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.
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