test-set.jsonl

{"id":"f3b12f70-f904-4209-8c64-216f1e55cd3c","question":"What are the key factors that influence the rate at which a patient can progress through the rotator cuff physical therapy program?","reference_answer":"The key factors that influence the rate at which a patient can progress through the rotator cuff physical therapy program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear.","reference_context":"Document 7: Visit per week:  2 to 3 times  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Advanced Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  2  4 WEEKS POST  OP (Maximum Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN)  2  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises  Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  4  6 WEEKS POST  OP (Moderate Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  3  7  12 WEEKS POST  OP: (Early Strengthening Phase)  GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  13  19 WEEKS POST  OP: (Late Strengthening Phase)  GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 weeks  Continue with throwing and racquet program if appropriate  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  20-24 WEEKS POST-OP: (Return to Sports or Full Activity)  GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control\n\nDocument 2: Visit per week:  2 to 3 times  Diagnosis:   LEFT or RIGHT Shoulder Arthroscopic Large Rotator Cuff Repair - Supraspinatus and Infraspinatus Repair - Subscapularis Repair  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Slow or Conservative Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  ** Weeks 0-3: Patient stays in the sling and abduction pillow at all times. Pendulums ok to start Week #3 (NO PAIN). NO Shoulder PROM. Elbow and wrist ROM is ok. **  4-6 WEEKS POST-OP (Maximum Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility  2 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Start Post Op Week #4 Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN), Pts with Subscapularis Repair: (Limit Passive ER to 20\u00b0)  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises and Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  6-8 WEEKS POST-OP (Moderate Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain  3 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  9-14 WEEKS POST-OP: (Early Strengthening Phase) GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  15-23 WEEKS POST-OP: (Late Strengthening Phase) GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 week. Continue with throwing program  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  24-26 WEEKS POST-OP: (Return to Sports or Full Activity) GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control\n\nDocument 6: PHYSICAL THERAPY PRESCRIPTION:  TOTAL SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: At all times except for showering and exercise. (Sleep in sofa recliner)  Total of 6 weeks in the Sling and the Abduction pillow  Exercises: Pendulums ok 2 weeks after surgery Passive ER to 10 degrees and extension to neutral  Passive supine FF in scapular plane to 130 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed  Advancement Criteria: ER the above set criteria FF in scapular plane to 130 Minimal pain and inflammation with motion and exercise Incision is well healed with no drainage and no redness  Weeks 6  10: Phase II  Sling Immobilizer: Discontinue at week 6  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER \u2013 limit 45 deg  2  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF to 150  ER to 45  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF 160, ER >45  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  3  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation\n\nDocument 8: PHYSICAL THERAPY PRESCRIPTION:  REVERSE SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: Please Transition out of the sling between 2 to 3 weeks after surgery (Sleep in sofa recliner with your sling for the first 2 weeks) for Primary Reverse Shoulder Replacement or 5 to 6 weeks for Fracture and Revision Reverse Shoulder Replacement.  2 Weeks  6 Weeks  Activities of Daily Living: You may use your arm and hand on the operative shoulder for your ADL activates 2 weeks after surgery. Pendulums are also encouraged 1 week after surgery.  Exercises: Passive ER to 20 degrees and extension to neutral, pendulums daily  Passive supine FF in scapular plane to 90 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed: ice  Advancement Criteria: ER to the above set criteria FF in scapular plane to 90 Minimal pain and inflammation with any motion or exercise Incision is well healed with no drainage or redness  2  Weeks 6  10: Phase II  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER as tolerated by the patient  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF > 120  ER > 30  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF > 120, ER >30  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  3  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation","conversation_history":[],"metadata":{"question_type":"simple","seed_document_id":7,"topic":"Others"}}
{"id":"6c479fd2-676b-4a35-b4d5-a35a276a2cd6","question":"What are the rehabilitation goals for the immediate post-op phase (0-3 weeks) after Ulnar Collateral Ligament Reconstruction?","reference_answer":"The rehabilitation goals for the immediate post-op phase (0-3 weeks) after Ulnar Collateral Ligament Reconstruction are to protect the healing tissue, reduce pain and inflammation, protect the graft site, and reduce muscle atrophy.","reference_context":"Document 1: Massachusetts General Brigham Sports Medicine  Rehabilitation Guidelines for Ulnar Collateral Ligament Reconstruction (Palmaris Longus Graft, Gracilis Graft)  This protocol is intended to guide clinicians through the post-operative course for Ulnar Collateral Ligament Reconstruction (Palmaris Longus Graft, Gracilis Graft). This protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs of the individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes contained within this guideline may vary based on surgeon\u2019s preference, additional procedures performed, and\/or complications. If a clinician requires assistance in the progression of a post-operative patient, they should consult with the referring surgeon.  The interventions included within this protocol are not intended to be an inclusive list of exercises. Therapeutic interventions should be included and modified based on the progress of the patient and under the discretion of the clinician.  Considerations for the Post-operative Many different factors influence the post-operative UCL reconstruction rehabilitation outcomes, including whether a palmaris longus or gracilis graft was performed and individual co-morbidities. It is recommended that clinicians collaborate closely with the referring physician.  If you develop a fever, excessive drainage from incision, severe heat and\/or redness along incision, uncontrolled pain, or any other symptoms that concern you please call your doctor.  PHASE I: IMMEDIATE POST-OP PHASE (0-3 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Protect healing tissue \u2022 Reduce pain and inflammation \u2022 Protect graft site \u2022 Reduce muscle atrophy Brace \u2022 Week 1 \u2013 Immobilized in Posterior splint at 90 degrees of Elbow Flexion \u2022 Week 2: Hinged Brace: 25-100 degrees \u2022 Week 3: Hinged brace: 15-115 degrees \u2022 Elbow Post-op compression dressing for 5-7 days \u2022 Palmaris Longus Graft \u2013 Wrist post-op compression for 5-7 days Precautions \u2022 Shoulder External rotation isometrics \u2022 Valgus stress to the Elbow Intervention  Manual therapy \u2022 Soft tissue mobilization, retrograde massage for swelling  Modalities  Ice and compression  Gripping Exercises: \u2022 Squeeze towel, putty or foam with varying types of grips  Isometrics  Performed with brace on  Day 1  Shoulder: Flexion, ABD, IR  Avoid External Rotation  Performed with arm at side, gently push against a wall or opposite hand - Elbow Flexion  Performed at 90 degrees elbow flexion \u2022 Day 7 - Elbow Extension  Performed at 90 degrees elbow flexion  Range of Motion \u2022 Wrist AROM - Flexion, - Extension - Radial deviation - Ulnar deviation \u2022 Thumb opposition \u2022 Elbow PROM - Flexion and extension - Performed to tolerance, making sure the elbow is staying relaxed. \u2022 Shoulder AROM - Performed with brace on - Full Can \u2022 Elbow AROM: Begin day 14 \u2022 Low load, long duration stretching: - Use when elbow extension range of motion is lacking - Supine with towel roll under distal humerus. - Add a light weight - Must be pain-free - Hold 10-15 minutes up to 4 times a day, totaling 60 minutes a day  Gracilis Graft \u2013 Knee ROM immediately post  op; Bike on week 3  Criteria to Progress \u2022 Elbow ROM: at least 15-115 degrees \u2022 At least 4\/5 elbow MMT scores  PHASE II: PROTECTION PHASE (4-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Gradual increase to full ROM by week 6 \u2022 Promote healing of repaired tissue \u2022 Regain and improve muscular strength \u2013 slow integration of exercises \u2022 Restore full function of graft site Brace \u2022 Week 4: 0-125 degrees \u2022 Week 5: 0-135 degrees \u2022 Week 6: 0-145 degrees \u2022 Discontinue use of brace at week 6 if achieved full ROM, unless walking in crowds or slippery surfaces Precautions \u2022 No valgus stress to the graft \u2022 No ER strengthening until week 6 \u2022 Gracilis graft \u2013 Do not initiate progressive resistive hamstring strengthening until week 6 Additional Intervention *Continue with Phase I interventions Manual therapy \u2022 Soft tissue and scar mobilization  Modalities \u2022 Continue with ice and compression  Range of Motion \u2022 Elbow PROM \u2013 Focus on restoration of full elbow extension  Strengthening \u2022 Wrist and forearm strengthening: - Curls\/Extensions \u2013 Start with 1 lb. - Pronation\/Supination \u2013 Start with dowel \u2022 Biceps curl \u2013 Begin with 1lb \u2022 Triceps Extension \u2022 Scapula stabilization: Start at 1 lb - Prone Row - Prone Shoulder horizontal abduction - Prone Shoulder extension \u2022 Resistance band - Low rows - Shoulder internal rotation (at side) \u2022 Standing scaption (start with 1lb, do not exceed 10 lbs.) Criteria to Progress \u2022 Full Range of Motion \u2022 At least 70% of strength of wrist and shoulder of uninvolved arm \u2013 HHD, MMT or isokinetic testing \u2022 Good tolerance to all exercises with no pain  PHASE III: STRENGTHENING PHASE (6-12 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Increase strength\/endurance\/power \u2022 Maintain full elbow ROM especially extension Precautions \u2022 No Throwing \u2022 No valgus stress to the elbow Additional Intervention *Continue with Phase I-II Interventions Manual Therapy: \u2022 Soft tissue mobilizations as needed  Range of motion  Elbow PROM as needed  Maintain full elbow extension  Strengthening \u2022 Gracilis graft: Begin slow progression of hamstring strengthening \u2022 Forearm strengthening: - Emphasis on flexion and pronation \u2022 Elbow Strengthening: - Eccentric flexion and extension - Varied resistance and speed of contractions - (start slow build to fast) \u2022 Thrower\u2019s 10 program: Begin at week 6 - Initiate Advanced Thrower\u2019s 10 at Week 8 \u2013 as appropriate \u2022 UBE \u2022 Rows \u2022 Lat pull down \u2022 PNF exercises - Rhythmic stabilization\/manual resistance: (side-lying ER and diagonals)  Criteria to Progress \u2022 Maintain full pain-free ROM \u2022 At least 85% strength of uninvolved arm \u2013 HHD, or isokinetic testing \u2022 Good tolerance to all exercises with no pain  PHASE IV: ADVANCED STRENGTHENING PHASE (12-16 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Progress power\/endurance \u2022 Normalize shoulder\/forearm strength  Initiate plyometric exercises  Gradually initiate sports\/functional exercises Precautions  No Throwing  No valgus stress to elbow Additional Intervention  Continue with Phase II  III interventions as appropriate Strengthening  Advanced throwers ten program  Body blade \u2013 ER\/IR, push\/pull  Seated bench press  Supine dumbbell bench press  Begin a hitting program (if applicable to sport)  Initiate week 12  Plyometric Program \u2022 Week 12: - 2-handed drills only: 6-8 lbs. (emphasis on full extension) \u2022 Chest pass \u2022 Side throw close to body \u2022 Week 14: - 2 hands away from body \u2022 Side to side throws \u2022 Soccer throws \u2022 Side throws - Begin 1-arm plyometrics \u2022 1-handed stationary \u2022 Wall dribble: 1-2lb. medicine ball \u2022 Baseball throws into wall \u2022 Rhythmic stabilization in scapular plane with medicine ball on wall Criteria to Progress \u2022 Full, painless elbow\/wrist ROM \u2022 Shoulder total ROM within 5\u00b0 of non-throwing shoulder \u2022 > 40\u00b0 horizontal adduction of throwing shoulder \u2022 < 15\u00b0 Glenohumeral IR deficit \u2022 Elbow, shoulder and wrist strength with MMT, HHD or isokinetic: - ER\/IR ratio: 72-76% - ER\/ABD ratio: 68-73% - Throwing shoulder IR: > 115% of non-throwing shoulder - Throwing shoulder ER: > 95% of non-throwing shoulder - Elbow flexion\/extension: 100-115% of non-throwing shoulder - Wrist flexion\/extension: 100-115% of non-throwing shoulder \u2022 Functional test Scores: - Prone Drop ball test \u2013 110% of non-throwing side - 1-arm balls against wall @ 90\/90: \u2022 2lb ball \u2022 30 seconds with no pain \u2022 115% of throwing side - Single arm step down test: \u2022 8-inch \u2022 30 seconds \u2022 Satisfactory score on Kerlan-Jobe Orthopedic Clinic shoulder and elbow score (KJOC) throwers assessment. \u2022 Physician Clearance  PHASE V: EARLY RETURN TO SPORT - UNRESTRICTED RETURN TO SPORT (16+ WEEKS AFTER SURGERY)  Rehabilitation Goals \u2022 Increase strength, power and endurance \u2022 Safely initiate sport specific training program \u2022 Safely progress to full sport.  Additional Intervention *Continue with Phase II-IV interventions \u2022 Interval Throwing Program: 16 weeks after surgery \u2013 unless indicated otherwise by surgeon \u2022 ***Refer to return-to-sport protocol\/throwing protocol for further detail  Criteria to Progress \u2022 Last stage, no additional criteria Revised 6\/2021  Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol  References: 1. Biz C, Crim\u00ec A, Belluzzi E, et al. Conservative Versus Surgical Management of Elbow Medial Ulnar Collateral Ligament Injury: A Systematic Review. Orthopaedic Surgery. 2019;11(6):974-984. doi:10.1111\/os.12571 2. Ellenbecker TS, Wilk KE, Altchek DW, Andrews JR. Current concepts in rehabilitation following ulnar collateral ligament reconstruction. Sports Health. 2009;1(4):301-313. 3. Evans JP, Smith CD, Fine NF, et al. Clinical Rating systems in elbow research \u2013 a systematic review exploring trends and distributions of use. Journal of Shoulder and Elbow Surgery. 2018;25:98-106. 4. Glogovac G, Kakazu R, Aretakis AC, Grawe BM. Return to Sport and Sports-Specific outcomes following Ulnar Collateral Ligament reconstruction in adolescent athletes: A Systematic review. HSS Journal. 2019;16:242-249. Doi: 10.1007\/s11420-019-09689-9. 5. Hodgins JL, Vitale M, Arons RR, Ahmad CS. Epidemiology of Medial Ulnar Collateral Ligament Reconstruction. The American Journal of Sports Medicine. 2016;44(3):729-734. doi:10.1177\/0363546515622407 6. Lightsey HM, Trofa DP, Sonnenfeld JJ, et al. Rehabilitation variability after elbow Ulnar Collateral ligament reconstruction. The Orthopedic Journal of Sports medicine. 2019;7(3): 1-7. Doi: 10.1177\/2325967119833363. 7. Olds M, Coulter C, Marrant D, Uhl T. Reliability of a shoulder arm return to sport test battery. Physical Therapy in Sport. 2019;39:16-22. 8. Peters SD, Bullock GS, Goode AP, Garrigues GE, Ruch DS, Reiman MP.  The success of return to sport after ulnar collateral ligament injury in baseball: a systematic review and meta-analysis. Journal of Shoulder and Elbow Surgery. 2018;27(3):561-571. doi:10.1016\/j.jse.2017.12.003 9. Saper M, Shung J, Pearce S, Bompadre V, Andrews JR. Outcomes and Return to Sport after Ulnar Collateral ligament reconstruction in adolescent baseball players. The Orthopedic Journal of Sports Medicine. 2018;6(4):1-7. Doi: 10.1177\/2325967118769328. 10. Wilk KE, Arrigo CA, Dugas JR, Cain EL, Andrews JR. Rehabilitation and Return-to-Play Criteria Following Ulnar Collateral Ligament Reconstruction. Operative Techniques in Sports Medicine. 2017;25(3):154-171. doi:10.1053\/j.otsm.2017.07.004 11. Wilk KE, Arrigo CA, Arrigo RJ. Rehabilitation following UCL repair with Internal Brace. Orthopedics and Sports Medicine. 2019;3(1): 212-217. Doi: 10.32474\/OSMOAJ.2019.03.000151.","conversation_history":[],"metadata":{"question_type":"simple","seed_document_id":1,"topic":"Others"}}
{"id":"12171ead-3541-4468-b29c-62e5ba2ef193","question":"What is the recommended frequency of visits per week for the physical therapy prescription for a rotator cuff repair?","reference_answer":"The recommended frequency of visits per week for the physical therapy prescription for a rotator cuff repair is 2 to 3 times.","reference_context":"Document 2: Visit per week:  2 to 3 times  Diagnosis:   LEFT or RIGHT Shoulder Arthroscopic Large Rotator Cuff Repair - Supraspinatus and Infraspinatus Repair - Subscapularis Repair  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Slow or Conservative Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  ** Weeks 0-3: Patient stays in the sling and abduction pillow at all times. Pendulums ok to start Week #3 (NO PAIN). NO Shoulder PROM. Elbow and wrist ROM is ok. **  4-6 WEEKS POST-OP (Maximum Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility  2 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Start Post Op Week #4 Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN), Pts with Subscapularis Repair: (Limit Passive ER to 20\u00b0)  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises and Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  6-8 WEEKS POST-OP (Moderate Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain  3 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  9-14 WEEKS POST-OP: (Early Strengthening Phase) GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  15-23 WEEKS POST-OP: (Late Strengthening Phase) GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 week. Continue with throwing program  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  24-26 WEEKS POST-OP: (Return to Sports or Full Activity) GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control\n\nDocument 7: Visit per week:  2 to 3 times  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Advanced Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  2  4 WEEKS POST  OP (Maximum Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN)  2  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises  Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  4  6 WEEKS POST  OP (Moderate Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  3  7  12 WEEKS POST  OP: (Early Strengthening Phase)  GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  13  19 WEEKS POST  OP: (Late Strengthening Phase)  GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 weeks  Continue with throwing and racquet program if appropriate  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  20-24 WEEKS POST-OP: (Return to Sports or Full Activity)  GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control\n\nDocument 6: PHYSICAL THERAPY PRESCRIPTION:  TOTAL SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: At all times except for showering and exercise. (Sleep in sofa recliner)  Total of 6 weeks in the Sling and the Abduction pillow  Exercises: Pendulums ok 2 weeks after surgery Passive ER to 10 degrees and extension to neutral  Passive supine FF in scapular plane to 130 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed  Advancement Criteria: ER the above set criteria FF in scapular plane to 130 Minimal pain and inflammation with motion and exercise Incision is well healed with no drainage and no redness  Weeks 6  10: Phase II  Sling Immobilizer: Discontinue at week 6  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER \u2013 limit 45 deg  2  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF to 150  ER to 45  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF 160, ER >45  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  3  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation\n\nDocument 8: PHYSICAL THERAPY PRESCRIPTION:  REVERSE SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: Please Transition out of the sling between 2 to 3 weeks after surgery (Sleep in sofa recliner with your sling for the first 2 weeks) for Primary Reverse Shoulder Replacement or 5 to 6 weeks for Fracture and Revision Reverse Shoulder Replacement.  2 Weeks  6 Weeks  Activities of Daily Living: You may use your arm and hand on the operative shoulder for your ADL activates 2 weeks after surgery. Pendulums are also encouraged 1 week after surgery.  Exercises: Passive ER to 20 degrees and extension to neutral, pendulums daily  Passive supine FF in scapular plane to 90 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed: ice  Advancement Criteria: ER to the above set criteria FF in scapular plane to 90 Minimal pain and inflammation with any motion or exercise Incision is well healed with no drainage or redness  2  Weeks 6  10: Phase II  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER as tolerated by the patient  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF > 120  ER > 30  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF > 120, ER >30  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  3  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation","conversation_history":[],"metadata":{"question_type":"simple","seed_document_id":2,"topic":"Others"}}
{"id":"c9bdd86f-f5e0-4d38-9fe4-b095d824ad84","question":"What are the rehabilitation goals during the intermediate post-op phase (4-6 weeks after surgery) of a Total Shoulder Arthroplasty and Hemiarthroplasty?","reference_answer":"The rehabilitation goals during the intermediate post-op phase (4-6 weeks after surgery) of a Total Shoulder Arthroplasty and Hemiarthroplasty are to continue to protect surgical repair, reduce swelling, minimize pain, gradually increase shoulder PROM, minimize substitution patterns with AROM and AAROM, improve periscapular muscle activation\/strength, initiate RTC (external rotators) activation, and provide patient education.","reference_context":"Document 3: Rehabilitation Protocol for SLAP Repair-Type II  This protocol is intended to guide clinicians through the post-operative course for SLAP Repair-Type II. This protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs of the individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes contained within this guideline may vary based on surgeon\u2019s preference, additional procedures performed, and\/or complications. If a clinician requires assistance in the progression of a post-operative patient, they should consult with the referring surgeon.  The interventions included within this protocol are not intended to be an inclusive list. Therapeutic interventions should be included and modified based on the progress of the patient and under the discretion of the clinician.  Considerations for the Post-operative SLAP repair Rehabilitation Program Many different factors influence the post-operative SLAP repair rehabilitation outcome, including the type of SLAP lesion, the size of the tear\/number of anchors placed, concomitant procedures and amount of shoulder hypermobility and\/or hyperlaxity. Consider mechanism of injury as well as the sport the athlete would like to return to when initiating certain interventions.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: IMMEDIATE POST-OP (0-3 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Maintain UE ROM in elbow, hand and wrist \u2022 Gradually increase shoulder PROM \u2022 Minimize muscle inhibition \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM\/AAROM \u2022 No elbow AROM (avoid biceps contraction) \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 No reaching behind back Intervention Swelling Management \u2022 Ice, compression  Range of motion\/Mobility \u2022 PROM: ER<30 scapular plane, Forward elevation <90, full elbow flex and ext, seated GH flexion table slide, horizontal table slide (add hyperlink) \u2022 AROM: hand, wrist \u2022 AAROM: none  Strengthening (Week 2)  Periscapular: scap retraction  , prone scapular retraction  , standing scapular setting  , supported scapular setting, inferior glide, low row  to neutral; avoid shoulder extension  Rotator cuff: submaximal pain  free isometrics  Ball squeeze Criteria to Progress  90 degrees shoulder PROM forward elevation  30 degrees of shoulder PROM ER in the scapular plane  Full elbow PROM flexion and extension  Palpable muscle contraction felt in scapular and shoulder musculature  No complications with Phase I  PHASE II: INTERMEDIATE POST-OP (4-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Continue to protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM \u2022 Minimize substitution patterns with shoulder AAROM \u2022 Initiate motor control exercise \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM \u2022 No elbow AROM (avoid biceps contraction) \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 No reaching behind back Intervention *Continue with Phase I interventions  Range of motion\/Mobility \u2022 PROM: ER<45 scapular plane, Forward elevation <120 \u2022 AAROM: Active assistive shoulder flexion, shoulder flexion with cane, cane external rotation stretch, washcloth press, sidelying elevation to 90 degrees  Strengthening \u2022 Periscapular: Row on physioball*, shoulder extension on physioball*, serratus punches - *to neutral; avoid shoulder extension  Motor Control \u2022 Internal and external rotation in scaption and Flex 90-125 (rhythmic stabilization)  Stretching \u2022 Sidelying horizontal ADD, sleeper stretch Criteria to Progress \u2022 120 degrees shoulder PROM forward elevation \u2022 45 degrees shoulder PROM ER in scapular plane \u2022 Minimal substitution patterns with shoulder AAROM \u2022 Pain < 4\/10 \u2022 No complications with Phase II  PHASE III: INTERMEDIATE POST-OP CONT\u2019d (7-8 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM\/AAROM \u2022 Initiate shoulder and elbow AROM \u2022 Initiate RTC strengthening  Improve scapular muscle activation  Patient education Sling  Discontinue Precautions  No resisted elbow flexion  No lifting of heavy objects (>10 lbs) Intervention  Continue with Phase I  II interventions Range of motion\/Mobility  PROM: ER Full in scapular plane, \uf0a390 degrees ER in 90 degrees of abduction, IR Full in scapular plane, Forward elevation Full  do not push beyond 90 degrees ER in 90 degrees of abduction  AAROM: seated shoulder elevation with cane, seated incline table slides, ball roll on wall  AROM: supine flexion, salutes, supine punch, wall climbs, elbow flexion  Strengthening \u2022 Rotator cuff: side-lying external rotation, standing external rotation w\/ resistance band, standing internal rotation w\/ resistance band, internal  rotation, external rotation \u2022 Periscapular: Resistance band shoulder extension*, resistance band seated rows*, rowing*, lawn mowers, robbery - *to neutral; avoid shoulder extension \u2022 Elbow: Triceps  Motor Control \u2022 Quadruped alternating isometrics Criteria to Progress \u2022 Full pain-free shoulder PROM ER and forward elevation \u2022 Within 10 degrees of shoulder IR PROM of contralateral shoulder \u2022 Minimal substitution patterns with shoulder AROM \u2022 Pain < 4\/10  PHASE IV: TRANSITIONAL POST-OP (9-12 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue \u2022 Restore full shoulder PROM and AROM \u2022 Initiate resisted elbow flexion at 12 weeks \u2022 Improve dynamic shoulder stability \u2022 Progress periscapular strength \u2022 Gradually return to full functional activities Precautions \u2022 No lifting of heavy objects (> 10 lbs) Intervention *Continue with Phase II-III interventions Range of motion\/mobility \u2022 PROM: Full \u2022 AROM: Supine forward elevation with elastic resistance to 90 deg, scaption and shoulder flexion to 90  degrees elevation  Strengthening \u2022 Periscapular: Push-up plus on knees, prone shoulder extension Is*, resistance band forward punch, forward punch, tripod o *to neutral; avoid shoulder extension \u2022 Elbow (12 weeks): Biceps curl, resistance band bicep curls  Motor control  Ball stabilization on wall  Stretching \u2022 Hands behind head, IR behind back with towel, triceps and lats, doorway series Criteria to Progress \u2022 Full pain-free shoulder PROM and AROM \u2022 Minimal to no substitution patterns with shoulder AROM \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 Pain < 2\/10  PHASE V: LATE POST-OP (13-16 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free shoulder ROM \u2022 Enhance functional use of upper extremity Intervention *Continue with Phase II-IV interventions Strengthening \u2022 Rotator cuff: External rotation at 90 degrees, internal rotation at 90 degrees, resistance band standing external rotation at 90 degrees, resistance band standing internal rotation at 90 degrees \u2022 Periscapular: T and Y, \u201cT\u201d exercise, push-up plus knees extended, pointer, wall push up, \u201cW\u201d exercise, resistance band Ws, dynamic hug, resistance band dynamic hug  Motor Control \u2022  PNF \u2013 D1 diagonal lifts, PNF \u2013 D2 diagonal lifts, field goals , resistance band PNF pattern, PNF \u2013 D1 diagonal lifts w\/ resistance, diagonal-up, diagonal-down, wall slides w\/ resistance band Criteria to Progress \u2022 Clearance from MD and ALL milestone criteria below have been met \u2022 Full pain-free shoulder PROM and AROM \u2022 ER\/IR strength minimum 85% of the uninvolved arm \u2022 ER\/IR ratio 60% or higher \u2022 Negative impingement and instability signs \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 QuickDASH \u2022 PENN  PHASE VI: EARLY RETURN-TO-SPORT (4-6 MONTHS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free ROM \u2022 Continue strengthening and motor control exercises \u2022 Enhance functional use of upper extremity \u2022 Gradual return to strenuous work\/sport activity Intervention *Continue with Phase II-V interventions Strengthening \u2022 See specific return-to-sport\/throwing program (coordinate with physician) Criteria to Progress \u2022 Last stage-no additional criteria Return-to-Sport \u2022 For the recreational or competitive athlete, return-to-sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non-contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return-to-sport rehabilitation program. Revised 7\/2020  Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol  References:  1. Ahsan, ZS, Hsu JE, et al. The Snyder classification of superior labrum anterior and posterior (SLAP) lesions. Clin Orthop Relat Res. 2016. 474:2075- 2078.  2. Christopher ZR, Kennedy J, et al. Rehabilitation and return to play following superior labral anterior to posterior repair. Oper Tech Sports Med. 2017. 25:132-144.  3. Cools AM, Borms D, Cottens S, et al. Rehabilitation exercises for athletes with biceps disorders and SLAP lesions. AJSM. 2014. 42(6): 1315-1323.  4. Itoi E, Hatakeyama Y, et al. Position of immobilization after dislocation of the shoulder. JBJS. 1999. 81-A(3): 385-390.  5. Kibler, W.B., Sciascia, A. D., Uhl, T. L., et al. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. The American Journal of Sports Medicine. 2008. 36(9): p. 1789-1798.  6. Wilk KE, Reinold MM, et al. Current concepts in the recognition and treatment of superior labral (SLAP) lesions. JOSPT. 2005. 35(5): 273-291.\n\nDocument 5: Rehabilitation Protocol for Sternoclavicular Joint Reconstruction  This protocol is intended to guide clinicians through the post-operative course for sternoclavicular joint reconstruction. This protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs of the individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes contained within this guideline may vary based on surgeon\u2019s preference, additional procedures performed, and\/or complications. If a clinician requires assistance in the progression of a post-operative patient, they should consult with the referring surgeon.  The interventions included within this protocol are not intended to be an inclusive list of exercises. Therapeutic interventions should be included and modified based on the progress of the patient and under the discretion of the clinician.  Considerations for the Post-operative sternoclavicular joint reconstruction Many different factors influence the post-operative rehabilitation outcome, including surgical technique (ie. tendon autograft harvest for repair), degree of SC joint instability, concomitant soft tissue or bone injury\/repair, and individual patient factors including co-morbidities. It is recommended that patients meet all rehabilitation criteria in order to progress to the next phase and clinicians collaborate closely with the referring physician throughout the rehabilitation process.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: EARLY POST-OP (0-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Reduce pain and swelling of the operative shoulder \u2022 Maintain elbow, wrist and hand AROM \u2022 Patient education Sling\/precautions \u2022 Sling to be worn for 6 weeks (or as directed by surgeon) \u2022 Avoid PROM of the glenohumeral joint \u2022 Avoid scapular AROM (protraction, retraction, depression and elevation) as it may disrupt the repair and healing tissues \u2022 Avoid bearing weight through involved extremity \u2022 Avoid lifting any lifting with involved extremity \u2022 Avoid running and jumping due to impact forces upon landing that may aggravate healing tissues and bone Intervention \u2022 Cryotherapy as needed \u2022 AROM: cervical spine, elbow, wrist, hand \u2022 Hand gripping: ball squeeze \u2022 Cardiovascular exercise as tolerated: walking, stationary bike Criteria to Progress \u2022 Well controlled pain and swelling \u2022 Protect reconstruction site and autograft site (if applicable) \u2022 Maintain elbow, wrist and hand AROM  PHASE II: INTERMEDIATE POST-OP (6-12WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Activation of muscles responsible for stabilizing the scapulothoracic and glenohumeral joint \u2022 Gradually restore PROM, AAROM of the GH joint at 6-8 weeks \u2022 Gradually restore AROM of the scapulothoracic joint and glenohumeral joint at 8 weeks \u2022 Wean from sling (if still wearing) \u2022 Begin shoulder and scapular strengthening at 8 weeks \u2022 Begin proprioception and neuromuscular control training \u2022 Identify and correct postural dysfunction as indicated Sling\/precautions \u2022 Avoid repetitive overhead activities \u2022 No lifting > 5 pounds with involved extremity until 9 weeks post-op \u2022 Post-rehabilitation soreness should resolve within 12-24 hours Additional Interventions *Continue with Phase I interventions \u2022 AROM in all cardinal plane assessing scapular rhythm \u2022 Gentle glenohumeral mobilization as indicated  Strengthening: \u2022 Rotator cuff strengthening in non-provocative positions (generally 0-45 degrees Scaption\/abduction): scaption raises against gravity, Sidelying ER, lightly resisted ER\/IR with theraband, isometrics \u2022 Scapular strengthening and dynamic neuromuscular control: low row, straight arm pulldowns, serratus punch, resisted T\u2019s  Stretching: Gentle corner or doorway pec stretch \u2022 Postural endurance exercises: scapular retractions, chin tucks \u2022 Walking, stationary bike, Stairmaster Criteria to Progress \u2022 Full AROM of the operative shoulder \u2022 Normal (5\/5) strength for glenohumeral flexion\/abduction\/IR\/ER degrees abduction  PHASE III: LATE POST-OP AND GRADUAL RETURN TO SPORT(13+ WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Restore normal (5\/5) rotator cuff strength at 90 degrees abduction including supraspinatus \u2022 Full multi-planar AROM with minimal to no substitution patterns \u2022 Advance proprioceptive and dynamic neuromuscular control training \u2022 Identify and correct postural dysfunction with sport\/work specific tasks as indicated \u2022 Develop strength and control movements required for sport\/work Sling\/ precautions \u2022 Post-rehabilitation soreness should resolve within 12 hours \u2022 No lifting restrictions at ~4 months Additional Interventions *Continue with Phase I-II Interventions \u2022 Glenohumeral mobilizations as indicated \u2022 Multiplane AROM with gradual increase in velocity of movement  Strengthening: \u2022 Rotator cuff strengthening at 45 degrees progressing to 90 degrees abduction and sport\/work specific positions as well as other provocative positions: resisted IR\/ER, elevation with ER, resisted scaption raises, facepulls\/resisted W\u2019s \u2022 Scapular strengthening and dynamic neuromuscular control in overhead or sport\/work positions: prone or resisted I\u2019s, T\u2019s and Y\u2019s, lower trap setting at wall, manual perturbations in varying degrees in elevation, serratus wall slides\/roll ups, wall pushups, quadruped shoulder taps \u2022 Core strengthening  Stretching:  Corner or doorway pec stretch, Gentle posterior capsule stretch (across body)  Walking, stationary bike, Stairmaster, return to running\/jumping as tolerated  Begin education in sport specific biomechanics with initial program for throwing, swimming, or overhead racquet sports Criteria to Return to Sport  Clearance from MD and ALL milestone criteria have been met  Maintains pain  free PROM and AROM  Performs all exercises demonstrating symmetric scapular mechanics  QuickDASH  PENN  For the recreational or competitive athlete, return  to  sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non  contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return  to  sport rehabilitation program.  Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol References: 1. Logan C, Shahien A, Altintas B, Millett PJ. Rehabilitation following sternoclavicular joint reconstruction for persistent instability. International Journal of Sports Physical Therapy. 2018;13(4):752-762. doi:10.26603\/ijspt20180752 2. Petri, M., Greenspoon, J. A., Horan, M. P., Martetschl\u00e4ger, F., Warth, R. J., & Millett, P. J. (2016). Clinical outcomes after autograft reconstruction for sternoclavicular joint instability. Journal of Shoulder and Elbow Surgery, 25(3), 435\u2013441. https:\/\/doi.org\/10.1016\/j.jse.2015.08.004 3. Garcia JA, Arguello AM, Momaya AM, Ponce BA. Sternoclavicular Joint Instability: Symptoms, Diagnosis And Management. Orthop Res Rev. 2020 Jul 28;12:75-87. doi: 10.2147\/ORR.S170964. PMID: 32801951; PMCID: PMC7395708.\n\nDocument 4: Rehabilitation Protocol for Total Shoulder Arthroplasty and Hemiarthroplasty  This protocol is intended to guide clinicians and patients through the post-operative course after a total shoulder arthroplasty (TSA) and hemiarthroplasty. Specific interventions should be based on the needs of the individual and should consider exam findings and clinical decision making. If you have questions, contact the referring physician.  Considerations for the Total Shoulder Arthroplasty and Hemiarthroplasty Rehabilitation Program Many different factors influence the post-operative rehabilitation outcome, including surgical approach, concomitant repair of the rotator cuff, arthroplasty secondary to fracture, arthroplasty secondary to rheumatoid arthritis or osteonecrosis, and individual patient factors including co-morbidities. It is recommended that patients meet all rehabilitation criteria in order to progress to the next phase and clinicians collaborate closely with the referring physician throughout the rehabilitation process.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: IMMEDIATE POST-OP (0-3 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Maintain UE ROM in elbow, hand and wrist \u2022 Gradually increase shoulder PROM \u2022 Minimize muscle inhibition \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM \u2022 No reaching behind back, especially in to internal rotation \u2022 No excessive shoulder external rotation or abduction \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 Place small pillow\/towel roll under elbow while lying on back to avoid shoulder hyperextension Intervention Swelling Management \u2022 Ice, compression Range of motion\/Mobility \u2022 PROM: ER <\/= 30 degrees in the scapular plane, IR to belt line in scapular plane, Flex\/Scaption to tolerance, ABD <\/= 90 degrees, pendulums, seated GH flexion table slide, seated horizontal table slide \u2022 AAROM: Active assistive shoulder flexion \u2022 AROM: elbow, hand, wrist Strengthening (Week 2) \u2022 Periscapular: scap retraction, prone scapular retraction, standing scapular setting, supported scapular setting, inferior glide, low row \u2022 Ball squeeze Criteria to Progress \u2022 >\/= 50% shoulder PROM flex, scaption as compared to contralateral side \u2022 <\/= 90 degrees of shoulder ABD PROM \u2022 <\/= 30 degrees of shoulder ER PROM in scapular plane \u2022 >\/= 70 degrees of IR PROM in scapular plane  Palpable muscle contraction felt in scapular musculature  Pain < 4\/10  No complications with Phase I  PHASE II: INTERMEDIATE POST-OP (4-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Continue to protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM \u2022 Minimize substitution patterns with AROM and AAROM \u2022 Improve periscapular muscle activation\/strength \u2022 Initiate RTC (external rotators) activation \u2022 Patient education Sling \u2022 Use at night while sleeping \u2022 Gradually start weaning sling over the next two weeks during the day Precautions \u2022 No excessive shoulder external rotation or abduction \u2022 No lifting of objects heavier than a coffee cup \u2022 No supporting of body weight with hands \u2022 Place small pillow\/towel roll under elbow while lying on back to avoid shoulder hyperextension Intervention *Continue with Phase I interventions  Range of motion\/Mobility \u2022 PROM: Full with exception of ER <\/= 30 degrees in scapular plane and <\/= 90 degrees ABD \u2022 AAROM: shoulder flexion with cane, cane external rotation stretch, washcloth press, seated shoulder elevation with cane \u2022 AROM: supine flexion, salutes, supine punch Strengthening \u2022 Rotator cuff: external rotation isometrics \u2022 Periscapular: Row on physioball, serratus punches \u2022 Elbow: Biceps curl, resistance band bicep curls and triceps Motor control \u2022 ER in scaption and Flex 90-125 (rhythmic stabilization) Stretching \u2022 Sidelying horizontal ADD Criteria to Progress \u2022 >\/=75% shoulder PROM flex, scaption, as compared to contralateral side \u2022 >\/=75% shoulder PROM IR in scapular plane as compared to contralateral side \u2022 30 degrees of shoulder PROM ER in scapular plane \u2022 90 degrees of shoulder PROM ABD \u2022 Minimal substitution patterns with AAROM \u2022 AROM shoulder elevation to 100 degrees with minimal substitution patterns \u2022 Pain < 4\/10 \u2022 No complications with Phase II  PHASE III: INTERMEDIATE POST-OP CONTD (7-8 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue (especially the anterior capsule) \u2022 Minimize pain \u2022 Maintain PROM \u2022 Improve AROM \u2022 Progress periscapular and RTC strength \u2022 Return to full functional activities \u2022 Patient education Sling \u2022 Discontinue Precautions \u2022 No lifting of heavy objects (>10 lbs) Intervention *Continue with Phase I-II interventions Range of motion\/Mobility \u2022 Full ROM in all planes \u2022 AAROM: incline table slides, ball roll on wall, wall climbs, pulleys \u2022 AROM: seated scaption, seated flexion, supine forward elevation with elastic resistance to 90 deg  Strengthening \u2022 Rotator cuff: internal rotation isometrics, side-lying external rotation, \u2022 Standing external rotation w\/ resistance band, standing internal rotation w\/ resistance band, internal  rotation, external rotation, \u2022 Periscapular: Resistance band shoulder extension, resistance band seated rows, rowing, lawn mowers, robbery Motor control \u2022 IR\/ER and Flex 90-125 (rhythmic stabilization) \u2022 Quadruped alternating isometrics and ball stabilization on wall \u2022 PNF-D1 diagonal lifts, PNF-D2 diagonal lifts Stretching \u2022 IR behind back with towel, sidelying horizontal ADD, sleeper stretch, triceps and lats Criteria to Progress \u2022 Minimal to no substitution patterns with shoulder AROM \u2022 Pain < 4\/10  PHASE IV: TRANSITIONAL POST-OP (9-11 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue (especially the anterior capsule) \u2022 Maintain pain-free PROM \u2022 Continue improving AROM \u2022 Improve dynamic shoulder stability \u2022 Gradually restore shoulder strength and endurance Precautions \u2022 No lifting of heavy objects (> 10 lbs) \u2022 Avoid exercises that put stress on the anterior shoulder capsule (ie: shoulder ER above 80 degrees of ABD) Intervention *Continue with Phase II-III interventions Range of motion\/mobility \u2022 Full ROM in all planes Strengthening \u2022 Rotator cuff: increase resistance rotator cuff exercise \u2022 Periscapular: Push-up plus on knees, \u201cW\u201d exercise, resistance band Ws, dynamic hug, resistance band dynamic hug, prone shoulder extension Is, resistance band forward punch, forward punch, tripod, pointer Motor control \u2022 Resistance band PNF pattern, PNF \u2013 D1 diagonal lifts w\/ resistance, diagonal-up, diagonal-down Wall slides w\/ resistance band Criteria to Progress \u2022 Supine AROM Flex >\/=140 degrees \u2022 Supine AROM ABD >\/=120 degrees \u2022 Supine AROM ER in scapular plane >\/= 60 degrees \u2022 Supine AROM IR in scapular plane >\/= 70 degrees \u2022 AROM shoulder elevation to 120 degrees with minimal substitution patterns \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 Pain < 2\/10  PHASE V: ADVANCED STRENGTHENING POST-OP (12-16 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free ROM \u2022 Improve shoulder strength and endurance \u2022 Enhance functional use of upper extremity  Intervention *Continue with Phase II-IV interventions Strengthening \u2022 Rotator cuff:  External rotation at 90 degrees, internal rotation at 90 degrees, resistance band standing external rotation at 90 degrees, resistance band standing internal rotation at 90 degrees \u2022 Periscapular: T and Y, \u201cT\u201d exercise, push-up plus knees extended, wall push up Motor Control \u2022 Progress ball stabilization on wall to overhead alternating isometrics\/rhythmic stabilization  Criteria to Progress \u2022 Clearance from MD and ALL milestone criteria have been met \u2022 Maintains pain-free PROM and AROM \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 QuickDASH \u2022 PENN Return-to-Sport \u2022 For the recreational or competitive athlete, return-to-sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non-contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return-to-sport rehabilitation program.  Revised December 2018 Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol  References  Angst, F, Goldhahn, J, et al. Responsiveness of six outcome assessment instruments in total shoulder arthroplasty. Arthritis & Rheumatism. 2008. 59 (3): 391-398.  Garcia, GH, Liu, JN, et al. High satisfaction and return to sports after total shoulder arthroplasty in patients aged 55 years and younger. AJSM. 2017. 45 (7): 1664-1669.  Gaunt BW, McCluskey GM, Uhl TL. An electromyographic evaluation of subdividing active-assistive shoulder elevation exercises. Sports Health. 2010. 2 (5): 424-432.  Hughes, M, Neer II, CS. Glenohumeral joint replacement and postoperative rehabilitation. Physical Therapy. 1975. 55(8): 850-858.  Kibler, W.B., Sciascia, A. D., Uhl, T. L., et al. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. The American Journal of Sports Medicine. 2008. 36(9): p. 1789-1798.  Knesek M, Brunfeldt, A, et al. Patterns of strain and the determination of the safe arc of motion after subscapularis repair-a biomechanical study. Journal of Orthopaedic Research. 2016. 34: 518-524.  Piasecki, DP, Nicholson, GP. Tears of the subscapularis tendon in athletes-diagnosis and repair techniques. Clin Sports Med. 2008. 27: 731-745.  Uhl TL, Muir TA, et al. Electromyographical assessment of passive, active assistive, and active shoulder rehabilitation exercises. PM R. 2010. 2: 132-141.  Wilcox III R.B., Arslanian L.E., Millett P.J. Rehabilitation following total shoulder arthroplasty. JOSPT. 2005. 35 (12): 821-837  Wolff. AL, Rosenzweig, L. Anatomical and biomechanical framework for shoulder arthroplasty rehabilitation. Journal of Hand Therapy. 2017. 30: 167-174.  Wright, T, Easley, T, et al. Shoulder arthroplasty and its effect on strain in the subscapularis muscle. Clinical Biomechanics. 2015. 30: 373-376.  Zarkadas P.C., Throckmorton T., et al. Patient reported activities after shoulder replacement: total and hemiarthroplasty. J Shoulder Elbow Surg. 2011. 20: 273-280.  Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med. 1996;(6):602-608.  Leggin BG, Michener, LA, et al. The Penn Shoulder Score: reliability and validity. JOSPT. 36 (3): 138-151.","conversation_history":[],"metadata":{"question_type":"simple","seed_document_id":3,"topic":"Others"}}
{"id":"38332bb7-9901-483a-8ccc-72591d5aca8c","question":"What are the criteria for moving from the 'Moderate Protection Phase' to the 'Early Strengthening Phase' in a slow or conservative program for left or right shoulder arthroscopic large rotator cuff repair?","reference_answer":"The criteria for advancement from the 'Moderate Protection Phase' to the 'Early Strengthening Phase' include the ability to activate cuff and deltoid without pain, toleration of the arm out of the sling, and a range of motion 80% or greater for elevation in the plane of the scapula and external rotation.","reference_context":"Document 7: Visit per week:  2 to 3 times  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Advanced Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  2  4 WEEKS POST  OP (Maximum Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN)  2  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises  Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  4  6 WEEKS POST  OP (Moderate Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  3  7  12 WEEKS POST  OP: (Early Strengthening Phase)  GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  13  19 WEEKS POST  OP: (Late Strengthening Phase)  GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 weeks  Continue with throwing and racquet program if appropriate  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  20-24 WEEKS POST-OP: (Return to Sports or Full Activity)  GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control\n\nDocument 2: Visit per week:  2 to 3 times  Diagnosis:   LEFT or RIGHT Shoulder Arthroscopic Large Rotator Cuff Repair - Supraspinatus and Infraspinatus Repair - Subscapularis Repair  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Slow or Conservative Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  ** Weeks 0-3: Patient stays in the sling and abduction pillow at all times. Pendulums ok to start Week #3 (NO PAIN). NO Shoulder PROM. Elbow and wrist ROM is ok. **  4-6 WEEKS POST-OP (Maximum Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility  2 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Start Post Op Week #4 Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN), Pts with Subscapularis Repair: (Limit Passive ER to 20\u00b0)  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises and Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  6-8 WEEKS POST-OP (Moderate Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain  3 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  9-14 WEEKS POST-OP: (Early Strengthening Phase) GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  15-23 WEEKS POST-OP: (Late Strengthening Phase) GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 week. Continue with throwing program  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  24-26 WEEKS POST-OP: (Return to Sports or Full Activity) GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control\n\nDocument 6: PHYSICAL THERAPY PRESCRIPTION:  TOTAL SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: At all times except for showering and exercise. (Sleep in sofa recliner)  Total of 6 weeks in the Sling and the Abduction pillow  Exercises: Pendulums ok 2 weeks after surgery Passive ER to 10 degrees and extension to neutral  Passive supine FF in scapular plane to 130 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed  Advancement Criteria: ER the above set criteria FF in scapular plane to 130 Minimal pain and inflammation with motion and exercise Incision is well healed with no drainage and no redness  Weeks 6  10: Phase II  Sling Immobilizer: Discontinue at week 6  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER \u2013 limit 45 deg  2  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF to 150  ER to 45  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF 160, ER >45  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  3  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation\n\nDocument 8: PHYSICAL THERAPY PRESCRIPTION:  REVERSE SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: Please Transition out of the sling between 2 to 3 weeks after surgery (Sleep in sofa recliner with your sling for the first 2 weeks) for Primary Reverse Shoulder Replacement or 5 to 6 weeks for Fracture and Revision Reverse Shoulder Replacement.  2 Weeks  6 Weeks  Activities of Daily Living: You may use your arm and hand on the operative shoulder for your ADL activates 2 weeks after surgery. Pendulums are also encouraged 1 week after surgery.  Exercises: Passive ER to 20 degrees and extension to neutral, pendulums daily  Passive supine FF in scapular plane to 90 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed: ice  Advancement Criteria: ER to the above set criteria FF in scapular plane to 90 Minimal pain and inflammation with any motion or exercise Incision is well healed with no drainage or redness  2  Weeks 6  10: Phase II  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER as tolerated by the patient  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF > 120  ER > 30  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF > 120, ER >30  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  3  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation","conversation_history":[],"metadata":{"question_type":"simple","seed_document_id":7,"topic":"Others"}}
{"id":"2c19364b-853f-4bcd-b9bc-54078b06547e","question":"What is the minimum criteria for advancement to the next phase in the 4-6 weeks post-op phase of the left or right shoulder arthroscopic large rotator cuff repair therapy?","reference_answer":"The minimum criteria for advancement to the next phase include normal scapular mobility, full active range of motion distal to the shoulder, and shoulder range of motion to within surgeon\u2019s set range of motion goals.","reference_context":"Document 7: Visit per week:  2 to 3 times  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Advanced Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  2  4 WEEKS POST  OP (Maximum Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN)  2  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises  Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  4  6 WEEKS POST  OP (Moderate Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  3  7  12 WEEKS POST  OP: (Early Strengthening Phase)  GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  13  19 WEEKS POST  OP: (Late Strengthening Phase)  GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 weeks  Continue with throwing and racquet program if appropriate  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  20-24 WEEKS POST-OP: (Return to Sports or Full Activity)  GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control\n\nDocument 2: Visit per week:  2 to 3 times  Diagnosis:   LEFT or RIGHT Shoulder Arthroscopic Large Rotator Cuff Repair - Supraspinatus and Infraspinatus Repair - Subscapularis Repair  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Slow or Conservative Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  ** Weeks 0-3: Patient stays in the sling and abduction pillow at all times. Pendulums ok to start Week #3 (NO PAIN). NO Shoulder PROM. Elbow and wrist ROM is ok. **  4-6 WEEKS POST-OP (Maximum Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility  2 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Start Post Op Week #4 Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN), Pts with Subscapularis Repair: (Limit Passive ER to 20\u00b0)  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises and Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  6-8 WEEKS POST-OP (Moderate Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain  3 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  9-14 WEEKS POST-OP: (Early Strengthening Phase) GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  15-23 WEEKS POST-OP: (Late Strengthening Phase) GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 week. Continue with throwing program  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  24-26 WEEKS POST-OP: (Return to Sports or Full Activity) GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control\n\nDocument 6: PHYSICAL THERAPY PRESCRIPTION:  TOTAL SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: At all times except for showering and exercise. (Sleep in sofa recliner)  Total of 6 weeks in the Sling and the Abduction pillow  Exercises: Pendulums ok 2 weeks after surgery Passive ER to 10 degrees and extension to neutral  Passive supine FF in scapular plane to 130 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed  Advancement Criteria: ER the above set criteria FF in scapular plane to 130 Minimal pain and inflammation with motion and exercise Incision is well healed with no drainage and no redness  Weeks 6  10: Phase II  Sling Immobilizer: Discontinue at week 6  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER \u2013 limit 45 deg  2  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF to 150  ER to 45  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF 160, ER >45  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  3  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation\n\nDocument 8: PHYSICAL THERAPY PRESCRIPTION:  REVERSE SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: Please Transition out of the sling between 2 to 3 weeks after surgery (Sleep in sofa recliner with your sling for the first 2 weeks) for Primary Reverse Shoulder Replacement or 5 to 6 weeks for Fracture and Revision Reverse Shoulder Replacement.  2 Weeks  6 Weeks  Activities of Daily Living: You may use your arm and hand on the operative shoulder for your ADL activates 2 weeks after surgery. Pendulums are also encouraged 1 week after surgery.  Exercises: Passive ER to 20 degrees and extension to neutral, pendulums daily  Passive supine FF in scapular plane to 90 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed: ice  Advancement Criteria: ER to the above set criteria FF in scapular plane to 90 Minimal pain and inflammation with any motion or exercise Incision is well healed with no drainage or redness  2  Weeks 6  10: Phase II  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER as tolerated by the patient  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF > 120  ER > 30  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF > 120, ER >30  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  3  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation","conversation_history":[],"metadata":{"question_type":"simple","seed_document_id":7,"topic":"Others"}}
{"id":"564d206f-0ee9-4c96-a8ba-5b9974a9334b","question":"What is the goal of the Maximum Protection Phase in the Slow or Conservative Program for Large Rotator Cuff Repair?","reference_answer":"The goals of the Maximum Protection Phase (4-6 weeks post-op) in the Slow or Conservative Program for Large Rotator Cuff Repair are to protect the surgical repair, decrease pain and inflammation, gradually increase shoulder Range of Motion (ROM) as directed by the doctor, improve proximal (scapula) and distal strength and mobility, and achieve independence in a home exercise program.","reference_context":"Document 6: PHYSICAL THERAPY PRESCRIPTION:  TOTAL SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: At all times except for showering and exercise. (Sleep in sofa recliner)  Total of 6 weeks in the Sling and the Abduction pillow  Exercises: Pendulums ok 2 weeks after surgery Passive ER to 10 degrees and extension to neutral  Passive supine FF in scapular plane to 130 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed  Advancement Criteria: ER the above set criteria FF in scapular plane to 130 Minimal pain and inflammation with motion and exercise Incision is well healed with no drainage and no redness  Weeks 6  10: Phase II  Sling Immobilizer: Discontinue at week 6  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER \u2013 limit 45 deg  2  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF to 150  ER to 45  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF 160, ER >45  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  3  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation\n\nDocument 8: PHYSICAL THERAPY PRESCRIPTION:  REVERSE SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: Please Transition out of the sling between 2 to 3 weeks after surgery (Sleep in sofa recliner with your sling for the first 2 weeks) for Primary Reverse Shoulder Replacement or 5 to 6 weeks for Fracture and Revision Reverse Shoulder Replacement.  2 Weeks  6 Weeks  Activities of Daily Living: You may use your arm and hand on the operative shoulder for your ADL activates 2 weeks after surgery. Pendulums are also encouraged 1 week after surgery.  Exercises: Passive ER to 20 degrees and extension to neutral, pendulums daily  Passive supine FF in scapular plane to 90 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed: ice  Advancement Criteria: ER to the above set criteria FF in scapular plane to 90 Minimal pain and inflammation with any motion or exercise Incision is well healed with no drainage or redness  2  Weeks 6  10: Phase II  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER as tolerated by the patient  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF > 120  ER > 30  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF > 120, ER >30  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  3  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation\n\nDocument 7: Visit per week:  2 to 3 times  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Advanced Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  2  4 WEEKS POST  OP (Maximum Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN)  2  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises  Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  4  6 WEEKS POST  OP (Moderate Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  3  7  12 WEEKS POST  OP: (Early Strengthening Phase)  GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  13  19 WEEKS POST  OP: (Late Strengthening Phase)  GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 weeks  Continue with throwing and racquet program if appropriate  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  20-24 WEEKS POST-OP: (Return to Sports or Full Activity)  GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control\n\nDocument 2: Visit per week:  2 to 3 times  Diagnosis:   LEFT or RIGHT Shoulder Arthroscopic Large Rotator Cuff Repair - Supraspinatus and Infraspinatus Repair - Subscapularis Repair  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Slow or Conservative Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  ** Weeks 0-3: Patient stays in the sling and abduction pillow at all times. Pendulums ok to start Week #3 (NO PAIN). NO Shoulder PROM. Elbow and wrist ROM is ok. **  4-6 WEEKS POST-OP (Maximum Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility  2 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Start Post Op Week #4 Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN), Pts with Subscapularis Repair: (Limit Passive ER to 20\u00b0)  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises and Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  6-8 WEEKS POST-OP (Moderate Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain  3 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  9-14 WEEKS POST-OP: (Early Strengthening Phase) GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  15-23 WEEKS POST-OP: (Late Strengthening Phase) GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 week. Continue with throwing program  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  24-26 WEEKS POST-OP: (Return to Sports or Full Activity) GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control","conversation_history":[],"metadata":{"question_type":"simple","seed_document_id":6,"topic":"Others"}}
{"id":"7f5e0a85-fa2d-4400-bb61-359c611b7a9e","question":"What are the specific conditions that need to be met in order for a patient to progress to the next stage from the 4-6 weeks post-op maximum protection phase in the slow or conservative program for rotator cuff physical therapy?","reference_answer":"The minimum criteria for advancement to the next phase are: 1. Normal scapular mobility, 2. Full active ROM distal to shoulder, 3. Shoulder ROM to within surgeon\u2019s set ROM goals.","reference_context":"Document 7: Visit per week:  2 to 3 times  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Advanced Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  2  4 WEEKS POST  OP (Maximum Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN)  2  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises  Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  4  6 WEEKS POST  OP (Moderate Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  3  7  12 WEEKS POST  OP: (Early Strengthening Phase)  GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  13  19 WEEKS POST  OP: (Late Strengthening Phase)  GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 weeks  Continue with throwing and racquet program if appropriate  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  20-24 WEEKS POST-OP: (Return to Sports or Full Activity)  GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control\n\nDocument 2: Visit per week:  2 to 3 times  Diagnosis:   LEFT or RIGHT Shoulder Arthroscopic Large Rotator Cuff Repair - Supraspinatus and Infraspinatus Repair - Subscapularis Repair  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Slow or Conservative Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  ** Weeks 0-3: Patient stays in the sling and abduction pillow at all times. Pendulums ok to start Week #3 (NO PAIN). NO Shoulder PROM. Elbow and wrist ROM is ok. **  4-6 WEEKS POST-OP (Maximum Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility  2 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Start Post Op Week #4 Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN), Pts with Subscapularis Repair: (Limit Passive ER to 20\u00b0)  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises and Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  6-8 WEEKS POST-OP (Moderate Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain  3 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  9-14 WEEKS POST-OP: (Early Strengthening Phase) GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  15-23 WEEKS POST-OP: (Late Strengthening Phase) GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 week. Continue with throwing program  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  24-26 WEEKS POST-OP: (Return to Sports or Full Activity) GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control\n\nDocument 6: PHYSICAL THERAPY PRESCRIPTION:  TOTAL SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: At all times except for showering and exercise. (Sleep in sofa recliner)  Total of 6 weeks in the Sling and the Abduction pillow  Exercises: Pendulums ok 2 weeks after surgery Passive ER to 10 degrees and extension to neutral  Passive supine FF in scapular plane to 130 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed  Advancement Criteria: ER the above set criteria FF in scapular plane to 130 Minimal pain and inflammation with motion and exercise Incision is well healed with no drainage and no redness  Weeks 6  10: Phase II  Sling Immobilizer: Discontinue at week 6  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER \u2013 limit 45 deg  2  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF to 150  ER to 45  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF 160, ER >45  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  3  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation\n\nDocument 8: PHYSICAL THERAPY PRESCRIPTION:  REVERSE SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: Please Transition out of the sling between 2 to 3 weeks after surgery (Sleep in sofa recliner with your sling for the first 2 weeks) for Primary Reverse Shoulder Replacement or 5 to 6 weeks for Fracture and Revision Reverse Shoulder Replacement.  2 Weeks  6 Weeks  Activities of Daily Living: You may use your arm and hand on the operative shoulder for your ADL activates 2 weeks after surgery. Pendulums are also encouraged 1 week after surgery.  Exercises: Passive ER to 20 degrees and extension to neutral, pendulums daily  Passive supine FF in scapular plane to 90 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed: ice  Advancement Criteria: ER to the above set criteria FF in scapular plane to 90 Minimal pain and inflammation with any motion or exercise Incision is well healed with no drainage or redness  2  Weeks 6  10: Phase II  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER as tolerated by the patient  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF > 120  ER > 30  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF > 120, ER >30  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  3  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation","conversation_history":[],"metadata":{"question_type":"complex","seed_document_id":7,"topic":"Others"}}
{"id":"e3467a3c-f380-45d1-8bbc-66bf02ac59bb","question":"In the context of the Rehabilitation Protocol for SLAP Repair-Type II, what are the specific objectives to be achieved during the intermediate post-operative stage, which spans from the 4th to the 6th week after surgery?","reference_answer":"The rehabilitation goals for the intermediate post-op phase (4-6 weeks after surgery) in the Rehabilitation Protocol for SLAP Repair-Type II are to continue to protect the surgical repair, reduce swelling, minimize pain, gradually increase shoulder PROM, minimize substitution patterns with shoulder AAROM, initiate motor control exercise, and provide patient education.","reference_context":"Document 4: Rehabilitation Protocol for Total Shoulder Arthroplasty and Hemiarthroplasty  This protocol is intended to guide clinicians and patients through the post-operative course after a total shoulder arthroplasty (TSA) and hemiarthroplasty. Specific interventions should be based on the needs of the individual and should consider exam findings and clinical decision making. If you have questions, contact the referring physician.  Considerations for the Total Shoulder Arthroplasty and Hemiarthroplasty Rehabilitation Program Many different factors influence the post-operative rehabilitation outcome, including surgical approach, concomitant repair of the rotator cuff, arthroplasty secondary to fracture, arthroplasty secondary to rheumatoid arthritis or osteonecrosis, and individual patient factors including co-morbidities. It is recommended that patients meet all rehabilitation criteria in order to progress to the next phase and clinicians collaborate closely with the referring physician throughout the rehabilitation process.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: IMMEDIATE POST-OP (0-3 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Maintain UE ROM in elbow, hand and wrist \u2022 Gradually increase shoulder PROM \u2022 Minimize muscle inhibition \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM \u2022 No reaching behind back, especially in to internal rotation \u2022 No excessive shoulder external rotation or abduction \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 Place small pillow\/towel roll under elbow while lying on back to avoid shoulder hyperextension Intervention Swelling Management \u2022 Ice, compression Range of motion\/Mobility \u2022 PROM: ER <\/= 30 degrees in the scapular plane, IR to belt line in scapular plane, Flex\/Scaption to tolerance, ABD <\/= 90 degrees, pendulums, seated GH flexion table slide, seated horizontal table slide \u2022 AAROM: Active assistive shoulder flexion \u2022 AROM: elbow, hand, wrist Strengthening (Week 2) \u2022 Periscapular: scap retraction, prone scapular retraction, standing scapular setting, supported scapular setting, inferior glide, low row \u2022 Ball squeeze Criteria to Progress \u2022 >\/= 50% shoulder PROM flex, scaption as compared to contralateral side \u2022 <\/= 90 degrees of shoulder ABD PROM \u2022 <\/= 30 degrees of shoulder ER PROM in scapular plane \u2022 >\/= 70 degrees of IR PROM in scapular plane  Palpable muscle contraction felt in scapular musculature  Pain < 4\/10  No complications with Phase I  PHASE II: INTERMEDIATE POST-OP (4-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Continue to protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM \u2022 Minimize substitution patterns with AROM and AAROM \u2022 Improve periscapular muscle activation\/strength \u2022 Initiate RTC (external rotators) activation \u2022 Patient education Sling \u2022 Use at night while sleeping \u2022 Gradually start weaning sling over the next two weeks during the day Precautions \u2022 No excessive shoulder external rotation or abduction \u2022 No lifting of objects heavier than a coffee cup \u2022 No supporting of body weight with hands \u2022 Place small pillow\/towel roll under elbow while lying on back to avoid shoulder hyperextension Intervention *Continue with Phase I interventions  Range of motion\/Mobility \u2022 PROM: Full with exception of ER <\/= 30 degrees in scapular plane and <\/= 90 degrees ABD \u2022 AAROM: shoulder flexion with cane, cane external rotation stretch, washcloth press, seated shoulder elevation with cane \u2022 AROM: supine flexion, salutes, supine punch Strengthening \u2022 Rotator cuff: external rotation isometrics \u2022 Periscapular: Row on physioball, serratus punches \u2022 Elbow: Biceps curl, resistance band bicep curls and triceps Motor control \u2022 ER in scaption and Flex 90-125 (rhythmic stabilization) Stretching \u2022 Sidelying horizontal ADD Criteria to Progress \u2022 >\/=75% shoulder PROM flex, scaption, as compared to contralateral side \u2022 >\/=75% shoulder PROM IR in scapular plane as compared to contralateral side \u2022 30 degrees of shoulder PROM ER in scapular plane \u2022 90 degrees of shoulder PROM ABD \u2022 Minimal substitution patterns with AAROM \u2022 AROM shoulder elevation to 100 degrees with minimal substitution patterns \u2022 Pain < 4\/10 \u2022 No complications with Phase II  PHASE III: INTERMEDIATE POST-OP CONTD (7-8 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue (especially the anterior capsule) \u2022 Minimize pain \u2022 Maintain PROM \u2022 Improve AROM \u2022 Progress periscapular and RTC strength \u2022 Return to full functional activities \u2022 Patient education Sling \u2022 Discontinue Precautions \u2022 No lifting of heavy objects (>10 lbs) Intervention *Continue with Phase I-II interventions Range of motion\/Mobility \u2022 Full ROM in all planes \u2022 AAROM: incline table slides, ball roll on wall, wall climbs, pulleys \u2022 AROM: seated scaption, seated flexion, supine forward elevation with elastic resistance to 90 deg  Strengthening \u2022 Rotator cuff: internal rotation isometrics, side-lying external rotation, \u2022 Standing external rotation w\/ resistance band, standing internal rotation w\/ resistance band, internal  rotation, external rotation, \u2022 Periscapular: Resistance band shoulder extension, resistance band seated rows, rowing, lawn mowers, robbery Motor control \u2022 IR\/ER and Flex 90-125 (rhythmic stabilization) \u2022 Quadruped alternating isometrics and ball stabilization on wall \u2022 PNF-D1 diagonal lifts, PNF-D2 diagonal lifts Stretching \u2022 IR behind back with towel, sidelying horizontal ADD, sleeper stretch, triceps and lats Criteria to Progress \u2022 Minimal to no substitution patterns with shoulder AROM \u2022 Pain < 4\/10  PHASE IV: TRANSITIONAL POST-OP (9-11 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue (especially the anterior capsule) \u2022 Maintain pain-free PROM \u2022 Continue improving AROM \u2022 Improve dynamic shoulder stability \u2022 Gradually restore shoulder strength and endurance Precautions \u2022 No lifting of heavy objects (> 10 lbs) \u2022 Avoid exercises that put stress on the anterior shoulder capsule (ie: shoulder ER above 80 degrees of ABD) Intervention *Continue with Phase II-III interventions Range of motion\/mobility \u2022 Full ROM in all planes Strengthening \u2022 Rotator cuff: increase resistance rotator cuff exercise \u2022 Periscapular: Push-up plus on knees, \u201cW\u201d exercise, resistance band Ws, dynamic hug, resistance band dynamic hug, prone shoulder extension Is, resistance band forward punch, forward punch, tripod, pointer Motor control \u2022 Resistance band PNF pattern, PNF \u2013 D1 diagonal lifts w\/ resistance, diagonal-up, diagonal-down Wall slides w\/ resistance band Criteria to Progress \u2022 Supine AROM Flex >\/=140 degrees \u2022 Supine AROM ABD >\/=120 degrees \u2022 Supine AROM ER in scapular plane >\/= 60 degrees \u2022 Supine AROM IR in scapular plane >\/= 70 degrees \u2022 AROM shoulder elevation to 120 degrees with minimal substitution patterns \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 Pain < 2\/10  PHASE V: ADVANCED STRENGTHENING POST-OP (12-16 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free ROM \u2022 Improve shoulder strength and endurance \u2022 Enhance functional use of upper extremity  Intervention *Continue with Phase II-IV interventions Strengthening \u2022 Rotator cuff:  External rotation at 90 degrees, internal rotation at 90 degrees, resistance band standing external rotation at 90 degrees, resistance band standing internal rotation at 90 degrees \u2022 Periscapular: T and Y, \u201cT\u201d exercise, push-up plus knees extended, wall push up Motor Control \u2022 Progress ball stabilization on wall to overhead alternating isometrics\/rhythmic stabilization  Criteria to Progress \u2022 Clearance from MD and ALL milestone criteria have been met \u2022 Maintains pain-free PROM and AROM \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 QuickDASH \u2022 PENN Return-to-Sport \u2022 For the recreational or competitive athlete, return-to-sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non-contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return-to-sport rehabilitation program.  Revised December 2018 Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol  References  Angst, F, Goldhahn, J, et al. Responsiveness of six outcome assessment instruments in total shoulder arthroplasty. Arthritis & Rheumatism. 2008. 59 (3): 391-398.  Garcia, GH, Liu, JN, et al. High satisfaction and return to sports after total shoulder arthroplasty in patients aged 55 years and younger. AJSM. 2017. 45 (7): 1664-1669.  Gaunt BW, McCluskey GM, Uhl TL. An electromyographic evaluation of subdividing active-assistive shoulder elevation exercises. Sports Health. 2010. 2 (5): 424-432.  Hughes, M, Neer II, CS. Glenohumeral joint replacement and postoperative rehabilitation. Physical Therapy. 1975. 55(8): 850-858.  Kibler, W.B., Sciascia, A. D., Uhl, T. L., et al. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. The American Journal of Sports Medicine. 2008. 36(9): p. 1789-1798.  Knesek M, Brunfeldt, A, et al. Patterns of strain and the determination of the safe arc of motion after subscapularis repair-a biomechanical study. Journal of Orthopaedic Research. 2016. 34: 518-524.  Piasecki, DP, Nicholson, GP. Tears of the subscapularis tendon in athletes-diagnosis and repair techniques. Clin Sports Med. 2008. 27: 731-745.  Uhl TL, Muir TA, et al. Electromyographical assessment of passive, active assistive, and active shoulder rehabilitation exercises. PM R. 2010. 2: 132-141.  Wilcox III R.B., Arslanian L.E., Millett P.J. Rehabilitation following total shoulder arthroplasty. JOSPT. 2005. 35 (12): 821-837  Wolff. AL, Rosenzweig, L. Anatomical and biomechanical framework for shoulder arthroplasty rehabilitation. Journal of Hand Therapy. 2017. 30: 167-174.  Wright, T, Easley, T, et al. Shoulder arthroplasty and its effect on strain in the subscapularis muscle. Clinical Biomechanics. 2015. 30: 373-376.  Zarkadas P.C., Throckmorton T., et al. Patient reported activities after shoulder replacement: total and hemiarthroplasty. J Shoulder Elbow Surg. 2011. 20: 273-280.  Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med. 1996;(6):602-608.  Leggin BG, Michener, LA, et al. The Penn Shoulder Score: reliability and validity. JOSPT. 36 (3): 138-151.\n\nDocument 5: Rehabilitation Protocol for Sternoclavicular Joint Reconstruction  This protocol is intended to guide clinicians through the post-operative course for sternoclavicular joint reconstruction. This protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs of the individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes contained within this guideline may vary based on surgeon\u2019s preference, additional procedures performed, and\/or complications. If a clinician requires assistance in the progression of a post-operative patient, they should consult with the referring surgeon.  The interventions included within this protocol are not intended to be an inclusive list of exercises. Therapeutic interventions should be included and modified based on the progress of the patient and under the discretion of the clinician.  Considerations for the Post-operative sternoclavicular joint reconstruction Many different factors influence the post-operative rehabilitation outcome, including surgical technique (ie. tendon autograft harvest for repair), degree of SC joint instability, concomitant soft tissue or bone injury\/repair, and individual patient factors including co-morbidities. It is recommended that patients meet all rehabilitation criteria in order to progress to the next phase and clinicians collaborate closely with the referring physician throughout the rehabilitation process.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: EARLY POST-OP (0-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Reduce pain and swelling of the operative shoulder \u2022 Maintain elbow, wrist and hand AROM \u2022 Patient education Sling\/precautions \u2022 Sling to be worn for 6 weeks (or as directed by surgeon) \u2022 Avoid PROM of the glenohumeral joint \u2022 Avoid scapular AROM (protraction, retraction, depression and elevation) as it may disrupt the repair and healing tissues \u2022 Avoid bearing weight through involved extremity \u2022 Avoid lifting any lifting with involved extremity \u2022 Avoid running and jumping due to impact forces upon landing that may aggravate healing tissues and bone Intervention \u2022 Cryotherapy as needed \u2022 AROM: cervical spine, elbow, wrist, hand \u2022 Hand gripping: ball squeeze \u2022 Cardiovascular exercise as tolerated: walking, stationary bike Criteria to Progress \u2022 Well controlled pain and swelling \u2022 Protect reconstruction site and autograft site (if applicable) \u2022 Maintain elbow, wrist and hand AROM  PHASE II: INTERMEDIATE POST-OP (6-12WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Activation of muscles responsible for stabilizing the scapulothoracic and glenohumeral joint \u2022 Gradually restore PROM, AAROM of the GH joint at 6-8 weeks \u2022 Gradually restore AROM of the scapulothoracic joint and glenohumeral joint at 8 weeks \u2022 Wean from sling (if still wearing) \u2022 Begin shoulder and scapular strengthening at 8 weeks \u2022 Begin proprioception and neuromuscular control training \u2022 Identify and correct postural dysfunction as indicated Sling\/precautions \u2022 Avoid repetitive overhead activities \u2022 No lifting > 5 pounds with involved extremity until 9 weeks post-op \u2022 Post-rehabilitation soreness should resolve within 12-24 hours Additional Interventions *Continue with Phase I interventions \u2022 AROM in all cardinal plane assessing scapular rhythm \u2022 Gentle glenohumeral mobilization as indicated  Strengthening: \u2022 Rotator cuff strengthening in non-provocative positions (generally 0-45 degrees Scaption\/abduction): scaption raises against gravity, Sidelying ER, lightly resisted ER\/IR with theraband, isometrics \u2022 Scapular strengthening and dynamic neuromuscular control: low row, straight arm pulldowns, serratus punch, resisted T\u2019s  Stretching: Gentle corner or doorway pec stretch \u2022 Postural endurance exercises: scapular retractions, chin tucks \u2022 Walking, stationary bike, Stairmaster Criteria to Progress \u2022 Full AROM of the operative shoulder \u2022 Normal (5\/5) strength for glenohumeral flexion\/abduction\/IR\/ER degrees abduction  PHASE III: LATE POST-OP AND GRADUAL RETURN TO SPORT(13+ WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Restore normal (5\/5) rotator cuff strength at 90 degrees abduction including supraspinatus \u2022 Full multi-planar AROM with minimal to no substitution patterns \u2022 Advance proprioceptive and dynamic neuromuscular control training \u2022 Identify and correct postural dysfunction with sport\/work specific tasks as indicated \u2022 Develop strength and control movements required for sport\/work Sling\/ precautions \u2022 Post-rehabilitation soreness should resolve within 12 hours \u2022 No lifting restrictions at ~4 months Additional Interventions *Continue with Phase I-II Interventions \u2022 Glenohumeral mobilizations as indicated \u2022 Multiplane AROM with gradual increase in velocity of movement  Strengthening: \u2022 Rotator cuff strengthening at 45 degrees progressing to 90 degrees abduction and sport\/work specific positions as well as other provocative positions: resisted IR\/ER, elevation with ER, resisted scaption raises, facepulls\/resisted W\u2019s \u2022 Scapular strengthening and dynamic neuromuscular control in overhead or sport\/work positions: prone or resisted I\u2019s, T\u2019s and Y\u2019s, lower trap setting at wall, manual perturbations in varying degrees in elevation, serratus wall slides\/roll ups, wall pushups, quadruped shoulder taps \u2022 Core strengthening  Stretching:  Corner or doorway pec stretch, Gentle posterior capsule stretch (across body)  Walking, stationary bike, Stairmaster, return to running\/jumping as tolerated  Begin education in sport specific biomechanics with initial program for throwing, swimming, or overhead racquet sports Criteria to Return to Sport  Clearance from MD and ALL milestone criteria have been met  Maintains pain  free PROM and AROM  Performs all exercises demonstrating symmetric scapular mechanics  QuickDASH  PENN  For the recreational or competitive athlete, return  to  sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non  contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return  to  sport rehabilitation program.  Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol References: 1. Logan C, Shahien A, Altintas B, Millett PJ. Rehabilitation following sternoclavicular joint reconstruction for persistent instability. International Journal of Sports Physical Therapy. 2018;13(4):752-762. doi:10.26603\/ijspt20180752 2. Petri, M., Greenspoon, J. A., Horan, M. P., Martetschl\u00e4ger, F., Warth, R. J., & Millett, P. J. (2016). Clinical outcomes after autograft reconstruction for sternoclavicular joint instability. Journal of Shoulder and Elbow Surgery, 25(3), 435\u2013441. https:\/\/doi.org\/10.1016\/j.jse.2015.08.004 3. Garcia JA, Arguello AM, Momaya AM, Ponce BA. Sternoclavicular Joint Instability: Symptoms, Diagnosis And Management. Orthop Res Rev. 2020 Jul 28;12:75-87. doi: 10.2147\/ORR.S170964. PMID: 32801951; PMCID: PMC7395708.\n\nDocument 3: Rehabilitation Protocol for SLAP Repair-Type II  This protocol is intended to guide clinicians through the post-operative course for SLAP Repair-Type II. This protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs of the individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes contained within this guideline may vary based on surgeon\u2019s preference, additional procedures performed, and\/or complications. If a clinician requires assistance in the progression of a post-operative patient, they should consult with the referring surgeon.  The interventions included within this protocol are not intended to be an inclusive list. Therapeutic interventions should be included and modified based on the progress of the patient and under the discretion of the clinician.  Considerations for the Post-operative SLAP repair Rehabilitation Program Many different factors influence the post-operative SLAP repair rehabilitation outcome, including the type of SLAP lesion, the size of the tear\/number of anchors placed, concomitant procedures and amount of shoulder hypermobility and\/or hyperlaxity. Consider mechanism of injury as well as the sport the athlete would like to return to when initiating certain interventions.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: IMMEDIATE POST-OP (0-3 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Maintain UE ROM in elbow, hand and wrist \u2022 Gradually increase shoulder PROM \u2022 Minimize muscle inhibition \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM\/AAROM \u2022 No elbow AROM (avoid biceps contraction) \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 No reaching behind back Intervention Swelling Management \u2022 Ice, compression  Range of motion\/Mobility \u2022 PROM: ER<30 scapular plane, Forward elevation <90, full elbow flex and ext, seated GH flexion table slide, horizontal table slide (add hyperlink) \u2022 AROM: hand, wrist \u2022 AAROM: none  Strengthening (Week 2)  Periscapular: scap retraction  , prone scapular retraction  , standing scapular setting  , supported scapular setting, inferior glide, low row  to neutral; avoid shoulder extension  Rotator cuff: submaximal pain  free isometrics  Ball squeeze Criteria to Progress  90 degrees shoulder PROM forward elevation  30 degrees of shoulder PROM ER in the scapular plane  Full elbow PROM flexion and extension  Palpable muscle contraction felt in scapular and shoulder musculature  No complications with Phase I  PHASE II: INTERMEDIATE POST-OP (4-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Continue to protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM \u2022 Minimize substitution patterns with shoulder AAROM \u2022 Initiate motor control exercise \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM \u2022 No elbow AROM (avoid biceps contraction) \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 No reaching behind back Intervention *Continue with Phase I interventions  Range of motion\/Mobility \u2022 PROM: ER<45 scapular plane, Forward elevation <120 \u2022 AAROM: Active assistive shoulder flexion, shoulder flexion with cane, cane external rotation stretch, washcloth press, sidelying elevation to 90 degrees  Strengthening \u2022 Periscapular: Row on physioball*, shoulder extension on physioball*, serratus punches - *to neutral; avoid shoulder extension  Motor Control \u2022 Internal and external rotation in scaption and Flex 90-125 (rhythmic stabilization)  Stretching \u2022 Sidelying horizontal ADD, sleeper stretch Criteria to Progress \u2022 120 degrees shoulder PROM forward elevation \u2022 45 degrees shoulder PROM ER in scapular plane \u2022 Minimal substitution patterns with shoulder AAROM \u2022 Pain < 4\/10 \u2022 No complications with Phase II  PHASE III: INTERMEDIATE POST-OP CONT\u2019d (7-8 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM\/AAROM \u2022 Initiate shoulder and elbow AROM \u2022 Initiate RTC strengthening  Improve scapular muscle activation  Patient education Sling  Discontinue Precautions  No resisted elbow flexion  No lifting of heavy objects (>10 lbs) Intervention  Continue with Phase I  II interventions Range of motion\/Mobility  PROM: ER Full in scapular plane, \uf0a390 degrees ER in 90 degrees of abduction, IR Full in scapular plane, Forward elevation Full  do not push beyond 90 degrees ER in 90 degrees of abduction  AAROM: seated shoulder elevation with cane, seated incline table slides, ball roll on wall  AROM: supine flexion, salutes, supine punch, wall climbs, elbow flexion  Strengthening \u2022 Rotator cuff: side-lying external rotation, standing external rotation w\/ resistance band, standing internal rotation w\/ resistance band, internal  rotation, external rotation \u2022 Periscapular: Resistance band shoulder extension*, resistance band seated rows*, rowing*, lawn mowers, robbery - *to neutral; avoid shoulder extension \u2022 Elbow: Triceps  Motor Control \u2022 Quadruped alternating isometrics Criteria to Progress \u2022 Full pain-free shoulder PROM ER and forward elevation \u2022 Within 10 degrees of shoulder IR PROM of contralateral shoulder \u2022 Minimal substitution patterns with shoulder AROM \u2022 Pain < 4\/10  PHASE IV: TRANSITIONAL POST-OP (9-12 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue \u2022 Restore full shoulder PROM and AROM \u2022 Initiate resisted elbow flexion at 12 weeks \u2022 Improve dynamic shoulder stability \u2022 Progress periscapular strength \u2022 Gradually return to full functional activities Precautions \u2022 No lifting of heavy objects (> 10 lbs) Intervention *Continue with Phase II-III interventions Range of motion\/mobility \u2022 PROM: Full \u2022 AROM: Supine forward elevation with elastic resistance to 90 deg, scaption and shoulder flexion to 90  degrees elevation  Strengthening \u2022 Periscapular: Push-up plus on knees, prone shoulder extension Is*, resistance band forward punch, forward punch, tripod o *to neutral; avoid shoulder extension \u2022 Elbow (12 weeks): Biceps curl, resistance band bicep curls  Motor control  Ball stabilization on wall  Stretching \u2022 Hands behind head, IR behind back with towel, triceps and lats, doorway series Criteria to Progress \u2022 Full pain-free shoulder PROM and AROM \u2022 Minimal to no substitution patterns with shoulder AROM \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 Pain < 2\/10  PHASE V: LATE POST-OP (13-16 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free shoulder ROM \u2022 Enhance functional use of upper extremity Intervention *Continue with Phase II-IV interventions Strengthening \u2022 Rotator cuff: External rotation at 90 degrees, internal rotation at 90 degrees, resistance band standing external rotation at 90 degrees, resistance band standing internal rotation at 90 degrees \u2022 Periscapular: T and Y, \u201cT\u201d exercise, push-up plus knees extended, pointer, wall push up, \u201cW\u201d exercise, resistance band Ws, dynamic hug, resistance band dynamic hug  Motor Control \u2022  PNF \u2013 D1 diagonal lifts, PNF \u2013 D2 diagonal lifts, field goals , resistance band PNF pattern, PNF \u2013 D1 diagonal lifts w\/ resistance, diagonal-up, diagonal-down, wall slides w\/ resistance band Criteria to Progress \u2022 Clearance from MD and ALL milestone criteria below have been met \u2022 Full pain-free shoulder PROM and AROM \u2022 ER\/IR strength minimum 85% of the uninvolved arm \u2022 ER\/IR ratio 60% or higher \u2022 Negative impingement and instability signs \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 QuickDASH \u2022 PENN  PHASE VI: EARLY RETURN-TO-SPORT (4-6 MONTHS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free ROM \u2022 Continue strengthening and motor control exercises \u2022 Enhance functional use of upper extremity \u2022 Gradual return to strenuous work\/sport activity Intervention *Continue with Phase II-V interventions Strengthening \u2022 See specific return-to-sport\/throwing program (coordinate with physician) Criteria to Progress \u2022 Last stage-no additional criteria Return-to-Sport \u2022 For the recreational or competitive athlete, return-to-sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non-contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return-to-sport rehabilitation program. Revised 7\/2020  Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol  References:  1. Ahsan, ZS, Hsu JE, et al. The Snyder classification of superior labrum anterior and posterior (SLAP) lesions. Clin Orthop Relat Res. 2016. 474:2075- 2078.  2. Christopher ZR, Kennedy J, et al. Rehabilitation and return to play following superior labral anterior to posterior repair. Oper Tech Sports Med. 2017. 25:132-144.  3. Cools AM, Borms D, Cottens S, et al. Rehabilitation exercises for athletes with biceps disorders and SLAP lesions. AJSM. 2014. 42(6): 1315-1323.  4. Itoi E, Hatakeyama Y, et al. Position of immobilization after dislocation of the shoulder. JBJS. 1999. 81-A(3): 385-390.  5. Kibler, W.B., Sciascia, A. D., Uhl, T. L., et al. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. The American Journal of Sports Medicine. 2008. 36(9): p. 1789-1798.  6. Wilk KE, Reinold MM, et al. Current concepts in the recognition and treatment of superior labral (SLAP) lesions. JOSPT. 2005. 35(5): 273-291.","conversation_history":[],"metadata":{"question_type":"complex","seed_document_id":4,"topic":"Others"}}
{"id":"2f247a12-2398-41a4-bd83-e4ec7c02b4db","question":"What are the specific factors that must be met in order for a patient to be discharged after participating in a slow or conservative program for rotator cuff repair, considering the patient's pain levels, range of motion, and strength?","reference_answer":"The criteria for discharge after undergoing a slow or conservative program for rotator cuff repair include isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry, and independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control.","reference_context":"Document 6: PHYSICAL THERAPY PRESCRIPTION:  TOTAL SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: At all times except for showering and exercise. (Sleep in sofa recliner)  Total of 6 weeks in the Sling and the Abduction pillow  Exercises: Pendulums ok 2 weeks after surgery Passive ER to 10 degrees and extension to neutral  Passive supine FF in scapular plane to 130 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed  Advancement Criteria: ER the above set criteria FF in scapular plane to 130 Minimal pain and inflammation with motion and exercise Incision is well healed with no drainage and no redness  Weeks 6  10: Phase II  Sling Immobilizer: Discontinue at week 6  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER \u2013 limit 45 deg  2  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF to 150  ER to 45  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF 160, ER >45  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  3  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation\n\nDocument 8: PHYSICAL THERAPY PRESCRIPTION:  REVERSE SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: Please Transition out of the sling between 2 to 3 weeks after surgery (Sleep in sofa recliner with your sling for the first 2 weeks) for Primary Reverse Shoulder Replacement or 5 to 6 weeks for Fracture and Revision Reverse Shoulder Replacement.  2 Weeks  6 Weeks  Activities of Daily Living: You may use your arm and hand on the operative shoulder for your ADL activates 2 weeks after surgery. Pendulums are also encouraged 1 week after surgery.  Exercises: Passive ER to 20 degrees and extension to neutral, pendulums daily  Passive supine FF in scapular plane to 90 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed: ice  Advancement Criteria: ER to the above set criteria FF in scapular plane to 90 Minimal pain and inflammation with any motion or exercise Incision is well healed with no drainage or redness  2  Weeks 6  10: Phase II  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER as tolerated by the patient  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF > 120  ER > 30  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF > 120, ER >30  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  3  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation\n\nDocument 7: Visit per week:  2 to 3 times  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Advanced Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  2  4 WEEKS POST  OP (Maximum Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN)  2  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises  Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  4  6 WEEKS POST  OP (Moderate Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  3  7  12 WEEKS POST  OP: (Early Strengthening Phase)  GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  13  19 WEEKS POST  OP: (Late Strengthening Phase)  GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 weeks  Continue with throwing and racquet program if appropriate  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  20-24 WEEKS POST-OP: (Return to Sports or Full Activity)  GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control\n\nDocument 2: Visit per week:  2 to 3 times  Diagnosis:   LEFT or RIGHT Shoulder Arthroscopic Large Rotator Cuff Repair - Supraspinatus and Infraspinatus Repair - Subscapularis Repair  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Slow or Conservative Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  ** Weeks 0-3: Patient stays in the sling and abduction pillow at all times. Pendulums ok to start Week #3 (NO PAIN). NO Shoulder PROM. Elbow and wrist ROM is ok. **  4-6 WEEKS POST-OP (Maximum Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility  2 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Start Post Op Week #4 Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN), Pts with Subscapularis Repair: (Limit Passive ER to 20\u00b0)  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises and Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  6-8 WEEKS POST-OP (Moderate Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain  3 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  9-14 WEEKS POST-OP: (Early Strengthening Phase) GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  15-23 WEEKS POST-OP: (Late Strengthening Phase) GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 week. Continue with throwing program  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  24-26 WEEKS POST-OP: (Return to Sports or Full Activity) GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control","conversation_history":[],"metadata":{"question_type":"complex","seed_document_id":6,"topic":"Others"}}
{"id":"d4d4f1eb-1019-469b-a91a-88f310a10297","question":"Could you elaborate on the various elements that may impact the rehabilitation outcomes following a Total Shoulder Arthroplasty (TSA) and Hemiarthroplasty, particularly focusing on surgical approach, concomitant repair of the rotator cuff, arthroplasty secondary to fracture or rheumatoid arthritis, and individual patient factors including co-morbidities?","reference_answer":"Many different factors influence the post-operative rehabilitation outcome, including surgical approach, concomitant repair of the rotator cuff, arthroplasty secondary to fracture, arthroplasty secondary to rheumatoid arthritis or osteonecrosis, and individual patient factors including co-morbidities.","reference_context":"Document 4: Rehabilitation Protocol for Total Shoulder Arthroplasty and Hemiarthroplasty  This protocol is intended to guide clinicians and patients through the post-operative course after a total shoulder arthroplasty (TSA) and hemiarthroplasty. Specific interventions should be based on the needs of the individual and should consider exam findings and clinical decision making. If you have questions, contact the referring physician.  Considerations for the Total Shoulder Arthroplasty and Hemiarthroplasty Rehabilitation Program Many different factors influence the post-operative rehabilitation outcome, including surgical approach, concomitant repair of the rotator cuff, arthroplasty secondary to fracture, arthroplasty secondary to rheumatoid arthritis or osteonecrosis, and individual patient factors including co-morbidities. It is recommended that patients meet all rehabilitation criteria in order to progress to the next phase and clinicians collaborate closely with the referring physician throughout the rehabilitation process.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: IMMEDIATE POST-OP (0-3 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Maintain UE ROM in elbow, hand and wrist \u2022 Gradually increase shoulder PROM \u2022 Minimize muscle inhibition \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM \u2022 No reaching behind back, especially in to internal rotation \u2022 No excessive shoulder external rotation or abduction \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 Place small pillow\/towel roll under elbow while lying on back to avoid shoulder hyperextension Intervention Swelling Management \u2022 Ice, compression Range of motion\/Mobility \u2022 PROM: ER <\/= 30 degrees in the scapular plane, IR to belt line in scapular plane, Flex\/Scaption to tolerance, ABD <\/= 90 degrees, pendulums, seated GH flexion table slide, seated horizontal table slide \u2022 AAROM: Active assistive shoulder flexion \u2022 AROM: elbow, hand, wrist Strengthening (Week 2) \u2022 Periscapular: scap retraction, prone scapular retraction, standing scapular setting, supported scapular setting, inferior glide, low row \u2022 Ball squeeze Criteria to Progress \u2022 >\/= 50% shoulder PROM flex, scaption as compared to contralateral side \u2022 <\/= 90 degrees of shoulder ABD PROM \u2022 <\/= 30 degrees of shoulder ER PROM in scapular plane \u2022 >\/= 70 degrees of IR PROM in scapular plane  Palpable muscle contraction felt in scapular musculature  Pain < 4\/10  No complications with Phase I  PHASE II: INTERMEDIATE POST-OP (4-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Continue to protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM \u2022 Minimize substitution patterns with AROM and AAROM \u2022 Improve periscapular muscle activation\/strength \u2022 Initiate RTC (external rotators) activation \u2022 Patient education Sling \u2022 Use at night while sleeping \u2022 Gradually start weaning sling over the next two weeks during the day Precautions \u2022 No excessive shoulder external rotation or abduction \u2022 No lifting of objects heavier than a coffee cup \u2022 No supporting of body weight with hands \u2022 Place small pillow\/towel roll under elbow while lying on back to avoid shoulder hyperextension Intervention *Continue with Phase I interventions  Range of motion\/Mobility \u2022 PROM: Full with exception of ER <\/= 30 degrees in scapular plane and <\/= 90 degrees ABD \u2022 AAROM: shoulder flexion with cane, cane external rotation stretch, washcloth press, seated shoulder elevation with cane \u2022 AROM: supine flexion, salutes, supine punch Strengthening \u2022 Rotator cuff: external rotation isometrics \u2022 Periscapular: Row on physioball, serratus punches \u2022 Elbow: Biceps curl, resistance band bicep curls and triceps Motor control \u2022 ER in scaption and Flex 90-125 (rhythmic stabilization) Stretching \u2022 Sidelying horizontal ADD Criteria to Progress \u2022 >\/=75% shoulder PROM flex, scaption, as compared to contralateral side \u2022 >\/=75% shoulder PROM IR in scapular plane as compared to contralateral side \u2022 30 degrees of shoulder PROM ER in scapular plane \u2022 90 degrees of shoulder PROM ABD \u2022 Minimal substitution patterns with AAROM \u2022 AROM shoulder elevation to 100 degrees with minimal substitution patterns \u2022 Pain < 4\/10 \u2022 No complications with Phase II  PHASE III: INTERMEDIATE POST-OP CONTD (7-8 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue (especially the anterior capsule) \u2022 Minimize pain \u2022 Maintain PROM \u2022 Improve AROM \u2022 Progress periscapular and RTC strength \u2022 Return to full functional activities \u2022 Patient education Sling \u2022 Discontinue Precautions \u2022 No lifting of heavy objects (>10 lbs) Intervention *Continue with Phase I-II interventions Range of motion\/Mobility \u2022 Full ROM in all planes \u2022 AAROM: incline table slides, ball roll on wall, wall climbs, pulleys \u2022 AROM: seated scaption, seated flexion, supine forward elevation with elastic resistance to 90 deg  Strengthening \u2022 Rotator cuff: internal rotation isometrics, side-lying external rotation, \u2022 Standing external rotation w\/ resistance band, standing internal rotation w\/ resistance band, internal  rotation, external rotation, \u2022 Periscapular: Resistance band shoulder extension, resistance band seated rows, rowing, lawn mowers, robbery Motor control \u2022 IR\/ER and Flex 90-125 (rhythmic stabilization) \u2022 Quadruped alternating isometrics and ball stabilization on wall \u2022 PNF-D1 diagonal lifts, PNF-D2 diagonal lifts Stretching \u2022 IR behind back with towel, sidelying horizontal ADD, sleeper stretch, triceps and lats Criteria to Progress \u2022 Minimal to no substitution patterns with shoulder AROM \u2022 Pain < 4\/10  PHASE IV: TRANSITIONAL POST-OP (9-11 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue (especially the anterior capsule) \u2022 Maintain pain-free PROM \u2022 Continue improving AROM \u2022 Improve dynamic shoulder stability \u2022 Gradually restore shoulder strength and endurance Precautions \u2022 No lifting of heavy objects (> 10 lbs) \u2022 Avoid exercises that put stress on the anterior shoulder capsule (ie: shoulder ER above 80 degrees of ABD) Intervention *Continue with Phase II-III interventions Range of motion\/mobility \u2022 Full ROM in all planes Strengthening \u2022 Rotator cuff: increase resistance rotator cuff exercise \u2022 Periscapular: Push-up plus on knees, \u201cW\u201d exercise, resistance band Ws, dynamic hug, resistance band dynamic hug, prone shoulder extension Is, resistance band forward punch, forward punch, tripod, pointer Motor control \u2022 Resistance band PNF pattern, PNF \u2013 D1 diagonal lifts w\/ resistance, diagonal-up, diagonal-down Wall slides w\/ resistance band Criteria to Progress \u2022 Supine AROM Flex >\/=140 degrees \u2022 Supine AROM ABD >\/=120 degrees \u2022 Supine AROM ER in scapular plane >\/= 60 degrees \u2022 Supine AROM IR in scapular plane >\/= 70 degrees \u2022 AROM shoulder elevation to 120 degrees with minimal substitution patterns \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 Pain < 2\/10  PHASE V: ADVANCED STRENGTHENING POST-OP (12-16 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free ROM \u2022 Improve shoulder strength and endurance \u2022 Enhance functional use of upper extremity  Intervention *Continue with Phase II-IV interventions Strengthening \u2022 Rotator cuff:  External rotation at 90 degrees, internal rotation at 90 degrees, resistance band standing external rotation at 90 degrees, resistance band standing internal rotation at 90 degrees \u2022 Periscapular: T and Y, \u201cT\u201d exercise, push-up plus knees extended, wall push up Motor Control \u2022 Progress ball stabilization on wall to overhead alternating isometrics\/rhythmic stabilization  Criteria to Progress \u2022 Clearance from MD and ALL milestone criteria have been met \u2022 Maintains pain-free PROM and AROM \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 QuickDASH \u2022 PENN Return-to-Sport \u2022 For the recreational or competitive athlete, return-to-sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non-contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return-to-sport rehabilitation program.  Revised December 2018 Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol  References  Angst, F, Goldhahn, J, et al. Responsiveness of six outcome assessment instruments in total shoulder arthroplasty. Arthritis & Rheumatism. 2008. 59 (3): 391-398.  Garcia, GH, Liu, JN, et al. High satisfaction and return to sports after total shoulder arthroplasty in patients aged 55 years and younger. AJSM. 2017. 45 (7): 1664-1669.  Gaunt BW, McCluskey GM, Uhl TL. An electromyographic evaluation of subdividing active-assistive shoulder elevation exercises. Sports Health. 2010. 2 (5): 424-432.  Hughes, M, Neer II, CS. Glenohumeral joint replacement and postoperative rehabilitation. Physical Therapy. 1975. 55(8): 850-858.  Kibler, W.B., Sciascia, A. D., Uhl, T. L., et al. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. The American Journal of Sports Medicine. 2008. 36(9): p. 1789-1798.  Knesek M, Brunfeldt, A, et al. Patterns of strain and the determination of the safe arc of motion after subscapularis repair-a biomechanical study. Journal of Orthopaedic Research. 2016. 34: 518-524.  Piasecki, DP, Nicholson, GP. Tears of the subscapularis tendon in athletes-diagnosis and repair techniques. Clin Sports Med. 2008. 27: 731-745.  Uhl TL, Muir TA, et al. Electromyographical assessment of passive, active assistive, and active shoulder rehabilitation exercises. PM R. 2010. 2: 132-141.  Wilcox III R.B., Arslanian L.E., Millett P.J. Rehabilitation following total shoulder arthroplasty. JOSPT. 2005. 35 (12): 821-837  Wolff. AL, Rosenzweig, L. Anatomical and biomechanical framework for shoulder arthroplasty rehabilitation. Journal of Hand Therapy. 2017. 30: 167-174.  Wright, T, Easley, T, et al. Shoulder arthroplasty and its effect on strain in the subscapularis muscle. Clinical Biomechanics. 2015. 30: 373-376.  Zarkadas P.C., Throckmorton T., et al. Patient reported activities after shoulder replacement: total and hemiarthroplasty. J Shoulder Elbow Surg. 2011. 20: 273-280.  Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med. 1996;(6):602-608.  Leggin BG, Michener, LA, et al. The Penn Shoulder Score: reliability and validity. JOSPT. 36 (3): 138-151.\n\nDocument 5: Rehabilitation Protocol for Sternoclavicular Joint Reconstruction  This protocol is intended to guide clinicians through the post-operative course for sternoclavicular joint reconstruction. This protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs of the individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes contained within this guideline may vary based on surgeon\u2019s preference, additional procedures performed, and\/or complications. If a clinician requires assistance in the progression of a post-operative patient, they should consult with the referring surgeon.  The interventions included within this protocol are not intended to be an inclusive list of exercises. Therapeutic interventions should be included and modified based on the progress of the patient and under the discretion of the clinician.  Considerations for the Post-operative sternoclavicular joint reconstruction Many different factors influence the post-operative rehabilitation outcome, including surgical technique (ie. tendon autograft harvest for repair), degree of SC joint instability, concomitant soft tissue or bone injury\/repair, and individual patient factors including co-morbidities. It is recommended that patients meet all rehabilitation criteria in order to progress to the next phase and clinicians collaborate closely with the referring physician throughout the rehabilitation process.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: EARLY POST-OP (0-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Reduce pain and swelling of the operative shoulder \u2022 Maintain elbow, wrist and hand AROM \u2022 Patient education Sling\/precautions \u2022 Sling to be worn for 6 weeks (or as directed by surgeon) \u2022 Avoid PROM of the glenohumeral joint \u2022 Avoid scapular AROM (protraction, retraction, depression and elevation) as it may disrupt the repair and healing tissues \u2022 Avoid bearing weight through involved extremity \u2022 Avoid lifting any lifting with involved extremity \u2022 Avoid running and jumping due to impact forces upon landing that may aggravate healing tissues and bone Intervention \u2022 Cryotherapy as needed \u2022 AROM: cervical spine, elbow, wrist, hand \u2022 Hand gripping: ball squeeze \u2022 Cardiovascular exercise as tolerated: walking, stationary bike Criteria to Progress \u2022 Well controlled pain and swelling \u2022 Protect reconstruction site and autograft site (if applicable) \u2022 Maintain elbow, wrist and hand AROM  PHASE II: INTERMEDIATE POST-OP (6-12WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Activation of muscles responsible for stabilizing the scapulothoracic and glenohumeral joint \u2022 Gradually restore PROM, AAROM of the GH joint at 6-8 weeks \u2022 Gradually restore AROM of the scapulothoracic joint and glenohumeral joint at 8 weeks \u2022 Wean from sling (if still wearing) \u2022 Begin shoulder and scapular strengthening at 8 weeks \u2022 Begin proprioception and neuromuscular control training \u2022 Identify and correct postural dysfunction as indicated Sling\/precautions \u2022 Avoid repetitive overhead activities \u2022 No lifting > 5 pounds with involved extremity until 9 weeks post-op \u2022 Post-rehabilitation soreness should resolve within 12-24 hours Additional Interventions *Continue with Phase I interventions \u2022 AROM in all cardinal plane assessing scapular rhythm \u2022 Gentle glenohumeral mobilization as indicated  Strengthening: \u2022 Rotator cuff strengthening in non-provocative positions (generally 0-45 degrees Scaption\/abduction): scaption raises against gravity, Sidelying ER, lightly resisted ER\/IR with theraband, isometrics \u2022 Scapular strengthening and dynamic neuromuscular control: low row, straight arm pulldowns, serratus punch, resisted T\u2019s  Stretching: Gentle corner or doorway pec stretch \u2022 Postural endurance exercises: scapular retractions, chin tucks \u2022 Walking, stationary bike, Stairmaster Criteria to Progress \u2022 Full AROM of the operative shoulder \u2022 Normal (5\/5) strength for glenohumeral flexion\/abduction\/IR\/ER degrees abduction  PHASE III: LATE POST-OP AND GRADUAL RETURN TO SPORT(13+ WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Restore normal (5\/5) rotator cuff strength at 90 degrees abduction including supraspinatus \u2022 Full multi-planar AROM with minimal to no substitution patterns \u2022 Advance proprioceptive and dynamic neuromuscular control training \u2022 Identify and correct postural dysfunction with sport\/work specific tasks as indicated \u2022 Develop strength and control movements required for sport\/work Sling\/ precautions \u2022 Post-rehabilitation soreness should resolve within 12 hours \u2022 No lifting restrictions at ~4 months Additional Interventions *Continue with Phase I-II Interventions \u2022 Glenohumeral mobilizations as indicated \u2022 Multiplane AROM with gradual increase in velocity of movement  Strengthening: \u2022 Rotator cuff strengthening at 45 degrees progressing to 90 degrees abduction and sport\/work specific positions as well as other provocative positions: resisted IR\/ER, elevation with ER, resisted scaption raises, facepulls\/resisted W\u2019s \u2022 Scapular strengthening and dynamic neuromuscular control in overhead or sport\/work positions: prone or resisted I\u2019s, T\u2019s and Y\u2019s, lower trap setting at wall, manual perturbations in varying degrees in elevation, serratus wall slides\/roll ups, wall pushups, quadruped shoulder taps \u2022 Core strengthening  Stretching:  Corner or doorway pec stretch, Gentle posterior capsule stretch (across body)  Walking, stationary bike, Stairmaster, return to running\/jumping as tolerated  Begin education in sport specific biomechanics with initial program for throwing, swimming, or overhead racquet sports Criteria to Return to Sport  Clearance from MD and ALL milestone criteria have been met  Maintains pain  free PROM and AROM  Performs all exercises demonstrating symmetric scapular mechanics  QuickDASH  PENN  For the recreational or competitive athlete, return  to  sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non  contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return  to  sport rehabilitation program.  Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol References: 1. Logan C, Shahien A, Altintas B, Millett PJ. Rehabilitation following sternoclavicular joint reconstruction for persistent instability. International Journal of Sports Physical Therapy. 2018;13(4):752-762. doi:10.26603\/ijspt20180752 2. Petri, M., Greenspoon, J. A., Horan, M. P., Martetschl\u00e4ger, F., Warth, R. J., & Millett, P. J. (2016). Clinical outcomes after autograft reconstruction for sternoclavicular joint instability. Journal of Shoulder and Elbow Surgery, 25(3), 435\u2013441. https:\/\/doi.org\/10.1016\/j.jse.2015.08.004 3. Garcia JA, Arguello AM, Momaya AM, Ponce BA. Sternoclavicular Joint Instability: Symptoms, Diagnosis And Management. Orthop Res Rev. 2020 Jul 28;12:75-87. doi: 10.2147\/ORR.S170964. PMID: 32801951; PMCID: PMC7395708.\n\nDocument 3: Rehabilitation Protocol for SLAP Repair-Type II  This protocol is intended to guide clinicians through the post-operative course for SLAP Repair-Type II. This protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs of the individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes contained within this guideline may vary based on surgeon\u2019s preference, additional procedures performed, and\/or complications. If a clinician requires assistance in the progression of a post-operative patient, they should consult with the referring surgeon.  The interventions included within this protocol are not intended to be an inclusive list. Therapeutic interventions should be included and modified based on the progress of the patient and under the discretion of the clinician.  Considerations for the Post-operative SLAP repair Rehabilitation Program Many different factors influence the post-operative SLAP repair rehabilitation outcome, including the type of SLAP lesion, the size of the tear\/number of anchors placed, concomitant procedures and amount of shoulder hypermobility and\/or hyperlaxity. Consider mechanism of injury as well as the sport the athlete would like to return to when initiating certain interventions.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: IMMEDIATE POST-OP (0-3 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Maintain UE ROM in elbow, hand and wrist \u2022 Gradually increase shoulder PROM \u2022 Minimize muscle inhibition \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM\/AAROM \u2022 No elbow AROM (avoid biceps contraction) \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 No reaching behind back Intervention Swelling Management \u2022 Ice, compression  Range of motion\/Mobility \u2022 PROM: ER<30 scapular plane, Forward elevation <90, full elbow flex and ext, seated GH flexion table slide, horizontal table slide (add hyperlink) \u2022 AROM: hand, wrist \u2022 AAROM: none  Strengthening (Week 2)  Periscapular: scap retraction  , prone scapular retraction  , standing scapular setting  , supported scapular setting, inferior glide, low row  to neutral; avoid shoulder extension  Rotator cuff: submaximal pain  free isometrics  Ball squeeze Criteria to Progress  90 degrees shoulder PROM forward elevation  30 degrees of shoulder PROM ER in the scapular plane  Full elbow PROM flexion and extension  Palpable muscle contraction felt in scapular and shoulder musculature  No complications with Phase I  PHASE II: INTERMEDIATE POST-OP (4-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Continue to protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM \u2022 Minimize substitution patterns with shoulder AAROM \u2022 Initiate motor control exercise \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM \u2022 No elbow AROM (avoid biceps contraction) \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 No reaching behind back Intervention *Continue with Phase I interventions  Range of motion\/Mobility \u2022 PROM: ER<45 scapular plane, Forward elevation <120 \u2022 AAROM: Active assistive shoulder flexion, shoulder flexion with cane, cane external rotation stretch, washcloth press, sidelying elevation to 90 degrees  Strengthening \u2022 Periscapular: Row on physioball*, shoulder extension on physioball*, serratus punches - *to neutral; avoid shoulder extension  Motor Control \u2022 Internal and external rotation in scaption and Flex 90-125 (rhythmic stabilization)  Stretching \u2022 Sidelying horizontal ADD, sleeper stretch Criteria to Progress \u2022 120 degrees shoulder PROM forward elevation \u2022 45 degrees shoulder PROM ER in scapular plane \u2022 Minimal substitution patterns with shoulder AAROM \u2022 Pain < 4\/10 \u2022 No complications with Phase II  PHASE III: INTERMEDIATE POST-OP CONT\u2019d (7-8 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM\/AAROM \u2022 Initiate shoulder and elbow AROM \u2022 Initiate RTC strengthening  Improve scapular muscle activation  Patient education Sling  Discontinue Precautions  No resisted elbow flexion  No lifting of heavy objects (>10 lbs) Intervention  Continue with Phase I  II interventions Range of motion\/Mobility  PROM: ER Full in scapular plane, \uf0a390 degrees ER in 90 degrees of abduction, IR Full in scapular plane, Forward elevation Full  do not push beyond 90 degrees ER in 90 degrees of abduction  AAROM: seated shoulder elevation with cane, seated incline table slides, ball roll on wall  AROM: supine flexion, salutes, supine punch, wall climbs, elbow flexion  Strengthening \u2022 Rotator cuff: side-lying external rotation, standing external rotation w\/ resistance band, standing internal rotation w\/ resistance band, internal  rotation, external rotation \u2022 Periscapular: Resistance band shoulder extension*, resistance band seated rows*, rowing*, lawn mowers, robbery - *to neutral; avoid shoulder extension \u2022 Elbow: Triceps  Motor Control \u2022 Quadruped alternating isometrics Criteria to Progress \u2022 Full pain-free shoulder PROM ER and forward elevation \u2022 Within 10 degrees of shoulder IR PROM of contralateral shoulder \u2022 Minimal substitution patterns with shoulder AROM \u2022 Pain < 4\/10  PHASE IV: TRANSITIONAL POST-OP (9-12 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue \u2022 Restore full shoulder PROM and AROM \u2022 Initiate resisted elbow flexion at 12 weeks \u2022 Improve dynamic shoulder stability \u2022 Progress periscapular strength \u2022 Gradually return to full functional activities Precautions \u2022 No lifting of heavy objects (> 10 lbs) Intervention *Continue with Phase II-III interventions Range of motion\/mobility \u2022 PROM: Full \u2022 AROM: Supine forward elevation with elastic resistance to 90 deg, scaption and shoulder flexion to 90  degrees elevation  Strengthening \u2022 Periscapular: Push-up plus on knees, prone shoulder extension Is*, resistance band forward punch, forward punch, tripod o *to neutral; avoid shoulder extension \u2022 Elbow (12 weeks): Biceps curl, resistance band bicep curls  Motor control  Ball stabilization on wall  Stretching \u2022 Hands behind head, IR behind back with towel, triceps and lats, doorway series Criteria to Progress \u2022 Full pain-free shoulder PROM and AROM \u2022 Minimal to no substitution patterns with shoulder AROM \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 Pain < 2\/10  PHASE V: LATE POST-OP (13-16 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free shoulder ROM \u2022 Enhance functional use of upper extremity Intervention *Continue with Phase II-IV interventions Strengthening \u2022 Rotator cuff: External rotation at 90 degrees, internal rotation at 90 degrees, resistance band standing external rotation at 90 degrees, resistance band standing internal rotation at 90 degrees \u2022 Periscapular: T and Y, \u201cT\u201d exercise, push-up plus knees extended, pointer, wall push up, \u201cW\u201d exercise, resistance band Ws, dynamic hug, resistance band dynamic hug  Motor Control \u2022  PNF \u2013 D1 diagonal lifts, PNF \u2013 D2 diagonal lifts, field goals , resistance band PNF pattern, PNF \u2013 D1 diagonal lifts w\/ resistance, diagonal-up, diagonal-down, wall slides w\/ resistance band Criteria to Progress \u2022 Clearance from MD and ALL milestone criteria below have been met \u2022 Full pain-free shoulder PROM and AROM \u2022 ER\/IR strength minimum 85% of the uninvolved arm \u2022 ER\/IR ratio 60% or higher \u2022 Negative impingement and instability signs \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 QuickDASH \u2022 PENN  PHASE VI: EARLY RETURN-TO-SPORT (4-6 MONTHS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free ROM \u2022 Continue strengthening and motor control exercises \u2022 Enhance functional use of upper extremity \u2022 Gradual return to strenuous work\/sport activity Intervention *Continue with Phase II-V interventions Strengthening \u2022 See specific return-to-sport\/throwing program (coordinate with physician) Criteria to Progress \u2022 Last stage-no additional criteria Return-to-Sport \u2022 For the recreational or competitive athlete, return-to-sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non-contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return-to-sport rehabilitation program. Revised 7\/2020  Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol  References:  1. Ahsan, ZS, Hsu JE, et al. The Snyder classification of superior labrum anterior and posterior (SLAP) lesions. Clin Orthop Relat Res. 2016. 474:2075- 2078.  2. Christopher ZR, Kennedy J, et al. Rehabilitation and return to play following superior labral anterior to posterior repair. Oper Tech Sports Med. 2017. 25:132-144.  3. Cools AM, Borms D, Cottens S, et al. Rehabilitation exercises for athletes with biceps disorders and SLAP lesions. AJSM. 2014. 42(6): 1315-1323.  4. Itoi E, Hatakeyama Y, et al. Position of immobilization after dislocation of the shoulder. JBJS. 1999. 81-A(3): 385-390.  5. Kibler, W.B., Sciascia, A. D., Uhl, T. L., et al. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. The American Journal of Sports Medicine. 2008. 36(9): p. 1789-1798.  6. Wilk KE, Reinold MM, et al. Current concepts in the recognition and treatment of superior labral (SLAP) lesions. JOSPT. 2005. 35(5): 273-291.","conversation_history":[],"metadata":{"question_type":"complex","seed_document_id":4,"topic":"Others"}}
{"id":"fae6b387-d252-4044-8ad5-0e9cae0847a2","question":"What are the specific criteria that must be met for a patient to progress from the Moderate Protection Phase of the advanced program for rotator cuff physical therapy?","reference_answer":"The advancement criteria for the Moderate Protection Phase of the rotator cuff physical therapy advanced program are: 1. Ability to activate cuff and deltoid without pain, 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane), 3. ROM 80% or greater for elevation in plane of the scapula and external rotation.","reference_context":"Document 2: Visit per week:  2 to 3 times  Diagnosis:   LEFT or RIGHT Shoulder Arthroscopic Large Rotator Cuff Repair - Supraspinatus and Infraspinatus Repair - Subscapularis Repair  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Slow or Conservative Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  ** Weeks 0-3: Patient stays in the sling and abduction pillow at all times. Pendulums ok to start Week #3 (NO PAIN). NO Shoulder PROM. Elbow and wrist ROM is ok. **  4-6 WEEKS POST-OP (Maximum Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility  2 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Start Post Op Week #4 Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN), Pts with Subscapularis Repair: (Limit Passive ER to 20\u00b0)  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises and Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  6-8 WEEKS POST-OP (Moderate Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain  3 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  9-14 WEEKS POST-OP: (Early Strengthening Phase) GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  15-23 WEEKS POST-OP: (Late Strengthening Phase) GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 week. Continue with throwing program  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  24-26 WEEKS POST-OP: (Return to Sports or Full Activity) GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control\n\nDocument 7: Visit per week:  2 to 3 times  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Advanced Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  2  4 WEEKS POST  OP (Maximum Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN)  2  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises  Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  4  6 WEEKS POST  OP (Moderate Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  3  7  12 WEEKS POST  OP: (Early Strengthening Phase)  GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  13  19 WEEKS POST  OP: (Late Strengthening Phase)  GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 weeks  Continue with throwing and racquet program if appropriate  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  20-24 WEEKS POST-OP: (Return to Sports or Full Activity)  GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control\n\nDocument 6: PHYSICAL THERAPY PRESCRIPTION:  TOTAL SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: At all times except for showering and exercise. (Sleep in sofa recliner)  Total of 6 weeks in the Sling and the Abduction pillow  Exercises: Pendulums ok 2 weeks after surgery Passive ER to 10 degrees and extension to neutral  Passive supine FF in scapular plane to 130 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed  Advancement Criteria: ER the above set criteria FF in scapular plane to 130 Minimal pain and inflammation with motion and exercise Incision is well healed with no drainage and no redness  Weeks 6  10: Phase II  Sling Immobilizer: Discontinue at week 6  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER \u2013 limit 45 deg  2  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF to 150  ER to 45  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF 160, ER >45  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  3  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation\n\nDocument 8: PHYSICAL THERAPY PRESCRIPTION:  REVERSE SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: Please Transition out of the sling between 2 to 3 weeks after surgery (Sleep in sofa recliner with your sling for the first 2 weeks) for Primary Reverse Shoulder Replacement or 5 to 6 weeks for Fracture and Revision Reverse Shoulder Replacement.  2 Weeks  6 Weeks  Activities of Daily Living: You may use your arm and hand on the operative shoulder for your ADL activates 2 weeks after surgery. Pendulums are also encouraged 1 week after surgery.  Exercises: Passive ER to 20 degrees and extension to neutral, pendulums daily  Passive supine FF in scapular plane to 90 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed: ice  Advancement Criteria: ER to the above set criteria FF in scapular plane to 90 Minimal pain and inflammation with any motion or exercise Incision is well healed with no drainage or redness  2  Weeks 6  10: Phase II  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER as tolerated by the patient  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF > 120  ER > 30  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF > 120, ER >30  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  3  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation","conversation_history":[],"metadata":{"question_type":"complex","seed_document_id":2,"topic":"Others"}}
{"id":"ff0bf806-bfdd-4801-be5a-dc0955e3e306","question":"What are the minimal prerequisites a patient must meet in order to progress to the subsequent stage during the 4-6 weeks post-operative phase in a Slow or Conservative Program for a large rotator cuff repair, taking into account factors such as pain levels, range of motion, and scapular mobility?","reference_answer":"The minimum criteria for advancement to the next phase during the 4-6 weeks post-op phase for a Slow or Conservative Program for a large rotator cuff repair are 1. Normal scapular mobility, 2. Full active ROM distal to shoulder, 3. Shoulder ROM to within surgeon\u2019s set ROM goals.","reference_context":"Document 6: PHYSICAL THERAPY PRESCRIPTION:  TOTAL SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: At all times except for showering and exercise. (Sleep in sofa recliner)  Total of 6 weeks in the Sling and the Abduction pillow  Exercises: Pendulums ok 2 weeks after surgery Passive ER to 10 degrees and extension to neutral  Passive supine FF in scapular plane to 130 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed  Advancement Criteria: ER the above set criteria FF in scapular plane to 130 Minimal pain and inflammation with motion and exercise Incision is well healed with no drainage and no redness  Weeks 6  10: Phase II  Sling Immobilizer: Discontinue at week 6  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER \u2013 limit 45 deg  2  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF to 150  ER to 45  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF 160, ER >45  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  3  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation\n\nDocument 8: PHYSICAL THERAPY PRESCRIPTION:  REVERSE SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: Please Transition out of the sling between 2 to 3 weeks after surgery (Sleep in sofa recliner with your sling for the first 2 weeks) for Primary Reverse Shoulder Replacement or 5 to 6 weeks for Fracture and Revision Reverse Shoulder Replacement.  2 Weeks  6 Weeks  Activities of Daily Living: You may use your arm and hand on the operative shoulder for your ADL activates 2 weeks after surgery. Pendulums are also encouraged 1 week after surgery.  Exercises: Passive ER to 20 degrees and extension to neutral, pendulums daily  Passive supine FF in scapular plane to 90 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed: ice  Advancement Criteria: ER to the above set criteria FF in scapular plane to 90 Minimal pain and inflammation with any motion or exercise Incision is well healed with no drainage or redness  2  Weeks 6  10: Phase II  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER as tolerated by the patient  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF > 120  ER > 30  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF > 120, ER >30  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  3  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation\n\nDocument 7: Visit per week:  2 to 3 times  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Advanced Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  2  4 WEEKS POST  OP (Maximum Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN)  2  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises  Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  4  6 WEEKS POST  OP (Moderate Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  3  7  12 WEEKS POST  OP: (Early Strengthening Phase)  GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  13  19 WEEKS POST  OP: (Late Strengthening Phase)  GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 weeks  Continue with throwing and racquet program if appropriate  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  20-24 WEEKS POST-OP: (Return to Sports or Full Activity)  GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control\n\nDocument 2: Visit per week:  2 to 3 times  Diagnosis:   LEFT or RIGHT Shoulder Arthroscopic Large Rotator Cuff Repair - Supraspinatus and Infraspinatus Repair - Subscapularis Repair  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Slow or Conservative Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  ** Weeks 0-3: Patient stays in the sling and abduction pillow at all times. Pendulums ok to start Week #3 (NO PAIN). NO Shoulder PROM. Elbow and wrist ROM is ok. **  4-6 WEEKS POST-OP (Maximum Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility  2 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Start Post Op Week #4 Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN), Pts with Subscapularis Repair: (Limit Passive ER to 20\u00b0)  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises and Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  6-8 WEEKS POST-OP (Moderate Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain  3 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  9-14 WEEKS POST-OP: (Early Strengthening Phase) GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  15-23 WEEKS POST-OP: (Late Strengthening Phase) GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 week. Continue with throwing program  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  24-26 WEEKS POST-OP: (Return to Sports or Full Activity) GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control","conversation_history":[],"metadata":{"question_type":"complex","seed_document_id":6,"topic":"Others"}}
{"id":"9a0afe17-19e0-4bcc-8a14-a362d7c9ac06","question":"Within the context of the Rehabilitation Protocol for SLAP Repair-Type II, what are the specific objectives or targets for the rehabilitation process during the intermediate post-operative phase, which is between 4 to 6 weeks after surgery?","reference_answer":"The rehabilitation goals for the intermediate post-op phase (4-6 weeks after surgery) in the Rehabilitation Protocol for SLAP Repair-Type II are to continue to protect the surgical repair, reduce swelling, minimize pain, gradually increase shoulder PROM, minimize substitution patterns with shoulder AAROM, initiate motor control exercise and provide patient education.","reference_context":"Document 4: Rehabilitation Protocol for Total Shoulder Arthroplasty and Hemiarthroplasty  This protocol is intended to guide clinicians and patients through the post-operative course after a total shoulder arthroplasty (TSA) and hemiarthroplasty. Specific interventions should be based on the needs of the individual and should consider exam findings and clinical decision making. If you have questions, contact the referring physician.  Considerations for the Total Shoulder Arthroplasty and Hemiarthroplasty Rehabilitation Program Many different factors influence the post-operative rehabilitation outcome, including surgical approach, concomitant repair of the rotator cuff, arthroplasty secondary to fracture, arthroplasty secondary to rheumatoid arthritis or osteonecrosis, and individual patient factors including co-morbidities. It is recommended that patients meet all rehabilitation criteria in order to progress to the next phase and clinicians collaborate closely with the referring physician throughout the rehabilitation process.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: IMMEDIATE POST-OP (0-3 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Maintain UE ROM in elbow, hand and wrist \u2022 Gradually increase shoulder PROM \u2022 Minimize muscle inhibition \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM \u2022 No reaching behind back, especially in to internal rotation \u2022 No excessive shoulder external rotation or abduction \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 Place small pillow\/towel roll under elbow while lying on back to avoid shoulder hyperextension Intervention Swelling Management \u2022 Ice, compression Range of motion\/Mobility \u2022 PROM: ER <\/= 30 degrees in the scapular plane, IR to belt line in scapular plane, Flex\/Scaption to tolerance, ABD <\/= 90 degrees, pendulums, seated GH flexion table slide, seated horizontal table slide \u2022 AAROM: Active assistive shoulder flexion \u2022 AROM: elbow, hand, wrist Strengthening (Week 2) \u2022 Periscapular: scap retraction, prone scapular retraction, standing scapular setting, supported scapular setting, inferior glide, low row \u2022 Ball squeeze Criteria to Progress \u2022 >\/= 50% shoulder PROM flex, scaption as compared to contralateral side \u2022 <\/= 90 degrees of shoulder ABD PROM \u2022 <\/= 30 degrees of shoulder ER PROM in scapular plane \u2022 >\/= 70 degrees of IR PROM in scapular plane  Palpable muscle contraction felt in scapular musculature  Pain < 4\/10  No complications with Phase I  PHASE II: INTERMEDIATE POST-OP (4-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Continue to protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM \u2022 Minimize substitution patterns with AROM and AAROM \u2022 Improve periscapular muscle activation\/strength \u2022 Initiate RTC (external rotators) activation \u2022 Patient education Sling \u2022 Use at night while sleeping \u2022 Gradually start weaning sling over the next two weeks during the day Precautions \u2022 No excessive shoulder external rotation or abduction \u2022 No lifting of objects heavier than a coffee cup \u2022 No supporting of body weight with hands \u2022 Place small pillow\/towel roll under elbow while lying on back to avoid shoulder hyperextension Intervention *Continue with Phase I interventions  Range of motion\/Mobility \u2022 PROM: Full with exception of ER <\/= 30 degrees in scapular plane and <\/= 90 degrees ABD \u2022 AAROM: shoulder flexion with cane, cane external rotation stretch, washcloth press, seated shoulder elevation with cane \u2022 AROM: supine flexion, salutes, supine punch Strengthening \u2022 Rotator cuff: external rotation isometrics \u2022 Periscapular: Row on physioball, serratus punches \u2022 Elbow: Biceps curl, resistance band bicep curls and triceps Motor control \u2022 ER in scaption and Flex 90-125 (rhythmic stabilization) Stretching \u2022 Sidelying horizontal ADD Criteria to Progress \u2022 >\/=75% shoulder PROM flex, scaption, as compared to contralateral side \u2022 >\/=75% shoulder PROM IR in scapular plane as compared to contralateral side \u2022 30 degrees of shoulder PROM ER in scapular plane \u2022 90 degrees of shoulder PROM ABD \u2022 Minimal substitution patterns with AAROM \u2022 AROM shoulder elevation to 100 degrees with minimal substitution patterns \u2022 Pain < 4\/10 \u2022 No complications with Phase II  PHASE III: INTERMEDIATE POST-OP CONTD (7-8 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue (especially the anterior capsule) \u2022 Minimize pain \u2022 Maintain PROM \u2022 Improve AROM \u2022 Progress periscapular and RTC strength \u2022 Return to full functional activities \u2022 Patient education Sling \u2022 Discontinue Precautions \u2022 No lifting of heavy objects (>10 lbs) Intervention *Continue with Phase I-II interventions Range of motion\/Mobility \u2022 Full ROM in all planes \u2022 AAROM: incline table slides, ball roll on wall, wall climbs, pulleys \u2022 AROM: seated scaption, seated flexion, supine forward elevation with elastic resistance to 90 deg  Strengthening \u2022 Rotator cuff: internal rotation isometrics, side-lying external rotation, \u2022 Standing external rotation w\/ resistance band, standing internal rotation w\/ resistance band, internal  rotation, external rotation, \u2022 Periscapular: Resistance band shoulder extension, resistance band seated rows, rowing, lawn mowers, robbery Motor control \u2022 IR\/ER and Flex 90-125 (rhythmic stabilization) \u2022 Quadruped alternating isometrics and ball stabilization on wall \u2022 PNF-D1 diagonal lifts, PNF-D2 diagonal lifts Stretching \u2022 IR behind back with towel, sidelying horizontal ADD, sleeper stretch, triceps and lats Criteria to Progress \u2022 Minimal to no substitution patterns with shoulder AROM \u2022 Pain < 4\/10  PHASE IV: TRANSITIONAL POST-OP (9-11 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue (especially the anterior capsule) \u2022 Maintain pain-free PROM \u2022 Continue improving AROM \u2022 Improve dynamic shoulder stability \u2022 Gradually restore shoulder strength and endurance Precautions \u2022 No lifting of heavy objects (> 10 lbs) \u2022 Avoid exercises that put stress on the anterior shoulder capsule (ie: shoulder ER above 80 degrees of ABD) Intervention *Continue with Phase II-III interventions Range of motion\/mobility \u2022 Full ROM in all planes Strengthening \u2022 Rotator cuff: increase resistance rotator cuff exercise \u2022 Periscapular: Push-up plus on knees, \u201cW\u201d exercise, resistance band Ws, dynamic hug, resistance band dynamic hug, prone shoulder extension Is, resistance band forward punch, forward punch, tripod, pointer Motor control \u2022 Resistance band PNF pattern, PNF \u2013 D1 diagonal lifts w\/ resistance, diagonal-up, diagonal-down Wall slides w\/ resistance band Criteria to Progress \u2022 Supine AROM Flex >\/=140 degrees \u2022 Supine AROM ABD >\/=120 degrees \u2022 Supine AROM ER in scapular plane >\/= 60 degrees \u2022 Supine AROM IR in scapular plane >\/= 70 degrees \u2022 AROM shoulder elevation to 120 degrees with minimal substitution patterns \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 Pain < 2\/10  PHASE V: ADVANCED STRENGTHENING POST-OP (12-16 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free ROM \u2022 Improve shoulder strength and endurance \u2022 Enhance functional use of upper extremity  Intervention *Continue with Phase II-IV interventions Strengthening \u2022 Rotator cuff:  External rotation at 90 degrees, internal rotation at 90 degrees, resistance band standing external rotation at 90 degrees, resistance band standing internal rotation at 90 degrees \u2022 Periscapular: T and Y, \u201cT\u201d exercise, push-up plus knees extended, wall push up Motor Control \u2022 Progress ball stabilization on wall to overhead alternating isometrics\/rhythmic stabilization  Criteria to Progress \u2022 Clearance from MD and ALL milestone criteria have been met \u2022 Maintains pain-free PROM and AROM \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 QuickDASH \u2022 PENN Return-to-Sport \u2022 For the recreational or competitive athlete, return-to-sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non-contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return-to-sport rehabilitation program.  Revised December 2018 Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol  References  Angst, F, Goldhahn, J, et al. Responsiveness of six outcome assessment instruments in total shoulder arthroplasty. Arthritis & Rheumatism. 2008. 59 (3): 391-398.  Garcia, GH, Liu, JN, et al. High satisfaction and return to sports after total shoulder arthroplasty in patients aged 55 years and younger. AJSM. 2017. 45 (7): 1664-1669.  Gaunt BW, McCluskey GM, Uhl TL. An electromyographic evaluation of subdividing active-assistive shoulder elevation exercises. Sports Health. 2010. 2 (5): 424-432.  Hughes, M, Neer II, CS. Glenohumeral joint replacement and postoperative rehabilitation. Physical Therapy. 1975. 55(8): 850-858.  Kibler, W.B., Sciascia, A. D., Uhl, T. L., et al. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. The American Journal of Sports Medicine. 2008. 36(9): p. 1789-1798.  Knesek M, Brunfeldt, A, et al. Patterns of strain and the determination of the safe arc of motion after subscapularis repair-a biomechanical study. Journal of Orthopaedic Research. 2016. 34: 518-524.  Piasecki, DP, Nicholson, GP. Tears of the subscapularis tendon in athletes-diagnosis and repair techniques. Clin Sports Med. 2008. 27: 731-745.  Uhl TL, Muir TA, et al. Electromyographical assessment of passive, active assistive, and active shoulder rehabilitation exercises. PM R. 2010. 2: 132-141.  Wilcox III R.B., Arslanian L.E., Millett P.J. Rehabilitation following total shoulder arthroplasty. JOSPT. 2005. 35 (12): 821-837  Wolff. AL, Rosenzweig, L. Anatomical and biomechanical framework for shoulder arthroplasty rehabilitation. Journal of Hand Therapy. 2017. 30: 167-174.  Wright, T, Easley, T, et al. Shoulder arthroplasty and its effect on strain in the subscapularis muscle. Clinical Biomechanics. 2015. 30: 373-376.  Zarkadas P.C., Throckmorton T., et al. Patient reported activities after shoulder replacement: total and hemiarthroplasty. J Shoulder Elbow Surg. 2011. 20: 273-280.  Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med. 1996;(6):602-608.  Leggin BG, Michener, LA, et al. The Penn Shoulder Score: reliability and validity. JOSPT. 36 (3): 138-151.\n\nDocument 5: Rehabilitation Protocol for Sternoclavicular Joint Reconstruction  This protocol is intended to guide clinicians through the post-operative course for sternoclavicular joint reconstruction. This protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs of the individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes contained within this guideline may vary based on surgeon\u2019s preference, additional procedures performed, and\/or complications. If a clinician requires assistance in the progression of a post-operative patient, they should consult with the referring surgeon.  The interventions included within this protocol are not intended to be an inclusive list of exercises. Therapeutic interventions should be included and modified based on the progress of the patient and under the discretion of the clinician.  Considerations for the Post-operative sternoclavicular joint reconstruction Many different factors influence the post-operative rehabilitation outcome, including surgical technique (ie. tendon autograft harvest for repair), degree of SC joint instability, concomitant soft tissue or bone injury\/repair, and individual patient factors including co-morbidities. It is recommended that patients meet all rehabilitation criteria in order to progress to the next phase and clinicians collaborate closely with the referring physician throughout the rehabilitation process.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: EARLY POST-OP (0-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Reduce pain and swelling of the operative shoulder \u2022 Maintain elbow, wrist and hand AROM \u2022 Patient education Sling\/precautions \u2022 Sling to be worn for 6 weeks (or as directed by surgeon) \u2022 Avoid PROM of the glenohumeral joint \u2022 Avoid scapular AROM (protraction, retraction, depression and elevation) as it may disrupt the repair and healing tissues \u2022 Avoid bearing weight through involved extremity \u2022 Avoid lifting any lifting with involved extremity \u2022 Avoid running and jumping due to impact forces upon landing that may aggravate healing tissues and bone Intervention \u2022 Cryotherapy as needed \u2022 AROM: cervical spine, elbow, wrist, hand \u2022 Hand gripping: ball squeeze \u2022 Cardiovascular exercise as tolerated: walking, stationary bike Criteria to Progress \u2022 Well controlled pain and swelling \u2022 Protect reconstruction site and autograft site (if applicable) \u2022 Maintain elbow, wrist and hand AROM  PHASE II: INTERMEDIATE POST-OP (6-12WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Activation of muscles responsible for stabilizing the scapulothoracic and glenohumeral joint \u2022 Gradually restore PROM, AAROM of the GH joint at 6-8 weeks \u2022 Gradually restore AROM of the scapulothoracic joint and glenohumeral joint at 8 weeks \u2022 Wean from sling (if still wearing) \u2022 Begin shoulder and scapular strengthening at 8 weeks \u2022 Begin proprioception and neuromuscular control training \u2022 Identify and correct postural dysfunction as indicated Sling\/precautions \u2022 Avoid repetitive overhead activities \u2022 No lifting > 5 pounds with involved extremity until 9 weeks post-op \u2022 Post-rehabilitation soreness should resolve within 12-24 hours Additional Interventions *Continue with Phase I interventions \u2022 AROM in all cardinal plane assessing scapular rhythm \u2022 Gentle glenohumeral mobilization as indicated  Strengthening: \u2022 Rotator cuff strengthening in non-provocative positions (generally 0-45 degrees Scaption\/abduction): scaption raises against gravity, Sidelying ER, lightly resisted ER\/IR with theraband, isometrics \u2022 Scapular strengthening and dynamic neuromuscular control: low row, straight arm pulldowns, serratus punch, resisted T\u2019s  Stretching: Gentle corner or doorway pec stretch \u2022 Postural endurance exercises: scapular retractions, chin tucks \u2022 Walking, stationary bike, Stairmaster Criteria to Progress \u2022 Full AROM of the operative shoulder \u2022 Normal (5\/5) strength for glenohumeral flexion\/abduction\/IR\/ER degrees abduction  PHASE III: LATE POST-OP AND GRADUAL RETURN TO SPORT(13+ WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Restore normal (5\/5) rotator cuff strength at 90 degrees abduction including supraspinatus \u2022 Full multi-planar AROM with minimal to no substitution patterns \u2022 Advance proprioceptive and dynamic neuromuscular control training \u2022 Identify and correct postural dysfunction with sport\/work specific tasks as indicated \u2022 Develop strength and control movements required for sport\/work Sling\/ precautions \u2022 Post-rehabilitation soreness should resolve within 12 hours \u2022 No lifting restrictions at ~4 months Additional Interventions *Continue with Phase I-II Interventions \u2022 Glenohumeral mobilizations as indicated \u2022 Multiplane AROM with gradual increase in velocity of movement  Strengthening: \u2022 Rotator cuff strengthening at 45 degrees progressing to 90 degrees abduction and sport\/work specific positions as well as other provocative positions: resisted IR\/ER, elevation with ER, resisted scaption raises, facepulls\/resisted W\u2019s \u2022 Scapular strengthening and dynamic neuromuscular control in overhead or sport\/work positions: prone or resisted I\u2019s, T\u2019s and Y\u2019s, lower trap setting at wall, manual perturbations in varying degrees in elevation, serratus wall slides\/roll ups, wall pushups, quadruped shoulder taps \u2022 Core strengthening  Stretching:  Corner or doorway pec stretch, Gentle posterior capsule stretch (across body)  Walking, stationary bike, Stairmaster, return to running\/jumping as tolerated  Begin education in sport specific biomechanics with initial program for throwing, swimming, or overhead racquet sports Criteria to Return to Sport  Clearance from MD and ALL milestone criteria have been met  Maintains pain  free PROM and AROM  Performs all exercises demonstrating symmetric scapular mechanics  QuickDASH  PENN  For the recreational or competitive athlete, return  to  sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non  contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return  to  sport rehabilitation program.  Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol References: 1. Logan C, Shahien A, Altintas B, Millett PJ. Rehabilitation following sternoclavicular joint reconstruction for persistent instability. International Journal of Sports Physical Therapy. 2018;13(4):752-762. doi:10.26603\/ijspt20180752 2. Petri, M., Greenspoon, J. A., Horan, M. P., Martetschl\u00e4ger, F., Warth, R. J., & Millett, P. J. (2016). Clinical outcomes after autograft reconstruction for sternoclavicular joint instability. Journal of Shoulder and Elbow Surgery, 25(3), 435\u2013441. https:\/\/doi.org\/10.1016\/j.jse.2015.08.004 3. Garcia JA, Arguello AM, Momaya AM, Ponce BA. Sternoclavicular Joint Instability: Symptoms, Diagnosis And Management. Orthop Res Rev. 2020 Jul 28;12:75-87. doi: 10.2147\/ORR.S170964. PMID: 32801951; PMCID: PMC7395708.\n\nDocument 3: Rehabilitation Protocol for SLAP Repair-Type II  This protocol is intended to guide clinicians through the post-operative course for SLAP Repair-Type II. This protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs of the individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes contained within this guideline may vary based on surgeon\u2019s preference, additional procedures performed, and\/or complications. If a clinician requires assistance in the progression of a post-operative patient, they should consult with the referring surgeon.  The interventions included within this protocol are not intended to be an inclusive list. Therapeutic interventions should be included and modified based on the progress of the patient and under the discretion of the clinician.  Considerations for the Post-operative SLAP repair Rehabilitation Program Many different factors influence the post-operative SLAP repair rehabilitation outcome, including the type of SLAP lesion, the size of the tear\/number of anchors placed, concomitant procedures and amount of shoulder hypermobility and\/or hyperlaxity. Consider mechanism of injury as well as the sport the athlete would like to return to when initiating certain interventions.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: IMMEDIATE POST-OP (0-3 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Maintain UE ROM in elbow, hand and wrist \u2022 Gradually increase shoulder PROM \u2022 Minimize muscle inhibition \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM\/AAROM \u2022 No elbow AROM (avoid biceps contraction) \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 No reaching behind back Intervention Swelling Management \u2022 Ice, compression  Range of motion\/Mobility \u2022 PROM: ER<30 scapular plane, Forward elevation <90, full elbow flex and ext, seated GH flexion table slide, horizontal table slide (add hyperlink) \u2022 AROM: hand, wrist \u2022 AAROM: none  Strengthening (Week 2)  Periscapular: scap retraction  , prone scapular retraction  , standing scapular setting  , supported scapular setting, inferior glide, low row  to neutral; avoid shoulder extension  Rotator cuff: submaximal pain  free isometrics  Ball squeeze Criteria to Progress  90 degrees shoulder PROM forward elevation  30 degrees of shoulder PROM ER in the scapular plane  Full elbow PROM flexion and extension  Palpable muscle contraction felt in scapular and shoulder musculature  No complications with Phase I  PHASE II: INTERMEDIATE POST-OP (4-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Continue to protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM \u2022 Minimize substitution patterns with shoulder AAROM \u2022 Initiate motor control exercise \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM \u2022 No elbow AROM (avoid biceps contraction) \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 No reaching behind back Intervention *Continue with Phase I interventions  Range of motion\/Mobility \u2022 PROM: ER<45 scapular plane, Forward elevation <120 \u2022 AAROM: Active assistive shoulder flexion, shoulder flexion with cane, cane external rotation stretch, washcloth press, sidelying elevation to 90 degrees  Strengthening \u2022 Periscapular: Row on physioball*, shoulder extension on physioball*, serratus punches - *to neutral; avoid shoulder extension  Motor Control \u2022 Internal and external rotation in scaption and Flex 90-125 (rhythmic stabilization)  Stretching \u2022 Sidelying horizontal ADD, sleeper stretch Criteria to Progress \u2022 120 degrees shoulder PROM forward elevation \u2022 45 degrees shoulder PROM ER in scapular plane \u2022 Minimal substitution patterns with shoulder AAROM \u2022 Pain < 4\/10 \u2022 No complications with Phase II  PHASE III: INTERMEDIATE POST-OP CONT\u2019d (7-8 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM\/AAROM \u2022 Initiate shoulder and elbow AROM \u2022 Initiate RTC strengthening  Improve scapular muscle activation  Patient education Sling  Discontinue Precautions  No resisted elbow flexion  No lifting of heavy objects (>10 lbs) Intervention  Continue with Phase I  II interventions Range of motion\/Mobility  PROM: ER Full in scapular plane, \uf0a390 degrees ER in 90 degrees of abduction, IR Full in scapular plane, Forward elevation Full  do not push beyond 90 degrees ER in 90 degrees of abduction  AAROM: seated shoulder elevation with cane, seated incline table slides, ball roll on wall  AROM: supine flexion, salutes, supine punch, wall climbs, elbow flexion  Strengthening \u2022 Rotator cuff: side-lying external rotation, standing external rotation w\/ resistance band, standing internal rotation w\/ resistance band, internal  rotation, external rotation \u2022 Periscapular: Resistance band shoulder extension*, resistance band seated rows*, rowing*, lawn mowers, robbery - *to neutral; avoid shoulder extension \u2022 Elbow: Triceps  Motor Control \u2022 Quadruped alternating isometrics Criteria to Progress \u2022 Full pain-free shoulder PROM ER and forward elevation \u2022 Within 10 degrees of shoulder IR PROM of contralateral shoulder \u2022 Minimal substitution patterns with shoulder AROM \u2022 Pain < 4\/10  PHASE IV: TRANSITIONAL POST-OP (9-12 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue \u2022 Restore full shoulder PROM and AROM \u2022 Initiate resisted elbow flexion at 12 weeks \u2022 Improve dynamic shoulder stability \u2022 Progress periscapular strength \u2022 Gradually return to full functional activities Precautions \u2022 No lifting of heavy objects (> 10 lbs) Intervention *Continue with Phase II-III interventions Range of motion\/mobility \u2022 PROM: Full \u2022 AROM: Supine forward elevation with elastic resistance to 90 deg, scaption and shoulder flexion to 90  degrees elevation  Strengthening \u2022 Periscapular: Push-up plus on knees, prone shoulder extension Is*, resistance band forward punch, forward punch, tripod o *to neutral; avoid shoulder extension \u2022 Elbow (12 weeks): Biceps curl, resistance band bicep curls  Motor control  Ball stabilization on wall  Stretching \u2022 Hands behind head, IR behind back with towel, triceps and lats, doorway series Criteria to Progress \u2022 Full pain-free shoulder PROM and AROM \u2022 Minimal to no substitution patterns with shoulder AROM \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 Pain < 2\/10  PHASE V: LATE POST-OP (13-16 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free shoulder ROM \u2022 Enhance functional use of upper extremity Intervention *Continue with Phase II-IV interventions Strengthening \u2022 Rotator cuff: External rotation at 90 degrees, internal rotation at 90 degrees, resistance band standing external rotation at 90 degrees, resistance band standing internal rotation at 90 degrees \u2022 Periscapular: T and Y, \u201cT\u201d exercise, push-up plus knees extended, pointer, wall push up, \u201cW\u201d exercise, resistance band Ws, dynamic hug, resistance band dynamic hug  Motor Control \u2022  PNF \u2013 D1 diagonal lifts, PNF \u2013 D2 diagonal lifts, field goals , resistance band PNF pattern, PNF \u2013 D1 diagonal lifts w\/ resistance, diagonal-up, diagonal-down, wall slides w\/ resistance band Criteria to Progress \u2022 Clearance from MD and ALL milestone criteria below have been met \u2022 Full pain-free shoulder PROM and AROM \u2022 ER\/IR strength minimum 85% of the uninvolved arm \u2022 ER\/IR ratio 60% or higher \u2022 Negative impingement and instability signs \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 QuickDASH \u2022 PENN  PHASE VI: EARLY RETURN-TO-SPORT (4-6 MONTHS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free ROM \u2022 Continue strengthening and motor control exercises \u2022 Enhance functional use of upper extremity \u2022 Gradual return to strenuous work\/sport activity Intervention *Continue with Phase II-V interventions Strengthening \u2022 See specific return-to-sport\/throwing program (coordinate with physician) Criteria to Progress \u2022 Last stage-no additional criteria Return-to-Sport \u2022 For the recreational or competitive athlete, return-to-sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non-contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return-to-sport rehabilitation program. Revised 7\/2020  Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol  References:  1. Ahsan, ZS, Hsu JE, et al. The Snyder classification of superior labrum anterior and posterior (SLAP) lesions. Clin Orthop Relat Res. 2016. 474:2075- 2078.  2. Christopher ZR, Kennedy J, et al. Rehabilitation and return to play following superior labral anterior to posterior repair. Oper Tech Sports Med. 2017. 25:132-144.  3. Cools AM, Borms D, Cottens S, et al. Rehabilitation exercises for athletes with biceps disorders and SLAP lesions. AJSM. 2014. 42(6): 1315-1323.  4. Itoi E, Hatakeyama Y, et al. Position of immobilization after dislocation of the shoulder. JBJS. 1999. 81-A(3): 385-390.  5. Kibler, W.B., Sciascia, A. D., Uhl, T. L., et al. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. The American Journal of Sports Medicine. 2008. 36(9): p. 1789-1798.  6. Wilk KE, Reinold MM, et al. Current concepts in the recognition and treatment of superior labral (SLAP) lesions. JOSPT. 2005. 35(5): 273-291.","conversation_history":[],"metadata":{"question_type":"complex","seed_document_id":4,"topic":"Others"}}
{"id":"9b35fc94-160a-4e1a-aa0f-2b691f14cdcf","question":"Given that the patient has undergone a LEFT or RIGHT Shoulder Arthroscopic Large Rotator Cuff Repair, what is the recommended frequency of physical therapy sessions per week, taking into account factors such as surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear?","reference_answer":"The recommended frequency of visits per week for the physical therapy sessions for a rotator cuff repair is 2 to 3 times.","reference_context":"Document 7: Visit per week:  2 to 3 times  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Advanced Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  2  4 WEEKS POST  OP (Maximum Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN)  2  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises  Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  4  6 WEEKS POST  OP (Moderate Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  3  7  12 WEEKS POST  OP: (Early Strengthening Phase)  GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  13  19 WEEKS POST  OP: (Late Strengthening Phase)  GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 weeks  Continue with throwing and racquet program if appropriate  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  20-24 WEEKS POST-OP: (Return to Sports or Full Activity)  GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control\n\nDocument 2: Visit per week:  2 to 3 times  Diagnosis:   LEFT or RIGHT Shoulder Arthroscopic Large Rotator Cuff Repair - Supraspinatus and Infraspinatus Repair - Subscapularis Repair  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Slow or Conservative Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  ** Weeks 0-3: Patient stays in the sling and abduction pillow at all times. Pendulums ok to start Week #3 (NO PAIN). NO Shoulder PROM. Elbow and wrist ROM is ok. **  4-6 WEEKS POST-OP (Maximum Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility  2 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Start Post Op Week #4 Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN), Pts with Subscapularis Repair: (Limit Passive ER to 20\u00b0)  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises and Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  6-8 WEEKS POST-OP (Moderate Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain  3 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  9-14 WEEKS POST-OP: (Early Strengthening Phase) GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  15-23 WEEKS POST-OP: (Late Strengthening Phase) GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 week. Continue with throwing program  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  24-26 WEEKS POST-OP: (Return to Sports or Full Activity) GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control\n\nDocument 6: PHYSICAL THERAPY PRESCRIPTION:  TOTAL SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: At all times except for showering and exercise. (Sleep in sofa recliner)  Total of 6 weeks in the Sling and the Abduction pillow  Exercises: Pendulums ok 2 weeks after surgery Passive ER to 10 degrees and extension to neutral  Passive supine FF in scapular plane to 130 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed  Advancement Criteria: ER the above set criteria FF in scapular plane to 130 Minimal pain and inflammation with motion and exercise Incision is well healed with no drainage and no redness  Weeks 6  10: Phase II  Sling Immobilizer: Discontinue at week 6  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER \u2013 limit 45 deg  2  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF to 150  ER to 45  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF 160, ER >45  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  3  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation\n\nDocument 8: PHYSICAL THERAPY PRESCRIPTION:  REVERSE SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: Please Transition out of the sling between 2 to 3 weeks after surgery (Sleep in sofa recliner with your sling for the first 2 weeks) for Primary Reverse Shoulder Replacement or 5 to 6 weeks for Fracture and Revision Reverse Shoulder Replacement.  2 Weeks  6 Weeks  Activities of Daily Living: You may use your arm and hand on the operative shoulder for your ADL activates 2 weeks after surgery. Pendulums are also encouraged 1 week after surgery.  Exercises: Passive ER to 20 degrees and extension to neutral, pendulums daily  Passive supine FF in scapular plane to 90 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed: ice  Advancement Criteria: ER to the above set criteria FF in scapular plane to 90 Minimal pain and inflammation with any motion or exercise Incision is well healed with no drainage or redness  2  Weeks 6  10: Phase II  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER as tolerated by the patient  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF > 120  ER > 30  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF > 120, ER >30  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  3  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation","conversation_history":[],"metadata":{"question_type":"distracting element","seed_document_id":7,"distracting_context":"Visit per week:  2 to 3 times  Diagnosis:   LEFT or RIGHT Shoulder Arthroscopic Large Rotator Cuff Repair - Supraspinatus and Infraspinatus Repair - Subscapularis Repair  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Slow or Conservative Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  ** Weeks 0-3: Patient stays in the sling and abduction pillow at all times. Pendulums ok to start Week #3 (NO PAIN). NO Shoulder PROM. Elbow and wrist ROM is ok. **  4-6 WEEKS POST-OP (Maximum Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility  2 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Start Post Op Week #4 Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN), Pts with Subscapularis Repair: (Limit Passive ER to 20\u00b0)  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises and Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  6-8 WEEKS POST-OP (Moderate Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain  3 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  9-14 WEEKS POST-OP: (Early Strengthening Phase) GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  15-23 WEEKS POST-OP: (Late Strengthening Phase) GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 week. Continue with throwing program  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  24-26 WEEKS POST-OP: (Return to Sports or Full Activity) GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control","topic":"Others"}}
{"id":"cec27540-a827-43c9-b48d-06b2304ea8df","question":"In the context of a rehabilitation program after a Total Shoulder Arthroplasty and Hemiarthroplasty, what are the specific goals to be achieved during the immediate post-operative phase, considering patient factors such as co-morbidities and potential post-operative complications?","reference_answer":"The goals of the immediate post-operative phase after a Total Shoulder Arthroplasty and Hemiarthroplasty are to protect the surgical repair, reduce swelling, minimize pain, maintain upper extremity range of motion in elbow, hand and wrist, gradually increase shoulder passive range of motion, minimize muscle inhibition, and provide patient education.","reference_context":"Document 3: Rehabilitation Protocol for SLAP Repair-Type II  This protocol is intended to guide clinicians through the post-operative course for SLAP Repair-Type II. This protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs of the individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes contained within this guideline may vary based on surgeon\u2019s preference, additional procedures performed, and\/or complications. If a clinician requires assistance in the progression of a post-operative patient, they should consult with the referring surgeon.  The interventions included within this protocol are not intended to be an inclusive list. Therapeutic interventions should be included and modified based on the progress of the patient and under the discretion of the clinician.  Considerations for the Post-operative SLAP repair Rehabilitation Program Many different factors influence the post-operative SLAP repair rehabilitation outcome, including the type of SLAP lesion, the size of the tear\/number of anchors placed, concomitant procedures and amount of shoulder hypermobility and\/or hyperlaxity. Consider mechanism of injury as well as the sport the athlete would like to return to when initiating certain interventions.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: IMMEDIATE POST-OP (0-3 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Maintain UE ROM in elbow, hand and wrist \u2022 Gradually increase shoulder PROM \u2022 Minimize muscle inhibition \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM\/AAROM \u2022 No elbow AROM (avoid biceps contraction) \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 No reaching behind back Intervention Swelling Management \u2022 Ice, compression  Range of motion\/Mobility \u2022 PROM: ER<30 scapular plane, Forward elevation <90, full elbow flex and ext, seated GH flexion table slide, horizontal table slide (add hyperlink) \u2022 AROM: hand, wrist \u2022 AAROM: none  Strengthening (Week 2)  Periscapular: scap retraction  , prone scapular retraction  , standing scapular setting  , supported scapular setting, inferior glide, low row  to neutral; avoid shoulder extension  Rotator cuff: submaximal pain  free isometrics  Ball squeeze Criteria to Progress  90 degrees shoulder PROM forward elevation  30 degrees of shoulder PROM ER in the scapular plane  Full elbow PROM flexion and extension  Palpable muscle contraction felt in scapular and shoulder musculature  No complications with Phase I  PHASE II: INTERMEDIATE POST-OP (4-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Continue to protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM \u2022 Minimize substitution patterns with shoulder AAROM \u2022 Initiate motor control exercise \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM \u2022 No elbow AROM (avoid biceps contraction) \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 No reaching behind back Intervention *Continue with Phase I interventions  Range of motion\/Mobility \u2022 PROM: ER<45 scapular plane, Forward elevation <120 \u2022 AAROM: Active assistive shoulder flexion, shoulder flexion with cane, cane external rotation stretch, washcloth press, sidelying elevation to 90 degrees  Strengthening \u2022 Periscapular: Row on physioball*, shoulder extension on physioball*, serratus punches - *to neutral; avoid shoulder extension  Motor Control \u2022 Internal and external rotation in scaption and Flex 90-125 (rhythmic stabilization)  Stretching \u2022 Sidelying horizontal ADD, sleeper stretch Criteria to Progress \u2022 120 degrees shoulder PROM forward elevation \u2022 45 degrees shoulder PROM ER in scapular plane \u2022 Minimal substitution patterns with shoulder AAROM \u2022 Pain < 4\/10 \u2022 No complications with Phase II  PHASE III: INTERMEDIATE POST-OP CONT\u2019d (7-8 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM\/AAROM \u2022 Initiate shoulder and elbow AROM \u2022 Initiate RTC strengthening  Improve scapular muscle activation  Patient education Sling  Discontinue Precautions  No resisted elbow flexion  No lifting of heavy objects (>10 lbs) Intervention  Continue with Phase I  II interventions Range of motion\/Mobility  PROM: ER Full in scapular plane, \uf0a390 degrees ER in 90 degrees of abduction, IR Full in scapular plane, Forward elevation Full  do not push beyond 90 degrees ER in 90 degrees of abduction  AAROM: seated shoulder elevation with cane, seated incline table slides, ball roll on wall  AROM: supine flexion, salutes, supine punch, wall climbs, elbow flexion  Strengthening \u2022 Rotator cuff: side-lying external rotation, standing external rotation w\/ resistance band, standing internal rotation w\/ resistance band, internal  rotation, external rotation \u2022 Periscapular: Resistance band shoulder extension*, resistance band seated rows*, rowing*, lawn mowers, robbery - *to neutral; avoid shoulder extension \u2022 Elbow: Triceps  Motor Control \u2022 Quadruped alternating isometrics Criteria to Progress \u2022 Full pain-free shoulder PROM ER and forward elevation \u2022 Within 10 degrees of shoulder IR PROM of contralateral shoulder \u2022 Minimal substitution patterns with shoulder AROM \u2022 Pain < 4\/10  PHASE IV: TRANSITIONAL POST-OP (9-12 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue \u2022 Restore full shoulder PROM and AROM \u2022 Initiate resisted elbow flexion at 12 weeks \u2022 Improve dynamic shoulder stability \u2022 Progress periscapular strength \u2022 Gradually return to full functional activities Precautions \u2022 No lifting of heavy objects (> 10 lbs) Intervention *Continue with Phase II-III interventions Range of motion\/mobility \u2022 PROM: Full \u2022 AROM: Supine forward elevation with elastic resistance to 90 deg, scaption and shoulder flexion to 90  degrees elevation  Strengthening \u2022 Periscapular: Push-up plus on knees, prone shoulder extension Is*, resistance band forward punch, forward punch, tripod o *to neutral; avoid shoulder extension \u2022 Elbow (12 weeks): Biceps curl, resistance band bicep curls  Motor control  Ball stabilization on wall  Stretching \u2022 Hands behind head, IR behind back with towel, triceps and lats, doorway series Criteria to Progress \u2022 Full pain-free shoulder PROM and AROM \u2022 Minimal to no substitution patterns with shoulder AROM \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 Pain < 2\/10  PHASE V: LATE POST-OP (13-16 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free shoulder ROM \u2022 Enhance functional use of upper extremity Intervention *Continue with Phase II-IV interventions Strengthening \u2022 Rotator cuff: External rotation at 90 degrees, internal rotation at 90 degrees, resistance band standing external rotation at 90 degrees, resistance band standing internal rotation at 90 degrees \u2022 Periscapular: T and Y, \u201cT\u201d exercise, push-up plus knees extended, pointer, wall push up, \u201cW\u201d exercise, resistance band Ws, dynamic hug, resistance band dynamic hug  Motor Control \u2022  PNF \u2013 D1 diagonal lifts, PNF \u2013 D2 diagonal lifts, field goals , resistance band PNF pattern, PNF \u2013 D1 diagonal lifts w\/ resistance, diagonal-up, diagonal-down, wall slides w\/ resistance band Criteria to Progress \u2022 Clearance from MD and ALL milestone criteria below have been met \u2022 Full pain-free shoulder PROM and AROM \u2022 ER\/IR strength minimum 85% of the uninvolved arm \u2022 ER\/IR ratio 60% or higher \u2022 Negative impingement and instability signs \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 QuickDASH \u2022 PENN  PHASE VI: EARLY RETURN-TO-SPORT (4-6 MONTHS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free ROM \u2022 Continue strengthening and motor control exercises \u2022 Enhance functional use of upper extremity \u2022 Gradual return to strenuous work\/sport activity Intervention *Continue with Phase II-V interventions Strengthening \u2022 See specific return-to-sport\/throwing program (coordinate with physician) Criteria to Progress \u2022 Last stage-no additional criteria Return-to-Sport \u2022 For the recreational or competitive athlete, return-to-sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non-contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return-to-sport rehabilitation program. Revised 7\/2020  Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol  References:  1. Ahsan, ZS, Hsu JE, et al. The Snyder classification of superior labrum anterior and posterior (SLAP) lesions. Clin Orthop Relat Res. 2016. 474:2075- 2078.  2. Christopher ZR, Kennedy J, et al. Rehabilitation and return to play following superior labral anterior to posterior repair. Oper Tech Sports Med. 2017. 25:132-144.  3. Cools AM, Borms D, Cottens S, et al. Rehabilitation exercises for athletes with biceps disorders and SLAP lesions. AJSM. 2014. 42(6): 1315-1323.  4. Itoi E, Hatakeyama Y, et al. Position of immobilization after dislocation of the shoulder. JBJS. 1999. 81-A(3): 385-390.  5. Kibler, W.B., Sciascia, A. D., Uhl, T. L., et al. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. The American Journal of Sports Medicine. 2008. 36(9): p. 1789-1798.  6. Wilk KE, Reinold MM, et al. Current concepts in the recognition and treatment of superior labral (SLAP) lesions. JOSPT. 2005. 35(5): 273-291.\n\nDocument 5: Rehabilitation Protocol for Sternoclavicular Joint Reconstruction  This protocol is intended to guide clinicians through the post-operative course for sternoclavicular joint reconstruction. This protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs of the individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes contained within this guideline may vary based on surgeon\u2019s preference, additional procedures performed, and\/or complications. If a clinician requires assistance in the progression of a post-operative patient, they should consult with the referring surgeon.  The interventions included within this protocol are not intended to be an inclusive list of exercises. Therapeutic interventions should be included and modified based on the progress of the patient and under the discretion of the clinician.  Considerations for the Post-operative sternoclavicular joint reconstruction Many different factors influence the post-operative rehabilitation outcome, including surgical technique (ie. tendon autograft harvest for repair), degree of SC joint instability, concomitant soft tissue or bone injury\/repair, and individual patient factors including co-morbidities. It is recommended that patients meet all rehabilitation criteria in order to progress to the next phase and clinicians collaborate closely with the referring physician throughout the rehabilitation process.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: EARLY POST-OP (0-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Reduce pain and swelling of the operative shoulder \u2022 Maintain elbow, wrist and hand AROM \u2022 Patient education Sling\/precautions \u2022 Sling to be worn for 6 weeks (or as directed by surgeon) \u2022 Avoid PROM of the glenohumeral joint \u2022 Avoid scapular AROM (protraction, retraction, depression and elevation) as it may disrupt the repair and healing tissues \u2022 Avoid bearing weight through involved extremity \u2022 Avoid lifting any lifting with involved extremity \u2022 Avoid running and jumping due to impact forces upon landing that may aggravate healing tissues and bone Intervention \u2022 Cryotherapy as needed \u2022 AROM: cervical spine, elbow, wrist, hand \u2022 Hand gripping: ball squeeze \u2022 Cardiovascular exercise as tolerated: walking, stationary bike Criteria to Progress \u2022 Well controlled pain and swelling \u2022 Protect reconstruction site and autograft site (if applicable) \u2022 Maintain elbow, wrist and hand AROM  PHASE II: INTERMEDIATE POST-OP (6-12WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Activation of muscles responsible for stabilizing the scapulothoracic and glenohumeral joint \u2022 Gradually restore PROM, AAROM of the GH joint at 6-8 weeks \u2022 Gradually restore AROM of the scapulothoracic joint and glenohumeral joint at 8 weeks \u2022 Wean from sling (if still wearing) \u2022 Begin shoulder and scapular strengthening at 8 weeks \u2022 Begin proprioception and neuromuscular control training \u2022 Identify and correct postural dysfunction as indicated Sling\/precautions \u2022 Avoid repetitive overhead activities \u2022 No lifting > 5 pounds with involved extremity until 9 weeks post-op \u2022 Post-rehabilitation soreness should resolve within 12-24 hours Additional Interventions *Continue with Phase I interventions \u2022 AROM in all cardinal plane assessing scapular rhythm \u2022 Gentle glenohumeral mobilization as indicated  Strengthening: \u2022 Rotator cuff strengthening in non-provocative positions (generally 0-45 degrees Scaption\/abduction): scaption raises against gravity, Sidelying ER, lightly resisted ER\/IR with theraband, isometrics \u2022 Scapular strengthening and dynamic neuromuscular control: low row, straight arm pulldowns, serratus punch, resisted T\u2019s  Stretching: Gentle corner or doorway pec stretch \u2022 Postural endurance exercises: scapular retractions, chin tucks \u2022 Walking, stationary bike, Stairmaster Criteria to Progress \u2022 Full AROM of the operative shoulder \u2022 Normal (5\/5) strength for glenohumeral flexion\/abduction\/IR\/ER degrees abduction  PHASE III: LATE POST-OP AND GRADUAL RETURN TO SPORT(13+ WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Restore normal (5\/5) rotator cuff strength at 90 degrees abduction including supraspinatus \u2022 Full multi-planar AROM with minimal to no substitution patterns \u2022 Advance proprioceptive and dynamic neuromuscular control training \u2022 Identify and correct postural dysfunction with sport\/work specific tasks as indicated \u2022 Develop strength and control movements required for sport\/work Sling\/ precautions \u2022 Post-rehabilitation soreness should resolve within 12 hours \u2022 No lifting restrictions at ~4 months Additional Interventions *Continue with Phase I-II Interventions \u2022 Glenohumeral mobilizations as indicated \u2022 Multiplane AROM with gradual increase in velocity of movement  Strengthening: \u2022 Rotator cuff strengthening at 45 degrees progressing to 90 degrees abduction and sport\/work specific positions as well as other provocative positions: resisted IR\/ER, elevation with ER, resisted scaption raises, facepulls\/resisted W\u2019s \u2022 Scapular strengthening and dynamic neuromuscular control in overhead or sport\/work positions: prone or resisted I\u2019s, T\u2019s and Y\u2019s, lower trap setting at wall, manual perturbations in varying degrees in elevation, serratus wall slides\/roll ups, wall pushups, quadruped shoulder taps \u2022 Core strengthening  Stretching:  Corner or doorway pec stretch, Gentle posterior capsule stretch (across body)  Walking, stationary bike, Stairmaster, return to running\/jumping as tolerated  Begin education in sport specific biomechanics with initial program for throwing, swimming, or overhead racquet sports Criteria to Return to Sport  Clearance from MD and ALL milestone criteria have been met  Maintains pain  free PROM and AROM  Performs all exercises demonstrating symmetric scapular mechanics  QuickDASH  PENN  For the recreational or competitive athlete, return  to  sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non  contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return  to  sport rehabilitation program.  Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol References: 1. Logan C, Shahien A, Altintas B, Millett PJ. Rehabilitation following sternoclavicular joint reconstruction for persistent instability. International Journal of Sports Physical Therapy. 2018;13(4):752-762. doi:10.26603\/ijspt20180752 2. Petri, M., Greenspoon, J. A., Horan, M. P., Martetschl\u00e4ger, F., Warth, R. J., & Millett, P. J. (2016). Clinical outcomes after autograft reconstruction for sternoclavicular joint instability. Journal of Shoulder and Elbow Surgery, 25(3), 435\u2013441. https:\/\/doi.org\/10.1016\/j.jse.2015.08.004 3. Garcia JA, Arguello AM, Momaya AM, Ponce BA. Sternoclavicular Joint Instability: Symptoms, Diagnosis And Management. Orthop Res Rev. 2020 Jul 28;12:75-87. doi: 10.2147\/ORR.S170964. PMID: 32801951; PMCID: PMC7395708.\n\nDocument 4: Rehabilitation Protocol for Total Shoulder Arthroplasty and Hemiarthroplasty  This protocol is intended to guide clinicians and patients through the post-operative course after a total shoulder arthroplasty (TSA) and hemiarthroplasty. Specific interventions should be based on the needs of the individual and should consider exam findings and clinical decision making. If you have questions, contact the referring physician.  Considerations for the Total Shoulder Arthroplasty and Hemiarthroplasty Rehabilitation Program Many different factors influence the post-operative rehabilitation outcome, including surgical approach, concomitant repair of the rotator cuff, arthroplasty secondary to fracture, arthroplasty secondary to rheumatoid arthritis or osteonecrosis, and individual patient factors including co-morbidities. It is recommended that patients meet all rehabilitation criteria in order to progress to the next phase and clinicians collaborate closely with the referring physician throughout the rehabilitation process.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: IMMEDIATE POST-OP (0-3 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Maintain UE ROM in elbow, hand and wrist \u2022 Gradually increase shoulder PROM \u2022 Minimize muscle inhibition \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM \u2022 No reaching behind back, especially in to internal rotation \u2022 No excessive shoulder external rotation or abduction \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 Place small pillow\/towel roll under elbow while lying on back to avoid shoulder hyperextension Intervention Swelling Management \u2022 Ice, compression Range of motion\/Mobility \u2022 PROM: ER <\/= 30 degrees in the scapular plane, IR to belt line in scapular plane, Flex\/Scaption to tolerance, ABD <\/= 90 degrees, pendulums, seated GH flexion table slide, seated horizontal table slide \u2022 AAROM: Active assistive shoulder flexion \u2022 AROM: elbow, hand, wrist Strengthening (Week 2) \u2022 Periscapular: scap retraction, prone scapular retraction, standing scapular setting, supported scapular setting, inferior glide, low row \u2022 Ball squeeze Criteria to Progress \u2022 >\/= 50% shoulder PROM flex, scaption as compared to contralateral side \u2022 <\/= 90 degrees of shoulder ABD PROM \u2022 <\/= 30 degrees of shoulder ER PROM in scapular plane \u2022 >\/= 70 degrees of IR PROM in scapular plane  Palpable muscle contraction felt in scapular musculature  Pain < 4\/10  No complications with Phase I  PHASE II: INTERMEDIATE POST-OP (4-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Continue to protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM \u2022 Minimize substitution patterns with AROM and AAROM \u2022 Improve periscapular muscle activation\/strength \u2022 Initiate RTC (external rotators) activation \u2022 Patient education Sling \u2022 Use at night while sleeping \u2022 Gradually start weaning sling over the next two weeks during the day Precautions \u2022 No excessive shoulder external rotation or abduction \u2022 No lifting of objects heavier than a coffee cup \u2022 No supporting of body weight with hands \u2022 Place small pillow\/towel roll under elbow while lying on back to avoid shoulder hyperextension Intervention *Continue with Phase I interventions  Range of motion\/Mobility \u2022 PROM: Full with exception of ER <\/= 30 degrees in scapular plane and <\/= 90 degrees ABD \u2022 AAROM: shoulder flexion with cane, cane external rotation stretch, washcloth press, seated shoulder elevation with cane \u2022 AROM: supine flexion, salutes, supine punch Strengthening \u2022 Rotator cuff: external rotation isometrics \u2022 Periscapular: Row on physioball, serratus punches \u2022 Elbow: Biceps curl, resistance band bicep curls and triceps Motor control \u2022 ER in scaption and Flex 90-125 (rhythmic stabilization) Stretching \u2022 Sidelying horizontal ADD Criteria to Progress \u2022 >\/=75% shoulder PROM flex, scaption, as compared to contralateral side \u2022 >\/=75% shoulder PROM IR in scapular plane as compared to contralateral side \u2022 30 degrees of shoulder PROM ER in scapular plane \u2022 90 degrees of shoulder PROM ABD \u2022 Minimal substitution patterns with AAROM \u2022 AROM shoulder elevation to 100 degrees with minimal substitution patterns \u2022 Pain < 4\/10 \u2022 No complications with Phase II  PHASE III: INTERMEDIATE POST-OP CONTD (7-8 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue (especially the anterior capsule) \u2022 Minimize pain \u2022 Maintain PROM \u2022 Improve AROM \u2022 Progress periscapular and RTC strength \u2022 Return to full functional activities \u2022 Patient education Sling \u2022 Discontinue Precautions \u2022 No lifting of heavy objects (>10 lbs) Intervention *Continue with Phase I-II interventions Range of motion\/Mobility \u2022 Full ROM in all planes \u2022 AAROM: incline table slides, ball roll on wall, wall climbs, pulleys \u2022 AROM: seated scaption, seated flexion, supine forward elevation with elastic resistance to 90 deg  Strengthening \u2022 Rotator cuff: internal rotation isometrics, side-lying external rotation, \u2022 Standing external rotation w\/ resistance band, standing internal rotation w\/ resistance band, internal  rotation, external rotation, \u2022 Periscapular: Resistance band shoulder extension, resistance band seated rows, rowing, lawn mowers, robbery Motor control \u2022 IR\/ER and Flex 90-125 (rhythmic stabilization) \u2022 Quadruped alternating isometrics and ball stabilization on wall \u2022 PNF-D1 diagonal lifts, PNF-D2 diagonal lifts Stretching \u2022 IR behind back with towel, sidelying horizontal ADD, sleeper stretch, triceps and lats Criteria to Progress \u2022 Minimal to no substitution patterns with shoulder AROM \u2022 Pain < 4\/10  PHASE IV: TRANSITIONAL POST-OP (9-11 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue (especially the anterior capsule) \u2022 Maintain pain-free PROM \u2022 Continue improving AROM \u2022 Improve dynamic shoulder stability \u2022 Gradually restore shoulder strength and endurance Precautions \u2022 No lifting of heavy objects (> 10 lbs) \u2022 Avoid exercises that put stress on the anterior shoulder capsule (ie: shoulder ER above 80 degrees of ABD) Intervention *Continue with Phase II-III interventions Range of motion\/mobility \u2022 Full ROM in all planes Strengthening \u2022 Rotator cuff: increase resistance rotator cuff exercise \u2022 Periscapular: Push-up plus on knees, \u201cW\u201d exercise, resistance band Ws, dynamic hug, resistance band dynamic hug, prone shoulder extension Is, resistance band forward punch, forward punch, tripod, pointer Motor control \u2022 Resistance band PNF pattern, PNF \u2013 D1 diagonal lifts w\/ resistance, diagonal-up, diagonal-down Wall slides w\/ resistance band Criteria to Progress \u2022 Supine AROM Flex >\/=140 degrees \u2022 Supine AROM ABD >\/=120 degrees \u2022 Supine AROM ER in scapular plane >\/= 60 degrees \u2022 Supine AROM IR in scapular plane >\/= 70 degrees \u2022 AROM shoulder elevation to 120 degrees with minimal substitution patterns \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 Pain < 2\/10  PHASE V: ADVANCED STRENGTHENING POST-OP (12-16 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free ROM \u2022 Improve shoulder strength and endurance \u2022 Enhance functional use of upper extremity  Intervention *Continue with Phase II-IV interventions Strengthening \u2022 Rotator cuff:  External rotation at 90 degrees, internal rotation at 90 degrees, resistance band standing external rotation at 90 degrees, resistance band standing internal rotation at 90 degrees \u2022 Periscapular: T and Y, \u201cT\u201d exercise, push-up plus knees extended, wall push up Motor Control \u2022 Progress ball stabilization on wall to overhead alternating isometrics\/rhythmic stabilization  Criteria to Progress \u2022 Clearance from MD and ALL milestone criteria have been met \u2022 Maintains pain-free PROM and AROM \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 QuickDASH \u2022 PENN Return-to-Sport \u2022 For the recreational or competitive athlete, return-to-sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non-contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return-to-sport rehabilitation program.  Revised December 2018 Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol  References  Angst, F, Goldhahn, J, et al. Responsiveness of six outcome assessment instruments in total shoulder arthroplasty. Arthritis & Rheumatism. 2008. 59 (3): 391-398.  Garcia, GH, Liu, JN, et al. High satisfaction and return to sports after total shoulder arthroplasty in patients aged 55 years and younger. AJSM. 2017. 45 (7): 1664-1669.  Gaunt BW, McCluskey GM, Uhl TL. An electromyographic evaluation of subdividing active-assistive shoulder elevation exercises. Sports Health. 2010. 2 (5): 424-432.  Hughes, M, Neer II, CS. Glenohumeral joint replacement and postoperative rehabilitation. Physical Therapy. 1975. 55(8): 850-858.  Kibler, W.B., Sciascia, A. D., Uhl, T. L., et al. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. The American Journal of Sports Medicine. 2008. 36(9): p. 1789-1798.  Knesek M, Brunfeldt, A, et al. Patterns of strain and the determination of the safe arc of motion after subscapularis repair-a biomechanical study. Journal of Orthopaedic Research. 2016. 34: 518-524.  Piasecki, DP, Nicholson, GP. Tears of the subscapularis tendon in athletes-diagnosis and repair techniques. Clin Sports Med. 2008. 27: 731-745.  Uhl TL, Muir TA, et al. Electromyographical assessment of passive, active assistive, and active shoulder rehabilitation exercises. PM R. 2010. 2: 132-141.  Wilcox III R.B., Arslanian L.E., Millett P.J. Rehabilitation following total shoulder arthroplasty. JOSPT. 2005. 35 (12): 821-837  Wolff. AL, Rosenzweig, L. Anatomical and biomechanical framework for shoulder arthroplasty rehabilitation. Journal of Hand Therapy. 2017. 30: 167-174.  Wright, T, Easley, T, et al. Shoulder arthroplasty and its effect on strain in the subscapularis muscle. Clinical Biomechanics. 2015. 30: 373-376.  Zarkadas P.C., Throckmorton T., et al. Patient reported activities after shoulder replacement: total and hemiarthroplasty. J Shoulder Elbow Surg. 2011. 20: 273-280.  Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med. 1996;(6):602-608.  Leggin BG, Michener, LA, et al. The Penn Shoulder Score: reliability and validity. JOSPT. 36 (3): 138-151.","conversation_history":[],"metadata":{"question_type":"distracting element","seed_document_id":3,"distracting_context":"Rehabilitation Protocol for Total Shoulder Arthroplasty and Hemiarthroplasty  This protocol is intended to guide clinicians and patients through the post-operative course after a total shoulder arthroplasty (TSA) and hemiarthroplasty. Specific interventions should be based on the needs of the individual and should consider exam findings and clinical decision making. If you have questions, contact the referring physician.  Considerations for the Total Shoulder Arthroplasty and Hemiarthroplasty Rehabilitation Program Many different factors influence the post-operative rehabilitation outcome, including surgical approach, concomitant repair of the rotator cuff, arthroplasty secondary to fracture, arthroplasty secondary to rheumatoid arthritis or osteonecrosis, and individual patient factors including co-morbidities. It is recommended that patients meet all rehabilitation criteria in order to progress to the next phase and clinicians collaborate closely with the referring physician throughout the rehabilitation process.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: IMMEDIATE POST-OP (0-3 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Maintain UE ROM in elbow, hand and wrist \u2022 Gradually increase shoulder PROM \u2022 Minimize muscle inhibition \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM \u2022 No reaching behind back, especially in to internal rotation \u2022 No excessive shoulder external rotation or abduction \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 Place small pillow\/towel roll under elbow while lying on back to avoid shoulder hyperextension Intervention Swelling Management \u2022 Ice, compression Range of motion\/Mobility \u2022 PROM: ER <\/= 30 degrees in the scapular plane, IR to belt line in scapular plane, Flex\/Scaption to tolerance, ABD <\/= 90 degrees, pendulums, seated GH flexion table slide, seated horizontal table slide \u2022 AAROM: Active assistive shoulder flexion \u2022 AROM: elbow, hand, wrist Strengthening (Week 2) \u2022 Periscapular: scap retraction, prone scapular retraction, standing scapular setting, supported scapular setting, inferior glide, low row \u2022 Ball squeeze Criteria to Progress \u2022 >\/= 50% shoulder PROM flex, scaption as compared to contralateral side \u2022 <\/= 90 degrees of shoulder ABD PROM \u2022 <\/= 30 degrees of shoulder ER PROM in scapular plane \u2022 >\/= 70 degrees of IR PROM in scapular plane  Palpable muscle contraction felt in scapular musculature  Pain < 4\/10  No complications with Phase I  PHASE II: INTERMEDIATE POST-OP (4-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Continue to protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM \u2022 Minimize substitution patterns with AROM and AAROM \u2022 Improve periscapular muscle activation\/strength \u2022 Initiate RTC (external rotators) activation \u2022 Patient education Sling \u2022 Use at night while sleeping \u2022 Gradually start weaning sling over the next two weeks during the day Precautions \u2022 No excessive shoulder external rotation or abduction \u2022 No lifting of objects heavier than a coffee cup \u2022 No supporting of body weight with hands \u2022 Place small pillow\/towel roll under elbow while lying on back to avoid shoulder hyperextension Intervention *Continue with Phase I interventions  Range of motion\/Mobility \u2022 PROM: Full with exception of ER <\/= 30 degrees in scapular plane and <\/= 90 degrees ABD \u2022 AAROM: shoulder flexion with cane, cane external rotation stretch, washcloth press, seated shoulder elevation with cane \u2022 AROM: supine flexion, salutes, supine punch Strengthening \u2022 Rotator cuff: external rotation isometrics \u2022 Periscapular: Row on physioball, serratus punches \u2022 Elbow: Biceps curl, resistance band bicep curls and triceps Motor control \u2022 ER in scaption and Flex 90-125 (rhythmic stabilization) Stretching \u2022 Sidelying horizontal ADD Criteria to Progress \u2022 >\/=75% shoulder PROM flex, scaption, as compared to contralateral side \u2022 >\/=75% shoulder PROM IR in scapular plane as compared to contralateral side \u2022 30 degrees of shoulder PROM ER in scapular plane \u2022 90 degrees of shoulder PROM ABD \u2022 Minimal substitution patterns with AAROM \u2022 AROM shoulder elevation to 100 degrees with minimal substitution patterns \u2022 Pain < 4\/10 \u2022 No complications with Phase II  PHASE III: INTERMEDIATE POST-OP CONTD (7-8 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue (especially the anterior capsule) \u2022 Minimize pain \u2022 Maintain PROM \u2022 Improve AROM \u2022 Progress periscapular and RTC strength \u2022 Return to full functional activities \u2022 Patient education Sling \u2022 Discontinue Precautions \u2022 No lifting of heavy objects (>10 lbs) Intervention *Continue with Phase I-II interventions Range of motion\/Mobility \u2022 Full ROM in all planes \u2022 AAROM: incline table slides, ball roll on wall, wall climbs, pulleys \u2022 AROM: seated scaption, seated flexion, supine forward elevation with elastic resistance to 90 deg  Strengthening \u2022 Rotator cuff: internal rotation isometrics, side-lying external rotation, \u2022 Standing external rotation w\/ resistance band, standing internal rotation w\/ resistance band, internal  rotation, external rotation, \u2022 Periscapular: Resistance band shoulder extension, resistance band seated rows, rowing, lawn mowers, robbery Motor control \u2022 IR\/ER and Flex 90-125 (rhythmic stabilization) \u2022 Quadruped alternating isometrics and ball stabilization on wall \u2022 PNF-D1 diagonal lifts, PNF-D2 diagonal lifts Stretching \u2022 IR behind back with towel, sidelying horizontal ADD, sleeper stretch, triceps and lats Criteria to Progress \u2022 Minimal to no substitution patterns with shoulder AROM \u2022 Pain < 4\/10  PHASE IV: TRANSITIONAL POST-OP (9-11 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue (especially the anterior capsule) \u2022 Maintain pain-free PROM \u2022 Continue improving AROM \u2022 Improve dynamic shoulder stability \u2022 Gradually restore shoulder strength and endurance Precautions \u2022 No lifting of heavy objects (> 10 lbs) \u2022 Avoid exercises that put stress on the anterior shoulder capsule (ie: shoulder ER above 80 degrees of ABD) Intervention *Continue with Phase II-III interventions Range of motion\/mobility \u2022 Full ROM in all planes Strengthening \u2022 Rotator cuff: increase resistance rotator cuff exercise \u2022 Periscapular: Push-up plus on knees, \u201cW\u201d exercise, resistance band Ws, dynamic hug, resistance band dynamic hug, prone shoulder extension Is, resistance band forward punch, forward punch, tripod, pointer Motor control \u2022 Resistance band PNF pattern, PNF \u2013 D1 diagonal lifts w\/ resistance, diagonal-up, diagonal-down Wall slides w\/ resistance band Criteria to Progress \u2022 Supine AROM Flex >\/=140 degrees \u2022 Supine AROM ABD >\/=120 degrees \u2022 Supine AROM ER in scapular plane >\/= 60 degrees \u2022 Supine AROM IR in scapular plane >\/= 70 degrees \u2022 AROM shoulder elevation to 120 degrees with minimal substitution patterns \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 Pain < 2\/10  PHASE V: ADVANCED STRENGTHENING POST-OP (12-16 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free ROM \u2022 Improve shoulder strength and endurance \u2022 Enhance functional use of upper extremity  Intervention *Continue with Phase II-IV interventions Strengthening \u2022 Rotator cuff:  External rotation at 90 degrees, internal rotation at 90 degrees, resistance band standing external rotation at 90 degrees, resistance band standing internal rotation at 90 degrees \u2022 Periscapular: T and Y, \u201cT\u201d exercise, push-up plus knees extended, wall push up Motor Control \u2022 Progress ball stabilization on wall to overhead alternating isometrics\/rhythmic stabilization  Criteria to Progress \u2022 Clearance from MD and ALL milestone criteria have been met \u2022 Maintains pain-free PROM and AROM \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 QuickDASH \u2022 PENN Return-to-Sport \u2022 For the recreational or competitive athlete, return-to-sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non-contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return-to-sport rehabilitation program.  Revised December 2018 Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol  References  Angst, F, Goldhahn, J, et al. Responsiveness of six outcome assessment instruments in total shoulder arthroplasty. Arthritis & Rheumatism. 2008. 59 (3): 391-398.  Garcia, GH, Liu, JN, et al. High satisfaction and return to sports after total shoulder arthroplasty in patients aged 55 years and younger. AJSM. 2017. 45 (7): 1664-1669.  Gaunt BW, McCluskey GM, Uhl TL. An electromyographic evaluation of subdividing active-assistive shoulder elevation exercises. Sports Health. 2010. 2 (5): 424-432.  Hughes, M, Neer II, CS. Glenohumeral joint replacement and postoperative rehabilitation. Physical Therapy. 1975. 55(8): 850-858.  Kibler, W.B., Sciascia, A. D., Uhl, T. L., et al. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. The American Journal of Sports Medicine. 2008. 36(9): p. 1789-1798.  Knesek M, Brunfeldt, A, et al. Patterns of strain and the determination of the safe arc of motion after subscapularis repair-a biomechanical study. Journal of Orthopaedic Research. 2016. 34: 518-524.  Piasecki, DP, Nicholson, GP. Tears of the subscapularis tendon in athletes-diagnosis and repair techniques. Clin Sports Med. 2008. 27: 731-745.  Uhl TL, Muir TA, et al. Electromyographical assessment of passive, active assistive, and active shoulder rehabilitation exercises. PM R. 2010. 2: 132-141.  Wilcox III R.B., Arslanian L.E., Millett P.J. Rehabilitation following total shoulder arthroplasty. JOSPT. 2005. 35 (12): 821-837  Wolff. AL, Rosenzweig, L. Anatomical and biomechanical framework for shoulder arthroplasty rehabilitation. Journal of Hand Therapy. 2017. 30: 167-174.  Wright, T, Easley, T, et al. Shoulder arthroplasty and its effect on strain in the subscapularis muscle. Clinical Biomechanics. 2015. 30: 373-376.  Zarkadas P.C., Throckmorton T., et al. Patient reported activities after shoulder replacement: total and hemiarthroplasty. J Shoulder Elbow Surg. 2011. 20: 273-280.  Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med. 1996;(6):602-608.  Leggin BG, Michener, LA, et al. The Penn Shoulder Score: reliability and validity. JOSPT. 36 (3): 138-151.","topic":"Others"}}
{"id":"41405bb1-6d6c-4415-bed4-2987c69fad8b","question":"Given the detailed protocol for postoperative rehabilitation of a rotator cuff repair, could you explain the approach for returning to sports following a sports-related concussion in a similar stepwise, time-based, and criterion-based manner?","reference_answer":"The return to sport following a sports-related concussion is guided by a time-based and criterion-based protocol. The specific intervention should be based on the needs of the individual and should consider exam findings and clinical decision making. The process should be approached with a multidisciplinary team approach. If a patient is not progressing as expected, they should quickly be referred to a concussion specialty clinic. The interventions included within this protocol are not intended to be an inclusive list. Therapeutic interventions should be included and modified based on the progress of the patient and under the discretion of the clinician.","reference_context":"Document 0: Rehabilitation Protocol for Concussion Return-to-Sport  This protocol is intended to guide clinicians through the return to sport following sports-related concussion. This protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs of the individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes contained within this guideline may vary based on physician preference, healing timeline and sporting activity. Return to sport following concussion can be a complex decision-making process and should be approached with a multidisciplinary team approach. If a patient is not progressing as expected, they should quickly be referred to a concussion specialty clinic.  The interventions included within this protocol are not intended to be an inclusive list. Therapeutic interventions should be included and modified based on the progress of the patient and under the discretion of the clinician.  Considerations for concussion return to sport Current literature no longer supports a period of complete rest beyond 72 hours. Concussion recovery should be focused around active rehabilitation. Activities should be performed at a sub-symptom threshold to the patient\u2019s tolerance. A patient should undergo formal exertional testing and a graded exercise protocol should be based on max exercise tolerance. If a clinician is not familiar with this testing and exercise prescription, the patient should be referred to a specialist.  PHASE I: EARLY POST-INJURY (0-3 DAYS) Rehabilitation Goals \u2022 Relative rest Precautions \u2022 Throughout progression, there should be minimal symptoms. If symptoms are  starting, rest see if symptoms resolve and the resume at a slightly lower heart rate with goal of not increasing symptoms for pre-exercise level Intervention \u2022 Household and community activities as tolerated Criteria to Progress \u2022 3 days post injury  PHASE II: INTERMEDIATE POST-INJURY Rehabilitation Goals \u2022 Gradually reintroduce aerobic activity \u2022 Decrease deconditioning Precautions \u2022 Limit head movement, distractions and maintain neutral neck position \u2022 Avoid Valsalva \u2022 No contact Additional Intervention *Continue with Phase I interventions \u2022 Light activity to gradually increase heart rate. If symptoms do not increase next session can increase workload slightly more \u2022 Exercise examples: \u2022 Light biking \u2022 Walking Criteria to Progress \u2022 Tolerating activity well without symptoms, progress through gradually until able to achieve 85% of age adjust heart rate without symptoms \u2022 Able to tolerate daily activities without significant increase in visual\/vestibular symptoms  PHASE III: LATE POST-INJURY Rehabilitation Goals \u2022 Reintroduce movement \u2022 Progress active rehab Precautions \u2022 Avoid Valsalva \u2022 No contact Additional Intervention *Continue with Phase I-II Interventions \u2022 Increased head movement with activity \u2022 Running, skating, swimming, rowing, shooting on empty goal, foot work, stick work \u2022 Increased environmental distractions \u2022 Busy gym, running with people around \u2022 Increased cognitive demands \u2022 Doing math in head, talking, thinking through plays while exercising Criteria to Progress \u2022 No symptoms with above exercise \u2022 Minimal to no symptoms with all activities including daily activities, school, work etc.  PHASE IV: TRANSITIONAL Rehabilitation Goals Reintroduce sport specific activity, while continuing to avoid contact Additional Intervention *Continue with Phase I-III interventions Sport specific activity Passing drills, shooting drills, non-contact drill participation Criteria to Progress No symptoms with above activity  PHASE V: FULL RETURN TO SPORT ( MONTHS AFTER SURGERY) Rehabilitation Goals Full return to sport Additional Intervention *Continue with Phase II-IV interventions Scrimmage play first, then full game play if asymptomatic Revised 9\/2021  Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol References:  1. Clausen M et al, Cerebral Blood Flow during Treadmill exercise is a marker of physiological post-concussion syndrome in female athletes. Journal of Head Trauma Rehabilitation 2016 31 (3): 215-24. 2. Coslick, A, et al. Participation in Physical Activity at Time of Presentation to a Specialty Concussion Clinic Is Associated With Shorter Time to Recovery. PM&R,; 2020 (12)12: 1195\u20131204. 3. DiFazio, M., Silverberg, N. D., Kirkwood, M. W., Bernier, R., & Iverson, G. L. (2016). Prolonged Activity Restriction after Concussion: Are We Worsening Outcomes? Clinical Pediatrics, 55(5), 443\u2013451. 4. Grool AM, Aglipay M, Momoli F, et al. Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent Postconcussive Symptoms in Children and Adolescents. JAMA. 2016;316(23):2504. doi:10.1001\/jama.2016.17396 5. Kamins J, Bigler E, Covassin T, et al. What is the physiological time to recovery after concussion? A systematic review. Br J Sports Med. 2017;51(12):935-940. doi:10.1136\/bjsports-2016-097464 6. Leddy JJ et al. Use of graded exercise testing in concussion and return-to-activity management. Current Sports Medicine Reports 12 (6): 370-376, 2013. 7. Leddy JJ, Haider MN, Ellis M, Willer BS. Exercise is Medicine for Concussion. Curr Sports Med Rep. 2018;17(8):262-270. doi:10.1249\/JSR.0000000000000505 8. Leddy JJ, Willer B. Use of Graded Exercise Testing in Concussion and Return-to-Activity Management.  Curr Sports Med Rep. 2013;12(6):370-376. doi:10.1249\/JSR.0000000000000008 9. Muruta J et al. Visual Tracking synchronization as a metric for concussion screening. J Head Trauma Rehabil 2010 Jul-Aug; 25 (4):293-305. 10. Thomas DG, Apps JN, Hoffmann RG, McCrea M, Hammeke T. Benefits of Strict Rest After Acute Concussion: A Randomized Controlled Trial. Pediatrics. 2015;135(2).","conversation_history":[],"metadata":{"question_type":"distracting element","seed_document_id":0,"distracting_context":"Visit per week:  2 to 3 times  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Advanced Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  2  4 WEEKS POST  OP (Maximum Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN)  2  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises  Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  4  6 WEEKS POST  OP (Moderate Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  3  7  12 WEEKS POST  OP: (Early Strengthening Phase)  GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  13  19 WEEKS POST  OP: (Late Strengthening Phase)  GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 weeks  Continue with throwing and racquet program if appropriate  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  20-24 WEEKS POST-OP: (Return to Sports or Full Activity)  GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control","topic":"Others"}}
{"id":"f124150b-38f3-4668-82a1-4bd2d81fd757","question":"What are the primary objectives during the immediate post-operative phase of the Rehabilitation Protocol for Sternoclavicular Joint Reconstruction, given that the patient has undergone Total Shoulder Arthroplasty and Hemiarthroplasty?","reference_answer":"The main goals in the immediate post-op phase are to protect the surgical repair, reduce swelling, minimize pain, maintain upper extremity range of motion in elbow, hand and wrist, gradually increase shoulder passive range of motion, minimize muscle inhibition, and educate the patient.","reference_context":"Document 5: Rehabilitation Protocol for Sternoclavicular Joint Reconstruction  This protocol is intended to guide clinicians through the post-operative course for sternoclavicular joint reconstruction. This protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs of the individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes contained within this guideline may vary based on surgeon\u2019s preference, additional procedures performed, and\/or complications. If a clinician requires assistance in the progression of a post-operative patient, they should consult with the referring surgeon.  The interventions included within this protocol are not intended to be an inclusive list of exercises. Therapeutic interventions should be included and modified based on the progress of the patient and under the discretion of the clinician.  Considerations for the Post-operative sternoclavicular joint reconstruction Many different factors influence the post-operative rehabilitation outcome, including surgical technique (ie. tendon autograft harvest for repair), degree of SC joint instability, concomitant soft tissue or bone injury\/repair, and individual patient factors including co-morbidities. It is recommended that patients meet all rehabilitation criteria in order to progress to the next phase and clinicians collaborate closely with the referring physician throughout the rehabilitation process.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: EARLY POST-OP (0-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Reduce pain and swelling of the operative shoulder \u2022 Maintain elbow, wrist and hand AROM \u2022 Patient education Sling\/precautions \u2022 Sling to be worn for 6 weeks (or as directed by surgeon) \u2022 Avoid PROM of the glenohumeral joint \u2022 Avoid scapular AROM (protraction, retraction, depression and elevation) as it may disrupt the repair and healing tissues \u2022 Avoid bearing weight through involved extremity \u2022 Avoid lifting any lifting with involved extremity \u2022 Avoid running and jumping due to impact forces upon landing that may aggravate healing tissues and bone Intervention \u2022 Cryotherapy as needed \u2022 AROM: cervical spine, elbow, wrist, hand \u2022 Hand gripping: ball squeeze \u2022 Cardiovascular exercise as tolerated: walking, stationary bike Criteria to Progress \u2022 Well controlled pain and swelling \u2022 Protect reconstruction site and autograft site (if applicable) \u2022 Maintain elbow, wrist and hand AROM  PHASE II: INTERMEDIATE POST-OP (6-12WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Activation of muscles responsible for stabilizing the scapulothoracic and glenohumeral joint \u2022 Gradually restore PROM, AAROM of the GH joint at 6-8 weeks \u2022 Gradually restore AROM of the scapulothoracic joint and glenohumeral joint at 8 weeks \u2022 Wean from sling (if still wearing) \u2022 Begin shoulder and scapular strengthening at 8 weeks \u2022 Begin proprioception and neuromuscular control training \u2022 Identify and correct postural dysfunction as indicated Sling\/precautions \u2022 Avoid repetitive overhead activities \u2022 No lifting > 5 pounds with involved extremity until 9 weeks post-op \u2022 Post-rehabilitation soreness should resolve within 12-24 hours Additional Interventions *Continue with Phase I interventions \u2022 AROM in all cardinal plane assessing scapular rhythm \u2022 Gentle glenohumeral mobilization as indicated  Strengthening: \u2022 Rotator cuff strengthening in non-provocative positions (generally 0-45 degrees Scaption\/abduction): scaption raises against gravity, Sidelying ER, lightly resisted ER\/IR with theraband, isometrics \u2022 Scapular strengthening and dynamic neuromuscular control: low row, straight arm pulldowns, serratus punch, resisted T\u2019s  Stretching: Gentle corner or doorway pec stretch \u2022 Postural endurance exercises: scapular retractions, chin tucks \u2022 Walking, stationary bike, Stairmaster Criteria to Progress \u2022 Full AROM of the operative shoulder \u2022 Normal (5\/5) strength for glenohumeral flexion\/abduction\/IR\/ER degrees abduction  PHASE III: LATE POST-OP AND GRADUAL RETURN TO SPORT(13+ WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Restore normal (5\/5) rotator cuff strength at 90 degrees abduction including supraspinatus \u2022 Full multi-planar AROM with minimal to no substitution patterns \u2022 Advance proprioceptive and dynamic neuromuscular control training \u2022 Identify and correct postural dysfunction with sport\/work specific tasks as indicated \u2022 Develop strength and control movements required for sport\/work Sling\/ precautions \u2022 Post-rehabilitation soreness should resolve within 12 hours \u2022 No lifting restrictions at ~4 months Additional Interventions *Continue with Phase I-II Interventions \u2022 Glenohumeral mobilizations as indicated \u2022 Multiplane AROM with gradual increase in velocity of movement  Strengthening: \u2022 Rotator cuff strengthening at 45 degrees progressing to 90 degrees abduction and sport\/work specific positions as well as other provocative positions: resisted IR\/ER, elevation with ER, resisted scaption raises, facepulls\/resisted W\u2019s \u2022 Scapular strengthening and dynamic neuromuscular control in overhead or sport\/work positions: prone or resisted I\u2019s, T\u2019s and Y\u2019s, lower trap setting at wall, manual perturbations in varying degrees in elevation, serratus wall slides\/roll ups, wall pushups, quadruped shoulder taps \u2022 Core strengthening  Stretching:  Corner or doorway pec stretch, Gentle posterior capsule stretch (across body)  Walking, stationary bike, Stairmaster, return to running\/jumping as tolerated  Begin education in sport specific biomechanics with initial program for throwing, swimming, or overhead racquet sports Criteria to Return to Sport  Clearance from MD and ALL milestone criteria have been met  Maintains pain  free PROM and AROM  Performs all exercises demonstrating symmetric scapular mechanics  QuickDASH  PENN  For the recreational or competitive athlete, return  to  sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non  contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return  to  sport rehabilitation program.  Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol References: 1. Logan C, Shahien A, Altintas B, Millett PJ. Rehabilitation following sternoclavicular joint reconstruction for persistent instability. International Journal of Sports Physical Therapy. 2018;13(4):752-762. doi:10.26603\/ijspt20180752 2. Petri, M., Greenspoon, J. A., Horan, M. P., Martetschl\u00e4ger, F., Warth, R. J., & Millett, P. J. (2016). Clinical outcomes after autograft reconstruction for sternoclavicular joint instability. Journal of Shoulder and Elbow Surgery, 25(3), 435\u2013441. https:\/\/doi.org\/10.1016\/j.jse.2015.08.004 3. Garcia JA, Arguello AM, Momaya AM, Ponce BA. Sternoclavicular Joint Instability: Symptoms, Diagnosis And Management. Orthop Res Rev. 2020 Jul 28;12:75-87. doi: 10.2147\/ORR.S170964. PMID: 32801951; PMCID: PMC7395708.\n\nDocument 3: Rehabilitation Protocol for SLAP Repair-Type II  This protocol is intended to guide clinicians through the post-operative course for SLAP Repair-Type II. This protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs of the individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes contained within this guideline may vary based on surgeon\u2019s preference, additional procedures performed, and\/or complications. If a clinician requires assistance in the progression of a post-operative patient, they should consult with the referring surgeon.  The interventions included within this protocol are not intended to be an inclusive list. Therapeutic interventions should be included and modified based on the progress of the patient and under the discretion of the clinician.  Considerations for the Post-operative SLAP repair Rehabilitation Program Many different factors influence the post-operative SLAP repair rehabilitation outcome, including the type of SLAP lesion, the size of the tear\/number of anchors placed, concomitant procedures and amount of shoulder hypermobility and\/or hyperlaxity. Consider mechanism of injury as well as the sport the athlete would like to return to when initiating certain interventions.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: IMMEDIATE POST-OP (0-3 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Maintain UE ROM in elbow, hand and wrist \u2022 Gradually increase shoulder PROM \u2022 Minimize muscle inhibition \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM\/AAROM \u2022 No elbow AROM (avoid biceps contraction) \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 No reaching behind back Intervention Swelling Management \u2022 Ice, compression  Range of motion\/Mobility \u2022 PROM: ER<30 scapular plane, Forward elevation <90, full elbow flex and ext, seated GH flexion table slide, horizontal table slide (add hyperlink) \u2022 AROM: hand, wrist \u2022 AAROM: none  Strengthening (Week 2)  Periscapular: scap retraction  , prone scapular retraction  , standing scapular setting  , supported scapular setting, inferior glide, low row  to neutral; avoid shoulder extension  Rotator cuff: submaximal pain  free isometrics  Ball squeeze Criteria to Progress  90 degrees shoulder PROM forward elevation  30 degrees of shoulder PROM ER in the scapular plane  Full elbow PROM flexion and extension  Palpable muscle contraction felt in scapular and shoulder musculature  No complications with Phase I  PHASE II: INTERMEDIATE POST-OP (4-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Continue to protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM \u2022 Minimize substitution patterns with shoulder AAROM \u2022 Initiate motor control exercise \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM \u2022 No elbow AROM (avoid biceps contraction) \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 No reaching behind back Intervention *Continue with Phase I interventions  Range of motion\/Mobility \u2022 PROM: ER<45 scapular plane, Forward elevation <120 \u2022 AAROM: Active assistive shoulder flexion, shoulder flexion with cane, cane external rotation stretch, washcloth press, sidelying elevation to 90 degrees  Strengthening \u2022 Periscapular: Row on physioball*, shoulder extension on physioball*, serratus punches - *to neutral; avoid shoulder extension  Motor Control \u2022 Internal and external rotation in scaption and Flex 90-125 (rhythmic stabilization)  Stretching \u2022 Sidelying horizontal ADD, sleeper stretch Criteria to Progress \u2022 120 degrees shoulder PROM forward elevation \u2022 45 degrees shoulder PROM ER in scapular plane \u2022 Minimal substitution patterns with shoulder AAROM \u2022 Pain < 4\/10 \u2022 No complications with Phase II  PHASE III: INTERMEDIATE POST-OP CONT\u2019d (7-8 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM\/AAROM \u2022 Initiate shoulder and elbow AROM \u2022 Initiate RTC strengthening  Improve scapular muscle activation  Patient education Sling  Discontinue Precautions  No resisted elbow flexion  No lifting of heavy objects (>10 lbs) Intervention  Continue with Phase I  II interventions Range of motion\/Mobility  PROM: ER Full in scapular plane, \uf0a390 degrees ER in 90 degrees of abduction, IR Full in scapular plane, Forward elevation Full  do not push beyond 90 degrees ER in 90 degrees of abduction  AAROM: seated shoulder elevation with cane, seated incline table slides, ball roll on wall  AROM: supine flexion, salutes, supine punch, wall climbs, elbow flexion  Strengthening \u2022 Rotator cuff: side-lying external rotation, standing external rotation w\/ resistance band, standing internal rotation w\/ resistance band, internal  rotation, external rotation \u2022 Periscapular: Resistance band shoulder extension*, resistance band seated rows*, rowing*, lawn mowers, robbery - *to neutral; avoid shoulder extension \u2022 Elbow: Triceps  Motor Control \u2022 Quadruped alternating isometrics Criteria to Progress \u2022 Full pain-free shoulder PROM ER and forward elevation \u2022 Within 10 degrees of shoulder IR PROM of contralateral shoulder \u2022 Minimal substitution patterns with shoulder AROM \u2022 Pain < 4\/10  PHASE IV: TRANSITIONAL POST-OP (9-12 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue \u2022 Restore full shoulder PROM and AROM \u2022 Initiate resisted elbow flexion at 12 weeks \u2022 Improve dynamic shoulder stability \u2022 Progress periscapular strength \u2022 Gradually return to full functional activities Precautions \u2022 No lifting of heavy objects (> 10 lbs) Intervention *Continue with Phase II-III interventions Range of motion\/mobility \u2022 PROM: Full \u2022 AROM: Supine forward elevation with elastic resistance to 90 deg, scaption and shoulder flexion to 90  degrees elevation  Strengthening \u2022 Periscapular: Push-up plus on knees, prone shoulder extension Is*, resistance band forward punch, forward punch, tripod o *to neutral; avoid shoulder extension \u2022 Elbow (12 weeks): Biceps curl, resistance band bicep curls  Motor control  Ball stabilization on wall  Stretching \u2022 Hands behind head, IR behind back with towel, triceps and lats, doorway series Criteria to Progress \u2022 Full pain-free shoulder PROM and AROM \u2022 Minimal to no substitution patterns with shoulder AROM \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 Pain < 2\/10  PHASE V: LATE POST-OP (13-16 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free shoulder ROM \u2022 Enhance functional use of upper extremity Intervention *Continue with Phase II-IV interventions Strengthening \u2022 Rotator cuff: External rotation at 90 degrees, internal rotation at 90 degrees, resistance band standing external rotation at 90 degrees, resistance band standing internal rotation at 90 degrees \u2022 Periscapular: T and Y, \u201cT\u201d exercise, push-up plus knees extended, pointer, wall push up, \u201cW\u201d exercise, resistance band Ws, dynamic hug, resistance band dynamic hug  Motor Control \u2022  PNF \u2013 D1 diagonal lifts, PNF \u2013 D2 diagonal lifts, field goals , resistance band PNF pattern, PNF \u2013 D1 diagonal lifts w\/ resistance, diagonal-up, diagonal-down, wall slides w\/ resistance band Criteria to Progress \u2022 Clearance from MD and ALL milestone criteria below have been met \u2022 Full pain-free shoulder PROM and AROM \u2022 ER\/IR strength minimum 85% of the uninvolved arm \u2022 ER\/IR ratio 60% or higher \u2022 Negative impingement and instability signs \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 QuickDASH \u2022 PENN  PHASE VI: EARLY RETURN-TO-SPORT (4-6 MONTHS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free ROM \u2022 Continue strengthening and motor control exercises \u2022 Enhance functional use of upper extremity \u2022 Gradual return to strenuous work\/sport activity Intervention *Continue with Phase II-V interventions Strengthening \u2022 See specific return-to-sport\/throwing program (coordinate with physician) Criteria to Progress \u2022 Last stage-no additional criteria Return-to-Sport \u2022 For the recreational or competitive athlete, return-to-sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non-contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return-to-sport rehabilitation program. Revised 7\/2020  Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol  References:  1. Ahsan, ZS, Hsu JE, et al. The Snyder classification of superior labrum anterior and posterior (SLAP) lesions. Clin Orthop Relat Res. 2016. 474:2075- 2078.  2. Christopher ZR, Kennedy J, et al. Rehabilitation and return to play following superior labral anterior to posterior repair. Oper Tech Sports Med. 2017. 25:132-144.  3. Cools AM, Borms D, Cottens S, et al. Rehabilitation exercises for athletes with biceps disorders and SLAP lesions. AJSM. 2014. 42(6): 1315-1323.  4. Itoi E, Hatakeyama Y, et al. Position of immobilization after dislocation of the shoulder. JBJS. 1999. 81-A(3): 385-390.  5. Kibler, W.B., Sciascia, A. D., Uhl, T. L., et al. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. The American Journal of Sports Medicine. 2008. 36(9): p. 1789-1798.  6. Wilk KE, Reinold MM, et al. Current concepts in the recognition and treatment of superior labral (SLAP) lesions. JOSPT. 2005. 35(5): 273-291.\n\nDocument 4: Rehabilitation Protocol for Total Shoulder Arthroplasty and Hemiarthroplasty  This protocol is intended to guide clinicians and patients through the post-operative course after a total shoulder arthroplasty (TSA) and hemiarthroplasty. Specific interventions should be based on the needs of the individual and should consider exam findings and clinical decision making. If you have questions, contact the referring physician.  Considerations for the Total Shoulder Arthroplasty and Hemiarthroplasty Rehabilitation Program Many different factors influence the post-operative rehabilitation outcome, including surgical approach, concomitant repair of the rotator cuff, arthroplasty secondary to fracture, arthroplasty secondary to rheumatoid arthritis or osteonecrosis, and individual patient factors including co-morbidities. It is recommended that patients meet all rehabilitation criteria in order to progress to the next phase and clinicians collaborate closely with the referring physician throughout the rehabilitation process.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: IMMEDIATE POST-OP (0-3 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Maintain UE ROM in elbow, hand and wrist \u2022 Gradually increase shoulder PROM \u2022 Minimize muscle inhibition \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM \u2022 No reaching behind back, especially in to internal rotation \u2022 No excessive shoulder external rotation or abduction \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 Place small pillow\/towel roll under elbow while lying on back to avoid shoulder hyperextension Intervention Swelling Management \u2022 Ice, compression Range of motion\/Mobility \u2022 PROM: ER <\/= 30 degrees in the scapular plane, IR to belt line in scapular plane, Flex\/Scaption to tolerance, ABD <\/= 90 degrees, pendulums, seated GH flexion table slide, seated horizontal table slide \u2022 AAROM: Active assistive shoulder flexion \u2022 AROM: elbow, hand, wrist Strengthening (Week 2) \u2022 Periscapular: scap retraction, prone scapular retraction, standing scapular setting, supported scapular setting, inferior glide, low row \u2022 Ball squeeze Criteria to Progress \u2022 >\/= 50% shoulder PROM flex, scaption as compared to contralateral side \u2022 <\/= 90 degrees of shoulder ABD PROM \u2022 <\/= 30 degrees of shoulder ER PROM in scapular plane \u2022 >\/= 70 degrees of IR PROM in scapular plane  Palpable muscle contraction felt in scapular musculature  Pain < 4\/10  No complications with Phase I  PHASE II: INTERMEDIATE POST-OP (4-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Continue to protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM \u2022 Minimize substitution patterns with AROM and AAROM \u2022 Improve periscapular muscle activation\/strength \u2022 Initiate RTC (external rotators) activation \u2022 Patient education Sling \u2022 Use at night while sleeping \u2022 Gradually start weaning sling over the next two weeks during the day Precautions \u2022 No excessive shoulder external rotation or abduction \u2022 No lifting of objects heavier than a coffee cup \u2022 No supporting of body weight with hands \u2022 Place small pillow\/towel roll under elbow while lying on back to avoid shoulder hyperextension Intervention *Continue with Phase I interventions  Range of motion\/Mobility \u2022 PROM: Full with exception of ER <\/= 30 degrees in scapular plane and <\/= 90 degrees ABD \u2022 AAROM: shoulder flexion with cane, cane external rotation stretch, washcloth press, seated shoulder elevation with cane \u2022 AROM: supine flexion, salutes, supine punch Strengthening \u2022 Rotator cuff: external rotation isometrics \u2022 Periscapular: Row on physioball, serratus punches \u2022 Elbow: Biceps curl, resistance band bicep curls and triceps Motor control \u2022 ER in scaption and Flex 90-125 (rhythmic stabilization) Stretching \u2022 Sidelying horizontal ADD Criteria to Progress \u2022 >\/=75% shoulder PROM flex, scaption, as compared to contralateral side \u2022 >\/=75% shoulder PROM IR in scapular plane as compared to contralateral side \u2022 30 degrees of shoulder PROM ER in scapular plane \u2022 90 degrees of shoulder PROM ABD \u2022 Minimal substitution patterns with AAROM \u2022 AROM shoulder elevation to 100 degrees with minimal substitution patterns \u2022 Pain < 4\/10 \u2022 No complications with Phase II  PHASE III: INTERMEDIATE POST-OP CONTD (7-8 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue (especially the anterior capsule) \u2022 Minimize pain \u2022 Maintain PROM \u2022 Improve AROM \u2022 Progress periscapular and RTC strength \u2022 Return to full functional activities \u2022 Patient education Sling \u2022 Discontinue Precautions \u2022 No lifting of heavy objects (>10 lbs) Intervention *Continue with Phase I-II interventions Range of motion\/Mobility \u2022 Full ROM in all planes \u2022 AAROM: incline table slides, ball roll on wall, wall climbs, pulleys \u2022 AROM: seated scaption, seated flexion, supine forward elevation with elastic resistance to 90 deg  Strengthening \u2022 Rotator cuff: internal rotation isometrics, side-lying external rotation, \u2022 Standing external rotation w\/ resistance band, standing internal rotation w\/ resistance band, internal  rotation, external rotation, \u2022 Periscapular: Resistance band shoulder extension, resistance band seated rows, rowing, lawn mowers, robbery Motor control \u2022 IR\/ER and Flex 90-125 (rhythmic stabilization) \u2022 Quadruped alternating isometrics and ball stabilization on wall \u2022 PNF-D1 diagonal lifts, PNF-D2 diagonal lifts Stretching \u2022 IR behind back with towel, sidelying horizontal ADD, sleeper stretch, triceps and lats Criteria to Progress \u2022 Minimal to no substitution patterns with shoulder AROM \u2022 Pain < 4\/10  PHASE IV: TRANSITIONAL POST-OP (9-11 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue (especially the anterior capsule) \u2022 Maintain pain-free PROM \u2022 Continue improving AROM \u2022 Improve dynamic shoulder stability \u2022 Gradually restore shoulder strength and endurance Precautions \u2022 No lifting of heavy objects (> 10 lbs) \u2022 Avoid exercises that put stress on the anterior shoulder capsule (ie: shoulder ER above 80 degrees of ABD) Intervention *Continue with Phase II-III interventions Range of motion\/mobility \u2022 Full ROM in all planes Strengthening \u2022 Rotator cuff: increase resistance rotator cuff exercise \u2022 Periscapular: Push-up plus on knees, \u201cW\u201d exercise, resistance band Ws, dynamic hug, resistance band dynamic hug, prone shoulder extension Is, resistance band forward punch, forward punch, tripod, pointer Motor control \u2022 Resistance band PNF pattern, PNF \u2013 D1 diagonal lifts w\/ resistance, diagonal-up, diagonal-down Wall slides w\/ resistance band Criteria to Progress \u2022 Supine AROM Flex >\/=140 degrees \u2022 Supine AROM ABD >\/=120 degrees \u2022 Supine AROM ER in scapular plane >\/= 60 degrees \u2022 Supine AROM IR in scapular plane >\/= 70 degrees \u2022 AROM shoulder elevation to 120 degrees with minimal substitution patterns \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 Pain < 2\/10  PHASE V: ADVANCED STRENGTHENING POST-OP (12-16 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free ROM \u2022 Improve shoulder strength and endurance \u2022 Enhance functional use of upper extremity  Intervention *Continue with Phase II-IV interventions Strengthening \u2022 Rotator cuff:  External rotation at 90 degrees, internal rotation at 90 degrees, resistance band standing external rotation at 90 degrees, resistance band standing internal rotation at 90 degrees \u2022 Periscapular: T and Y, \u201cT\u201d exercise, push-up plus knees extended, wall push up Motor Control \u2022 Progress ball stabilization on wall to overhead alternating isometrics\/rhythmic stabilization  Criteria to Progress \u2022 Clearance from MD and ALL milestone criteria have been met \u2022 Maintains pain-free PROM and AROM \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 QuickDASH \u2022 PENN Return-to-Sport \u2022 For the recreational or competitive athlete, return-to-sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non-contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return-to-sport rehabilitation program.  Revised December 2018 Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol  References  Angst, F, Goldhahn, J, et al. Responsiveness of six outcome assessment instruments in total shoulder arthroplasty. Arthritis & Rheumatism. 2008. 59 (3): 391-398.  Garcia, GH, Liu, JN, et al. High satisfaction and return to sports after total shoulder arthroplasty in patients aged 55 years and younger. AJSM. 2017. 45 (7): 1664-1669.  Gaunt BW, McCluskey GM, Uhl TL. An electromyographic evaluation of subdividing active-assistive shoulder elevation exercises. Sports Health. 2010. 2 (5): 424-432.  Hughes, M, Neer II, CS. Glenohumeral joint replacement and postoperative rehabilitation. Physical Therapy. 1975. 55(8): 850-858.  Kibler, W.B., Sciascia, A. D., Uhl, T. L., et al. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. The American Journal of Sports Medicine. 2008. 36(9): p. 1789-1798.  Knesek M, Brunfeldt, A, et al. Patterns of strain and the determination of the safe arc of motion after subscapularis repair-a biomechanical study. Journal of Orthopaedic Research. 2016. 34: 518-524.  Piasecki, DP, Nicholson, GP. Tears of the subscapularis tendon in athletes-diagnosis and repair techniques. Clin Sports Med. 2008. 27: 731-745.  Uhl TL, Muir TA, et al. Electromyographical assessment of passive, active assistive, and active shoulder rehabilitation exercises. PM R. 2010. 2: 132-141.  Wilcox III R.B., Arslanian L.E., Millett P.J. Rehabilitation following total shoulder arthroplasty. JOSPT. 2005. 35 (12): 821-837  Wolff. AL, Rosenzweig, L. Anatomical and biomechanical framework for shoulder arthroplasty rehabilitation. Journal of Hand Therapy. 2017. 30: 167-174.  Wright, T, Easley, T, et al. Shoulder arthroplasty and its effect on strain in the subscapularis muscle. Clinical Biomechanics. 2015. 30: 373-376.  Zarkadas P.C., Throckmorton T., et al. Patient reported activities after shoulder replacement: total and hemiarthroplasty. J Shoulder Elbow Surg. 2011. 20: 273-280.  Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med. 1996;(6):602-608.  Leggin BG, Michener, LA, et al. The Penn Shoulder Score: reliability and validity. JOSPT. 36 (3): 138-151.","conversation_history":[],"metadata":{"question_type":"distracting element","seed_document_id":5,"distracting_context":"Rehabilitation Protocol for Sternoclavicular Joint Reconstruction  This protocol is intended to guide clinicians through the post-operative course for sternoclavicular joint reconstruction. This protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs of the individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes contained within this guideline may vary based on surgeon\u2019s preference, additional procedures performed, and\/or complications. If a clinician requires assistance in the progression of a post-operative patient, they should consult with the referring surgeon.  The interventions included within this protocol are not intended to be an inclusive list of exercises. Therapeutic interventions should be included and modified based on the progress of the patient and under the discretion of the clinician.  Considerations for the Post-operative sternoclavicular joint reconstruction Many different factors influence the post-operative rehabilitation outcome, including surgical technique (ie. tendon autograft harvest for repair), degree of SC joint instability, concomitant soft tissue or bone injury\/repair, and individual patient factors including co-morbidities. It is recommended that patients meet all rehabilitation criteria in order to progress to the next phase and clinicians collaborate closely with the referring physician throughout the rehabilitation process.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: EARLY POST-OP (0-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Reduce pain and swelling of the operative shoulder \u2022 Maintain elbow, wrist and hand AROM \u2022 Patient education Sling\/precautions \u2022 Sling to be worn for 6 weeks (or as directed by surgeon) \u2022 Avoid PROM of the glenohumeral joint \u2022 Avoid scapular AROM (protraction, retraction, depression and elevation) as it may disrupt the repair and healing tissues \u2022 Avoid bearing weight through involved extremity \u2022 Avoid lifting any lifting with involved extremity \u2022 Avoid running and jumping due to impact forces upon landing that may aggravate healing tissues and bone Intervention \u2022 Cryotherapy as needed \u2022 AROM: cervical spine, elbow, wrist, hand \u2022 Hand gripping: ball squeeze \u2022 Cardiovascular exercise as tolerated: walking, stationary bike Criteria to Progress \u2022 Well controlled pain and swelling \u2022 Protect reconstruction site and autograft site (if applicable) \u2022 Maintain elbow, wrist and hand AROM  PHASE II: INTERMEDIATE POST-OP (6-12WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Activation of muscles responsible for stabilizing the scapulothoracic and glenohumeral joint \u2022 Gradually restore PROM, AAROM of the GH joint at 6-8 weeks \u2022 Gradually restore AROM of the scapulothoracic joint and glenohumeral joint at 8 weeks \u2022 Wean from sling (if still wearing) \u2022 Begin shoulder and scapular strengthening at 8 weeks \u2022 Begin proprioception and neuromuscular control training \u2022 Identify and correct postural dysfunction as indicated Sling\/precautions \u2022 Avoid repetitive overhead activities \u2022 No lifting > 5 pounds with involved extremity until 9 weeks post-op \u2022 Post-rehabilitation soreness should resolve within 12-24 hours Additional Interventions *Continue with Phase I interventions \u2022 AROM in all cardinal plane assessing scapular rhythm \u2022 Gentle glenohumeral mobilization as indicated  Strengthening: \u2022 Rotator cuff strengthening in non-provocative positions (generally 0-45 degrees Scaption\/abduction): scaption raises against gravity, Sidelying ER, lightly resisted ER\/IR with theraband, isometrics \u2022 Scapular strengthening and dynamic neuromuscular control: low row, straight arm pulldowns, serratus punch, resisted T\u2019s  Stretching: Gentle corner or doorway pec stretch \u2022 Postural endurance exercises: scapular retractions, chin tucks \u2022 Walking, stationary bike, Stairmaster Criteria to Progress \u2022 Full AROM of the operative shoulder \u2022 Normal (5\/5) strength for glenohumeral flexion\/abduction\/IR\/ER degrees abduction  PHASE III: LATE POST-OP AND GRADUAL RETURN TO SPORT(13+ WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Restore normal (5\/5) rotator cuff strength at 90 degrees abduction including supraspinatus \u2022 Full multi-planar AROM with minimal to no substitution patterns \u2022 Advance proprioceptive and dynamic neuromuscular control training \u2022 Identify and correct postural dysfunction with sport\/work specific tasks as indicated \u2022 Develop strength and control movements required for sport\/work Sling\/ precautions \u2022 Post-rehabilitation soreness should resolve within 12 hours \u2022 No lifting restrictions at ~4 months Additional Interventions *Continue with Phase I-II Interventions \u2022 Glenohumeral mobilizations as indicated \u2022 Multiplane AROM with gradual increase in velocity of movement  Strengthening: \u2022 Rotator cuff strengthening at 45 degrees progressing to 90 degrees abduction and sport\/work specific positions as well as other provocative positions: resisted IR\/ER, elevation with ER, resisted scaption raises, facepulls\/resisted W\u2019s \u2022 Scapular strengthening and dynamic neuromuscular control in overhead or sport\/work positions: prone or resisted I\u2019s, T\u2019s and Y\u2019s, lower trap setting at wall, manual perturbations in varying degrees in elevation, serratus wall slides\/roll ups, wall pushups, quadruped shoulder taps \u2022 Core strengthening  Stretching:  Corner or doorway pec stretch, Gentle posterior capsule stretch (across body)  Walking, stationary bike, Stairmaster, return to running\/jumping as tolerated  Begin education in sport specific biomechanics with initial program for throwing, swimming, or overhead racquet sports Criteria to Return to Sport  Clearance from MD and ALL milestone criteria have been met  Maintains pain  free PROM and AROM  Performs all exercises demonstrating symmetric scapular mechanics  QuickDASH  PENN  For the recreational or competitive athlete, return  to  sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non  contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return  to  sport rehabilitation program.  Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol References: 1. Logan C, Shahien A, Altintas B, Millett PJ. Rehabilitation following sternoclavicular joint reconstruction for persistent instability. International Journal of Sports Physical Therapy. 2018;13(4):752-762. doi:10.26603\/ijspt20180752 2. Petri, M., Greenspoon, J. A., Horan, M. P., Martetschl\u00e4ger, F., Warth, R. J., & Millett, P. J. (2016). Clinical outcomes after autograft reconstruction for sternoclavicular joint instability. Journal of Shoulder and Elbow Surgery, 25(3), 435\u2013441. https:\/\/doi.org\/10.1016\/j.jse.2015.08.004 3. Garcia JA, Arguello AM, Momaya AM, Ponce BA. Sternoclavicular Joint Instability: Symptoms, Diagnosis And Management. Orthop Res Rev. 2020 Jul 28;12:75-87. doi: 10.2147\/ORR.S170964. PMID: 32801951; PMCID: PMC7395708.","topic":"Others"}}
{"id":"38352d56-7edb-4f08-bf25-ef65863a8a5f","question":"Considering the guidelines developed by Dr. Xinning Li for the postoperative rehabilitation of a rotator cuff repair, what are the objectives of the 'Maximum Protection Phase' during the first 4-6 weeks post-op in a 'Slow or Conservative Program' for patients who have undergone this procedure?","reference_answer":"The goals of the 'Maximum Protection Phase' in the first 4-6 weeks post-op of a 'Slow or Conservative Program' for a rotator cuff repair are: 1. Protecting the surgical repair (Sling and Abduction Pillow at ALL TIMES), 2. Decreasing pain\/ inflammation, 3. Gradually increasing shoulder ROM (MD directed), 4. Improving proximal (scapula) and distal strength and mobility, and 5. Achieving independence in a home exercise program (HEP).","reference_context":"Document 8: PHYSICAL THERAPY PRESCRIPTION:  REVERSE SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: Please Transition out of the sling between 2 to 3 weeks after surgery (Sleep in sofa recliner with your sling for the first 2 weeks) for Primary Reverse Shoulder Replacement or 5 to 6 weeks for Fracture and Revision Reverse Shoulder Replacement.  2 Weeks  6 Weeks  Activities of Daily Living: You may use your arm and hand on the operative shoulder for your ADL activates 2 weeks after surgery. Pendulums are also encouraged 1 week after surgery.  Exercises: Passive ER to 20 degrees and extension to neutral, pendulums daily  Passive supine FF in scapular plane to 90 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed: ice  Advancement Criteria: ER to the above set criteria FF in scapular plane to 90 Minimal pain and inflammation with any motion or exercise Incision is well healed with no drainage or redness  2  Weeks 6  10: Phase II  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER as tolerated by the patient  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF > 120  ER > 30  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF > 120, ER >30  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  3  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation\n\nDocument 6: PHYSICAL THERAPY PRESCRIPTION:  TOTAL SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: At all times except for showering and exercise. (Sleep in sofa recliner)  Total of 6 weeks in the Sling and the Abduction pillow  Exercises: Pendulums ok 2 weeks after surgery Passive ER to 10 degrees and extension to neutral  Passive supine FF in scapular plane to 130 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed  Advancement Criteria: ER the above set criteria FF in scapular plane to 130 Minimal pain and inflammation with motion and exercise Incision is well healed with no drainage and no redness  Weeks 6  10: Phase II  Sling Immobilizer: Discontinue at week 6  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER \u2013 limit 45 deg  2  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF to 150  ER to 45  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF 160, ER >45  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  3  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation\n\nDocument 7: Visit per week:  2 to 3 times  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Advanced Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  2  4 WEEKS POST  OP (Maximum Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN)  2  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises  Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  4  6 WEEKS POST  OP (Moderate Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  3  7  12 WEEKS POST  OP: (Early Strengthening Phase)  GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  13  19 WEEKS POST  OP: (Late Strengthening Phase)  GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 weeks  Continue with throwing and racquet program if appropriate  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  20-24 WEEKS POST-OP: (Return to Sports or Full Activity)  GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control\n\nDocument 2: Visit per week:  2 to 3 times  Diagnosis:   LEFT or RIGHT Shoulder Arthroscopic Large Rotator Cuff Repair - Supraspinatus and Infraspinatus Repair - Subscapularis Repair  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Slow or Conservative Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  ** Weeks 0-3: Patient stays in the sling and abduction pillow at all times. Pendulums ok to start Week #3 (NO PAIN). NO Shoulder PROM. Elbow and wrist ROM is ok. **  4-6 WEEKS POST-OP (Maximum Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility  2 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Start Post Op Week #4 Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN), Pts with Subscapularis Repair: (Limit Passive ER to 20\u00b0)  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises and Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  6-8 WEEKS POST-OP (Moderate Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain  3 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  9-14 WEEKS POST-OP: (Early Strengthening Phase) GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  15-23 WEEKS POST-OP: (Late Strengthening Phase) GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 week. Continue with throwing program  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  24-26 WEEKS POST-OP: (Return to Sports or Full Activity) GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control","conversation_history":[],"metadata":{"question_type":"distracting element","seed_document_id":8,"distracting_context":"Visit per week:  2 to 3 times  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Advanced Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  2  4 WEEKS POST  OP (Maximum Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN)  2  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises  Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  4  6 WEEKS POST  OP (Moderate Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  3  7  12 WEEKS POST  OP: (Early Strengthening Phase)  GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  13  19 WEEKS POST  OP: (Late Strengthening Phase)  GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 weeks  Continue with throwing and racquet program if appropriate  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  20-24 WEEKS POST-OP: (Return to Sports or Full Activity)  GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control","topic":"Others"}}
{"id":"119e8d88-3500-416c-9072-c6a1a68a25ae","question":"What are the objectives of the immediate post-surgery phase in the rehabilitation guidelines for Ulnar Collateral Ligament Reconstruction, considering the need to protect the repair site and reduce muscle atrophy as seen in Sternoclavicular Joint Reconstruction rehabilitation?","reference_answer":"The goals of the immediate post-op phase in the rehabilitation guidelines for Ulnar Collateral Ligament Reconstruction are to protect healing tissue, reduce pain and inflammation, protect the graft site, and reduce muscle atrophy.","reference_context":"Document 1: Massachusetts General Brigham Sports Medicine  Rehabilitation Guidelines for Ulnar Collateral Ligament Reconstruction (Palmaris Longus Graft, Gracilis Graft)  This protocol is intended to guide clinicians through the post-operative course for Ulnar Collateral Ligament Reconstruction (Palmaris Longus Graft, Gracilis Graft). This protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs of the individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes contained within this guideline may vary based on surgeon\u2019s preference, additional procedures performed, and\/or complications. If a clinician requires assistance in the progression of a post-operative patient, they should consult with the referring surgeon.  The interventions included within this protocol are not intended to be an inclusive list of exercises. Therapeutic interventions should be included and modified based on the progress of the patient and under the discretion of the clinician.  Considerations for the Post-operative Many different factors influence the post-operative UCL reconstruction rehabilitation outcomes, including whether a palmaris longus or gracilis graft was performed and individual co-morbidities. It is recommended that clinicians collaborate closely with the referring physician.  If you develop a fever, excessive drainage from incision, severe heat and\/or redness along incision, uncontrolled pain, or any other symptoms that concern you please call your doctor.  PHASE I: IMMEDIATE POST-OP PHASE (0-3 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Protect healing tissue \u2022 Reduce pain and inflammation \u2022 Protect graft site \u2022 Reduce muscle atrophy Brace \u2022 Week 1 \u2013 Immobilized in Posterior splint at 90 degrees of Elbow Flexion \u2022 Week 2: Hinged Brace: 25-100 degrees \u2022 Week 3: Hinged brace: 15-115 degrees \u2022 Elbow Post-op compression dressing for 5-7 days \u2022 Palmaris Longus Graft \u2013 Wrist post-op compression for 5-7 days Precautions \u2022 Shoulder External rotation isometrics \u2022 Valgus stress to the Elbow Intervention  Manual therapy \u2022 Soft tissue mobilization, retrograde massage for swelling  Modalities  Ice and compression  Gripping Exercises: \u2022 Squeeze towel, putty or foam with varying types of grips  Isometrics  Performed with brace on  Day 1  Shoulder: Flexion, ABD, IR  Avoid External Rotation  Performed with arm at side, gently push against a wall or opposite hand - Elbow Flexion  Performed at 90 degrees elbow flexion \u2022 Day 7 - Elbow Extension  Performed at 90 degrees elbow flexion  Range of Motion \u2022 Wrist AROM - Flexion, - Extension - Radial deviation - Ulnar deviation \u2022 Thumb opposition \u2022 Elbow PROM - Flexion and extension - Performed to tolerance, making sure the elbow is staying relaxed. \u2022 Shoulder AROM - Performed with brace on - Full Can \u2022 Elbow AROM: Begin day 14 \u2022 Low load, long duration stretching: - Use when elbow extension range of motion is lacking - Supine with towel roll under distal humerus. - Add a light weight - Must be pain-free - Hold 10-15 minutes up to 4 times a day, totaling 60 minutes a day  Gracilis Graft \u2013 Knee ROM immediately post  op; Bike on week 3  Criteria to Progress \u2022 Elbow ROM: at least 15-115 degrees \u2022 At least 4\/5 elbow MMT scores  PHASE II: PROTECTION PHASE (4-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Gradual increase to full ROM by week 6 \u2022 Promote healing of repaired tissue \u2022 Regain and improve muscular strength \u2013 slow integration of exercises \u2022 Restore full function of graft site Brace \u2022 Week 4: 0-125 degrees \u2022 Week 5: 0-135 degrees \u2022 Week 6: 0-145 degrees \u2022 Discontinue use of brace at week 6 if achieved full ROM, unless walking in crowds or slippery surfaces Precautions \u2022 No valgus stress to the graft \u2022 No ER strengthening until week 6 \u2022 Gracilis graft \u2013 Do not initiate progressive resistive hamstring strengthening until week 6 Additional Intervention *Continue with Phase I interventions Manual therapy \u2022 Soft tissue and scar mobilization  Modalities \u2022 Continue with ice and compression  Range of Motion \u2022 Elbow PROM \u2013 Focus on restoration of full elbow extension  Strengthening \u2022 Wrist and forearm strengthening: - Curls\/Extensions \u2013 Start with 1 lb. - Pronation\/Supination \u2013 Start with dowel \u2022 Biceps curl \u2013 Begin with 1lb \u2022 Triceps Extension \u2022 Scapula stabilization: Start at 1 lb - Prone Row - Prone Shoulder horizontal abduction - Prone Shoulder extension \u2022 Resistance band - Low rows - Shoulder internal rotation (at side) \u2022 Standing scaption (start with 1lb, do not exceed 10 lbs.) Criteria to Progress \u2022 Full Range of Motion \u2022 At least 70% of strength of wrist and shoulder of uninvolved arm \u2013 HHD, MMT or isokinetic testing \u2022 Good tolerance to all exercises with no pain  PHASE III: STRENGTHENING PHASE (6-12 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Increase strength\/endurance\/power \u2022 Maintain full elbow ROM especially extension Precautions \u2022 No Throwing \u2022 No valgus stress to the elbow Additional Intervention *Continue with Phase I-II Interventions Manual Therapy: \u2022 Soft tissue mobilizations as needed  Range of motion  Elbow PROM as needed  Maintain full elbow extension  Strengthening \u2022 Gracilis graft: Begin slow progression of hamstring strengthening \u2022 Forearm strengthening: - Emphasis on flexion and pronation \u2022 Elbow Strengthening: - Eccentric flexion and extension - Varied resistance and speed of contractions - (start slow build to fast) \u2022 Thrower\u2019s 10 program: Begin at week 6 - Initiate Advanced Thrower\u2019s 10 at Week 8 \u2013 as appropriate \u2022 UBE \u2022 Rows \u2022 Lat pull down \u2022 PNF exercises - Rhythmic stabilization\/manual resistance: (side-lying ER and diagonals)  Criteria to Progress \u2022 Maintain full pain-free ROM \u2022 At least 85% strength of uninvolved arm \u2013 HHD, or isokinetic testing \u2022 Good tolerance to all exercises with no pain  PHASE IV: ADVANCED STRENGTHENING PHASE (12-16 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Progress power\/endurance \u2022 Normalize shoulder\/forearm strength  Initiate plyometric exercises  Gradually initiate sports\/functional exercises Precautions  No Throwing  No valgus stress to elbow Additional Intervention  Continue with Phase II  III interventions as appropriate Strengthening  Advanced throwers ten program  Body blade \u2013 ER\/IR, push\/pull  Seated bench press  Supine dumbbell bench press  Begin a hitting program (if applicable to sport)  Initiate week 12  Plyometric Program \u2022 Week 12: - 2-handed drills only: 6-8 lbs. (emphasis on full extension) \u2022 Chest pass \u2022 Side throw close to body \u2022 Week 14: - 2 hands away from body \u2022 Side to side throws \u2022 Soccer throws \u2022 Side throws - Begin 1-arm plyometrics \u2022 1-handed stationary \u2022 Wall dribble: 1-2lb. medicine ball \u2022 Baseball throws into wall \u2022 Rhythmic stabilization in scapular plane with medicine ball on wall Criteria to Progress \u2022 Full, painless elbow\/wrist ROM \u2022 Shoulder total ROM within 5\u00b0 of non-throwing shoulder \u2022 > 40\u00b0 horizontal adduction of throwing shoulder \u2022 < 15\u00b0 Glenohumeral IR deficit \u2022 Elbow, shoulder and wrist strength with MMT, HHD or isokinetic: - ER\/IR ratio: 72-76% - ER\/ABD ratio: 68-73% - Throwing shoulder IR: > 115% of non-throwing shoulder - Throwing shoulder ER: > 95% of non-throwing shoulder - Elbow flexion\/extension: 100-115% of non-throwing shoulder - Wrist flexion\/extension: 100-115% of non-throwing shoulder \u2022 Functional test Scores: - Prone Drop ball test \u2013 110% of non-throwing side - 1-arm balls against wall @ 90\/90: \u2022 2lb ball \u2022 30 seconds with no pain \u2022 115% of throwing side - Single arm step down test: \u2022 8-inch \u2022 30 seconds \u2022 Satisfactory score on Kerlan-Jobe Orthopedic Clinic shoulder and elbow score (KJOC) throwers assessment. \u2022 Physician Clearance  PHASE V: EARLY RETURN TO SPORT - UNRESTRICTED RETURN TO SPORT (16+ WEEKS AFTER SURGERY)  Rehabilitation Goals \u2022 Increase strength, power and endurance \u2022 Safely initiate sport specific training program \u2022 Safely progress to full sport.  Additional Intervention *Continue with Phase II-IV interventions \u2022 Interval Throwing Program: 16 weeks after surgery \u2013 unless indicated otherwise by surgeon \u2022 ***Refer to return-to-sport protocol\/throwing protocol for further detail  Criteria to Progress \u2022 Last stage, no additional criteria Revised 6\/2021  Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol  References: 1. Biz C, Crim\u00ec A, Belluzzi E, et al. Conservative Versus Surgical Management of Elbow Medial Ulnar Collateral Ligament Injury: A Systematic Review. Orthopaedic Surgery. 2019;11(6):974-984. doi:10.1111\/os.12571 2. Ellenbecker TS, Wilk KE, Altchek DW, Andrews JR. Current concepts in rehabilitation following ulnar collateral ligament reconstruction. Sports Health. 2009;1(4):301-313. 3. Evans JP, Smith CD, Fine NF, et al. Clinical Rating systems in elbow research \u2013 a systematic review exploring trends and distributions of use. Journal of Shoulder and Elbow Surgery. 2018;25:98-106. 4. Glogovac G, Kakazu R, Aretakis AC, Grawe BM. Return to Sport and Sports-Specific outcomes following Ulnar Collateral Ligament reconstruction in adolescent athletes: A Systematic review. HSS Journal. 2019;16:242-249. Doi: 10.1007\/s11420-019-09689-9. 5. Hodgins JL, Vitale M, Arons RR, Ahmad CS. Epidemiology of Medial Ulnar Collateral Ligament Reconstruction. The American Journal of Sports Medicine. 2016;44(3):729-734. doi:10.1177\/0363546515622407 6. Lightsey HM, Trofa DP, Sonnenfeld JJ, et al. Rehabilitation variability after elbow Ulnar Collateral ligament reconstruction. The Orthopedic Journal of Sports medicine. 2019;7(3): 1-7. Doi: 10.1177\/2325967119833363. 7. Olds M, Coulter C, Marrant D, Uhl T. Reliability of a shoulder arm return to sport test battery. Physical Therapy in Sport. 2019;39:16-22. 8. Peters SD, Bullock GS, Goode AP, Garrigues GE, Ruch DS, Reiman MP.  The success of return to sport after ulnar collateral ligament injury in baseball: a systematic review and meta-analysis. Journal of Shoulder and Elbow Surgery. 2018;27(3):561-571. doi:10.1016\/j.jse.2017.12.003 9. Saper M, Shung J, Pearce S, Bompadre V, Andrews JR. Outcomes and Return to Sport after Ulnar Collateral ligament reconstruction in adolescent baseball players. The Orthopedic Journal of Sports Medicine. 2018;6(4):1-7. Doi: 10.1177\/2325967118769328. 10. Wilk KE, Arrigo CA, Dugas JR, Cain EL, Andrews JR. Rehabilitation and Return-to-Play Criteria Following Ulnar Collateral Ligament Reconstruction. Operative Techniques in Sports Medicine. 2017;25(3):154-171. doi:10.1053\/j.otsm.2017.07.004 11. Wilk KE, Arrigo CA, Arrigo RJ. Rehabilitation following UCL repair with Internal Brace. Orthopedics and Sports Medicine. 2019;3(1): 212-217. Doi: 10.32474\/OSMOAJ.2019.03.000151.","conversation_history":[],"metadata":{"question_type":"distracting element","seed_document_id":1,"distracting_context":"Rehabilitation Protocol for Sternoclavicular Joint Reconstruction  This protocol is intended to guide clinicians through the post-operative course for sternoclavicular joint reconstruction. This protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs of the individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes contained within this guideline may vary based on surgeon\u2019s preference, additional procedures performed, and\/or complications. If a clinician requires assistance in the progression of a post-operative patient, they should consult with the referring surgeon.  The interventions included within this protocol are not intended to be an inclusive list of exercises. Therapeutic interventions should be included and modified based on the progress of the patient and under the discretion of the clinician.  Considerations for the Post-operative sternoclavicular joint reconstruction Many different factors influence the post-operative rehabilitation outcome, including surgical technique (ie. tendon autograft harvest for repair), degree of SC joint instability, concomitant soft tissue or bone injury\/repair, and individual patient factors including co-morbidities. It is recommended that patients meet all rehabilitation criteria in order to progress to the next phase and clinicians collaborate closely with the referring physician throughout the rehabilitation process.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: EARLY POST-OP (0-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Reduce pain and swelling of the operative shoulder \u2022 Maintain elbow, wrist and hand AROM \u2022 Patient education Sling\/precautions \u2022 Sling to be worn for 6 weeks (or as directed by surgeon) \u2022 Avoid PROM of the glenohumeral joint \u2022 Avoid scapular AROM (protraction, retraction, depression and elevation) as it may disrupt the repair and healing tissues \u2022 Avoid bearing weight through involved extremity \u2022 Avoid lifting any lifting with involved extremity \u2022 Avoid running and jumping due to impact forces upon landing that may aggravate healing tissues and bone Intervention \u2022 Cryotherapy as needed \u2022 AROM: cervical spine, elbow, wrist, hand \u2022 Hand gripping: ball squeeze \u2022 Cardiovascular exercise as tolerated: walking, stationary bike Criteria to Progress \u2022 Well controlled pain and swelling \u2022 Protect reconstruction site and autograft site (if applicable) \u2022 Maintain elbow, wrist and hand AROM  PHASE II: INTERMEDIATE POST-OP (6-12WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Activation of muscles responsible for stabilizing the scapulothoracic and glenohumeral joint \u2022 Gradually restore PROM, AAROM of the GH joint at 6-8 weeks \u2022 Gradually restore AROM of the scapulothoracic joint and glenohumeral joint at 8 weeks \u2022 Wean from sling (if still wearing) \u2022 Begin shoulder and scapular strengthening at 8 weeks \u2022 Begin proprioception and neuromuscular control training \u2022 Identify and correct postural dysfunction as indicated Sling\/precautions \u2022 Avoid repetitive overhead activities \u2022 No lifting > 5 pounds with involved extremity until 9 weeks post-op \u2022 Post-rehabilitation soreness should resolve within 12-24 hours Additional Interventions *Continue with Phase I interventions \u2022 AROM in all cardinal plane assessing scapular rhythm \u2022 Gentle glenohumeral mobilization as indicated  Strengthening: \u2022 Rotator cuff strengthening in non-provocative positions (generally 0-45 degrees Scaption\/abduction): scaption raises against gravity, Sidelying ER, lightly resisted ER\/IR with theraband, isometrics \u2022 Scapular strengthening and dynamic neuromuscular control: low row, straight arm pulldowns, serratus punch, resisted T\u2019s  Stretching: Gentle corner or doorway pec stretch \u2022 Postural endurance exercises: scapular retractions, chin tucks \u2022 Walking, stationary bike, Stairmaster Criteria to Progress \u2022 Full AROM of the operative shoulder \u2022 Normal (5\/5) strength for glenohumeral flexion\/abduction\/IR\/ER degrees abduction  PHASE III: LATE POST-OP AND GRADUAL RETURN TO SPORT(13+ WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Restore normal (5\/5) rotator cuff strength at 90 degrees abduction including supraspinatus \u2022 Full multi-planar AROM with minimal to no substitution patterns \u2022 Advance proprioceptive and dynamic neuromuscular control training \u2022 Identify and correct postural dysfunction with sport\/work specific tasks as indicated \u2022 Develop strength and control movements required for sport\/work Sling\/ precautions \u2022 Post-rehabilitation soreness should resolve within 12 hours \u2022 No lifting restrictions at ~4 months Additional Interventions *Continue with Phase I-II Interventions \u2022 Glenohumeral mobilizations as indicated \u2022 Multiplane AROM with gradual increase in velocity of movement  Strengthening: \u2022 Rotator cuff strengthening at 45 degrees progressing to 90 degrees abduction and sport\/work specific positions as well as other provocative positions: resisted IR\/ER, elevation with ER, resisted scaption raises, facepulls\/resisted W\u2019s \u2022 Scapular strengthening and dynamic neuromuscular control in overhead or sport\/work positions: prone or resisted I\u2019s, T\u2019s and Y\u2019s, lower trap setting at wall, manual perturbations in varying degrees in elevation, serratus wall slides\/roll ups, wall pushups, quadruped shoulder taps \u2022 Core strengthening  Stretching:  Corner or doorway pec stretch, Gentle posterior capsule stretch (across body)  Walking, stationary bike, Stairmaster, return to running\/jumping as tolerated  Begin education in sport specific biomechanics with initial program for throwing, swimming, or overhead racquet sports Criteria to Return to Sport  Clearance from MD and ALL milestone criteria have been met  Maintains pain  free PROM and AROM  Performs all exercises demonstrating symmetric scapular mechanics  QuickDASH  PENN  For the recreational or competitive athlete, return  to  sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non  contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return  to  sport rehabilitation program.  Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol References: 1. Logan C, Shahien A, Altintas B, Millett PJ. Rehabilitation following sternoclavicular joint reconstruction for persistent instability. International Journal of Sports Physical Therapy. 2018;13(4):752-762. doi:10.26603\/ijspt20180752 2. Petri, M., Greenspoon, J. A., Horan, M. P., Martetschl\u00e4ger, F., Warth, R. J., & Millett, P. J. (2016). Clinical outcomes after autograft reconstruction for sternoclavicular joint instability. Journal of Shoulder and Elbow Surgery, 25(3), 435\u2013441. https:\/\/doi.org\/10.1016\/j.jse.2015.08.004 3. Garcia JA, Arguello AM, Momaya AM, Ponce BA. Sternoclavicular Joint Instability: Symptoms, Diagnosis And Management. Orthop Res Rev. 2020 Jul 28;12:75-87. doi: 10.2147\/ORR.S170964. PMID: 32801951; PMCID: PMC7395708.","topic":"Others"}}
{"id":"16caa9d2-853f-4470-ad92-1b09e06dab3a","question":"What are the crucial factors to consider when developing a post-operative rehabilitation program for a patient who has undergone Total Shoulder Arthroplasty and Hemiarthroplasty, particularly when the patient has also had a SLAP Repair-Type II?","reference_answer":"Many different factors influence the post-operative rehabilitation outcome, including surgical approach, concomitant repair of the rotator cuff, arthroplasty secondary to fracture, arthroplasty secondary to rheumatoid arthritis or osteonecrosis, and individual patient factors including co-morbidities. It is recommended that patients meet all rehabilitation criteria in order to progress to the next phase and clinicians collaborate closely with the referring physician throughout the rehabilitation process.","reference_context":"Document 3: Rehabilitation Protocol for SLAP Repair-Type II  This protocol is intended to guide clinicians through the post-operative course for SLAP Repair-Type II. This protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs of the individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes contained within this guideline may vary based on surgeon\u2019s preference, additional procedures performed, and\/or complications. If a clinician requires assistance in the progression of a post-operative patient, they should consult with the referring surgeon.  The interventions included within this protocol are not intended to be an inclusive list. Therapeutic interventions should be included and modified based on the progress of the patient and under the discretion of the clinician.  Considerations for the Post-operative SLAP repair Rehabilitation Program Many different factors influence the post-operative SLAP repair rehabilitation outcome, including the type of SLAP lesion, the size of the tear\/number of anchors placed, concomitant procedures and amount of shoulder hypermobility and\/or hyperlaxity. Consider mechanism of injury as well as the sport the athlete would like to return to when initiating certain interventions.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: IMMEDIATE POST-OP (0-3 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Maintain UE ROM in elbow, hand and wrist \u2022 Gradually increase shoulder PROM \u2022 Minimize muscle inhibition \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM\/AAROM \u2022 No elbow AROM (avoid biceps contraction) \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 No reaching behind back Intervention Swelling Management \u2022 Ice, compression  Range of motion\/Mobility \u2022 PROM: ER<30 scapular plane, Forward elevation <90, full elbow flex and ext, seated GH flexion table slide, horizontal table slide (add hyperlink) \u2022 AROM: hand, wrist \u2022 AAROM: none  Strengthening (Week 2)  Periscapular: scap retraction  , prone scapular retraction  , standing scapular setting  , supported scapular setting, inferior glide, low row  to neutral; avoid shoulder extension  Rotator cuff: submaximal pain  free isometrics  Ball squeeze Criteria to Progress  90 degrees shoulder PROM forward elevation  30 degrees of shoulder PROM ER in the scapular plane  Full elbow PROM flexion and extension  Palpable muscle contraction felt in scapular and shoulder musculature  No complications with Phase I  PHASE II: INTERMEDIATE POST-OP (4-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Continue to protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM \u2022 Minimize substitution patterns with shoulder AAROM \u2022 Initiate motor control exercise \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM \u2022 No elbow AROM (avoid biceps contraction) \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 No reaching behind back Intervention *Continue with Phase I interventions  Range of motion\/Mobility \u2022 PROM: ER<45 scapular plane, Forward elevation <120 \u2022 AAROM: Active assistive shoulder flexion, shoulder flexion with cane, cane external rotation stretch, washcloth press, sidelying elevation to 90 degrees  Strengthening \u2022 Periscapular: Row on physioball*, shoulder extension on physioball*, serratus punches - *to neutral; avoid shoulder extension  Motor Control \u2022 Internal and external rotation in scaption and Flex 90-125 (rhythmic stabilization)  Stretching \u2022 Sidelying horizontal ADD, sleeper stretch Criteria to Progress \u2022 120 degrees shoulder PROM forward elevation \u2022 45 degrees shoulder PROM ER in scapular plane \u2022 Minimal substitution patterns with shoulder AAROM \u2022 Pain < 4\/10 \u2022 No complications with Phase II  PHASE III: INTERMEDIATE POST-OP CONT\u2019d (7-8 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM\/AAROM \u2022 Initiate shoulder and elbow AROM \u2022 Initiate RTC strengthening  Improve scapular muscle activation  Patient education Sling  Discontinue Precautions  No resisted elbow flexion  No lifting of heavy objects (>10 lbs) Intervention  Continue with Phase I  II interventions Range of motion\/Mobility  PROM: ER Full in scapular plane, \uf0a390 degrees ER in 90 degrees of abduction, IR Full in scapular plane, Forward elevation Full  do not push beyond 90 degrees ER in 90 degrees of abduction  AAROM: seated shoulder elevation with cane, seated incline table slides, ball roll on wall  AROM: supine flexion, salutes, supine punch, wall climbs, elbow flexion  Strengthening \u2022 Rotator cuff: side-lying external rotation, standing external rotation w\/ resistance band, standing internal rotation w\/ resistance band, internal  rotation, external rotation \u2022 Periscapular: Resistance band shoulder extension*, resistance band seated rows*, rowing*, lawn mowers, robbery - *to neutral; avoid shoulder extension \u2022 Elbow: Triceps  Motor Control \u2022 Quadruped alternating isometrics Criteria to Progress \u2022 Full pain-free shoulder PROM ER and forward elevation \u2022 Within 10 degrees of shoulder IR PROM of contralateral shoulder \u2022 Minimal substitution patterns with shoulder AROM \u2022 Pain < 4\/10  PHASE IV: TRANSITIONAL POST-OP (9-12 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue \u2022 Restore full shoulder PROM and AROM \u2022 Initiate resisted elbow flexion at 12 weeks \u2022 Improve dynamic shoulder stability \u2022 Progress periscapular strength \u2022 Gradually return to full functional activities Precautions \u2022 No lifting of heavy objects (> 10 lbs) Intervention *Continue with Phase II-III interventions Range of motion\/mobility \u2022 PROM: Full \u2022 AROM: Supine forward elevation with elastic resistance to 90 deg, scaption and shoulder flexion to 90  degrees elevation  Strengthening \u2022 Periscapular: Push-up plus on knees, prone shoulder extension Is*, resistance band forward punch, forward punch, tripod o *to neutral; avoid shoulder extension \u2022 Elbow (12 weeks): Biceps curl, resistance band bicep curls  Motor control  Ball stabilization on wall  Stretching \u2022 Hands behind head, IR behind back with towel, triceps and lats, doorway series Criteria to Progress \u2022 Full pain-free shoulder PROM and AROM \u2022 Minimal to no substitution patterns with shoulder AROM \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 Pain < 2\/10  PHASE V: LATE POST-OP (13-16 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free shoulder ROM \u2022 Enhance functional use of upper extremity Intervention *Continue with Phase II-IV interventions Strengthening \u2022 Rotator cuff: External rotation at 90 degrees, internal rotation at 90 degrees, resistance band standing external rotation at 90 degrees, resistance band standing internal rotation at 90 degrees \u2022 Periscapular: T and Y, \u201cT\u201d exercise, push-up plus knees extended, pointer, wall push up, \u201cW\u201d exercise, resistance band Ws, dynamic hug, resistance band dynamic hug  Motor Control \u2022  PNF \u2013 D1 diagonal lifts, PNF \u2013 D2 diagonal lifts, field goals , resistance band PNF pattern, PNF \u2013 D1 diagonal lifts w\/ resistance, diagonal-up, diagonal-down, wall slides w\/ resistance band Criteria to Progress \u2022 Clearance from MD and ALL milestone criteria below have been met \u2022 Full pain-free shoulder PROM and AROM \u2022 ER\/IR strength minimum 85% of the uninvolved arm \u2022 ER\/IR ratio 60% or higher \u2022 Negative impingement and instability signs \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 QuickDASH \u2022 PENN  PHASE VI: EARLY RETURN-TO-SPORT (4-6 MONTHS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free ROM \u2022 Continue strengthening and motor control exercises \u2022 Enhance functional use of upper extremity \u2022 Gradual return to strenuous work\/sport activity Intervention *Continue with Phase II-V interventions Strengthening \u2022 See specific return-to-sport\/throwing program (coordinate with physician) Criteria to Progress \u2022 Last stage-no additional criteria Return-to-Sport \u2022 For the recreational or competitive athlete, return-to-sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non-contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return-to-sport rehabilitation program. Revised 7\/2020  Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol  References:  1. Ahsan, ZS, Hsu JE, et al. The Snyder classification of superior labrum anterior and posterior (SLAP) lesions. Clin Orthop Relat Res. 2016. 474:2075- 2078.  2. Christopher ZR, Kennedy J, et al. Rehabilitation and return to play following superior labral anterior to posterior repair. Oper Tech Sports Med. 2017. 25:132-144.  3. Cools AM, Borms D, Cottens S, et al. Rehabilitation exercises for athletes with biceps disorders and SLAP lesions. AJSM. 2014. 42(6): 1315-1323.  4. Itoi E, Hatakeyama Y, et al. Position of immobilization after dislocation of the shoulder. JBJS. 1999. 81-A(3): 385-390.  5. Kibler, W.B., Sciascia, A. D., Uhl, T. L., et al. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. The American Journal of Sports Medicine. 2008. 36(9): p. 1789-1798.  6. Wilk KE, Reinold MM, et al. Current concepts in the recognition and treatment of superior labral (SLAP) lesions. JOSPT. 2005. 35(5): 273-291.\n\nDocument 5: Rehabilitation Protocol for Sternoclavicular Joint Reconstruction  This protocol is intended to guide clinicians through the post-operative course for sternoclavicular joint reconstruction. This protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs of the individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes contained within this guideline may vary based on surgeon\u2019s preference, additional procedures performed, and\/or complications. If a clinician requires assistance in the progression of a post-operative patient, they should consult with the referring surgeon.  The interventions included within this protocol are not intended to be an inclusive list of exercises. Therapeutic interventions should be included and modified based on the progress of the patient and under the discretion of the clinician.  Considerations for the Post-operative sternoclavicular joint reconstruction Many different factors influence the post-operative rehabilitation outcome, including surgical technique (ie. tendon autograft harvest for repair), degree of SC joint instability, concomitant soft tissue or bone injury\/repair, and individual patient factors including co-morbidities. It is recommended that patients meet all rehabilitation criteria in order to progress to the next phase and clinicians collaborate closely with the referring physician throughout the rehabilitation process.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: EARLY POST-OP (0-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Reduce pain and swelling of the operative shoulder \u2022 Maintain elbow, wrist and hand AROM \u2022 Patient education Sling\/precautions \u2022 Sling to be worn for 6 weeks (or as directed by surgeon) \u2022 Avoid PROM of the glenohumeral joint \u2022 Avoid scapular AROM (protraction, retraction, depression and elevation) as it may disrupt the repair and healing tissues \u2022 Avoid bearing weight through involved extremity \u2022 Avoid lifting any lifting with involved extremity \u2022 Avoid running and jumping due to impact forces upon landing that may aggravate healing tissues and bone Intervention \u2022 Cryotherapy as needed \u2022 AROM: cervical spine, elbow, wrist, hand \u2022 Hand gripping: ball squeeze \u2022 Cardiovascular exercise as tolerated: walking, stationary bike Criteria to Progress \u2022 Well controlled pain and swelling \u2022 Protect reconstruction site and autograft site (if applicable) \u2022 Maintain elbow, wrist and hand AROM  PHASE II: INTERMEDIATE POST-OP (6-12WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Activation of muscles responsible for stabilizing the scapulothoracic and glenohumeral joint \u2022 Gradually restore PROM, AAROM of the GH joint at 6-8 weeks \u2022 Gradually restore AROM of the scapulothoracic joint and glenohumeral joint at 8 weeks \u2022 Wean from sling (if still wearing) \u2022 Begin shoulder and scapular strengthening at 8 weeks \u2022 Begin proprioception and neuromuscular control training \u2022 Identify and correct postural dysfunction as indicated Sling\/precautions \u2022 Avoid repetitive overhead activities \u2022 No lifting > 5 pounds with involved extremity until 9 weeks post-op \u2022 Post-rehabilitation soreness should resolve within 12-24 hours Additional Interventions *Continue with Phase I interventions \u2022 AROM in all cardinal plane assessing scapular rhythm \u2022 Gentle glenohumeral mobilization as indicated  Strengthening: \u2022 Rotator cuff strengthening in non-provocative positions (generally 0-45 degrees Scaption\/abduction): scaption raises against gravity, Sidelying ER, lightly resisted ER\/IR with theraband, isometrics \u2022 Scapular strengthening and dynamic neuromuscular control: low row, straight arm pulldowns, serratus punch, resisted T\u2019s  Stretching: Gentle corner or doorway pec stretch \u2022 Postural endurance exercises: scapular retractions, chin tucks \u2022 Walking, stationary bike, Stairmaster Criteria to Progress \u2022 Full AROM of the operative shoulder \u2022 Normal (5\/5) strength for glenohumeral flexion\/abduction\/IR\/ER degrees abduction  PHASE III: LATE POST-OP AND GRADUAL RETURN TO SPORT(13+ WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Restore normal (5\/5) rotator cuff strength at 90 degrees abduction including supraspinatus \u2022 Full multi-planar AROM with minimal to no substitution patterns \u2022 Advance proprioceptive and dynamic neuromuscular control training \u2022 Identify and correct postural dysfunction with sport\/work specific tasks as indicated \u2022 Develop strength and control movements required for sport\/work Sling\/ precautions \u2022 Post-rehabilitation soreness should resolve within 12 hours \u2022 No lifting restrictions at ~4 months Additional Interventions *Continue with Phase I-II Interventions \u2022 Glenohumeral mobilizations as indicated \u2022 Multiplane AROM with gradual increase in velocity of movement  Strengthening: \u2022 Rotator cuff strengthening at 45 degrees progressing to 90 degrees abduction and sport\/work specific positions as well as other provocative positions: resisted IR\/ER, elevation with ER, resisted scaption raises, facepulls\/resisted W\u2019s \u2022 Scapular strengthening and dynamic neuromuscular control in overhead or sport\/work positions: prone or resisted I\u2019s, T\u2019s and Y\u2019s, lower trap setting at wall, manual perturbations in varying degrees in elevation, serratus wall slides\/roll ups, wall pushups, quadruped shoulder taps \u2022 Core strengthening  Stretching:  Corner or doorway pec stretch, Gentle posterior capsule stretch (across body)  Walking, stationary bike, Stairmaster, return to running\/jumping as tolerated  Begin education in sport specific biomechanics with initial program for throwing, swimming, or overhead racquet sports Criteria to Return to Sport  Clearance from MD and ALL milestone criteria have been met  Maintains pain  free PROM and AROM  Performs all exercises demonstrating symmetric scapular mechanics  QuickDASH  PENN  For the recreational or competitive athlete, return  to  sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non  contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return  to  sport rehabilitation program.  Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol References: 1. Logan C, Shahien A, Altintas B, Millett PJ. Rehabilitation following sternoclavicular joint reconstruction for persistent instability. International Journal of Sports Physical Therapy. 2018;13(4):752-762. doi:10.26603\/ijspt20180752 2. Petri, M., Greenspoon, J. A., Horan, M. P., Martetschl\u00e4ger, F., Warth, R. J., & Millett, P. J. (2016). Clinical outcomes after autograft reconstruction for sternoclavicular joint instability. Journal of Shoulder and Elbow Surgery, 25(3), 435\u2013441. https:\/\/doi.org\/10.1016\/j.jse.2015.08.004 3. Garcia JA, Arguello AM, Momaya AM, Ponce BA. Sternoclavicular Joint Instability: Symptoms, Diagnosis And Management. Orthop Res Rev. 2020 Jul 28;12:75-87. doi: 10.2147\/ORR.S170964. PMID: 32801951; PMCID: PMC7395708.\n\nDocument 4: Rehabilitation Protocol for Total Shoulder Arthroplasty and Hemiarthroplasty  This protocol is intended to guide clinicians and patients through the post-operative course after a total shoulder arthroplasty (TSA) and hemiarthroplasty. Specific interventions should be based on the needs of the individual and should consider exam findings and clinical decision making. If you have questions, contact the referring physician.  Considerations for the Total Shoulder Arthroplasty and Hemiarthroplasty Rehabilitation Program Many different factors influence the post-operative rehabilitation outcome, including surgical approach, concomitant repair of the rotator cuff, arthroplasty secondary to fracture, arthroplasty secondary to rheumatoid arthritis or osteonecrosis, and individual patient factors including co-morbidities. It is recommended that patients meet all rehabilitation criteria in order to progress to the next phase and clinicians collaborate closely with the referring physician throughout the rehabilitation process.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: IMMEDIATE POST-OP (0-3 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Maintain UE ROM in elbow, hand and wrist \u2022 Gradually increase shoulder PROM \u2022 Minimize muscle inhibition \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM \u2022 No reaching behind back, especially in to internal rotation \u2022 No excessive shoulder external rotation or abduction \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 Place small pillow\/towel roll under elbow while lying on back to avoid shoulder hyperextension Intervention Swelling Management \u2022 Ice, compression Range of motion\/Mobility \u2022 PROM: ER <\/= 30 degrees in the scapular plane, IR to belt line in scapular plane, Flex\/Scaption to tolerance, ABD <\/= 90 degrees, pendulums, seated GH flexion table slide, seated horizontal table slide \u2022 AAROM: Active assistive shoulder flexion \u2022 AROM: elbow, hand, wrist Strengthening (Week 2) \u2022 Periscapular: scap retraction, prone scapular retraction, standing scapular setting, supported scapular setting, inferior glide, low row \u2022 Ball squeeze Criteria to Progress \u2022 >\/= 50% shoulder PROM flex, scaption as compared to contralateral side \u2022 <\/= 90 degrees of shoulder ABD PROM \u2022 <\/= 30 degrees of shoulder ER PROM in scapular plane \u2022 >\/= 70 degrees of IR PROM in scapular plane  Palpable muscle contraction felt in scapular musculature  Pain < 4\/10  No complications with Phase I  PHASE II: INTERMEDIATE POST-OP (4-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Continue to protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM \u2022 Minimize substitution patterns with AROM and AAROM \u2022 Improve periscapular muscle activation\/strength \u2022 Initiate RTC (external rotators) activation \u2022 Patient education Sling \u2022 Use at night while sleeping \u2022 Gradually start weaning sling over the next two weeks during the day Precautions \u2022 No excessive shoulder external rotation or abduction \u2022 No lifting of objects heavier than a coffee cup \u2022 No supporting of body weight with hands \u2022 Place small pillow\/towel roll under elbow while lying on back to avoid shoulder hyperextension Intervention *Continue with Phase I interventions  Range of motion\/Mobility \u2022 PROM: Full with exception of ER <\/= 30 degrees in scapular plane and <\/= 90 degrees ABD \u2022 AAROM: shoulder flexion with cane, cane external rotation stretch, washcloth press, seated shoulder elevation with cane \u2022 AROM: supine flexion, salutes, supine punch Strengthening \u2022 Rotator cuff: external rotation isometrics \u2022 Periscapular: Row on physioball, serratus punches \u2022 Elbow: Biceps curl, resistance band bicep curls and triceps Motor control \u2022 ER in scaption and Flex 90-125 (rhythmic stabilization) Stretching \u2022 Sidelying horizontal ADD Criteria to Progress \u2022 >\/=75% shoulder PROM flex, scaption, as compared to contralateral side \u2022 >\/=75% shoulder PROM IR in scapular plane as compared to contralateral side \u2022 30 degrees of shoulder PROM ER in scapular plane \u2022 90 degrees of shoulder PROM ABD \u2022 Minimal substitution patterns with AAROM \u2022 AROM shoulder elevation to 100 degrees with minimal substitution patterns \u2022 Pain < 4\/10 \u2022 No complications with Phase II  PHASE III: INTERMEDIATE POST-OP CONTD (7-8 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue (especially the anterior capsule) \u2022 Minimize pain \u2022 Maintain PROM \u2022 Improve AROM \u2022 Progress periscapular and RTC strength \u2022 Return to full functional activities \u2022 Patient education Sling \u2022 Discontinue Precautions \u2022 No lifting of heavy objects (>10 lbs) Intervention *Continue with Phase I-II interventions Range of motion\/Mobility \u2022 Full ROM in all planes \u2022 AAROM: incline table slides, ball roll on wall, wall climbs, pulleys \u2022 AROM: seated scaption, seated flexion, supine forward elevation with elastic resistance to 90 deg  Strengthening \u2022 Rotator cuff: internal rotation isometrics, side-lying external rotation, \u2022 Standing external rotation w\/ resistance band, standing internal rotation w\/ resistance band, internal  rotation, external rotation, \u2022 Periscapular: Resistance band shoulder extension, resistance band seated rows, rowing, lawn mowers, robbery Motor control \u2022 IR\/ER and Flex 90-125 (rhythmic stabilization) \u2022 Quadruped alternating isometrics and ball stabilization on wall \u2022 PNF-D1 diagonal lifts, PNF-D2 diagonal lifts Stretching \u2022 IR behind back with towel, sidelying horizontal ADD, sleeper stretch, triceps and lats Criteria to Progress \u2022 Minimal to no substitution patterns with shoulder AROM \u2022 Pain < 4\/10  PHASE IV: TRANSITIONAL POST-OP (9-11 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue (especially the anterior capsule) \u2022 Maintain pain-free PROM \u2022 Continue improving AROM \u2022 Improve dynamic shoulder stability \u2022 Gradually restore shoulder strength and endurance Precautions \u2022 No lifting of heavy objects (> 10 lbs) \u2022 Avoid exercises that put stress on the anterior shoulder capsule (ie: shoulder ER above 80 degrees of ABD) Intervention *Continue with Phase II-III interventions Range of motion\/mobility \u2022 Full ROM in all planes Strengthening \u2022 Rotator cuff: increase resistance rotator cuff exercise \u2022 Periscapular: Push-up plus on knees, \u201cW\u201d exercise, resistance band Ws, dynamic hug, resistance band dynamic hug, prone shoulder extension Is, resistance band forward punch, forward punch, tripod, pointer Motor control \u2022 Resistance band PNF pattern, PNF \u2013 D1 diagonal lifts w\/ resistance, diagonal-up, diagonal-down Wall slides w\/ resistance band Criteria to Progress \u2022 Supine AROM Flex >\/=140 degrees \u2022 Supine AROM ABD >\/=120 degrees \u2022 Supine AROM ER in scapular plane >\/= 60 degrees \u2022 Supine AROM IR in scapular plane >\/= 70 degrees \u2022 AROM shoulder elevation to 120 degrees with minimal substitution patterns \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 Pain < 2\/10  PHASE V: ADVANCED STRENGTHENING POST-OP (12-16 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free ROM \u2022 Improve shoulder strength and endurance \u2022 Enhance functional use of upper extremity  Intervention *Continue with Phase II-IV interventions Strengthening \u2022 Rotator cuff:  External rotation at 90 degrees, internal rotation at 90 degrees, resistance band standing external rotation at 90 degrees, resistance band standing internal rotation at 90 degrees \u2022 Periscapular: T and Y, \u201cT\u201d exercise, push-up plus knees extended, wall push up Motor Control \u2022 Progress ball stabilization on wall to overhead alternating isometrics\/rhythmic stabilization  Criteria to Progress \u2022 Clearance from MD and ALL milestone criteria have been met \u2022 Maintains pain-free PROM and AROM \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 QuickDASH \u2022 PENN Return-to-Sport \u2022 For the recreational or competitive athlete, return-to-sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non-contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return-to-sport rehabilitation program.  Revised December 2018 Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol  References  Angst, F, Goldhahn, J, et al. Responsiveness of six outcome assessment instruments in total shoulder arthroplasty. Arthritis & Rheumatism. 2008. 59 (3): 391-398.  Garcia, GH, Liu, JN, et al. High satisfaction and return to sports after total shoulder arthroplasty in patients aged 55 years and younger. AJSM. 2017. 45 (7): 1664-1669.  Gaunt BW, McCluskey GM, Uhl TL. An electromyographic evaluation of subdividing active-assistive shoulder elevation exercises. Sports Health. 2010. 2 (5): 424-432.  Hughes, M, Neer II, CS. Glenohumeral joint replacement and postoperative rehabilitation. Physical Therapy. 1975. 55(8): 850-858.  Kibler, W.B., Sciascia, A. D., Uhl, T. L., et al. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. The American Journal of Sports Medicine. 2008. 36(9): p. 1789-1798.  Knesek M, Brunfeldt, A, et al. Patterns of strain and the determination of the safe arc of motion after subscapularis repair-a biomechanical study. Journal of Orthopaedic Research. 2016. 34: 518-524.  Piasecki, DP, Nicholson, GP. Tears of the subscapularis tendon in athletes-diagnosis and repair techniques. Clin Sports Med. 2008. 27: 731-745.  Uhl TL, Muir TA, et al. Electromyographical assessment of passive, active assistive, and active shoulder rehabilitation exercises. PM R. 2010. 2: 132-141.  Wilcox III R.B., Arslanian L.E., Millett P.J. Rehabilitation following total shoulder arthroplasty. JOSPT. 2005. 35 (12): 821-837  Wolff. AL, Rosenzweig, L. Anatomical and biomechanical framework for shoulder arthroplasty rehabilitation. Journal of Hand Therapy. 2017. 30: 167-174.  Wright, T, Easley, T, et al. Shoulder arthroplasty and its effect on strain in the subscapularis muscle. Clinical Biomechanics. 2015. 30: 373-376.  Zarkadas P.C., Throckmorton T., et al. Patient reported activities after shoulder replacement: total and hemiarthroplasty. J Shoulder Elbow Surg. 2011. 20: 273-280.  Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med. 1996;(6):602-608.  Leggin BG, Michener, LA, et al. The Penn Shoulder Score: reliability and validity. JOSPT. 36 (3): 138-151.","conversation_history":[],"metadata":{"question_type":"distracting element","seed_document_id":3,"distracting_context":"Rehabilitation Protocol for SLAP Repair-Type II  This protocol is intended to guide clinicians through the post-operative course for SLAP Repair-Type II. This protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs of the individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes contained within this guideline may vary based on surgeon\u2019s preference, additional procedures performed, and\/or complications. If a clinician requires assistance in the progression of a post-operative patient, they should consult with the referring surgeon.  The interventions included within this protocol are not intended to be an inclusive list. Therapeutic interventions should be included and modified based on the progress of the patient and under the discretion of the clinician.  Considerations for the Post-operative SLAP repair Rehabilitation Program Many different factors influence the post-operative SLAP repair rehabilitation outcome, including the type of SLAP lesion, the size of the tear\/number of anchors placed, concomitant procedures and amount of shoulder hypermobility and\/or hyperlaxity. Consider mechanism of injury as well as the sport the athlete would like to return to when initiating certain interventions.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: IMMEDIATE POST-OP (0-3 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Maintain UE ROM in elbow, hand and wrist \u2022 Gradually increase shoulder PROM \u2022 Minimize muscle inhibition \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM\/AAROM \u2022 No elbow AROM (avoid biceps contraction) \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 No reaching behind back Intervention Swelling Management \u2022 Ice, compression  Range of motion\/Mobility \u2022 PROM: ER<30 scapular plane, Forward elevation <90, full elbow flex and ext, seated GH flexion table slide, horizontal table slide (add hyperlink) \u2022 AROM: hand, wrist \u2022 AAROM: none  Strengthening (Week 2)  Periscapular: scap retraction  , prone scapular retraction  , standing scapular setting  , supported scapular setting, inferior glide, low row  to neutral; avoid shoulder extension  Rotator cuff: submaximal pain  free isometrics  Ball squeeze Criteria to Progress  90 degrees shoulder PROM forward elevation  30 degrees of shoulder PROM ER in the scapular plane  Full elbow PROM flexion and extension  Palpable muscle contraction felt in scapular and shoulder musculature  No complications with Phase I  PHASE II: INTERMEDIATE POST-OP (4-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Continue to protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM \u2022 Minimize substitution patterns with shoulder AAROM \u2022 Initiate motor control exercise \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM \u2022 No elbow AROM (avoid biceps contraction) \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 No reaching behind back Intervention *Continue with Phase I interventions  Range of motion\/Mobility \u2022 PROM: ER<45 scapular plane, Forward elevation <120 \u2022 AAROM: Active assistive shoulder flexion, shoulder flexion with cane, cane external rotation stretch, washcloth press, sidelying elevation to 90 degrees  Strengthening \u2022 Periscapular: Row on physioball*, shoulder extension on physioball*, serratus punches - *to neutral; avoid shoulder extension  Motor Control \u2022 Internal and external rotation in scaption and Flex 90-125 (rhythmic stabilization)  Stretching \u2022 Sidelying horizontal ADD, sleeper stretch Criteria to Progress \u2022 120 degrees shoulder PROM forward elevation \u2022 45 degrees shoulder PROM ER in scapular plane \u2022 Minimal substitution patterns with shoulder AAROM \u2022 Pain < 4\/10 \u2022 No complications with Phase II  PHASE III: INTERMEDIATE POST-OP CONT\u2019d (7-8 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM\/AAROM \u2022 Initiate shoulder and elbow AROM \u2022 Initiate RTC strengthening  Improve scapular muscle activation  Patient education Sling  Discontinue Precautions  No resisted elbow flexion  No lifting of heavy objects (>10 lbs) Intervention  Continue with Phase I  II interventions Range of motion\/Mobility  PROM: ER Full in scapular plane, \uf0a390 degrees ER in 90 degrees of abduction, IR Full in scapular plane, Forward elevation Full  do not push beyond 90 degrees ER in 90 degrees of abduction  AAROM: seated shoulder elevation with cane, seated incline table slides, ball roll on wall  AROM: supine flexion, salutes, supine punch, wall climbs, elbow flexion  Strengthening \u2022 Rotator cuff: side-lying external rotation, standing external rotation w\/ resistance band, standing internal rotation w\/ resistance band, internal  rotation, external rotation \u2022 Periscapular: Resistance band shoulder extension*, resistance band seated rows*, rowing*, lawn mowers, robbery - *to neutral; avoid shoulder extension \u2022 Elbow: Triceps  Motor Control \u2022 Quadruped alternating isometrics Criteria to Progress \u2022 Full pain-free shoulder PROM ER and forward elevation \u2022 Within 10 degrees of shoulder IR PROM of contralateral shoulder \u2022 Minimal substitution patterns with shoulder AROM \u2022 Pain < 4\/10  PHASE IV: TRANSITIONAL POST-OP (9-12 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue \u2022 Restore full shoulder PROM and AROM \u2022 Initiate resisted elbow flexion at 12 weeks \u2022 Improve dynamic shoulder stability \u2022 Progress periscapular strength \u2022 Gradually return to full functional activities Precautions \u2022 No lifting of heavy objects (> 10 lbs) Intervention *Continue with Phase II-III interventions Range of motion\/mobility \u2022 PROM: Full \u2022 AROM: Supine forward elevation with elastic resistance to 90 deg, scaption and shoulder flexion to 90  degrees elevation  Strengthening \u2022 Periscapular: Push-up plus on knees, prone shoulder extension Is*, resistance band forward punch, forward punch, tripod o *to neutral; avoid shoulder extension \u2022 Elbow (12 weeks): Biceps curl, resistance band bicep curls  Motor control  Ball stabilization on wall  Stretching \u2022 Hands behind head, IR behind back with towel, triceps and lats, doorway series Criteria to Progress \u2022 Full pain-free shoulder PROM and AROM \u2022 Minimal to no substitution patterns with shoulder AROM \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 Pain < 2\/10  PHASE V: LATE POST-OP (13-16 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free shoulder ROM \u2022 Enhance functional use of upper extremity Intervention *Continue with Phase II-IV interventions Strengthening \u2022 Rotator cuff: External rotation at 90 degrees, internal rotation at 90 degrees, resistance band standing external rotation at 90 degrees, resistance band standing internal rotation at 90 degrees \u2022 Periscapular: T and Y, \u201cT\u201d exercise, push-up plus knees extended, pointer, wall push up, \u201cW\u201d exercise, resistance band Ws, dynamic hug, resistance band dynamic hug  Motor Control \u2022  PNF \u2013 D1 diagonal lifts, PNF \u2013 D2 diagonal lifts, field goals , resistance band PNF pattern, PNF \u2013 D1 diagonal lifts w\/ resistance, diagonal-up, diagonal-down, wall slides w\/ resistance band Criteria to Progress \u2022 Clearance from MD and ALL milestone criteria below have been met \u2022 Full pain-free shoulder PROM and AROM \u2022 ER\/IR strength minimum 85% of the uninvolved arm \u2022 ER\/IR ratio 60% or higher \u2022 Negative impingement and instability signs \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 QuickDASH \u2022 PENN  PHASE VI: EARLY RETURN-TO-SPORT (4-6 MONTHS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free ROM \u2022 Continue strengthening and motor control exercises \u2022 Enhance functional use of upper extremity \u2022 Gradual return to strenuous work\/sport activity Intervention *Continue with Phase II-V interventions Strengthening \u2022 See specific return-to-sport\/throwing program (coordinate with physician) Criteria to Progress \u2022 Last stage-no additional criteria Return-to-Sport \u2022 For the recreational or competitive athlete, return-to-sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non-contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return-to-sport rehabilitation program. Revised 7\/2020  Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol  References:  1. Ahsan, ZS, Hsu JE, et al. The Snyder classification of superior labrum anterior and posterior (SLAP) lesions. Clin Orthop Relat Res. 2016. 474:2075- 2078.  2. Christopher ZR, Kennedy J, et al. Rehabilitation and return to play following superior labral anterior to posterior repair. Oper Tech Sports Med. 2017. 25:132-144.  3. Cools AM, Borms D, Cottens S, et al. Rehabilitation exercises for athletes with biceps disorders and SLAP lesions. AJSM. 2014. 42(6): 1315-1323.  4. Itoi E, Hatakeyama Y, et al. Position of immobilization after dislocation of the shoulder. JBJS. 1999. 81-A(3): 385-390.  5. Kibler, W.B., Sciascia, A. D., Uhl, T. L., et al. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. The American Journal of Sports Medicine. 2008. 36(9): p. 1789-1798.  6. Wilk KE, Reinold MM, et al. Current concepts in the recognition and treatment of superior labral (SLAP) lesions. JOSPT. 2005. 35(5): 273-291.","topic":"Others"}}
{"id":"ef2a44c7-2db6-4b9a-8cc7-8836b28d7723","question":"As a professional athlete recovering from shoulder surgery, I need guidance on rehabilitation exercises to regain strength and mobility in my shoulder. Could you tell me what the goals for the intermediate post-op phase (4-6 weeks after surgery) in the Rehabilitation Protocol for SLAP Repair-Type II are?","reference_answer":"The goals for the intermediate post-op phase (4-6 weeks after surgery) in the Rehabilitation Protocol for SLAP Repair-Type II are to continue to protect the surgical repair, reduce swelling and minimize pain, gradually increase shoulder PROM, minimize substitution patterns with shoulder AAROM, initiate motor control exercise, and provide patient education.","reference_context":"Document 4: Rehabilitation Protocol for Total Shoulder Arthroplasty and Hemiarthroplasty  This protocol is intended to guide clinicians and patients through the post-operative course after a total shoulder arthroplasty (TSA) and hemiarthroplasty. Specific interventions should be based on the needs of the individual and should consider exam findings and clinical decision making. If you have questions, contact the referring physician.  Considerations for the Total Shoulder Arthroplasty and Hemiarthroplasty Rehabilitation Program Many different factors influence the post-operative rehabilitation outcome, including surgical approach, concomitant repair of the rotator cuff, arthroplasty secondary to fracture, arthroplasty secondary to rheumatoid arthritis or osteonecrosis, and individual patient factors including co-morbidities. It is recommended that patients meet all rehabilitation criteria in order to progress to the next phase and clinicians collaborate closely with the referring physician throughout the rehabilitation process.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: IMMEDIATE POST-OP (0-3 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Maintain UE ROM in elbow, hand and wrist \u2022 Gradually increase shoulder PROM \u2022 Minimize muscle inhibition \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM \u2022 No reaching behind back, especially in to internal rotation \u2022 No excessive shoulder external rotation or abduction \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 Place small pillow\/towel roll under elbow while lying on back to avoid shoulder hyperextension Intervention Swelling Management \u2022 Ice, compression Range of motion\/Mobility \u2022 PROM: ER <\/= 30 degrees in the scapular plane, IR to belt line in scapular plane, Flex\/Scaption to tolerance, ABD <\/= 90 degrees, pendulums, seated GH flexion table slide, seated horizontal table slide \u2022 AAROM: Active assistive shoulder flexion \u2022 AROM: elbow, hand, wrist Strengthening (Week 2) \u2022 Periscapular: scap retraction, prone scapular retraction, standing scapular setting, supported scapular setting, inferior glide, low row \u2022 Ball squeeze Criteria to Progress \u2022 >\/= 50% shoulder PROM flex, scaption as compared to contralateral side \u2022 <\/= 90 degrees of shoulder ABD PROM \u2022 <\/= 30 degrees of shoulder ER PROM in scapular plane \u2022 >\/= 70 degrees of IR PROM in scapular plane  Palpable muscle contraction felt in scapular musculature  Pain < 4\/10  No complications with Phase I  PHASE II: INTERMEDIATE POST-OP (4-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Continue to protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM \u2022 Minimize substitution patterns with AROM and AAROM \u2022 Improve periscapular muscle activation\/strength \u2022 Initiate RTC (external rotators) activation \u2022 Patient education Sling \u2022 Use at night while sleeping \u2022 Gradually start weaning sling over the next two weeks during the day Precautions \u2022 No excessive shoulder external rotation or abduction \u2022 No lifting of objects heavier than a coffee cup \u2022 No supporting of body weight with hands \u2022 Place small pillow\/towel roll under elbow while lying on back to avoid shoulder hyperextension Intervention *Continue with Phase I interventions  Range of motion\/Mobility \u2022 PROM: Full with exception of ER <\/= 30 degrees in scapular plane and <\/= 90 degrees ABD \u2022 AAROM: shoulder flexion with cane, cane external rotation stretch, washcloth press, seated shoulder elevation with cane \u2022 AROM: supine flexion, salutes, supine punch Strengthening \u2022 Rotator cuff: external rotation isometrics \u2022 Periscapular: Row on physioball, serratus punches \u2022 Elbow: Biceps curl, resistance band bicep curls and triceps Motor control \u2022 ER in scaption and Flex 90-125 (rhythmic stabilization) Stretching \u2022 Sidelying horizontal ADD Criteria to Progress \u2022 >\/=75% shoulder PROM flex, scaption, as compared to contralateral side \u2022 >\/=75% shoulder PROM IR in scapular plane as compared to contralateral side \u2022 30 degrees of shoulder PROM ER in scapular plane \u2022 90 degrees of shoulder PROM ABD \u2022 Minimal substitution patterns with AAROM \u2022 AROM shoulder elevation to 100 degrees with minimal substitution patterns \u2022 Pain < 4\/10 \u2022 No complications with Phase II  PHASE III: INTERMEDIATE POST-OP CONTD (7-8 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue (especially the anterior capsule) \u2022 Minimize pain \u2022 Maintain PROM \u2022 Improve AROM \u2022 Progress periscapular and RTC strength \u2022 Return to full functional activities \u2022 Patient education Sling \u2022 Discontinue Precautions \u2022 No lifting of heavy objects (>10 lbs) Intervention *Continue with Phase I-II interventions Range of motion\/Mobility \u2022 Full ROM in all planes \u2022 AAROM: incline table slides, ball roll on wall, wall climbs, pulleys \u2022 AROM: seated scaption, seated flexion, supine forward elevation with elastic resistance to 90 deg  Strengthening \u2022 Rotator cuff: internal rotation isometrics, side-lying external rotation, \u2022 Standing external rotation w\/ resistance band, standing internal rotation w\/ resistance band, internal  rotation, external rotation, \u2022 Periscapular: Resistance band shoulder extension, resistance band seated rows, rowing, lawn mowers, robbery Motor control \u2022 IR\/ER and Flex 90-125 (rhythmic stabilization) \u2022 Quadruped alternating isometrics and ball stabilization on wall \u2022 PNF-D1 diagonal lifts, PNF-D2 diagonal lifts Stretching \u2022 IR behind back with towel, sidelying horizontal ADD, sleeper stretch, triceps and lats Criteria to Progress \u2022 Minimal to no substitution patterns with shoulder AROM \u2022 Pain < 4\/10  PHASE IV: TRANSITIONAL POST-OP (9-11 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue (especially the anterior capsule) \u2022 Maintain pain-free PROM \u2022 Continue improving AROM \u2022 Improve dynamic shoulder stability \u2022 Gradually restore shoulder strength and endurance Precautions \u2022 No lifting of heavy objects (> 10 lbs) \u2022 Avoid exercises that put stress on the anterior shoulder capsule (ie: shoulder ER above 80 degrees of ABD) Intervention *Continue with Phase II-III interventions Range of motion\/mobility \u2022 Full ROM in all planes Strengthening \u2022 Rotator cuff: increase resistance rotator cuff exercise \u2022 Periscapular: Push-up plus on knees, \u201cW\u201d exercise, resistance band Ws, dynamic hug, resistance band dynamic hug, prone shoulder extension Is, resistance band forward punch, forward punch, tripod, pointer Motor control \u2022 Resistance band PNF pattern, PNF \u2013 D1 diagonal lifts w\/ resistance, diagonal-up, diagonal-down Wall slides w\/ resistance band Criteria to Progress \u2022 Supine AROM Flex >\/=140 degrees \u2022 Supine AROM ABD >\/=120 degrees \u2022 Supine AROM ER in scapular plane >\/= 60 degrees \u2022 Supine AROM IR in scapular plane >\/= 70 degrees \u2022 AROM shoulder elevation to 120 degrees with minimal substitution patterns \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 Pain < 2\/10  PHASE V: ADVANCED STRENGTHENING POST-OP (12-16 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free ROM \u2022 Improve shoulder strength and endurance \u2022 Enhance functional use of upper extremity  Intervention *Continue with Phase II-IV interventions Strengthening \u2022 Rotator cuff:  External rotation at 90 degrees, internal rotation at 90 degrees, resistance band standing external rotation at 90 degrees, resistance band standing internal rotation at 90 degrees \u2022 Periscapular: T and Y, \u201cT\u201d exercise, push-up plus knees extended, wall push up Motor Control \u2022 Progress ball stabilization on wall to overhead alternating isometrics\/rhythmic stabilization  Criteria to Progress \u2022 Clearance from MD and ALL milestone criteria have been met \u2022 Maintains pain-free PROM and AROM \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 QuickDASH \u2022 PENN Return-to-Sport \u2022 For the recreational or competitive athlete, return-to-sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non-contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return-to-sport rehabilitation program.  Revised December 2018 Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol  References  Angst, F, Goldhahn, J, et al. Responsiveness of six outcome assessment instruments in total shoulder arthroplasty. Arthritis & Rheumatism. 2008. 59 (3): 391-398.  Garcia, GH, Liu, JN, et al. High satisfaction and return to sports after total shoulder arthroplasty in patients aged 55 years and younger. AJSM. 2017. 45 (7): 1664-1669.  Gaunt BW, McCluskey GM, Uhl TL. An electromyographic evaluation of subdividing active-assistive shoulder elevation exercises. Sports Health. 2010. 2 (5): 424-432.  Hughes, M, Neer II, CS. Glenohumeral joint replacement and postoperative rehabilitation. Physical Therapy. 1975. 55(8): 850-858.  Kibler, W.B., Sciascia, A. D., Uhl, T. L., et al. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. The American Journal of Sports Medicine. 2008. 36(9): p. 1789-1798.  Knesek M, Brunfeldt, A, et al. Patterns of strain and the determination of the safe arc of motion after subscapularis repair-a biomechanical study. Journal of Orthopaedic Research. 2016. 34: 518-524.  Piasecki, DP, Nicholson, GP. Tears of the subscapularis tendon in athletes-diagnosis and repair techniques. Clin Sports Med. 2008. 27: 731-745.  Uhl TL, Muir TA, et al. Electromyographical assessment of passive, active assistive, and active shoulder rehabilitation exercises. PM R. 2010. 2: 132-141.  Wilcox III R.B., Arslanian L.E., Millett P.J. Rehabilitation following total shoulder arthroplasty. JOSPT. 2005. 35 (12): 821-837  Wolff. AL, Rosenzweig, L. Anatomical and biomechanical framework for shoulder arthroplasty rehabilitation. Journal of Hand Therapy. 2017. 30: 167-174.  Wright, T, Easley, T, et al. Shoulder arthroplasty and its effect on strain in the subscapularis muscle. Clinical Biomechanics. 2015. 30: 373-376.  Zarkadas P.C., Throckmorton T., et al. Patient reported activities after shoulder replacement: total and hemiarthroplasty. J Shoulder Elbow Surg. 2011. 20: 273-280.  Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med. 1996;(6):602-608.  Leggin BG, Michener, LA, et al. The Penn Shoulder Score: reliability and validity. JOSPT. 36 (3): 138-151.\n\nDocument 5: Rehabilitation Protocol for Sternoclavicular Joint Reconstruction  This protocol is intended to guide clinicians through the post-operative course for sternoclavicular joint reconstruction. This protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs of the individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes contained within this guideline may vary based on surgeon\u2019s preference, additional procedures performed, and\/or complications. If a clinician requires assistance in the progression of a post-operative patient, they should consult with the referring surgeon.  The interventions included within this protocol are not intended to be an inclusive list of exercises. Therapeutic interventions should be included and modified based on the progress of the patient and under the discretion of the clinician.  Considerations for the Post-operative sternoclavicular joint reconstruction Many different factors influence the post-operative rehabilitation outcome, including surgical technique (ie. tendon autograft harvest for repair), degree of SC joint instability, concomitant soft tissue or bone injury\/repair, and individual patient factors including co-morbidities. It is recommended that patients meet all rehabilitation criteria in order to progress to the next phase and clinicians collaborate closely with the referring physician throughout the rehabilitation process.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: EARLY POST-OP (0-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Reduce pain and swelling of the operative shoulder \u2022 Maintain elbow, wrist and hand AROM \u2022 Patient education Sling\/precautions \u2022 Sling to be worn for 6 weeks (or as directed by surgeon) \u2022 Avoid PROM of the glenohumeral joint \u2022 Avoid scapular AROM (protraction, retraction, depression and elevation) as it may disrupt the repair and healing tissues \u2022 Avoid bearing weight through involved extremity \u2022 Avoid lifting any lifting with involved extremity \u2022 Avoid running and jumping due to impact forces upon landing that may aggravate healing tissues and bone Intervention \u2022 Cryotherapy as needed \u2022 AROM: cervical spine, elbow, wrist, hand \u2022 Hand gripping: ball squeeze \u2022 Cardiovascular exercise as tolerated: walking, stationary bike Criteria to Progress \u2022 Well controlled pain and swelling \u2022 Protect reconstruction site and autograft site (if applicable) \u2022 Maintain elbow, wrist and hand AROM  PHASE II: INTERMEDIATE POST-OP (6-12WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Activation of muscles responsible for stabilizing the scapulothoracic and glenohumeral joint \u2022 Gradually restore PROM, AAROM of the GH joint at 6-8 weeks \u2022 Gradually restore AROM of the scapulothoracic joint and glenohumeral joint at 8 weeks \u2022 Wean from sling (if still wearing) \u2022 Begin shoulder and scapular strengthening at 8 weeks \u2022 Begin proprioception and neuromuscular control training \u2022 Identify and correct postural dysfunction as indicated Sling\/precautions \u2022 Avoid repetitive overhead activities \u2022 No lifting > 5 pounds with involved extremity until 9 weeks post-op \u2022 Post-rehabilitation soreness should resolve within 12-24 hours Additional Interventions *Continue with Phase I interventions \u2022 AROM in all cardinal plane assessing scapular rhythm \u2022 Gentle glenohumeral mobilization as indicated  Strengthening: \u2022 Rotator cuff strengthening in non-provocative positions (generally 0-45 degrees Scaption\/abduction): scaption raises against gravity, Sidelying ER, lightly resisted ER\/IR with theraband, isometrics \u2022 Scapular strengthening and dynamic neuromuscular control: low row, straight arm pulldowns, serratus punch, resisted T\u2019s  Stretching: Gentle corner or doorway pec stretch \u2022 Postural endurance exercises: scapular retractions, chin tucks \u2022 Walking, stationary bike, Stairmaster Criteria to Progress \u2022 Full AROM of the operative shoulder \u2022 Normal (5\/5) strength for glenohumeral flexion\/abduction\/IR\/ER degrees abduction  PHASE III: LATE POST-OP AND GRADUAL RETURN TO SPORT(13+ WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Restore normal (5\/5) rotator cuff strength at 90 degrees abduction including supraspinatus \u2022 Full multi-planar AROM with minimal to no substitution patterns \u2022 Advance proprioceptive and dynamic neuromuscular control training \u2022 Identify and correct postural dysfunction with sport\/work specific tasks as indicated \u2022 Develop strength and control movements required for sport\/work Sling\/ precautions \u2022 Post-rehabilitation soreness should resolve within 12 hours \u2022 No lifting restrictions at ~4 months Additional Interventions *Continue with Phase I-II Interventions \u2022 Glenohumeral mobilizations as indicated \u2022 Multiplane AROM with gradual increase in velocity of movement  Strengthening: \u2022 Rotator cuff strengthening at 45 degrees progressing to 90 degrees abduction and sport\/work specific positions as well as other provocative positions: resisted IR\/ER, elevation with ER, resisted scaption raises, facepulls\/resisted W\u2019s \u2022 Scapular strengthening and dynamic neuromuscular control in overhead or sport\/work positions: prone or resisted I\u2019s, T\u2019s and Y\u2019s, lower trap setting at wall, manual perturbations in varying degrees in elevation, serratus wall slides\/roll ups, wall pushups, quadruped shoulder taps \u2022 Core strengthening  Stretching:  Corner or doorway pec stretch, Gentle posterior capsule stretch (across body)  Walking, stationary bike, Stairmaster, return to running\/jumping as tolerated  Begin education in sport specific biomechanics with initial program for throwing, swimming, or overhead racquet sports Criteria to Return to Sport  Clearance from MD and ALL milestone criteria have been met  Maintains pain  free PROM and AROM  Performs all exercises demonstrating symmetric scapular mechanics  QuickDASH  PENN  For the recreational or competitive athlete, return  to  sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non  contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return  to  sport rehabilitation program.  Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol References: 1. Logan C, Shahien A, Altintas B, Millett PJ. Rehabilitation following sternoclavicular joint reconstruction for persistent instability. International Journal of Sports Physical Therapy. 2018;13(4):752-762. doi:10.26603\/ijspt20180752 2. Petri, M., Greenspoon, J. A., Horan, M. P., Martetschl\u00e4ger, F., Warth, R. J., & Millett, P. J. (2016). Clinical outcomes after autograft reconstruction for sternoclavicular joint instability. Journal of Shoulder and Elbow Surgery, 25(3), 435\u2013441. https:\/\/doi.org\/10.1016\/j.jse.2015.08.004 3. Garcia JA, Arguello AM, Momaya AM, Ponce BA. Sternoclavicular Joint Instability: Symptoms, Diagnosis And Management. Orthop Res Rev. 2020 Jul 28;12:75-87. doi: 10.2147\/ORR.S170964. PMID: 32801951; PMCID: PMC7395708.\n\nDocument 3: Rehabilitation Protocol for SLAP Repair-Type II  This protocol is intended to guide clinicians through the post-operative course for SLAP Repair-Type II. This protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs of the individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes contained within this guideline may vary based on surgeon\u2019s preference, additional procedures performed, and\/or complications. If a clinician requires assistance in the progression of a post-operative patient, they should consult with the referring surgeon.  The interventions included within this protocol are not intended to be an inclusive list. Therapeutic interventions should be included and modified based on the progress of the patient and under the discretion of the clinician.  Considerations for the Post-operative SLAP repair Rehabilitation Program Many different factors influence the post-operative SLAP repair rehabilitation outcome, including the type of SLAP lesion, the size of the tear\/number of anchors placed, concomitant procedures and amount of shoulder hypermobility and\/or hyperlaxity. Consider mechanism of injury as well as the sport the athlete would like to return to when initiating certain interventions.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: IMMEDIATE POST-OP (0-3 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Maintain UE ROM in elbow, hand and wrist \u2022 Gradually increase shoulder PROM \u2022 Minimize muscle inhibition \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM\/AAROM \u2022 No elbow AROM (avoid biceps contraction) \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 No reaching behind back Intervention Swelling Management \u2022 Ice, compression  Range of motion\/Mobility \u2022 PROM: ER<30 scapular plane, Forward elevation <90, full elbow flex and ext, seated GH flexion table slide, horizontal table slide (add hyperlink) \u2022 AROM: hand, wrist \u2022 AAROM: none  Strengthening (Week 2)  Periscapular: scap retraction  , prone scapular retraction  , standing scapular setting  , supported scapular setting, inferior glide, low row  to neutral; avoid shoulder extension  Rotator cuff: submaximal pain  free isometrics  Ball squeeze Criteria to Progress  90 degrees shoulder PROM forward elevation  30 degrees of shoulder PROM ER in the scapular plane  Full elbow PROM flexion and extension  Palpable muscle contraction felt in scapular and shoulder musculature  No complications with Phase I  PHASE II: INTERMEDIATE POST-OP (4-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Continue to protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM \u2022 Minimize substitution patterns with shoulder AAROM \u2022 Initiate motor control exercise \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM \u2022 No elbow AROM (avoid biceps contraction) \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 No reaching behind back Intervention *Continue with Phase I interventions  Range of motion\/Mobility \u2022 PROM: ER<45 scapular plane, Forward elevation <120 \u2022 AAROM: Active assistive shoulder flexion, shoulder flexion with cane, cane external rotation stretch, washcloth press, sidelying elevation to 90 degrees  Strengthening \u2022 Periscapular: Row on physioball*, shoulder extension on physioball*, serratus punches - *to neutral; avoid shoulder extension  Motor Control \u2022 Internal and external rotation in scaption and Flex 90-125 (rhythmic stabilization)  Stretching \u2022 Sidelying horizontal ADD, sleeper stretch Criteria to Progress \u2022 120 degrees shoulder PROM forward elevation \u2022 45 degrees shoulder PROM ER in scapular plane \u2022 Minimal substitution patterns with shoulder AAROM \u2022 Pain < 4\/10 \u2022 No complications with Phase II  PHASE III: INTERMEDIATE POST-OP CONT\u2019d (7-8 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM\/AAROM \u2022 Initiate shoulder and elbow AROM \u2022 Initiate RTC strengthening  Improve scapular muscle activation  Patient education Sling  Discontinue Precautions  No resisted elbow flexion  No lifting of heavy objects (>10 lbs) Intervention  Continue with Phase I  II interventions Range of motion\/Mobility  PROM: ER Full in scapular plane, \uf0a390 degrees ER in 90 degrees of abduction, IR Full in scapular plane, Forward elevation Full  do not push beyond 90 degrees ER in 90 degrees of abduction  AAROM: seated shoulder elevation with cane, seated incline table slides, ball roll on wall  AROM: supine flexion, salutes, supine punch, wall climbs, elbow flexion  Strengthening \u2022 Rotator cuff: side-lying external rotation, standing external rotation w\/ resistance band, standing internal rotation w\/ resistance band, internal  rotation, external rotation \u2022 Periscapular: Resistance band shoulder extension*, resistance band seated rows*, rowing*, lawn mowers, robbery - *to neutral; avoid shoulder extension \u2022 Elbow: Triceps  Motor Control \u2022 Quadruped alternating isometrics Criteria to Progress \u2022 Full pain-free shoulder PROM ER and forward elevation \u2022 Within 10 degrees of shoulder IR PROM of contralateral shoulder \u2022 Minimal substitution patterns with shoulder AROM \u2022 Pain < 4\/10  PHASE IV: TRANSITIONAL POST-OP (9-12 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue \u2022 Restore full shoulder PROM and AROM \u2022 Initiate resisted elbow flexion at 12 weeks \u2022 Improve dynamic shoulder stability \u2022 Progress periscapular strength \u2022 Gradually return to full functional activities Precautions \u2022 No lifting of heavy objects (> 10 lbs) Intervention *Continue with Phase II-III interventions Range of motion\/mobility \u2022 PROM: Full \u2022 AROM: Supine forward elevation with elastic resistance to 90 deg, scaption and shoulder flexion to 90  degrees elevation  Strengthening \u2022 Periscapular: Push-up plus on knees, prone shoulder extension Is*, resistance band forward punch, forward punch, tripod o *to neutral; avoid shoulder extension \u2022 Elbow (12 weeks): Biceps curl, resistance band bicep curls  Motor control  Ball stabilization on wall  Stretching \u2022 Hands behind head, IR behind back with towel, triceps and lats, doorway series Criteria to Progress \u2022 Full pain-free shoulder PROM and AROM \u2022 Minimal to no substitution patterns with shoulder AROM \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 Pain < 2\/10  PHASE V: LATE POST-OP (13-16 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free shoulder ROM \u2022 Enhance functional use of upper extremity Intervention *Continue with Phase II-IV interventions Strengthening \u2022 Rotator cuff: External rotation at 90 degrees, internal rotation at 90 degrees, resistance band standing external rotation at 90 degrees, resistance band standing internal rotation at 90 degrees \u2022 Periscapular: T and Y, \u201cT\u201d exercise, push-up plus knees extended, pointer, wall push up, \u201cW\u201d exercise, resistance band Ws, dynamic hug, resistance band dynamic hug  Motor Control \u2022  PNF \u2013 D1 diagonal lifts, PNF \u2013 D2 diagonal lifts, field goals , resistance band PNF pattern, PNF \u2013 D1 diagonal lifts w\/ resistance, diagonal-up, diagonal-down, wall slides w\/ resistance band Criteria to Progress \u2022 Clearance from MD and ALL milestone criteria below have been met \u2022 Full pain-free shoulder PROM and AROM \u2022 ER\/IR strength minimum 85% of the uninvolved arm \u2022 ER\/IR ratio 60% or higher \u2022 Negative impingement and instability signs \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 QuickDASH \u2022 PENN  PHASE VI: EARLY RETURN-TO-SPORT (4-6 MONTHS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free ROM \u2022 Continue strengthening and motor control exercises \u2022 Enhance functional use of upper extremity \u2022 Gradual return to strenuous work\/sport activity Intervention *Continue with Phase II-V interventions Strengthening \u2022 See specific return-to-sport\/throwing program (coordinate with physician) Criteria to Progress \u2022 Last stage-no additional criteria Return-to-Sport \u2022 For the recreational or competitive athlete, return-to-sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non-contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return-to-sport rehabilitation program. Revised 7\/2020  Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol  References:  1. Ahsan, ZS, Hsu JE, et al. The Snyder classification of superior labrum anterior and posterior (SLAP) lesions. Clin Orthop Relat Res. 2016. 474:2075- 2078.  2. Christopher ZR, Kennedy J, et al. Rehabilitation and return to play following superior labral anterior to posterior repair. Oper Tech Sports Med. 2017. 25:132-144.  3. Cools AM, Borms D, Cottens S, et al. Rehabilitation exercises for athletes with biceps disorders and SLAP lesions. AJSM. 2014. 42(6): 1315-1323.  4. Itoi E, Hatakeyama Y, et al. Position of immobilization after dislocation of the shoulder. JBJS. 1999. 81-A(3): 385-390.  5. Kibler, W.B., Sciascia, A. D., Uhl, T. L., et al. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. The American Journal of Sports Medicine. 2008. 36(9): p. 1789-1798.  6. Wilk KE, Reinold MM, et al. Current concepts in the recognition and treatment of superior labral (SLAP) lesions. JOSPT. 2005. 35(5): 273-291.","conversation_history":[],"metadata":{"question_type":"situational","seed_document_id":4,"situational_context":"A professional athlete is recovering from shoulder surgery and needs guidance on rehabilitation exercises to regain strength and mobility in their shoulder.","topic":"Others"}}
{"id":"c906feb0-84dd-4e3c-9e6e-5fd6c33e2bb1","question":"As a professional athlete, I am seeking information on recovery strategies post-operation. Could you please tell me what the rehabilitation goals are for the immediate post-operative phase, specifically 0-3 weeks, after an Ulnar Collateral Ligament Reconstruction?","reference_answer":"The rehabilitation goals for the immediate post-op phase (0-3 weeks) after an Ulnar Collateral Ligament Reconstruction are to protect healing tissue, reduce pain and inflammation, protect the graft site, and reduce muscle atrophy.","reference_context":"Document 1: Massachusetts General Brigham Sports Medicine  Rehabilitation Guidelines for Ulnar Collateral Ligament Reconstruction (Palmaris Longus Graft, Gracilis Graft)  This protocol is intended to guide clinicians through the post-operative course for Ulnar Collateral Ligament Reconstruction (Palmaris Longus Graft, Gracilis Graft). This protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs of the individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes contained within this guideline may vary based on surgeon\u2019s preference, additional procedures performed, and\/or complications. If a clinician requires assistance in the progression of a post-operative patient, they should consult with the referring surgeon.  The interventions included within this protocol are not intended to be an inclusive list of exercises. Therapeutic interventions should be included and modified based on the progress of the patient and under the discretion of the clinician.  Considerations for the Post-operative Many different factors influence the post-operative UCL reconstruction rehabilitation outcomes, including whether a palmaris longus or gracilis graft was performed and individual co-morbidities. It is recommended that clinicians collaborate closely with the referring physician.  If you develop a fever, excessive drainage from incision, severe heat and\/or redness along incision, uncontrolled pain, or any other symptoms that concern you please call your doctor.  PHASE I: IMMEDIATE POST-OP PHASE (0-3 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Protect healing tissue \u2022 Reduce pain and inflammation \u2022 Protect graft site \u2022 Reduce muscle atrophy Brace \u2022 Week 1 \u2013 Immobilized in Posterior splint at 90 degrees of Elbow Flexion \u2022 Week 2: Hinged Brace: 25-100 degrees \u2022 Week 3: Hinged brace: 15-115 degrees \u2022 Elbow Post-op compression dressing for 5-7 days \u2022 Palmaris Longus Graft \u2013 Wrist post-op compression for 5-7 days Precautions \u2022 Shoulder External rotation isometrics \u2022 Valgus stress to the Elbow Intervention  Manual therapy \u2022 Soft tissue mobilization, retrograde massage for swelling  Modalities  Ice and compression  Gripping Exercises: \u2022 Squeeze towel, putty or foam with varying types of grips  Isometrics  Performed with brace on  Day 1  Shoulder: Flexion, ABD, IR  Avoid External Rotation  Performed with arm at side, gently push against a wall or opposite hand - Elbow Flexion  Performed at 90 degrees elbow flexion \u2022 Day 7 - Elbow Extension  Performed at 90 degrees elbow flexion  Range of Motion \u2022 Wrist AROM - Flexion, - Extension - Radial deviation - Ulnar deviation \u2022 Thumb opposition \u2022 Elbow PROM - Flexion and extension - Performed to tolerance, making sure the elbow is staying relaxed. \u2022 Shoulder AROM - Performed with brace on - Full Can \u2022 Elbow AROM: Begin day 14 \u2022 Low load, long duration stretching: - Use when elbow extension range of motion is lacking - Supine with towel roll under distal humerus. - Add a light weight - Must be pain-free - Hold 10-15 minutes up to 4 times a day, totaling 60 minutes a day  Gracilis Graft \u2013 Knee ROM immediately post  op; Bike on week 3  Criteria to Progress \u2022 Elbow ROM: at least 15-115 degrees \u2022 At least 4\/5 elbow MMT scores  PHASE II: PROTECTION PHASE (4-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Gradual increase to full ROM by week 6 \u2022 Promote healing of repaired tissue \u2022 Regain and improve muscular strength \u2013 slow integration of exercises \u2022 Restore full function of graft site Brace \u2022 Week 4: 0-125 degrees \u2022 Week 5: 0-135 degrees \u2022 Week 6: 0-145 degrees \u2022 Discontinue use of brace at week 6 if achieved full ROM, unless walking in crowds or slippery surfaces Precautions \u2022 No valgus stress to the graft \u2022 No ER strengthening until week 6 \u2022 Gracilis graft \u2013 Do not initiate progressive resistive hamstring strengthening until week 6 Additional Intervention *Continue with Phase I interventions Manual therapy \u2022 Soft tissue and scar mobilization  Modalities \u2022 Continue with ice and compression  Range of Motion \u2022 Elbow PROM \u2013 Focus on restoration of full elbow extension  Strengthening \u2022 Wrist and forearm strengthening: - Curls\/Extensions \u2013 Start with 1 lb. - Pronation\/Supination \u2013 Start with dowel \u2022 Biceps curl \u2013 Begin with 1lb \u2022 Triceps Extension \u2022 Scapula stabilization: Start at 1 lb - Prone Row - Prone Shoulder horizontal abduction - Prone Shoulder extension \u2022 Resistance band - Low rows - Shoulder internal rotation (at side) \u2022 Standing scaption (start with 1lb, do not exceed 10 lbs.) Criteria to Progress \u2022 Full Range of Motion \u2022 At least 70% of strength of wrist and shoulder of uninvolved arm \u2013 HHD, MMT or isokinetic testing \u2022 Good tolerance to all exercises with no pain  PHASE III: STRENGTHENING PHASE (6-12 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Increase strength\/endurance\/power \u2022 Maintain full elbow ROM especially extension Precautions \u2022 No Throwing \u2022 No valgus stress to the elbow Additional Intervention *Continue with Phase I-II Interventions Manual Therapy: \u2022 Soft tissue mobilizations as needed  Range of motion  Elbow PROM as needed  Maintain full elbow extension  Strengthening \u2022 Gracilis graft: Begin slow progression of hamstring strengthening \u2022 Forearm strengthening: - Emphasis on flexion and pronation \u2022 Elbow Strengthening: - Eccentric flexion and extension - Varied resistance and speed of contractions - (start slow build to fast) \u2022 Thrower\u2019s 10 program: Begin at week 6 - Initiate Advanced Thrower\u2019s 10 at Week 8 \u2013 as appropriate \u2022 UBE \u2022 Rows \u2022 Lat pull down \u2022 PNF exercises - Rhythmic stabilization\/manual resistance: (side-lying ER and diagonals)  Criteria to Progress \u2022 Maintain full pain-free ROM \u2022 At least 85% strength of uninvolved arm \u2013 HHD, or isokinetic testing \u2022 Good tolerance to all exercises with no pain  PHASE IV: ADVANCED STRENGTHENING PHASE (12-16 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Progress power\/endurance \u2022 Normalize shoulder\/forearm strength  Initiate plyometric exercises  Gradually initiate sports\/functional exercises Precautions  No Throwing  No valgus stress to elbow Additional Intervention  Continue with Phase II  III interventions as appropriate Strengthening  Advanced throwers ten program  Body blade \u2013 ER\/IR, push\/pull  Seated bench press  Supine dumbbell bench press  Begin a hitting program (if applicable to sport)  Initiate week 12  Plyometric Program \u2022 Week 12: - 2-handed drills only: 6-8 lbs. (emphasis on full extension) \u2022 Chest pass \u2022 Side throw close to body \u2022 Week 14: - 2 hands away from body \u2022 Side to side throws \u2022 Soccer throws \u2022 Side throws - Begin 1-arm plyometrics \u2022 1-handed stationary \u2022 Wall dribble: 1-2lb. medicine ball \u2022 Baseball throws into wall \u2022 Rhythmic stabilization in scapular plane with medicine ball on wall Criteria to Progress \u2022 Full, painless elbow\/wrist ROM \u2022 Shoulder total ROM within 5\u00b0 of non-throwing shoulder \u2022 > 40\u00b0 horizontal adduction of throwing shoulder \u2022 < 15\u00b0 Glenohumeral IR deficit \u2022 Elbow, shoulder and wrist strength with MMT, HHD or isokinetic: - ER\/IR ratio: 72-76% - ER\/ABD ratio: 68-73% - Throwing shoulder IR: > 115% of non-throwing shoulder - Throwing shoulder ER: > 95% of non-throwing shoulder - Elbow flexion\/extension: 100-115% of non-throwing shoulder - Wrist flexion\/extension: 100-115% of non-throwing shoulder \u2022 Functional test Scores: - Prone Drop ball test \u2013 110% of non-throwing side - 1-arm balls against wall @ 90\/90: \u2022 2lb ball \u2022 30 seconds with no pain \u2022 115% of throwing side - Single arm step down test: \u2022 8-inch \u2022 30 seconds \u2022 Satisfactory score on Kerlan-Jobe Orthopedic Clinic shoulder and elbow score (KJOC) throwers assessment. \u2022 Physician Clearance  PHASE V: EARLY RETURN TO SPORT - UNRESTRICTED RETURN TO SPORT (16+ WEEKS AFTER SURGERY)  Rehabilitation Goals \u2022 Increase strength, power and endurance \u2022 Safely initiate sport specific training program \u2022 Safely progress to full sport.  Additional Intervention *Continue with Phase II-IV interventions \u2022 Interval Throwing Program: 16 weeks after surgery \u2013 unless indicated otherwise by surgeon \u2022 ***Refer to return-to-sport protocol\/throwing protocol for further detail  Criteria to Progress \u2022 Last stage, no additional criteria Revised 6\/2021  Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol  References: 1. Biz C, Crim\u00ec A, Belluzzi E, et al. Conservative Versus Surgical Management of Elbow Medial Ulnar Collateral Ligament Injury: A Systematic Review. Orthopaedic Surgery. 2019;11(6):974-984. doi:10.1111\/os.12571 2. Ellenbecker TS, Wilk KE, Altchek DW, Andrews JR. Current concepts in rehabilitation following ulnar collateral ligament reconstruction. Sports Health. 2009;1(4):301-313. 3. Evans JP, Smith CD, Fine NF, et al. Clinical Rating systems in elbow research \u2013 a systematic review exploring trends and distributions of use. Journal of Shoulder and Elbow Surgery. 2018;25:98-106. 4. Glogovac G, Kakazu R, Aretakis AC, Grawe BM. Return to Sport and Sports-Specific outcomes following Ulnar Collateral Ligament reconstruction in adolescent athletes: A Systematic review. HSS Journal. 2019;16:242-249. Doi: 10.1007\/s11420-019-09689-9. 5. Hodgins JL, Vitale M, Arons RR, Ahmad CS. Epidemiology of Medial Ulnar Collateral Ligament Reconstruction. The American Journal of Sports Medicine. 2016;44(3):729-734. doi:10.1177\/0363546515622407 6. Lightsey HM, Trofa DP, Sonnenfeld JJ, et al. Rehabilitation variability after elbow Ulnar Collateral ligament reconstruction. The Orthopedic Journal of Sports medicine. 2019;7(3): 1-7. Doi: 10.1177\/2325967119833363. 7. Olds M, Coulter C, Marrant D, Uhl T. Reliability of a shoulder arm return to sport test battery. Physical Therapy in Sport. 2019;39:16-22. 8. Peters SD, Bullock GS, Goode AP, Garrigues GE, Ruch DS, Reiman MP.  The success of return to sport after ulnar collateral ligament injury in baseball: a systematic review and meta-analysis. Journal of Shoulder and Elbow Surgery. 2018;27(3):561-571. doi:10.1016\/j.jse.2017.12.003 9. Saper M, Shung J, Pearce S, Bompadre V, Andrews JR. Outcomes and Return to Sport after Ulnar Collateral ligament reconstruction in adolescent baseball players. The Orthopedic Journal of Sports Medicine. 2018;6(4):1-7. Doi: 10.1177\/2325967118769328. 10. Wilk KE, Arrigo CA, Dugas JR, Cain EL, Andrews JR. Rehabilitation and Return-to-Play Criteria Following Ulnar Collateral Ligament Reconstruction. Operative Techniques in Sports Medicine. 2017;25(3):154-171. doi:10.1053\/j.otsm.2017.07.004 11. Wilk KE, Arrigo CA, Arrigo RJ. Rehabilitation following UCL repair with Internal Brace. Orthopedics and Sports Medicine. 2019;3(1): 212-217. Doi: 10.32474\/OSMOAJ.2019.03.000151.","conversation_history":[],"metadata":{"question_type":"situational","seed_document_id":1,"situational_context":"A professional athlete is seeking information on recovery strategies for post-operative Ulnar Collateral Ligament Reconstruction.","topic":"Others"}}
{"id":"838a14a2-8524-47a3-b082-fa00613205a8","question":"As a patient who's currently going through postoperative rehabilitation for a rotator cuff repair, can you explain to me the goals of the Maximum Protection Phase in the Slow or Conservative Program? I'm particularly interested in understanding the detailed exercise regimen and guidelines to aid in my recovery.","reference_answer":"The goals of the Maximum Protection Phase (4-6 weeks post-op) in the Slow or Conservative Program for a Rotator Cuff Repair are: 1. To protect the surgical repair, 2. To decrease pain and inflammation, 3. To gradually increase shoulder range of motion as directed by the doctor, 4. To improve proximal (scapula) and distal strength and mobility, 5. To achieve independence in a home exercise program.","reference_context":"Document 8: PHYSICAL THERAPY PRESCRIPTION:  REVERSE SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: Please Transition out of the sling between 2 to 3 weeks after surgery (Sleep in sofa recliner with your sling for the first 2 weeks) for Primary Reverse Shoulder Replacement or 5 to 6 weeks for Fracture and Revision Reverse Shoulder Replacement.  2 Weeks  6 Weeks  Activities of Daily Living: You may use your arm and hand on the operative shoulder for your ADL activates 2 weeks after surgery. Pendulums are also encouraged 1 week after surgery.  Exercises: Passive ER to 20 degrees and extension to neutral, pendulums daily  Passive supine FF in scapular plane to 90 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed: ice  Advancement Criteria: ER to the above set criteria FF in scapular plane to 90 Minimal pain and inflammation with any motion or exercise Incision is well healed with no drainage or redness  2  Weeks 6  10: Phase II  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER as tolerated by the patient  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF > 120  ER > 30  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF > 120, ER >30  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  3  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation\n\nDocument 6: PHYSICAL THERAPY PRESCRIPTION:  TOTAL SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: At all times except for showering and exercise. (Sleep in sofa recliner)  Total of 6 weeks in the Sling and the Abduction pillow  Exercises: Pendulums ok 2 weeks after surgery Passive ER to 10 degrees and extension to neutral  Passive supine FF in scapular plane to 130 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed  Advancement Criteria: ER the above set criteria FF in scapular plane to 130 Minimal pain and inflammation with motion and exercise Incision is well healed with no drainage and no redness  Weeks 6  10: Phase II  Sling Immobilizer: Discontinue at week 6  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER \u2013 limit 45 deg  2  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF to 150  ER to 45  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF 160, ER >45  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  3  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation\n\nDocument 7: Visit per week:  2 to 3 times  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Advanced Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  2  4 WEEKS POST  OP (Maximum Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN)  2  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises  Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  4  6 WEEKS POST  OP (Moderate Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  3  7  12 WEEKS POST  OP: (Early Strengthening Phase)  GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  13  19 WEEKS POST  OP: (Late Strengthening Phase)  GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 weeks  Continue with throwing and racquet program if appropriate  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  20-24 WEEKS POST-OP: (Return to Sports or Full Activity)  GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control\n\nDocument 2: Visit per week:  2 to 3 times  Diagnosis:   LEFT or RIGHT Shoulder Arthroscopic Large Rotator Cuff Repair - Supraspinatus and Infraspinatus Repair - Subscapularis Repair  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Slow or Conservative Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  ** Weeks 0-3: Patient stays in the sling and abduction pillow at all times. Pendulums ok to start Week #3 (NO PAIN). NO Shoulder PROM. Elbow and wrist ROM is ok. **  4-6 WEEKS POST-OP (Maximum Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility  2 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Start Post Op Week #4 Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN), Pts with Subscapularis Repair: (Limit Passive ER to 20\u00b0)  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises and Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  6-8 WEEKS POST-OP (Moderate Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain  3 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  9-14 WEEKS POST-OP: (Early Strengthening Phase) GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  15-23 WEEKS POST-OP: (Late Strengthening Phase) GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 week. Continue with throwing program  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  24-26 WEEKS POST-OP: (Return to Sports or Full Activity) GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control","conversation_history":[],"metadata":{"question_type":"situational","seed_document_id":8,"situational_context":"A physical therapy patient is trying to understand their postoperative rehabilitation progress for a rotator cuff repair, looking for a detailed exercise regimen and guidelines to aid in their recovery.","topic":"Others"}}
{"id":"6533c75e-5481-4fc2-a404-71e6d472bd7d","question":"As a professional athlete recovering from a shoulder injury, I'm trying to understand the stages of my physical therapy. Could you explain what the rehabilitation goals are for the intermediate post-op phase, specifically 4-6 weeks after my SLAP Repair-Type II surgery, and the exercises I'll need to do for successful recovery?","reference_answer":"The rehabilitation goals for the intermediate post-op phase (4-6 weeks after surgery) of a SLAP Repair-Type II are to continue to protect the surgical repair, reduce swelling and minimize pain, gradually increase shoulder PROM, minimize substitution patterns with shoulder AAROM, initiate motor control exercise, and educate the patient.","reference_context":"Document 4: Rehabilitation Protocol for Total Shoulder Arthroplasty and Hemiarthroplasty  This protocol is intended to guide clinicians and patients through the post-operative course after a total shoulder arthroplasty (TSA) and hemiarthroplasty. Specific interventions should be based on the needs of the individual and should consider exam findings and clinical decision making. If you have questions, contact the referring physician.  Considerations for the Total Shoulder Arthroplasty and Hemiarthroplasty Rehabilitation Program Many different factors influence the post-operative rehabilitation outcome, including surgical approach, concomitant repair of the rotator cuff, arthroplasty secondary to fracture, arthroplasty secondary to rheumatoid arthritis or osteonecrosis, and individual patient factors including co-morbidities. It is recommended that patients meet all rehabilitation criteria in order to progress to the next phase and clinicians collaborate closely with the referring physician throughout the rehabilitation process.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: IMMEDIATE POST-OP (0-3 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Maintain UE ROM in elbow, hand and wrist \u2022 Gradually increase shoulder PROM \u2022 Minimize muscle inhibition \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM \u2022 No reaching behind back, especially in to internal rotation \u2022 No excessive shoulder external rotation or abduction \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 Place small pillow\/towel roll under elbow while lying on back to avoid shoulder hyperextension Intervention Swelling Management \u2022 Ice, compression Range of motion\/Mobility \u2022 PROM: ER <\/= 30 degrees in the scapular plane, IR to belt line in scapular plane, Flex\/Scaption to tolerance, ABD <\/= 90 degrees, pendulums, seated GH flexion table slide, seated horizontal table slide \u2022 AAROM: Active assistive shoulder flexion \u2022 AROM: elbow, hand, wrist Strengthening (Week 2) \u2022 Periscapular: scap retraction, prone scapular retraction, standing scapular setting, supported scapular setting, inferior glide, low row \u2022 Ball squeeze Criteria to Progress \u2022 >\/= 50% shoulder PROM flex, scaption as compared to contralateral side \u2022 <\/= 90 degrees of shoulder ABD PROM \u2022 <\/= 30 degrees of shoulder ER PROM in scapular plane \u2022 >\/= 70 degrees of IR PROM in scapular plane  Palpable muscle contraction felt in scapular musculature  Pain < 4\/10  No complications with Phase I  PHASE II: INTERMEDIATE POST-OP (4-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Continue to protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM \u2022 Minimize substitution patterns with AROM and AAROM \u2022 Improve periscapular muscle activation\/strength \u2022 Initiate RTC (external rotators) activation \u2022 Patient education Sling \u2022 Use at night while sleeping \u2022 Gradually start weaning sling over the next two weeks during the day Precautions \u2022 No excessive shoulder external rotation or abduction \u2022 No lifting of objects heavier than a coffee cup \u2022 No supporting of body weight with hands \u2022 Place small pillow\/towel roll under elbow while lying on back to avoid shoulder hyperextension Intervention *Continue with Phase I interventions  Range of motion\/Mobility \u2022 PROM: Full with exception of ER <\/= 30 degrees in scapular plane and <\/= 90 degrees ABD \u2022 AAROM: shoulder flexion with cane, cane external rotation stretch, washcloth press, seated shoulder elevation with cane \u2022 AROM: supine flexion, salutes, supine punch Strengthening \u2022 Rotator cuff: external rotation isometrics \u2022 Periscapular: Row on physioball, serratus punches \u2022 Elbow: Biceps curl, resistance band bicep curls and triceps Motor control \u2022 ER in scaption and Flex 90-125 (rhythmic stabilization) Stretching \u2022 Sidelying horizontal ADD Criteria to Progress \u2022 >\/=75% shoulder PROM flex, scaption, as compared to contralateral side \u2022 >\/=75% shoulder PROM IR in scapular plane as compared to contralateral side \u2022 30 degrees of shoulder PROM ER in scapular plane \u2022 90 degrees of shoulder PROM ABD \u2022 Minimal substitution patterns with AAROM \u2022 AROM shoulder elevation to 100 degrees with minimal substitution patterns \u2022 Pain < 4\/10 \u2022 No complications with Phase II  PHASE III: INTERMEDIATE POST-OP CONTD (7-8 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue (especially the anterior capsule) \u2022 Minimize pain \u2022 Maintain PROM \u2022 Improve AROM \u2022 Progress periscapular and RTC strength \u2022 Return to full functional activities \u2022 Patient education Sling \u2022 Discontinue Precautions \u2022 No lifting of heavy objects (>10 lbs) Intervention *Continue with Phase I-II interventions Range of motion\/Mobility \u2022 Full ROM in all planes \u2022 AAROM: incline table slides, ball roll on wall, wall climbs, pulleys \u2022 AROM: seated scaption, seated flexion, supine forward elevation with elastic resistance to 90 deg  Strengthening \u2022 Rotator cuff: internal rotation isometrics, side-lying external rotation, \u2022 Standing external rotation w\/ resistance band, standing internal rotation w\/ resistance band, internal  rotation, external rotation, \u2022 Periscapular: Resistance band shoulder extension, resistance band seated rows, rowing, lawn mowers, robbery Motor control \u2022 IR\/ER and Flex 90-125 (rhythmic stabilization) \u2022 Quadruped alternating isometrics and ball stabilization on wall \u2022 PNF-D1 diagonal lifts, PNF-D2 diagonal lifts Stretching \u2022 IR behind back with towel, sidelying horizontal ADD, sleeper stretch, triceps and lats Criteria to Progress \u2022 Minimal to no substitution patterns with shoulder AROM \u2022 Pain < 4\/10  PHASE IV: TRANSITIONAL POST-OP (9-11 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue (especially the anterior capsule) \u2022 Maintain pain-free PROM \u2022 Continue improving AROM \u2022 Improve dynamic shoulder stability \u2022 Gradually restore shoulder strength and endurance Precautions \u2022 No lifting of heavy objects (> 10 lbs) \u2022 Avoid exercises that put stress on the anterior shoulder capsule (ie: shoulder ER above 80 degrees of ABD) Intervention *Continue with Phase II-III interventions Range of motion\/mobility \u2022 Full ROM in all planes Strengthening \u2022 Rotator cuff: increase resistance rotator cuff exercise \u2022 Periscapular: Push-up plus on knees, \u201cW\u201d exercise, resistance band Ws, dynamic hug, resistance band dynamic hug, prone shoulder extension Is, resistance band forward punch, forward punch, tripod, pointer Motor control \u2022 Resistance band PNF pattern, PNF \u2013 D1 diagonal lifts w\/ resistance, diagonal-up, diagonal-down Wall slides w\/ resistance band Criteria to Progress \u2022 Supine AROM Flex >\/=140 degrees \u2022 Supine AROM ABD >\/=120 degrees \u2022 Supine AROM ER in scapular plane >\/= 60 degrees \u2022 Supine AROM IR in scapular plane >\/= 70 degrees \u2022 AROM shoulder elevation to 120 degrees with minimal substitution patterns \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 Pain < 2\/10  PHASE V: ADVANCED STRENGTHENING POST-OP (12-16 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free ROM \u2022 Improve shoulder strength and endurance \u2022 Enhance functional use of upper extremity  Intervention *Continue with Phase II-IV interventions Strengthening \u2022 Rotator cuff:  External rotation at 90 degrees, internal rotation at 90 degrees, resistance band standing external rotation at 90 degrees, resistance band standing internal rotation at 90 degrees \u2022 Periscapular: T and Y, \u201cT\u201d exercise, push-up plus knees extended, wall push up Motor Control \u2022 Progress ball stabilization on wall to overhead alternating isometrics\/rhythmic stabilization  Criteria to Progress \u2022 Clearance from MD and ALL milestone criteria have been met \u2022 Maintains pain-free PROM and AROM \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 QuickDASH \u2022 PENN Return-to-Sport \u2022 For the recreational or competitive athlete, return-to-sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non-contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return-to-sport rehabilitation program.  Revised December 2018 Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol  References  Angst, F, Goldhahn, J, et al. Responsiveness of six outcome assessment instruments in total shoulder arthroplasty. Arthritis & Rheumatism. 2008. 59 (3): 391-398.  Garcia, GH, Liu, JN, et al. High satisfaction and return to sports after total shoulder arthroplasty in patients aged 55 years and younger. AJSM. 2017. 45 (7): 1664-1669.  Gaunt BW, McCluskey GM, Uhl TL. An electromyographic evaluation of subdividing active-assistive shoulder elevation exercises. Sports Health. 2010. 2 (5): 424-432.  Hughes, M, Neer II, CS. Glenohumeral joint replacement and postoperative rehabilitation. Physical Therapy. 1975. 55(8): 850-858.  Kibler, W.B., Sciascia, A. D., Uhl, T. L., et al. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. The American Journal of Sports Medicine. 2008. 36(9): p. 1789-1798.  Knesek M, Brunfeldt, A, et al. Patterns of strain and the determination of the safe arc of motion after subscapularis repair-a biomechanical study. Journal of Orthopaedic Research. 2016. 34: 518-524.  Piasecki, DP, Nicholson, GP. Tears of the subscapularis tendon in athletes-diagnosis and repair techniques. Clin Sports Med. 2008. 27: 731-745.  Uhl TL, Muir TA, et al. Electromyographical assessment of passive, active assistive, and active shoulder rehabilitation exercises. PM R. 2010. 2: 132-141.  Wilcox III R.B., Arslanian L.E., Millett P.J. Rehabilitation following total shoulder arthroplasty. JOSPT. 2005. 35 (12): 821-837  Wolff. AL, Rosenzweig, L. Anatomical and biomechanical framework for shoulder arthroplasty rehabilitation. Journal of Hand Therapy. 2017. 30: 167-174.  Wright, T, Easley, T, et al. Shoulder arthroplasty and its effect on strain in the subscapularis muscle. Clinical Biomechanics. 2015. 30: 373-376.  Zarkadas P.C., Throckmorton T., et al. Patient reported activities after shoulder replacement: total and hemiarthroplasty. J Shoulder Elbow Surg. 2011. 20: 273-280.  Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med. 1996;(6):602-608.  Leggin BG, Michener, LA, et al. The Penn Shoulder Score: reliability and validity. JOSPT. 36 (3): 138-151.\n\nDocument 5: Rehabilitation Protocol for Sternoclavicular Joint Reconstruction  This protocol is intended to guide clinicians through the post-operative course for sternoclavicular joint reconstruction. This protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs of the individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes contained within this guideline may vary based on surgeon\u2019s preference, additional procedures performed, and\/or complications. If a clinician requires assistance in the progression of a post-operative patient, they should consult with the referring surgeon.  The interventions included within this protocol are not intended to be an inclusive list of exercises. Therapeutic interventions should be included and modified based on the progress of the patient and under the discretion of the clinician.  Considerations for the Post-operative sternoclavicular joint reconstruction Many different factors influence the post-operative rehabilitation outcome, including surgical technique (ie. tendon autograft harvest for repair), degree of SC joint instability, concomitant soft tissue or bone injury\/repair, and individual patient factors including co-morbidities. It is recommended that patients meet all rehabilitation criteria in order to progress to the next phase and clinicians collaborate closely with the referring physician throughout the rehabilitation process.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: EARLY POST-OP (0-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Reduce pain and swelling of the operative shoulder \u2022 Maintain elbow, wrist and hand AROM \u2022 Patient education Sling\/precautions \u2022 Sling to be worn for 6 weeks (or as directed by surgeon) \u2022 Avoid PROM of the glenohumeral joint \u2022 Avoid scapular AROM (protraction, retraction, depression and elevation) as it may disrupt the repair and healing tissues \u2022 Avoid bearing weight through involved extremity \u2022 Avoid lifting any lifting with involved extremity \u2022 Avoid running and jumping due to impact forces upon landing that may aggravate healing tissues and bone Intervention \u2022 Cryotherapy as needed \u2022 AROM: cervical spine, elbow, wrist, hand \u2022 Hand gripping: ball squeeze \u2022 Cardiovascular exercise as tolerated: walking, stationary bike Criteria to Progress \u2022 Well controlled pain and swelling \u2022 Protect reconstruction site and autograft site (if applicable) \u2022 Maintain elbow, wrist and hand AROM  PHASE II: INTERMEDIATE POST-OP (6-12WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Activation of muscles responsible for stabilizing the scapulothoracic and glenohumeral joint \u2022 Gradually restore PROM, AAROM of the GH joint at 6-8 weeks \u2022 Gradually restore AROM of the scapulothoracic joint and glenohumeral joint at 8 weeks \u2022 Wean from sling (if still wearing) \u2022 Begin shoulder and scapular strengthening at 8 weeks \u2022 Begin proprioception and neuromuscular control training \u2022 Identify and correct postural dysfunction as indicated Sling\/precautions \u2022 Avoid repetitive overhead activities \u2022 No lifting > 5 pounds with involved extremity until 9 weeks post-op \u2022 Post-rehabilitation soreness should resolve within 12-24 hours Additional Interventions *Continue with Phase I interventions \u2022 AROM in all cardinal plane assessing scapular rhythm \u2022 Gentle glenohumeral mobilization as indicated  Strengthening: \u2022 Rotator cuff strengthening in non-provocative positions (generally 0-45 degrees Scaption\/abduction): scaption raises against gravity, Sidelying ER, lightly resisted ER\/IR with theraband, isometrics \u2022 Scapular strengthening and dynamic neuromuscular control: low row, straight arm pulldowns, serratus punch, resisted T\u2019s  Stretching: Gentle corner or doorway pec stretch \u2022 Postural endurance exercises: scapular retractions, chin tucks \u2022 Walking, stationary bike, Stairmaster Criteria to Progress \u2022 Full AROM of the operative shoulder \u2022 Normal (5\/5) strength for glenohumeral flexion\/abduction\/IR\/ER degrees abduction  PHASE III: LATE POST-OP AND GRADUAL RETURN TO SPORT(13+ WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Restore normal (5\/5) rotator cuff strength at 90 degrees abduction including supraspinatus \u2022 Full multi-planar AROM with minimal to no substitution patterns \u2022 Advance proprioceptive and dynamic neuromuscular control training \u2022 Identify and correct postural dysfunction with sport\/work specific tasks as indicated \u2022 Develop strength and control movements required for sport\/work Sling\/ precautions \u2022 Post-rehabilitation soreness should resolve within 12 hours \u2022 No lifting restrictions at ~4 months Additional Interventions *Continue with Phase I-II Interventions \u2022 Glenohumeral mobilizations as indicated \u2022 Multiplane AROM with gradual increase in velocity of movement  Strengthening: \u2022 Rotator cuff strengthening at 45 degrees progressing to 90 degrees abduction and sport\/work specific positions as well as other provocative positions: resisted IR\/ER, elevation with ER, resisted scaption raises, facepulls\/resisted W\u2019s \u2022 Scapular strengthening and dynamic neuromuscular control in overhead or sport\/work positions: prone or resisted I\u2019s, T\u2019s and Y\u2019s, lower trap setting at wall, manual perturbations in varying degrees in elevation, serratus wall slides\/roll ups, wall pushups, quadruped shoulder taps \u2022 Core strengthening  Stretching:  Corner or doorway pec stretch, Gentle posterior capsule stretch (across body)  Walking, stationary bike, Stairmaster, return to running\/jumping as tolerated  Begin education in sport specific biomechanics with initial program for throwing, swimming, or overhead racquet sports Criteria to Return to Sport  Clearance from MD and ALL milestone criteria have been met  Maintains pain  free PROM and AROM  Performs all exercises demonstrating symmetric scapular mechanics  QuickDASH  PENN  For the recreational or competitive athlete, return  to  sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non  contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return  to  sport rehabilitation program.  Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol References: 1. Logan C, Shahien A, Altintas B, Millett PJ. Rehabilitation following sternoclavicular joint reconstruction for persistent instability. International Journal of Sports Physical Therapy. 2018;13(4):752-762. doi:10.26603\/ijspt20180752 2. Petri, M., Greenspoon, J. A., Horan, M. P., Martetschl\u00e4ger, F., Warth, R. J., & Millett, P. J. (2016). Clinical outcomes after autograft reconstruction for sternoclavicular joint instability. Journal of Shoulder and Elbow Surgery, 25(3), 435\u2013441. https:\/\/doi.org\/10.1016\/j.jse.2015.08.004 3. Garcia JA, Arguello AM, Momaya AM, Ponce BA. Sternoclavicular Joint Instability: Symptoms, Diagnosis And Management. Orthop Res Rev. 2020 Jul 28;12:75-87. doi: 10.2147\/ORR.S170964. PMID: 32801951; PMCID: PMC7395708.\n\nDocument 3: Rehabilitation Protocol for SLAP Repair-Type II  This protocol is intended to guide clinicians through the post-operative course for SLAP Repair-Type II. This protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs of the individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes contained within this guideline may vary based on surgeon\u2019s preference, additional procedures performed, and\/or complications. If a clinician requires assistance in the progression of a post-operative patient, they should consult with the referring surgeon.  The interventions included within this protocol are not intended to be an inclusive list. Therapeutic interventions should be included and modified based on the progress of the patient and under the discretion of the clinician.  Considerations for the Post-operative SLAP repair Rehabilitation Program Many different factors influence the post-operative SLAP repair rehabilitation outcome, including the type of SLAP lesion, the size of the tear\/number of anchors placed, concomitant procedures and amount of shoulder hypermobility and\/or hyperlaxity. Consider mechanism of injury as well as the sport the athlete would like to return to when initiating certain interventions.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: IMMEDIATE POST-OP (0-3 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Maintain UE ROM in elbow, hand and wrist \u2022 Gradually increase shoulder PROM \u2022 Minimize muscle inhibition \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM\/AAROM \u2022 No elbow AROM (avoid biceps contraction) \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 No reaching behind back Intervention Swelling Management \u2022 Ice, compression  Range of motion\/Mobility \u2022 PROM: ER<30 scapular plane, Forward elevation <90, full elbow flex and ext, seated GH flexion table slide, horizontal table slide (add hyperlink) \u2022 AROM: hand, wrist \u2022 AAROM: none  Strengthening (Week 2)  Periscapular: scap retraction  , prone scapular retraction  , standing scapular setting  , supported scapular setting, inferior glide, low row  to neutral; avoid shoulder extension  Rotator cuff: submaximal pain  free isometrics  Ball squeeze Criteria to Progress  90 degrees shoulder PROM forward elevation  30 degrees of shoulder PROM ER in the scapular plane  Full elbow PROM flexion and extension  Palpable muscle contraction felt in scapular and shoulder musculature  No complications with Phase I  PHASE II: INTERMEDIATE POST-OP (4-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Continue to protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM \u2022 Minimize substitution patterns with shoulder AAROM \u2022 Initiate motor control exercise \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM \u2022 No elbow AROM (avoid biceps contraction) \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 No reaching behind back Intervention *Continue with Phase I interventions  Range of motion\/Mobility \u2022 PROM: ER<45 scapular plane, Forward elevation <120 \u2022 AAROM: Active assistive shoulder flexion, shoulder flexion with cane, cane external rotation stretch, washcloth press, sidelying elevation to 90 degrees  Strengthening \u2022 Periscapular: Row on physioball*, shoulder extension on physioball*, serratus punches - *to neutral; avoid shoulder extension  Motor Control \u2022 Internal and external rotation in scaption and Flex 90-125 (rhythmic stabilization)  Stretching \u2022 Sidelying horizontal ADD, sleeper stretch Criteria to Progress \u2022 120 degrees shoulder PROM forward elevation \u2022 45 degrees shoulder PROM ER in scapular plane \u2022 Minimal substitution patterns with shoulder AAROM \u2022 Pain < 4\/10 \u2022 No complications with Phase II  PHASE III: INTERMEDIATE POST-OP CONT\u2019d (7-8 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM\/AAROM \u2022 Initiate shoulder and elbow AROM \u2022 Initiate RTC strengthening  Improve scapular muscle activation  Patient education Sling  Discontinue Precautions  No resisted elbow flexion  No lifting of heavy objects (>10 lbs) Intervention  Continue with Phase I  II interventions Range of motion\/Mobility  PROM: ER Full in scapular plane, \uf0a390 degrees ER in 90 degrees of abduction, IR Full in scapular plane, Forward elevation Full  do not push beyond 90 degrees ER in 90 degrees of abduction  AAROM: seated shoulder elevation with cane, seated incline table slides, ball roll on wall  AROM: supine flexion, salutes, supine punch, wall climbs, elbow flexion  Strengthening \u2022 Rotator cuff: side-lying external rotation, standing external rotation w\/ resistance band, standing internal rotation w\/ resistance band, internal  rotation, external rotation \u2022 Periscapular: Resistance band shoulder extension*, resistance band seated rows*, rowing*, lawn mowers, robbery - *to neutral; avoid shoulder extension \u2022 Elbow: Triceps  Motor Control \u2022 Quadruped alternating isometrics Criteria to Progress \u2022 Full pain-free shoulder PROM ER and forward elevation \u2022 Within 10 degrees of shoulder IR PROM of contralateral shoulder \u2022 Minimal substitution patterns with shoulder AROM \u2022 Pain < 4\/10  PHASE IV: TRANSITIONAL POST-OP (9-12 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue \u2022 Restore full shoulder PROM and AROM \u2022 Initiate resisted elbow flexion at 12 weeks \u2022 Improve dynamic shoulder stability \u2022 Progress periscapular strength \u2022 Gradually return to full functional activities Precautions \u2022 No lifting of heavy objects (> 10 lbs) Intervention *Continue with Phase II-III interventions Range of motion\/mobility \u2022 PROM: Full \u2022 AROM: Supine forward elevation with elastic resistance to 90 deg, scaption and shoulder flexion to 90  degrees elevation  Strengthening \u2022 Periscapular: Push-up plus on knees, prone shoulder extension Is*, resistance band forward punch, forward punch, tripod o *to neutral; avoid shoulder extension \u2022 Elbow (12 weeks): Biceps curl, resistance band bicep curls  Motor control  Ball stabilization on wall  Stretching \u2022 Hands behind head, IR behind back with towel, triceps and lats, doorway series Criteria to Progress \u2022 Full pain-free shoulder PROM and AROM \u2022 Minimal to no substitution patterns with shoulder AROM \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 Pain < 2\/10  PHASE V: LATE POST-OP (13-16 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free shoulder ROM \u2022 Enhance functional use of upper extremity Intervention *Continue with Phase II-IV interventions Strengthening \u2022 Rotator cuff: External rotation at 90 degrees, internal rotation at 90 degrees, resistance band standing external rotation at 90 degrees, resistance band standing internal rotation at 90 degrees \u2022 Periscapular: T and Y, \u201cT\u201d exercise, push-up plus knees extended, pointer, wall push up, \u201cW\u201d exercise, resistance band Ws, dynamic hug, resistance band dynamic hug  Motor Control \u2022  PNF \u2013 D1 diagonal lifts, PNF \u2013 D2 diagonal lifts, field goals , resistance band PNF pattern, PNF \u2013 D1 diagonal lifts w\/ resistance, diagonal-up, diagonal-down, wall slides w\/ resistance band Criteria to Progress \u2022 Clearance from MD and ALL milestone criteria below have been met \u2022 Full pain-free shoulder PROM and AROM \u2022 ER\/IR strength minimum 85% of the uninvolved arm \u2022 ER\/IR ratio 60% or higher \u2022 Negative impingement and instability signs \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 QuickDASH \u2022 PENN  PHASE VI: EARLY RETURN-TO-SPORT (4-6 MONTHS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free ROM \u2022 Continue strengthening and motor control exercises \u2022 Enhance functional use of upper extremity \u2022 Gradual return to strenuous work\/sport activity Intervention *Continue with Phase II-V interventions Strengthening \u2022 See specific return-to-sport\/throwing program (coordinate with physician) Criteria to Progress \u2022 Last stage-no additional criteria Return-to-Sport \u2022 For the recreational or competitive athlete, return-to-sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non-contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return-to-sport rehabilitation program. Revised 7\/2020  Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol  References:  1. Ahsan, ZS, Hsu JE, et al. The Snyder classification of superior labrum anterior and posterior (SLAP) lesions. Clin Orthop Relat Res. 2016. 474:2075- 2078.  2. Christopher ZR, Kennedy J, et al. Rehabilitation and return to play following superior labral anterior to posterior repair. Oper Tech Sports Med. 2017. 25:132-144.  3. Cools AM, Borms D, Cottens S, et al. Rehabilitation exercises for athletes with biceps disorders and SLAP lesions. AJSM. 2014. 42(6): 1315-1323.  4. Itoi E, Hatakeyama Y, et al. Position of immobilization after dislocation of the shoulder. JBJS. 1999. 81-A(3): 385-390.  5. Kibler, W.B., Sciascia, A. D., Uhl, T. L., et al. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. The American Journal of Sports Medicine. 2008. 36(9): p. 1789-1798.  6. Wilk KE, Reinold MM, et al. Current concepts in the recognition and treatment of superior labral (SLAP) lesions. JOSPT. 2005. 35(5): 273-291.","conversation_history":[],"metadata":{"question_type":"situational","seed_document_id":4,"situational_context":"A professional athlete recovering from a shoulder injury is looking to understand the stages of their physical therapy and the exercises they will need to do for successful rehabilitation.","topic":"Others"}}
{"id":"fb941deb-8d72-44fb-858d-df1502e73628","question":"As a physical therapist, I'm currently consulting the Rehabilitation Protocol for Concussion Return-to-Sport to guide me through the return to sport process for my patient who is recovering from a concussion. Can you explain to me what the recommended protocol for returning to sport after a concussion is?","reference_answer":"The protocol for returning to sport after a concussion is time based and criterion based, and includes several phases. Phase I (0-3 days post-injury) involves relative rest and household activities as tolerated. Phase II reintroduces aerobic activity and limits head movement and contact. Phase III reintroduces movement and progresses active rehab. Phase IV reintroduces sport specific activity while avoiding contact. Phase V involves a full return to sport. These phases are guided by the patient's progress and the clinician's discretion. If a patient is not progressing as expected, they should be referred to a concussion specialty clinic.","reference_context":"Document 0: Rehabilitation Protocol for Concussion Return-to-Sport  This protocol is intended to guide clinicians through the return to sport following sports-related concussion. This protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs of the individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes contained within this guideline may vary based on physician preference, healing timeline and sporting activity. Return to sport following concussion can be a complex decision-making process and should be approached with a multidisciplinary team approach. If a patient is not progressing as expected, they should quickly be referred to a concussion specialty clinic.  The interventions included within this protocol are not intended to be an inclusive list. Therapeutic interventions should be included and modified based on the progress of the patient and under the discretion of the clinician.  Considerations for concussion return to sport Current literature no longer supports a period of complete rest beyond 72 hours. Concussion recovery should be focused around active rehabilitation. Activities should be performed at a sub-symptom threshold to the patient\u2019s tolerance. A patient should undergo formal exertional testing and a graded exercise protocol should be based on max exercise tolerance. If a clinician is not familiar with this testing and exercise prescription, the patient should be referred to a specialist.  PHASE I: EARLY POST-INJURY (0-3 DAYS) Rehabilitation Goals \u2022 Relative rest Precautions \u2022 Throughout progression, there should be minimal symptoms. If symptoms are  starting, rest see if symptoms resolve and the resume at a slightly lower heart rate with goal of not increasing symptoms for pre-exercise level Intervention \u2022 Household and community activities as tolerated Criteria to Progress \u2022 3 days post injury  PHASE II: INTERMEDIATE POST-INJURY Rehabilitation Goals \u2022 Gradually reintroduce aerobic activity \u2022 Decrease deconditioning Precautions \u2022 Limit head movement, distractions and maintain neutral neck position \u2022 Avoid Valsalva \u2022 No contact Additional Intervention *Continue with Phase I interventions \u2022 Light activity to gradually increase heart rate. If symptoms do not increase next session can increase workload slightly more \u2022 Exercise examples: \u2022 Light biking \u2022 Walking Criteria to Progress \u2022 Tolerating activity well without symptoms, progress through gradually until able to achieve 85% of age adjust heart rate without symptoms \u2022 Able to tolerate daily activities without significant increase in visual\/vestibular symptoms  PHASE III: LATE POST-INJURY Rehabilitation Goals \u2022 Reintroduce movement \u2022 Progress active rehab Precautions \u2022 Avoid Valsalva \u2022 No contact Additional Intervention *Continue with Phase I-II Interventions \u2022 Increased head movement with activity \u2022 Running, skating, swimming, rowing, shooting on empty goal, foot work, stick work \u2022 Increased environmental distractions \u2022 Busy gym, running with people around \u2022 Increased cognitive demands \u2022 Doing math in head, talking, thinking through plays while exercising Criteria to Progress \u2022 No symptoms with above exercise \u2022 Minimal to no symptoms with all activities including daily activities, school, work etc.  PHASE IV: TRANSITIONAL Rehabilitation Goals Reintroduce sport specific activity, while continuing to avoid contact Additional Intervention *Continue with Phase I-III interventions Sport specific activity Passing drills, shooting drills, non-contact drill participation Criteria to Progress No symptoms with above activity  PHASE V: FULL RETURN TO SPORT ( MONTHS AFTER SURGERY) Rehabilitation Goals Full return to sport Additional Intervention *Continue with Phase II-IV interventions Scrimmage play first, then full game play if asymptomatic Revised 9\/2021  Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol References:  1. Clausen M et al, Cerebral Blood Flow during Treadmill exercise is a marker of physiological post-concussion syndrome in female athletes. Journal of Head Trauma Rehabilitation 2016 31 (3): 215-24. 2. Coslick, A, et al. Participation in Physical Activity at Time of Presentation to a Specialty Concussion Clinic Is Associated With Shorter Time to Recovery. PM&R,; 2020 (12)12: 1195\u20131204. 3. DiFazio, M., Silverberg, N. D., Kirkwood, M. W., Bernier, R., & Iverson, G. L. (2016). Prolonged Activity Restriction after Concussion: Are We Worsening Outcomes? Clinical Pediatrics, 55(5), 443\u2013451. 4. Grool AM, Aglipay M, Momoli F, et al. Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent Postconcussive Symptoms in Children and Adolescents. JAMA. 2016;316(23):2504. doi:10.1001\/jama.2016.17396 5. Kamins J, Bigler E, Covassin T, et al. What is the physiological time to recovery after concussion? A systematic review. Br J Sports Med. 2017;51(12):935-940. doi:10.1136\/bjsports-2016-097464 6. Leddy JJ et al. Use of graded exercise testing in concussion and return-to-activity management. Current Sports Medicine Reports 12 (6): 370-376, 2013. 7. Leddy JJ, Haider MN, Ellis M, Willer BS. Exercise is Medicine for Concussion. Curr Sports Med Rep. 2018;17(8):262-270. doi:10.1249\/JSR.0000000000000505 8. Leddy JJ, Willer B. Use of Graded Exercise Testing in Concussion and Return-to-Activity Management.  Curr Sports Med Rep. 2013;12(6):370-376. doi:10.1249\/JSR.0000000000000008 9. Muruta J et al. Visual Tracking synchronization as a metric for concussion screening. J Head Trauma Rehabil 2010 Jul-Aug; 25 (4):293-305. 10. Thomas DG, Apps JN, Hoffmann RG, McCrea M, Hammeke T. Benefits of Strict Rest After Acute Concussion: A Randomized Controlled Trial. Pediatrics. 2015;135(2).","conversation_history":[],"metadata":{"question_type":"situational","seed_document_id":0,"situational_context":"A physical therapist is consulting the Rehabilitation Protocol for Concussion Return-to-Sport to guide them through the return to sport process for their patient recovering from a concussion.","topic":"Others"}}
{"id":"335f65b4-9046-4cec-8cb6-0a8ab32fff86","question":"As a physical therapist, I'm currently handling a patient who suffered a sports-related concussion. Could you tell me what the recommended period of complete rest for this case is?","reference_answer":"Current literature no longer supports a period of complete rest beyond 72 hours.","reference_context":"Document 0: Rehabilitation Protocol for Concussion Return-to-Sport  This protocol is intended to guide clinicians through the return to sport following sports-related concussion. This protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs of the individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes contained within this guideline may vary based on physician preference, healing timeline and sporting activity. Return to sport following concussion can be a complex decision-making process and should be approached with a multidisciplinary team approach. If a patient is not progressing as expected, they should quickly be referred to a concussion specialty clinic.  The interventions included within this protocol are not intended to be an inclusive list. Therapeutic interventions should be included and modified based on the progress of the patient and under the discretion of the clinician.  Considerations for concussion return to sport Current literature no longer supports a period of complete rest beyond 72 hours. Concussion recovery should be focused around active rehabilitation. Activities should be performed at a sub-symptom threshold to the patient\u2019s tolerance. A patient should undergo formal exertional testing and a graded exercise protocol should be based on max exercise tolerance. If a clinician is not familiar with this testing and exercise prescription, the patient should be referred to a specialist.  PHASE I: EARLY POST-INJURY (0-3 DAYS) Rehabilitation Goals \u2022 Relative rest Precautions \u2022 Throughout progression, there should be minimal symptoms. If symptoms are  starting, rest see if symptoms resolve and the resume at a slightly lower heart rate with goal of not increasing symptoms for pre-exercise level Intervention \u2022 Household and community activities as tolerated Criteria to Progress \u2022 3 days post injury  PHASE II: INTERMEDIATE POST-INJURY Rehabilitation Goals \u2022 Gradually reintroduce aerobic activity \u2022 Decrease deconditioning Precautions \u2022 Limit head movement, distractions and maintain neutral neck position \u2022 Avoid Valsalva \u2022 No contact Additional Intervention *Continue with Phase I interventions \u2022 Light activity to gradually increase heart rate. If symptoms do not increase next session can increase workload slightly more \u2022 Exercise examples: \u2022 Light biking \u2022 Walking Criteria to Progress \u2022 Tolerating activity well without symptoms, progress through gradually until able to achieve 85% of age adjust heart rate without symptoms \u2022 Able to tolerate daily activities without significant increase in visual\/vestibular symptoms  PHASE III: LATE POST-INJURY Rehabilitation Goals \u2022 Reintroduce movement \u2022 Progress active rehab Precautions \u2022 Avoid Valsalva \u2022 No contact Additional Intervention *Continue with Phase I-II Interventions \u2022 Increased head movement with activity \u2022 Running, skating, swimming, rowing, shooting on empty goal, foot work, stick work \u2022 Increased environmental distractions \u2022 Busy gym, running with people around \u2022 Increased cognitive demands \u2022 Doing math in head, talking, thinking through plays while exercising Criteria to Progress \u2022 No symptoms with above exercise \u2022 Minimal to no symptoms with all activities including daily activities, school, work etc.  PHASE IV: TRANSITIONAL Rehabilitation Goals Reintroduce sport specific activity, while continuing to avoid contact Additional Intervention *Continue with Phase I-III interventions Sport specific activity Passing drills, shooting drills, non-contact drill participation Criteria to Progress No symptoms with above activity  PHASE V: FULL RETURN TO SPORT ( MONTHS AFTER SURGERY) Rehabilitation Goals Full return to sport Additional Intervention *Continue with Phase II-IV interventions Scrimmage play first, then full game play if asymptomatic Revised 9\/2021  Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol References:  1. Clausen M et al, Cerebral Blood Flow during Treadmill exercise is a marker of physiological post-concussion syndrome in female athletes. Journal of Head Trauma Rehabilitation 2016 31 (3): 215-24. 2. Coslick, A, et al. Participation in Physical Activity at Time of Presentation to a Specialty Concussion Clinic Is Associated With Shorter Time to Recovery. PM&R,; 2020 (12)12: 1195\u20131204. 3. DiFazio, M., Silverberg, N. D., Kirkwood, M. W., Bernier, R., & Iverson, G. L. (2016). Prolonged Activity Restriction after Concussion: Are We Worsening Outcomes? Clinical Pediatrics, 55(5), 443\u2013451. 4. Grool AM, Aglipay M, Momoli F, et al. Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent Postconcussive Symptoms in Children and Adolescents. JAMA. 2016;316(23):2504. doi:10.1001\/jama.2016.17396 5. Kamins J, Bigler E, Covassin T, et al. What is the physiological time to recovery after concussion? A systematic review. Br J Sports Med. 2017;51(12):935-940. doi:10.1136\/bjsports-2016-097464 6. Leddy JJ et al. Use of graded exercise testing in concussion and return-to-activity management. Current Sports Medicine Reports 12 (6): 370-376, 2013. 7. Leddy JJ, Haider MN, Ellis M, Willer BS. Exercise is Medicine for Concussion. Curr Sports Med Rep. 2018;17(8):262-270. doi:10.1249\/JSR.0000000000000505 8. Leddy JJ, Willer B. Use of Graded Exercise Testing in Concussion and Return-to-Activity Management.  Curr Sports Med Rep. 2013;12(6):370-376. doi:10.1249\/JSR.0000000000000008 9. Muruta J et al. Visual Tracking synchronization as a metric for concussion screening. J Head Trauma Rehabil 2010 Jul-Aug; 25 (4):293-305. 10. Thomas DG, Apps JN, Hoffmann RG, McCrea M, Hammeke T. Benefits of Strict Rest After Acute Concussion: A Randomized Controlled Trial. Pediatrics. 2015;135(2).","conversation_history":[],"metadata":{"question_type":"situational","seed_document_id":0,"situational_context":"A physical therapist is seeking help about the rehabilitation protocol for a patient who suffered a sports-related concussion.\n","topic":"Others"}}
{"id":"46f6ff65-57e6-4da2-ac5d-4beedfa73a09","question":"As a physical therapist working with patients who have undergone rotator cuff repair and shoulder arthroplasty, I'm looking for detailed postoperative rehabilitation programs. Could you tell me what are the criteria for a patient to advance to the next phase in the 4-6 weeks post-op of the rotator cuff physical therapy prescription?","reference_answer":"The minimum criteria for advancement to the next phase are: 1. Normal scapular mobility, 2. Full active ROM distal to shoulder, 3. Shoulder ROM to within surgeon\u2019s set ROM goals","reference_context":"Document 7: Visit per week:  2 to 3 times  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Advanced Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  2  4 WEEKS POST  OP (Maximum Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN)  2  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises  Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  4  6 WEEKS POST  OP (Moderate Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  3  7  12 WEEKS POST  OP: (Early Strengthening Phase)  GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  13  19 WEEKS POST  OP: (Late Strengthening Phase)  GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 weeks  Continue with throwing and racquet program if appropriate  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  20-24 WEEKS POST-OP: (Return to Sports or Full Activity)  GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control\n\nDocument 2: Visit per week:  2 to 3 times  Diagnosis:   LEFT or RIGHT Shoulder Arthroscopic Large Rotator Cuff Repair - Supraspinatus and Infraspinatus Repair - Subscapularis Repair  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Slow or Conservative Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  ** Weeks 0-3: Patient stays in the sling and abduction pillow at all times. Pendulums ok to start Week #3 (NO PAIN). NO Shoulder PROM. Elbow and wrist ROM is ok. **  4-6 WEEKS POST-OP (Maximum Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility  2 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Start Post Op Week #4 Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN), Pts with Subscapularis Repair: (Limit Passive ER to 20\u00b0)  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises and Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  6-8 WEEKS POST-OP (Moderate Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain  3 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  9-14 WEEKS POST-OP: (Early Strengthening Phase) GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  15-23 WEEKS POST-OP: (Late Strengthening Phase) GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 week. Continue with throwing program  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  24-26 WEEKS POST-OP: (Return to Sports or Full Activity) GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control\n\nDocument 6: PHYSICAL THERAPY PRESCRIPTION:  TOTAL SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: At all times except for showering and exercise. (Sleep in sofa recliner)  Total of 6 weeks in the Sling and the Abduction pillow  Exercises: Pendulums ok 2 weeks after surgery Passive ER to 10 degrees and extension to neutral  Passive supine FF in scapular plane to 130 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed  Advancement Criteria: ER the above set criteria FF in scapular plane to 130 Minimal pain and inflammation with motion and exercise Incision is well healed with no drainage and no redness  Weeks 6  10: Phase II  Sling Immobilizer: Discontinue at week 6  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER \u2013 limit 45 deg  2  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF to 150  ER to 45  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF 160, ER >45  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  3  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation\n\nDocument 8: PHYSICAL THERAPY PRESCRIPTION:  REVERSE SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: Please Transition out of the sling between 2 to 3 weeks after surgery (Sleep in sofa recliner with your sling for the first 2 weeks) for Primary Reverse Shoulder Replacement or 5 to 6 weeks for Fracture and Revision Reverse Shoulder Replacement.  2 Weeks  6 Weeks  Activities of Daily Living: You may use your arm and hand on the operative shoulder for your ADL activates 2 weeks after surgery. Pendulums are also encouraged 1 week after surgery.  Exercises: Passive ER to 20 degrees and extension to neutral, pendulums daily  Passive supine FF in scapular plane to 90 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed: ice  Advancement Criteria: ER to the above set criteria FF in scapular plane to 90 Minimal pain and inflammation with any motion or exercise Incision is well healed with no drainage or redness  2  Weeks 6  10: Phase II  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER as tolerated by the patient  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF > 120  ER > 30  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF > 120, ER >30  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  3  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation","conversation_history":[],"metadata":{"question_type":"situational","seed_document_id":7,"situational_context":"A physical therapist is looking for detailed postoperative rehabilitation programs for rotator cuff repair and shoulder arthroplasty, to better service their patients.","topic":"Others"}}
{"id":"b6b1f6b9-ed13-46de-aa6c-6109fd0fa738","question":"What is the general approach to return to sport following a concussion and what is the recommended approach to concussion recovery according to current literature?","reference_answer":"Return to sport following concussion can be a complex decision-making process and should be approached with a multidisciplinary team approach. The process is time based as well as criterion based, and specific intervention should be based on the needs of the individual. The protocol includes various phases, starting with relative rest and gradually reintroducing activity, movement, sport specific activity, and finally full return to sport. According to current literature, concussion recovery should no longer support a period of complete rest beyond 72 hours and should be focused around active rehabilitation. Activities should be performed at a sub-symptom threshold to the patient\u2019s tolerance. A patient should undergo formal exertional testing and a graded exercise protocol should be based on max exercise tolerance.","reference_context":"Document 0: Rehabilitation Protocol for Concussion Return-to-Sport  This protocol is intended to guide clinicians through the return to sport following sports-related concussion. This protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs of the individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes contained within this guideline may vary based on physician preference, healing timeline and sporting activity. Return to sport following concussion can be a complex decision-making process and should be approached with a multidisciplinary team approach. If a patient is not progressing as expected, they should quickly be referred to a concussion specialty clinic.  The interventions included within this protocol are not intended to be an inclusive list. Therapeutic interventions should be included and modified based on the progress of the patient and under the discretion of the clinician.  Considerations for concussion return to sport Current literature no longer supports a period of complete rest beyond 72 hours. Concussion recovery should be focused around active rehabilitation. Activities should be performed at a sub-symptom threshold to the patient\u2019s tolerance. A patient should undergo formal exertional testing and a graded exercise protocol should be based on max exercise tolerance. If a clinician is not familiar with this testing and exercise prescription, the patient should be referred to a specialist.  PHASE I: EARLY POST-INJURY (0-3 DAYS) Rehabilitation Goals \u2022 Relative rest Precautions \u2022 Throughout progression, there should be minimal symptoms. If symptoms are  starting, rest see if symptoms resolve and the resume at a slightly lower heart rate with goal of not increasing symptoms for pre-exercise level Intervention \u2022 Household and community activities as tolerated Criteria to Progress \u2022 3 days post injury  PHASE II: INTERMEDIATE POST-INJURY Rehabilitation Goals \u2022 Gradually reintroduce aerobic activity \u2022 Decrease deconditioning Precautions \u2022 Limit head movement, distractions and maintain neutral neck position \u2022 Avoid Valsalva \u2022 No contact Additional Intervention *Continue with Phase I interventions \u2022 Light activity to gradually increase heart rate. If symptoms do not increase next session can increase workload slightly more \u2022 Exercise examples: \u2022 Light biking \u2022 Walking Criteria to Progress \u2022 Tolerating activity well without symptoms, progress through gradually until able to achieve 85% of age adjust heart rate without symptoms \u2022 Able to tolerate daily activities without significant increase in visual\/vestibular symptoms  PHASE III: LATE POST-INJURY Rehabilitation Goals \u2022 Reintroduce movement \u2022 Progress active rehab Precautions \u2022 Avoid Valsalva \u2022 No contact Additional Intervention *Continue with Phase I-II Interventions \u2022 Increased head movement with activity \u2022 Running, skating, swimming, rowing, shooting on empty goal, foot work, stick work \u2022 Increased environmental distractions \u2022 Busy gym, running with people around \u2022 Increased cognitive demands \u2022 Doing math in head, talking, thinking through plays while exercising Criteria to Progress \u2022 No symptoms with above exercise \u2022 Minimal to no symptoms with all activities including daily activities, school, work etc.  PHASE IV: TRANSITIONAL Rehabilitation Goals Reintroduce sport specific activity, while continuing to avoid contact Additional Intervention *Continue with Phase I-III interventions Sport specific activity Passing drills, shooting drills, non-contact drill participation Criteria to Progress No symptoms with above activity  PHASE V: FULL RETURN TO SPORT ( MONTHS AFTER SURGERY) Rehabilitation Goals Full return to sport Additional Intervention *Continue with Phase II-IV interventions Scrimmage play first, then full game play if asymptomatic Revised 9\/2021  Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol References:  1. Clausen M et al, Cerebral Blood Flow during Treadmill exercise is a marker of physiological post-concussion syndrome in female athletes. Journal of Head Trauma Rehabilitation 2016 31 (3): 215-24. 2. Coslick, A, et al. Participation in Physical Activity at Time of Presentation to a Specialty Concussion Clinic Is Associated With Shorter Time to Recovery. PM&R,; 2020 (12)12: 1195\u20131204. 3. DiFazio, M., Silverberg, N. D., Kirkwood, M. W., Bernier, R., & Iverson, G. L. (2016). Prolonged Activity Restriction after Concussion: Are We Worsening Outcomes? Clinical Pediatrics, 55(5), 443\u2013451. 4. Grool AM, Aglipay M, Momoli F, et al. Association Between Early Participation in Physical Activity Following Acute Concussion and Persistent Postconcussive Symptoms in Children and Adolescents. JAMA. 2016;316(23):2504. doi:10.1001\/jama.2016.17396 5. Kamins J, Bigler E, Covassin T, et al. What is the physiological time to recovery after concussion? A systematic review. Br J Sports Med. 2017;51(12):935-940. doi:10.1136\/bjsports-2016-097464 6. Leddy JJ et al. Use of graded exercise testing in concussion and return-to-activity management. Current Sports Medicine Reports 12 (6): 370-376, 2013. 7. Leddy JJ, Haider MN, Ellis M, Willer BS. Exercise is Medicine for Concussion. Curr Sports Med Rep. 2018;17(8):262-270. doi:10.1249\/JSR.0000000000000505 8. Leddy JJ, Willer B. Use of Graded Exercise Testing in Concussion and Return-to-Activity Management.  Curr Sports Med Rep. 2013;12(6):370-376. doi:10.1249\/JSR.0000000000000008 9. Muruta J et al. Visual Tracking synchronization as a metric for concussion screening. J Head Trauma Rehabil 2010 Jul-Aug; 25 (4):293-305. 10. Thomas DG, Apps JN, Hoffmann RG, McCrea M, Hammeke T. Benefits of Strict Rest After Acute Concussion: A Randomized Controlled Trial. Pediatrics. 2015;135(2).","conversation_history":[],"metadata":{"question_type":"double","original_questions":[{"question":"What is the general approach to return to sport following a concussion?","answer":"Return to sport following concussion can be a complex decision-making process and should be approached with a multidisciplinary team approach. The process is time based as well as criterion based, and specific intervention should be based on the needs of the individual. The protocol includes various phases, starting with relative rest and gradually reintroducing activity, movement, sport specific activity, and finally full return to sport."},{"question":"What is the recommended approach to concussion recovery according to current literature?","answer":"Current literature no longer supports a period of complete rest beyond 72 hours. Concussion recovery should be focused around active rehabilitation. Activities should be performed at a sub-symptom threshold to the patient\u2019s tolerance. A patient should undergo formal exertional testing and a graded exercise protocol should be based on max exercise tolerance."}],"seed_document_id":0,"topic":"Others"}}
{"id":"3406924a-ece0-4819-ad02-03b676b41afe","question":"What is the general goal of the physical therapy prescription for a reverse shoulder arthroplasty and what factors influence the rate at which a patient can progress through the rotator cuff physical therapy program?","reference_answer":"The general goal of the physical therapy prescription for a reverse shoulder arthroplasty is to gradually increase the range of motion, minimize pain and inflammation, and restore muscle strength and function. The rate at which a patient can progress through the program is influenced by factors such as surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear.","reference_context":"Document 8: PHYSICAL THERAPY PRESCRIPTION:  REVERSE SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: Please Transition out of the sling between 2 to 3 weeks after surgery (Sleep in sofa recliner with your sling for the first 2 weeks) for Primary Reverse Shoulder Replacement or 5 to 6 weeks for Fracture and Revision Reverse Shoulder Replacement.  2 Weeks  6 Weeks  Activities of Daily Living: You may use your arm and hand on the operative shoulder for your ADL activates 2 weeks after surgery. Pendulums are also encouraged 1 week after surgery.  Exercises: Passive ER to 20 degrees and extension to neutral, pendulums daily  Passive supine FF in scapular plane to 90 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed: ice  Advancement Criteria: ER to the above set criteria FF in scapular plane to 90 Minimal pain and inflammation with any motion or exercise Incision is well healed with no drainage or redness  2  Weeks 6  10: Phase II  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER as tolerated by the patient  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF > 120  ER > 30  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF > 120, ER >30  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  3  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation\n\nDocument 6: PHYSICAL THERAPY PRESCRIPTION:  TOTAL SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: At all times except for showering and exercise. (Sleep in sofa recliner)  Total of 6 weeks in the Sling and the Abduction pillow  Exercises: Pendulums ok 2 weeks after surgery Passive ER to 10 degrees and extension to neutral  Passive supine FF in scapular plane to 130 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed  Advancement Criteria: ER the above set criteria FF in scapular plane to 130 Minimal pain and inflammation with motion and exercise Incision is well healed with no drainage and no redness  Weeks 6  10: Phase II  Sling Immobilizer: Discontinue at week 6  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER \u2013 limit 45 deg  2  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF to 150  ER to 45  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF 160, ER >45  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  3  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation\n\nDocument 7: Visit per week:  2 to 3 times  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Advanced Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  2  4 WEEKS POST  OP (Maximum Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN)  2  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises  Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  4  6 WEEKS POST  OP (Moderate Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  3  7  12 WEEKS POST  OP: (Early Strengthening Phase)  GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  13  19 WEEKS POST  OP: (Late Strengthening Phase)  GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 weeks  Continue with throwing and racquet program if appropriate  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  20-24 WEEKS POST-OP: (Return to Sports or Full Activity)  GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control\n\nDocument 2: Visit per week:  2 to 3 times  Diagnosis:   LEFT or RIGHT Shoulder Arthroscopic Large Rotator Cuff Repair - Supraspinatus and Infraspinatus Repair - Subscapularis Repair  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Slow or Conservative Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  ** Weeks 0-3: Patient stays in the sling and abduction pillow at all times. Pendulums ok to start Week #3 (NO PAIN). NO Shoulder PROM. Elbow and wrist ROM is ok. **  4-6 WEEKS POST-OP (Maximum Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility  2 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Start Post Op Week #4 Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN), Pts with Subscapularis Repair: (Limit Passive ER to 20\u00b0)  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises and Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  6-8 WEEKS POST-OP (Moderate Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain  3 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  9-14 WEEKS POST-OP: (Early Strengthening Phase) GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  15-23 WEEKS POST-OP: (Late Strengthening Phase) GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 week. Continue with throwing program  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  24-26 WEEKS POST-OP: (Return to Sports or Full Activity) GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control","conversation_history":[],"metadata":{"question_type":"double","original_questions":[{"question":"What is the general goal of the physical therapy prescription for a reverse shoulder arthroplasty?","answer":"The general goal of the physical therapy prescription for a reverse shoulder arthroplasty is to gradually increase the range of motion, minimize pain and inflammation, and restore muscle strength and function."},{"question":"What are the factors that influence the rate at which a patient can progress through the rotator cuff physical therapy program?","answer":"The factors that influence the rate at which a patient can progress through the rotator cuff physical therapy program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear."}],"seed_document_id":8,"topic":"Others"}}
{"id":"ba8f5b0b-136c-4f8b-b6b4-85bd1e045562","question":"What is the typical visit frequency for the Slow or Conservative Program and what are the goals for the Maximum Protection Phase in the Advanced Program for rotator cuff physical therapy?","reference_answer":"The typical visit frequency for the Slow or Conservative Program for rotator cuff physical therapy is 2 to 3 times per week. The goals for the Maximum Protection Phase in the Advanced Program are to protect the surgical repair, decrease pain and inflammation, gradually increase shoulder range of motion, improve proximal and distal strength and mobility, and achieve independence in a home exercise program.","reference_context":"Document 2: Visit per week:  2 to 3 times  Diagnosis:   LEFT or RIGHT Shoulder Arthroscopic Large Rotator Cuff Repair - Supraspinatus and Infraspinatus Repair - Subscapularis Repair  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Slow or Conservative Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  ** Weeks 0-3: Patient stays in the sling and abduction pillow at all times. Pendulums ok to start Week #3 (NO PAIN). NO Shoulder PROM. Elbow and wrist ROM is ok. **  4-6 WEEKS POST-OP (Maximum Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility  2 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Start Post Op Week #4 Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN), Pts with Subscapularis Repair: (Limit Passive ER to 20\u00b0)  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises and Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  6-8 WEEKS POST-OP (Moderate Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain  3 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  9-14 WEEKS POST-OP: (Early Strengthening Phase) GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  15-23 WEEKS POST-OP: (Late Strengthening Phase) GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 week. Continue with throwing program  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  24-26 WEEKS POST-OP: (Return to Sports or Full Activity) GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control\n\nDocument 7: Visit per week:  2 to 3 times  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Advanced Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  2  4 WEEKS POST  OP (Maximum Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN)  2  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises  Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  4  6 WEEKS POST  OP (Moderate Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  3  7  12 WEEKS POST  OP: (Early Strengthening Phase)  GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  13  19 WEEKS POST  OP: (Late Strengthening Phase)  GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 weeks  Continue with throwing and racquet program if appropriate  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  20-24 WEEKS POST-OP: (Return to Sports or Full Activity)  GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control\n\nDocument 6: PHYSICAL THERAPY PRESCRIPTION:  TOTAL SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: At all times except for showering and exercise. (Sleep in sofa recliner)  Total of 6 weeks in the Sling and the Abduction pillow  Exercises: Pendulums ok 2 weeks after surgery Passive ER to 10 degrees and extension to neutral  Passive supine FF in scapular plane to 130 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed  Advancement Criteria: ER the above set criteria FF in scapular plane to 130 Minimal pain and inflammation with motion and exercise Incision is well healed with no drainage and no redness  Weeks 6  10: Phase II  Sling Immobilizer: Discontinue at week 6  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER \u2013 limit 45 deg  2  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF to 150  ER to 45  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF 160, ER >45  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  3  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation\n\nDocument 8: PHYSICAL THERAPY PRESCRIPTION:  REVERSE SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: Please Transition out of the sling between 2 to 3 weeks after surgery (Sleep in sofa recliner with your sling for the first 2 weeks) for Primary Reverse Shoulder Replacement or 5 to 6 weeks for Fracture and Revision Reverse Shoulder Replacement.  2 Weeks  6 Weeks  Activities of Daily Living: You may use your arm and hand on the operative shoulder for your ADL activates 2 weeks after surgery. Pendulums are also encouraged 1 week after surgery.  Exercises: Passive ER to 20 degrees and extension to neutral, pendulums daily  Passive supine FF in scapular plane to 90 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed: ice  Advancement Criteria: ER to the above set criteria FF in scapular plane to 90 Minimal pain and inflammation with any motion or exercise Incision is well healed with no drainage or redness  2  Weeks 6  10: Phase II  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER as tolerated by the patient  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF > 120  ER > 30  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF > 120, ER >30  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  3  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation","conversation_history":[],"metadata":{"question_type":"double","original_questions":[{"question":"What is the typical visit frequency for the Slow or Conservative Program for rotator cuff physical therapy?","answer":"The typical visit frequency for the Slow or Conservative Program for rotator cuff physical therapy is 2 to 3 times per week."},{"question":"What are the goals for the Maximum Protection Phase in the Advanced Program for rotator cuff physical therapy?","answer":"The goals for the Maximum Protection Phase in the Advanced Program for rotator cuff physical therapy are to protect the surgical repair, decrease pain and inflammation, gradually increase shoulder range of motion, improve proximal and distal strength and mobility, and achieve independence in a home exercise program."}],"seed_document_id":2,"topic":"Others"}}
{"id":"ff146f98-4b06-4604-a2a0-a9cb4144377a","question":"What is the progression of physical therapy for a total shoulder arthroplasty and for a large rotator cuff repair?","reference_answer":"The physical therapy for a total shoulder arthroplasty is divided into four phases, focusing on immobilization, gentle exercises, active exercises, ROM progression, isotonic strengthening, and individualization to the patient's needs. The physical therapy for a large rotator cuff repair is divided into phases focusing on protection of the surgical repair, gradual increase in shoulder ROM, decrease in pain and inflammation, improvement in ROM and strength, restoration of full PROM, and improvement in strength and neuromuscular control.","reference_context":"Document 6: PHYSICAL THERAPY PRESCRIPTION:  TOTAL SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: At all times except for showering and exercise. (Sleep in sofa recliner)  Total of 6 weeks in the Sling and the Abduction pillow  Exercises: Pendulums ok 2 weeks after surgery Passive ER to 10 degrees and extension to neutral  Passive supine FF in scapular plane to 130 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed  Advancement Criteria: ER the above set criteria FF in scapular plane to 130 Minimal pain and inflammation with motion and exercise Incision is well healed with no drainage and no redness  Weeks 6  10: Phase II  Sling Immobilizer: Discontinue at week 6  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER \u2013 limit 45 deg  2  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF to 150  ER to 45  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF 160, ER >45  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  3  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation\n\nDocument 8: PHYSICAL THERAPY PRESCRIPTION:  REVERSE SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: Please Transition out of the sling between 2 to 3 weeks after surgery (Sleep in sofa recliner with your sling for the first 2 weeks) for Primary Reverse Shoulder Replacement or 5 to 6 weeks for Fracture and Revision Reverse Shoulder Replacement.  2 Weeks  6 Weeks  Activities of Daily Living: You may use your arm and hand on the operative shoulder for your ADL activates 2 weeks after surgery. Pendulums are also encouraged 1 week after surgery.  Exercises: Passive ER to 20 degrees and extension to neutral, pendulums daily  Passive supine FF in scapular plane to 90 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed: ice  Advancement Criteria: ER to the above set criteria FF in scapular plane to 90 Minimal pain and inflammation with any motion or exercise Incision is well healed with no drainage or redness  2  Weeks 6  10: Phase II  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER as tolerated by the patient  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF > 120  ER > 30  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF > 120, ER >30  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  3  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation\n\nDocument 7: Visit per week:  2 to 3 times  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Advanced Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  2  4 WEEKS POST  OP (Maximum Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN)  2  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises  Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  4  6 WEEKS POST  OP (Moderate Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  3  7  12 WEEKS POST  OP: (Early Strengthening Phase)  GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  13  19 WEEKS POST  OP: (Late Strengthening Phase)  GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 weeks  Continue with throwing and racquet program if appropriate  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  20-24 WEEKS POST-OP: (Return to Sports or Full Activity)  GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control\n\nDocument 2: Visit per week:  2 to 3 times  Diagnosis:   LEFT or RIGHT Shoulder Arthroscopic Large Rotator Cuff Repair - Supraspinatus and Infraspinatus Repair - Subscapularis Repair  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Slow or Conservative Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  ** Weeks 0-3: Patient stays in the sling and abduction pillow at all times. Pendulums ok to start Week #3 (NO PAIN). NO Shoulder PROM. Elbow and wrist ROM is ok. **  4-6 WEEKS POST-OP (Maximum Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility  2 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Start Post Op Week #4 Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN), Pts with Subscapularis Repair: (Limit Passive ER to 20\u00b0)  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises and Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  6-8 WEEKS POST-OP (Moderate Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain  3 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  9-14 WEEKS POST-OP: (Early Strengthening Phase) GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  15-23 WEEKS POST-OP: (Late Strengthening Phase) GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 week. Continue with throwing program  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  24-26 WEEKS POST-OP: (Return to Sports or Full Activity) GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control","conversation_history":[],"metadata":{"question_type":"double","original_questions":[{"question":"What is the progression of physical therapy for a total shoulder arthroplasty?","answer":"The physical therapy for a total shoulder arthroplasty is divided into four phases. Phase I (Weeks 2-6) focuses on immobilization and gentle exercises like pendulums and passive supine FF. Phase II (Weeks 6-10) discontinues the sling immobilizer and introduces more active exercises. Phase III (Weeks 10-16) progresses ROM as tolerated and introduces isotonic strengthening. Phase IV (Weeks 16-22) addresses any remaining deficits and individualizes the program to the patient's needs."},{"question":"What is the physical therapy prescription for a large rotator cuff repair?","answer":"The physical therapy for a large rotator cuff repair is also divided into phases. The first phase (Weeks 0-3) focuses on protection of the surgical repair and gradual increase in shoulder ROM. The second phase (Weeks 4-6) aims to decrease pain and inflammation and improve ROM. The third phase (Weeks 6-8) continues to protect the surgical repair and improve ROM and strength. The fourth phase (Weeks 9-14) aims to restore full PROM and improve strength and flexibility. The final phase (Weeks 15-23) focuses on improving strength and neuromuscular control."}],"seed_document_id":6,"topic":"Others"}}
{"id":"47e46d1a-54e1-4cc3-a72d-71e1b048b8fa","question":"What are the main goals of the physical therapy prescription for a patient after a rotator cuff repair and what are the criteria for advancing to the next phase in the physical therapy prescription for a total shoulder arthroplasty?","reference_answer":"The main goals of the physical therapy prescription after a rotator cuff repair are to protect the surgical repair, decrease pain and inflammation, gradually increase shoulder range of motion, improve proximal and distal strength and mobility, and achieve independence in a home exercise program. The criteria for advancing to the next phase in the physical therapy prescription for a total shoulder arthroplasty include: minimal pain and inflammation with motion and exercise, incision is well healed with no drainage and no redness, and achieving the set range of motion goals.","reference_context":"Document 2: Visit per week:  2 to 3 times  Diagnosis:   LEFT or RIGHT Shoulder Arthroscopic Large Rotator Cuff Repair - Supraspinatus and Infraspinatus Repair - Subscapularis Repair  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Slow or Conservative Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  ** Weeks 0-3: Patient stays in the sling and abduction pillow at all times. Pendulums ok to start Week #3 (NO PAIN). NO Shoulder PROM. Elbow and wrist ROM is ok. **  4-6 WEEKS POST-OP (Maximum Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility  2 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Start Post Op Week #4 Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN), Pts with Subscapularis Repair: (Limit Passive ER to 20\u00b0)  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises and Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  6-8 WEEKS POST-OP (Moderate Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain  3 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  9-14 WEEKS POST-OP: (Early Strengthening Phase) GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  15-23 WEEKS POST-OP: (Late Strengthening Phase) GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 week. Continue with throwing program  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  24-26 WEEKS POST-OP: (Return to Sports or Full Activity) GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control\n\nDocument 7: Visit per week:  2 to 3 times  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Advanced Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  2  4 WEEKS POST  OP (Maximum Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN)  2  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises  Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  4  6 WEEKS POST  OP (Moderate Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  3  7  12 WEEKS POST  OP: (Early Strengthening Phase)  GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  13  19 WEEKS POST  OP: (Late Strengthening Phase)  GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 weeks  Continue with throwing and racquet program if appropriate  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  20-24 WEEKS POST-OP: (Return to Sports or Full Activity)  GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control\n\nDocument 6: PHYSICAL THERAPY PRESCRIPTION:  TOTAL SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: At all times except for showering and exercise. (Sleep in sofa recliner)  Total of 6 weeks in the Sling and the Abduction pillow  Exercises: Pendulums ok 2 weeks after surgery Passive ER to 10 degrees and extension to neutral  Passive supine FF in scapular plane to 130 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed  Advancement Criteria: ER the above set criteria FF in scapular plane to 130 Minimal pain and inflammation with motion and exercise Incision is well healed with no drainage and no redness  Weeks 6  10: Phase II  Sling Immobilizer: Discontinue at week 6  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER \u2013 limit 45 deg  2  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF to 150  ER to 45  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF 160, ER >45  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  3  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation\n\nDocument 8: PHYSICAL THERAPY PRESCRIPTION:  REVERSE SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: Please Transition out of the sling between 2 to 3 weeks after surgery (Sleep in sofa recliner with your sling for the first 2 weeks) for Primary Reverse Shoulder Replacement or 5 to 6 weeks for Fracture and Revision Reverse Shoulder Replacement.  2 Weeks  6 Weeks  Activities of Daily Living: You may use your arm and hand on the operative shoulder for your ADL activates 2 weeks after surgery. Pendulums are also encouraged 1 week after surgery.  Exercises: Passive ER to 20 degrees and extension to neutral, pendulums daily  Passive supine FF in scapular plane to 90 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed: ice  Advancement Criteria: ER to the above set criteria FF in scapular plane to 90 Minimal pain and inflammation with any motion or exercise Incision is well healed with no drainage or redness  2  Weeks 6  10: Phase II  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER as tolerated by the patient  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF > 120  ER > 30  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF > 120, ER >30  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  3  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation","conversation_history":[],"metadata":{"question_type":"double","original_questions":[{"question":"What are the main goals of the physical therapy prescription for a patient after a rotator cuff repair?","answer":"The main goals of the physical therapy prescription after a rotator cuff repair are to protect the surgical repair, decrease pain and inflammation, gradually increase shoulder range of motion, improve proximal and distal strength and mobility, and achieve independence in a home exercise program."},{"question":"What are the criteria for advancing to the next phase in the physical therapy prescription for a total shoulder arthroplasty?","answer":"The criteria for advancing to the next phase in the physical therapy prescription for a total shoulder arthroplasty include: minimal pain and inflammation with motion and exercise, incision is well healed with no drainage and no redness, and achieving the set range of motion goals."}],"seed_document_id":2,"topic":"Others"}}
{"id":"c50d496a-a3e2-45ea-89f7-19aae1b7edb1","question":"What are the goals of the first 4 weeks post-operation for an Advanced Program for rotator cuff physical therapy and what are the advancement criteria for the phase III (weeks 10-16) of the total shoulder arthroplasty physical therapy prescription?","reference_answer":"The goals of the first 4 weeks post-operation for an Advanced Program for rotator cuff physical therapy are to protect the surgical repair, decrease pain and inflammation, gradually increase shoulder range of motion as directed by the doctor, improve proximal and distal strength and mobility, and achieve independence in a home exercise program. The advancement criteria for the phase III of the total shoulder arthroplasty physical therapy prescription are muscle strength of 4\/5, passive forward flexion of 160 degrees, external rotation greater than 45 degrees, restoration of normal scapulohumeral rhythm below 90 degree elevation, and minimal pain and inflammation.","reference_context":"Document 7: Visit per week:  2 to 3 times  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Advanced Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  2  4 WEEKS POST  OP (Maximum Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN)  2  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises  Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  4  6 WEEKS POST  OP (Moderate Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  3  7  12 WEEKS POST  OP: (Early Strengthening Phase)  GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  13  19 WEEKS POST  OP: (Late Strengthening Phase)  GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 weeks  Continue with throwing and racquet program if appropriate  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  20-24 WEEKS POST-OP: (Return to Sports or Full Activity)  GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control\n\nDocument 2: Visit per week:  2 to 3 times  Diagnosis:   LEFT or RIGHT Shoulder Arthroscopic Large Rotator Cuff Repair - Supraspinatus and Infraspinatus Repair - Subscapularis Repair  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Slow or Conservative Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  ** Weeks 0-3: Patient stays in the sling and abduction pillow at all times. Pendulums ok to start Week #3 (NO PAIN). NO Shoulder PROM. Elbow and wrist ROM is ok. **  4-6 WEEKS POST-OP (Maximum Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility  2 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Start Post Op Week #4 Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN), Pts with Subscapularis Repair: (Limit Passive ER to 20\u00b0)  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises and Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  6-8 WEEKS POST-OP (Moderate Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain  3 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  9-14 WEEKS POST-OP: (Early Strengthening Phase) GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  15-23 WEEKS POST-OP: (Late Strengthening Phase) GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 week. Continue with throwing program  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  24-26 WEEKS POST-OP: (Return to Sports or Full Activity) GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control\n\nDocument 6: PHYSICAL THERAPY PRESCRIPTION:  TOTAL SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: At all times except for showering and exercise. (Sleep in sofa recliner)  Total of 6 weeks in the Sling and the Abduction pillow  Exercises: Pendulums ok 2 weeks after surgery Passive ER to 10 degrees and extension to neutral  Passive supine FF in scapular plane to 130 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed  Advancement Criteria: ER the above set criteria FF in scapular plane to 130 Minimal pain and inflammation with motion and exercise Incision is well healed with no drainage and no redness  Weeks 6  10: Phase II  Sling Immobilizer: Discontinue at week 6  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER \u2013 limit 45 deg  2  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF to 150  ER to 45  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF 160, ER >45  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  3  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation\n\nDocument 8: PHYSICAL THERAPY PRESCRIPTION:  REVERSE SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: Please Transition out of the sling between 2 to 3 weeks after surgery (Sleep in sofa recliner with your sling for the first 2 weeks) for Primary Reverse Shoulder Replacement or 5 to 6 weeks for Fracture and Revision Reverse Shoulder Replacement.  2 Weeks  6 Weeks  Activities of Daily Living: You may use your arm and hand on the operative shoulder for your ADL activates 2 weeks after surgery. Pendulums are also encouraged 1 week after surgery.  Exercises: Passive ER to 20 degrees and extension to neutral, pendulums daily  Passive supine FF in scapular plane to 90 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed: ice  Advancement Criteria: ER to the above set criteria FF in scapular plane to 90 Minimal pain and inflammation with any motion or exercise Incision is well healed with no drainage or redness  2  Weeks 6  10: Phase II  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER as tolerated by the patient  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF > 120  ER > 30  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF > 120, ER >30  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  3  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation","conversation_history":[],"metadata":{"question_type":"double","original_questions":[{"question":"What are the goals of the first 4 weeks post-operation for an Advanced Program for rotator cuff physical therapy?","answer":"The goals of the first 4 weeks post-operation for an Advanced Program for rotator cuff physical therapy are to protect the surgical repair, decrease pain and inflammation, gradually increase shoulder range of motion as directed by the doctor, improve proximal and distal strength and mobility, and achieve independence in a home exercise program."},{"question":"What are the advancement criteria for the phase III (weeks 10-16) of the total shoulder arthroplasty physical therapy prescription?","answer":"The advancement criteria for the phase III of the total shoulder arthroplasty physical therapy prescription are muscle strength of 4\/5, passive forward flexion of 160 degrees, external rotation greater than 45 degrees, restoration of normal scapulohumeral rhythm below 90 degree elevation, and minimal pain and inflammation."}],"seed_document_id":7,"topic":"Others"}}
{"id":"fe9aac60-d511-4b9e-8d39-0fe32428590d","question":"What factors influence this?","reference_answer":"Many different factors influence the post-operative rehabilitation outcome, including surgical approach, concomitant repair of the rotator cuff, arthroplasty secondary to fracture, arthroplasty secondary to rheumatoid arthritis or osteonecrosis, and individual patient factors including co-morbidities.","reference_context":"Document 3: Rehabilitation Protocol for SLAP Repair-Type II  This protocol is intended to guide clinicians through the post-operative course for SLAP Repair-Type II. This protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs of the individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes contained within this guideline may vary based on surgeon\u2019s preference, additional procedures performed, and\/or complications. If a clinician requires assistance in the progression of a post-operative patient, they should consult with the referring surgeon.  The interventions included within this protocol are not intended to be an inclusive list. Therapeutic interventions should be included and modified based on the progress of the patient and under the discretion of the clinician.  Considerations for the Post-operative SLAP repair Rehabilitation Program Many different factors influence the post-operative SLAP repair rehabilitation outcome, including the type of SLAP lesion, the size of the tear\/number of anchors placed, concomitant procedures and amount of shoulder hypermobility and\/or hyperlaxity. Consider mechanism of injury as well as the sport the athlete would like to return to when initiating certain interventions.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: IMMEDIATE POST-OP (0-3 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Maintain UE ROM in elbow, hand and wrist \u2022 Gradually increase shoulder PROM \u2022 Minimize muscle inhibition \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM\/AAROM \u2022 No elbow AROM (avoid biceps contraction) \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 No reaching behind back Intervention Swelling Management \u2022 Ice, compression  Range of motion\/Mobility \u2022 PROM: ER<30 scapular plane, Forward elevation <90, full elbow flex and ext, seated GH flexion table slide, horizontal table slide (add hyperlink) \u2022 AROM: hand, wrist \u2022 AAROM: none  Strengthening (Week 2)  Periscapular: scap retraction  , prone scapular retraction  , standing scapular setting  , supported scapular setting, inferior glide, low row  to neutral; avoid shoulder extension  Rotator cuff: submaximal pain  free isometrics  Ball squeeze Criteria to Progress  90 degrees shoulder PROM forward elevation  30 degrees of shoulder PROM ER in the scapular plane  Full elbow PROM flexion and extension  Palpable muscle contraction felt in scapular and shoulder musculature  No complications with Phase I  PHASE II: INTERMEDIATE POST-OP (4-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Continue to protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM \u2022 Minimize substitution patterns with shoulder AAROM \u2022 Initiate motor control exercise \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM \u2022 No elbow AROM (avoid biceps contraction) \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 No reaching behind back Intervention *Continue with Phase I interventions  Range of motion\/Mobility \u2022 PROM: ER<45 scapular plane, Forward elevation <120 \u2022 AAROM: Active assistive shoulder flexion, shoulder flexion with cane, cane external rotation stretch, washcloth press, sidelying elevation to 90 degrees  Strengthening \u2022 Periscapular: Row on physioball*, shoulder extension on physioball*, serratus punches - *to neutral; avoid shoulder extension  Motor Control \u2022 Internal and external rotation in scaption and Flex 90-125 (rhythmic stabilization)  Stretching \u2022 Sidelying horizontal ADD, sleeper stretch Criteria to Progress \u2022 120 degrees shoulder PROM forward elevation \u2022 45 degrees shoulder PROM ER in scapular plane \u2022 Minimal substitution patterns with shoulder AAROM \u2022 Pain < 4\/10 \u2022 No complications with Phase II  PHASE III: INTERMEDIATE POST-OP CONT\u2019d (7-8 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM\/AAROM \u2022 Initiate shoulder and elbow AROM \u2022 Initiate RTC strengthening  Improve scapular muscle activation  Patient education Sling  Discontinue Precautions  No resisted elbow flexion  No lifting of heavy objects (>10 lbs) Intervention  Continue with Phase I  II interventions Range of motion\/Mobility  PROM: ER Full in scapular plane, \uf0a390 degrees ER in 90 degrees of abduction, IR Full in scapular plane, Forward elevation Full  do not push beyond 90 degrees ER in 90 degrees of abduction  AAROM: seated shoulder elevation with cane, seated incline table slides, ball roll on wall  AROM: supine flexion, salutes, supine punch, wall climbs, elbow flexion  Strengthening \u2022 Rotator cuff: side-lying external rotation, standing external rotation w\/ resistance band, standing internal rotation w\/ resistance band, internal  rotation, external rotation \u2022 Periscapular: Resistance band shoulder extension*, resistance band seated rows*, rowing*, lawn mowers, robbery - *to neutral; avoid shoulder extension \u2022 Elbow: Triceps  Motor Control \u2022 Quadruped alternating isometrics Criteria to Progress \u2022 Full pain-free shoulder PROM ER and forward elevation \u2022 Within 10 degrees of shoulder IR PROM of contralateral shoulder \u2022 Minimal substitution patterns with shoulder AROM \u2022 Pain < 4\/10  PHASE IV: TRANSITIONAL POST-OP (9-12 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue \u2022 Restore full shoulder PROM and AROM \u2022 Initiate resisted elbow flexion at 12 weeks \u2022 Improve dynamic shoulder stability \u2022 Progress periscapular strength \u2022 Gradually return to full functional activities Precautions \u2022 No lifting of heavy objects (> 10 lbs) Intervention *Continue with Phase II-III interventions Range of motion\/mobility \u2022 PROM: Full \u2022 AROM: Supine forward elevation with elastic resistance to 90 deg, scaption and shoulder flexion to 90  degrees elevation  Strengthening \u2022 Periscapular: Push-up plus on knees, prone shoulder extension Is*, resistance band forward punch, forward punch, tripod o *to neutral; avoid shoulder extension \u2022 Elbow (12 weeks): Biceps curl, resistance band bicep curls  Motor control  Ball stabilization on wall  Stretching \u2022 Hands behind head, IR behind back with towel, triceps and lats, doorway series Criteria to Progress \u2022 Full pain-free shoulder PROM and AROM \u2022 Minimal to no substitution patterns with shoulder AROM \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 Pain < 2\/10  PHASE V: LATE POST-OP (13-16 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free shoulder ROM \u2022 Enhance functional use of upper extremity Intervention *Continue with Phase II-IV interventions Strengthening \u2022 Rotator cuff: External rotation at 90 degrees, internal rotation at 90 degrees, resistance band standing external rotation at 90 degrees, resistance band standing internal rotation at 90 degrees \u2022 Periscapular: T and Y, \u201cT\u201d exercise, push-up plus knees extended, pointer, wall push up, \u201cW\u201d exercise, resistance band Ws, dynamic hug, resistance band dynamic hug  Motor Control \u2022  PNF \u2013 D1 diagonal lifts, PNF \u2013 D2 diagonal lifts, field goals , resistance band PNF pattern, PNF \u2013 D1 diagonal lifts w\/ resistance, diagonal-up, diagonal-down, wall slides w\/ resistance band Criteria to Progress \u2022 Clearance from MD and ALL milestone criteria below have been met \u2022 Full pain-free shoulder PROM and AROM \u2022 ER\/IR strength minimum 85% of the uninvolved arm \u2022 ER\/IR ratio 60% or higher \u2022 Negative impingement and instability signs \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 QuickDASH \u2022 PENN  PHASE VI: EARLY RETURN-TO-SPORT (4-6 MONTHS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free ROM \u2022 Continue strengthening and motor control exercises \u2022 Enhance functional use of upper extremity \u2022 Gradual return to strenuous work\/sport activity Intervention *Continue with Phase II-V interventions Strengthening \u2022 See specific return-to-sport\/throwing program (coordinate with physician) Criteria to Progress \u2022 Last stage-no additional criteria Return-to-Sport \u2022 For the recreational or competitive athlete, return-to-sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non-contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return-to-sport rehabilitation program. Revised 7\/2020  Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol  References:  1. Ahsan, ZS, Hsu JE, et al. The Snyder classification of superior labrum anterior and posterior (SLAP) lesions. Clin Orthop Relat Res. 2016. 474:2075- 2078.  2. Christopher ZR, Kennedy J, et al. Rehabilitation and return to play following superior labral anterior to posterior repair. Oper Tech Sports Med. 2017. 25:132-144.  3. Cools AM, Borms D, Cottens S, et al. Rehabilitation exercises for athletes with biceps disorders and SLAP lesions. AJSM. 2014. 42(6): 1315-1323.  4. Itoi E, Hatakeyama Y, et al. Position of immobilization after dislocation of the shoulder. JBJS. 1999. 81-A(3): 385-390.  5. Kibler, W.B., Sciascia, A. D., Uhl, T. L., et al. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. The American Journal of Sports Medicine. 2008. 36(9): p. 1789-1798.  6. Wilk KE, Reinold MM, et al. Current concepts in the recognition and treatment of superior labral (SLAP) lesions. JOSPT. 2005. 35(5): 273-291.\n\nDocument 5: Rehabilitation Protocol for Sternoclavicular Joint Reconstruction  This protocol is intended to guide clinicians through the post-operative course for sternoclavicular joint reconstruction. This protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs of the individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes contained within this guideline may vary based on surgeon\u2019s preference, additional procedures performed, and\/or complications. If a clinician requires assistance in the progression of a post-operative patient, they should consult with the referring surgeon.  The interventions included within this protocol are not intended to be an inclusive list of exercises. Therapeutic interventions should be included and modified based on the progress of the patient and under the discretion of the clinician.  Considerations for the Post-operative sternoclavicular joint reconstruction Many different factors influence the post-operative rehabilitation outcome, including surgical technique (ie. tendon autograft harvest for repair), degree of SC joint instability, concomitant soft tissue or bone injury\/repair, and individual patient factors including co-morbidities. It is recommended that patients meet all rehabilitation criteria in order to progress to the next phase and clinicians collaborate closely with the referring physician throughout the rehabilitation process.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: EARLY POST-OP (0-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Reduce pain and swelling of the operative shoulder \u2022 Maintain elbow, wrist and hand AROM \u2022 Patient education Sling\/precautions \u2022 Sling to be worn for 6 weeks (or as directed by surgeon) \u2022 Avoid PROM of the glenohumeral joint \u2022 Avoid scapular AROM (protraction, retraction, depression and elevation) as it may disrupt the repair and healing tissues \u2022 Avoid bearing weight through involved extremity \u2022 Avoid lifting any lifting with involved extremity \u2022 Avoid running and jumping due to impact forces upon landing that may aggravate healing tissues and bone Intervention \u2022 Cryotherapy as needed \u2022 AROM: cervical spine, elbow, wrist, hand \u2022 Hand gripping: ball squeeze \u2022 Cardiovascular exercise as tolerated: walking, stationary bike Criteria to Progress \u2022 Well controlled pain and swelling \u2022 Protect reconstruction site and autograft site (if applicable) \u2022 Maintain elbow, wrist and hand AROM  PHASE II: INTERMEDIATE POST-OP (6-12WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Activation of muscles responsible for stabilizing the scapulothoracic and glenohumeral joint \u2022 Gradually restore PROM, AAROM of the GH joint at 6-8 weeks \u2022 Gradually restore AROM of the scapulothoracic joint and glenohumeral joint at 8 weeks \u2022 Wean from sling (if still wearing) \u2022 Begin shoulder and scapular strengthening at 8 weeks \u2022 Begin proprioception and neuromuscular control training \u2022 Identify and correct postural dysfunction as indicated Sling\/precautions \u2022 Avoid repetitive overhead activities \u2022 No lifting > 5 pounds with involved extremity until 9 weeks post-op \u2022 Post-rehabilitation soreness should resolve within 12-24 hours Additional Interventions *Continue with Phase I interventions \u2022 AROM in all cardinal plane assessing scapular rhythm \u2022 Gentle glenohumeral mobilization as indicated  Strengthening: \u2022 Rotator cuff strengthening in non-provocative positions (generally 0-45 degrees Scaption\/abduction): scaption raises against gravity, Sidelying ER, lightly resisted ER\/IR with theraband, isometrics \u2022 Scapular strengthening and dynamic neuromuscular control: low row, straight arm pulldowns, serratus punch, resisted T\u2019s  Stretching: Gentle corner or doorway pec stretch \u2022 Postural endurance exercises: scapular retractions, chin tucks \u2022 Walking, stationary bike, Stairmaster Criteria to Progress \u2022 Full AROM of the operative shoulder \u2022 Normal (5\/5) strength for glenohumeral flexion\/abduction\/IR\/ER degrees abduction  PHASE III: LATE POST-OP AND GRADUAL RETURN TO SPORT(13+ WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Restore normal (5\/5) rotator cuff strength at 90 degrees abduction including supraspinatus \u2022 Full multi-planar AROM with minimal to no substitution patterns \u2022 Advance proprioceptive and dynamic neuromuscular control training \u2022 Identify and correct postural dysfunction with sport\/work specific tasks as indicated \u2022 Develop strength and control movements required for sport\/work Sling\/ precautions \u2022 Post-rehabilitation soreness should resolve within 12 hours \u2022 No lifting restrictions at ~4 months Additional Interventions *Continue with Phase I-II Interventions \u2022 Glenohumeral mobilizations as indicated \u2022 Multiplane AROM with gradual increase in velocity of movement  Strengthening: \u2022 Rotator cuff strengthening at 45 degrees progressing to 90 degrees abduction and sport\/work specific positions as well as other provocative positions: resisted IR\/ER, elevation with ER, resisted scaption raises, facepulls\/resisted W\u2019s \u2022 Scapular strengthening and dynamic neuromuscular control in overhead or sport\/work positions: prone or resisted I\u2019s, T\u2019s and Y\u2019s, lower trap setting at wall, manual perturbations in varying degrees in elevation, serratus wall slides\/roll ups, wall pushups, quadruped shoulder taps \u2022 Core strengthening  Stretching:  Corner or doorway pec stretch, Gentle posterior capsule stretch (across body)  Walking, stationary bike, Stairmaster, return to running\/jumping as tolerated  Begin education in sport specific biomechanics with initial program for throwing, swimming, or overhead racquet sports Criteria to Return to Sport  Clearance from MD and ALL milestone criteria have been met  Maintains pain  free PROM and AROM  Performs all exercises demonstrating symmetric scapular mechanics  QuickDASH  PENN  For the recreational or competitive athlete, return  to  sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non  contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return  to  sport rehabilitation program.  Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol References: 1. Logan C, Shahien A, Altintas B, Millett PJ. Rehabilitation following sternoclavicular joint reconstruction for persistent instability. International Journal of Sports Physical Therapy. 2018;13(4):752-762. doi:10.26603\/ijspt20180752 2. Petri, M., Greenspoon, J. A., Horan, M. P., Martetschl\u00e4ger, F., Warth, R. J., & Millett, P. J. (2016). Clinical outcomes after autograft reconstruction for sternoclavicular joint instability. Journal of Shoulder and Elbow Surgery, 25(3), 435\u2013441. https:\/\/doi.org\/10.1016\/j.jse.2015.08.004 3. Garcia JA, Arguello AM, Momaya AM, Ponce BA. Sternoclavicular Joint Instability: Symptoms, Diagnosis And Management. Orthop Res Rev. 2020 Jul 28;12:75-87. doi: 10.2147\/ORR.S170964. PMID: 32801951; PMCID: PMC7395708.\n\nDocument 4: Rehabilitation Protocol for Total Shoulder Arthroplasty and Hemiarthroplasty  This protocol is intended to guide clinicians and patients through the post-operative course after a total shoulder arthroplasty (TSA) and hemiarthroplasty. Specific interventions should be based on the needs of the individual and should consider exam findings and clinical decision making. If you have questions, contact the referring physician.  Considerations for the Total Shoulder Arthroplasty and Hemiarthroplasty Rehabilitation Program Many different factors influence the post-operative rehabilitation outcome, including surgical approach, concomitant repair of the rotator cuff, arthroplasty secondary to fracture, arthroplasty secondary to rheumatoid arthritis or osteonecrosis, and individual patient factors including co-morbidities. It is recommended that patients meet all rehabilitation criteria in order to progress to the next phase and clinicians collaborate closely with the referring physician throughout the rehabilitation process.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: IMMEDIATE POST-OP (0-3 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Maintain UE ROM in elbow, hand and wrist \u2022 Gradually increase shoulder PROM \u2022 Minimize muscle inhibition \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM \u2022 No reaching behind back, especially in to internal rotation \u2022 No excessive shoulder external rotation or abduction \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 Place small pillow\/towel roll under elbow while lying on back to avoid shoulder hyperextension Intervention Swelling Management \u2022 Ice, compression Range of motion\/Mobility \u2022 PROM: ER <\/= 30 degrees in the scapular plane, IR to belt line in scapular plane, Flex\/Scaption to tolerance, ABD <\/= 90 degrees, pendulums, seated GH flexion table slide, seated horizontal table slide \u2022 AAROM: Active assistive shoulder flexion \u2022 AROM: elbow, hand, wrist Strengthening (Week 2) \u2022 Periscapular: scap retraction, prone scapular retraction, standing scapular setting, supported scapular setting, inferior glide, low row \u2022 Ball squeeze Criteria to Progress \u2022 >\/= 50% shoulder PROM flex, scaption as compared to contralateral side \u2022 <\/= 90 degrees of shoulder ABD PROM \u2022 <\/= 30 degrees of shoulder ER PROM in scapular plane \u2022 >\/= 70 degrees of IR PROM in scapular plane  Palpable muscle contraction felt in scapular musculature  Pain < 4\/10  No complications with Phase I  PHASE II: INTERMEDIATE POST-OP (4-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Continue to protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM \u2022 Minimize substitution patterns with AROM and AAROM \u2022 Improve periscapular muscle activation\/strength \u2022 Initiate RTC (external rotators) activation \u2022 Patient education Sling \u2022 Use at night while sleeping \u2022 Gradually start weaning sling over the next two weeks during the day Precautions \u2022 No excessive shoulder external rotation or abduction \u2022 No lifting of objects heavier than a coffee cup \u2022 No supporting of body weight with hands \u2022 Place small pillow\/towel roll under elbow while lying on back to avoid shoulder hyperextension Intervention *Continue with Phase I interventions  Range of motion\/Mobility \u2022 PROM: Full with exception of ER <\/= 30 degrees in scapular plane and <\/= 90 degrees ABD \u2022 AAROM: shoulder flexion with cane, cane external rotation stretch, washcloth press, seated shoulder elevation with cane \u2022 AROM: supine flexion, salutes, supine punch Strengthening \u2022 Rotator cuff: external rotation isometrics \u2022 Periscapular: Row on physioball, serratus punches \u2022 Elbow: Biceps curl, resistance band bicep curls and triceps Motor control \u2022 ER in scaption and Flex 90-125 (rhythmic stabilization) Stretching \u2022 Sidelying horizontal ADD Criteria to Progress \u2022 >\/=75% shoulder PROM flex, scaption, as compared to contralateral side \u2022 >\/=75% shoulder PROM IR in scapular plane as compared to contralateral side \u2022 30 degrees of shoulder PROM ER in scapular plane \u2022 90 degrees of shoulder PROM ABD \u2022 Minimal substitution patterns with AAROM \u2022 AROM shoulder elevation to 100 degrees with minimal substitution patterns \u2022 Pain < 4\/10 \u2022 No complications with Phase II  PHASE III: INTERMEDIATE POST-OP CONTD (7-8 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue (especially the anterior capsule) \u2022 Minimize pain \u2022 Maintain PROM \u2022 Improve AROM \u2022 Progress periscapular and RTC strength \u2022 Return to full functional activities \u2022 Patient education Sling \u2022 Discontinue Precautions \u2022 No lifting of heavy objects (>10 lbs) Intervention *Continue with Phase I-II interventions Range of motion\/Mobility \u2022 Full ROM in all planes \u2022 AAROM: incline table slides, ball roll on wall, wall climbs, pulleys \u2022 AROM: seated scaption, seated flexion, supine forward elevation with elastic resistance to 90 deg  Strengthening \u2022 Rotator cuff: internal rotation isometrics, side-lying external rotation, \u2022 Standing external rotation w\/ resistance band, standing internal rotation w\/ resistance band, internal  rotation, external rotation, \u2022 Periscapular: Resistance band shoulder extension, resistance band seated rows, rowing, lawn mowers, robbery Motor control \u2022 IR\/ER and Flex 90-125 (rhythmic stabilization) \u2022 Quadruped alternating isometrics and ball stabilization on wall \u2022 PNF-D1 diagonal lifts, PNF-D2 diagonal lifts Stretching \u2022 IR behind back with towel, sidelying horizontal ADD, sleeper stretch, triceps and lats Criteria to Progress \u2022 Minimal to no substitution patterns with shoulder AROM \u2022 Pain < 4\/10  PHASE IV: TRANSITIONAL POST-OP (9-11 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue (especially the anterior capsule) \u2022 Maintain pain-free PROM \u2022 Continue improving AROM \u2022 Improve dynamic shoulder stability \u2022 Gradually restore shoulder strength and endurance Precautions \u2022 No lifting of heavy objects (> 10 lbs) \u2022 Avoid exercises that put stress on the anterior shoulder capsule (ie: shoulder ER above 80 degrees of ABD) Intervention *Continue with Phase II-III interventions Range of motion\/mobility \u2022 Full ROM in all planes Strengthening \u2022 Rotator cuff: increase resistance rotator cuff exercise \u2022 Periscapular: Push-up plus on knees, \u201cW\u201d exercise, resistance band Ws, dynamic hug, resistance band dynamic hug, prone shoulder extension Is, resistance band forward punch, forward punch, tripod, pointer Motor control \u2022 Resistance band PNF pattern, PNF \u2013 D1 diagonal lifts w\/ resistance, diagonal-up, diagonal-down Wall slides w\/ resistance band Criteria to Progress \u2022 Supine AROM Flex >\/=140 degrees \u2022 Supine AROM ABD >\/=120 degrees \u2022 Supine AROM ER in scapular plane >\/= 60 degrees \u2022 Supine AROM IR in scapular plane >\/= 70 degrees \u2022 AROM shoulder elevation to 120 degrees with minimal substitution patterns \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 Pain < 2\/10  PHASE V: ADVANCED STRENGTHENING POST-OP (12-16 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free ROM \u2022 Improve shoulder strength and endurance \u2022 Enhance functional use of upper extremity  Intervention *Continue with Phase II-IV interventions Strengthening \u2022 Rotator cuff:  External rotation at 90 degrees, internal rotation at 90 degrees, resistance band standing external rotation at 90 degrees, resistance band standing internal rotation at 90 degrees \u2022 Periscapular: T and Y, \u201cT\u201d exercise, push-up plus knees extended, wall push up Motor Control \u2022 Progress ball stabilization on wall to overhead alternating isometrics\/rhythmic stabilization  Criteria to Progress \u2022 Clearance from MD and ALL milestone criteria have been met \u2022 Maintains pain-free PROM and AROM \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 QuickDASH \u2022 PENN Return-to-Sport \u2022 For the recreational or competitive athlete, return-to-sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non-contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return-to-sport rehabilitation program.  Revised December 2018 Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol  References  Angst, F, Goldhahn, J, et al. Responsiveness of six outcome assessment instruments in total shoulder arthroplasty. Arthritis & Rheumatism. 2008. 59 (3): 391-398.  Garcia, GH, Liu, JN, et al. High satisfaction and return to sports after total shoulder arthroplasty in patients aged 55 years and younger. AJSM. 2017. 45 (7): 1664-1669.  Gaunt BW, McCluskey GM, Uhl TL. An electromyographic evaluation of subdividing active-assistive shoulder elevation exercises. Sports Health. 2010. 2 (5): 424-432.  Hughes, M, Neer II, CS. Glenohumeral joint replacement and postoperative rehabilitation. Physical Therapy. 1975. 55(8): 850-858.  Kibler, W.B., Sciascia, A. D., Uhl, T. L., et al. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. The American Journal of Sports Medicine. 2008. 36(9): p. 1789-1798.  Knesek M, Brunfeldt, A, et al. Patterns of strain and the determination of the safe arc of motion after subscapularis repair-a biomechanical study. Journal of Orthopaedic Research. 2016. 34: 518-524.  Piasecki, DP, Nicholson, GP. Tears of the subscapularis tendon in athletes-diagnosis and repair techniques. Clin Sports Med. 2008. 27: 731-745.  Uhl TL, Muir TA, et al. Electromyographical assessment of passive, active assistive, and active shoulder rehabilitation exercises. PM R. 2010. 2: 132-141.  Wilcox III R.B., Arslanian L.E., Millett P.J. Rehabilitation following total shoulder arthroplasty. JOSPT. 2005. 35 (12): 821-837  Wolff. AL, Rosenzweig, L. Anatomical and biomechanical framework for shoulder arthroplasty rehabilitation. Journal of Hand Therapy. 2017. 30: 167-174.  Wright, T, Easley, T, et al. Shoulder arthroplasty and its effect on strain in the subscapularis muscle. Clinical Biomechanics. 2015. 30: 373-376.  Zarkadas P.C., Throckmorton T., et al. Patient reported activities after shoulder replacement: total and hemiarthroplasty. J Shoulder Elbow Surg. 2011. 20: 273-280.  Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med. 1996;(6):602-608.  Leggin BG, Michener, LA, et al. The Penn Shoulder Score: reliability and validity. JOSPT. 36 (3): 138-151.","conversation_history":[{"role":"user","content":"I am interested in the post-operative rehabilitation outcome of a Total Shoulder Arthroplasty and Hemiarthroplasty."},{"role":"assistant","content":"How can I help you with that?"}],"metadata":{"question_type":"conversational","seed_document_id":3,"topic":"Others"}}
{"id":"0406a76e-d432-435e-95e7-e181989d7cff","question":"What are some factors that could influence this?","reference_answer":"Some of the factors that influence the post-operative SLAP repair rehabilitation outcome include the type of SLAP lesion, the size of the tear\/number of anchors placed, concomitant procedures and amount of shoulder hypermobility and\/or hyperlaxity. Consideration of the mechanism of injury as well as the sport the athlete would like to return to when initiating certain interventions is also important.","reference_context":"Document 5: Rehabilitation Protocol for Sternoclavicular Joint Reconstruction  This protocol is intended to guide clinicians through the post-operative course for sternoclavicular joint reconstruction. This protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs of the individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes contained within this guideline may vary based on surgeon\u2019s preference, additional procedures performed, and\/or complications. If a clinician requires assistance in the progression of a post-operative patient, they should consult with the referring surgeon.  The interventions included within this protocol are not intended to be an inclusive list of exercises. Therapeutic interventions should be included and modified based on the progress of the patient and under the discretion of the clinician.  Considerations for the Post-operative sternoclavicular joint reconstruction Many different factors influence the post-operative rehabilitation outcome, including surgical technique (ie. tendon autograft harvest for repair), degree of SC joint instability, concomitant soft tissue or bone injury\/repair, and individual patient factors including co-morbidities. It is recommended that patients meet all rehabilitation criteria in order to progress to the next phase and clinicians collaborate closely with the referring physician throughout the rehabilitation process.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: EARLY POST-OP (0-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Reduce pain and swelling of the operative shoulder \u2022 Maintain elbow, wrist and hand AROM \u2022 Patient education Sling\/precautions \u2022 Sling to be worn for 6 weeks (or as directed by surgeon) \u2022 Avoid PROM of the glenohumeral joint \u2022 Avoid scapular AROM (protraction, retraction, depression and elevation) as it may disrupt the repair and healing tissues \u2022 Avoid bearing weight through involved extremity \u2022 Avoid lifting any lifting with involved extremity \u2022 Avoid running and jumping due to impact forces upon landing that may aggravate healing tissues and bone Intervention \u2022 Cryotherapy as needed \u2022 AROM: cervical spine, elbow, wrist, hand \u2022 Hand gripping: ball squeeze \u2022 Cardiovascular exercise as tolerated: walking, stationary bike Criteria to Progress \u2022 Well controlled pain and swelling \u2022 Protect reconstruction site and autograft site (if applicable) \u2022 Maintain elbow, wrist and hand AROM  PHASE II: INTERMEDIATE POST-OP (6-12WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Activation of muscles responsible for stabilizing the scapulothoracic and glenohumeral joint \u2022 Gradually restore PROM, AAROM of the GH joint at 6-8 weeks \u2022 Gradually restore AROM of the scapulothoracic joint and glenohumeral joint at 8 weeks \u2022 Wean from sling (if still wearing) \u2022 Begin shoulder and scapular strengthening at 8 weeks \u2022 Begin proprioception and neuromuscular control training \u2022 Identify and correct postural dysfunction as indicated Sling\/precautions \u2022 Avoid repetitive overhead activities \u2022 No lifting > 5 pounds with involved extremity until 9 weeks post-op \u2022 Post-rehabilitation soreness should resolve within 12-24 hours Additional Interventions *Continue with Phase I interventions \u2022 AROM in all cardinal plane assessing scapular rhythm \u2022 Gentle glenohumeral mobilization as indicated  Strengthening: \u2022 Rotator cuff strengthening in non-provocative positions (generally 0-45 degrees Scaption\/abduction): scaption raises against gravity, Sidelying ER, lightly resisted ER\/IR with theraband, isometrics \u2022 Scapular strengthening and dynamic neuromuscular control: low row, straight arm pulldowns, serratus punch, resisted T\u2019s  Stretching: Gentle corner or doorway pec stretch \u2022 Postural endurance exercises: scapular retractions, chin tucks \u2022 Walking, stationary bike, Stairmaster Criteria to Progress \u2022 Full AROM of the operative shoulder \u2022 Normal (5\/5) strength for glenohumeral flexion\/abduction\/IR\/ER degrees abduction  PHASE III: LATE POST-OP AND GRADUAL RETURN TO SPORT(13+ WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Restore normal (5\/5) rotator cuff strength at 90 degrees abduction including supraspinatus \u2022 Full multi-planar AROM with minimal to no substitution patterns \u2022 Advance proprioceptive and dynamic neuromuscular control training \u2022 Identify and correct postural dysfunction with sport\/work specific tasks as indicated \u2022 Develop strength and control movements required for sport\/work Sling\/ precautions \u2022 Post-rehabilitation soreness should resolve within 12 hours \u2022 No lifting restrictions at ~4 months Additional Interventions *Continue with Phase I-II Interventions \u2022 Glenohumeral mobilizations as indicated \u2022 Multiplane AROM with gradual increase in velocity of movement  Strengthening: \u2022 Rotator cuff strengthening at 45 degrees progressing to 90 degrees abduction and sport\/work specific positions as well as other provocative positions: resisted IR\/ER, elevation with ER, resisted scaption raises, facepulls\/resisted W\u2019s \u2022 Scapular strengthening and dynamic neuromuscular control in overhead or sport\/work positions: prone or resisted I\u2019s, T\u2019s and Y\u2019s, lower trap setting at wall, manual perturbations in varying degrees in elevation, serratus wall slides\/roll ups, wall pushups, quadruped shoulder taps \u2022 Core strengthening  Stretching:  Corner or doorway pec stretch, Gentle posterior capsule stretch (across body)  Walking, stationary bike, Stairmaster, return to running\/jumping as tolerated  Begin education in sport specific biomechanics with initial program for throwing, swimming, or overhead racquet sports Criteria to Return to Sport  Clearance from MD and ALL milestone criteria have been met  Maintains pain  free PROM and AROM  Performs all exercises demonstrating symmetric scapular mechanics  QuickDASH  PENN  For the recreational or competitive athlete, return  to  sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non  contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return  to  sport rehabilitation program.  Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol References: 1. Logan C, Shahien A, Altintas B, Millett PJ. Rehabilitation following sternoclavicular joint reconstruction for persistent instability. International Journal of Sports Physical Therapy. 2018;13(4):752-762. doi:10.26603\/ijspt20180752 2. Petri, M., Greenspoon, J. A., Horan, M. P., Martetschl\u00e4ger, F., Warth, R. J., & Millett, P. J. (2016). Clinical outcomes after autograft reconstruction for sternoclavicular joint instability. Journal of Shoulder and Elbow Surgery, 25(3), 435\u2013441. https:\/\/doi.org\/10.1016\/j.jse.2015.08.004 3. Garcia JA, Arguello AM, Momaya AM, Ponce BA. Sternoclavicular Joint Instability: Symptoms, Diagnosis And Management. Orthop Res Rev. 2020 Jul 28;12:75-87. doi: 10.2147\/ORR.S170964. PMID: 32801951; PMCID: PMC7395708.\n\nDocument 3: Rehabilitation Protocol for SLAP Repair-Type II  This protocol is intended to guide clinicians through the post-operative course for SLAP Repair-Type II. This protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs of the individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes contained within this guideline may vary based on surgeon\u2019s preference, additional procedures performed, and\/or complications. If a clinician requires assistance in the progression of a post-operative patient, they should consult with the referring surgeon.  The interventions included within this protocol are not intended to be an inclusive list. Therapeutic interventions should be included and modified based on the progress of the patient and under the discretion of the clinician.  Considerations for the Post-operative SLAP repair Rehabilitation Program Many different factors influence the post-operative SLAP repair rehabilitation outcome, including the type of SLAP lesion, the size of the tear\/number of anchors placed, concomitant procedures and amount of shoulder hypermobility and\/or hyperlaxity. Consider mechanism of injury as well as the sport the athlete would like to return to when initiating certain interventions.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: IMMEDIATE POST-OP (0-3 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Maintain UE ROM in elbow, hand and wrist \u2022 Gradually increase shoulder PROM \u2022 Minimize muscle inhibition \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM\/AAROM \u2022 No elbow AROM (avoid biceps contraction) \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 No reaching behind back Intervention Swelling Management \u2022 Ice, compression  Range of motion\/Mobility \u2022 PROM: ER<30 scapular plane, Forward elevation <90, full elbow flex and ext, seated GH flexion table slide, horizontal table slide (add hyperlink) \u2022 AROM: hand, wrist \u2022 AAROM: none  Strengthening (Week 2)  Periscapular: scap retraction  , prone scapular retraction  , standing scapular setting  , supported scapular setting, inferior glide, low row  to neutral; avoid shoulder extension  Rotator cuff: submaximal pain  free isometrics  Ball squeeze Criteria to Progress  90 degrees shoulder PROM forward elevation  30 degrees of shoulder PROM ER in the scapular plane  Full elbow PROM flexion and extension  Palpable muscle contraction felt in scapular and shoulder musculature  No complications with Phase I  PHASE II: INTERMEDIATE POST-OP (4-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Continue to protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM \u2022 Minimize substitution patterns with shoulder AAROM \u2022 Initiate motor control exercise \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM \u2022 No elbow AROM (avoid biceps contraction) \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 No reaching behind back Intervention *Continue with Phase I interventions  Range of motion\/Mobility \u2022 PROM: ER<45 scapular plane, Forward elevation <120 \u2022 AAROM: Active assistive shoulder flexion, shoulder flexion with cane, cane external rotation stretch, washcloth press, sidelying elevation to 90 degrees  Strengthening \u2022 Periscapular: Row on physioball*, shoulder extension on physioball*, serratus punches - *to neutral; avoid shoulder extension  Motor Control \u2022 Internal and external rotation in scaption and Flex 90-125 (rhythmic stabilization)  Stretching \u2022 Sidelying horizontal ADD, sleeper stretch Criteria to Progress \u2022 120 degrees shoulder PROM forward elevation \u2022 45 degrees shoulder PROM ER in scapular plane \u2022 Minimal substitution patterns with shoulder AAROM \u2022 Pain < 4\/10 \u2022 No complications with Phase II  PHASE III: INTERMEDIATE POST-OP CONT\u2019d (7-8 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM\/AAROM \u2022 Initiate shoulder and elbow AROM \u2022 Initiate RTC strengthening  Improve scapular muscle activation  Patient education Sling  Discontinue Precautions  No resisted elbow flexion  No lifting of heavy objects (>10 lbs) Intervention  Continue with Phase I  II interventions Range of motion\/Mobility  PROM: ER Full in scapular plane, \uf0a390 degrees ER in 90 degrees of abduction, IR Full in scapular plane, Forward elevation Full  do not push beyond 90 degrees ER in 90 degrees of abduction  AAROM: seated shoulder elevation with cane, seated incline table slides, ball roll on wall  AROM: supine flexion, salutes, supine punch, wall climbs, elbow flexion  Strengthening \u2022 Rotator cuff: side-lying external rotation, standing external rotation w\/ resistance band, standing internal rotation w\/ resistance band, internal  rotation, external rotation \u2022 Periscapular: Resistance band shoulder extension*, resistance band seated rows*, rowing*, lawn mowers, robbery - *to neutral; avoid shoulder extension \u2022 Elbow: Triceps  Motor Control \u2022 Quadruped alternating isometrics Criteria to Progress \u2022 Full pain-free shoulder PROM ER and forward elevation \u2022 Within 10 degrees of shoulder IR PROM of contralateral shoulder \u2022 Minimal substitution patterns with shoulder AROM \u2022 Pain < 4\/10  PHASE IV: TRANSITIONAL POST-OP (9-12 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue \u2022 Restore full shoulder PROM and AROM \u2022 Initiate resisted elbow flexion at 12 weeks \u2022 Improve dynamic shoulder stability \u2022 Progress periscapular strength \u2022 Gradually return to full functional activities Precautions \u2022 No lifting of heavy objects (> 10 lbs) Intervention *Continue with Phase II-III interventions Range of motion\/mobility \u2022 PROM: Full \u2022 AROM: Supine forward elevation with elastic resistance to 90 deg, scaption and shoulder flexion to 90  degrees elevation  Strengthening \u2022 Periscapular: Push-up plus on knees, prone shoulder extension Is*, resistance band forward punch, forward punch, tripod o *to neutral; avoid shoulder extension \u2022 Elbow (12 weeks): Biceps curl, resistance band bicep curls  Motor control  Ball stabilization on wall  Stretching \u2022 Hands behind head, IR behind back with towel, triceps and lats, doorway series Criteria to Progress \u2022 Full pain-free shoulder PROM and AROM \u2022 Minimal to no substitution patterns with shoulder AROM \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 Pain < 2\/10  PHASE V: LATE POST-OP (13-16 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free shoulder ROM \u2022 Enhance functional use of upper extremity Intervention *Continue with Phase II-IV interventions Strengthening \u2022 Rotator cuff: External rotation at 90 degrees, internal rotation at 90 degrees, resistance band standing external rotation at 90 degrees, resistance band standing internal rotation at 90 degrees \u2022 Periscapular: T and Y, \u201cT\u201d exercise, push-up plus knees extended, pointer, wall push up, \u201cW\u201d exercise, resistance band Ws, dynamic hug, resistance band dynamic hug  Motor Control \u2022  PNF \u2013 D1 diagonal lifts, PNF \u2013 D2 diagonal lifts, field goals , resistance band PNF pattern, PNF \u2013 D1 diagonal lifts w\/ resistance, diagonal-up, diagonal-down, wall slides w\/ resistance band Criteria to Progress \u2022 Clearance from MD and ALL milestone criteria below have been met \u2022 Full pain-free shoulder PROM and AROM \u2022 ER\/IR strength minimum 85% of the uninvolved arm \u2022 ER\/IR ratio 60% or higher \u2022 Negative impingement and instability signs \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 QuickDASH \u2022 PENN  PHASE VI: EARLY RETURN-TO-SPORT (4-6 MONTHS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free ROM \u2022 Continue strengthening and motor control exercises \u2022 Enhance functional use of upper extremity \u2022 Gradual return to strenuous work\/sport activity Intervention *Continue with Phase II-V interventions Strengthening \u2022 See specific return-to-sport\/throwing program (coordinate with physician) Criteria to Progress \u2022 Last stage-no additional criteria Return-to-Sport \u2022 For the recreational or competitive athlete, return-to-sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non-contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return-to-sport rehabilitation program. Revised 7\/2020  Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol  References:  1. Ahsan, ZS, Hsu JE, et al. The Snyder classification of superior labrum anterior and posterior (SLAP) lesions. Clin Orthop Relat Res. 2016. 474:2075- 2078.  2. Christopher ZR, Kennedy J, et al. Rehabilitation and return to play following superior labral anterior to posterior repair. Oper Tech Sports Med. 2017. 25:132-144.  3. Cools AM, Borms D, Cottens S, et al. Rehabilitation exercises for athletes with biceps disorders and SLAP lesions. AJSM. 2014. 42(6): 1315-1323.  4. Itoi E, Hatakeyama Y, et al. Position of immobilization after dislocation of the shoulder. JBJS. 1999. 81-A(3): 385-390.  5. Kibler, W.B., Sciascia, A. D., Uhl, T. L., et al. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. The American Journal of Sports Medicine. 2008. 36(9): p. 1789-1798.  6. Wilk KE, Reinold MM, et al. Current concepts in the recognition and treatment of superior labral (SLAP) lesions. JOSPT. 2005. 35(5): 273-291.\n\nDocument 4: Rehabilitation Protocol for Total Shoulder Arthroplasty and Hemiarthroplasty  This protocol is intended to guide clinicians and patients through the post-operative course after a total shoulder arthroplasty (TSA) and hemiarthroplasty. Specific interventions should be based on the needs of the individual and should consider exam findings and clinical decision making. If you have questions, contact the referring physician.  Considerations for the Total Shoulder Arthroplasty and Hemiarthroplasty Rehabilitation Program Many different factors influence the post-operative rehabilitation outcome, including surgical approach, concomitant repair of the rotator cuff, arthroplasty secondary to fracture, arthroplasty secondary to rheumatoid arthritis or osteonecrosis, and individual patient factors including co-morbidities. It is recommended that patients meet all rehabilitation criteria in order to progress to the next phase and clinicians collaborate closely with the referring physician throughout the rehabilitation process.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: IMMEDIATE POST-OP (0-3 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Maintain UE ROM in elbow, hand and wrist \u2022 Gradually increase shoulder PROM \u2022 Minimize muscle inhibition \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM \u2022 No reaching behind back, especially in to internal rotation \u2022 No excessive shoulder external rotation or abduction \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 Place small pillow\/towel roll under elbow while lying on back to avoid shoulder hyperextension Intervention Swelling Management \u2022 Ice, compression Range of motion\/Mobility \u2022 PROM: ER <\/= 30 degrees in the scapular plane, IR to belt line in scapular plane, Flex\/Scaption to tolerance, ABD <\/= 90 degrees, pendulums, seated GH flexion table slide, seated horizontal table slide \u2022 AAROM: Active assistive shoulder flexion \u2022 AROM: elbow, hand, wrist Strengthening (Week 2) \u2022 Periscapular: scap retraction, prone scapular retraction, standing scapular setting, supported scapular setting, inferior glide, low row \u2022 Ball squeeze Criteria to Progress \u2022 >\/= 50% shoulder PROM flex, scaption as compared to contralateral side \u2022 <\/= 90 degrees of shoulder ABD PROM \u2022 <\/= 30 degrees of shoulder ER PROM in scapular plane \u2022 >\/= 70 degrees of IR PROM in scapular plane  Palpable muscle contraction felt in scapular musculature  Pain < 4\/10  No complications with Phase I  PHASE II: INTERMEDIATE POST-OP (4-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Continue to protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM \u2022 Minimize substitution patterns with AROM and AAROM \u2022 Improve periscapular muscle activation\/strength \u2022 Initiate RTC (external rotators) activation \u2022 Patient education Sling \u2022 Use at night while sleeping \u2022 Gradually start weaning sling over the next two weeks during the day Precautions \u2022 No excessive shoulder external rotation or abduction \u2022 No lifting of objects heavier than a coffee cup \u2022 No supporting of body weight with hands \u2022 Place small pillow\/towel roll under elbow while lying on back to avoid shoulder hyperextension Intervention *Continue with Phase I interventions  Range of motion\/Mobility \u2022 PROM: Full with exception of ER <\/= 30 degrees in scapular plane and <\/= 90 degrees ABD \u2022 AAROM: shoulder flexion with cane, cane external rotation stretch, washcloth press, seated shoulder elevation with cane \u2022 AROM: supine flexion, salutes, supine punch Strengthening \u2022 Rotator cuff: external rotation isometrics \u2022 Periscapular: Row on physioball, serratus punches \u2022 Elbow: Biceps curl, resistance band bicep curls and triceps Motor control \u2022 ER in scaption and Flex 90-125 (rhythmic stabilization) Stretching \u2022 Sidelying horizontal ADD Criteria to Progress \u2022 >\/=75% shoulder PROM flex, scaption, as compared to contralateral side \u2022 >\/=75% shoulder PROM IR in scapular plane as compared to contralateral side \u2022 30 degrees of shoulder PROM ER in scapular plane \u2022 90 degrees of shoulder PROM ABD \u2022 Minimal substitution patterns with AAROM \u2022 AROM shoulder elevation to 100 degrees with minimal substitution patterns \u2022 Pain < 4\/10 \u2022 No complications with Phase II  PHASE III: INTERMEDIATE POST-OP CONTD (7-8 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue (especially the anterior capsule) \u2022 Minimize pain \u2022 Maintain PROM \u2022 Improve AROM \u2022 Progress periscapular and RTC strength \u2022 Return to full functional activities \u2022 Patient education Sling \u2022 Discontinue Precautions \u2022 No lifting of heavy objects (>10 lbs) Intervention *Continue with Phase I-II interventions Range of motion\/Mobility \u2022 Full ROM in all planes \u2022 AAROM: incline table slides, ball roll on wall, wall climbs, pulleys \u2022 AROM: seated scaption, seated flexion, supine forward elevation with elastic resistance to 90 deg  Strengthening \u2022 Rotator cuff: internal rotation isometrics, side-lying external rotation, \u2022 Standing external rotation w\/ resistance band, standing internal rotation w\/ resistance band, internal  rotation, external rotation, \u2022 Periscapular: Resistance band shoulder extension, resistance band seated rows, rowing, lawn mowers, robbery Motor control \u2022 IR\/ER and Flex 90-125 (rhythmic stabilization) \u2022 Quadruped alternating isometrics and ball stabilization on wall \u2022 PNF-D1 diagonal lifts, PNF-D2 diagonal lifts Stretching \u2022 IR behind back with towel, sidelying horizontal ADD, sleeper stretch, triceps and lats Criteria to Progress \u2022 Minimal to no substitution patterns with shoulder AROM \u2022 Pain < 4\/10  PHASE IV: TRANSITIONAL POST-OP (9-11 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue (especially the anterior capsule) \u2022 Maintain pain-free PROM \u2022 Continue improving AROM \u2022 Improve dynamic shoulder stability \u2022 Gradually restore shoulder strength and endurance Precautions \u2022 No lifting of heavy objects (> 10 lbs) \u2022 Avoid exercises that put stress on the anterior shoulder capsule (ie: shoulder ER above 80 degrees of ABD) Intervention *Continue with Phase II-III interventions Range of motion\/mobility \u2022 Full ROM in all planes Strengthening \u2022 Rotator cuff: increase resistance rotator cuff exercise \u2022 Periscapular: Push-up plus on knees, \u201cW\u201d exercise, resistance band Ws, dynamic hug, resistance band dynamic hug, prone shoulder extension Is, resistance band forward punch, forward punch, tripod, pointer Motor control \u2022 Resistance band PNF pattern, PNF \u2013 D1 diagonal lifts w\/ resistance, diagonal-up, diagonal-down Wall slides w\/ resistance band Criteria to Progress \u2022 Supine AROM Flex >\/=140 degrees \u2022 Supine AROM ABD >\/=120 degrees \u2022 Supine AROM ER in scapular plane >\/= 60 degrees \u2022 Supine AROM IR in scapular plane >\/= 70 degrees \u2022 AROM shoulder elevation to 120 degrees with minimal substitution patterns \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 Pain < 2\/10  PHASE V: ADVANCED STRENGTHENING POST-OP (12-16 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free ROM \u2022 Improve shoulder strength and endurance \u2022 Enhance functional use of upper extremity  Intervention *Continue with Phase II-IV interventions Strengthening \u2022 Rotator cuff:  External rotation at 90 degrees, internal rotation at 90 degrees, resistance band standing external rotation at 90 degrees, resistance band standing internal rotation at 90 degrees \u2022 Periscapular: T and Y, \u201cT\u201d exercise, push-up plus knees extended, wall push up Motor Control \u2022 Progress ball stabilization on wall to overhead alternating isometrics\/rhythmic stabilization  Criteria to Progress \u2022 Clearance from MD and ALL milestone criteria have been met \u2022 Maintains pain-free PROM and AROM \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 QuickDASH \u2022 PENN Return-to-Sport \u2022 For the recreational or competitive athlete, return-to-sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non-contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return-to-sport rehabilitation program.  Revised December 2018 Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol  References  Angst, F, Goldhahn, J, et al. Responsiveness of six outcome assessment instruments in total shoulder arthroplasty. Arthritis & Rheumatism. 2008. 59 (3): 391-398.  Garcia, GH, Liu, JN, et al. High satisfaction and return to sports after total shoulder arthroplasty in patients aged 55 years and younger. AJSM. 2017. 45 (7): 1664-1669.  Gaunt BW, McCluskey GM, Uhl TL. An electromyographic evaluation of subdividing active-assistive shoulder elevation exercises. Sports Health. 2010. 2 (5): 424-432.  Hughes, M, Neer II, CS. Glenohumeral joint replacement and postoperative rehabilitation. Physical Therapy. 1975. 55(8): 850-858.  Kibler, W.B., Sciascia, A. D., Uhl, T. L., et al. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. The American Journal of Sports Medicine. 2008. 36(9): p. 1789-1798.  Knesek M, Brunfeldt, A, et al. Patterns of strain and the determination of the safe arc of motion after subscapularis repair-a biomechanical study. Journal of Orthopaedic Research. 2016. 34: 518-524.  Piasecki, DP, Nicholson, GP. Tears of the subscapularis tendon in athletes-diagnosis and repair techniques. Clin Sports Med. 2008. 27: 731-745.  Uhl TL, Muir TA, et al. Electromyographical assessment of passive, active assistive, and active shoulder rehabilitation exercises. PM R. 2010. 2: 132-141.  Wilcox III R.B., Arslanian L.E., Millett P.J. Rehabilitation following total shoulder arthroplasty. JOSPT. 2005. 35 (12): 821-837  Wolff. AL, Rosenzweig, L. Anatomical and biomechanical framework for shoulder arthroplasty rehabilitation. Journal of Hand Therapy. 2017. 30: 167-174.  Wright, T, Easley, T, et al. Shoulder arthroplasty and its effect on strain in the subscapularis muscle. Clinical Biomechanics. 2015. 30: 373-376.  Zarkadas P.C., Throckmorton T., et al. Patient reported activities after shoulder replacement: total and hemiarthroplasty. J Shoulder Elbow Surg. 2011. 20: 273-280.  Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med. 1996;(6):602-608.  Leggin BG, Michener, LA, et al. The Penn Shoulder Score: reliability and validity. JOSPT. 36 (3): 138-151.","conversation_history":[{"role":"user","content":"Let's consider the post-operative rehabilitation outcome for SLAP Repair-Type II."},{"role":"assistant","content":"How can I help you with that?"}],"metadata":{"question_type":"conversational","seed_document_id":5,"topic":"Others"}}
{"id":"adfd30d9-3049-4c55-b3e7-320b7329aef2","question":"What is the recommended frequency of visits per week for these?","reference_answer":"The recommended frequency of visits per week for the physical therapy programs is 2 to 3 times.","reference_context":"Document 8: PHYSICAL THERAPY PRESCRIPTION:  REVERSE SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: Please Transition out of the sling between 2 to 3 weeks after surgery (Sleep in sofa recliner with your sling for the first 2 weeks) for Primary Reverse Shoulder Replacement or 5 to 6 weeks for Fracture and Revision Reverse Shoulder Replacement.  2 Weeks  6 Weeks  Activities of Daily Living: You may use your arm and hand on the operative shoulder for your ADL activates 2 weeks after surgery. Pendulums are also encouraged 1 week after surgery.  Exercises: Passive ER to 20 degrees and extension to neutral, pendulums daily  Passive supine FF in scapular plane to 90 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed: ice  Advancement Criteria: ER to the above set criteria FF in scapular plane to 90 Minimal pain and inflammation with any motion or exercise Incision is well healed with no drainage or redness  2  Weeks 6  10: Phase II  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER as tolerated by the patient  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF > 120  ER > 30  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF > 120, ER >30  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  3  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation\n\nDocument 6: PHYSICAL THERAPY PRESCRIPTION:  TOTAL SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: At all times except for showering and exercise. (Sleep in sofa recliner)  Total of 6 weeks in the Sling and the Abduction pillow  Exercises: Pendulums ok 2 weeks after surgery Passive ER to 10 degrees and extension to neutral  Passive supine FF in scapular plane to 130 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed  Advancement Criteria: ER the above set criteria FF in scapular plane to 130 Minimal pain and inflammation with motion and exercise Incision is well healed with no drainage and no redness  Weeks 6  10: Phase II  Sling Immobilizer: Discontinue at week 6  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER \u2013 limit 45 deg  2  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF to 150  ER to 45  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF 160, ER >45  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  3  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation\n\nDocument 7: Visit per week:  2 to 3 times  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Advanced Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  2  4 WEEKS POST  OP (Maximum Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN)  2  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises  Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  4  6 WEEKS POST  OP (Moderate Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  3  7  12 WEEKS POST  OP: (Early Strengthening Phase)  GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  13  19 WEEKS POST  OP: (Late Strengthening Phase)  GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 weeks  Continue with throwing and racquet program if appropriate  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  20-24 WEEKS POST-OP: (Return to Sports or Full Activity)  GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control\n\nDocument 2: Visit per week:  2 to 3 times  Diagnosis:   LEFT or RIGHT Shoulder Arthroscopic Large Rotator Cuff Repair - Supraspinatus and Infraspinatus Repair - Subscapularis Repair  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Slow or Conservative Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  ** Weeks 0-3: Patient stays in the sling and abduction pillow at all times. Pendulums ok to start Week #3 (NO PAIN). NO Shoulder PROM. Elbow and wrist ROM is ok. **  4-6 WEEKS POST-OP (Maximum Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility  2 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Start Post Op Week #4 Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN), Pts with Subscapularis Repair: (Limit Passive ER to 20\u00b0)  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises and Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  6-8 WEEKS POST-OP (Moderate Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain  3 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  9-14 WEEKS POST-OP: (Early Strengthening Phase) GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  15-23 WEEKS POST-OP: (Late Strengthening Phase) GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 week. Continue with throwing program  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  24-26 WEEKS POST-OP: (Return to Sports or Full Activity) GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control","conversation_history":[{"role":"user","content":"We are discussing the physical therapy programs described in the context."},{"role":"assistant","content":"How can I help you with that?"}],"metadata":{"question_type":"conversational","seed_document_id":8,"topic":"Others"}}
{"id":"b5a7ff17-87e3-43ce-8f48-f6476125b33b","question":"What are the rehabilitation goals for this phase?","reference_answer":"The rehabilitation goals for Phase I of the Sternoclavicular Joint Reconstruction protocol are to reduce pain and swelling of the operative shoulder, maintain elbow, wrist and hand AROM, and provide patient education.","reference_context":"Document 4: Rehabilitation Protocol for Total Shoulder Arthroplasty and Hemiarthroplasty  This protocol is intended to guide clinicians and patients through the post-operative course after a total shoulder arthroplasty (TSA) and hemiarthroplasty. Specific interventions should be based on the needs of the individual and should consider exam findings and clinical decision making. If you have questions, contact the referring physician.  Considerations for the Total Shoulder Arthroplasty and Hemiarthroplasty Rehabilitation Program Many different factors influence the post-operative rehabilitation outcome, including surgical approach, concomitant repair of the rotator cuff, arthroplasty secondary to fracture, arthroplasty secondary to rheumatoid arthritis or osteonecrosis, and individual patient factors including co-morbidities. It is recommended that patients meet all rehabilitation criteria in order to progress to the next phase and clinicians collaborate closely with the referring physician throughout the rehabilitation process.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: IMMEDIATE POST-OP (0-3 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Maintain UE ROM in elbow, hand and wrist \u2022 Gradually increase shoulder PROM \u2022 Minimize muscle inhibition \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM \u2022 No reaching behind back, especially in to internal rotation \u2022 No excessive shoulder external rotation or abduction \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 Place small pillow\/towel roll under elbow while lying on back to avoid shoulder hyperextension Intervention Swelling Management \u2022 Ice, compression Range of motion\/Mobility \u2022 PROM: ER <\/= 30 degrees in the scapular plane, IR to belt line in scapular plane, Flex\/Scaption to tolerance, ABD <\/= 90 degrees, pendulums, seated GH flexion table slide, seated horizontal table slide \u2022 AAROM: Active assistive shoulder flexion \u2022 AROM: elbow, hand, wrist Strengthening (Week 2) \u2022 Periscapular: scap retraction, prone scapular retraction, standing scapular setting, supported scapular setting, inferior glide, low row \u2022 Ball squeeze Criteria to Progress \u2022 >\/= 50% shoulder PROM flex, scaption as compared to contralateral side \u2022 <\/= 90 degrees of shoulder ABD PROM \u2022 <\/= 30 degrees of shoulder ER PROM in scapular plane \u2022 >\/= 70 degrees of IR PROM in scapular plane  Palpable muscle contraction felt in scapular musculature  Pain < 4\/10  No complications with Phase I  PHASE II: INTERMEDIATE POST-OP (4-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Continue to protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM \u2022 Minimize substitution patterns with AROM and AAROM \u2022 Improve periscapular muscle activation\/strength \u2022 Initiate RTC (external rotators) activation \u2022 Patient education Sling \u2022 Use at night while sleeping \u2022 Gradually start weaning sling over the next two weeks during the day Precautions \u2022 No excessive shoulder external rotation or abduction \u2022 No lifting of objects heavier than a coffee cup \u2022 No supporting of body weight with hands \u2022 Place small pillow\/towel roll under elbow while lying on back to avoid shoulder hyperextension Intervention *Continue with Phase I interventions  Range of motion\/Mobility \u2022 PROM: Full with exception of ER <\/= 30 degrees in scapular plane and <\/= 90 degrees ABD \u2022 AAROM: shoulder flexion with cane, cane external rotation stretch, washcloth press, seated shoulder elevation with cane \u2022 AROM: supine flexion, salutes, supine punch Strengthening \u2022 Rotator cuff: external rotation isometrics \u2022 Periscapular: Row on physioball, serratus punches \u2022 Elbow: Biceps curl, resistance band bicep curls and triceps Motor control \u2022 ER in scaption and Flex 90-125 (rhythmic stabilization) Stretching \u2022 Sidelying horizontal ADD Criteria to Progress \u2022 >\/=75% shoulder PROM flex, scaption, as compared to contralateral side \u2022 >\/=75% shoulder PROM IR in scapular plane as compared to contralateral side \u2022 30 degrees of shoulder PROM ER in scapular plane \u2022 90 degrees of shoulder PROM ABD \u2022 Minimal substitution patterns with AAROM \u2022 AROM shoulder elevation to 100 degrees with minimal substitution patterns \u2022 Pain < 4\/10 \u2022 No complications with Phase II  PHASE III: INTERMEDIATE POST-OP CONTD (7-8 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue (especially the anterior capsule) \u2022 Minimize pain \u2022 Maintain PROM \u2022 Improve AROM \u2022 Progress periscapular and RTC strength \u2022 Return to full functional activities \u2022 Patient education Sling \u2022 Discontinue Precautions \u2022 No lifting of heavy objects (>10 lbs) Intervention *Continue with Phase I-II interventions Range of motion\/Mobility \u2022 Full ROM in all planes \u2022 AAROM: incline table slides, ball roll on wall, wall climbs, pulleys \u2022 AROM: seated scaption, seated flexion, supine forward elevation with elastic resistance to 90 deg  Strengthening \u2022 Rotator cuff: internal rotation isometrics, side-lying external rotation, \u2022 Standing external rotation w\/ resistance band, standing internal rotation w\/ resistance band, internal  rotation, external rotation, \u2022 Periscapular: Resistance band shoulder extension, resistance band seated rows, rowing, lawn mowers, robbery Motor control \u2022 IR\/ER and Flex 90-125 (rhythmic stabilization) \u2022 Quadruped alternating isometrics and ball stabilization on wall \u2022 PNF-D1 diagonal lifts, PNF-D2 diagonal lifts Stretching \u2022 IR behind back with towel, sidelying horizontal ADD, sleeper stretch, triceps and lats Criteria to Progress \u2022 Minimal to no substitution patterns with shoulder AROM \u2022 Pain < 4\/10  PHASE IV: TRANSITIONAL POST-OP (9-11 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue (especially the anterior capsule) \u2022 Maintain pain-free PROM \u2022 Continue improving AROM \u2022 Improve dynamic shoulder stability \u2022 Gradually restore shoulder strength and endurance Precautions \u2022 No lifting of heavy objects (> 10 lbs) \u2022 Avoid exercises that put stress on the anterior shoulder capsule (ie: shoulder ER above 80 degrees of ABD) Intervention *Continue with Phase II-III interventions Range of motion\/mobility \u2022 Full ROM in all planes Strengthening \u2022 Rotator cuff: increase resistance rotator cuff exercise \u2022 Periscapular: Push-up plus on knees, \u201cW\u201d exercise, resistance band Ws, dynamic hug, resistance band dynamic hug, prone shoulder extension Is, resistance band forward punch, forward punch, tripod, pointer Motor control \u2022 Resistance band PNF pattern, PNF \u2013 D1 diagonal lifts w\/ resistance, diagonal-up, diagonal-down Wall slides w\/ resistance band Criteria to Progress \u2022 Supine AROM Flex >\/=140 degrees \u2022 Supine AROM ABD >\/=120 degrees \u2022 Supine AROM ER in scapular plane >\/= 60 degrees \u2022 Supine AROM IR in scapular plane >\/= 70 degrees \u2022 AROM shoulder elevation to 120 degrees with minimal substitution patterns \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 Pain < 2\/10  PHASE V: ADVANCED STRENGTHENING POST-OP (12-16 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free ROM \u2022 Improve shoulder strength and endurance \u2022 Enhance functional use of upper extremity  Intervention *Continue with Phase II-IV interventions Strengthening \u2022 Rotator cuff:  External rotation at 90 degrees, internal rotation at 90 degrees, resistance band standing external rotation at 90 degrees, resistance band standing internal rotation at 90 degrees \u2022 Periscapular: T and Y, \u201cT\u201d exercise, push-up plus knees extended, wall push up Motor Control \u2022 Progress ball stabilization on wall to overhead alternating isometrics\/rhythmic stabilization  Criteria to Progress \u2022 Clearance from MD and ALL milestone criteria have been met \u2022 Maintains pain-free PROM and AROM \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 QuickDASH \u2022 PENN Return-to-Sport \u2022 For the recreational or competitive athlete, return-to-sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non-contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return-to-sport rehabilitation program.  Revised December 2018 Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol  References  Angst, F, Goldhahn, J, et al. Responsiveness of six outcome assessment instruments in total shoulder arthroplasty. Arthritis & Rheumatism. 2008. 59 (3): 391-398.  Garcia, GH, Liu, JN, et al. High satisfaction and return to sports after total shoulder arthroplasty in patients aged 55 years and younger. AJSM. 2017. 45 (7): 1664-1669.  Gaunt BW, McCluskey GM, Uhl TL. An electromyographic evaluation of subdividing active-assistive shoulder elevation exercises. Sports Health. 2010. 2 (5): 424-432.  Hughes, M, Neer II, CS. Glenohumeral joint replacement and postoperative rehabilitation. Physical Therapy. 1975. 55(8): 850-858.  Kibler, W.B., Sciascia, A. D., Uhl, T. L., et al. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. The American Journal of Sports Medicine. 2008. 36(9): p. 1789-1798.  Knesek M, Brunfeldt, A, et al. Patterns of strain and the determination of the safe arc of motion after subscapularis repair-a biomechanical study. Journal of Orthopaedic Research. 2016. 34: 518-524.  Piasecki, DP, Nicholson, GP. Tears of the subscapularis tendon in athletes-diagnosis and repair techniques. Clin Sports Med. 2008. 27: 731-745.  Uhl TL, Muir TA, et al. Electromyographical assessment of passive, active assistive, and active shoulder rehabilitation exercises. PM R. 2010. 2: 132-141.  Wilcox III R.B., Arslanian L.E., Millett P.J. Rehabilitation following total shoulder arthroplasty. JOSPT. 2005. 35 (12): 821-837  Wolff. AL, Rosenzweig, L. Anatomical and biomechanical framework for shoulder arthroplasty rehabilitation. Journal of Hand Therapy. 2017. 30: 167-174.  Wright, T, Easley, T, et al. Shoulder arthroplasty and its effect on strain in the subscapularis muscle. Clinical Biomechanics. 2015. 30: 373-376.  Zarkadas P.C., Throckmorton T., et al. Patient reported activities after shoulder replacement: total and hemiarthroplasty. J Shoulder Elbow Surg. 2011. 20: 273-280.  Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med. 1996;(6):602-608.  Leggin BG, Michener, LA, et al. The Penn Shoulder Score: reliability and validity. JOSPT. 36 (3): 138-151.\n\nDocument 5: Rehabilitation Protocol for Sternoclavicular Joint Reconstruction  This protocol is intended to guide clinicians through the post-operative course for sternoclavicular joint reconstruction. This protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs of the individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes contained within this guideline may vary based on surgeon\u2019s preference, additional procedures performed, and\/or complications. If a clinician requires assistance in the progression of a post-operative patient, they should consult with the referring surgeon.  The interventions included within this protocol are not intended to be an inclusive list of exercises. Therapeutic interventions should be included and modified based on the progress of the patient and under the discretion of the clinician.  Considerations for the Post-operative sternoclavicular joint reconstruction Many different factors influence the post-operative rehabilitation outcome, including surgical technique (ie. tendon autograft harvest for repair), degree of SC joint instability, concomitant soft tissue or bone injury\/repair, and individual patient factors including co-morbidities. It is recommended that patients meet all rehabilitation criteria in order to progress to the next phase and clinicians collaborate closely with the referring physician throughout the rehabilitation process.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: EARLY POST-OP (0-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Reduce pain and swelling of the operative shoulder \u2022 Maintain elbow, wrist and hand AROM \u2022 Patient education Sling\/precautions \u2022 Sling to be worn for 6 weeks (or as directed by surgeon) \u2022 Avoid PROM of the glenohumeral joint \u2022 Avoid scapular AROM (protraction, retraction, depression and elevation) as it may disrupt the repair and healing tissues \u2022 Avoid bearing weight through involved extremity \u2022 Avoid lifting any lifting with involved extremity \u2022 Avoid running and jumping due to impact forces upon landing that may aggravate healing tissues and bone Intervention \u2022 Cryotherapy as needed \u2022 AROM: cervical spine, elbow, wrist, hand \u2022 Hand gripping: ball squeeze \u2022 Cardiovascular exercise as tolerated: walking, stationary bike Criteria to Progress \u2022 Well controlled pain and swelling \u2022 Protect reconstruction site and autograft site (if applicable) \u2022 Maintain elbow, wrist and hand AROM  PHASE II: INTERMEDIATE POST-OP (6-12WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Activation of muscles responsible for stabilizing the scapulothoracic and glenohumeral joint \u2022 Gradually restore PROM, AAROM of the GH joint at 6-8 weeks \u2022 Gradually restore AROM of the scapulothoracic joint and glenohumeral joint at 8 weeks \u2022 Wean from sling (if still wearing) \u2022 Begin shoulder and scapular strengthening at 8 weeks \u2022 Begin proprioception and neuromuscular control training \u2022 Identify and correct postural dysfunction as indicated Sling\/precautions \u2022 Avoid repetitive overhead activities \u2022 No lifting > 5 pounds with involved extremity until 9 weeks post-op \u2022 Post-rehabilitation soreness should resolve within 12-24 hours Additional Interventions *Continue with Phase I interventions \u2022 AROM in all cardinal plane assessing scapular rhythm \u2022 Gentle glenohumeral mobilization as indicated  Strengthening: \u2022 Rotator cuff strengthening in non-provocative positions (generally 0-45 degrees Scaption\/abduction): scaption raises against gravity, Sidelying ER, lightly resisted ER\/IR with theraband, isometrics \u2022 Scapular strengthening and dynamic neuromuscular control: low row, straight arm pulldowns, serratus punch, resisted T\u2019s  Stretching: Gentle corner or doorway pec stretch \u2022 Postural endurance exercises: scapular retractions, chin tucks \u2022 Walking, stationary bike, Stairmaster Criteria to Progress \u2022 Full AROM of the operative shoulder \u2022 Normal (5\/5) strength for glenohumeral flexion\/abduction\/IR\/ER degrees abduction  PHASE III: LATE POST-OP AND GRADUAL RETURN TO SPORT(13+ WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Restore normal (5\/5) rotator cuff strength at 90 degrees abduction including supraspinatus \u2022 Full multi-planar AROM with minimal to no substitution patterns \u2022 Advance proprioceptive and dynamic neuromuscular control training \u2022 Identify and correct postural dysfunction with sport\/work specific tasks as indicated \u2022 Develop strength and control movements required for sport\/work Sling\/ precautions \u2022 Post-rehabilitation soreness should resolve within 12 hours \u2022 No lifting restrictions at ~4 months Additional Interventions *Continue with Phase I-II Interventions \u2022 Glenohumeral mobilizations as indicated \u2022 Multiplane AROM with gradual increase in velocity of movement  Strengthening: \u2022 Rotator cuff strengthening at 45 degrees progressing to 90 degrees abduction and sport\/work specific positions as well as other provocative positions: resisted IR\/ER, elevation with ER, resisted scaption raises, facepulls\/resisted W\u2019s \u2022 Scapular strengthening and dynamic neuromuscular control in overhead or sport\/work positions: prone or resisted I\u2019s, T\u2019s and Y\u2019s, lower trap setting at wall, manual perturbations in varying degrees in elevation, serratus wall slides\/roll ups, wall pushups, quadruped shoulder taps \u2022 Core strengthening  Stretching:  Corner or doorway pec stretch, Gentle posterior capsule stretch (across body)  Walking, stationary bike, Stairmaster, return to running\/jumping as tolerated  Begin education in sport specific biomechanics with initial program for throwing, swimming, or overhead racquet sports Criteria to Return to Sport  Clearance from MD and ALL milestone criteria have been met  Maintains pain  free PROM and AROM  Performs all exercises demonstrating symmetric scapular mechanics  QuickDASH  PENN  For the recreational or competitive athlete, return  to  sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non  contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return  to  sport rehabilitation program.  Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol References: 1. Logan C, Shahien A, Altintas B, Millett PJ. Rehabilitation following sternoclavicular joint reconstruction for persistent instability. International Journal of Sports Physical Therapy. 2018;13(4):752-762. doi:10.26603\/ijspt20180752 2. Petri, M., Greenspoon, J. A., Horan, M. P., Martetschl\u00e4ger, F., Warth, R. J., & Millett, P. J. (2016). Clinical outcomes after autograft reconstruction for sternoclavicular joint instability. Journal of Shoulder and Elbow Surgery, 25(3), 435\u2013441. https:\/\/doi.org\/10.1016\/j.jse.2015.08.004 3. Garcia JA, Arguello AM, Momaya AM, Ponce BA. Sternoclavicular Joint Instability: Symptoms, Diagnosis And Management. Orthop Res Rev. 2020 Jul 28;12:75-87. doi: 10.2147\/ORR.S170964. PMID: 32801951; PMCID: PMC7395708.\n\nDocument 3: Rehabilitation Protocol for SLAP Repair-Type II  This protocol is intended to guide clinicians through the post-operative course for SLAP Repair-Type II. This protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be based on the needs of the individual and should consider exam findings and clinical decision making. The timeframes for expected outcomes contained within this guideline may vary based on surgeon\u2019s preference, additional procedures performed, and\/or complications. If a clinician requires assistance in the progression of a post-operative patient, they should consult with the referring surgeon.  The interventions included within this protocol are not intended to be an inclusive list. Therapeutic interventions should be included and modified based on the progress of the patient and under the discretion of the clinician.  Considerations for the Post-operative SLAP repair Rehabilitation Program Many different factors influence the post-operative SLAP repair rehabilitation outcome, including the type of SLAP lesion, the size of the tear\/number of anchors placed, concomitant procedures and amount of shoulder hypermobility and\/or hyperlaxity. Consider mechanism of injury as well as the sport the athlete would like to return to when initiating certain interventions.  Post-operative Complications If you develop a fever, unresolving numbness\/tingling, excessive drainage from the incision, uncontrolled pain or any other symptoms you have concerns about you should contact the referring physician.  PHASE I: IMMEDIATE POST-OP (0-3 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Maintain UE ROM in elbow, hand and wrist \u2022 Gradually increase shoulder PROM \u2022 Minimize muscle inhibition \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM\/AAROM \u2022 No elbow AROM (avoid biceps contraction) \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 No reaching behind back Intervention Swelling Management \u2022 Ice, compression  Range of motion\/Mobility \u2022 PROM: ER<30 scapular plane, Forward elevation <90, full elbow flex and ext, seated GH flexion table slide, horizontal table slide (add hyperlink) \u2022 AROM: hand, wrist \u2022 AAROM: none  Strengthening (Week 2)  Periscapular: scap retraction  , prone scapular retraction  , standing scapular setting  , supported scapular setting, inferior glide, low row  to neutral; avoid shoulder extension  Rotator cuff: submaximal pain  free isometrics  Ball squeeze Criteria to Progress  90 degrees shoulder PROM forward elevation  30 degrees of shoulder PROM ER in the scapular plane  Full elbow PROM flexion and extension  Palpable muscle contraction felt in scapular and shoulder musculature  No complications with Phase I  PHASE II: INTERMEDIATE POST-OP (4-6 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Continue to protect surgical repair \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM \u2022 Minimize substitution patterns with shoulder AAROM \u2022 Initiate motor control exercise \u2022 Patient education Sling \u2022 Neutral rotation \u2022 Use of abduction pillow in 30-45 degrees abduction \u2022 Use at night while sleeping Precautions \u2022 No shoulder AROM \u2022 No elbow AROM (avoid biceps contraction) \u2022 No lifting of objects \u2022 No supporting of body weight with hands \u2022 No reaching behind back Intervention *Continue with Phase I interventions  Range of motion\/Mobility \u2022 PROM: ER<45 scapular plane, Forward elevation <120 \u2022 AAROM: Active assistive shoulder flexion, shoulder flexion with cane, cane external rotation stretch, washcloth press, sidelying elevation to 90 degrees  Strengthening \u2022 Periscapular: Row on physioball*, shoulder extension on physioball*, serratus punches - *to neutral; avoid shoulder extension  Motor Control \u2022 Internal and external rotation in scaption and Flex 90-125 (rhythmic stabilization)  Stretching \u2022 Sidelying horizontal ADD, sleeper stretch Criteria to Progress \u2022 120 degrees shoulder PROM forward elevation \u2022 45 degrees shoulder PROM ER in scapular plane \u2022 Minimal substitution patterns with shoulder AAROM \u2022 Pain < 4\/10 \u2022 No complications with Phase II  PHASE III: INTERMEDIATE POST-OP CONT\u2019d (7-8 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue \u2022 Reduce swelling, minimize pain \u2022 Gradually increase shoulder PROM\/AAROM \u2022 Initiate shoulder and elbow AROM \u2022 Initiate RTC strengthening  Improve scapular muscle activation  Patient education Sling  Discontinue Precautions  No resisted elbow flexion  No lifting of heavy objects (>10 lbs) Intervention  Continue with Phase I  II interventions Range of motion\/Mobility  PROM: ER Full in scapular plane, \uf0a390 degrees ER in 90 degrees of abduction, IR Full in scapular plane, Forward elevation Full  do not push beyond 90 degrees ER in 90 degrees of abduction  AAROM: seated shoulder elevation with cane, seated incline table slides, ball roll on wall  AROM: supine flexion, salutes, supine punch, wall climbs, elbow flexion  Strengthening \u2022 Rotator cuff: side-lying external rotation, standing external rotation w\/ resistance band, standing internal rotation w\/ resistance band, internal  rotation, external rotation \u2022 Periscapular: Resistance band shoulder extension*, resistance band seated rows*, rowing*, lawn mowers, robbery - *to neutral; avoid shoulder extension \u2022 Elbow: Triceps  Motor Control \u2022 Quadruped alternating isometrics Criteria to Progress \u2022 Full pain-free shoulder PROM ER and forward elevation \u2022 Within 10 degrees of shoulder IR PROM of contralateral shoulder \u2022 Minimal substitution patterns with shoulder AROM \u2022 Pain < 4\/10  PHASE IV: TRANSITIONAL POST-OP (9-12 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Do not overstress healing tissue \u2022 Restore full shoulder PROM and AROM \u2022 Initiate resisted elbow flexion at 12 weeks \u2022 Improve dynamic shoulder stability \u2022 Progress periscapular strength \u2022 Gradually return to full functional activities Precautions \u2022 No lifting of heavy objects (> 10 lbs) Intervention *Continue with Phase II-III interventions Range of motion\/mobility \u2022 PROM: Full \u2022 AROM: Supine forward elevation with elastic resistance to 90 deg, scaption and shoulder flexion to 90  degrees elevation  Strengthening \u2022 Periscapular: Push-up plus on knees, prone shoulder extension Is*, resistance band forward punch, forward punch, tripod o *to neutral; avoid shoulder extension \u2022 Elbow (12 weeks): Biceps curl, resistance band bicep curls  Motor control  Ball stabilization on wall  Stretching \u2022 Hands behind head, IR behind back with towel, triceps and lats, doorway series Criteria to Progress \u2022 Full pain-free shoulder PROM and AROM \u2022 Minimal to no substitution patterns with shoulder AROM \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 Pain < 2\/10  PHASE V: LATE POST-OP (13-16 WEEKS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free shoulder ROM \u2022 Enhance functional use of upper extremity Intervention *Continue with Phase II-IV interventions Strengthening \u2022 Rotator cuff: External rotation at 90 degrees, internal rotation at 90 degrees, resistance band standing external rotation at 90 degrees, resistance band standing internal rotation at 90 degrees \u2022 Periscapular: T and Y, \u201cT\u201d exercise, push-up plus knees extended, pointer, wall push up, \u201cW\u201d exercise, resistance band Ws, dynamic hug, resistance band dynamic hug  Motor Control \u2022  PNF \u2013 D1 diagonal lifts, PNF \u2013 D2 diagonal lifts, field goals , resistance band PNF pattern, PNF \u2013 D1 diagonal lifts w\/ resistance, diagonal-up, diagonal-down, wall slides w\/ resistance band Criteria to Progress \u2022 Clearance from MD and ALL milestone criteria below have been met \u2022 Full pain-free shoulder PROM and AROM \u2022 ER\/IR strength minimum 85% of the uninvolved arm \u2022 ER\/IR ratio 60% or higher \u2022 Negative impingement and instability signs \u2022 Performs all exercises demonstrating symmetric scapular mechanics \u2022 QuickDASH \u2022 PENN  PHASE VI: EARLY RETURN-TO-SPORT (4-6 MONTHS AFTER SURGERY) Rehabilitation Goals \u2022 Maintain pain-free ROM \u2022 Continue strengthening and motor control exercises \u2022 Enhance functional use of upper extremity \u2022 Gradual return to strenuous work\/sport activity Intervention *Continue with Phase II-V interventions Strengthening \u2022 See specific return-to-sport\/throwing program (coordinate with physician) Criteria to Progress \u2022 Last stage-no additional criteria Return-to-Sport \u2022 For the recreational or competitive athlete, return-to-sport decision making should be individualized and based upon factors including level of demand on the upper extremity, contact vs non-contact sport, frequency of participation, etc. We encourage close discussion with the referring surgeon prior to advancing to a return-to-sport rehabilitation program. Revised 7\/2020  Contact Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol  References:  1. Ahsan, ZS, Hsu JE, et al. The Snyder classification of superior labrum anterior and posterior (SLAP) lesions. Clin Orthop Relat Res. 2016. 474:2075- 2078.  2. Christopher ZR, Kennedy J, et al. Rehabilitation and return to play following superior labral anterior to posterior repair. Oper Tech Sports Med. 2017. 25:132-144.  3. Cools AM, Borms D, Cottens S, et al. Rehabilitation exercises for athletes with biceps disorders and SLAP lesions. AJSM. 2014. 42(6): 1315-1323.  4. Itoi E, Hatakeyama Y, et al. Position of immobilization after dislocation of the shoulder. JBJS. 1999. 81-A(3): 385-390.  5. Kibler, W.B., Sciascia, A. D., Uhl, T. L., et al. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. The American Journal of Sports Medicine. 2008. 36(9): p. 1789-1798.  6. Wilk KE, Reinold MM, et al. Current concepts in the recognition and treatment of superior labral (SLAP) lesions. JOSPT. 2005. 35(5): 273-291.","conversation_history":[{"role":"user","content":"I am referring to Phase I of the Sternoclavicular Joint Reconstruction protocol."},{"role":"assistant","content":"How can I help you with that?"}],"metadata":{"question_type":"conversational","seed_document_id":4,"topic":"Others"}}
{"id":"9a3730e1-00b4-43ff-878d-3bc8b0fd0402","question":"Can you tell me what the goals of this phase are?","reference_answer":"The goals of the 'Early Strengthening Phase' are: 1. Eliminate\/ minimize pain and inflammation, 2. Restore full passive range of motion, 3. Gradual return to light activities of daily living below 90\u00ba elevation, 4. Improve strength\/ flexibility, 5. Normal scapulohumeral rhythm below 90\u00ba elevation.","reference_context":"Document 8: PHYSICAL THERAPY PRESCRIPTION:  REVERSE SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: Please Transition out of the sling between 2 to 3 weeks after surgery (Sleep in sofa recliner with your sling for the first 2 weeks) for Primary Reverse Shoulder Replacement or 5 to 6 weeks for Fracture and Revision Reverse Shoulder Replacement.  2 Weeks  6 Weeks  Activities of Daily Living: You may use your arm and hand on the operative shoulder for your ADL activates 2 weeks after surgery. Pendulums are also encouraged 1 week after surgery.  Exercises: Passive ER to 20 degrees and extension to neutral, pendulums daily  Passive supine FF in scapular plane to 90 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed: ice  Advancement Criteria: ER to the above set criteria FF in scapular plane to 90 Minimal pain and inflammation with any motion or exercise Incision is well healed with no drainage or redness  2  Weeks 6  10: Phase II  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER as tolerated by the patient  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF > 120  ER > 30  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF > 120, ER >30  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  3  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation\n\nDocument 6: PHYSICAL THERAPY PRESCRIPTION:  TOTAL SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: At all times except for showering and exercise. (Sleep in sofa recliner)  Total of 6 weeks in the Sling and the Abduction pillow  Exercises: Pendulums ok 2 weeks after surgery Passive ER to 10 degrees and extension to neutral  Passive supine FF in scapular plane to 130 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed  Advancement Criteria: ER the above set criteria FF in scapular plane to 130 Minimal pain and inflammation with motion and exercise Incision is well healed with no drainage and no redness  Weeks 6  10: Phase II  Sling Immobilizer: Discontinue at week 6  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER \u2013 limit 45 deg  2  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF to 150  ER to 45  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF 160, ER >45  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  3  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation\n\nDocument 7: Visit per week:  2 to 3 times  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Advanced Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  2  4 WEEKS POST  OP (Maximum Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN)  2  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises  Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  4  6 WEEKS POST  OP (Moderate Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  3  7  12 WEEKS POST  OP: (Early Strengthening Phase)  GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  13  19 WEEKS POST  OP: (Late Strengthening Phase)  GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 weeks  Continue with throwing and racquet program if appropriate  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  20-24 WEEKS POST-OP: (Return to Sports or Full Activity)  GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control\n\nDocument 2: Visit per week:  2 to 3 times  Diagnosis:   LEFT or RIGHT Shoulder Arthroscopic Large Rotator Cuff Repair - Supraspinatus and Infraspinatus Repair - Subscapularis Repair  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Slow or Conservative Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  ** Weeks 0-3: Patient stays in the sling and abduction pillow at all times. Pendulums ok to start Week #3 (NO PAIN). NO Shoulder PROM. Elbow and wrist ROM is ok. **  4-6 WEEKS POST-OP (Maximum Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility  2 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Start Post Op Week #4 Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN), Pts with Subscapularis Repair: (Limit Passive ER to 20\u00b0)  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises and Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  6-8 WEEKS POST-OP (Moderate Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain  3 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  9-14 WEEKS POST-OP: (Early Strengthening Phase) GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  15-23 WEEKS POST-OP: (Late Strengthening Phase) GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 week. Continue with throwing program  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  24-26 WEEKS POST-OP: (Return to Sports or Full Activity) GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control","conversation_history":[{"role":"user","content":"I'm interested in the 'Early Strengthening Phase' of the 'Slow or Conservative Program' for a rotator cuff repair."},{"role":"assistant","content":"How can I help you with that?"}],"metadata":{"question_type":"conversational","seed_document_id":8,"topic":"Others"}}
{"id":"6ed82377-4a2e-49a6-bf2f-47d3010f337b","question":"What is it?","reference_answer":"The progression for physical therapy following a total shoulder arthroplasty is divided into four phases. Phase I (Weeks 2-6) involves sling immobilization, passive exercises, and scapular pinches. Phase II (Weeks 6-10) discontinues the sling immobilizer and introduces passive & active assisted exercises, manual scapular side lying stabilization exercises, and humeral head control exercises. Phase III (Weeks 10-16) progresses ROM as tolerated and introduces flexibility exercises, isotonic strengthening, scapular stabilization, rhythmic stabilization, and the use of progressive resistive equipment. Phase IV (Weeks 16-22) addresses any remaining deficits in ROM, flexibility, and strength, and individualizes the program to meet the specific needs of the patient. The discharge criteria include maximizing ROM, achieving full independent ADLs, and normal scapulohumeral rhythm.","reference_context":"Document 6: PHYSICAL THERAPY PRESCRIPTION:  TOTAL SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: At all times except for showering and exercise. (Sleep in sofa recliner)  Total of 6 weeks in the Sling and the Abduction pillow  Exercises: Pendulums ok 2 weeks after surgery Passive ER to 10 degrees and extension to neutral  Passive supine FF in scapular plane to 130 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed  Advancement Criteria: ER the above set criteria FF in scapular plane to 130 Minimal pain and inflammation with motion and exercise Incision is well healed with no drainage and no redness  Weeks 6  10: Phase II  Sling Immobilizer: Discontinue at week 6  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER \u2013 limit 45 deg  2  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF to 150  ER to 45  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF 160, ER >45  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  3  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation\n\nDocument 8: PHYSICAL THERAPY PRESCRIPTION:  REVERSE SHOULDER ARTHROPLASTY  Weeks 2  6: Phase I  Sling Immobilizer: Please Transition out of the sling between 2 to 3 weeks after surgery (Sleep in sofa recliner with your sling for the first 2 weeks) for Primary Reverse Shoulder Replacement or 5 to 6 weeks for Fracture and Revision Reverse Shoulder Replacement.  2 Weeks  6 Weeks  Activities of Daily Living: You may use your arm and hand on the operative shoulder for your ADL activates 2 weeks after surgery. Pendulums are also encouraged 1 week after surgery.  Exercises: Passive ER to 20 degrees and extension to neutral, pendulums daily  Passive supine FF in scapular plane to 90 (NO aggressive stretching and NO PAIN)  AROM wrist\/elbow  Submax (50%) pain free deltoid isometics in neutral  Scapular \u201cpinches\u201d  Modalities as needed: ice  Advancement Criteria: ER to the above set criteria FF in scapular plane to 90 Minimal pain and inflammation with any motion or exercise Incision is well healed with no drainage or redness  2  Weeks 6  10: Phase II  Exercises: Passive & Active assisted FF in scapular plane \u2013 no limits (wand exercises, pulleys)  Passive & Active assisted ER as tolerated by the patient  Active supine FF in scapular plane  Manual scapular side  lying stabilization exercises  Isometrics: Deltoid in neutral  ER (modified neutral) ROM < 30 deg  IR (modified neutral)  Scapular retraction with elastic bands  Humeral head control exercises:  ER\/IR (supine\/scapular plane)  Elevation at 100 deg  Modalities as needed  Advancement Criteria: FF > 120  ER > 30  Good humeral head control  Minimal to no pain with ADLs  Weeks 10  16: Phase III  Exercises:  Progress ROM as tolerated  AAROM for full FF and ER AAROM for IR \u2013 no limits Flexibility exercises: towel stretch, posterior capsule stretch  IR\/ER\/FF isotonic strengthening  Scapular stabilization  Rhythmic stabilization  PREs for scapula, elbow (biceps\/triceps)  Forward flexion in scapular plane  Progressive resistive equipment: row, chest press (light weight) Modalities as needed  Advancement Criteria: Muscle strength 4\/5  Passive FF > 120, ER >30  Restore normal scapulohumeral rhythm <90 deg elevation Minimal pain and inflammation  Weeks 16  22: Phase IV  Exercises: Access and address any remaining deficits in ROM, flexibility, strength  Active, active-assisted, and passive ROM exercises  Flexibility exercises: towel stretch (IR), posterior capsule stretch  Progressive resistive strengthening:  Dumbbells  Progressive resistive equipment  Elastic band IR\/ER (modified neurtral)  3  Rhythmic stabilization  Modalities as needed  Individualize program to meet specific needs of patient  Discharge Criteria: Maximize ROM  Full independent ADLs  Normal scapulohumeral rhythm >100deg elevation\n\nDocument 7: Visit per week:  2 to 3 times  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Advanced Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  2  4 WEEKS POST  OP (Maximum Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN)  2  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises  Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  4  6 WEEKS POST  OP (Moderate Protection Phase):  GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  3  7  12 WEEKS POST  OP: (Early Strengthening Phase)  GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  13  19 WEEKS POST  OP: (Late Strengthening Phase)  GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 weeks  Continue with throwing and racquet program if appropriate  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  20-24 WEEKS POST-OP: (Return to Sports or Full Activity)  GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control\n\nDocument 2: Visit per week:  2 to 3 times  Diagnosis:   LEFT or RIGHT Shoulder Arthroscopic Large Rotator Cuff Repair - Supraspinatus and Infraspinatus Repair - Subscapularis Repair  ROTATOR CUFF PHYSICAL THERAPY PRESCRIPTION (Slow or Conservative Program)  The following rotator cuff repair guidelines were developed by Dr. Xinning Li, which is based on the postoperative rehabilitation recommendations from the Hospital for Special Surgery. Progression is both criteria based and patient specific. Phases and time frames are designed to give the clinician and therapist a general sense of progression. The rehabilitation program following rotator cuff repair must take into account and allow for the healing of surgically repaired tissue. The patient should NOT have pain with these exercises. The program should balance the aspects of tissue healing and appropriate interventions to restore ROM, strength, and function. Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, timing of the repair, etiology of the tear, and the location of tear. All of these factors may alter the guideline. Please call and notify Dr. Li\u2019s office if you are deviating from these recommendations or if the patient has increased pain or stiffness that is not expected.  ** Weeks 0-3: Patient stays in the sling and abduction pillow at all times. Pendulums ok to start Week #3 (NO PAIN). NO Shoulder PROM. Elbow and wrist ROM is ok. **  4-6 WEEKS POST-OP (Maximum Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation 3. Gradually increase shoulder ROM (MD directed) 4. Improve proximal (scapula) and distal strength and mobility  2 5. Independence in a home exercise program (HEP)  Passive range of motion of the shoulder: Start Post Op Week #4 Pendulum exercises Passive Supine Elevation in Scapular plane using the opposite hand  (NO PAIN) Passive ER to 40\u00b0 (NO PAIN), Pts with Subscapularis Repair: (Limit Passive ER to 20\u00b0)  Can begin Active  Assisted ROM in pool (water depth up to shoulder to remove gravity)  Modalities, Cryocuff \/ Ice, as Needed  Hand, Wrist, Elbow, Active ROM  Side  lying Scapular stabilization exercises  Sub  maximal Deltoid isometrics  Activities of Daily Living Exercises and Sleep Postures  MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE: 1. Normal scapular mobility 2. Full active ROM distal to shoulder 3. Shoulder ROM to within surgeon\u2019s set ROM goals  6-8 WEEKS POST-OP (Moderate Protection Phase): GOALS: 1. Protect surgical repair (Sling and Abduction Pillow at ALL TIMES) 2. Decrease pain\/ inflammation, minimize rotator cuff inhibition 3. Improve Range of Motion 80-100% of normal elevation in the plane of the scapula and external rotation 4. Improve proximal scapula strength\/stability, scapulohumeral rhythm and neuromuscular control  Continue Pendulums, passive supine elevation, passive ER  Active  Assisted ROM: Scapular plane elevation to 160\u00b0 (NO PAIN) Pulleys as motion improves  Use cane for ER to 60\u00b0 (NO PAIN)  Begin Internal Rotation as tolerated.  Begin Scapular strengthening program, in protective range of motion  Physioball Scapular stabilization (below horizontal)  Isometric exercises: Deltoid isometrics Submaximal ER\/IR isometrics at neutral  Isotonic exercises for Scapular stabilizers  Elbow Modalities as needed  Joint Mobilization by the Therapist  Pool Therapy if available  PRECAUTIONS: 1. Avoid pain with ADLs, ROM\/ therapeutic exercise 2. Avoid active elevation of arm until 6 weeks, avoid exceeding ROM limitations 3. No maximal cuff activation  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Ability to activate cuff and deltoid without pain  3 2. Tolerates arm out of sling (May discontinue the sling at Week #6, Slowly Wane) 3. ROM 80% or greater for elevation in plane of the scapula and external rotation  9-14 WEEKS POST-OP: (Early Strengthening Phase) GOALS: 1. Eliminate\/ minimize pain and inflammation 2. Restore full PROM 3. Gradual return to light ADLs below 90\u00ba elevation 4. Improve strength\/ flexibility 5. Normal scapulohumeral rhythm below 90\u00ba elevation  Patient Should NOT have pain with any of these exercises  AROM elevation in the plane of the scapula (supine progress to standing), progress closed chain exercises  Begin Theraband IR \/ ER at week 7  Use towel to increase IR  ROM activities and emphasize flexion. Gentle passive stretch.  Deltoid isometrics at 30\u00b0 elevation  Deltoid isotonics in plane of Scapula, only after positive Rotator Cuff strength is determined (especially forward flexion)  Continue with Scapular PRE\u2019s.  Biceps PREs  Upper body Ergometer  Continue with modalities, prn.  Restore full ROM by 12 weeks  PRECAUTIONS: 1. Monitor activity level (patient to avoid jerking movements and lifting heavy objects) 2. Limit overhead activity 3. Avoid shoulder \u201cshrug\u201d with activity and AROM\/strengthening exercises  MINIMUM CRITERIA FOR ADVANCEMENT: 1. Minimal pain and\/or inflammation 2. Full PROM 3. Improved rotator cuff and scapula strength 4. Normal scapulohumeral rhythm with shoulder elevation below 90\u00ba  15-23 WEEKS POST-OP: (Late Strengthening Phase) GOALS: 1. Improve strength to 5\/5 for scapula and shoulder musculature 2. Improve neuromuscular control 3. Normalize scapulohumeral rhythm throughout the full ROM  Progress Rotator cuff and Periscapular isotonics  Continue with aggressive Scapular exercises \/ stabilization  Upper extremity PRE\u2019s for large muscle groups, i.e. Pects, Lats, etc.  Begin isokinetic program, IR \/ ER emphasize eccentrics  Continue with flexibility activities (Posterior Cuff and Capsule)  Begin plyometric program for overhead athletes at 15 week. Continue with throwing program  Sports specific strengthening (when PROM and AROM is full)  Posterior capsule stretching after warm  ups  4 - Progress PRE\u2019s from side for overhead athletes  24-26 WEEKS POST-OP: (Return to Sports or Full Activity) GOALS: 1. Maximize flexibility, strength & neuromuscular control to meet demands of sport, return to work, recreational and daily activity 2. Isokinetic testing (If Available) - 85% limb symmetry 3. Independent in home & gym therapeutic exercise programs for maintenance and progression of functional level at discharge  Plyometrics above horizontal if no pain  Continue with isotonics and stabilization for rotator cuff  Continue with strengthening exercises for large upper body muscle groups and periscapular muscles  Continue with the above program and advance per patient progress  PRECAUTIONS: 1. Avoid pain with therapeutic exercises and activity 2. Avoid sport activity until adequate strength, flexibility and neuromuscular control 3. MD clearance needed for sport activity or back to work (heavy laborer) without restrictions  CRITERIA FOR DISCHARGE: 1. Isokinetic testing close to normal ER\/IR ratios (66%), 85% symmetry 2. Independence with home\/gym program at discharge for maintenance and progression of flexibility, strength and neuromuscular control","conversation_history":[{"role":"user","content":"Let's talk about the recommended progression for physical therapy following a total shoulder arthroplasty."},{"role":"assistant","content":"How can I help you with that?"}],"metadata":{"question_type":"conversational","seed_document_id":6,"topic":"Others"}}