Also known as Total Shoulder Arthroplasty (TSA), shoulder replacements are an effective procedure used to treat the severe pain and stiffness that often accompany various forms of arthritis, degenerative joint disease, and trauma. Although this procedure is seen less often as compared to other joint replacements, such as knees or hips, it is equally as successful at relieving pain, which is the primary goal.
As an occupational therapist (OT), this is a diagnosis you will likely treat if you work with adults in almost any setting, including acute care, skilled nursing facilities, and home health to name a few. As a home health and acute care OT I will focus on the rehabilitation of TSAs from those specific settings and based on my experience.
Types of shoulder replacements
For a typical shoulder replacement, the surgeon will begin by separating the deltoid and pectoral muscles followed by opening the anterior portion of the rotator cuff muscles to allow the surgeon to get an accurate view of all of the arthritic areas of the joint. Once the arthritic sections are cleared out, the surgeon will insert the implant, stitch the muscles back together, and apply a sling to immobilize the arm.
There are three main types of shoulder replacement surgeries:
- Total shoulder replacement: the most common type of shoulder replacement, this procedure replaces the ball and socket surfaces of the shoulder with prosthetics. This method is not ideal for individuals who want to maintain a very active lifestyle or who have damaged rotator cuff muscles.
- Reverse total shoulder replacement: during this procedure the surgeon reverses the positions of the shoulder’s ball and socket. The top of the humerus is replaced with a socket-like prosthetic and the shoulder’s socket is replaced with a prosthetic ball. This option is ideal for individuals with damaged rotator cuff muscles.
- Partial shoulder replacement: the shoulder’s natural socket stays while the humeral head is replaced with a prosthetic ball.
Precautions for shoulder replacements
Patients will be limited in how and how much they can move the surgical arm for the first 6-8 weeks post surgery. Patient protocol as well as any restrictions or precautions are typically determined by the surgeon, or in collaboration with the surgeon and rehab team. Typically the patient will be in the sling 24/7 for the first four weeks unless they are completing self care tasks (bathing, dressing) or completing their home exercises, and even then this movement will be limited to joints including and just below the elbow.
Precautions for TSA generally involve no active range of motion of the shoulder joint for the first four weeks, including no active internal or external range of motion. Reverse total shoulder replacements have different precautions; the patient will not be able to extend the surgical arm beyond neutral and will not be able to do a combination of adduction, internal rotation, and extension, such as tucking in a shirt. Again, post-surgical rehabilitation protocol and precautions are determined by the surgeon so it is important that as an OT you know what protocols your facility follows.
Every TSA rehabilitation protocol will differ slightly in timeline and movements. Within the specific acute care setting I work in, OTs are the rehab professionals that see the patient first. We educate the patient and review the home exercise program that they will follow for roughly the next four weeks. This program includes active range of motion of the digits, wrist, and elbow as well as pendulum exercises to the shoulder. Again, for the first four weeks or so post-surgery, if the patient is not performing these exercises or self care tasks, they should be in their sling.
Once the patient returns home from the hospital, many will begin outpatient therapy when ready. Some patients, however, are not appropriate for outpatient therapy and will require home therapy. When a patient is unable to get to outpatient therapy for whatever reason, they will likely get referred to a home health therapist to continue their rehabilitation protocol from the comfort of their home.
Around one month post-surgery the patient will be able to discontinue wearing the sling and begin passive range of motion of the shoulder followed by active range of motion of the shoulder, all while being cautious not to overstretch. Modalities can be used as needed, but in home health, access to modalities is often limited. Around the eight to ten week post-surgical period, the patient will be able to begin strengthening of the shoulder, with a gradual return to normal range of motion and functional strength. With shoulder replacements, I often suggest that a slow and steady return to normal functioning wins the race. As a therapist you want to ensure that your patient is not over-doing activity too soon, which can set them back from any progress they have already made.
With shoulder replacement surgery, as with any surgery, the patient’s ability to complete functional tasks will be severely impaired. In the acute care setting, it is extremely important for OTs to address how the patient will complete self-care tasks while maintaining all of their restrictions and precautions that are in place. In my experience, one of the most difficult tasks for patients to master is donning and doffing their new sling. As a new graduate, I would recommend practicing taking the sling on and off yourself prior to treating a patient so that you know how to instruct a patient in the best way possible. Sometimes patients may have a significant other or family member at home that can assist them with this, if so I will also educate the family members on sling management. If not, I will go over it multiple times until the patient feels comfortable.
Two other common issues for patients are donning and doffing a shirt and washing under their arms. For bathing, the surgeon will give the patient clearance to shower, this usually occurs at the first post-op visit. Once cleared, the therapist should instruct the patient to bend forward at the waist, allowing the surgical arm to dangle so that the patient can wash underneath the arm. It is important that all the work is done by the non-surgical arm to maintain restrictions. To dress the upper body, instruct the patient to dress the surgical arm first using the non-surgical arm. Once this is complete, continue putting on the shirt by slipping the head through if it’s a pull over shirt, followed by the non-surgical arm. To doff a shirt, complete these steps in reverse.
Oftentimes, with these types of surgeries, the patient may only stay one night. This of course depends on a lot of variables, but it is imperative that as an OT treating a patient who is receiving a shoulder replacement that you ensure that they can maintain their precautions while performing their activities of daily living. Once the patient transitions home it is pertinent that the therapist reinforces everything that the patient was educated on in the hospital in order to maintain the patient’s precautions. Additional issues may also arise that the patient or therapist did not think about while in the hospital and it is important that, as OT practitioners, we address these as well.
To sum it up
Total shoulder replacements are both a challenging and rewarding diagnosis for OTs to treat. They offer both biomechanical and functional impairments to address; however, progress is visible within the first few weeks and months post-surgery. If I were to give some advice to new graduates seeing this diagnosis based on my experience I would recommend learning the protocols your facility follows, practicing the various exercises associated with those protocols, as well as reviewing compensatory methods to complete self care tasks, and asking as many questions as you can! It is important to note that this guide is not all-inclusive of everything OTs will experience when working with patients who have TSAs, but it is a great place to start.
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