I Wrote a Lot

It’s interesting to think how much this blog has changed since I started writing in February 2013.

We’ve gone from cliff notes of books, to cliff notes of courses, to the occasional self-musing.

While I still plan on reviewing and assimilating courses I take, my hope is to expand and reflect upon whatever is in my brain a smidge more.

It makes sense to start this trend with post 100.

And today, postoperative care is piquing my interest.

Yes, post-op intervention is a guilty pleasure of mine. And it’s not because it’s easy.

Far from easy.

Post op treatment gives you a license to create under various constraints. Meaning you have to dig a little deeper to achieve desired goals.

I think it can be way sexier, and effective, than your typical post-op protocol BS. So let’s create some successful post-op fun.

The First Constraint

Before we even talk about specific patients, we have to first look at the largest constraint yet: available tools.

At my current digs, I don’t have much of anything in terms of heavyweights. So here is what I have at my disposal that I can implement:

• 1-on-1 care for 60 minutes
• Kettlebells: 10, 15, 25 pounds
• Therabands and theratubes of various sizes
• Cook bands of various resistances
• PRI trial orthotics (mouth splints, arch supports, reading glasses, yada)
• Steps
• Tape
• IPAD
• 3D stretch cage (aka very expensive equipment to tie therabands to)
• Access to higher level brain centers
• Heart of gold

We keep things simple at EV.

Early Stages

This is every clinician’s favorite rehabilitation stage, namely because it is incredibly boring.

That is, boring if said clinician has absolutely zero temporal wobble.

You can be amazed at what the patient can actually be do at this stage to expedite the rehab process once movement constraints are lifted.

The most common upper quadrant restriction involves no movement of the involved extremity.

The goals during this stage ought to include:

• Promote a safe healing environment – reduce fear, pain, swelling, etc.
• Restore local mobility
• Restore system variability
• Remap affected regions in the somatosensory homunculus
• Challenge the aerobic system

Let’s take a patient I am seeing post-rotator cuff repair on his right arm. He cannot move his arm for 6 weeks.

Top priority of course is restoring range of motion, so session bulk was spent on pain-free manual therapy and passive range of motion. For home he gets elbow/wrist ROM and nerve glides.

But there is no way in hell I am doing that for 60 minutes.

There are many other things that this fellow can work on aside from basic range. Let’s address the other qualities.

Restore System Variability

In PRI-land, this gentleman was a PEC/RBC/RTMCC. We began to address this protective pattern day 1 after surgery.

Reduce sympathetic tone, reduce threat perception, promote a safe healing environment. Everybody is happy.

Since I knew he would be living in a recliner for the forseeable future, we kept things simple by blowing up a balloon.

One week later our guy came in as a LAIC/RBC with decreased left hip internal rotation, so we shifted our emphasis towards improving right apical expansion while shifting into his left hip.

With this strategy, we were able to maximize system variability within the confines of his restrictions. Gaining apical expansion on the right side was a nice way for the patient to relax the shoulder tissues while keeping the repair intact.

Remap Affected Regions

Use it or lose it reigns king in post-op land. But how can we get this gentleman to use his arm while respecting the passive-only barrier?

Here is where I love graded motor imagery the most. The shoulder’s motor pathways can still run while the repair stays intact.

So day one, we assessed our guy’s left/right discrimination using the NOI Recognise app.

He ended up blowing this stage out of the park, so once we went through all the different challenges this program allows we went straight to explicit motor imagery.

I asked our guy to visualize what his shoulder looked like without the brace first. Once he was able to do this, I had him imagine moving his arm in various movement planes, to progress to envisioning ADL performance with his affected extremity.

In the clinic, I would teach him push/pull movement on his left arm while he imagined performing those actions on his right.

Once he mastered imagery, we began to implement mirror box therapy.

We first started out by just watching him move his “right” arm in the mirror, which he said was very freaky.

Despite the freakiness, it blew him away how much this technique reduced his pain and stiffness.

Once he could do basic movements no problem, we had him work on push/pull movements using his left hand while watching his “right”arm.

His most challenging piece? Open loop arm movements. This task was a beast for his mind:

Combining GMI with working the non-affected extremity tremendously expedited re-learning basic movements on his affected extremity as we progressed later into postoperative care.

Challenge the Aerobic System

 Our guy is in his 50’s and a blue collar worker, so we aren’t getting super wild and crazy here.

Day one we emphasized nice easy walking 20-30 minutes per day to increase circulation and promote healing.

Clinic-wise, we taught him squatting, deadlifting, pressing, and rowing. To emphasize the aerobic system, we kept things at tempo pace to emphasize slow-twitch hypertrophy and aerobic development.

Tempo lifting

• 2-4 sets of 10-12 reps
• Pace 3 second eccentric—no pause—3 second concentric. I tell patients to say this mantra slowly – Screw…you…Zac (eccentric) Screw…you…Zac (concentric). This mantra also helps boost the immune system because patients find it funny. Two points for me!
• 30-40 seconds rests between sets.

Later Rehab Stages

 The later rehab stages look somewhat similar to typical fare, though I do not emphasize isolated strengthening so much.

Once the active assist/active unresisted phase is allowed, we switch to that stuff. Shoulder remapping becomes a greater active process, so most of GMI is stopped. Let’s get him moving.

Our program also shifts toward him using his right extremity to aide in variability restoration. He has limited flexion, so I like a doorway lat stretch:

http://www.youtube.com/watch?v=tSaCPVLfSHU

[side note: amazing that most comments I’ve heard on this vid involve my glutes and not the technique. Upon reflection of most of my life, this probably is not as surprising]

I also like him doing unresisted reaching:

We still emphasize challenging the aerobic system and the unaffected extremities, but this usually accounts for about 20% of the session at this time.

Once we can start resistance training the extremity, we keep things simple. I like push/pull movements and static/dynamic motor control exercises. So we teach our guys armbars, get-ups, carries, crawling, etc.

I don’t use a whole lot of isolated cuff work during the rehab process. The cuff doesn’t really work as a prime mover, so unless the goal is cuff hypertrophy (aka gettin’ Swolebodan Milosevic), I don’t do it.

In the cases that I have scrapped cuff isolation exercises, I still saw manual muscle testing improve just the same. So let’s teach the cuff to be a cuff.

We finish the rehab process by making it look a lot more like fitness. By the end, the hope is to have system variability restored, local mobility in the clear, and strength up to snuff. Teach your guys and gals the basic movements and emphasize patient-specific functional activities, and you are in the clear.

Final Thoughts

 That’s where I am right now with upper quadrant post-operative care. There is a lot that these folks can be doing, and my challenge to you is to make those early stages of rehab some of the most exciting for the patient.

Now go and create!