- This topic has 5 replies, 4 voices, and was last updated 6 years, 7 months ago by .
-
Posts
-
-
Hi Everyone! Looking forward to seeing you all this weekend! Here is my case for next week.
Subjective:
Patient is a 65 yo F, retired attorney, with a chief complaint of right shoulder pain that began at the end of September. Reported that she woke up one morning with pain. No specific MOI, had felt aches prior, but not this level of pain. Reported that she had been very busy the week before cleaning and caring for her mother who lives in an assisted living facility. When pain first started, she felt it in anterior shoulder from mid-clavicle to acromion, along superior and posterior aspect of the shoulder and along the lateral aspect of the upper arm. In the past few weeks (was evaluated on 10/23) pain now more localized to superior shoulder and lateral arm (about mid-way to elbow) that is described as a stabbing, achy pain, constant but variable in intensity. Denies any N/T. Also reporting a constant, variable intensity upper to mid thoracic “stiffness” that is made worse by time on her phone (not a new symptom for her). Her favorite activities are playing games on the computer and iphone and reading.PMH: history of headaches made worse by stress and when she spends hours on her phone. Bankart repair on left shoulder in 1995, h/o DM, hypercholesterolemia, and depression. X-Ray for right shoulder was normal (per pt report) and she had a subacromial cortisone injection on 10/3/17 with no significant relief of symptoms.
Aggs: lifting overhead, lifting any object out away from her body (can be light weight) and reaching behind her back. Both exacerbated if done quickly and she feels pain immediately. Prolonged cellphone use as she often holds it in her right hand. Biggest agg: lifting her mother’s transport chair and/or Rollator into and out of her car.
Eases: rest with arm at her side, biofreeze.Pain: Best: 3/10 Average: 5/10 Worst: 8/10
Severity: Mod-Severe (pain 8/10 at worst with moderate interference with ADLs and more limited with lifting tasks associated with being caregiver for mother)
Irritability: Mild-Mod (Able to reproduce symptoms quickly, but alleviates to baseline quickly (a few minutes) with rest.
Nature: Mechanical/ somatic
Stage: Acute
Stability: WorseningObjective:
– Posture: forward, rounded shoulders, forward head
– Negative for cervical pain or reproduction of symptoms with cervical AROM + overpressure.
– Negative Spurling’s, distraction, and Negative neuro screen
– Shoulder AROM: Full on left, about 165 degrees flexion and abduction on right feeling pain at end range and reporting “weakness” into abduction. Pain and “tightness” reproduced at 150 degrees PROM flexion as well.
– TTP of pec minor, subscapularis, upper trapezius, biceps.
– Speed’s, Drop Arm were Negative. Hawkins and Full Can were Positive for pain reproduction, + Painful Arc.
– MMT: good strength, but painful with resisted RTC testing (supraspinatus, infraspinatus (mild), and subscapularis).
– Joint Mobility: GH: Hypomobile posterior capsule, ST: hypomobile ER, posterior tilt, upward rotation (pain relieving with mobilization), T-spine: hypomobile upper to mid-thoracic (and later assessed hypomobile 1st rib on R).
– FOTO: Intake 51 (predicted final score 63)– Primary hypothesis: primary impingement, rotator cuff tendinopathy.
Asterisks:
*+Painful arc/Hawkins/Infraspinatus, positive full can for pain reproduction
*Hypomobility of posterior capsule
*Decreased thoracic mobility, poor posture
*Pain relief with scapular mobilizations, repositioningTreatment:
Day 1 at Eval:
-Scapular mobilizations for pain relief followed by scapular PNF (rhythmic initiation, slow reversals) in side-lying with re test of forward flexion (resulting in slight decrease in pain).
-Shoulder ER isometrics with arm at side, starting with 5 second holds for 10 repetitions, once daily.
-Education on relative rest due to acute phase, use of ice for symptom management, and activity modification (discussed phone usage and strategies for her to get assistance lifting assistive devices for her mom).Day 2:
Patient reporting increased stress and pain after having to take her mom to multiple doctor’s appointments, left her AD (14lbs), etc.
-Continued discussion on activity modification strategies (getting help from front desk for chair, deferring unnecessary trips with her mom, use of pillows for sleep positioning, computer/phone ergonomics).
-Started with MT: MFR upper trapezius, scapular mobilizations into posterior tilt, external rotation, upward rotation. Followed by PNF and AAROM flexion and ER with cues for scapular setting first. Re test of forward flexion, inc from 164 deg to 172 deg with pain at end range.
-Continued isometrics, now pain-free with arm at side.HEP:
-ER isometrics
-UT stretches
-Scapular retractionsFuture components to investigate:
–GH joint mobilizations, Effects of thoracic manual therapy (due to poor posture, complaints of thoracic spine stiffness)PICO:
In patients with shoulder impingement, does the addition of thoracic manipulation result in a greater reduction of pain in less time than a treatment plan consisting of mobilization and exercise, as indicated by their numeric pain rating scale?Discussion Questions:
1) With the acute nature and irritability level of this patient (and those like her), what are your immediate strategies for pain relief? Further, what are some of the strategies you like to use when discussing activity modification with the patient who is a caretaker for others or may have a physical job?
2) When evaluating a patient with shoulder pain, is there any further subjective information you would have liked to have day 1? Would you have looked at something differently on her objective exam?
3) There is a body of evidence showing thoracic manipulation can be effective for pain relief and perception of disability (though results can be inconclusive or reported to be just as effective as the alternate treatment with higher level evidence, i.e. systematic reviews). My question is, do you consider thoracic manipulation in your shoulder impingement patients, and if so, what subjective and objective asterisks are you looking for in your decision-making? At what point in the rehab process would you consider manipulation?
a. Mintken et al. developed a CPR to identify patients with a primary complaint of shoulder pain who will have a favorable response to cervical and thoracic thrust manipulation…however, in a secondary analysis done in March 2017, the results of the current study did not validate the previously identified prognostic variables.
4) What are some treatment strategies do you find effective in this patient population in conjunctions with therapeutic exercises? (i.e. taping, educational tools, muscle energy techniques, etc.) -
-
Hi Sarah, thanks for posting!
It sounds like this patient would have fit the inclusion criteria in this study, although I am wondering if the author’s note about the high percentage of the participants who had more chronic pain than your patient does caused you any concern about the applicability of their results to your patient? As we know, chronic pain can present very differently than acute pain, such as with your patient, and I am wondering if this caused you to interpret the article’s results any differently for your specific patient?
In your objective exam, did you look at ER/IR ROM? I see that you said she had trouble putting her hand behind her back as an aggravating factor, but was there any kind of ROM limitations there or capsular pattern?
As for your third question considering thoracic manipulation with these patients, I think I go to mobilization before manipulation, although admittedly, I do not have a much experience treating this patient population. In my limited experience, I have gone to mobilization before manipulation as well as giving thoracic mobility exercises for HEP. I think if I were having success here and her irritability at the GH joint prevented aggressive intervention to the shoulder, I would consider manipulation at that point.
Looking forward to hearing more tomorrow!
-
Hi Sarah,
Great summary of your case.
1. For a patient like this, I would likely try some scapular mobilizations first day, assuming that she doesn’t tolerate Glenohumeral mobilization as well. I might try ice with the shoulder positioned and supported by pillows – and instruct the patient to try the same at home when symptoms are aggravated. I’ve had some success with taping the shoulder encouraging posterior tilt of the scapula, which could be an option to help decrease pain with ADL’s. In terms of activity modification, I try to encourage the patient to be mindful of how they move. I try to express that I understand they have to do certain movements, and that’s okay, but I’d like them to be more aware of how they are moving during those challenging tasks. In this example, I would look at her movement pattern with lifting an assistive device. It’s awkward placing a rollator or wheelchair into a car, so I think it can be tweaked to avoid a long lever arm at the shoulder. Depending on the specifics of her car, there’s usually an easier way to get a device loaded that hasn’t occurred to the caregiver. -
As for subjectively, I’d want to know the specifics of her left shoulder injury and how she arrived at surgery, as well as her rehab post surgery.
Objectively, I have the same question as Katie – ER/IR AROM/PROM?
As for treatment strategies, I try to teach the caregiver how to use their body effectively for transferring their family member so they can decrease unnecessary stress on the shoulder. Kinesiotaping as a proprioceptive cue for posterior tilt of the scap has been helpful at times. -
Hey Sarah,
Initially, I find that gentle oscillations in distraction work well for pain relief with these patients. For home, I would try what Justin suggested and tape the scapula into a posteriorly tilted and depressed position to see if that changes anything for her. I would also want to see what her mechanics are like when having to lift her mother’s AD and see if there is anything you can work on there. I’m curious to know if you were able to get a sense of how much having to care for her mother seems to affect her pain levels and her overall psychosocial status. Other than assessing her ER/IR ROM at different levels of abduction, I like to get an idea of what level they can reach to behind their back bilaterally so that you have a baseline. I’ve had moderate success with mobilization with movement into that position in similar patients.
-
- You must be logged in to reply to this topic.