Surgical repair for shoulder disorders will require different immobilisation features. What is the rationale for prescribing the immobilisation component? Are orthoses' costs a barrier for prescribing sling/braces in the public health system?
Good relevant question. Although this has not been studied extensively there are some studies that incompletely answer the question. http://www.ncbi.nlm.nih.gov/pubmed/25957544
I believe there is no rationale to immobilization except to limit excursion of repair until healing takes place. For example after Bankart reconstruction a range of motion of ER and ABD and ER in theatre, provides limitation for PROM and AAROM performed immediately post-operatively. Also believe that the sling helps to identify operated individuals from others so that inadvertent injury is avoided.
Personally, except for massive rotator cuff tears I only sling for a maximum of 3 weeks and allow active range of motion below shoulder height at that time.
This would be a good area to perform SR and if the area is found lacking of good data, a good prospective study could answer this question more effectively, and with that I would be happy to participate.
Do not believe there is a cost barrier....slings are very inexpensive....maybe a waste though as they may not be needed. Interesting food for thought.
It has been my experience working with many patients post surgically as well as listening to many orthopedic surgeons. Also reading many biomechanical and physiological healing literature, that the most successful outcomes is the development of an individualized post op rehabilitation program. An understanding of healing and stresses to anatomical tissues with rehabilitation exercises is needed. Also an understanding of each individual's ability to be in compliance with post-op instructions should be taken into consideration. General rehabilitation post op protocols could be used as guidelines, however a time and criteria based progression for each individual would be needed for optimal progression which includes sling use. Many factors to consider is severity, tissue integrity, chronicity, co-morbidities, compliance, skill and experience of the rehabilitation therapist, type of surgery, type of sutures and/or fixation, potential for healing, bone quality, etc, etc.
Slings or braces are prescribed for the following main reasons; elimination of gravity and relative immobilisation of the shoulder to help healing. As mentioned by Paul beautifully each and every patient has to be treated individually and he mentioned factors that have to be considered. In my practice money never been an issue, but the cost of treatment (of any patient and for any procedure) has to be considered. So in a case where usually an inexpensive sling can be used the surgeon has to think if a brace that was prescribed was appropriate. Literature, information, peer opinions, experience, reflection and audits of practice as well as common sense will help the decision.
Thank you for all your valuable answers. The reason for my question is that there are very few studies in the topic and prescription seems to rely mainly in doctor's experience. I haven't found so far studies testing tension load of different braces with abduction wedges or slings. I agree with William Murrell that a SR is clearly needed. Do you think that the immobilization method may influence other outcomes like pain or function?
The brief answer is Yes. Prolonged sling use may contribute to greater chance of joint stiffness, pain, and delayed functional use of the upper extremity. A comprehensive knowledge of normal and abnormal arthrokinematics as well as an understanding of the stresses and strains about the glenohumeral capsuloligamentous complex is needed for common rehabilitation and home exercises to provide optimal healing without compromising the stabilization that is needed. Obtaining the crucial information and determining a good evaluation based on a very good examination along with reading the operative report and understanding the compliance factor for prescribed adherence to the sling and home ex program is needed to provide a time and criteria based progression that will provide a successful outcome with gradual decrease in pain and gradual increase in function without sacrificing the operative repair. There are many factors to consider including sets, reps, body position, load volume, ex. order etc., etc.. I hope this helps.
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