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Advances in shoulder surgery and rehabilitation - Len Funk 2012
 

Advances in shoulder surgery and rehabilitation - Len Funk 2012

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    Advances in shoulder surgery and rehabilitation - Len Funk 2012 Advances in shoulder surgery and rehabilitation - Len Funk 2012 Presentation Transcript

    • Arthroscopic Shoulder Surgery has Progressed ... Has the Rehab? Lennard FunkSunday, 18 March 2012
    • Full Time / Part TimeSunday, 18 March 2012
    • YES and NOSunday, 18 March 2012
    • Quiz ...Sunday, 18 March 2012
    • Question 1 The exercises that best protect a surgical repair are: a. Open kinetic chain b. Closed kinetic chain c. Concentric d. Full range of motionSunday, 18 March 2012
    • Question 2 Exercise progression should be based on: a. Procedure performed b. Range of motion c. Control of scapular position d. Acquisition of functionSunday, 18 March 2012
    • Question 3 Immobilisation after shoulder surgery repair leads to: a. More stiffness b. Less revisions c. Earlier recovery of Strength d. Better ProprioceptionSunday, 18 March 2012
    • Question 4 Tendon healing: a. Is improved with movement b. Takes less than 3 months c. Is strain related d. Is improved by steroid injectionsSunday, 18 March 2012
    • Shoulder Surgery Progress Hippocrates (460-377 BC) Codman (1937) Watanabe Neer 1990s+ Snyder, Andrews, Burkhart, Gerber, Copeland etc.Sunday, 18 March 2012
    • Arthroscopy The needle with an eye “The everyday miracle, that keeps getting better”Sunday, 18 March 2012
    • Same Surgery – Smaller AccessSunday, 18 March 2012
    • Faster RecoverySunday, 18 March 2012
    • A systematic review of rehabilitation protocols following arthroscopic repair of rotator cuff tears Donaldson, Wright & Funk. SECEC 2011 “There was insufficient evidence in any of the papers for the protocols or exercises advocated in the rehabilitation programs.”Sunday, 18 March 2012
    • Rehabilitation The surgeon’s viewSunday, 18 March 2012
    • Post-operative CareSunday, 18 March 2012
    • The effects of ImmobilisationSunday, 18 March 2012
    • Fracture HealingSunday, 18 March 2012
    • Too much movementSunday, 18 March 2012
    • Controlled Motion Rigid Fixation Micro-motion (immobilised) (closed chain)Sunday, 18 March 2012
    • Sunday, 18 March 2012
    • Soft Tissues • Tendon • Ligaments • LabrumSunday, 18 March 2012
    • Tendon CollagenSunday, 18 March 2012
    • Tendon Failure 1.Primary or toe region. 2.Secondary or linear region.= Elastic Region. 3. Yield point. 4. The ultimate stress/ strength 5. Sequential failure 6. Alternative failureSunday, 18 March 2012
    • Tendon HealingSunday, 18 March 2012
    • Tissue differentiation with Healing Pendergrast. K Biomech. 1997 1yearSunday, 18 March 2012
    • Immobilisation & ExerciseSunday, 18 March 2012
    • Strain Studies Talwalker, Evans, TrailSunday, 18 March 2012
    • ‘Fracture’ Healing is like sex: • It’s natural • Needs two parts Alan Graham Apley (1914-1996) • ... and a bit of movementSunday, 18 March 2012
    • Standard Shoulder Practice Leftley & Funk, 2006 Shoulder Surgeons Shoulder Therapists • Active & Passive ROM in • Immobilisation 3-6 weeks safe zone, week 1 • Resistance training 6 weeks+ • Controlled resistance in safe zone week 2 • Sport specific training after 12 weeks • Resistance work end of range, weeks 6-8 • Return to Sport 6-8 months • Return to Rugby 12 wksSunday, 18 March 2012
    • Can you Protect and Rehab? • Tendon Healing • EMG Studies • Kinetic Chains • Clinical • Stiffness • ResultsSunday, 18 March 2012
    • Tendon Loading Immobilisation: Exercise: • Decr. Tendon weight !Incr. Growth Factors !Incr. tensile strength • Decr. Stiffness & !Incr. cross-sectional tensile strength area • Irregular collagen !Realign collagen fibres !Type 1 > Type 3 collagen • Type 3 > Type 1 collagen Mechanical Adaptation • Degenerative changes Mehta. Clin J Sports Med. 2003Sunday, 18 March 2012
    • Muscles - EMG Studies Kibler WB, Sciascia AD, Uhl TL, Tambay N, Cunningham T. AJSM, 2008.Sunday, 18 March 2012
    • Kinetic Chains • Open Chain: • Terminal link in the chain is not loaded and is freely mobile • Muscle activation is usually proximal to distal • Closed Chain: • Terminal link meets enough resistance to prohibit or restrain its free motion • Extremity muscle activation is sequential from distal to proximalSunday, 18 March 2012
    • Closed Chain:Sunday, 18 March 2012
    • Open Chain:Sunday, 18 March 2012
    • Closed Chains • Relatively small joint movements • Low joint accelerations • Large resistance forces • Joint compression • Decreased joint shear,translation, distraction • Stimulation of joint proprioception • Enhanced dynamic stabilisation through muscle co-activationSunday, 18 March 2012
    • Closed Chains Kibler WB, Livingston B. AAOS. 2001. Veeger HEJ, van der Helm FCT. Journal of Biomechanics. 2007 Anatomical: • Anterior strut: • S- C joint, clavicle, A- C joint • Bony attachment to axial skeleton • Posterior strut: • Scapula • Muscular attachment to axial skeletonSunday, 18 March 2012
    • Closed Chain Disrupted • Anterior • Clavicle fracture- shortening, angulation, malrotation • AC joint separation • Excessive distal clavicle resection • Posterior- Scapular dyskinesis • Muscular alteration (inhibition, fatigue, patterning) • Inflexibility (pec minor, biceps, GIRD) • Scapular muscle detachment • Nerve injury/palsySunday, 18 March 2012
    • Principles of Rehab Correct the mechanical flaws Restore the integrity of the kinetic chain Reestablish normal functionSunday, 18 March 2012
    • Restoration of the Kinetic Chains 1.Pre operative 2. Early Post-op 1. Restore motion and stability in non- injured areas 1. Even while shoulder is protected 1. Anterior coracoid muscles 2. Restore scapular posture, position 2. GIRD 3. Allow early safe scapular motion 3. Scapular retraction 2. Early start on post operative 4. Minimal strain on shoulder repair rehabilitation 3. Instruction in post operative exercises 3. Later Rehab: 1. Allow maximal concavity/compression 1. Kibler & Livingston. AAOS. 2001. 2. Allow maximal rotator cuff activation & strength 2. Veeger et al. Journal of Biomech. 2007 3. Proximal base for open chain motions of armSunday, 18 March 2012
    • Shoulder Proprioception • Rapidly lost after injury • Reduced with immobilisation • Improved with closed-chain rehab. •Smith & Brunolli, 1989 •Lephart, 1994, 1997 •Zuckerman, 1996 • Edmonds, 2003Sunday, 18 March 2012
    • Immobilisation • No such thing! ! • High Cuff activity during all light resisted backward pulling motions (25.2% to 32.1% MVC) [Padgett, 2004] • Low Cuff activity with closed-chain scapulothoracic exercises (<20% MVC) [Smith et al. Arch Phys Med Rehab.2006]Sunday, 18 March 2012
    • Recovery of Strength Hortobágyi et al. J Physiology. 2004Sunday, 18 March 2012
    • Recovery of Strength Hortobágyi et al. J Physiology. 2004Sunday, 18 March 2012
    • Stiffness • No difference in long-term • Monga & Funk. SAE. 2011; Parsons et al. JSES. 2010 Patients with Residual stiffness vs Time 300 250 200 Number 150 100 50 0 0 1 2 3 4 5 6 7 8 9 10 11 12 TimeSunday, 18 March 2012
    • Clinical Literature • Strict immobilisation resulted in functional instability with rotator cuff inhibition, muscular atrophy and poor neuromuscular control (Wilk et al 1993) • Moderate stresses should be placed on the suture line before the end of 3 weeks to influence the scar tissue outcome (Blackburn & Guido 2000) • Increased stress within a certain limit enhances ligament healing and improves joint function (Kim et al 2003) • Closed chain exercises are an integral part of accelerated rehab programmes, they should be started early and used throughout the rehab process (Kibler 2000) • Accelerated rehabilitation promotes functional recovery and reduces postoperative pain, which allows patients an early return to desired activities (Kim et al 2003)Sunday, 18 March 2012
    • What we know: • Early ‘safe’ mobilisation is GOOD for: • Strength • Tendon healing • Kinetic Chain • ProprioceptionSunday, 18 March 2012
    • We also know: • No difference to: StiffnessSunday, 18 March 2012
    • We don’t know: • Effect of immobilisation / mobilisation on retear ratesSunday, 18 March 2012
    • Considerations Kathleen Tatlow Reduce Pain Timing ROM Post-op Return to considerations Normal ADL Muscle Muscle Flexibility powerSunday, 18 March 2012
    • Rehab Guidance Medical Multimedia GroupSunday, 18 March 2012
    • Exercise BookletSunday, 18 March 2012
    • Protocol • Day 1 – 3 Weeks • 0-20% EMG Exercises • Low activity • 3 – 6 Weeks • 21-40% EMG Exercises • Minimal activity • 6 Weeks + • 40% + EMG Exercises Tim Uhl, 2005 Leftley & Funk, 2006 • Moderate to high activitySunday, 18 March 2012
    • Sunday, 18 March 2012
    • 0 – 3 weeks 0 – 20% EMGSunday, 18 March 2012
    • 3 – 6 weeks 21 – 40% EMGSunday, 18 March 2012
    • Week 6 + 40% + EMGSunday, 18 March 2012
    • Arthroscopic Shoulder Surgery has Progressed ... Has the Rehab?Sunday, 18 March 2012
    • YES and NOSunday, 18 March 2012
    • YES • Tendon Healing • Mechanical Adaptation • Kinetic Chains • Proprioception • Early MobilisationSunday, 18 March 2012
    • NO • Application • Fear • Tradition • IgnoranceSunday, 18 March 2012
    • Quiz ...Sunday, 18 March 2012
    • Question 1 The exercises that best protect a surgical repair are: a. Open kinetic chain b. Closed kinetic chain c. Concentric d. Full range of motionSunday, 18 March 2012
    • Question 2 Exercise progression should be based on: a. Procedure performed b. Range of motion c. Control of scapular position d. Acquisition of functionSunday, 18 March 2012
    • Question 3 Immobilisation after shoulder surgery repair: a. More stiffness [Monga & Funk. SAE. 2011] b. Less revisions [Kralinger. AJSM. 2002] c. Earlier recovery of Strength d. Better ProprioceptionSunday, 18 March 2012
    • Question 4 Tendon healing: a. Is improved with movement b. Takes less than 3 months c. Is strain related d. Is improved by steroid injectionsSunday, 18 March 2012
    • derdoc .co.uk lenfunk @shoulSunday, 18 March 2012