Tips for OTs Working with Patients Post-Total Shoulder Replacement
According to the Agency for Healthcare Research and Quality, roughly 53,000 people per year undergo surgery for a shoulder replacement in the United States (OrthoInfo, 2020).
Although this number is quite small compared to the 900,000 people per year who go in for hip and knee replacements, this means occupational therapy practitioners working in joint rehabilitation have plenty to do.
In this article, we have provided OT practitioners and students with a “go-to” guide for post-total shoulder replacement evaluation and intervention.
What Does a Total Shoulder Replacement Look Like?
A total shoulder replacement – or a total shoulder arthroplasty (TSA) – involves the removal of damaged portions of the shoulder joint and replacing it with a prosthesis. The head of the humerus is replaced with a ball-shaped artificial joint (hemiarthroplasty), but some surgeries require the replacement of both the ball and the glenoid (total replacement).
Ball prosthetic joints are typically made of titanium or cobalt-chrome and fixated with cement while socket replacements are made of plastic components. The ball comes with a stem that is inserted into the bone for osseointegration and the promotion of natural bone growth around the stem (HSS, 2020).
What is the Difference Between a Total Shoulder and a Reverse Total Shoulder Replacement?
A reverse total shoulder replacement is when the ball and socket replacement parts are fixated in reverse. The stems of the ball are inserted into the glenoid while the new artificial socket joint is placed on the head of the humerus (HSS, 2020). You can see x-rays and animation videos of this here. Surgeons will suggest a reverse total shoulder for severe shoulder damage in which full range of motion is very unlikely to return.
What Medical Conditions Merit a Shoulder Replacement?
Arthritis in the shoulder joint means that the cartilage has thinned or completely eroded away, causing the joint to move bone-on-bone. Without the cartilage, joint movement becomes rigid and extremely painful which means a shoulder replacement is in order. Other medical causes that require shoulder replacements include fractures, torn rotator cuff tendons, and rheumatoid joint diseases (John Hopkins Medicine, 2020).
A total shoulder replacement helps patients who require new surface areas of the bones, but still have relatively healthy shoulder muscles and tendons to stabilize the joint. Reverse total shoulder replacements are more appropriate for individuals who need to replace damaged bone and who lack healthy soft tissue (i.e. rotator cuff tendons) for joint stabilization (HSS, 2020).
What is the Recovery Time and Process Post Shoulder Replacement?
Immediately after surgery, a patient will be admitted into inpatient recovery for typically 1 to 2 days where they receive medical and rehabilitative services, including occupational therapy. Full recovery can take several months, but the first few weeks of rehabilitation are broken down into phases:
Phase 1 (1 to 4 weeks post-surgery):
No weight-bearing and no AROM (active range of motion) of the operative arm; the arm is in a sling for all out-of-bed activity; arm can be propped on a pillow in bed; No showering until permitted by the surgeon; OT may begin PROM (passive range of motion) of the operative shoulder if permitted by the surgeon.
Phase 2 (4-6 weeks):
No heavy lifting or weight-bearing with the operative arm; the patient will begin to phase out the use of the sling with permission from the surgeon; OT may begin minimal AROM therapeutic exercises of the operative shoulder.
Phase 3 (6-12 weeks):
No lifting of objects greater than 5 lbs and no sudden, jerky movements of the operative arm; OT will continue gradual AROM in combination with strengthening and endurance within prescribed lifting precautions.
Phase 4 (12 weeks+):
Weight-bearing precautions are lifted; the patient should not be wearing the sling at all. OT continues efforts with patient to increase AROM, strength, functional activity tolerance, and functional mobility of the operative shoulder joint. (Beacon Orthopedics & Sports Medicine, 2020).
Phases of recovery provide a general outline for many patients with total shoulder replacements who are otherwise healthy. Some individuals may require more customized recovery plans based on comorbidities including discharge to transitional settings before returning home.
Be sure to check with your surgeon’s post-op shoulder guidelines at your hospital in case their precautions differ.
What Should Be Covered During the Initial OT Evaluation?
What we mean by “initial evaluation” is the first assessment conducted by the overseeing OT practitioner regardless of the setting. Here is a list of a few areas that should be covered in the evaluation via observation and standardized assessments:
- PLOF (prior level of function): Assess the patient’s functional capacity prior to surgery.
- Medical History: Note all previous medical conditions that could impact recovery and therapy participation. Examples include heart and respiratory conditions, arthritic and bone disorders, nerve damage our nervous system disorders, previous surgical operations, mental illness, falls, etc.
- Occupational Profile: Build a short profile regarding the patient’s priorities, interests, and therapy goals.
- Pain Levels: Pain at the operative joint or other body parts at rest and with activity (note which activities exacerbate pain).
- Cognition and Mental Health: Gather information about the patient’s current cognitive capacity and history of mental illness. Cognitive decline or mental health problems could determine whether or not the patient will adhere to precautions and therapy programs.
- AROM/PROM of the Non-Operative Arm: Determine hand dominance and whether or not the patient has full use of the non-operative arm, since he/she will be doing many tasks one-handed for several weeks. Do NOT range the operative arm in inpatient or acute care when they are fresh out of surgery.
- Functional Mobility and Transfers: Assess how well the patient can perform functional transfers with one arm (i.e. sit-to-stand from the bed, the wheelchair, the toilet, the shower, the car, etc.).
- Sitting and Standing Balance: Analyze the patient’s sitting and standing balance with or without external supports. This will give the OT an idea of the patient’s risk for falling and re-injuring the operative shoulder.
- Fall History: Inquire about ground-level falls or near-falls within the last year, what activities lead up to the fall, and whether or not those falls resulted in bodily injury.
- Social Support Systems: Ask about the patient’s current familial or caregiver support at home. Lack of social support can deter recovery and place the patient at risk for hospital re-admission.
- Environmental or Community Assessment: Assess the patient’s physical living environment (which is probably easier to do in home health). Ask about potential barriers such as stairs, heavy doors, hand-rails on the operative side, etc.).
What are Some Specific Post-Total Shoulder Surgery Therapeutic Interventions?
Shoulder replacement OT intervention strategies will vary depending on the setting and which phase of recovery the patient is currently working through. Intervention areas may include:
- ADL Performance and Management: Instructing in one-handed performance of dressing tasks (including donning/doffing the sling).
- Functional Mobility Training: Teaching patients to transfer from various seating surfaces with one hand.
- Pain Management Techniques: Educating patients about positional and ROM techniques (when permitted by the doctor) in combination with prescribed pain medication schedule.
- Manual Therapy: PROM, lymphatic massage, and myofascial release methods to gradually increase functional range of the shoulder and to minimize pain.
- AROM Techniques: When permitted by the doctor, gradually introduce active-range and pendulum activities to increase joint range and to prevent frozen shoulder and muscle atrophy.
- Fine/Gross Motor Coordination: After the initial four weeks, use table-top fine motor and gross motor activities to enhance purposeful movement of the operative arm.
- Physical Agent Modalities: Incorporate the use of modalities for pain management and increasing ROM (i.e. hot packs, cold packs, ultrasound, E-stimulation) as permitted by the surgeon.
- Family/Caregiver Education and Training: For patients who require caregiver assistance before and/or after surgery, make sure to involve them in the therapy process to encourage carry over of exercise programs, restorative strategies, and lifestyle modifications. For more caregiver education tips, be sure to check out our family education post here.
We hope this article helped give you a good foundation of post-shoulder replacement information and interventions for OTs. We want to add that interested new OT graduates or practitioners who are unfamiliar with total shoulder replacement rehabilitation should also seek out mentorship and continuing education opportunities to properly train in relevant evaluation and intervention methods.
Total shoulder replacement recovery plan (2020). Beacon Orthopedic and Sports Medicine. https://www.beaconortho.com/blog/total-shoulder-replacement-recovery-plan/
Total Shoulder Replacement. (2020). John Hopkins Medicine, Orthopaedic Surgery. https://www.hopkinsmedicine.org/orthopaedic-surgery/specialty-areas/shoulder/treatments-procedures/total-shoulder-replacements.html#:~:text=The%20shoulder%20joint%20can%20be,on%20bone%20in%20the%20joint.
Treatment: Shoulder joint replacement. (2020). OrthoInfo. https://orthoinfo.aaos.org/en/treatment/shoulder-joint-replacement/#:~:text=The%20typical%20total%20shoulder%20replacement,press%20fit%22%20into%20the%20bone
Shoulder Replacement (2020). Hospital for Special Surgery. https://www.hss.edu/condition-list_shoulder-replacement.asp