Rehabilitation Protocol for Reverse Shoulder ArthroplastyThis protocol is intended to guide clinicians and patients through the post-operative course after a reverse shoulderarthroplasty. Specific interventions should be based on the needs of the individual and should consider exam findingsand clinical decision making. If you have questions, contact the referring physician.There are a few significant differences in post-operative guidelines between a total shoulder arthroplasty (TSA) andreverse shoulder arthroplasty (RSA) primarily due to rotator cuff arthropathy. Deltoid function and periscapular strengthbecome primary sources of shoulder mobility and stability.Considerations for the Reverse Shoulder Arthroplasty Rehabilitation ProgramMany different factors influence the post-operative reverse shoulder arthroplasty rehabilitation outcome, includingsurgical approach, concomitant repair of the rotator cuff, arthroplasty secondary to fracture, arthroplasty secondary torheumatoid arthritis or osteonecrosis, revision arthroplasty, and individual patient factors including co-morbidities. It isrecommended that patients meet all rehabilitation criteria in order to progress to the next phase and clinicianscollaborate closely with the referring physician throughout the rehabilitation process.Post-operative ComplicationsIf you develop a fever, unresolving numbness/tingling, excessive drainage from the incision, uncontrolled pain,unresolving tenderness over the acromion or any other symptoms you have concerns about you should contact thereferring physician.PHASE I: IMMEDIATE POST-OP (2-3 WEEKS AFTER ntionCriteria toProgress Protect surgical repair Reduce swelling, minimize pain Maintain UE ROM in elbow, hand and wrist Gradually increase shoulder PROM Minimize muscle inhibition Patient education Neutral rotation Use of abduction pillow in 30-45 degrees abduction Use at night while sleeping No shoulder AROM No shoulder AAROM No shoulder PROM in to IR No reaching behind back, especially in to internal rotation No lifting of objects No supporting of body weight with hands Place small pillow/towel roll under elbow while lying on back to avoid shoulder hyperextensionSwelling Management Ice, compressionRange of motion/Mobility PROM: ER in the scapular plane to tolerance, Flex/Scaption / 120 degrees, ABD / 90degrees, seated GH flexion table slide, pendulums, seated horizontal table slides AAROM: none AROM: elbow, hand, wrist Gradual increase in shoulder PROM 0 degrees shoulder PROM in to IR Pain 4/10 No complications with Phase I

PHASE II: INTERMEDIATE POST-OP (4-6 WEEKS AFTER ntion*Continue withPhase IinterventionsCriteria toProgress Continue to protect surgical repair Reduce swelling, minimize pain Gradually increase shoulder PROM Initiate shoulder AAROM/AROM Initiate periscapular muscle activation Initiate deltoid activation (avoid shoulder extension when activating posterior deltoid) Patient education Use at night while sleeping Gradually start weaning sling over the next two weeks during the day No reaching behind back, especially in to internal rotation No lifting of objects heavier than a coffee cup No supporting of body weight with hands Place small pillow/towel roll under elbow while lying on back to avoid shoulder hyperextensionRange of motion/Mobility AAROM: Active assistive shoulder flexion, shoulder flexion with cane, cane external rotationstretch, washcloth press, seated shoulder elevation with cane AROM: supine flexion, salutes, supine punchStrengthening Periscapular: scap retraction, standing scapular setting, supported scapular setting, low row,inferior glide Deltoid: isometrics in the scapular plane Gradual increase in shoulder PROM, AAROM, AROM 0 degrees shoulder PROM in to IR Palpable muscle contraction felt in scapular musculature Pain 4/10 No complications with Phase IIPHASE III: INTERMEDIATE POST-OP CONTD (7-8 WEEKS AFTER ntion*Continue withPhase I-IIinterventions Minimize pain Gradually progress shoulder PROM, initiate shoulder PROM IR in the scapular plane Gradually progress shoulder AAROM Gradually progress shoulder AROM Progress deltoid strengthening Progress periscapular strengthening Initiate motor control exercise Patient education Discontinue No reaching behind back beyond pant pocket No lifting of objects heavier than a coffee cup No supporting of body weight with hands Avoid shoulder hyperextensionRange of motion/Mobility PROM: Full in all planes, gradual PROM IR in scapular plane / 50 degrees AAROM: incline table slides, wall climbs, pulleys, seated shoulder elevation with cane with activelowering AROM: seated scaption, seated flexion, supine forward elevation with elastic resistance to 90 degStrengthening Periscapular: Row on physioball, serratus punches Deltoid: seated shoulder elevation with cane, seated shoulder elevation with cane with activelowering, ball roll on wallMotor control IR/ER in scaption plane and Flex 90-125 (rhythmic stabilization) in supineStretching Sidelying horizontal ADD, triceps and latsMassachusetts General Hospital Sports Medicine2

Criteria toProgress ROM goals**:o Elevation / 140 degreeso ER / 30 degrees in neutralo IR / 50 degrees in scapular plane or back pocketo **PROM and AROM expectations are individualized and dependent upon ROM measurementsattained in the OR post-operativelyMinimal to no substitution patterns with shoulder AROMPain 4/10PHASE IV: TRANSITIONAL POST-OP (9-11 WEEKS AFTER *Continue withPhase II-IIIinterventionsCriteria toProgress Maintain pain-free ROM Progress periscapular strengthening Progress deltoid strengthening Progress motor control exercise Improve dynamic shoulder stability Gradually restore shoulder strength and endurance Return to full functional activities No lifting of heavy objects ( 10 lbs)Range of motion/mobility PROM: Full ROM in all planesStrengthening Periscapular: Resistance band shoulder extension, resistance band seated rows, rowing, robbery,lawnmowers, tripod, pointer Deltoid: gradually add resistance with deltoid exerciseMotor control IR/ER and Flex 90-125 (rhythmic stabilization) Quadruped alternating isometrics and ball stabilization on wall Field goals PNF – D1 diagonal lifts, PNF – D2 diagonal lifts Performs all exercises demonstrating symmetric scapular mechanics Pain 2/10PHASE V: ADVANCED STRENGTHENING POST-OP (12-16 WEEKS AFTER *Continue withPhase II-IVinterventionsCriteria toProgress Maintain pain-free ROM Initiate RTC strengthening with a concomitant repair Improve shoulder strength and endurance Enhance functional use of upper extremity No lifting of objects ( 15 lbs)Strengthening Periscapular: Push-up plus on knees, “W” exercise, resistance band Ws, prone shoulder extensionIs, dynamic hug, resistance band dynamic hug, resistance band forward punch, forward punch, Tand Y, “T” exercise Deltoid: continue gradually increasing resisted flexion and scaption in functional positions Elbow: Bicep curl, resistance band bicep curls, and triceps Rotator cuff: internal external rotation isometrics, side-lying external rotation, Standing externalrotation w/ resistance band, standing internal rotation w/ resistance band, internal rotation,external rotation, sidelying ABD standing ABDMotor Control Resistance band PNF pattern, PNF – D1 diagonal lifts w/ resistance, diagonal-up, diagonal-down,wall slides w/ resistance band Clearance from MD and ALL milestone criteria have been met Maintains pain-free PROM and AROM Performs all exercises demonstrating symmetric scapular mechanics QuickDASH PENNMassachusetts General Hospital Sports Medicine3

Revised December 2018ContactPlease email [email protected] with questions specific to this protocolReferencesAngst F, Goldhahn J, et al. Responsiveness of six outcome assessment instruments in total shoulder arthroplasty. Arthritis & Rheumatism. 2008. 59 (3): 391-398.Boudreau S, Boudreau E. Higgins LD, Wilcox III R.B. Rehabilitation following reverse total shoulder arthroplasty. JOSPT. 2007. 37 (12): 734-744.Garcia GH, Taylor SA, et al. Patient activity level after reverse total shoulder arthroplasty: what are patients doing? Am J of Sports Med. 2015. 43 (11): 2816-2821.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 WB, Sciascia, AD, Uhl, TL, et al. Electromyographic analysis of specific exercises for scapular control in early phases of shoulder rehabilitation. The AmericanJournal 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 OrthopaedicResearch. 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.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.Massachusetts General Hospital Sports Medicine4

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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 CollaborativeGroup (UECG). Am J Ind Med. 1996;(6):602-608.Massachusetts General Hospital Sports Medicine6

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Leggin BG, Michener, LA, et al. The Penn Shoulder Score: reliability and validity. JOSPT. 36 (3): 138-151.Massachusetts General Hospital Sports Medicine8

Massachusetts General Hospital Sports Medicine 4 Revised December 2018 Contact Please email [email protected] with questions specific to this protocol References Angst F, Goldhahn J, et al. Responsiveness of six outcome assessment instruments in total shoulder arthroplasty.