Part 2: Following AZOPT’s Client through Total Shoulder Replacement Surgery

Part 2: Following AZOPT’s Client through Total Shoulder Replacement Surgery

Read Part 1

In the 1950’s, shoulder replacement surgery was first performed to treat severe shoulder fractures.  Through the years, shoulder replacement surgery has been used to treat many other painful conditions in the shoulder, like arthritis.  Today, according to the Agency for Healthcare Research and Quality, approximately 53,000 people in the U.S. have shoulder replacement surgery each year.  Compared to more than 900,000 Americans who have knee and hip replacement surgery each year, shoulder replacement surgery is not as common, but still just as successful at relieving joint pain.  Just ask AZOPT patient Mr. A.

When we last left AZOPT client Mr. A, he was preparing for total shoulder replacement surgery on his left shoulder on January 10, 2013 following successful shoulder replacement surgery on his right shoulder April 26, 2012.  In fact, the success of rehabilitation on his right shoulder led him to the decision to have the surgery on the left shoulder.  The surgery of his left shoulder was performed by Dr. Jason Scalise, TheCore Institute, at Banner Thunderbird Hospital.  AZOPT’s Doug Lehman, PT, watched the entire surgery over the shoulder of Dr. Scalise.

Mr. A’s total shoulder replacement involved replacing the arthritic joint surfaces with a highly polished metal ball attached to a stem, and a plastic socket.  This was “press fit” into the bone.  To do this, Dr. Scalise saws off the humeral head (ball) and reams out the glenoid fossa (socket).  He then drills a hole into the remaining humerus bone and fits the stem of the prosthetic into the hole.  The plastic socket is screwed into what remains of the glenoid fossa.  The ball is then put back together with the socket, the range of motion is checked, and if all of the movement and alignment is positive, the incisions are sewed up and Mr. A is on his way to recovery.  The entire surgery from wheeling in to wheeling out was approximately three hours, with half of that being actual surgery time.

For the first two weeks following surgery, Mr. A kept his arm in a sling.  He performed basic exercises for the hand, wrist, and elbow along with pendulum exercises for the shoulder.  With his elbows in, Mr. A was asked to simply turn his hands from palm up to palm down, touch his fingers, and straighten then bend his elbow.  Additionally, the pendulum exercises involved allowing the surgical arm to hang loosely in a bent over position, swinging the arm gently front to back, and in circles.

01/25/2013

On January 25, 2013, two weeks after the surgery, Mr. A came to AZOPT for his initial evaluation.  Doug recorded the following active range of motion measurements:

	Right	Left (prior to surgery	Left (initial evaluation)
Flexion	140	150	92
Abduction	120	111	80
External Rotation	75	72
Internal Rotation	72	60

01/25/2013

Active range of motion means Mr. A performs these motions by himself.  Flexion is the range of motion (ROM) measurement from lifting your arm straight forward from your hip to above your head.  Abduction is the ROM measurement from lifting your arm straight from your hip out to the side and above your head.  External rotation is the ROM measurement with your elbow at 90 degree, rotating your hand outward.  Internal rotation is the ROM measurement with your elbow at 90 degrees, rotating your hand inward.  These measurements translate directly to functional activities – washing your hair, tucking in your shirt in the back, putting away dishes in the cupboard.  Generally speaking, a healthy range of motion would be 160 degrees flexion and abduction, and 90 degrees external and internal, although this does vary person to person.

Doug tells us “by observing the surgery, I was able to see the actual structures, how they were cut and reattached, and how the prosthetic pieces were attached.  Dr. Scalise guided me through the specific techniques and we discussed his rehabilitation expectations.  By learning the process and the range of motion available while Mr. A was under anesthesia, I am more comfortable aggressively obtaining range of motion and active movement early in the rehabilitation process.”

Mr. A attends physical therapy at AZOPT three times weekly.  In the first 3 weeks of physical therapy, Mr. A’s physical therapy program consisted of manual therapy focusing on improving range of motion with a slow progression of exercises and activities to regain strength and stability as his pain tolerance allowed.  According to Doug, Mr. A has responded extremely well to therapy.  Mr. A tells us his progress on his left shoulder has been quicker than his right shoulder.  With the factor of the unknown removed, Mr. A is familiar with the process and comfortable with what he needs to do to recover quickly. 

02/15/2013

On February 15, 2013, after ten physical therapy visits, Doug recorded the following active range of motion measurements:

	Right	Left (prior to surgery	Left (i.e.)	Left (02/15)
Flexion	140	150	92	135
Abduction	120	111	80	97
External Rotation	75	72		60
Internal Rotation	72	60		40

02/15/2013

A large factor to Mr. A’s recovery is his compliance with the Home Exercise Program prescribed during physical therapy.  This program ultimately gives him the greatest chance at success.  Mr. A has a pulley at home that helps with his range of motion and strength.  He also uses a golf club at home to do shoulder extensions and shoulder raises.  Furthermore, Mr. A guides a rolled up towel up and down a wall.  It is extremely important for anyone recovering from any injury to keep up with the Home Exercise Program.  Without it, physical therapy will stall and set the patient back.

 

With the addition of the Home Exercise Program, physical therapy visits continued to include progressions of manual therapy and therapeutic exercises to decrease pain and increase range of motion, strength, and stability.  After 21 visits, on March 13, 2013, Mr. A reported an overall improvement of 75% compared to his normal function.  He was still experiencing pain with activities and a decreased ability to complete normal activities of daily life that require the use of the left arm.  On this day, Doug recorded the following active range of motion measurements:

 

	Right	Left (prior to surgery	Left (i.e.)	Left (02/15)	Left (03/13)
Flexion	140	150	92	135	140
Abduction	120	111	80	97	90
External Rotation	75	72		60	67
Internal Rotation	72	60		40	62

Mr. A will continue physical therapy three times per week at this time.  He actually loves coming to AZOPT because he knows this is making him better.  While Mr. A cannot accomplish all of his goals, he realizes he is much closer.  He still cannot lift a mug of coffee, but he is able to drive again.  He also no longer experiences clicking or pain when brushing his hair.  His biggest fear before surgery was the idea of a “frozen arm” – that every time you move the arm, there’s pain, so you just don’t move it.  Through two total shoulder replacement surgeries and rehabilitation at AZOPT, Mr. A no longer has “frozen arm,” and is 75% closer to returning to normal function with no pain.

Check back with us for the third, and final, installment of Mr. A’s recovery, when Mr. A is discharged from physical therapy.

What is Sensory Integration and Why is it Important in a Child’s Development?

What is Sensory Integration and Why is it Important in a Child’s Development?

By: Liezel Fernandez, OTR/L

Pediatric Occupational Therapist at AZOPT Kids Place

Does your child have difficulty engaging in tasks?  Do they overreact to movement activities like swinging or even when their feet leave the ground? Maybe your child walks on their toes, dislikes textures or messy play, or covers their ears and negatively reacts to loud noises like a vacuum or fire alarms.  Do they refuse bathing, nail cutting, or tooth brushing?  Chew on pencils or other objects?  Does your child seek all kinds of movement, crash into walls, or lack safety awareness?  These are some of the possible signs that a child has difficulty in processing sensory information.

Sensory Processing/Sensory Integration is when our different sensory systems work together to process different sensations from our body and/or environment. When this occurs, we are able to identify and give meaning to the different sensations we experience to accomplish daily activities and move in a coordinated manner. Adversely, Sensory Processing Disorder is the inability to receive and efficiently use sensory information. Difficulty in processing sensory information interferes in our daily activities and impacts our functional ability to perform different tasks.

Our sensory systems tell us what is going on around us or in the environment. Our bodies absorb different sensory inputs, which our brain then interprets and translates. We have 7 different sensory systems that we must know: proprioception, vestibular, tactile, auditory, olfactory, oral and visual.

The Proprioceptive system (position sense) commands our body position in space, timing of movements and amount of force we are exerting during activities.  It is necessary to have a strong proprioceptive sense to develop good body awareness, motor planning and coordination.  Proprioceptive input helps calm a child, improves attention and boosts focus.  Heavy work, deep pressure and resistive activities can strengthen the proprioceptive sense.

Example of Proprioceptive activities: (Calming/Organizing)

• Deep pressure massage
• Joint compression
• Wheelbarrow walk
• Animal walks (crab walk, bear walk, seal walk, etc.)
• Chair push up
• Wall push up
• Pushing and pulling activities
• Playing tug of war
• Carrying groceries or books
• Riding a bicycle
• Swimming
• Popping bubble wraps

Our Vestibular system (movement sense) regulates tolerances to changes in movement, position in space and sense of balance.  Children with difficulties or irregularities in vestibular system are either over responsive/hypersensitive or under responsive/sensory seeker.  Vestibular input can be calming or alerting.  Slow repetitive movements tend to be calming.  Fast, jerky movements tend to be alerting.  A strong vestibular system is necessary to improve balance and postural control.

Examples of Vestibular activities:

• Swing
• Somersault
• Log rolling
• Figure eight walk
• Spinning using a swivel chair
• Bouncing or inverting on a therapy ball
• Playground slides
• Playing hopscotch or a balancing game
• Slow rocking
• Jump rope
• Jumping jacks
• Sit ups

The Tactile system (sense of touch) allows us to determine the location of touch, amount of pressure, pain and temperature.  It helps us to differentiate types of textures, size and shape of objects in the environment. Tactile system is necessary in developing fine motor skills.

Example of Tactile input/activities:

• Playing with Play doh or putty
• Sand, water, rice play
• Lotion massage
• Use of hand fidget toys
• Giving hugs
• Finger painting or messy play
• Use of vibrating toys

The Auditory system (sense of sounds) recognizes and interprets sounds in the environment and our ability to respond to it.

Examples of Auditory Input

• Listening to classical or slow music
• Use of headphones
• Singing
• Nature sounds
• Play musical instruments
• Humming
• Labeling sounds

Our Oral system processes different tastes, textures and input inside the mouth.

Examples of Oral input

• Blowing bubbles
• Use of straw when drinking
• Blowing whistles
• Exploring different taste and texture of food
• Calming:
• Sweet – lollipop, hard candy, fruits
• Chewy – bagels, gum, gummy candy
• Warm food- soup
• Alerting: Salty, crunchy, sour, spicy and cold food

Our Olfactory system processes and responds to different odors. Examples of Olfactory input

• Scented candles
• Calming scents – vanilla, lavender, sweet orange
• Alerting scents – peppermint, lemon/lime

The Visual system gives us information about what we see in the environment. Example of Visual input

• Dimming lights
• Completing puzzles, mazes, dot to dots
• Decreasing visual distractions/use of environmental modifications
• Looking at picture books
• Playing I Spy
• Putting out less toys to avoid visual overloads

If you believe that your child is experiencing any of the difficulties mentioned, then you may seek assistance from a licensed Occupational Therapist.  An Occupational Therapist will evaluate and assist in the development and/or strengthening of these areas through therapeutic interventions.

Call Kids Place at (623) 229-7808 for more information or to schedule an evaluation.

Attention Baby Boomers: Stay Healthy While Staying Fit

Attention Baby Boomers: Stay Healthy While Staying Fit

Mitch Kaye, PT,

PTPN Director of Quality Assurance

“Sixty is the new 40,” say many early baby boomers celebrating their 60th birthday this year.

This generation of 76 million people born between 1946 and 1964, determined to ward off aging, has focused more on exercise and wellness than did their parents. They were at the forefront of the aerobics and fitness movement that began in the 1970s and are now flocking to health clubs in even greater numbers.

But, as a result, increasing numbers are suffering from “Boomeritis” — the phenomenon of boomers becoming injured while exercising and playing sports at a level often too intense for their aging bodies.

Sound familiar?

It’s not just about soreness or stiffness. As boomers refuse to let injuries get in the way of their exercise routines, they’re undergoing complex knee and hip replacements and surgical repairs to the shoulder, ankle and elbow. Orthopedic surgeons say they are performing such surgeries more often on patients in their 40s and 50s than in the past.

Physical therapists are also treating more boomer patients than ever, not only for rehab after injuries and surgeries, but also for customized fitness training geared to their musculoskeletal limitations.

Staying healthy and avoiding injuries

If you’re a boomer, regular exercise is key to preventing or improving chronic conditions that come with increasing age. But you may need to make some modifications to avoid injuries.

Here are some tips for staying healthy and avoiding injury — at any age.

• Moderate cardiovascular exercise will improve the quality of your life, but be sure to get screened by a physician first.
• Exercise at a pace appropriate for your age. Adjust your activities and know that you have limitations: You may only be able to get your heart rate up so high, you may have joints that are not as flexible, or you may have arthritis.
• Seek the advice of physical therapists to work on your flexibility, strength, endurance and posture. You need to know what posture to have while sitting at a computer, as well as how to set your computer station ergonomically to reduce the risk of neck, shoulder and hand injuries.
• Stretch on a daily basis. Try to incorporate gentle stretches for your neck, back, arms and legs. Hold each stretch 15-30 seconds and do 3 repetitions each.
• Perform gradual strengthening exercises. Begin with light weights, 10 repetitions with 2-3 sets, and gradually increase the resistance.
• Eat well-balanced meals with protein at each meal, including plenty of fruits and vegetables. Drink eight glasses of water daily.
• A loss of mobility following injury, hospitalization, or even sustained sitting positions at work can speed the deterioration of muscles, joints and bone. A physical therapist can help you regain mobility and improve quality of movement.
• Exercise mentally, not just physically, by doing crossword puzzles, jigsaw puzzles, sudoku, Scrabble and other mind games.

Pregnancy and Back Pain: What You Can Do To Help

Pregnancy and Back Pain: What You Can Do To Help

By: Tyler Guymon, DPT

I am very blessed to be the father of four beautiful children.  But, as most people know, I would not have accomplished this great achievement without my wonderful wife.  Confidently I will say that while my wife would not change anything about our kids or what they have added to our family, she would happily change how she felt during the nine months prior to each of their births.  

Unfortunately, 50 to 70 percent of pregnant women experience back pain throughout their pregnancy.  While the reason for back pain varies from person to person, the majority of back pain concerns can be traced to one or more of the following factors:

• Increases in hormones
• Change’s to the body’s center of gravity
• Weight gain
• Poor posture
• Added stress

Over the last 40 years, the average age of women when they conceive their first child has risen from 21.4 to 25 years of age.  Furthermore, with women juggling the demands of pursuing a higher education and a competitive workforce, more and more women are conceiving their first child after the age of 35.  As a result, many women becoming pregnant are less physically active in their daily lives.  This decreased activity, along with the increasing national prevalence of a sedentary lifestyle, leaves an alarming number of women less prepared for the strenuous journey of carrying and delivering a baby.

You may be surprised to learn that the previously mentioned factors that cause back pain can be address by a physical therapist through a personalized program.  Through a detailed evaluation and a review of systems, a physical therapist will develop a plan of care that addresses:

• Back pain
• Decreased flexibility
• Muscle weakness
• Poor posture
• Nerve irritation/involvement
• Problems with joint alignment

Although it would be difficult to prescribe a generic exercise/stretching program that is appropriate for every woman, here are a few exercises that I feel would benefit all pregnant woman experiencing back pain:

Wall Push-Ups

Start your pregnancy exercises with wall push-ups, which work the pectoral muscles in the front of your chest and the triceps muscles in the back of your upper arm.

• Standing and facing a wall, lean forward and place your hands on the wall at shoulder height, slightly wider than shoulder-width apart.
• Keep your knees comfortably apart.  
• Slowly bend your elbows and lower your chest until your chin reaches the wall. 
• Remember to keep your back straight. 
• Then return to the starting position. 
• Gradually work up to 15 repetitions.

Squats With a Fitness Ball

Squatting during labor — even for short amounts of time — help open your pelvic outlet and allows more room for your baby to descend.  Practicing squats now will make it easier to squat during labor. Try squats with a fitness ball.

• Stand up straight with a fitness ball behind your back and against the wall, your feet about shoulder-width apart. 
• Be sure to have feet far enough from the wall that your knees do not pass the toes at the bottom of your squat.
• Slide down the wall until your knees reach a 90-degree angle, being careful to keep your heels flat on the floor. 
• Maintain upright posture - do not lean back over ball or bend forward as you descend.
• If you can't bend your knees to a 90-degree angle, simply go as low as you can — then return to the starting position. 
• Gradually work up to 10 repetitions.

Leg lifts

To strengthen your back and abdominal muscles, try leg lifts. 

• Start on your hands and knees, keeping your arms straight and your hands directly beneath your shoulders.
• Lift your right knee, straightening your leg behind you — ending with the raised leg parallel to the floor.
• Maintain level hips - do not roll to the side, and be sure to tighten
  your stomach.
• Repeat on the other side. 
• Gradually work up to 10 repetitions on both sides.

Side planks

The side plank challenges your stability and works the muscles along the side of your body.

• Lie on your left side and raise yourself onto your left forearm. 
• Place your left shoulder directly above your left elbow, keeping your shoulders, hips and knees in alignment.
• Again, do not roll to the side or lean back/forward
• Rest your right arm along the side of your body. 
• Hold for several seconds, and then lower yourself to the floor. 
• Gradually work up to 10 repetitions. 
• Repeat on the other side.

Step ups

To do a step-up, you'll need a small step stool — or you can stand in front of the stairs. 

• Position yourself near a wall or railing for extra balance or support, if needed. 
• Pushing primarily through your lead foot, lift your body up onto the step. 
• Then step backward to the starting position. 
• Alternate your lead foot each time you step up.
• Remember to keep your back straight and plant your foot entirely on the step. 
• Do as many repetitions as you can, depending on your fitness level. 
• Stop when you're fatigued or your form begins to suffer.

If you are new to exercise and fitness, or just don't know what to do, please first check with your doctor or a licensed physical therapist prior to starting an exercise program to reduce the risk of injury or increased pain.  

Call AZOPT at (623) 242-6908 to schedule an evaluation today if you feel you can benefit from a licensed physical therapist through your pregnancy.

Tips For Encouraging a Picky Toddler to Eat

Tips For Encouraging a Picky Toddler to Eat

By: Colleen Riordan, M.A., CCC-SLP

Licensed Pediatric Speech/Language Pathologist

Between the ages of 2 and 3, your child will likely go through a phase of “picky eating”.  This may range from a mild resistance to trying new foods , all the way to full-out screaming tantrums at the dinner table. While frustrating, it is important to continue to encourage your toddler to eat what the family is eating, and not give in to the temptation of offering only preferred foods.

It may help to know that  we are one of the few cultures in the world where children are routinely offered  highly processed and aggressively-marketed “kid foods”, such as chicken nuggets, macaroni and cheese,  pop tarts and tiny cheese crackers. Getting stuck in this pattern can easily turn parents into short-order cooks, preparing one meal for the children and another for the adults. It can also reinforce  food  refusals; if a child knows he will eventually get the hot dog,  there is no real motivation to try anything new and behaviors can increase.

Here are some tips for encouraging a picky toddler to eat:

• Present new foods in very small amounts to avoid overwhelming your child.
• Cut food into fun new shapes.
• Offer foods with dips your child already enjoys, such as ketchup or ranch.
• Continue to offer foods that were refused in the past; it takes multiple tastes for most people to determine if they like a new flavor.
• Present foods on divided plates or plates with fun pictures/characters under the food.
• Avoid mealtime battles by giving your child choices, both of which would be acceptable.
• Expose your child to new foods in more exciting ways:  let her help with grocery shopping, look at pictures in cookbooks, plan a meal together, visit farmers markets, plant a garden!
• Avoid “grazing” ; if your child is eating or drinking throughout the day, he is less likely to be hungry at mealtime. Adhere to a 3 meal/ 2 snack schedule.
• Eat meals together whenever possible, with your toddler remaining seated for the meal.

Check out these other helpful articles on picky-eating toddlers:

• The Mayo Clinic – Children’s Nutrition: 10 Tipsfor Picky Eaters
• Baby Center – How to Handle a Picky Eater
• NY Times – Picky Eaters?  They Get it From You

We would love to hear your feedback.  What do you do to encourage your picky eaters to try new foods?  Leave your ideas in the comment section below.