EXERCISES FOR RANGE OF MOTION AND STRENGTHENING OF SHOULDER Basic, Passive, And Active-Assisted Range-Of-Motion Exercises The rehabilitation exercises shown in this section are applicable to both nonoperative and postoperative treatment for all of the shoulder conditions discussed in this book. The specific exercises used, their progression, and their coordination with other treatment modalities are specific to the diagnosis, the severity of the pathologic process, and many other patient and surgical factors. A detailed discussion for each of these conditions is beyond the scope of this book. In general principles, the exercise program should start with the easiest exercises to perform and can be progressed when the early phase exercises can be done easily and with comfort. The first priority in rehabilitation of the shoulder is pain management and to avoid injury during the exercises. Pain management may include one or more of the following: application of ice or heat; use of nonsteroidal anti-inflammatory agents, narcotic medication, corticosteroid injections, or bracing; nerve blocks; or surgery. The first priority is to regain most of the passive range of motion before concentrating on strengthening. Strengthening should include both the shoulder and scapula as well as the trunk musculature. Strengthening of the scapula should begin at the time to start phase I strengthening of the glenohumeral musculature. Scapula-strengthening exercises include shoulder shrugs and rowing-type exercises (shoulder protraction and retraction). Coordination of scapula strengthening with glenohumeral strengthening is necessary for successful progression to the overhead exercises of phase II. In general, the progression of strengthening of the glenohumeral muscles should be first strengthening the rotator cuff in nonimpingement arcs of motion (phase I) to obtain good strength in rotation by the side as well as good scapula strength before beginning active elevation strengthening. Before starting resisted elevation with weights the patient should have full active elevation without a weight. If this is not achieved, continue phase I strengthening and scapula strengthening and add gatching and closed-chain active elevation strengthening. When full active elevation is achieved without resistance, then the patient can start phase II strengthening. Most effective rehabilitation programs require a daily home-based effort by the patient. In most circumstances the exercises should spread out over the day and not be concentrated into an intense once-a-day regimen. This basic principle of early shoulder rehabilitation is particularly important in the early or acute stages of rehabilitation when the shoulder is at its worst with respect to pain, motion, or strength. The worse the problems, the more frequent the exercises should be performed, but with short periods of exercise done well within the patient’s abilities. The initial program should focus on the most key and deficient problems for that diagnosis. For example, the primary problem with early severe frozen shoulder is pain and loss of passive range of motion. This should result in the need to achieve effective pharmacologic pain management and to focus on passive range-of-motion exercises to achieve improvements in passive range of motion and improvement in pain before considering adding strengthening exercises to the program. The more painful the shoulder, the more gentle the exercises, which are done for a shorter duration but frequently during the day. As the shoulder improves, the exercise periods can be more consolidated for longer duration and then progressed with respect to intensity. Patient education and participation is critical to success for either nonoperative rehabilitation or post-operative rehabilitation. Clear and precise communication between the physician and patient and therapist is as important to a successful outcome as is the precision and expertise by which all of the other treatment is performed, including surgery. Pendulum exercises are performed with the patient leaning forward with the arm supported on a stable structure such as a table and the waist bent at approximately 90 degrees. The affected extremity is allowed to dangle in front of the patient’s body, and small circular motions are made either clockwise or counterclockwise, allowing for general passive range of motion of the glenohumeral joint. Supine passive forward elevation is done in the supine position using the unaffected extremity as a means to move the affected arm passively or with active-assisted elevation (some muscle activity of the affected shoulder). This is generally done in the plane of the scapula. The plane of the scapula is midway between the true coronal plane (parallel to the plane of the body [pure abduction] and the sagittal plane, which is perpendicular to the plane of the body [pure forward flexion]). The plane of the scapula lies 30 to 40 degrees anterior to the coronal plane. The plane of the scapula for motion exercises places the rotator cuff and other muscles of the shoulder in the most physiologic and natural position with respect to the scapula body. For all passive exercises, when the arm reaches its maximum level of gentle passive arc, there is a gentle stretch given to increase the arc of motion. Repetitive movements are done during one session a few times each day. Active-assisted forward flexion can also be done using an assistive device such as an exercise wand in the standing position. Passive external rotation is done using a device such as a cane or exercise wand. Cross-body adduction stretches the posterior capsule, and normal posterior capsule length is important to achieve full forward elevation or full internal rotation. Basic Shoulder-Strengthening Exercises Progressive resistant strengthening exercises can be performed in phases. Phase I involves the use of an elastic band for external rotation with the arm by its side to avoid impingement or overstressing of the rotator cuff tendons. The concept of progression of strengthening from phase I to phase II is to first strengthen the rotator cuff by doing rotational exercises in the least difficult or pain-provocative arm and body position. After achievement of better rotator cuff strength and shoulder function with the phase I exercises performed with the arm by the side, then the shoulder should be better able to tolerate the more difficult exercises for phase II strengthening. Phase I strengthening can be done either using both hands with the elastic band or with the elastic band to a stationary object such as a doorknob with a pillow under the arm to provide slight abduction and then external rotation away from the body. It is best to use a stationary object so that the better or stronger shoulder does not overpower the weaker shoulder. Internal rotation can likewise be performed with the arm in slight abduction and internal rotation toward the abdomen. Extension is performed in a similar matter with the elbow by the side pulling the band. Forward flexion is shown with the elastic band with the arm moving in the forward position generally below shoulder level. Many of these same exercises can be performed with alternative techniques using a handheld 1- to 5-lb weight. For patients with severe weakness of forward elevation, graduated exercises are performed starting initially in the supine position without a weighted extremity. The arm is actively elevated with the patient in the supine position. When this can be easily achieved with multiple repetitions, a small 1-to 2-lb handheld weight is utilized again until this can be done easily and repetitively. When this is accomplished, the patient is then elevated with the torso at 30 to 40 degrees without a weighted extremity. This is again tested repetitively until this can be done with ease, after which a small 1-to 2-lb hand-held weight is added. This is repetitively accomplished until the patient is able to g adually bring the arm up actively in a seated position. An alternative way to graduate to the full active elevation without assistance is the use of closed-chain activeassistance strengthening in forward flexion. This can be done with an exercise wand or preferably by a lightweight exercise ball. The patient places both arms on the ball and with assistance squeezes the ball and raises the arm above the head. The weak side is on the upper portion of the ball and is assisted by the strong arm, which is on the lower part of the ball. As the weak shoulder becomes stronger, the patient moves his or her hands to an equal and opposite side of the ball and when very strong can use the affected arm on the underside of the ball as an assistant to the normal side. These exercises are useful as an intermediate step to achieve full active elevation and progressive resistive exercises and forward flexion above shoulder level.