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Rehibilitation Essay

5930 words - 24 pages

Rehabilitation of
Acromioclavicular
Joint Separations:
Operative and
Nonoperative
Considerations
Mark P. Cote, PT, DPTa, Karen E. Wojcik, MSPT, ATCb,
Gregg Gomlinski, MSPT, CSCSb, Augustus D. Mazzocca, MS, MDa,*

Acromioclavicular joint (AC) separations are one of the most common injuries seen in
orthopedic and sports medicine practices, accounting for 9% of all injuries to
the shoulder girdle.1–3 Various operative and nonoperative treatment schemes
have been described for the management of AC joint injuries.4–33 Although considerable
controversy exists over the efficacy of surgical reconstruction versus nonoperative
intervention for grade III type injuries, grade I and II ...view middle of the document...

Providing the rationale for rehabilitative services enables
rehabilitation clinicians to use their entire skill set in a safe and efficient manner,
thereby maximizing the quality of care provided to patients. Considering this conceptual
approach to rehabilitation, the following rehabilitation guidelines are presented for
the management of AC joint separations.

NONOPERATIVE MANAGEMENT
Historically, grade I and II AC separations have been managed nonoperatively with
periods of immobilization and rehabilitation.26–31 Although nonoperative treatment is
generally accepted as the treatment of choice for these injuries, evidence to support
the efficacy of rehabilitation protocols is limited to case series (level IV) and expert
opinion (level V). Mouhsine and colleagues27 reported on 33 grade I and II AC separations
treated conservatively with immobilization and physical therapy. At 6.3 years post treatment, the mean constant score was 82, with 17 of 33 subjects (52%) remaining
asymptomatic. Of those patients with residual symptoms, 9 (27%) required
surgical intervention to address continued pain and dysfunction.27 Bergfeld and
colleagues26 examined the results of conservative treatment and the management
of grade I and II AC separations in US Naval Academy shipmen. Their results demonstrated
30% of grade I and 42% of grade II separations presented with complaints of
pain and clicking with push-ups and dips on follow-up. Furthermore, persistent pain
and limitation of activities were present in 9% of type I and 23% of type II injuries.26
Literature to support the efficacy of specific rehabilitation protocols is also limited.
Gladstone and colleagues28 described a 4-part physical therapy protocol for the
treatment of grade I, II, and III AC joint injuries in athletes.

Phase 1 focuses on the elimination
of pain and protection of the AC joint through sling immobilization (3–10 days),
along with the prevention of muscular atrophy. Phase 2 consists of range of motion
exercises to restore full mobility and a gradual progression of strengthening with the
addition of isotonic exercise. Phase 3 involves advanced strengthening to enhance
the dynamic stability of the AC joint. Phase 4 incorporates sport-specific training to
prepare for a full return to prior level of activity.28
The guidelines set here follow those outlined by Gladstone and colleagues. The goal
of rehabilitation is to return the patient to the previous level of activity. Return to full
activity depends on how well the AC joint is able to function, which depends on the
ability to maximize dynamic stability of the AC joint through strength training of the
supporting
muscles of the shoulder girdle and the avoidance of degenerative joint disease
associated with these injuries. Advancements in rehabilitation programs are based on
the reduction of pain and inflammation, restoration of range of motion, improvements
in strength, and ability to perform sport-,...

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