Rehabilitative Protocols CPM upper limbs

Fisiotek HP2
the complete C.P.M. machine for all the upper limbs


This study has been taken from a clinical report made by Dr. Riccardo Galassi, from Ceccarini Riccione Hospital (Riccione, Rimini, Italy), who has studied a rehabilitative protocol for the passive rehabiliation following the intervention of rotator cuff lesion.

In the protocol have been underlined the main important clinical features and values offered by the unit, which use is considered extremely effective in the earliest phases of the rehabilitation process.

INTRODUCTION

An operated shoulder requires continuous passive mobilization (c.p.m.) right from the immediate post-operative period to progressively and atraumatically reach the physiological joint range. This makes it possible for us to undertake the following rehabilitation phase in the best joint conditions both anatomically and functionally. Generally, the most “uncovered” period in the rehabilitation period of an operated shoulder is represented by the first 15-20 days after the operation. This is the period when the patients are often left to manage the situation by themselves, in an inadequate manner since they have been sent home with printed sheets with some tips and a prepared set of exercises to do. This behavior frequently has a completely negative influence on the following rehabilitation process.
Normal arm use requires consistent fluid movements coordinated by the humerus, scapula and clavicle. In order for these movements to be possible, all the joint and extra-joint components must be integral and there must be a complete range of motion (R.O.M.) in all spatial planes.
Thus complete joint function of the scapula humerus complex is our first important goal in the rehabilitation pathway not only for an operated shoulder, but for all its other pathologies.
Fisiotek HP 2, based on the c.p.m. design already used for the knee, is an optimal addition to this initial post-operative phase. Obviously, it is not intended to replace a physical therapist’s technical work, but to integrate it at a specific time in the rehabilitation pathway, where the main aim is to obtain the most complete possible recovery of the shoulder joint range.

PASSIVE CONTINUOUS MOBILIZATION (C.P.M.)

Passive joint mobilization is a maneuver made by applying an external force to one or more joint districts to gradually bring them to the limit of their R.O.M. (range of motion) with a fluid, slow and repeated movement, which is more importantly atraumatic and not painful.
The force can be applied manually by trained individuals or by applying motorized mobilizing devices. The mobilization techniques (manual or motorized) can have different aims, for example :
·      Mobilization to maintain mechanically healthy joints, but with a temporarily or permanent deficit motor system, this helps maintain tissue trophicity, lubrication of joint surfaces, improves sliding of tissue planes among each other, maintaining a good level of elasticity of the periarticular soft tissues. These mobilizations always require respecting the physiological mobility of each joint hinge.
·      Mobilization to recover the physiological joint range in all cases where the joint structure has totally or partly lost its mobility due to a pathological process or prolonged immobilization such as after a trauma or operation. The mobilization technique must scrupulously respect the physiology based on its anatomical characteristics and the type of pathology or operation it has undergone..
Immediate post-operative mobilization, within the limits allowed by the repair process, as often described in literature, has proved to be beneficial to the repair process and recovery of joint function. The list below provides a summary of its principle effects on the healing process:
1.    Maintain trophicity of the joint elements.
2.    Improve exchange of synovial fluid among the various joint tissue components.
3.    Maintain the cartilage surfaces in a state of dynamic pressure and thus improve the exchange of nutrients.
4.    Progressively enhance a condition of physiological tension of the capsule ligament system.
5.    Maintain muscle fiber elasticity improving muscle trophicity and decreasing hypotrophy from immobility.
6.    Improve progressive, atraumatic and painless recovery of joint function, until restoring  R.O.M. where possible.
7.    Reawaken the proprioceptive system of the mobilized joint complex.
8.    Accelerate reabsorption of post-operative hemarthroses and edemas.
9.    Prevent the formation of tissue adhesion thus minimizing the reduction of joint range.
10.Decrease the possibility of reflex sympathetic dystrophy.
11.Improve blood flow in tissues and thus aid the repair process.
12.Produce a positive psychological effect on patients who do not find themselves left to their own devices in the first post-operative weeks  as often happens.
It is important to start passive mobilization right from the very first post-operative days (2nd-3rd day), because due to the above mentioned effects, it aids the rehabilitation process, preventing the onset of complications which are a hindrance to recovery and difficult to resolve.

Passive mobilization with Fisiotek HP 2 can be used with many shoulder pathologies, both surgical and non-surgical

1.    Surgical pathologies

*      Operated recurring dislocations
*      Arthroscopy for calcified tendinitis
*      Tenotomy of the long head of the biceps tendon
*      Acromionplasty with tenotomy of the supraspinatus
*      Arthroscopy for supraspinatus lesion with acromioplasty
*      Synovectomy, bursectomy, arthroscopic acromioplasty
*      Shoulder prosthesis

2.    Non-surgical pathologies

*      Brachial nerve lesion
*      Conservatively treated humerus fracture
*      Rotator cuff tendinopathies
*      Tuberosity fracture
*      Calcified tendinopathies
*      Sub acromial impingement
*      Rotator cuff lesion
*      Arthrosis
*      Contusion traumas of the rotator cuff
*      Adhesive capsulitis



MATERIALS AND METHODS

In the Function Recovery and Reeducation Department of the Riccione Hospital we subjected all patients operated for rotator cuff lesion to passive continual mobilization.
In order to provide a correct and effective rehabilitation intervention, passive mobilization was administered from the first post-operative week for around three weeks. In the first week we started with passive mobilization in Abduction-Adduction and in Flexion on the scapular plane  (anterior/posterior flexion of around 20°), which turned out to be better tolerated. External rotation was only introduced in the third-fourth week. The procedure of the gradual recovery of joint range was not rigidly standardized in all patients, but personalized based on the entity of the rotator cuff lesion and arthrotomic or arthroscopic technique used, accelerating the time span for the latter. A faster recovery of joint function in abduction and flexion and earlier introduction of rotation in comparison to the classic models which do not start before the fourth week.
The exercises were administered in a sitting position for Abduction-Adduction and Flexion and in a supine position for the Rotations. Some of the machine characteristics and the goals we had set to reach with it were explained to patients before beginning the first session. The aim was to obtain patient relaxation and let them become comfortable with the machine in order to achieve the greatest possible collaboration. The duration of each passive session ranged from 45 to 60 minutes, divided into different joint movements (approximately 15-20 minutes for each one). We gave priority to the sitting position, when possible, compared to supine, as this gave us a more complete vision of the should joint, including pitching of the scapula on the thoracic plane.
Each patient was treated on the following joint planes:

Elevation with patient in sitting position: this mobilization is administered as early as the first week with progressive increase in R.O.M. of around 20°-40° per week, depending on the type of operation (arthrotomic or arthroscopic) and lesion. The speed varies between 2° and 3.2° per second, always opting for the one the patient deems most comfortable. We always followed the rule of no pain on all spatial planes.

Abduction-adduction with patient in sitting position: work time around 15-20 minutes per session, trying to find the speed that was the most comfortable for the patient, with the same values as above. The work range, i.e. joint range, varied between 35° and 150°. Obviously, the R.O.M. recovery was gradually programmed, with an increase between 20°-35° per week. This mobilization was also started early, from the first week.

Rotation with patient in supine position: the session was programmed according to the parameters of time, from 15 to 20 minutes, speed between 1.5° and 3.2° per second, modifying it based on the comfort level expressed by the patient; with movement range varying between 30°-0°-85°. This mobilization was introduced later than the others, generally from the third week varying the time based on the shoulder lesion and type of operation (arthrotomic or arthroscopic). The degree recovery was slower compared to the other mobilizations by around 50% (approximately 15°-20° per week).



CONSIDERATIONS

Fisiotek HP 2 device demonstrated a significant degree of versatility in passive mobilization of a shoulder operated on for rotator cuff lesion and in numerous other surgical and non-surgical pathologies, as mentioned above.
The limited number of patients treated at S.R.R.F. at Ceccarini Hospital does not make it possible to extrapolate absolute value figures, but it definitely makes it possible to express a favorable opinion regarding the use of this device in the earliest phases of the rehabilitation process.
There are numerous reason for this favorable impact. These are primarily linked to the significant degree of satisfaction expressed by the patient due to faster treatment by the public health service, as early as the first post-operative week, and because this treatment, with gradual and painless R.O.M. recovery, is viewed as very comfortable and pleasant by the patient..
Its easy use after a short period of training and many adjustment possibilities that can be used to move the should even with different elbow positions are elements which meet the needs of physical therapists. The use of the device carefully following the manual and the rule of painless mobilization proved safe and did not produce problems requiring its suspension.
The greatest advantages to using Fisiotek HP 2 are those linked to an early applied continuous passive mobilization (c.p.m.) which have been described above.
Obviously, Fisiotek HP 2 does not replace the technical and qualified work of the physical therapist, nor could it, just like other devices have not (isokinetic). Its role is to be integrated with the physical therapist’s work in the first three to four weeks of the rehabilitation pathway, which are the most “uncovered” and thus very touchy. C.p.m. was seem to have a series of positive effects in the repair processes of tissues which had been operated on, which make it an excellent therapeutic tool suitable for preventing various complications, which often delay the recovery process, as well as not being fast and easy to solve.
Its use must follow some simple but important rules: treatment must start early, as early as the 2nd-3rd post-operative day, and generally continue for two-three weeks, to be progressively replaced with active reeducation. Its use must comply with the no pain rule. Standardized protocols which are the same for everyone, must not be followed: like all rehabilitation processes, they must be personalized and adapted to the patient’s clinical situation, based on the pathological process and repair processes and the rehabilitation goals to be met.

The current opinion on post-operative rehabilitation treatment, has gone from an attitude of waiting and relying on varying lengths of immobilization, towards a more active and dynamic rehabilitation program. The principal to follow is that restoration of joint function must proceed at the same rate as restoration of tissue anatomy and must not be secondary or delayed. For the reason, early passive mobilization, as early as immediately after surgery, has proved to be very beneficial for the entire rehabilitation process, accelerating the timeframe and improving the healing of tissues which have been operated on and preventing various complications. Passive mobilization carried out with an instrument like Fisiotek HP 2, if started early, completes the rehabilitation pathway of the operated shoulder by profitably integrating the manual work of the physical therapist, who nevertheless remains the focal point of the entire rehabilitation process.