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Welcome to the 3rd installment of our web-based symposium about physical therapy.
Our panel:
- Chris Drew, PT, DPT – Website
- Paul Frizelle PT, DPT, MS, OCS, MTC, CSCS – Twitter
- Duncan Gerhard PT, DPT – Website, Facebook, Twitter
- Anna Marie Hammond PT, DPT, ATC – Website, Facebook
- Chris Marino PT, DPT – Website
- Robyn O’Connor PT, DPT, OCS, CSCS – Website, Facebook, Twitter
In prior posts, we discussed what physical therapy is and what your physical therapist can do for you. Now let’s get into some diagnosis specific questions…
Recovery from ROTATOR CUFF SURGERY can be difficult. In the early stages, there often is a fair amount of pain. Later there is stiffness. The process is long and usually will take nine months to a year before your symptoms resolve and your function satisfactorily returns. Recovery from rotator cuff surgery can be more like a marathon than a sprint and physical therapy is critical to help you get through it and have a successful outcome. So I asked our panel…
What do you see as the key patient and physical therapy factors that leads to a successful recovery after rotator cuff surgery?
Chris Drew, PT, DPT:
I think recovering from a Rotator Cuff surgery can be one of the most challenging to rehabilitate. There is a long list of factors that can be involved with outcome including the type of tear, body shape, activity lifestyle prior, and even DNA. We all heal differently! However these are things we cannot control. So more important are what we can control after a Rotator Cuff surgery to have a successful outcome. First and foremost would be following the restrictions the Doctor has set forth. Rotator Cuff surgeries can be very delicate and it is important to let them heal without aggravation to any repaired tissue. Generally the early period is considered more of a protection phase. Physical therapy is focused on minimizing loss of motion while protecting the repair. I have had occasional patient’s that did not follow the advice to avoid active movement and remain in a sling which may interrupt the healing process, while increasing inflammation/aggravation and leading to increased difficulty performing physical therapy activities to regain motion and strength.
Further into the rehab process, I think consistency with physical therapy and performing a home program to increase range of motion are most important factors. Rotator Cuff rehabilitation can be painful and difficult some times. The patients that I see do the best with outcome embrace the idea that the rehabilitation is not fun but attend the PT while doing their home exercise program every day anyway. Those that tend to miss appointments and tell me they are too busy to do the home program always tend to take longer, have more pain for a longer period, and get more frustrated. I remind my patients that they only see me 2-3 hours a week. If all the other time during the week the shoulder is not being worked to gain motion with a home program it is going to be difficult to make progress.
Paul Frizelle PT, DPT, MS, OCS, MTC, CSCS:
Physical therapy is a necessity for most people after a rotator cuff surgery. The rehabilitation process is quite involved, but there are many things that allow it to be successful.
One of the keys in rehabilitation is understanding the needs of the patient. What types of activities were you doing before surgery, and what types of activities do you plan on returning to after rehab. Communicating this information to your therapist will allow them to better measure your progress and plan your rehab process.
A second key is the communication between the surgeon, therapist, and patient. The surgeon who performed the repair has the best knowledge on the quality of the tissue, the extent of the repairs, and his expected time frames for your progression. As with any other relationship, communication is key to success!
The third key is a gradual progression back into function. I have worked with many patients who felt it was not necessary to wear a sling or pay attention to their prescribed movement restrictions. Ignoring limitations increases your risk of a sub optimal outcome. The success of a surgery is not measured in weeks, it is measured in years.
Early in the rehab process, my approach focuses on restoration of normal passive ranges of motion, and strength of the muscles that move the shoulder blade (scapular stabilizers). It is also important to address the elbow, wrist and neck to reduce limitations from the period of time where the affected shoulder is in a sling.
As the body heals from surgery, patients progress from passive ranges to active assistive ranges of motion. An examples of this might be using an overhead shoulder pulley, or using a cane to help you lift your affected arm. As you progress through therapy, I continue to use manual therapy but begin moving into active ranges of motion like lifting your arm forward and to the side.
The final part of rotator cuff repair is moving into resisted exercise using bands, machines, or light free weights. The goals behind this part of therapy are to increase strength of the shoulder complex, and begin simulating movements that you may do in your daily life.
The rotator cuff repair is a challenging surgery that requires a skilled orthopedic physician, a trained physical therapist, and most of all a dedicated patient.
Duncan Gerhard PT, DPT:
As a physical therapist, surgical intervention to repair a torn rotator cuff is one of the more challenging diagnoses that we treat. In general, shoulder injuries are challenging to treat due to the complexity and inherent instability of the shoulder complex. When you factor in the length of time to recover and the pain associated with the surgical procedure, it can be an uphill battle for both the patient and therapist. However, it is a battle that is won with sound surgical procedures, good physical therapy and patient perseverance. Over the course of my nine years in practice and extensive work treating complex shoulder injuries (both conservatively and surgically), I have discovered that there are a few key factors that help stack the deck in the favor of the patient and their recovery following a rotator cuff repair.
The primary key is to choose a skilled team of health professionals. Find an orthopaedic surgeon whom has demonstrated experience and positive results with the procedure. Do your research (if you are reading Dr. Berg’s blog you have made an excellent first step) and find someone you trust and who has a high success rate with this surgical intervention. Selecting the right physical therapist will help guide you through the long recovery process. Having trust with an experienced physical therapist is going to set you up to succeed in reaching your ultimate goals (whatever those may be). Be sure to talk to your surgeon and ask whom they recommend. They have your best interests at heart and want you to have a successful outcome.
The second key is to remain compliant with what your medical professionals are advising you do to. Following surgery there are multiple phases to the recovery process, from protecting the repair all the way to returning to sport (or whatever activities you wish to be able to perform). During each phase there are specific things you are and are not allowed to do. In addition, there will be exercises you will be asked to do at home in order to facilitate your recovery. Trust your healthcare team and follow their advisement. That is the reason you selected them.
The third key is to have patience and perseverance. This is a long recovery and one that can be frustrating at times. There will be challenging times when your shoulder feels weak or is in pain. However, if you have succeeded in accomplishing the first two keys these obstacles will be speed bumps that you will overcome. Unfortunately, you cannot rush the rehab process following a rotator cuff repair. Your physiology dictates what occurs and is the basis for post-operative physical therapy protocols.
If you keep these three keys in mind it will allow for a successful surgery and post-surgical rehabilitation.
Anna Marie Hammond PT, DPT, ATC:
The key components to a successful recovery starts with education. The first visit with the patient should go over the expected recovery time and protocol timeline. If a patient does not understand the expectations then frustration can plague the recovery process and diminish compliance with rehab. The more the patient knows and understands the expectations the better the recovery and detection to physical therapy. The second key component is making sure the patient is taking proper steps to manage their pain levels. If they are not this can limit their ability to achieve expected protocol goals and tolerance with physical therapy. Also making sure the patient is not over doing it when returning to normal daily activities especially when just out of the sling. Overuse can spike pain levels and again digress progress. The third key component is making sure the patient has an updated home exercise program for every transitionary period of the rotator cuff protocol. This keeps the patient on task and also keeps them motivated since they can perform new exercises to keep up their progress and improve recovery.
Overall, the physical therapist should also be aware of patients goals and desired expectations for activity level and gearing their treatment plan to accommodate these goals and activities. Making the recovery more patient geared improves motivation to be involved in the recovery.
Chris Marino PT,DPT:
The greatest challenge to a patient is adhering to their restrictions. It seems patients most often asked questions have to do with when they can return to an activity, whether it be dressing, driving, or exercising, without fear. They should be reassured that loss of motion and atrophy are temporary and not to rush into returning too soon so to avoid possible re-injury.
For a successful rehabilitation, the mentality of the therapist should be the same as the advice given to the patient. Some patients take longer to heal and may not be ready for the next step in the protocol if they have not achieved goals set for an early parameter. They should not be progressed too soon either if easily achieving benchmarks in PROM, AROM, and functional usage.
All goals from both the therapist and the patient should be to ensure a safe rehabilitation to reduce any possible re-injury.
Robyn O’Connor PT, DPT, OCS, CSCS:
Patient compliance and patient education are huge factors in my opinion. The surgeon, physical therapist, and the patient must be on the same page. Patients need to understand that they will need help the first few weeks and an appropriate support system at home needs to be in place. Recovery is a long process but has great outcomes when there is good communication amongst the medical providers and patient. Components of this education include topics such as necessary sling use, appropriate return to daily activities such as driving and working, and gradual return to sport specific activity.
Physical Therapy is a must and continues for 3-4 months following the surgery. Patient compliance with PT attendance and compliance with the home exercise program is of the utmost importance for a successful long term outcome. Non-compliance can lead to numerous complications such as frozen shoulder, tendinitis and re-injury but these are all easily preventable. A good PT program will consist of emphasis to the shoulder primarily but should also include some emphasis on the surrounding regions such as the cervical and thoracic spine, the elbow, and the abdomen. A comprehensive approach includes exercises to address joint and muscle flexibility, strengthening when appropriate, proprioception, range of motion, and nerve mobility of the neck and upper extremity.
Rotator cuff surgery has a positive outcome and can lead to a much improved quality life after injury. It does require lengthy rehabilitation following, but compliance and hard work will get you back to doing what you love in no time.
The KEY take home points are:
Recovering from rotor cuff surgery is not easy. You need to be prepared to work hard along side your therapist and at home for an extended period of time. This will be very challenging. Maintaining a positive outlook and staying focused on your end goals are key. There may be setbacks. You will have pain. Your surgeon can safely remove only some of your discomfort. Initially PT may make your pain even worse. Don’t wait until the pain is all gone before working in PT. That day will never come. PT is required to eliminate your pain and the longer you wait, the harder it gets.
Along with your surgeon, a good physical therapist will design a program that takes into account your unique situation. Follow it. Doing either too much or too little can jeopardize your outcome. This is hopefully your first time recovering from this problem, but your surgeon and therapist have done this many times before. Listen to them. Follow their instructions. Don’t “freelance”. With that said, communication is key. No recovery is “black and white”. The program often needs to be altered based on your progress and your response to treatment. So let your therapist and surgeon know what you are experiencing.
You are not alone, many people have traveled this difficult path before you. With consistency, perseverance and patience you too can heal, regain your function and return to your prior lifestyle.
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