NPTE Rehab Protocols

Anterior THA

Avoid 90* hip flexion

Hip extension, adduction, ER

Posterior THA

Avoid hip flexion >90*, IR, ADD

THA Phase 1: Maximal protection

• Education to patient/caregiver to avoid precautions

• Usually WBAT

• Ankle pumps to prevent DVT formation

• Monitor for possible infection

• Maximize Functional mobility (bed mobility, transfer training,

appropriate trunk mechanics when sit to stand to avoid violating

dislocation precautions)

• Strengthen UE's for assistance with daily tasks

• Avoid hip flexion contracture

THA Stage 2

Typically begins 4-6 weeks post-op

• Regain strength and muscular endurance

• Strengthen hip abductors and ER's

• Improve CV and Pulmonary endurance

• Restore ROM within dislocation precautions

• Improve postural stability, balance, gait

THA Stage 3

Begins around 12 weeks post-op

• Extended rehab and modification of activities if necessary

• Ensure good strength of hip abductors and ER's

• Return to sport and higher level activities

TKA Stage 1

(Weeks 1-4)

• Control postoperative swelling

• Minimize pain

• Control for DVT and infection development

• Increase ROM to 0-90 (Extension priority!)

• 3/5 to 4/5 strength of quadriceps

• Ambulate with or without assistive device

• Establish HEP

Intervention

• Ankle pumps

• Quad/Hamstring/Abductor/Adductor Setting

• Gait Training

• Patellar Mobilization

TKA Stage 2

(Weeks 4-8)

• Reduce swelling

• ROM 0-110

• 4/5 to 5/5 strength in all LE musculature

• Unrestricted ADL function

• Improve balance, functional mobility, neuromuscular control

Interventions

• Patellar mobilization

• LE stretching

• Closed chain strengthening and PRE's

• Tibiofemoral joint mobilization if needed

• Proprioceptive training

• Aerobic exercise (cycling, swimming, walking)

TKA Stage 3

(Week 8 onward)

• Develop maintenance program

• Community ambulation

• Improve cardiopulmonary endurance and aerobic fitness training

Interventions

• Same as Stage II with progressions

• Progress balance and advanced functional activities

• Exercises specific to sport or higher level activity

Total Shoulder Arthroplasty

• The most important thing to note on a TSA is whether or not

rotator cuff repair was performed

• If so, sling will be needed for at least 4-6 weeks

• If not, sling will be weaned off within the same day as surgery

• The two most prominent forms of shoulder arthroplasty are

the intact rotator cuff TSA and the reverse TSA

Intact Cuff TSA Phase 1

(Weeks 0-4)

• Elevation of the arm restricted to < 120 degrees

• ER of arm restricted < 30 degrees (with arm at side)

• Grade I/II joint oscillation

• AROM scapular and elbow

• PROM and AAROM

• AAROM in supine for first 3 weeks

• At week 4, can transition to sitting/standing

• No active IR for AT LEAST 6 weeks (protect subscapularis repair)

• Pendulum exercise

• Light, NWB isometrics of shoulder muscles in scapular plane

Intact Cuff TSA Phase 2

(Weeks 4-12)

• Continue AROM

• No GH extension past neutral (up to 6 weeks)

• Gradually increase GH rotation

• Gentle stretching after 6-8 weeks

• Improve function of rotator cuff and scapular stabilizers

• Submaximal isometrics of GH muscles with light weight bearing

through UE

• Delay resisted rotation for several weeks (if non-intact cuff)

• Progress to low-resistance dynamic strengthening

Intact Cuff TSA Phase 3

(12+ weeks)

• Combined adduction, internal rotation, and extension permitted

• Progress end range self stretches

• Progressive resistive exercises in functional patterns

• Closed chain stabilization

Reverse TSA Phase 1

(0-6 weeks)

• Abduction splint (24 hrs/day for < 3 but < 6 weeks)

• No GH extension or IR past neutral

• 0-20 of ER and up to 90-120 elevation in scapular plane

• Once immobilizer can be removed:

• Grade I/II oscillations

• AROM of scapula and elbow

• Pendulum

• PROM only of GH joint

• Only light, NWB isometrics of scapular stabilizers and deltoid

Reverse TSA Phase 2

(6-12 weeks)

• No GH extension or IR past neutral

• 0-20 ER and up to 90-120 arm elevation in scapular plane

• Increase PROM while observing above

• AAROM (begin in supine, progress to sitting)

• Improve function of deltoid/scapular stabilizers

• Submaximal isometrics (NWB only)

• Delay resisted rotation for several weeks

• Progress to low-resistance, dynamic strengthening of elbow/wrist

towards the end of this phase

Reverse TSA Phase 3

(Weeks 12+)

• Gentle stretching within motion restrictions

• Begin closed chain stabilization

• Progress UE PRE's in functional patterns

Rotator Cuff Repair

Passive or assisted ROM within SAFE and PAIN-FREE ranges

based on surgeon's report

• Only passive, non-assisted ROM for 6-8 weeks after repair

• Initially performed in supine with progression to sitting/standing

• Minimize superior/anterior translation of humeral head

• Do not allow active shoulder flexion/abduction until patient

can lift arm without hiking shoulder

Rotator Cuff Repair: Strengthening

Isometric scapular stabilizer strengthening with arm supported

• No weight bearing for 6 weeks

• Delay dynamic strengthening for minimum of 8 weeks

• Avoid ER in this time frame for supraspinatus/infraspinatus repairs

• Avoid IR in this time frame for subscapularis repairs

Rotator Cuff Repair: Stretching

Avoid vigorous stretching, contract-relax, or grade III+

mobilizations for at least 6 weeks

• If supraspinatus/infraspinatus, avoid stretching into IR

• If subscapularis, avoid stretching into ER

SLAP Repair

Limit passive or assisted elevation of arm to 60 degrees for

first 2 weeks, and up to 90 degrees at 3 to 4 weeks post-op

• Perform only passive assisted humeral rotation with the

shoulder in scapular plane for first two weeks

• ER to neutral, IR to 45

• During weeks 3-4, progress ER up to 30 and IR to 60

• Avoid positions that create tension in biceps (elbow extension

with shoulder extension) during first 4-6 weeks

• Postpone active elbow flexion for 6 weeks and resisted biceps

exercises until 8-12 weeks

• Avoid positions of abduction combined with ER (places stress

on biceps insertion on to glenoid)

Wrist- Flexor Tendon Repair

Wrist is immobilized after surgery for up to 5 days, unless

prolonged immobilization is necessary

• Zone I,II,III repair immobilization- 10° to 45° of wrist flexion

and from 40° to 70° of MCP flexion with the IP joints in full but

comfortable extension

• Exercises approaches to maintain tendon-gliding and prevent

adhesions :

-Early controlled passive motion

-Early controlled active motion

Flexor Tendon Repair Phase 1

(Up to 3-5 weeks)

• Passive MCP, PIP, and DIP flexion and extension of each individual

joint

• Place and hold exercises

• Minimum-tension, short-arc motion

Flexor Tendon Repair Phase 2

(4 to 8 weeks)

• Aim -Safely increase stress on the repaired tendon & achieve full

active flexion and extension of the wrist & glides of the tendons

• Place-and-hold exercises with gradual increase in tension

Active ROM - Flexion & extension of the IP joints with the MCP joints

flexed, MCP flexion/extension with IP joints relaxed, and active wrist

flexion and extension with fingers relaxed

• Initiate tendon-gliding and blocking exercises at 5-6 weeks

Flexor Tendon Repair Phase 3

(8 weeks)

• Resistance exercises to improve strength and endurance

• Dexterity exercises

• Use of the hand for light (1 to 2 lb) functional activities

Extensor Tendon Repair

Immobilization in an extended position. For zone III/IV repair,

the PIP and sometimes the DIP joints are placed in extension,

but for a zone V/VI repair, the wrist is held in 30° of extension

and the MCP joints in 30° to 45° of flexion.

Extensor Tendon Repair: Early Controlled Active Motion Approach (Central slip repair)

• Exercise is performed with finger splint.

• E.g. One splint is molded to limit PIP flexion to 30° and DIP flexion to

20° or 25° and the other splint is fabricated to hold the PIP joint in

full extension during isolated DIP flexion limited to 30° to 35°.

End of 4 weeks, the patient achieves 70° to 80° of active flexion &

full extension of the PIP joint.

• Composite MCP, PIP, and DIP flexion - At 4 weeks or when the

exercise splints have been discontinued.

• By 6 to 8 weeks- low-intensity resisted exercises, gradual use of the

hand for functional activities

Extensor Tendon Repair: Delayed Mobilization Approach

Exercises are delayed for at least several weeks after surgery and

depends on the extensor tendon zone

• Resisted exercises are not initiated until 8-12 weeks

Achilles Tendon Repair

Achilles Tendon Repair

• Weight bearing

• Conventional Approach- Six weeks immobilization and non-weight

bearing

• Early Remobilization Approach- immediately after surgery or after 1

or 2 weeks

Achilles Tendon Repair Phase 1

( Up to 4 to 6 weeks )

• Active ROM of non-immobilized joints

• Muscle setting exercise of dorsiflexors, invertors, evertors and

plantarflexors (at 2 weeks).

• Weight-shifting activities in bilateral stance while wearing the

orthosis (when partial weight bearing is permitted)

Achilles Tendon Repair Phase 2

(4-6 weeks to 12 weeks)

• Weaning from orthosis

• Grade III joint mobilisation techniques

• Self-stretching and active ROM exercises

• Strengthning exercise - OKC of hip, knee, ankle and CKC like heel

raise (B/L to U/L)

• Balance training wearing functional orthosis

• Gait training and cardiopulmonary exercises

Achilles Tendon Repair Phase 3

(After 12 to 16 weeks)

• Return to pre-injury level

• Strength and muscular endurance training

• Plyometric training and treadmill walking on an incline, advance

training