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PSRP has been designed to ensure complete patient compliance and at the same time providing optimal rehabilitation in the minimum time interval. The programme for primary impingement, rotator cuff tears and arthritis is designed as a two-phase therapy. The first phase is totally supervised for about two weeks followed by a home programme for about four weeks. Patients with chronic shoulder problems for more than two years and patients of adhesive capsulitis especially with diabetes are given an extended first phase of three weeks. Patients of SLAP tear, bankart repair and multi-directional instability require additional inputs in the form of scapular setting exercises & restoration of scapulo-humeral rhythm. Some of these young patients are keen to pursue an overhead sports hobby, in which case they need to attend the third phase, six months after surgery or normalization before they enter their desired sports programme.
Phase I essentially comprises of scapular strengthening programme along with capsular stretching exercises if the shoulder is stiff. Patients who have pain and disability without shoulder stiffness can be offered scapular setting exercises in lieu of the capsular stretching exercises. This is a crucial time for the therapist to gain confidence of the patient. From the patients perspective this can be a painful experience, especially so on the first few days, due to the dramatic increase in stresses on the shoulder joint. During the capsular stretches, all patients tend to be apprehensive and resist the stretches. It is important for the therapist to continuously distract the patient with plenty of shop talk and at the same time concentrate on gentle stretches. Each patient has his/her own individual parameters of tolerance. Each therapist has to in turn exceed these restraints, by marginal fractions each day.
Therapist who are new to this programme must at all times perform the stretches with the patient in supine position as this helps artificially stabilize the scapula without the support of the scapular muscles. If scapular muscles remain weak & unstable, then stretching in sitting position can encourage impingement, leading to pain and further non-compliance from the patient.
Stretching of the anterior capsule achieves improvement of external rotation and is usually the last movement to return to normal. The anterior capsule tends to be a thick obstinate structure which yields only with time particularly in diabetic patients and longstanding contractures. The anterior capsule should be stretched to its tolerance limit and held in the terminal position to a count of 10. This should be done as 10 repetitions of each stretch. The initial stretch may be done with the shoulder in neutral followed by shoulder in 90 degrees of abduction (if possible) for similar repetitions of ten each. This helps stretch different segments of the anterior capsule.
These involve guiding the shoulder without scapular elevation to occur in forward flexion and abduction. Similarly the therapist must reach to maximum point of patient tolerance and hold for 10 seconds with ten repetitions each. One must be careful to avoid impingement, especially in abduction, for fear of provoking pain. Experienced therapist will realize that forward flexion yields much earlier than abduction. The reason for this is unless a normal external rotation is restored it is impossible for the greater tuberosity to clear the acromion. In fact it is our experience that the progress of external rotation and abduction is interlinked and is often the last bastion to fall.
Occasionally the posterior capsule can behave like a tenacious unrelenting structure and restoration of internal rotation can thus be delayed. This is a very functional movement that a patient requires to reach his/her mouth and back and scratch the back or tie their bra strap. Stretches should be given in forward flexion adduction across the body and adduction internal rotation manoeuvre behind the back. Patients can be taught self stretches with a towel to lift the affected hand behind their back.
The emphasis is again on the rhomboids, serratus anterior, and levator scapulae along with the lower trapezius. It is important to include anti-gravity exercises as it is rather difficult to train these muscles for resistive exercises. The therapist must understand the watchforpain correct technique for each muscle and confirm whether the required muscle is recruited during the particular exercise. So often wasting or pain inhibition will allow a neighbouring muscle to be activated - this is a common problem for failure of the programme. Each muscle shoulder contracted for about 10 seconds followed by ten repetitions. With each passing day the repetitions and the old time can be progressively increased.
Therabands are useful to follow a closed chain exercise programme against resistance. Closed chain principle is all the more important in the shoulder joint which tends to be unstable. The knee joint can tolerate open chain exercises in most conditions and thus leading to controversies over pursuing an open pr closed chain programme. For the shoulder joint which is inherently unstable and prone to impingement the entire PSRP is based on the closed chain principle. These are colour coded bands ranging for yellow to red, followed by green, blue and black in increasing range of resistance. It is not mandatory to use only therabands and the PSRP does not patronise any particular brand as such. There are cheaper substitutes which can be used provided a reasonable standardization is achieved. PSRP does not advice starting therabands training on day one. Principally one must wait for some semblance of scapular control and increased tone of the scapular muscles. Hence depending on patients' physical fitness and response to Phase I, therabands are started at about the 5th day. Bracing the shoulders (often referred to as Ground Zero) is expected. Also while strengthening supraspinatus the maximum elevation allowed is 75 degrees in mid-abduction otherwise this can provoke impingement, leading to pain and noncompliance cycle. Smooth gentle movements without any jerks or kickback are advised. Maintaining a hold of ten seconds followed by ten repetitions is standard practice. These can progressively be increased daily. It is the therapist's duty to supervise correct technique of therabands exercise as patients are seen to frequently do these wrongly. Eccentric strengthening is also emphasized during rehabilitation i.e. controlling return movement during exercises with elastic bands.
There are three main components of the scapular stabilizing programme:
1. Setting in Neutral 2. Assisted Setting with Passive Control 3. Dynamic Control / Dissociation
It is essential that muscle imbalance problems are addressed to facilitate optimal scapula stability and scapulo/gleno-humeral alignment to minimize the risk of impingement and/or instability.
The scapular muscle strengthening programme addresses the scapular stabilization in neutral. The focus is on strengthening essentially rhomboids and the serratus anterior. However, along with these exercises, the levator scapulae with the lower trapezius is also exercised. By far the most important exercise here is the prone rhomboid strengthening - which is done in 3 steps.
Step 1 is in prone & replicates the standing bracing exercises by rolling the shoulder blades (Scapulae) towards each other. Frequently patients mistake this for levator strengthening and end up shrugging their shoulders. Once shrugged it is difficult for the shoulders to brace themselves. Therapists need to practice this exercise a few times themselves to achieve the correct movement pattern. The correct exercise involves rhomboid contraction for up to ten seconds followed by ten such repetitions to start with.
Step 2 & 3 involve recruiting different segments of the rhomboids and can be quite difficult to do for elderly, obese and patients with stiff shoulders. Hence we advocate step 2 & 3 only for the young instability patients as it is preferable to do few exercises but with the correct technique.
Step 2 is a variation of the same theme where the patient lies prone and braces the scapula and then with flexed elbows maintains the palms in contact with the bed and lifts the flexed elbows upwards. The patient does not bear any weight through the palms but only lightly keeps them on the floor or bed.
Step 3 is a further variation where instead of the palms the patient makes contact with the flexed elbow and lifts the palms up in the air. Similarly the patient does not bear weight through the flexed elbows. Each of step 2 & 3 exercise is done for ten seconds hold followed by ten repetitions.
* Patients should progress from Step 1 to 3 only after achieving proficiency at each stage.
With the therapist facing the patients scapula the patients affected arm is taken through the full arc of forward flexion passively. One hand of the therapist is supporting the inferior angle of the scapula and the other outer hand is supporting the hand to control the downward movement of the arm. The arm has to be brought down very slowly as the patient is required to develop cognition of the scapular position and also regenerate proprioception sense of the scapulohumeral rhythm. The restoration of proprioception pathways is a time consuming therapy. Repetitive simulation of the correct movement pattern will help the patient take cognition of the correct rhythm. The scapular stabilization program is recommended for three weeks during which patients are encouraged to understand correct scapular positioning and start to grasp control of their scapular positioning. Some intelligent patients, especially with a medical background, will achieve this within two weeks whereas chronic patients with muscle imbalance do take more time.
After achieving the goals of the previous two sets the patient is usually ready to go on the home exercise programme. Apart from the other standard rehab programme the younger instability patients are encouraged to develop dynamic control of their scapular rhythm & movement. By now patients have developed an awareness of their scapular position and at home are advised slow forward flexion (up to 90 degrees) and abduction (up to 60 degrees) exercises. During this 90/60 degree range of flexion/abduction patients should ideally achieve movement independent of scapular movement. Patients are warned about the fact that if they lose control over the scapular movement they will have to restart supervised proprioceptive exercises all over again. It is our experience that most patients develop their independent scapula control over three weeks and only patients with severe scapular instability have had to extend their program for a total of six weeks.
Deltoid responds quickly to resisted exercises. However in the absence of rotator cuff function, the deltoid contraction will result in proximal migration of the humerus. Basically the cuff contraction helps bind the head of the humerus to the glenoid resulting in effective abduction by deltoid without causing impingement. Hence, in patients with a rotator cuff tear or dysfunction, or post operative rotator cuff repair patients deltoid strengthening should not be taken up. The therapist should be awake to this problem and hence his/her clinical assessment is very important.