What is the best course of treatment for a 63-year-old female patient with a history of type 2 diabetes (T2D) and varicose veins, who is one month post-operative from rotator cuff repair surgery for an incomplete tear, and still has incomplete range of motion in her right shoulder?

From the Guidelines

The best course of treatment for this 63-year-old female patient with type 2 diabetes, varicose veins, and incomplete range of motion one month after rotator cuff repair surgery should focus on physical therapy, pain management, and continued monitoring of her comorbidities. Physical therapy should be the cornerstone of treatment, with sessions 2-3 times weekly for 8-12 weeks, focusing on progressive passive and active range of motion exercises, gentle strengthening, and scapular stabilization, as recommended by studies on optimizing the management of rotator cuff problems 1. For pain management, acetaminophen 500-1000mg every 6 hours as needed is preferred over NSAIDs due to her age and diabetes, considering the guidelines for exercise prescription in patients with type 2 diabetes which emphasize the importance of adapting exercise strategies based on comorbidities and contraindications 1. A home exercise program should be prescribed with daily exercises including pendulum stretches, wall crawls, and gentle internal/external rotation with a resistance band when appropriate. Her diabetes management should continue uninterrupted, with regular blood glucose monitoring as physical activity increases, following the recommendations for exercise in type 2 diabetes which include at least 150 minutes of moderate to vigorous aerobic exercise per week and resistance exercise at least twice weekly 1. The varicose veins require monitoring but shouldn't directly impact shoulder rehabilitation unless they cause significant discomfort during exercises, as the treatment for varicose veins typically involves compression therapy, saphenous vein ablation, or sclerotherapy, and may not be directly relevant to shoulder rehabilitation 1. Regular follow-up appointments at 6 weeks and 12 weeks post-surgery will allow assessment of progress and adjustment of the rehabilitation protocol as needed. This comprehensive approach addresses both the immediate need for shoulder rehabilitation while considering her underlying health conditions that could affect recovery. Key considerations include:

• Monitoring and managing her type 2 diabetes through regular exercise and blood glucose monitoring
• Avoiding NSAIDs for pain management due to her age and diabetes
• Implementing a home exercise program to support physical therapy
• Regular follow-up to assess progress and adjust the rehabilitation plan as necessary.

From the Research

Patient Assessment and Treatment

The patient, a 63-year-old female with a history of type 2 diabetes and varicose veins, is one month post-operative from rotator cuff repair surgery for an incomplete tear. She still has incomplete range of motion in her right shoulder.

• The patient's current condition and medical history should be taken into consideration when advising her on the best course of treatment.
• According to 2, a typical physical therapy protocol progresses sequentially through the following phases: pain control, restoring range of motion, restoring strength, neuromuscular retraining, and return to full activity.
• The patient's incomplete range of motion suggests that she may still be in the early stages of the rehabilitation process.

Rehabilitation and Exercise

• Therapeutic exercise is a key component of any rehabilitation program and should be included as part of the concurrent care of any patient 3.
• The goals of therapeutic exercises include the restoration of movement, improvement of function and strength, improvement in gait and balance, and the prevention and the promotion of health, wellness, and fitness.
• Exercises aimed at restoring strength, power, and work, or endurance, or a combination, can be beneficial for the patient.
• Range of motion exercises, in particular, can help improve the patient's current limited mobility.

Pain Management and Alternative Therapies

• Immersive virtual reality (VR) can be an effective adjunctive, nonpharmacologic pain-reduction technique for patients experiencing severe pain during physical therapy 4.
• The use of VR may help distract the patient from pain and improve her range of motion during exercises.
• Other physical therapy modalities, such as heat, cold, ultrasound, phonophoresis, iontophoresis, and electrical stimulation, may also be beneficial in managing the patient's pain and promoting healing 2.

Considerations for Patients with Type 2 Diabetes

• Low-intensity pulsed ultrasound (LIPUS) stimulation has been shown to have regulatory effects on brown adipose tissue (BAT) and may be beneficial in improving glucose tolerance and insulin sensitivity in patients with type 2 diabetes 5.
• However, more research is needed to confirm the effectiveness of LIPUS in humans and to determine the optimal intensity and duration of treatment.
• The patient's diabetes management plan should be taken into consideration when developing her rehabilitation program, and adjustments may be necessary to ensure optimal glucose control.