Shoulder Joint Replacement

[Dyvyne]

Hi there,

I'm not a physiotherapist, I'm a kinesiologist who just graduated. Therefore I don't have too much experience. The physio that I work for is unfortunately for our clients, not that great.

I have one client who had a motor vehicle accident (MVA) 1.5 years ago, and due to that had to have a shoulder joint replacement. The surgery unfortunately led to some ulnar nerve dysfunction for which my client underwent nerve grafting which is now slowly getting better.

As I mentioned, unfortunately all the physio wants to do is put the client on IFC for his neck and his ulnar nerve (from elbow to wrist) and give him a hot pack. There is no other manual therapies involved (no mobility, traction, myofascial release). The client performs some shoulder exercises (pulleys, abduction/adduction using therabands) but that's about it. Since now I'm involved, I need to do something about this to make him better. Any advice? Please explain why I should use the technique as well so I can better understand. I really like to see progress and it's very sad to see some physios acting this way.

Thank you!!

-D-

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[Dr Damien]

Dear Dyvyne

Thank you for your post but please do no be too hasty about any treatments given to given to any patient. All the techniques you mentioned are manual techniques, if they are not needed then they shouldnt be used...

I do not see what the purpose of traction would be in this situation, and are there any restrictions in range of motion that some techiques in myofascial release would be help to release. remember that this man has a shoulder replacement, emphasis should be on strengthening and ROM which i believe the physio is looking into based on your description. Like in most joint replacements, we desist from using manual techniques taking the hands off route unless perhaps to assist with movement.

The question really should be is the client seeing results? is he satisfied with his management? if he is, then I do not see a problem, If he isnt, its probably because his rehabilitation has not been made functional to his needs.

If you want to make a difference in this clients rehabilitation, start focusing on functional goals. Start by assessing what activities of daily living this gentleman is having problems with when he tries to use his hand. Then build up from there...

manual techniques have their place, try not to be too hasty about things you read that seem fantastic. They are useful when they are indicated and there are no contraindications.

Cheers

Try and follow the directions of the physiotherapist and when it comes to analysing movements, you can help the physio understand a better picture of the movement pathologies taken place....

[Dyvyne]

Thank you Dr. Damien,

I completely understand that certain techniques are not very useful during certain situations, however, this client has been with us for a long time and has been complaining of no improvement. He's been with this clinic for longer than I've worked there!

I guess I should explain a bit further, we have a lot of physio clients who require traction (people with sciatic or cervical spine problems), but the traction or whatever manual therapy that is required, is not being provided because the physio blatantly tells me that she is lazy. I have tried many times to ask her to teach me techniques, but she says that physio is only about giving people IFC/TENS/Ultrasound and nothing else. So as a last resort, I found this forum just so I could ask for help and as to how exactly to perform certain techniques.

The client with the shoulder joint replacement however, is not satisfied at all with the treatment that he is being given. I've given him more exercises but I have seen 0% improvement. As a side note, even the other clients who have other problems, are complaining about the physio and haven't seen any improvement. Which is the reason why I'm coming here to see what other physiotherapists are doing. =(

Sorry! Just really desperate to get these clients back into shape, or at least see some improvement!

[Dr Damien]

Dear Dyvyne

It is truly a great honour to see someone in the position of care who is passionate about giving his/her client the best care he/she can povide. I really should say that I am very impressed by the enthusiasm.

It is not easy to suggest anything without seeing the patient or assessing the patient. It is not also ideal to suggest treatment techniques to someone who is qualified to carry out this techniques on a patient.

However, I can suggest what your assessment should be looking out for so as to know where you wanna take the management of your patient.

the following should basically be assessed
A good knowledge of his Past medical history
a good knowledge of his drug history
a good knowledge of his current state of health
age and occupation


The clients posture (in general)
the range of cervical motion
The range of joint motion in the shoulder, active and passive
the range of scapular motion with regards to the arm
The muscle strength of the muscles of the shoulder, elbow, wrist and hand
sensation deficits
pain? if there is
Any deformities forming?
Grip strength?
Functional activities the client can manage with that upperlimb and things he is finding difficult to do that hinders his daily living.i.e is he right or left handed, which upperlimb is affected? dominant or non dominant arm, can he open doors, can he dress, can he button his clothes etc?
use an outcome measue such as the quick DASH or any other upper limb objective tests you have...to have a baseline of where this man is...

the most importantly ask him what he wants to achieve, i.e what does he want to be able to use his arm for...this has to be realistic considering the length of time that has passed...

List these goals out, they have to be realistic, have a time frame, can be achieved, can be reassed with you outcome measure (i.e ROM) etc

For example, the client might say I want to be able to comb my hair as one goal...
obviously for this task he will need approximately 110 degrees of shoulder flexion, good external rotation, horizontal abduction,
approximately 60 degrees, good strength and endurance in the rotator cuff stabilizers and deltoid
he would also need to be able to hold a comb/brush...so whats happening with his sensation of grip strength? how weak are his wrist deviators?

A treatment plan can now be formed to address towards getting this goal specifically...
Amongst treatment options, cane exercises can be done in lying to help gain shoulder range of motion, exercises can be done in lying to address the specific muscles you are hoping to improve for this task...this can be progressed through gravity eliminated, to gravity included and resistance...
If necessary scapular mobilization and control exercises might be given, this again can be done using different positions to include of exclude resistance.

How bad is his palsy? palsy or paresis? perhaps electrical stimulation is needed?...FES is good, combined with soft tissue massge to keep tissues pliable
home exercises can be given to task the functional use of the arm...putty exercises, foam squeezes, ball squeezing...

With longstanding nerve damage (if its a pure nerve resection), regrowth of the nerves can be abnormal, causing poor coordination,

there are several options for treatment to be honest...if all this are not helping...then adaptations may be needed, you could research on types of combs/brushes out there than people with hand poblems can use, in this case, a discussion with an occupational therapist is needed

throughout your input, it is good to keep the client well informed of the prognosis and the reality of his condition, therapist and patient should be working together to achieve the goals that they have both agreed on...

I know this is not very helpful but at least you can know how to approach the management of this patient and any other patient really...

all you need now is to perhaps attend courses on specific treatment techniques if your qualifications will allow you do that...

pls let me know how you get on with this assessments first and perhaps we can decide on treatment techniques together that you can discuss with the therapist managing this client as possible options

you will definitely see an improvement if you follow this systematic way of assessing, identifying problems, identifying goals and considering what your patient wants to achieve. Primarily because by the time you are gaining improvement I.e range of motion or strength, seemingly closer to what the client wants to do, it would be far more important to him than just exercising without any goals in mind...secondly, this systematic way gives you way of re-assessing and re-planning if something is not working out...

regards