PRINCIPLES OF HYDROTHERAPY

Rehabilitation in a warm-water pool facilitates gain of mobility after shoulder arthroplasty. Rehabilitation with the shoulder submerged or partially submerged in warm water provides a “weightless” environment. This “weightlessness” allows the arm to find the best path to achieve a specific movement. Additionally, a warm-water environment provides comfort and improves proprioception while minimizing pain. Whereas thermal neutrality is obtained with water heated to 34°C, a water temperature of 35°C increases skin comfort while increasing body temperature less than 1°C, thus minimizing the risk of development of a heat-induced inflammatory response.

REHABILITATION PROTOCOL

Rehabilitation starts with choosing the type of postoperative orthosis and its duration of use. This is based largely on the type of arthroplasty performed (unconstrained, fracture, reverse) and the performance of any associated procedures (posterior capsulorrhaphy). Table 43-1 summarizes the types of orthoses used and the duration of their use based on the procedure performed. All patients are instructed in hand, wrist, and elbow mobility exercises on postoperative day 1. Patients undergoing unconstrained shoulder arthroplasty for chronic conditions without performance of an associated posterior capsulorrhaphy are also instructed in pendulum exercises on postoperative day 1. These exercises are performed three to five times per day for approximately 15 minutes each time and are continued throughout the rehabilitative program. The time of initiation of hydrotherapy depends on the type of arthroplasty performed. Table 43-2 summarizes the time that hydrotherapy is instituted based on the procedure performed.

Table 43-1 TYPE OF POSTOPERATIVE ORTHOSIS USED AND DURATION OF USE

Table 43-2 TIME FOR INITIATION OF HYDROTHERAPY

Hydrotherapy is performed in a warm (35°C) rehabilitation pool that is approximately 1.3 m in depth at its deepest point. The pool is fitted with supports that can accommodate the straps and harnesses used in the rehabilitation process. The surgical wound is covered with a waterproof, air-permeable hypoallergenic adhesive dressing. Patients are equipped with a mask and snorkel for use during hydrotherapy.

Hydrotherapy takes place daily (5 to 7 days per week, depending on availability) in a single 30- to 45-minute session. An abbreviated land-based verification session follows to affirm gains in mobility achieved in the pool. Various exercises designed to gain elevation, extension, horizontal adduction, internal rotation, and external rotation are performed in sets of 10 repetitions (Figs. 43-1 through 43-4). The unaffected extremity is used to help power the movement. Active mobility of the operated extremity is allowed in the form of a slow, gentle breaststroke motion with the palms placed horizontally (to not invoke resistance from the water), which is performed with the patient supported by a harness and the shoulders submerged (Fig. 43-5). In patients who have undergone unconstrained shoulder arthroplasty, external rotation beyond neutral is not allowed until 4 weeks postoperatively in patients with primary osteoarthritis or osteonecrosis and 6 weeks in patients with compromised soft tissues (inflammatory arthropathies, revision surgery) to protect the subscapularis repair. In patients who have undergone an associated posterior capsulorrhaphy, internal rotation and horizontal adduction are avoided until 4 weeks postoperatively. With the exception of these cases, no limitations on mobility are imposed.

Figure. 43-1 Shoulder flexion and extension exercises.

Figure. 43-2 Internal rotation exercises.

Figure. 43-3 External rotation exercises.

Figure. 43-4 Horizontal adduction exercises.

Figure. 43-5 A and B, Breaststroke exercise.

Mobility exercises with total body immersion are advised for all patients; however, it is not forced on anyone. Patients who wish to try such exercises are fitted with a weighted belt and instructed to hold their breath as they kneel or recline supine on the bottom of the pool (Fig. 43-6). The same mobility exercises are then performed in the more insulated underwater environment. This technique is very helpful in accelerating gains in mobility.

Figure. 43-6 Total body immersion exercises.

As soon as the patient has achieved 140 degrees of elevation, the hands can be clasped behind the head in the “siesta” position (Fig. 43-7). Additional stretching exercises for the anterior capsule (Fig. 43-8) and posterior capsule (Fig. 43-9) can be performed in this position. From this position, motion is advanced until the “triple-locking” position is achieved, which stretches the inferior capsule (Fig. 43-10). Both the siesta and triple-locking positions are used extensively in a self-rehabilitation program implemented after the patient has been discharged from formal physical therapy.

Figure. 43-7 “Siesta” position.

Figure 43-8 Anterior capsule stretching from the siesta position.

Figure 43-9 Posterior capsule stretching from the siesta position.

Figure. 43-10 The triple-locking position.

An abbreviated session of land-based rehabilitation is used after the hydrotherapy session. The land-based session is performed principally to affirm the gains that the patient has made during the hydrotherapy sessions. The same exercises are used, but with fewer repetitions. Modality treatment (i.e., cryotherapy) is used on an as-needed basis. Analgesic pain medication is provided to patients for the first 6 postoperative weeks to alleviate the discomfort associated with surgery and subsequent rehabilitation.

All patients participate in at least 5 weeks of hydrotherapy, after which they are re-evaluated. If acceptable active mobility has been achieved, hydrotherapy is discontinued and the patient is graduated to a land-based self-rehabilitation regimen incorporating the siesta and triple-locking stretches performed several times per day indefinitely. If it is determined that the patient would benefit from continued hydrotherapy, 6 additional weeks of hydrotherapy is prescribed. Most patients are able to discontinue hydrotherapy and graduate to the self-rehabilitation program by 3 months postoperatively. Some patients, particularly those living in rural areas, do not have access to a physical therapist with a rehabilitation pool. In these circumstances, patients learn the program from an experienced therapist in a more urban location and perform the program in any public or private pool that they may have available on their own. Additionally, any patients who prove adept at performing the exercises in the hydrotherapy program are allowed to complete the program independently with periodic monitoring by a physical therapist.

Rarely, we encounter a patient with a true fear of water. Although an inability to swim is not a contraindication to hydrotherapy rehabilitation, anxiety or fearfulness at the prospect of aquatic-based rehabilitation is a contraindication. In these patients, we prescribe a land-based program incorporating the same exercises that are used in the rehabilitation pool. In general, the land-based program is effective in obtaining an end result similar to that achieved with hydrotherapy, but it usually takes longer to achieve this result and patients tend to have more pain during rehabilitation.

RETURN TO ACTIVITY

With this protocol, patients can be expected to resume activities of daily living on a normal basis before 3 months postoperatively. No specific strengthening exercises are performed in this protocol. Gradual resumption of normal activities is all that is required to regain strength, and it presents minimal risk to the patient.

We allow our patients to pursue most activities and sports after shoulder arthroplasty. We do limit patients to noncontact sports. The majority of our arthroplasty patients with athletic interests participate in golf and tennis. Restrictions placed on golfers and tennis players are designed to protect the subscapularis repair. Putting is allowed as soon as the patient can tolerate it postoperatively, usually within 6 weeks. At 3 months, half swings with a seven iron off a tee are allowed. This is advanced until the patient is allowed to hit a full swing with all clubs off a tee 4 to 5 months postoperatively. At 6 months after surgery, unrestricted golf is allowed. Tennis players are permitted to begin gentle ground strokes 3 months postoperatively. The intensity of the ground strokes is increased 4 to 5 months after surgery. Unrestricted tennis, including serves and overhead shots, is allowed 6 months postoperatively.

Although we do not recommend any specific strengthening exercises as part of the rehabilitation program, some of our younger patients enjoy weightlifting as part of their fitness regimen. Upper extremity weightlifting is allowed starting 6 months postoperatively. Patients are encouraged to use weightlifting for muscle toning only and not to engage in any type of power-lifting exercises. We have had patients participate in sports such as trap shooting, water skiing, snow skiing, and mountain climbing 6 months after undergoing shoulder arthroplasty.