EXERCISE TECHNIQUES DURING ACUTE AND EARLY SUBACUTE STAGES OF TISSUE HEALING
During the protection and early controlled motion phases
of management, when inflammation is present or just beginning to resolve and the
healing tissues should not be stressed, early motion may be utilized to inhibit
pain and muscle guarding and help prevent deleterious effects of complete
immobilization. This section describes and summarizes techniques that may be
used for these purposes. During the acute and early subacute stages, when
motion in the shoulder itself is limited to allow tissues to begin to heal, it
is also valuable to treat associated areas such as the cervical and thoracic
spine, the scapulae, and the remainder of the upper extremity (elbow, wrist,
and hand) to begin correcting faulty posture, relieve stresses to the shoulder
girdle, and prevent fluid stasis in the extremity.
Early motion is usually passive ROM (PROM) and applied within
pain-free ranges. When tolerated, active-assistive range of motion (A-AROM) is
initiated.
Early Motion of the Glenohumeral Joint Wand Exercises
Patient position and procedure: Initiate A-AROM using
a cane, wand, or T-bar in the supine position to provide stabilization and
control of the scapula during the protection and early controlled motion
phases. Motions usually included are flexion, abduction, flexion in the plane
of the scapula (scaption), and rotation . If it is necessary to relieve stress
on the anterior capsule, such as following surgical repair of the capsule or labrum,
place a folded towel under the humerus to position the humerus anterior to the
midline of the body when the patient performs internal or external rotation . When
treating a shoulder impingement (primary or secondary), have the patient grasp
the wand with the forearm supinated when flexing and abducting to emphasize external
rotation .
Ball Rolling or Table Top Dusting
Patient position and procedure: Sitting with the arm
resting on a table and hand placed on a 6- to 8-inch ball or towel and the shoulder
in the plane of the scapula. Have the patient initiate gentle circular motions of
the shoulder by moving the trunk forward, backward, and to the side, allowing
the hand to roll the ball or “dust the table.” As pain subsides, have the
patient use the shoulder muscles to actively move the ball or cloth through
greater ROMs.
Wall (Window) Washing
Patient position and procedure: Standing with hand
placed against a wall supporting a towel or a ball. Instruct the patient to
perform clockwise and counterclockwise circular motions with the hand moving
the towel or rolling the ball. Progress this activity by having the patient
reach upward and outward as far as tolerated without causing symptoms.
Pendulum (Codman’s) Exercises
Patient position and procedure: Standing, with the
trunk flexed at the hips about 90_. The arm hangs loosely downward in a
position between 60_ and 90_ flexion or scaption A pendulum or swinging motion
of the arm is initiated by having the patient move the trunk slightly back and forth.
Motions of flexion, extension, and horizontal abduction, adduction, and
circumduction can be done. Increase the arc of motion as tolerated. This
technique should not cause pain. If the patient cannot maintain balance while
leaning over, have the patient hold on to a solid structure or lie prone on a
table. If the patient experiences back pain from bending over, use the prone
position. Adding a weight to the hand or using wrist cuffs causes a greater
distraction force on the GH joint. Weights should be used only when joint
stretching maneuvers are indicated late in the subacute and chronic stages—and then
only if the scapula is stabilized by the therapist or a belt is placed around
the thorax and scapula so the stretch force is directed to the joint, not the
soft tissue of the scapulothoracic region.
“Gear Shift” Exercises
Patient position and procedure: Sitting with the
involved arm at the side, holding a cane or wand with the tip resting on the
floor to support the weight of the arm. Instruct the patient to move the pole forward
and back, diagonally, or laterally and medially in a motion similar to shifting
gears in a car with a floor shift .
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