An Occupational Therapist’s Guide to Shoulder Arthroplasty in the Acute Care Setting

Disclaimer

This information is for educational purposes only and is not intended to treat, diagnose, or cure any illness or disease. If you are someone who recently underwent a total shoulder replacement, talk with your doctor and occupational therapist (OT) before participating in any of these exercises. If you are an OT, OT student, or any other health care professional, ensure that you modify these exercises to meet your patient's specific and individual needs.

Whether you’re a new graduate occupational therapist (OT), an OT student, or a health care professional, this blog post is intended to provide introductory knowledge for evaluating and treating patients who have undergone a shoulder replacement. I recently started a job working in the acute care setting, and evaluate and treat joints (shoulder, knee, hip) often. Through my training, research, and experience I use a one-two day protocol with the patients who are admitted. (length of stay typically depends on the doctor). Here is the typical format I follow.

Also, another disclaimer is that each hospital has its own protocols and policies, and each patient has unique needs and goals for therapy! This protocol is based on my training as a new hire, my experiences, and the research I have accumulated.

Post-Operation Day One

1. Chart review

2. Check MD’s therapy orders: precautions, weight-bearing status (typically non weight-bearing (NWB)).

3. Upon entering the patient’s room ask about their:

   1. Pain (*If greater than a 6/10 call/notify RN and ask when pain meds were last issued)

   2. Sensation (upper extremity sensation deficits are common due to nerve block)

   3. Dizziness (dizziness/ nausea is common due to medications)

4. Ask the patient questions regarding their pain, prior level of function, home environment, adaptive equipment, etc.

5. Educate the patient/ caregiver about:

   Their specific weight-bearing precautions ordered from their doctor (MD) - usually non-weight bearing

   Safe positioning - (patient’s elbow supported on pillow and wearing shoulder immobilizer).

   *Research suggests a neutral rotation sling with an abduction pillow wedge vs. a traditional internal rotation (IR) sling shows greater external rotation and adduction motion up to one year following surgery as well as reduced night pain at 2 weeks postoperatively (Kennedy et al., p. 5, 2020).

   Use or (non use) of thumb strap 

   Clothing recommendations: (Elastic waist band/ no button up shirts/ loose fitting shirts, etc.)

6. Facilitate active finger, wrist, and forearm range of motion /passive elbow and shoulder range of motion (10 reps each)

   *Tip: Remove the sling prior to completing A/PROM; have the patient’s elbow rest on a pillow to limit shoulder internal/ external rotation.

AROM:

1. Opening/Closing Hand (“Hand squeezes.”)

2. Wrist Flexion/Extension (“Slaps".)

AAROM:

1. Forearm Pronation/Supination (Also called “pancakes.”)

PROM:

1. Shoulder External Rotation NO MORE THAN 10 degrees (some MD’s do not approved external or internal rotation post shoulder replacement- it depends on the doctor’s orders).

2. Elbow Flexion/Extension - no more than 90 (Typically, but not always the most painful).

3. Shoulder abduction/adduction

Provide Home Exercise Plan (HEP) x10 each; complete 2-3 times per day

1. Opening/Closing Hand (“Hand squeezes.”)

2. Wrist Flexion/Extension (“Slaps".)

3. Forearm Pronation/Supination (Also called “pancakes.”)

Post-Operation Day Two

1. Active/ Passive range of motion: (tip: keep the sling on while completing range of motion to provide more stability; however unfasten the straps.)

2. Dressing education using compensatory techniques (Donning shirt with affected arm FIRST; taking off shirt with affected side LAST).

   1. Upper Body (UB) Dressing My typical sequence is: 1. Doff sling/gown on top -> 2. don Shirt → 3. don sling (add thumb strap prior to standing) → 4. don pants.

3. Sling management - Describe to the patient/ patient’s spouse/ caregiver how to don/doff sling.

4. (OPTIONAL) Shower/ Toilet Transfers - in/out shower with tub transfer bench or shower chair while maintaining precautions/ toilet

5. Reinforce safety precautions and educate patient about potential discharge plan (Do they have home health/ outpatient/ post acute stay?).

This outline serves as a foundation for understanding shoulder replacement OT rehabilitation. Each patient's journey will differ, necessitating personalized and adaptable strategies. If you have any questions about any step of the protocol, please email me at juliannemadeline.ot@gmail.com or comment below! Thank you for reading, and I hope this information is useful to you as an OT or student!

Reference
Kennedy, J. S., Garrigues, G. E., Pozzi, F., Zens, M. J., Gaunt, B., Phillips, B., Bakshi, A., & Tate, A. R. (2020). The American Society of Shoulder and Elbow Therapists' consensus statement on rehabilitation for anatomic total shoulder arthroplasty. Journal of shoulder and elbow surgery, 29(10), 2149–2162. https://doi.org/10.1016/j.jse.2020.05.019