Hydrotherapy Rehabilitation After Shoulder Surgery

In 1975, Hughes and Neer introduced a shoulder arthroplasty rehabilitation protocol emphasizing recovery of passive mobility early in the postoperative course. The “Neer protocol” starts with recovery of passive elevation and external rotation and advances to recovery of internal rotation. Using the same protocol, Neer et al demonstrated that 47 of 48 patients who underwent rotator cuff repair had attained at least 140 degrees of passive anterior elevation and 40 degrees of passive external rotation within 6 days after surgery with no long-term adverse effects. The goal of postoperative shoulder rehabilitation is to restore a functional extremity in a timely fashion. Paramount in attaining this goal is the achievement of normal shoulder mobility. Limitations to obtaining this motion are imposed by biomechanical considerations following shoulder surgery. On a histologic level, shoulder surgery involves connective tissues (tendons, ligaments, and capsule), all of which are composed of collagen and as such are subject to the biomechanical properties and limitations of collagen, including plasticity, stretching, and temperature sensitivity. The plasticity of collagen allows connective tissues to adapt to physiologic and pathologic conditions. Rehabilitation is designed to maximize these adaptations, providing functional recovery. When subjected to oriented stresses, collagen fibers stretch along the lines of those stresses, allowing specific gains during prescribed mobility exercises. The heat solubility of collagen facilitates stretching of the collagen fibers in a warm environment. Early rehabilitation in a warm-water pool facilitates the timely gain of passive mobility following shoulder surgery. In addition to propagating collagen solubility allowing for easier stretching, rehabilitation with the shoulder submerged or partially submerged in warm water provides a “weightless” environment. This “weightlessness” allows the arm to find the best path to achieve a specific movement. Additionally, a warm-water pool provides comfort, improving proprioception while minimizing nociception. Thermal neutrality is obtained with water heated to 34°C (skin temperature of 29°C and core body temperature of 37°C). A water temperature of 35°C increases skin comfort and enhances collagen solubility Address correspondence and reprint requests to Dr. Gilles Walch, Department of Orthopaedic Surgery, Clinique Ste. Anne Lumière, 85 Cours Albert Thomas, 69003 Lyon, France. Techniques in Shoulder & Elbow Surgery 4(2):44–49, 2003 © 2003 Lippincott Williams & Wilkins, Inc., Philadelphia