View source for Rehabilitation program of the shoulder

== Traumatic  ==

This traumatic dislocation protocol will vary in length for each individual depending on the seven key factors and the arm dominance, desired goals and activities. <ref name="Wilk" /> 

<u>Phase 1 - The acute motion phase</u> 

The glenohumeral joint will be immobilized in an internally rotated and adducted position (2-4 weeks to allow scarring of the injured capsule and younger people 7-14 days). There is some discuss about the position of immobilisation. Several studies concluded that immobilization in external rotation significantly reduced the the recurrence rate of instability in first-time-dislocaters and chronic dislocation. <ref name="Wilk" /><ref name="Cutts">Cutts, S., Prempeh, M., Drew, S., 'Anterior shoulder dislocation', Ann R coll Surg Engl, VOL. 91 (2009), p. 2-7 (Level of evidence 2A)</ref> 

The goals of this phase are: decrease pain, inflammation and muscular spasms; re-establish [[Shoulder Instability|dynamic stability]] and non-painful range of motion; retard muscular atrophy; improve proprioception and protect the healing capsular structures. To achieve this goals, following aspects will be implement: 

*decrease pain and inflammation 
*Range of motion (ROM) exercise: activo-passive, passive and active whit some help<br> 
*Strengthening/proprioception exercises: isometrics performed with the arm at side 
*Rhythmic stabilization

Before the patient may enters the following phase, he must meet certain criteria which include: 

1) Full functional ROM, 2) minimal pain and diminished inflammation, 3) sufficient static stability and 4) adequate neuromuscular control. 

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<u>Phase 2 - Intermediate phase</u> 

Goals of this phase are: enhance the proprioception, kinesthesia and dynamic stabilization; regain and improve muscular strength and the neuromuscular control; and normalize arthrokinematics. To achieve this goals, following aspects will be implement: <ref name="Wilk" /> 

*Progress ROM at 90 degrees abduction (painfree) 
*Initiate isotonic strengthening: emphasis on external rotation and scapular strengthening 
*Neuromuscular control of the shoulder complex: initiating proprioceptive exercise, rhythmic stabilization drills 
*As needed: continue use of ice, [[Current Concepts in Electrotherapy|eletrotherapy]] modalities<br>

Before the patient may enters phase 3, he must meet certain criteria which include: 

1) minimal pain and tenderness, 2) symmetrical capsular mobility, 3) full non-painfull ROM and 4) good strength, endurance and dynamic stability of the upper extremity and scapulothoracic musculature. 

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<u>Phase 3 - Advances strengthening phase</u> 

Goals of this phase are: improve the neuromuscular control, strength, power and endurance; enhance the dynamic stabilizations; and prepare the patient or athlete for his activities. To achieve this goals, following aspects will be implement: <ref name="Wilk" /> 

*As needed: continue use of ice or electrotherapy modalities 
*Continue isotonic strengthening, but now progressing resistance 
*Emphasize PNF (45,90 and 145 degrees) 
*When working whit athletes: advanced neuromuscular control drills 
*Endurance training: increase the length of an exercise, more repetitions, more exercise periods throughout a day 
*Initiate plyometric training

Before the patient may enters phase 4, he must meet certain criteria which include: 

1) Full functional ROM, 2) static and dynamic stability and&nbsp; 3) sufficient strength and endurance. 



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<u>Phase 4 - Return to activity phase</u> 

Goals of this phase are: increase the activity level (progressively) to prepare the patient or the athlete for functional return to his activity or sport. To achieve this goals, following aspects will be implement: <ref name="Wilk" /> 

*Exercise as in phase 3 
*Progress the isotonic strengthening exercises 
*An interval sport program 
*consider a brace for contact sports (stabilizing the [[Glenohumeral Joint|glenohumeral joint)]]

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<u>Follow up</u>: 

*Isokinetic test (external and internal rotation; ab- and adduction) 
*a progress interval training 
*Maintain the exercise program

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