Pune!Shoulder!Rehabilitation!Program!(PSRP)! …jointandbones.com/pdf/psrp manual 2013 lw.pdfIt!includes!activation!of!transverse!abdominus!and!lower!abdominal!muscles!! For!Post!Surgery!Patients!

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Pune!Shoulder!Rehabilitation!Program!(PSRP)!

!

Introduction!

Pune!Shoulder!Rehabilitation!Programme!(PSRP)!is!essentially!developed!by!

Dr.Ashish!Babhulkar,!orthopaedic!surgeon!and!who!specialised!in!shoulder.!

After!finishing!his!formal!training!in!his!subject!of!interest!i.e.!shoulder!from!

Liverpool!UK!he!returned!to!Pune,!India!and!during!his!initial!practice!he!

noticed!the!lack!of!knowledge!and!awareness!in!shoulder!rehabilitation!and!it!

provoked!him!for!developing!the!complete!exercise!package!for!shoulder!

rehabilitation!PSRP.!

Its!been!more!than!10!years!that!we!are!practicing!PSRP!and!it!went!thru!lot!of!

modifications!over!the!period!of!10!years.!!

We!have!been!seeing!amazing!results!by!using!PSRP!in!these!10!years!in!

different!shoulder!conditions!ranging!from!simple!Mechanical!postural!

problem,!Rotator!cuff!tendinoses,!Rotator!cuff!tears,!Instabilities,!MDIs,!Nerve!

injuries,!Nerve!impairments,!Brachial!plexopathies,!shoulder!joint!arthritis!to!

different!surgical!interventions!including!Rotator!cuff!repairs,!Bankart!Repairs!

SLAP!repairs!Shoulder!Replacements!Reverse!Shoulder!Replacement.!

We!have!been!seeing!approximately!100/day!of!different!shoulder!conditions.!

And!we!have!been!departing!education!regarding!the!same!thru!one!day!

Didactic!lecture!programme!series!and!A_Z!shoulder!workshop!for!2days!n!10!

days!of!hands!on.!

!

PSRP!basically!consists!of!essence!of!shoulder!rehabilitation.!

It!is!divided!into!III!Phases.!

PHASE!I:!Patient!has!to!perform!the!programme!under!strict!supervision!of!

trained!shoulder!rehabilitation!therapist!which!is!compulsory!of!10!days!

duration.!

PHASE!II:!Patient!has!to!perform!all!the!exercises!at!home!for!6!weeks!and!then!

come!for!the!follow!up!with!Dr.!And!treating!shoulder!rehabilitation!therapist.!

PHASE!III:!These!are!special!exercises!only!for!patients!who!are!into!sports!or!

have!high!demand!activities!of!shoulder.!The!selection!criteria!is!necessarily!

done!by!Dr.!And!trained!shoulder!rehabilitation!therapist.!

!

Core!exercises!are!incorporated!compulsory!for!all!patients.!!

!

!

It!includes!activation!of!transverse!abdominus!and!lower!abdominal!muscles!

!

For!Post!Surgery!Patients!

The!demand!of!rehabilitation!is!different!in!post!surgery!patients!hence!we!

follow!slightly!different!protocol.!It!includes!different!exercises!than!only!PSRP!

For!day!1Y3!

For!day!3Yday!15!

For!day!15Yweek!6!

For!week!6!onwards!we!follow!Proper!PSRP.!

!

For!rotator!cuff!arthropathy!patients!or!for!patients!who!have!irreparable!full!

thickness!cuff!tear!we!follow!totally!different!programme!it’s!called!Cuff!

Substitution!Programme.!

!

Principle!of!PSRP!

Normalize!scapular!muscle!strength!

Normalize!scapuloYhumeral!rhythm!

Pain!relief!

Rotator!cuff!muscle!strengthening!

Restoration!of!ROM!

Restoration!of!function!

Maintaining!posture!and!core!!

!

It!is!imp!to!facilitate!the!optimal!scapular!stability!and!scapuloYhumeral!

alignment!by!reducing!muscle!imbalance!to!reduce!chances!of!impingement!

or!instability.!

Definition!of!PSRP!

This!is!an!exercise!programme!which!includes!exercises!with!lowYresistance,!

highYrepetition!performed!in!subYimpingement!region!for!strengthening!of!

scapular!and!rotator!cuff!muscles.!!!

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!

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Phase&I&

!This!is!a!primary!and!principle!stage!of!PSRP.!It!includes!!

a)!Scapular!setting,!strengthening!!

b)!Rotator!cuff!muscles!strengthening!

c)!Capsular!stretches!

d)!Core!muscle!strengthening!exercises.!

!

Phase!I!is!two!weeks!program!under!strict!supervision!of!trained!

Physiotherapist.!

!

Scapular!setting!exercises!

!

!

Rhomboids&/&Medial&scapular&Muscles&

&

Position:&

Standing!!!(Standing!sets)!!

!Prone!(Prone!sets)!

!

!

Techniques:&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&

Fig:&1a)&

Fig:1b)&

&

Standing&Position:&Exercise&1&&& &

a) Keeping!arms!in!neutral!position,!!

b) Retract!both!the!shoulders.!Hold!it!there!at!the!maximum!contraction,!as!

both!scapulae!should!come!nearer,!for!the!count!of!ten!and!release!

gradually.!

!

!

!

!

! Fig:&2&a)& &

Fig:&2b)!

Exercise&2&

a) Keeping!arms!in!neutral!position,!!

b) Retract!both!the!shoulders!same!like!above!and!gradually!extend!both!

arms!and!hold!it!there!for!the!count!of!ten.!

!

Compensations&that&can&occur:&

1. Patient!may!extend!the!neck.!

2. Patient!may!elevate!the!shoulder.!

3. Patient!may!hold!breath.!

4. Patient!may!extend!the!back.!

5. You!may!bend!your!elbow!and!do!the!same!activity!in!exe!2!

If!patient!has!knee!problem!or!back!problem!or!inability!to!stand!he!can!

perform!exercise!in!sitting!position!

!

Prone&Position:!(AntiYgravity)!

Exercise&1&

!

!

&&&&&&&&&&&&&&& Fig:3a)&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&

Fig:3b)&

a) Patient!lying!on!stomach!and!keeping!his!hands!by!the!side.!!

b) Retract!both!the!shoulders!in!the!same!position!hold!it!for!10!counts!and!

slowly!relax!

!

Exercise!4!

Fig&4a)!

!

!

!

Fig&4&b)!!

a)!Keeping!arms!in!neutral!position,!!

b)!Retract!both!the!shoulders!and!gradually!extend!both!arms!and!hold!it!

there!for!the!count!of!ten!and!then!slowly!relax.!

Exercise!5!

Fig&5a)&

&

While!in!Prone!position,!elbows!are!flexed!at!90!degrees!and!placed!at!

shoulder!level.!

!

!

a) For!Rhomboids!Lower!Fibres:!!!!!!

Fig:5b)&

&

Retract!shoulders!and!placing!the!elbows!down!try!to!raise!forearm!and!

hands!off!the!mat.!Slow!release.!Ten!counts!hold!and!release.!

1) For!Rhomboids!Upper!Fibres:!

!Fig:5c)!

Retract!both!shoulders!and!elbows!flexed!and!placed!as!above.!By!

Keeping!the!hands!touching!down!the!plinth!try!to!raise!the!elbows!up.!

Slow!release.!Ten!counts!hold!and!release.!

Compensations!that!can!occur:!




9. Patient!may!extend!the!back!

!

!

10. EXE!NO!5!a!b!&c!are!not!given!to!patients!who!has!range!restriction!or&severe!pain!and!impingement!and!cannot!maintain!the!position!

&

Dynamic!Scapular!muscle!strengthening!with!Theraband!

!

1) Rhomboids!(!medial!scapular!muscles)Y!Brugger’s!technique!!

!Fig:!6a)!!!!!!!!!!!!!!!!!!!!!!!!!!!

!Fig:6b)!

!

Position:!

Standing!!

Technique:!

a. Keep!shoulder!blades!retracted!and!depressed.!

!

!

b. Keep!both!the!elbows!flexed!at!90!degrees!and!fixed!to!body,!with!both!forearms!parallel!to!each!other!and!to!the!ground!also.!

c. Tie!the!TheraYband!above!both!wrists.!

d. Make!a!loop!like!tying!tie!knot!and!take!the!band!in!palm!from!behind!

measure!till!elbow!and!tie!the!loop!to!other!wrist!

e. Keeping!both!elbows!fixed!to!body,!Retract!both!shoulders!slowly!and!then!pull!the!forearms!apart!against!Theraband!resistance.!!

f. Hold!it!there!at!maximum!for!ten!counts!and!slowly!release!it!to!the!

neutral.!Repeat!this!for!ten!times.!

!

Compensations!to!look!for:!





!

!

!

!

!!!!!ASB!Rhomboids!Technique!:! Fig:7!

a)!

!

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Fig&:&7b)&

&

a. In!standing!position,!shoulders!must!be!abducted!and!externally!

rotated!and!then!elbows!must!be!flexed!to!90!degrees.!

b. !Retract!the!shoulders!in!above!position,!and!try!to!extend!the!elbows!by!concentrating!on!upper!portion!of!medial!scapular!area.!One!should!

feel!maximum!pinch!over!there.!

c. Hold!it!there!at!maximum!pinch!and!release!slowly.!Repeat!it!for!ten!

times.!!

Note:!ASB!Rhomboids!is!a!challenging!technique!and!needs!good!coY

activation!of!the!shoulder!stabilizers.!It!is!to!be!performed!only!after!

basic!exercises!are!mastered.!In!cases!of!severe!impingement!

dislocation!and!range!restriction!in!ABD/ER!this!exercise!is!not!given.!

Compensations!to!look!for!





5. Make!sure!patient!does!not!take!the!band!above!ear!level!

!

!

Modified!Brugger’s!Technique!

!

a) !Hold!the!band!in!both!the!hands!by!pinching!it!in!thumbs.!Take!reverse!

wrap!in!both!the!hands.!

!

!

b) Starting!position!is!like!a!womb!position!fingers!wrist!flexed!elbows!

flexed!and!pronated.!!

c) First!fan!your!fingers!by!extending!and!abducting!them,!then!fan!your!

thumb!!then!extend!both!the!wrists,!then!supinate!and!extend!both!

elbows!and!by!retracting!the!shoulders,!slowly!abduct!and!!extend!

both!the!arms!backwards!by!maintaining!the!above!position.!

d) Hold!it!there!for!ten!counts!and!release!slowly.!Repeat!it!for!ten!times.!!

!

!!


1. Patient!may!not!maintain!the!angle!of!the!elbows.!

2. Patient!may!elevate!the!shoulder.!!

3. Patient!may!hold!the!breath!

4. Patient!may!extend!the!back!instead!of!retraction!

!

2) !Serratus!Anterior!!!

Position:!

Standing!

Fig:8a)!

!

!

Fig:8b)!

Technique:!

a) !Patient!must!be!standing!straight.!

b) Put!the!band!on!the!upper!back!(on!scapulae)!by!tying!the!ends!of!the!

band!on!both!palms,!while!both!the!elbows!are!flexed!and!hands!close!

to!the!body.!

c) Pull!the!arms!forwards!and!cross!it!at!the!nipple!level!just!before!

complete!elbow!extension.!Avoid!complete!elbow!extension.!(Teddy!

bear!hug)!

d) Hold!it!there!for!ten!counts!and!slowly!release.!Repeat!it!for!ten!times.!

!


1. Patient!may!extend!the!elbows.!

2. Patient!may!elevate!the!shoulders.!

3. Patient!may!sway!back.!

!

3) Supraspinatus!

Position:!!!!!

Empty!Can!/!Full!Can!

!

!

Fig:9a) Fi F Fig !

Technique:!

a)!Keep!shoulder!blades!retracted!and!depressed!

b)!Arm!completely!internally!rotated!for!Empty!Can.!

!Tie! the! TheraYband! with! 2! knots! at! wrist! and! measure! complete! hand!

length!distance!which!is!the!lever!arm!for!exercise!and!put!your!feet!on!that!

point!then!start!the!exercise.!

c)!!Lift!the!arm!in!45!deg!in!scaption!position!

d)!Hold!for!10!secends!and!very!SLOWLY!take!down.!

e)!Repeat!the!same!for!10!repetitions!


1. Patient!may!arch!his!back!

2. Patient!!may!elevate!the!shoulder!

3. Patient!may!use!the!wrist!or!fingers!to!lift!the!arm!

4. Patient!may!bend!his!elbow!

!

Full!Can!

!

!

!Fig!9:c)!

Keep!the!hand!in!complete!external!rotation!and!then!complete!the!movement!

as!explained!in!empty!can!position!

!

4)!Infraspinatus:!

Position:!

Standing!with!elbow!flexed!at!90!degrees!

!

Technique:!

a) !!Patient!is!standing!with!the!elbow!is!flexed!at!90!degrees.!The!band!is!tied!on!the!wrist!with!two!knots.!

b) The!other!end!of!the!band!is!tied!to!the!fixed!support!which!should!be!

exactly!at!the!elbow!height.!And!band!length!should!be!equal!length!of!

the!forearm.!!

c) A!small!pillow!or!roll!of!towel!should!be!kept!under!the!elbow!so!as!to!fix!

it!there.!

d) The!exercising!arm!should!be!placed!opposite!to!the!fulcrum.!

e) By!retracting!the!shoulder!in!above!position!patient!should!externally!

rotate!the!forearm!(outward)from!complete!internal!rotation!till!

maximum!external!rotation,!maintaining!body!straight.!!

f) Hold!for!count!of!ten!at!the!maximum!and!slow!release.!Repeat!ten!

times.!!

!

!

!

!!!!!!!Compensations!to!look!for!

1. Patient!is!may!not!maintain!the!angle!of!the!elbows.!


3. Patient!may!compensate!with!wrist!extension.!!

4. Patient!may!turn!the!body.!

5. Patient!may!extend!elbow.!

6. May!be!shoulder!and!elbow!are!not!in!a!line!

!

5)!Subscapularis:!

!!Position:!

!!!!Standing!with!elbow!flexed!at!90!degrees!

!

!!Technique:!

a. Patient!is!standing!with!the!elbow!is!flexed!at!90!degrees.!The!band!is!tied!on!the!wrist!with!two!knots.!

b. The!other!end!of!the!band!is!tied!to!the!fixed!support!which!should!be!exactly!at!the!elbow!height.!And!band!length!should!be!equal!length!of!

the!forearm.!!

c. Exercising!arm!should!be!placed!to!the!side!of!fulcrum.!

d. By!retracting!the!shoulder!in!above!position!patient!should!internally!rotate!the!forearm!(inward)!at!maximum,!maintaining!body!straight.!!

e. Hold!for!count!of!ten!at!the!maximum!and!slow!release.!Repeat!ten!

times.!!

!

Note:!!Subscapularis!strengthening!should!be!given!in!exceptional!cases!

such!as!in!Subscapularis!tear/!repair!or!in!surgeries!in!which!

Subscapularis!is!being!handled.!

!

!!!!!!!Compensations!to!look!for!

1. Patient!is!may!not!maintain!the!angle!of!the!elbows.!


3. Patient!may!compensate!with!wrist!extension.!!

4. Patient!may!turn!the!body.!

!

!

!

CORE!EXERCISES!

These!exercises!are!compulsory!for!every!patient.!As!it!works!on!

improving!kinetic!chain!imbalances!and!improve!proprioceptive!ability!of!

body.!!

!

Transverses!Abdominus!(!Core!strengthening)!

!

Position:!

Supine!with!knees!flexed!at!60!degrees!

!

Techniques:!

1st!technique!

a) !While!patient!lying!in!supine!position!with!knees!flexed,!ask!patient!

to!breathe!in!slowly!with!the!nose!and!slowly!breathYout!with!the!

mouth!as!in!blowing!the!balloon.!!

b) Ask!patient!to!perform!“tummy!–!tuck”!and!perinea!contraction!and!

then!bring!up!the!neck!very!slowly.!

c) Patient!has!to!feel!the!contraction!in!between!two!ASIS.!d) Hold!for!count!of!ten!at!the!maximum!and!slow!release.!Repeat!ten!

times.!

!

!!!!!!Compensations!to!look!for!

1. Patient!may!hold!the!breathe.!

2. Patient!may!make!the!neck!stiff.!

3. Patient!may!use!other!abdominal!muscles!such!as!Rectus!abdominus.!

!

!!!!!!2nd!technique!(Bilateral!SLR)!

!

!

!

Position:!

Supine!with!legs!straight!

Technique:!

a) !Patient!lying!supine!with!legs!straight!and!parallel.!b) While!breathing!normal,!ask!patient!to!lift!both!legs!at!a!time!at!

maximum!!30!degrees!above!the!ground.!(Or!as!much!as!the!patient!

can).!

c) !Hold!for!count!of!ten!at!30!degrees!and!slow!release.!Repeat!ten!times.!

!


a) Patient!may!hold!the!breath.!

b) Patient!may!arch!the!back.!

c) Patient!may!use!other!abdominal!muscles!such!as!Rectus!Abdominis.!

!

3rd!Technique!(cycling)!

!

!

!

&&

Position:!!

Supine!

!

Technique:!

a) Patient!is!in!supine!position.!Ask!patient!to!perform!tummy!tuck!and!

the!lift!both!legs!at!a!time!at!30!degrees.!

b) Patient! has! to! flex! one! of! the! legs,! while! extending! the! other!alternately.! Allow! for! an! infinitesimal! pause! at! the! end! of! leg!

extension.!

c) Keep!repeating!till!the!count!of!ten!and!release!it!slowly.!Repeat!for!ten!times.!

!


i. Patient!may!hold!the!breath.!

ii. Patient!may!arch!the!back.!

iii. Patient! may! exercise! very! fast! thereby! recruiting! other! hip! and!

abdominal!muscles.!

!

!

!

4th!Technique!(Scissors)!

!

!

!

Position:!

Supine!

!

Technique:!

a) Ask! patient! to! perform! tummy! tuck! and! then! to! lift! both! legs! at! a!

time!as!above!to!30!degrees.!

b) Ask! the! patient! to! raise! one! leg! upwards!while! the! other! leg! going!down!slowly.!And!then!viceYaYversa.!

c) Keep!repeating!very!slowly,!till!the!count!of!ten!and!release!it!slowly.!Repeat!for!ten!times.!

!


1.!Patient!may!hold!the!breath.!

2.!Patient!may!arch!the!back.!

!

!

3.! Patient! may! do! it! very! fast! recruiting! other! hip! and! abdominal!

muscles.!

4.!Patient!may!bend!the!knees!

!

!

Capsular!Stretches!!

!

Inferior!capsular!stretch!

!

Position:!

!

Supine!

Technique:!

a) !Ask!the!patient!to!clasp!the!hands!properly.!b) Then! patient! has! to! take! it! overhead! slowly! with! the! help! of! good!

arm.!He!is!supposed!to!take!help!of!good!arm!to!stretch!it!beyond!the!

available!range.!

c) The!stretch!should!be!within!the!limit!of!pain!and!elastic!limit.!

d) Instead!of!using!hands,!patient!can!make!use!of!wand!for!stretching.!

!!!!!!!!!Same!stretch!can!be!performed! in!standing!position!by! fixing!the!body!

to!the!wall.!

Posterior!capsule!Stretch!

Position:!

!

!

!

Sitting!or!Supine!

Technique:!

a) Cross!adduct!the!affected!arm!of!the!patient!with!the!elbow!flexed.!

b) Either!therapist!can!stretch!it!by!putting!the!pressure!on!the!elbow!or!ask!the!patient!to!apply!it!with!the!opposite!arm.!

c) Maintain! the! stretch! for! count!of! ten!and! release.!Repeat! it! for!3Y4!

times.!

!

Anterior!Capsule!stretch!

!

Position:!

!

!

!

!

Standing!!

Technique:!

a) While! in! standing! position,! ask! the! patient! to! face! the! wall! at! its!

corner.!The!arm!should!be!abducted!and!externally!rotated!and!then!

elbow!should!be!flexed!to!90!degrees!and!the!forearm!must!be!fixed!

to!the!wall.!

b) In!above!position!patient!has!to!lean!forward!by!putting!the!opposite!leg!forward!(stride!stance)!

c) Patient!has!to!feel!the!stretch!anteriorly!at!the!shoulder.!d) Maintain! the! stretch! for! count!of! ten!and! release.!Repeat! it! for!3Y4!

times.!

!

Sleepers!Stretch!

Position:!

!

!

!

Side!lying!!

!

Technique:!

a) Patient!has!lie!down!in!lateral!decubitus!with!the!shoulder!abducted!and! the! elbow! flexed! at! 90! degrees! and! elbow! placed! at! shoulder!

level.!(90Y90!position).!

b) Very!carefully!and!slowly!therapist!has!to!apply!gentle!stretch!inward!(Posterior!capsule)!and!outward!(anterior!capsule),!alternately.!

c) Therapist!can!also!instruct!patient!carefully,!to!do!these!stretches!at!home!with!the!help!of!good!arm.!

!

Phase!II!

Phases!II!includes!the!same!exercises!as!Phase!1,!but!patient!has!to!

perform!it!at!home!after!learning!it!properly!by!a!trained!shoulder!

rehabilitation!therapist.!Duration!of!Phase!II!is!about!6!to!8!weeks.!

!

!

!

Phase!III!

!

Phase!III!protocol! is!started!only!after!basic!exercises!are!mastered!and!

principle! shoulder! muscles! like! rotator! cuff! muscles! and! scapular!

muscles!have!got!enough!strength!and!optimal!stability!of!the!shoulder!

complex!is!achieved.!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Sports! persons,! workers! or! individuals! who! are! in!

demand!of!high!intensity,!challenging!and!dynamic!activities,!must!go!for!

Phase!III!.Usually!after!6!to!8!weeks!generous!Phase!I!exercises.!!

!

!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!These! are! functional! dynamic! multiaxial! exercises!

which!puts!maximum!challenge!on!the!shoulder!muscles!so!as!to!do!any!

functional!activity.!Theraband!are!used! to!perform!PNF! (Proprioceptive!

Neuromuscular!Facilitation)!Patterns.!

D1!Pattern:!

!

Position:!

Standing!!

Technique:!

a) Patient! is! standing!straight!with!band!wrapped! in! the!affected!hand!and!the!other!end!under!the!foot!with!optimal!tension!maintain!good!

base!of!support.!

b) First!patient!has!to!pull!the!band!in!shoulder!flexion,!adduction!(with!elbow!and!wrist!flexed)and!external!rotation!as!if!he!is!trying!to!touch!

the! opposite! ear! (! D1Flexion! )! ,! like! in! Tennis! BackYHand! .The!

movement!must!be!smooth!and!slow.!

c) With! a! little! hold! at! the! end,! patient! has! to! take! the! arm! back! in!

shoulder,!elbow!and!wrist!extension,!shoulder!abduction!and!internal!

rotation.!(!D1!Extension)!

d) Repeat!it!for!ten!times.!

!

!

D2!Pattern:!

!

!

! !

Position:!

Standing!!

Technique:!

a. Patient! is! standing!straight!with!band!wrapped! in! the!affected!hand!and! the! other! end! is! tied! to! upper! fixed! point! optimal! tension!

maintaining!good!base!of!support.!

b. First!patient!has!to!keep!the!shoulder!flexion,!abduction!(with!elbow!and!wrist! flexed)and! external! rotation!while! the! forearm! supinated!

and!wrist!and!fingers!extended.!!

c. Go! as! far! in! each! plane! of! motion! so! as! to! lengthen! all! involved!

muscles.!This!is!the!ending!point!of!D2!Flexion.!!

d. Now!ask! the!patient! to!pull! the!band! so!as! to! rotate!and!move! the!

arm! diagonally! down! and! across! the! body! (putting! the! sword! back!

into! the! scabbard)!with! shoulder,! elbow! and!wrist! flexion,! shoulder!

adduction!and!internal!rotation.!(!D2!Extension)!

e. After! little! holding! at! the! maximum! gradually! come! back! to! D1!

Flexion.!Repeat!it!for!ten!times.!

f. Patient!can!do! it! in!exactly!reverse!way!as!per!the!functional!needs.!

i.e.!put!the!free!end!of!the!band!under!the!opposite!leg.!(!taking!the!

sword!out!of!the!scabbard)!!

!

!

!


1.!Patient!may!hold!the!breath.!


3.!Patient!may!rotate!the!body!with!the!arm.!

!

!

90!–!90!Rotational!Stability!

!

!

!

!

Position:!

Standing!with!stride!stance!

!

Technique:!

a) First!wrap!the!band!in!affected!hand,!taking!the!longer!free!end!ulnar!side!of!forearm.!Flex!the!shoulder!and!elbow!at!90!degrees!

and!putting!the!forearm!parallel!to!ground,!take!the!free!end!of!

theband!inside!the!forearm!from!above.!

!

!

b) Take! figure!of! eight!wrap! to!middle!arm,!and!put! the! free!end!

under!the!opposite!feet.!!

c) Take! stride! stance! by! putting! the! affected! side! leg! ahead.! This!the!starting!position!of!this!exercise.!

d) Now!externally!rotate!and!abduct!the!arm!to!90!degrees!keeping!

elbow! at! 90! degrees! of! flexion.! (! elbow! should! remain! at!

shoulder!level)!

e) With!a!little!hold!at!the!end,!gradually!take!the!band!to!neutral.!

!

Compensations!to!look!for&

1.!Patient!may!hold!the!breath!.!


3.!Patient!may!elevate!the!shoulders.!

!

!

Scapular!stabilization!exercises!

These!exercises!are!special!exercises!given!for!correction!of!scapular!positioning!

in!cases!of!scapular!dyskinesia!and!they!improve!force!couple!reaction!my!

reducing!muscle!imbalances!and!improving!proprioception.!

All!these!exercises!are!given!for!repetition!and!practice!has!to!be!performing!as!

many!times!as!possible!thru!out!the!day.!

There!are!approximately!four!types!of!exercises!in!this!type!

!

Setting!in!neutral!

Dissociation!

Scapular!clock!

Wall!washes!

!

!

Setting!in!neutral:!

The!position!of!scapula!has!to!be!at!T6!level!whenever!any!shoulder!movement!

initiates.!Scapula!has!to!be!braced!properly!without!any!protraction!and!anterior!

tilting!when!movement!starts.!

!

!

(First!exe!of!scapular!setting!is!similar!to!this)!

Dissociation!

When!scapula!setting!is!achieved!in!neural!even!dynamically!it!should!understand!

to!come!in!neutral!hence!shoulder!dissociation!exercise!is!given.!Patient!in!

standing!position!brace!the!scapulae!and!slowly!lift!the!arm!in!forward!flexion!till!

90!deg!without!any!movement!in!scapula.!Therapist!will!be!giving!verbal!as!well!

as!tactile!feedback!with!the!help!of!finger!when!ever!required;!at!home!patient!

can!use!the!opposite!hand!for!the!same.!

!

If!dyskinesia!is!severe!then!ask!patient!to!lie!down!on!ground!without!any!mat!

and!do!the!same!movement.!Ground!will!be!giving!required!proprioceptive!

feedback!

!

!

!

!

SCAPULAR DISSOCIATION

49

Setting!in!neutral!

!

&

Scapular!clock!

This!exercise!again!improves!proprioception!in!scapulae.!!

!

!

To!start!with!ask!patient!to!stand!at!the!wall!keeping!his!hand!above!level!as!if!he!

is!pressing!the!wall!and!then!ask!him!to!perform!protraction!and!retraction!in!the!

same!position!while!maintaining!scapular!position!

This!activity!has!to!be!performed!in!all!four!movements!like!elevation!depression!

protraction!and!retraction!and!hence!imagine!a!clock!on!wall!and!perform!the!

exercise!at!12!,!3!,!6!,!and!9!O’clock!position.!

!

You!can!add!a!basket!ball!in!the!exercise!to!make!it!unstable!and!adding!difficulty!

!

&

!

!

&!

!

Cuff&substitution&programme&!

It!is!usually!given!for!the!patients!who!are!treated!with!

conservative!treatment!for!full!thickness!cuff!tear.!And!also!

for!patients!who!has!irreparable!cuff!tears!and!cuff!

arthropathy,!

!

In!these!patients!PSRP!is!given!in!the!same!way!except!SUPRASPINTUS!is!

substituted!by!DELTOID!ALL!THREE!Fibers!!

!

Anterior!Deltoid!

Ask!patient!to!stand!straight!with!shoulder!retracted!and!depressed.!!

Tie!two!knots!to!the!wrist!and!then!take!full!hand!length!measurement!and!

stand!on!that!point.!Then!lift!the!arm!in!forward!flexion!without!elevating!the!

scapulae.!

!

!

!

Middle!Deltoid!



stand!on!that!point.!Then!lift!the!arm!in!abduction!without!elevating!the!

scapulae.!

Posterior!Deltoid!



stand!on!that!point.!Then!lift!the!arm!in!extension!without!elevating!the!

scapulae.!

!

!

!

!

!

!

!

!

!

!

!

!

!

!

!

!

!

!

&

Post&operative&exercise&programme&

!

!

Exercises&for&first&6&weeks&

!

Simple!pendulum!exercises!in!clockwise!and!anti!clockwise!manner!

for!about!10!times!each!three!to!four!times!a!day.!

Lean!on!a!table!with!uninvolved!hand!and!first!move!the!affected!

arm!forward!ten!times!slowly,!then!sideways!slowly!and!finally!round!

and!round!clockwise!and!anticlockwise.!!

Strictly!avoid!rapid!jerky!movements.!

Bracing!as!in!the!military&position&with!the!shoulders!thrust!back!and!chest!inflated!to!a!count!of!ten!and!repeated!ten!times.!!

While!sitting!one!must!make!a!constant!attempt!to!improve!posture!

by!avoiding!slouching!and!using!the!military&position.!!

Pendulum!Exercises!

&

From&3rd&week&onwards& Active!assisted!ex.!

Ask!patient!to!lift!the!arm!with!the!help!of!!stick!in!forward!&!

sideways!direction.!

Lift!only!till!the!shoulder!allows.!You!must!not!have!pain!while!doing!

this!exercise..!IF!it!hurts!then!do!not!do!it.!!Patient!CERTAINLY!should!

NOT!LIFT!the!arm!BEYOND!90.!

!

!

!

!

Static!Exercises!

Anterior!deltoid!

Stand!in!front!of!the!wall!and!face!the!wall.!

Try!to!push!the!wall!with!your!palm.!Hold!for!ten!counts!and!ten!

repetitions!

!

Middle!Deltoid!

Stand!in!front!of!the!wall!and!sideways!the!wall.!


repetitions!

!

!

Posterior!Deltoid!

Stand!in!front!of!the!wall!and!face!the!back!towards!the!wall.!


repetitions.!

!

After&Six&weeks&The!patient!must!undergo!a!supervised!rehab!programme!for!ROM!

restoration!with!a!shoulder!physiotherapist.!They!are!advised!to!

Strengthen!Scapular!muscles!(Rhomboids!&!Serratus)!&!The!Rotator!

cuff!muscles!with!Theraband!in!an!eccentric!closed!chain!manner.!

The!supervised!rehab!programme!lasts!for!about!two!weeks!after!

which!the!patient!does!the!exercises!at!home!for!four!weeks!at!least.!

Simultaneously!they!undergo!gentle!stretches!for!restoration!of!

forward!flexion!and!abduction!and!external!&!internal!rotation.!

!

!

Attention!to!core!stability!is!also!mandatory!during!the!supervised!

programme.!

&Landmarks&After!starting!phase!I!six!weeks!after!the!date!of!surgery!normally!

most!patients!would!attend!a!supervised!rehab!programme!under!

our!accredited!shoulder!physiotherapist.!Following!that!patients!

usually!achieve!a!good!range!of!movement!and!are!essentially!

lacking!in!strength,!Patients!then!leave!for!a!Phase!II!home!

programme!for!a!month!to!six!weeks.!Thus!about!three!months!after!

surgery!they!have!usually!achieved!90%!of!their!movement!and!

decent!strength.!Not!all!patients!follow!the!charted!path!and!there!

are!differences!depending!on!the!extent!of!tear,!the!preceding!

duration!of!illness!and!age.!If!after!Phase!I!patients!are!still!not!

achieved!50%!improvement!and!are!still!in!pain!should!seek!

immediate!advice.!

!

!

Important Tips • On!completion!of!phase!I!the!patient!is!advised!to!proceed!to!!

twice!daily!home!programme!for!all!the!previous!exercises!for!a!

period!of!one!month!when!he/she!is!followed!up.!!

• For! initiators! perform! Capsular! stretches! and! Active! assisted!

exercises!with! the! patient! lying! down.! This! helps! stabilise! the!

scapula!automatically,!avoiding!impingement,!!

• Scapular! setting! and! proprioception! restoration! are! best!demonstrated!practically!during!your!actual!programme!to!give!

you!a!placatory!feedback.!!

• It! is! important! for! patients! to! report! to! the! physician! of! they!

have!no!improvement!for!a!week!or!if!they!actually!deteriorate.!!

!

!

• !Most!patients!will!achieve!a! full!pain! free!function!at! the!end!

of!the!four!week!home!programme.!!

• !It!is!advisable!to!do!a!UCLA!score!before!phase!I!and!at!the!end!of!phase!II!to!establish!objective!criteria!of!improvement.!

• Strictly! no! STRETCHES! are! given! for! shoulder! replacement! or!

Reverse! replacement! osteoarthritis! and! rheumatic! shoulder!

arthritis!patient.!!

!

Watch! out! for! neighbouring! conditions! which! mimic! shoulder!

problems!!

!

DIFFERENTIAL&DIAGNOSIS&&!

�!Cervical!Disc!Disease!!�!Suprascapular!Nerve!palsy!!�!Long!Thoracic!Nerve!Palsy!!�!Rheumatoid!Arthritis!!

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Documents

Pune!Shoulder!Rehabilitation!Program!(PSRP)! …jointandbones.com/pdf/psrp manual 2013 lw.pdfIt!includes!activation!of!transverse!abdominus!and!lower!abdominal!muscles!! For!Post!Surgery!Patients!