June Journal Club Case

[sewhitta]

SUBJECTIVE
Case Description
History of Injury: 29 year old male slipped and fell on ice at work, reached to catch himself and suffered a L shoulder anterior dislocation on 2/15/16 (3 weeks prior to initial PT visit). Shoulder relocated the same day in the ER. Sling for 1 week. Arrived to clinic without sling.

Occupation: Developmental Engineer, currently still working with difficulty. Mostly computer work.
Now on Workmans Comp

Chief Complaint:
• Marked loss of motion. Marked degree of functional and recreational activity loss (UE ADL’s, running, swimming).
• Mild degree of pain anterior shoulder, aching – Currently a 2/10; Best 0/10. Aggs – reaching, lifting light weight objects, general UE use for ADL’s such as

Quick DASH: Disability score = 36; Work Module score = 7; Sports Performance score = 13

PMH: h/o chronic R shoulder subluxations resulting in labral tear and subsequent arthroscopic labral repair. Otherwise healthy guy.

Patient Goals: Gain as much function as possible. Patient states he has already stopped playing recreational sports, such as basketball and soccer, since his R shoulder injury and would be happy to just return to full functional use of his shoulder, running and maybe swimming for exercise if possible.

OBJECTIVE
Observation: L humeral head positioned anterior. Inferior angle scapular dysfunction.

Palpation: Moderate TTP to L biceps tendon

ROM Pre-Treatment: Flexion A/PROM = 100/110; External rotation PROM @ 45 & 90 deg = 55 & 70 deg. Internal Rotation @ 90 deg ABD = 30 deg

Strength: Left = 4/5 throughout, no apparent discomfort

Special Tests: Positive Apprehension and Relocation tests. Negative Sulcus, Load and Shift, Full Can test and Speed’s. Unable to accurately assess biceps load test secondary to mobility deficits. Biceps load negative test in available ER ROM.

Joint Mobility: Hypomobile posterior and inferior glides at 90 degree’s ABD and flexion

Cervical Spine Cleared

1st visit treatment: T-bar AAROM flexion and ER supine. Band resistance training: ER & IR at 0 deg; Scap stabilization activity – B ER + scap retraction in doorway, B wall slide + band resisted ER isometric.

Tolerance: Good, no complaints
Post-treatment ROM gained: flexion improved to 135 degree’s

2nd visit: Patient reports MRI findings indicate anterior labral tear from 6 to 12 o’clock

Patient questions and concerns: “The doctor says I have to have surgery to prevent my shoulder from dislocating again.” “Should I have surgery?” “How much can I expect to gain from therapy?” How is therapy going to fix the tear?

Workmans Comp initial allowable visits: 12

Discussion Question:

1) How do you handle the patient’s question, “Should I have surgery?” after the surgeon at your facility highly recommends surgery?

2) Do you agree with the surgeon and tell the patient they will need surgery, or do you tell him he will reach his goals with conservative treatment? What are you using to support your answer? Predictors? Clinical experience? Current research? Other?

3) What specific information do you provide this patient to give him a good picture of his most likely outcome? If you recommend conservative treatment, what functional level do you tell him he will be able to achieve and by what time frame? Would this be different with surgical intervention?

I believe this is always a critical time period to set your patient up for success. If we look and sound unsure of the answers we provide for a split second, our patient is likely to take the advice of the more confident surgeon, who is likely always confident in their answers. This patient, much like many of our injured patient’s, may be a better candidate for surgery. Are we always fully prepared for this situation to provide solid evidence based information? I felt I needed more detailed information. How is your confidence level?
I feel the surgeon is always prepared to give a confident response. Are we armed enough to provide the best advice in this situation at any given time, regardless of the injury?

The first article will be the focus of journal club (the case series). The other two are supporting articles I’ll briefly touch on that I’ve used to help answer my PICO, but just wanted to provide them for your library.

Attachments:

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[Nick Law]

Sean,

First, I would like to say that I completely agree and resonate with your comments at the end regarding our communication with the patient; notably, if we seem hesitant in providing answers to the patients prognostic questions then we may quickly lose their trust in favor of the MD who quickly gives a straight forward answer. However, while I think that the surgeons have a routinely confident answer to give, I would be sure not to confuse confidence with accuracy.

Prognostic questions/comparisons between conservative and surgical care can certainly be difficult at times. I am sure like most of us, I try to provide answers based on best available evidence as well as treatment experience. I also think that patient preference and personal factors /goals play a significant role.

Based on the research Eric presented in the course series as well as the patients seemingly low goals, I would confidently recommend to this patient a trial of non operative management. I would be slow to make any unqualified promises to the patient, however I would certainly sell at least a short period of non operative management to see if ROM, strength, and function will appear to be adequately regained. Being a male under the age of 30 are prognostically unfavorable, however he isn’t 18 either and his goals seem very modest.

A couple of questions that might influence me in thinking about this patient: does he have signs of systemic laxity? Also, perhaps more information behind his history of right shoulder injury and subsequent surgery, as well as how that shoulder is now functioning post operatively would certainly be valuable information as well.

• This reply was modified 7 years, 10 months ago by Nick Law.

[Laura Thornton]

Thanks for sharing this case Sean. This has prompted some great discussion with the therapists and students over at our clinic the past couple days.

This isn’t a black and white case and I don’t think that you can immediately answer the question “To operate or to not operate”. There’s a lot of factors at play and I would certainly be the person who helps him map out all the different pro and cons for each option so HE can help make the informed decision. Instead of telling him what he needs to do, list out what are the benefits and risks of each and have an open discussion on what each entail. I would think that most patients would appreciate this rather than having a PT and a surgeon pulling them in two different directions.

Richmond, the student at our clinic now, posed an excellent question. If you were to read through this case, but stop before you read the MRI findings of the labral tear, would you change your opinion about treatment? Would the patient?

Biopsychosocial vs. Biomedical. Do we treat the labral tear and probable ligament dysfunction, or do we treat the whole patient, his goals, his limitations, his preferences while keeping in mind the biomedical piece? His goals are to return to daily function and to swimming, he has mechanical impairments that we can address conservatively, and he already responded really well to the first session. I would definitely support a trial of conservative treatment but obviously monitoring progress, pain, any occurrences of further subluxations, and changing course if needed along the road.

[omikutin]

Thanks for the case Sean.

It’s tough when a surgeon states a patient needs surgery. I would first consider the fact of how much gain we’ve had in just one treatment. If the patient has 12 more visits left there could be much more gain that is if he continues to work through his exercises and stays away from aggravating factors.

I would also exaggerate all the positive findings we had such as no irritation during his manual muscle testing. Yes, the patient does have a labral tear but because of his goals returning to ADLs and running, it’s highly likely conservative care is promising. Swimming may be more challenging but possible. Now, if the patient wanted to get back to competitive triathlons or extreme sports then we would have to consider other options. I would say PTs are very goal oriented and surgeons are very outcome orientated. Regardless of what I think, the patient is the one who makes the decision. I agree with Laura, sitting down and talking through the pros and cons.

I found it interesting that age was the most reliable factor for predicting recurrent dislocations. I would have thought the activity level would have played a larger role. I also wonder why he has had chronic right shoulder dislocations?

[sewhitta]

Excellent comments guys, good discussion. Thanks for your input. I wanted to get your input as well in terms of how long it will take to reach a particular outcome or activity level. Obviously there are a lot of factors that play into this. I feel like sometimes, at least for me, I’m hesitant to provide a timeframe or unsure and that leads me to provide very vague answers. Maybe it’s just me, but this was the reason I wanted to do more research on this topic. What would you have said to this patient to answer the question, “how long will this take?” Would you treat for a month, two, six? Would you expect a plateau or a lull in progress at any point? Would you press on? Request more visits? Does your answer or the education you provide change after reading the articles.

This guy is awesome to work with, great attitude and always has something positive to say each day he comes in and never complains about his lack of function. He’s totally on board with rehab and really wants to avoid surgery. I initially advised him to improve his mobility and strength as much as possible before considering surgery. I’ve been treating him since March and he’s at the end of his 12 visits. He’s made excellent improvements, but his mobility and strength are still limited a moderate degree. My initial expectation was that he would have more mobility by this time. I wasn’t sure if he’s reached a plateau, if we needed to be more vigorous or if this was the natural course of the condition.

A lot of our patient’s may not be this easy to deal with and may be panicking at this point, especially if they’re worried about workman’s comp paying for their surgery if they need it.

[ABengtsson]

Great discussion about how to approach the subject! A lot of times I’ll tell patients that I’m generally biased towards PT, just like the surgeon is biased towards sx, but that there are definitely instances where sx is needed, or provides better outcomes. Leading with that usually helps me set up the rest of the conversation and most of the time the patient will immediately weigh in on what their bias or preference is. (I haven’t had a lot of people tell me that they’d rather have sx)

Especially, in cases where there’s not a lot of conclusive research on what the best approach is, I tell the patients that there really isn’t a good answer, but what the implications are and what I have to offer them.

I like Richmond’s point and I think it depends on severity of findings. Another question would be would you change your treatment approach just based on imaging findings, or would you still treat the same way? Also, do you think that the labral tear affects his improvement, or response to treatment? I think especially with a pt who is worried about imaging findings it helps to have the conversation whether these findings change anything in regards to what the treatments look like or whether you’d make changes to the imaging findings vs. your objective findings.

As for the prognosis/duration question… I’d try to answer that relative to your findings, i.e. tissue healing times, time to see neurophysiological changes/improvements in motor control, gaining strength etc.
While that may not be a straight forward answer, it helps outline what you can offer and what he can expect time wise for different goals in therapy.

I’d also emphasize that 1. PT before sx wouldn’t be a waste of his time and could improve outcomes, so he wouldn’t loose anything if he’d try PT first. That way he could always determine whether or not he really does need sx based on his personal outcome. 2. He’ll likely have PT after sx and 3. sx is another trauma to the system that he’ll have to recover from. What could help is showing him, or telling him about post-sx protocols for what sx he’s expected to have.

Based on his activities (run/swim) he doesn’t fall into the group for which sx is recommended despite his age, which is something I’d also emphasize.

[Laura Thornton]

Can you be more specific on the moderate mobility and strength deficits that he still presents with? Where is he currently in regards to functional return to work, daily activities, running, and swimming?

[sewhitta]

At this point he’s doing well. He’s working, able to run and doing a little swimming (breast stroke) without issue. He has about 150 degree’s of shoulder flexion AROM, 70 AROM ER and IR still quite limited at about 45 degree’s. No c/o pain, just stiffness and weakness. He’s able to lift objects such as grocery bags with one arm, and perform his ADL’s without limitations.

[Laura Thornton]

Wow, that’s fantastic! Nice work.

Do you think that the strength and mobility deficits would be addressed with an independent program and fitness regime? He has returned to work, running, beginning swimming, ADL’s, and is painfree. If he doesn’t require supervision for his program and you don’t think he needs more manual therapy/direct physical therapy, and he feels like he has met all of his functional goals, then is it possible to decrease frequency of visits and see him 1x/month for progression and guidance? If you think that he still requires supervised PT and needs direct treatment, then I would press on. If not, I would begin to transition.

4 months out and we are well into the remodeling phase of healing – which takes time. Dislocation can be a big trauma to the shoulder complex and I wouldn’t be surprised if you see more of a plateau when you get into the later stages of healing. Add in his history of recurrent subluxations of his right shoulder (did we confirm that he has general laxity?), I would think he would need more time to gain motor control and strength but this may be something that he could do on his own without consistent PT sessions.

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