts? Validity, reliability and
responsiveness of the Disabilities of the Arm, Shoulder and Hand outcome measure in
difference regions of the upper extremity. J Hand Ther. 2001;14:128-146.
6. Frankle M, Siegal S, Pupello D, et al. The reverse shoulder prosthesis for glenohumeral arthritis
associated with severe rotator cuff deficiency. J Bone Joint Surg. 2005;87:1697-1704.
7. Koch LD, Cofield RH, Ahlskog JE. Total shoulder arthroplasty in patients with Parkinson’s
Disease. J Shoulder Elbow Surg. 1997;6:24-28.
8. Kryzak TJ, Sperling JW, Schleck CD, Cofield RH. Total shoulder arthroplasty in patients with
Parkinson’s Disease. J Shoulder Elbow Surg. 2009;18:96-99.
9. Farley BG, Koshland GF. Training BIG to move faster: the application of the speed- amplitude
relation as a rehabilitation strategy for people with Parkinson’s Disease. Exp Br Res
2005;167:462-467.