Upper Extremity Interventions: Medical Model

• Upper Extremity Interventions by Michael Garrison, PT, DSc, Board-Certified Clinical Specialist in Sports/Orthopedic Physical Therapy, and Clinical Associate Professor

Medical Model

• It focuses on pathoanatomic diagnosis and treatment.
• Patient A with Rotator Cuff Tear(RCT) gets Rx A.
• Patient B with Subacromial Pain Syndrome(SAPS) gets Rx B.
• Identifying the diagnosis equals finding the right treatment.
• Some issues with this model entails no reliable correlation with symptoms and doesn't guide rehab clinical decision-making.
• The medical model starts with taking a history, performing a physical exam, assigning a diagnosis, and prescribing Rx based on diagnosis.
• This model is valid for some Musculoskeletal(MSK) disorders like fracture management and surgical treatment.
• It remains inadequate for most rehab patients.

Example of SAPS Scenarios

• Patient A presents subacromial pain, a 9/10 at worst, with recent exacerbation related to painting.
• Treatment for Patient A includes education, ruling out cuff involvement, rest, nonsteroidal anti-inflammatory drugs(NSAIDs), and isometrics.
• Patient B presents subacromial pain, a 0/10 pain at rest, and pain only with elevation and chronic intermittent pain.
• Treatment for Patient B includes education focusing on task-specific activities, and sleeper and eccentric post rotator cuff management.
• SINS (Severity, Irritability, Nature and Stage) and impairments guide interventions.

Rehab Model

• It is not strictly for Upper Extremity(UE) disorders.
• It includes pathoanatomic diagnosis.
• Patients want a label without adding fear and other medical providers are familiar with labels
• The rehab model involves integrating irritability and impairments to guide rehab decision making, improve outcomes and reduce healthcare costs.
• A key focus is self-efficacious interventions.

Physical Examination

• It is important that subjective and screening are complete.
• Previous imaging should also be reviewed.
• GH and scapular regions should be visualized.
• Patients should also be able to articulate their chief complaint and point to where they experience pain.
• Clear the neck.
  • Examine ROM with overpressure
  • Compression, Spurlings, Quadrant
• A neuro screen should be performed if indicated.

Social Determinants of Health

• Economic Stability: Includes job, bills, and support.
• Neighborhood and Physical Environment: This entails housing, transportation, parks, safety & walkability.
• Education: Literacy, language and understanding
• Food: Includes hunger, nutrition
• Social Context: Engagement with the community
• Health Care System: Coverage and competency

Interventions

• "The art of medicine consists in amusing the patient while nature cures the disease" ~Voltaire

Manual Therapy

• Hands-on evaluations and Rx is ideal.
• How Orthopedic Manual Physical Therapy(OMT) is applied is not as important.
• Low grades are used for pain control.
• Higher grades are used for capsular motion loss.
• Remember arthrokinematics: Assess, intervene, reassess
• Restricted elevation involves inferior glides.
• Restricted internal rotation involves posterior glides.
• Arthrokinematics are a good place to start that assist to addressing capsular restriction.
• Restricted external rotation motion entails arthrokinematics of anterior glides
• In reality, posterior or anterior glides are effective.
• Interventions should be performed in a way that's comfortable for the patient while also considering the patient's comfort and habitus.

Patient Scenario

• Acute shoulder pain with no Mechanism of Injury(MOI) in a 35 year old.
• The patient is at a 4/10 at rest, 7/10 with all movement.
• AROM is limited to 50% in all directions.
• PROM is at full with pain at end range.
• Long Term Goals(LTG) include full return to overhead lifting.
• Impairments include pain, motion and fear.

Staged Approach For Rehab

• Impairments with associated high irritability: Activity modification, manual therapy, and modalities
• Impairments with associated moderate irritability: Activity modification, manual therapy, and limited modality use
• Impairments with associated low irritability: no modalities
• Pain associated with central sensitization entails progressive exposure to activity and medical management with high irritability, comfortable end-range stretch intermittent ROM stretching manual therapy with moderate irritability, and tolerable stretch sensation endurance ROM stretching manual therapy with low irritability.
• Neuromuscular weakness associated with atrophy, disuse, and deconditioning entails AROM within pain-free ranges with high irritability, light or moderate resistance to fatigue and midranges with moderate irritability, and moderate or high resistance to fatigue with included end-ranges with low irritability.
• Poor patent understanding leading to inappropriate activity (or avoidance of activity) entails appropriate patient education McClure 2015

Interventions

• Management of Pain entails
  • Low grade mobilizations
  • Maximal isometrics
• Management of Motion entails
  • Pain free Assisted Active Range of Motion(AAROM)
  • Avoid painful end range
• Management of Fear entails
  • Build therapeutic alliance
  • Use calming and reassuring language
  • Use SMART formatted goals

Home Exercises - Motion

• This can include Wall walks, Table Slides, Sleeper stretches, Side lying ER, and External Rotation(ER) doorway stretches.

Strength Progressions

• Strength Progressions can include Submaximal isometrics, maximal isometrics, multi-angle isometrics, limited range concentric, full range concentric, heavy slow resistance, eccentric training, heavy load eccentric training and plyometric functional training.

Always Integrate Strength

• Exercises with high levels of Electromyography(EMG) activity.
• Rotator cuff
  • Open can scaption
  • Push-up plus
  • Standing rows
  • ER and IR with arm at 90
• Can also focus on scapula
  • High, low, or middle rows
  • Push-up plus

EMG Activity

• High levels of Supraspinatus include push-up plus, prone horizontal ABD 90 and 100, prone ER at 90, and full can scaption.
• Low levels of Supraspinatus include supine and upright bar assisted ER, wall assisted ER, supine Physical Therapy(PT) assisted elevation, and foward bow.
• High levels of Infraspinatus include push-up plus, full can scaption, prone ER at 90, and prone horizontal ABD.
• Low levels of Infraspinatus include forward bow, supine PT assisted elevation, supine bar assisted ER, and wall assisted ER.
• High levels of Subscapularis include resisted elevation, standing row, internal Rotation(IR) at 90 of ABD, and resisted shoulder EXT.
• Low levels of Subscapularis include pulley assisted elevation, table slide, and prone shoulder flexion.

Patient Scenario

• Patients present chronic lateral elbow pain with no moi, its a 42 year old mechanic experiencing 1/10 at rest, 7/10 at end of workday with AROM within normal limits.
• There lies pain with resisted extension and LTG which includes full return to mechanic work.
• This entails impairments of
  • Functional intolerance where ergonomics and endurance are important
  • Weakness and/or endurance where strengthening are important
  • Understanding of the condition throughout patient education

Radial Head Manipulation

• Procedure involves the patient's right arm and the examiner's left hand as the clinician pushes Posterior to Anterior (PA) to the patients radial head.
• There is wrist flexion and pronation with a maintained PA glide along with quick elbow extension.

Mobilization with Movement

• Procedure starts with the patient's left arm and stabilizing the humerus.
• The clinician performs a lateral glide of the patients ulna where arms are parallel and involves grip exercises.
• Mobilization is performed until pain free followed by adjusting elbow extension.

Carpal Tunnel Syndrome

• Education: The effects of mouse use and alternate strategies as well as use of keyboards with reduced strike force, Pathology, risk identification, symptom self-management, aggravating postures/activities.
• Orthoses entails Neutral-positioned wrist orthosis worn at night for short-term relief and functional improvement if night-only use is ineffective, include daytime, symptomatic, or full-time use for mild to moderate CTS and if no relief, add metacarpophalangeal joint immobilization or modify wrist joint position with is recommended for women with CTS during pregnancy with postpartum follow-up. Superficial heat: results short-term symptom relief with microwaving or shortwave diathermy for short-term pain and symptom relief for mild to moderate CTS
• Interventional Procedures entails trial for short-term pain relief of interferential current that is clinical symptom relief for mild to moderate CTS for Phonophoresis for short term relief for mild to moderate CTS with manual therapy.
• The procedures can include soft tissue mobilization at sites of potential median nerve entrapment and cervical spine stretching and mobilization.
• An orthotic/stretching program may be instated for short-term symptom relief for mild to moderate CTS in patients without thenar atrophy and with normal 2-point discrimination

Proximal Carpal Mobilization

• Assists with either wrist flexion or extension

ULTT 2a - Median Nerve

• This involves Shoulder girdle depression, elbow extension, forearm supination, whole arm external rotation, wrist finger and thumb extender and cervical side bending.

Overview of the medical model for upper extremity interventions, contrasting it with other approaches. It highlights the focus on pathoanatomic diagnosis and treatment. Specific examples, such as Rotator Cuff Tear and Subacromial Pain Syndrome, illustrate the model's application and limitations in guiding rehabilitation decision-making.