Please read this throughout your stay as it contains supplementary information to help you get the most from your rehabilitation programme.
Rehab Ward
020 8909 5341
Therapy Department
0208 909 5820 / 0208 909 5310
Email: rnoh.
Welcome to the shoulder and elbow rehabilitation programme at the RNOH.
On this webpage you will find some useful information for your stay. During your stay you will be seen by the Multi-Disciplinary Team (MDT).
You will see the Physiotherapists and Occupational Therapists daily regularly throughout your admission. You may also be seen by the psychologist if you are referred.
Porters are available if you need support getting from the ward to the therapy department. Please let your therapists know if this is something you will require at your first opportunity.
You will already have some aims and goals to work on which you should have discussed with the therapists during your pre-assessment. We will revisit these during your first therapy session as they will help to guide and tailor your treatment with us.
During your rehabilitation stay, some of your therapy sessions may explore:
- Education regarding your particular shoulder problem
- Advice regarding independent relocation of your shoulder
- Increasing the range of movement of neck, upper back, shoulder, elbow and hand
- Development of an independent home exercise programme
- Advice on coping techniques for pain e.g. relaxation, pacing and breath work
- Advice on performing personal and domestic activities of daily living
- Advice on resuming leisure activities
- Advice on managing the challenges of work/education
Please discuss any specific concerns related to your condition and recovery, as well as any expectations you may have from your therapists.
Shoulder Anatomy Class
During this session we will explore the shoulder anatomy in more detail, looking at the different components of the shoulder including the key bones, joints and muscles as well as a number of other structures. We will also look the basic biomechanics of the shoulder (how it functions) and why you may be experiencing instability, pain and other symptoms.
Recreational Movement
This session will take place in Aspire sports hall and is run jointly with the RNOH pain management programme. It usually lasts approximately 1 hour and is an opportunity for you to try out activities in a safe, supportive environment. To begin, there will be a short warm up activity lead by one of the therapists. You will then have the opportunity to try a range of sports activities in small groups or pairs including basketball, football, table tennis, darts, curling and an assault course. All of the activities can be adapted to individual abilities. We encourage you to pace yourself throughout the session and use this time to socialise with other patients.
Water Based Exercise
This group is run in conjunction with the RNOH pain management programme in Aspire swimming pool, although often we will run a smaller upper limb specific session. The session generally lasts for approximately 45 minutes in total, with 30 minutes of structured exercise and 15 minutes of free time. The session involves general whole body exercise in water, as well as upper limb specific range of movement and strengthening exercises. The exercises provided will be targeted at your own individual needs and abilities.
Reach
“Reach” is a group run on Jubilee ward, specifically looking at reaching activities. This aims to help improve your functional reaching abilities and find ways to problem solve raising your arm out in front of you or away from the body. You will be able to take part in a number of activities such as connect 4, jenga, x-box connect and darts.
Tai Chi
Tai chi is a Chinese meditative practice that involves slow, fluid movements and deep breathing. The session will involve a series of gentle movements and stretches targeted at the upper limbs. The therapist/therapy tech leading your session will demonstrate how to match your breathing with these movements in order to enhance relaxation. Tai chi has also been shown to enhance muscle strength, flexibility, balance, and aerobic conditioning.
Please write down any aims or goals you would like to work towards during your admission. These may have been things that you discussed with your therapists at your pre-admission appointment or during your initial therapy appointment.
If you have not already discussed these with your therapist, please make your therapist aware so that they can tailor their therapy sessions to your specific needs/aims.
Goals should be specific, measurable, realistic, and achievable and have value to you!
Some examples include:
Be able to dress myself independently, to understand my condition better, to establish strategies to help with managing my pain during a flare up, to be able to return to driving, to return to swimming three times a week.
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The bones and inner muscles of the Shoulder Girdle.
The shoulder girdle consists of 3 bones and has 4 separate joints.The muscles around the shoulder are important in providing control and movement around the shoulder girdle. The rotator cuff muscles help to optimise the position of the shoulder joint by stabilising the ball (humeral head) within the socket (glenoid), they also have a role in the rotational movements of your arm.
The Outer Muscles of the Shoulder Girdle
The larger muscle groups around the shoulder joint include the deltoid, trapezius, pectoralis major and latissimus dorsi. If any of these muscles are disrupted, they can affect how the arm moves as well as the position of the shoulder joint. This can be where some muscles become weak and underactive and/or where other muscles become too strong and over active. This muscle imbalance can result in symptoms of pain and instability.
As part of your admission, we suggest that you try some relaxation techniques. These can be a helpful way to cope with pain and anxiety without medication. When practiced regularly, the techniques become second nature so you should be able to use them during day to day life after your stay.
The Role of Relaxation
Relaxation techniques are a way of releasing unwanted tension by gaining control over the automatic nervous system. By consciously letting go of tension from the muscles and creating an environment which is safe and quiet our body naturally relaxes. Similarly, mental relaxation techniques work directly on releasing mental tension and this promotes physical relaxation.
Deep breathing
This is the easiest way to encourage relaxation and may help to lower your pain levels. Please refer to the breathing techniques on the next page for more information on this.
Guided visualisation
Visualising that you are somewhere that you feel safe and relaxed – in your garden or a nearby park or maybe at a favourite beach – can cause beneficial changes in your body and lead to a lowering of anxiety and pain.
Mindfulness
Focusing on one body part at a time is another technique that we use. This can distract from the painful area and some people find it deeply calming.
Progressive muscular relaxation
Relaxing different sets of muscles individually can also help with managing tension in particular muscles. This may also help you to perform your therapy exercises better.
During occupational therapy and physiotherapy sessions we will explore the relaxation techniques above in more depth.
What are breathing techniques?
Breathing enables us to get sufficient oxygen into our body. All our cells need oxygen to function. Breathing also gets rid of waste materials and chemicals from our body.
When we are anxious or stressed our breathing patterns change and we tend to breathe faster and shallower. This is helpful in the short-term as it gets more oxygen into our bodies, but in the longer-term it can mean that we do not get rid of the waste materials as efficiently.
Pain may also affect our breathing. When in pain we tend to hold our breath and tense our bodies making breathing more difficult.
Deep breathing techniques can help us to calm our bodies reactions to stress and pain. This can lead to us feeling like we have more energy and may help us to function more effectively.
Below are a variety of techniques and apps to explore. All of these are designed to help you manage your breathing.
Diaphragmatic breathing
- Sit comfortably with your back straight. Put one hand on your chest and the other on your abdomen.
- Breathe in (inhale) through your nose. The hand on your stomach should rise. The hand on your chest should move very little.
- Breathe out (exhale) through your mouth, pushing out as much air as you can while contracting your abdominal muscles. The hand on your stomach should move in as you exhale, but your other hand should move very little.
- Continue to breathe in through your nose and out through your mouth. Count your breaths as you inhale (1) and exhale (2). When you get to 10 start the count again.
4,7,8 Breathing
- Exhale completely through your mouth, making a whoosh sound.
- Close your mouth and inhale quietly through your nose to a mental count of four.
- Hold your breath for a count of seven.
- Exhale completely through your mouth, making a whoosh sound to a count of eight.
- This is one breath. Now inhale again and repeat the cycle three more times for a total of four breaths.
What is pacing?
Pacing breaks down activities into more manageable components, balancing periods of activity and rest, so you are better able to manage your symptoms more effectively. Over time, you may find you are able to increase your overall daily activity level.
Living with persistent pain and/or fatigue can lead to changes in:
- Lifestyle: reduced socialisation, reduced communication, giving up work, doing less around the home
- Behaviour: you may find you try and get everything completed on “good days” – then need a prolonged rest period to recover (boom and bust), or you avoid certain activities all together; these can lead to a general decline in endurance and stamina (deconditioning).
Aims of pacing
- To help you have more control over your symptoms
- To avoid periods of over/underactivity
- To help you participate in activities without a significant increase in symptoms
- To avoid the cycle of deconditioning
How to pace
If you are reading this, it is likely you are experiencing pain or fatigue during most day to day tasks. It may useful for you to consider a “traffic light” strategy to pace your day.
Baselines: First establish a baseline for your activities.
By varying regularly between red, amber and green tasks, you will have more energy to spend on the tasks your need to do and want to do during your day. A traffic light pacing template is shown below.
Questions to ask yourself when introducing pacing:
- Can I break this task down?
- Do I have everything I need for this activity (e.g. clothes for work, food for lunch etc.)
- Do I need to do this today?
- Do I have to do it all in one go?
- Can someone help with part/all of the task?
Pacing up - stepped approach
- Once you have established a manageable and consistent routine, look to gradually increase activity levels or add in a new activity.
- Use a stepped approach – try to increase activity by a small amount - let that stabilise before adding in additional increases in activity.
Remember: just like any new skill, pacing takes time and practice to master. It may always be something to be mindful of, but with time it might start to feel more natural and become part of your daily routine.
Problems with sleeping can start for many reasons (e.g. stress/worries, pain, changes in working habits). Reduced sleep can make pain and daily activities more difficult to manage.
Whilst in some cases, medication can provide short-term benefits, research has helped to develop some guides which offer alternative strategies and potentially longer-term solutions.
This webpage outlines some of the ways you might be able to adjust your lifestyle and surroundings to help to establish better sleeping habits.
| Things that can help sleep | Things that can impede sleep |
|---|---|
| Regular routine Try to keep to the same bedtime/waking routines on weekday and weekends. Establish a pre-bedtime routine to prepare your body for sleep (e.g. bath, gentle stretches, relaxation, music). |
Caffeine, nicotine and certain medications These can all act as stimulants, disrupting the quality of your sleep, so try to avoid for up to 8 hours before bed. Discuss with your pharmacist/GP which medications might be more suitable to take in the mornings. |
| Sleep when drowsy Try to go to bed before you are really sleepy, rather than falling asleep on the sofa. Also try not to lay in bed awake for long periods of time. If you’ve lain awake for twenty minutes or more, get up and do a calming, non-stimulating activity before going back to bed. |
Alcohol Whilst alcohol can make you feel drowsy – it can affect your ability to fall into a deeper sleep, resulting in poorer quality sleep. |
| Exercise Exercise can help you feel ready for sleep, but try not to do vigorous exercise 4 hours before bed. Instead, gentle stretches might help you feel relaxed and ready for sleep. |
Stress Stress can have a negative impact on sleep – its physical effects can be stimulating for the body and keep you awake (therefore using relaxation techniques as part of your sleep routine may be useful). |
| Temperature Try to maintain a constant temperature, that’s not too hot or cold. It’s better to have a slightly cooler room with blankets. |
Naps Naps can disrupt the body’s natural sleep cycle/body clock. If you cannot make it throughout the day without a nap, try to have a nap before 3pm for less than an hour’s duration. |
| Dark Try to have a darkened room, blocking out act as a cue for your body to be awake. Use blackout blinds/curtains if early morning light is a problem. |
Clock watching Frequent clock watching throughout the night can wake you up and reinforce negative thoughts. |
| Quiet Heavy curtains can block out some outside environmental noise. Ear plugs or white noise apps may also help. |
Bed Try to avoid watching television, eating and working in bed; keeping the space just for sleep and/or sexual intimacy. This way, your body will better associate being in bed as a cue for sleep. |
| Bathing Having a bath before bed can be a way to relax. This also raises your body temperature just prior to bedtime and the subsequent lowering of body temperature is seen as a key feature of preparing the body for sleep. |
Tech Laptops, phones, tablets and televisions all emit a light, which supress the natural hormones that cause sleepiness. Leave these turned off at night and try and not have these items near your bed where possible. |
| Late night heavy meals If you have a heavy meal close to bed time, it means your body starts working hard to digest any food. This can act as a stimulant, keeping your body more awake. |
Remember a flare-up is temporary. This plan can help you feel more confident at managing them when they occur.
What triggers my flare-ups?
E.g. feeling stressed, overdoing things, weather changes, lack of sleep etc.
Are there any early warning signs to my flare up?
E.g. Fatigue, headaches, lasting longer than usual, loss of appetite, feeling cold, becoming frustrated easily etc.
What strategies can I use to help me when I am in a flare-up?
How can I move on after a flare-up?
E.g. easing back into my routine, more pacing, arareness and support from others, acceptance etc.
My Tool box
- Relaxation
- Mindful movement
- Following my routine
- Realistic goals/aims
- Having fun
- Exercises
- Stretches
- Positive reflection
- Pacing and breaking down tasks
- Prioritising tasks
- Challenging unhelpful/negative thoughts
- Acknowledging achievements
- Being mindful of my emotions
- What have I learnt during my rehab stay?
Do you have any goals to work on once you go home?
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What might make it difficult to maintain change?
E.g. being busy with work/school, low mood.
How might you overcome these difficulties?
You might weant to discuss these with your therapist or family at the end of the rehab programme.
Decisions about your follow-up therapy sessions will be made with your therapists at the end of your stay. Often you will be seen for follow-up with both your occupational therapist and physiotherapist but this is not always the case. Depending on the individual case, you may or may not have a follow up appointment with your referring consultant.
Are you struggling with your mental health or have social issues which are contributing to low mood and/or anxiety? If so, the below resources will be able to support you in the community.
Mental Health Issues
Samaritans (24 hours)
020 8427 7777
SANEline (6pm – 11pm)
0300 304 7000
MIND
www.
0300 123 3393
Anxiety UK
www.
03444 775 774
No Panic
www.
0844 967 4848
CALM (Campaign Against Living Miserably - Men’s mental health resource)
www.
0800 585858
NHS choices
www.
Time to Change
www.
One You
www.
Self-Harm
National Self-Harm Network
www.
Hidden Universe of Self-Harm (HUSH)
www.
Self-Injury Support
www.
Financial
Citizens Advice Bureau
www.
03444 111 444
National Debt Line
www.
0808 808 4000
Money Advice Service
www.
0800 138 7777
Addictions
Drinkline (weekdays 9am – 8pm, weekends 11am – 4pm)
0300 123 1110
Alcoholics Anonymous (AA)
www.
0800 917 7650
Alcohol Change UK
www.
020 3907 8480
Narcotics Anonymous (NA)
www.
0300 999 1212
FRANK
www.
0300 123 6600
NHS Choices
www.
Drugs and Me
www.
Gambling
GamCare
www.
0808 8020 133
GA
www.
Bereavement
Cruse Bereavement Care
www.
0808 808 1677
Self Help Resources for Low mood and Anxiety Issues
Moodscope
This website aims to help people with low mood and depression to manage their moods by tracking their moods and using a buddy support system.
Website: www.
MoodGYM
Based on Cognitive Behavioural Therapy (CBT) this is an interactive website that aims to reduce depression and anxiety symptoms and consists of five modules to work through.
Website: www.
Living Life to the Full
A life skills course based on Cognitive Behaviour Therapy (CBT) covering areas such as tackling difficult situations and building confidence.
Website: www.
GET Self Help
A range of Cognitive Behavioural resources including information leaflets and workbooks.
Website: www.
CCI
The website provides a number of modular workbooks covering topics such as depression, anxiety and assertiveness.
Website: www.
Royal National Orthopaedic Hospital NHS Trust
Brockley Hill, Stanmore, Middlesex HA7 4LP
Royal National Orthopaedic Hospital NHS Trust
45-51 Bolsover Street, London W1W 5AQ
Switchboard: 020 3947 0100
Therapy department: 020 8909 5820
Rehabilitation ward: 020 8909 5341
Rehabilitation admissions: 020 8909 5783
Page last updated: 08 May 2025