Thursday, October 2, 2008

A Standard Rehabilitation Protocol For Glenohumeral Instability

The following program is for patients with glenohumeral instability who have either had an acute dislocation or chronic instability that is initially being treated nonsurgically. The important factors that will influence the success of the rehabilitation program include:
Past medical history,
Acute versus chronic condition,
Activity level,
Direction of instability,
Traumatic versus atraumatic etiology, and
In general, young, active patients with a 1st time dislocation may have up to a 90% risk of recurrent dislocations. Studies at West Point have shown nearly a 100% risk of recurrent dislocations in their high demand patient population. Early arthroscopic repair may be the best option for these patients in order to reduce the future morbidity associated with repeat shoulder dislocations. The following Rehab Protocol should be used for patients who decide NOT to have surgery after their 1st dislocation or for those who have chronic instability.

Patients with chronic instability should begin with Phase II. The use of a sling in Phase I is controversial. A prospective randomized study evaluating the utility of immobilization after an acute dislocation does not exist in the literature. The studies that do exist do not show a definitive reduction in recurrent instability for patients who do use a sling. Nevertheless, patients are more comfortable with a sling and therefore should use one until acute symptoms improve.

PHASE I (2-4 weeks)
Use a sling for 2-4 weeks (FOR COMFORT ONLY).
Cryotherapy 10-20 minutes 3-4 times daily for pain control and inflammation.
Nonsteroidal anti-inflammatory drugs (NSAIDs) and modalities such as high voltage electrical stimulation and/or ultrasound.
Codman’s type pendulum exercises.
Submaximal isometric contraction exercises.
Passive, active-assisted, and active range of motion exercises avoiding the positions of apprehension which include combined abduction and external rotation for patients with anterior instability.
Continue cryotherapy after exercise sessions
Concentric tubing exercises for rotator cuff and scapular stabilization in addition to the isometric exercises.
Postural exercises.
Begin dynamic muscular stabilization exercises (Proprioceptive Neuro Feedback- PNF).
Obtain full range of motion with minimal apprehension in all directions.
Progressive strengthening with concentric weighted activities.
Continued dynamic muscle stabilization exercises.
Isokinetic strength evaluation. Continued focus on strengthening in areas where weakness is noted.
Sport specific functional progression such as a throwing progression program.
Return to full sports activities as the patient is able to go through an entire functional progression program without pain or apprehension.
NB. As always progression through the Phases is individualized for each patient.

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