Canadian Physiotherapy Competency Exams - 2024 Written Course Manual PDF

Helping you prepare for and pass the Canadian Physiotherapy Competency Exams WRITTEN COURSE MANUAL 2024 Written Course Manual | Page 1 of 383  COPYRIGHT NOTICE OPYRIGHT NOTICE Attention Students Copy...

Helping you prepare for and pass the Canadian Physiotherapy Competency Exams WRITTEN COURSE MANUAL 2024 Written Course Manual | Page 1 of 383  COPYRIGHT NOTICE OPYRIGHT NOTICE Attention Students Copyright © 2024 PT Exam Prep Inc. All rights reserved. No part of this course manual or any portion thereof may be reproduced, distributed, or transmitted in any form by any means, including photocopying, recording, or other electronic or mechanical methods, without the express written permission of PT Exam Prep Inc. The unauthorized reproduction or distribution of this work is illegal. All suspected criminal copyright infringements will be investigated, and charges will be filed under the Criminal Code of Canada, Copyright Act. Access to this course manual has been granted to you on the basis that only you will use it. 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Your name has been imprinted onto the document in order to provide you with as much information as possible – without the risk of sharing it. 2024 Written Course Manual | Page 2 of 383  COURSE OUTLINE Session Topics Covered Session 1 Exercise Prescription Lower Extremity Musculoskeletal Conditions Session 2 Upper Extremity Musculoskeletal Conditions Posture Spine Scans Joint Mobilizations Myotomes/Dermatomes Deep Tendon Friction Massage Neurodynamic Testing Manual Muscle Testing Peripheral Nervous System Range of Motion and Goniometry Peripheral Nerve Injuries Session 3 Respiratory Anatomy IPMA Lung Volume and Capacity Breath Sounds Ventilation/ Perfusion Critical and Acute Care Respiratory Conditions Cardiovascular System Physiology Pulmonary Rehabilitation Cardiovascular Conditions Breathing Exercises Cardiopulmonary Exercise for Cardiac Patients Chest PT and Secretion Clearance Techniques Peripheral Vascular Disease Arterial Blood Gases Session 4 Mock Exam Review #1 Session 5 Gait Mechanics Traumatic Brain Injury Mobility and Transfers Non-Traumatic Brain Injury Joint Replacements Cerebellar Disorders Balance Spinal Cord Injuries Parts and Functions of the Brain Neurodegenerative Diseases Acquired Brain Injury Session 6 Movement Disorders Arthritis Inflammatory/Infectious Conditions of the CNS Bone Conditions Diseases Affecting the Neuromuscular Junction Pain Syndromes Peripheral Neuropathies Obesity Vestibular Disorders Pregnancy and Postpartum Conditions Cranial Nerves Pediatrics Neurological Glossary Orthotics Session 7 Modalities Scars Cancer Skin Conditions Liver Conditions Stress Blood Disorders Thyroid Hormonal Dysfunction Metabolic Disorders Adrenal Gland Dysfunction Infection Gastrointestinal Disorders Infection Transmission Temperature Associated Conditions Amputees Mood and Mental Disorders Connective Tissue Disorders Documentation Structural Deformities Research Burns Session 8 Mock Exam Review #2 2024 Written Course Manual | Page 3 of 383  Session 1 Foundations of Exercise Exercise Prescription Type of Exercise Load (%1-RM) Repetitions Sets Rest Strength >85% Abd > Shoulder Joint glenohumeral joint IR Modalities Anatomy Shoulder Mobilizations Risk factors: hike with AROM Posterior glides increase internal rotation Prolonged immobilization Inferior glides to increase abduction Diabetes There are NO special tests for Anterior glides to increase external Dupuytren’s disease (may frozen shoulder rotation be a relation between the genetic disposition of Sensory Passive stretching patients who have function and contractures) reflexes are not Appendix Frozen Shoulder Exercises Woman more than men affected Age 40-65 most common PROM is equal to AROM 2024 Written Course Manual | Page 58 of 383  Etiology/ Signs and Symptoms Diagnostic Tests General Education Precauti Additional Mechanism of Injury Approach to Points on/ Info Treatment Contra. ROTATOR CUFF TEAR Rotator cuff tears can be Tears that are traumatic often In a full thickness Specific to Partial tear Can present like caused by: cause intense pain – they may supraspinatus tear, the each (incomplete): pancoast tumor Degenerative changes feel a snapping sensation and muscle is no longer pathology damage to immediate weakness in arm functional and the person tendon, but is Appendix Pancoast o Poor of blood cannot initiate abduction Appendix not completely Tumor supply Appendix Summary of Common of the upper limb. If the Shoulder severed o Bone spurs Impairments with Rotator Cuff arm is passively abducted Stabilization Disease and Tendinopathies 15 degrees or more, the Exercises Full-thickness Repetitive micro traumas person can usually tear (complete): maintain or continue the Appendix Separate all of o Arms above head abduction using the Force the tendon o Static/awkward deltoid. Couples in from the bone postures Shoulder o Throwing Drop arm test +’ve Severe traumatic injuries Empty can test +’ve o Dislocations Risk factors: Obese, advanced age Metabolic disorders Muscle imbalance Decreased flexibility 2024 Written Course Manual | Page 59 of 383  Etiology/ Signs and Symptoms Diagnostic Tests General Education Precauti Additional Mechanism of Injury Approach to Points on/ Info Treatment Contra. SHOULDER IMPINGEMENT AND TENDINOPATHIES Terminology such as tendinitis, Appendix Summary of Common Impairments with Rotator Exercise Postural Appendix Cervical tendinopathy, rotator cuff Cuff Disease and Tendinopathies focusing on education Spondylosis disease and anterior shoulder opening pain are sometimes used to Supraspinatus tendonitis subacromial describe the result of Lesion usually near musculotendinous junction causing space and impingement syndrome painful arc with overhead reaching improving Painful palpation of the tendon inferior to the anterior posture The cause of impingement is aspect of the acromion when the patient’s hand is placed Stretch often multifactorial and can be behind their back shortened broken down into intrinsic and Infraspinatus tendonitis muscles extrinsic Lesion usually near musculotendinous junction, resulting (pec in painful arc during overhead movement, forward or major and Intrinsic cross body motions minor, Compromised structural Pain occurs with the tendon just inferior to the posterior latissimus integrity usually caused by corner of the acromion when the patient horizontally dorsi, aging or avascularity adducts and externally rotates the humerus teres major, Extrinsic Bursitis subscapul Primary – subacromial Subdeltoid or subacromial aris and space stenosis When acute, symptoms are the same as those seen with levator supraspinatus tendonitis. Once inflammation is reduced, scapulae) Secondary – instability there are no symptoms with resisted movements Appendix Bursa Strengthe Appendix Impaired Posture n and Leading to Shoulder Pathology stabilize Bicipital tendonitis Lesion involves the long tendon in the bicipital groove (serratus beneath the transverse humeral ligament anterior, Pain occurs with speeds test and on palpation of the LFT, MFT bicipital groove and rhomboid Special test for bicipital tendon: Speeds test s) Special tests for subacromial impingement: Hawkins Kennedy, Neer’s and painful arc test 2024 Written Course Manual | Page 60 of 383  Etiology/ Signs and Symptoms Diagnostic General Education Precaution/ Additional Mechanism of Injury Tests Approach to Points Contra. Info Treatment LATERAL EPICONDYLALGIA 90% involve extensor carpi Usually symptomatic with activities Maudsley’s: Appendix Tennis Differential Appendix radialis brevis (ECRB) involving wrist and/or finger Resisted third Elbow Toolkit diagnosis: Tendinopathy extension and/or gripping (middle) finger check mid- vs. ECRB: extension cervical region Tendinosis vs. Tendinitis in Origin: lateral epicondyle for nerve root session 1 Insertion: dorsal aspect of base Cozen's: compression appendix of 3rd metacarpal Resisted Function: extends and abducts radial Appendix the hand at the wrist deviation and Cervical extension Referral Pain Remaining other 10% are from Differential ECRL Mill's: Passive Diagnosis pronation of ECRL: forearm and Sensory nerve Origin: lateral supracondylar extension of distribution: ridge of humerus elbow with Lateral Insertion: dorsal aspect of base wrist flexion antebrachial of 2nd metacarpal distribution Function: extends and abducts Tenderness the hand at the wrist on or near Dermatomal lateral distribution of Most common epicondyle C6 (lateral overuse/repetitive use injury aspect of of the elbow elbow) 2024 Written Course Manual | Page 61 of 383  Etiology/ Signs and Symptoms Diagnostic General Education Precaution/ Additional Mechanism of Injury Tests Approach to Points Contra. Info Treatment MEDIAL EPICONDYLALGIA “Golfer’s Elbow”: pronator teres Pain in elbow after using wrist flexors Palpation Appendix Tennis Differential Appendix and the flexor carpi radialis tenderness on Elbow Toolkit diagnosis: Elbow Pain when muscle is stretched or or near the check mid- Anatomy Small tearing of collagen contracts against resistance medial Use toolkit but cervical region fibers of common flexor epicondyle incorporate for nerve root tendon that attaches to Decreased grip strength, limited by flexion rather compression medial epicondyle pain Pain with than extension resisted wrist into your Dermatomal Repetitive motions into wrist flexion and protocol – distribution of flexion, such as swinging a golf forearm eccentric flexion C8-T1 (medial club, pitching a ball, or work- pronation aspect of related grasping elbow) Pain with Repetitive use injury passive wrist extension while elbow is extended and forearm supinated Ulnar neuropathy is often an associated finding 2024 Written Course Manual | Page 62 of 383  Etiology/ Signs and Symptoms Diagnostic General Education Precaution/ Additional Mechanism of Injury Tests Approach to Points Contra. Info Treatment COLLES FRACTURE Fracture to the distal radius – Dinner fork deformity: X-ray Casted until Appendix Often Appendix with or without fracture of the calcification is Fractures associated Wrist Distal radius fragment is ulnar styloid present with ulnar Anatomy displaced dorsally styloid Defined as a linear transverse Keep fingers and fracture, fracture of the distal radius Dorsal wrist pain shoulder moving TFCC tear, while in cast and Fall on outstretched hand Swelling scapholunat (FOOSH) After calcification e dislocation Inability to grasp object begin with Risk factors: strength, ROM and functional Most common in young exercises and elderly More common in females with history of osteoporosis 2024 Written Course Manual | Page 63 of 383  Etiology/ Signs and Symptoms Dx Tests General Education Precaution/ Additional Mechanism of Injury Approach to Points Contra. Info Treatment SCAPHOID FRACTURE FOOSH fall on outstretched Pain with pinch or grasp X-ray Initially casting or When hand surgery returning to Visible swelling and or bruising in and activities that Scaphoid bone is located in the around snuff box While cast is in falling is a anatomical snuff box place: common Portions of the scaphoid have poor blood occurrence ROM of There are no specific risk supply, and a fracture can further disrupt (skating, surrounding factors or diseases that make the blood flow to the bone snowboarding, joints you more likely to experience rollerblading), (shoulder, a scaphoid fracture Complications are common: using wrist elbow, guard can Most commonly fractured Non-union: a fracture that does not fingers) decrease the heal, may need graft carpal bone chance of re- Following fracture Avascular necrosis: not enough blood successful supply leading to bone death and healing (cast inability to heal removal): Arthritis: over time, non-union and ROM wrist avascular necrosis can lead to OA and hand (address post immobility stiffness) Strengthenin g – start with isometrics 2024 Written Course Manual | Page 64 of 383  Etiology/ Signs and Symptoms Diagnostic General Education Precaution/ Additional Mechanism of Injury Tests Approach to Points Contra. Info Treatment DE QUERVAIN’S TENOSYNOVITIS Irritation of extensor pollicis Pain with radial deviation as well as Finkelstein’s PRICE Activity Draw the brevis (EPB) and abductor pain with stretch (ulnar deviation) test: tuck modification tendons on pollicis longus (APL) thumb in fist Splinting your thumbs Change Thickening and swelling over APL and ulnar so you can lifting Snuff box: and EPB may also be present deviate wrist, Gentle pain free visualize the mechanics, EPB and APL on one side look for pain ROM separate Swelling often present in keep wrist (laterally) and extensor pollicis along area of sheaths anatomical snuff box in neutral longus (EPL) (not involved) distal radius and avoid more towards the index finger radial deviation Overuse – radial deviation Chronic overuse injury Common in mothers lifting babies Golfing, paying the piano, office workers, repetitive gripping 2024 Written Course Manual | Page 65 of 383 Appendix Ergonomics Chair: o Backrest ▪ Adjust backrest height to support the lumbar spine. The curve in the backrest should match with the curve of the lumbar spine. o Arm Rests ▪ Adjust armrest height to support arms when shoulders are relaxed. ▪ Elbows should be at 90°- 110° angle. o Seat ▪ Allow 2-3 fingers of space between the edge of the seat and the back of legs. Ensure patient is sitting with buttocks all the way to the back of the chair. ▪ Adjust seat height so elbows are 90°- 100° when working on desk and hips are flexed to 90°- 100°. ▪ Use footrest if feet are not fully supported on floor. 2024 Written Course Manual | Page 66 of 383  Monitor: o Height: Align the eyes to the top of the monitor. ▪ Viewing range generally falls about 15 degrees below the horizontal, so the eyes will relax at the middle of the screen. ▪ Check neck posture: If head is forward flexed, monitor is too low. If neck extended, monitor is too high. o Distance: Monitor should be at least an arm’s length away. o Position: Monitor should be directly in front of the user to avoid twisting of the neck. o Tilt: Tilt the monitor upwards, so the top of the screen is slightly farther away than the bottom of the monitor. Mouse: o Place the mouse directly beside the keyboard. o Special contoured mouse can encourage neutral wrist postures. Keyboard: o Should be flat (negative tilt) with the wrist in neutral position. o Positive tilt (angled upwards) results in the wrists being positioned in too much extension. ▪ If the keyboard has those little feet, close them. Desk Organization: o Frequently used items, such as the phone and notebooks, should be kept within an arm’s length. Appendix WAD Grading Grade Clinical Presentation 0 No complaint about the neck. No physical signs. I Neck complaint of symptoms such as: stiffness, pain, or tenderness only. No physical signs. II Neck complaint (symptoms) AND MSK objective sign(s) such as: decreased ROM, point tenderness. No neurological signs. No fracture/dislocation. III Neck complaint (symptoms) AND peripheral neurological signs (motor or sensory), such as decreased/absent deep tendon reflexes, myotome weakness, sensory deficits. No fracture or dislocation. IV Neck complaint (symptoms) AND fracture or dislocation confirmed with medical imaging. 2024 Written Course Manual | Page 67 of 383 Appendix Canadian CSP Rules 2024 Written Course Manual | Page 68 of 383 Appendix Cervical Spondylosis History: Age 50+, acute or chronic. Primary risk factor is increased age: 85% of people over the age of 60 are affected Can presents as: Axial neck pain o No neural involvement Cervical myelopathy o Damage to the spinal cord o Differentiating symptoms: bilateral numbness, coordination issues, grip weakness, bowel and bladder complaints, clonus, babinski Cervical radiculopathy o Damage to nerve roots o Differentiating symptoms: dermatomal or myotomal dysfunction including numbness, pain or loss of function On assessment: Hallmark signs and symptoms: o Axial neck pain ▪ Tenderness and muscle spasm around cervical spine o Cervical spine AROM/PROM: limited ROM with pain o Radicular symptoms if compression of neural structures o X-ray: narrowing due to osteophytes o Special tests: spurling’s test positive, distraction test eases, upper limb tension tests (ULTT) positive 2024 Written Course Manual | Page 69 of 383 Appendix Differential Diagnosis Headache Clinical Features Cervicogenic Headache Migraine Tension Type Headache Female: Male Equal F>M F>M Location Ram’s horn Frontal, periorbital and Diffuse - bilateral Occipital to frontoparietal temporal – unilateral but and orbital - unilateral can shift sides Frequency Chronic, episodic 1-4 per month 1-30 per month Severity Moderate-severe Moderate-severe Mild-moderate Pain character Non-throbbing, non- Throbbing, pulsating Dull stabbing, pain that usually starts in the neck Triggers Neck movement and Multiple, neck movement Multiple, neck postures, palpation over not typically a trigger movement not typically upper cervical spine a trigger Associated Usually absent or similar to Nausea, vomiting, visual Occasionally decreased symptoms migraine but milder, changes, phonophobia, appetite, phonophobia or decreased CSP ROM, photophobia photophobia tenderness over upper cervical spine Appendix Temporomandibular Joint (TMJ) Anatomy Muscles of mastication innervated by cranial nerve V (trigeminal): Masseter o Masseter muscle is the thick rectangular muscle in the cheek. o Main function is to close the jaw and clench teeth. Temporalis o Fan-shaped muscle on each side of the temporal fossa, superior to zygomatic arch. o Main function is to retract the jaw. Medial pterygoid o Thick quadrilateral muscle with 2 heads. o Medial pterygoid functions include elevation (closing), protrusion and lateral deviation of the lower jaw; assists in chewing. Lateral pterygoid o Has 2 heads - superior head attaches directly to the articular disc - stabilizes and adjusts the position of the articular disc. o Lateral pterygoid is the only muscle of mastication that assists in depressing the mandible (opening the jaw); assists in protrusion, lateral deviation of the lower jaw and chewing. 2024 Written Course Manual | Page 70 of 383 Actions of Muscles of Mastication Movement (of mandible) Muscle that creates movement (in order of primary mover) Depression (opening of mouth) Lateral pterygoid Elevation (closing of mouth) Masseter Temporalis Medial pterygoid Protrusion Lateral pterygoid Medial pterygoid Masseter Retraction Temporalis Masseter Lateral deviation Lateral pterygoid (contralateral muscle) Medial pterygoid (contralateral muscle) Temporalis (ipsilateral muscle) Masseter (ipsilateral muscle) Three finger test Jaw should be able to open three finger width or suspect TMJD. Temporomandibular joint motion Articulation is between the head of the condyle (of the mandible) and the mandibular fossa (of the temporal bone). The articular disc is between the two joint surfaces and lubricates the joint. Both rotation (rolling) and sliding (gliding) occur at the TMJ. o Rotation occurs from the beginning to the midrange of movement. ▪ Lateral pterygoid (superior head) attaches directly onto the disc and draws it anteriorly to prepare the joint for motion. o Gliding occurs as a second movement as the condyle and disc glide along the slope of the articular eminence. Clicking is a result of abnormal motion of the disc and condyle. o The disc usually displaces anteriorly. o This is often due to the superior lateral pterygoid concentrically contracting to pull the disc forward. Tightness of the superior head of the lateral pterygoid is often caused by bruxism (side to side motion with clenching). o Once the disc is moved anteriorly, the patient can experience locking as the disc is forward and doesn’t relocate, causing the jaw to lock. 2024 Written Course Manual | Page 71 of 383 Jaw Deviation: TMJ dysfunction (e.g. hypomobility, mechanical locking) o Jaw will deviate towards the affected side Myofascial dysfunction (e.g. muscle tightness or spasm) o Ipsilateral jaw deviation with masseter and temporalis tightness o Contralateral jaw deviation with pterygoid tightness Normal lateral deviation = 10-15mm; depression = 35-55mm. Question: Your patient’s jaw deviates to the left side when opening her mouth. Which muscles are overactive? Question: Which movement happens first in the jaw, rolling (rotation) or gliding? Question: Which direction does the disc usually displace? Appendix Shoulder Labral Tears Labral lesions are frequently associated with shoulder instability and this must be addressed as part of the management. Bankart lesion: Anteroinferior labrum is torn. o Labrum detached anywhere from the 3 o’clock to the 7 o’clock position. Common in anterior shoulder dislocations. Causes anterior instability and loss of stability from the inferior glenohumeral ligament. Post-surgical rehabilitation: o Early: Goal is to isometrically strengthen internal rotators so as to reduce the incidence of recurrent dislocation. Important to begin pendular movements within the first 24 hours. The arm may be placed in a splint in some abduction and external rotation to limit the amount of anterior capsular shortening. o After three or so weeks, the patient is allowed to start active external rotation in addition to strengthening exercises. However, combined abduction and external rotation must be avoided for six weeks. o Return to full sport is often achieved at three to four months. o Remember, post-surgical protocols differ depending on the surgeon and severity of injury. It is important to understand general principles of these protocols (which we cover in the manual), rather than exact details. Hill Sachs lesion: Occurs secondary to an anterior shoulder dislocation. Sometimes referred to as an impact fracture. The humeral head collides with the anterior part of the glenoid, causing an osseous defect. 2024 Written Course Manual | Page 72 of 383 SLAP: Superior labrum injury o Labrum detached anywhere from the 10 o’clock to the 2 o’clock position. Often results from a FOOSH injury, occurs during deceleration when throwing, or arises when sudden traction is applied to the biceps. When the biceps tendon is involved = further instability. Surgery is often required to either reattach the labrum to the glenoid or debridement to eliminate mechanical irritation. Appendix AC Joint Separation Acromioclavicular joint anatomy The AC joint is formed by the medial aspect of the acromion process of the scapula and the lateral end of the clavicle (planar joint). Stability of the AC joint if provided by several structures. These are, in order of increasing importance: o Joint capsule o Acromioclavicular ligament (provides horizontal stability) o Coracoclavicular ligament (comprised of the conoid and trapezoid ligaments and provide vertical stability) Etiology: Occurs in men 5x more than woman and is most likely to occur in 20’s in sporting activity. Hallmark sign: Palpable step deformity Pain with horizontal adduction and full elevation Mechanism of injury: Usually caused from a direct hit or landing on the shoulder (arm is usually in adducted position). Incomplete separation more common than complete. Treatment: Management is based on the general principles of management of ligamentous injuries. Initially, ice is applied, and the arm is put into a sling for pain relief. This may be for 2-3 days for a minor sprain, up to six weeks for a severe sprain. Isometric exercise should begin once pain permits. o The deltoid and trapezius cross the joint, so when there is ligament laxity, contractile support is important to regain early in rehab. Return to spot is possible when there is no further localized tenderness and full range of pain free movement has been regained. 2024 Written Course Manual | Page 73 of 383 Grade of injury depends on severity of step deformity: Type 1: Pain around AC joint due to sprain of AC ligament o No displacement/step deformity Type 2: AC ligament torn, CC ligament sprain o Step deformity usually seen with long traction of humerus Type 3: Both AC and CC ligaments are torn o Severe step deformity at rest Type 4-6: Rare o More severe type 3 injuries with additional soft tissue damage surrounding the joint o Occur in high impact trauma like motor vehicle accidents Appendix Scapular Winging Characteristics: o Inferior dysfunction: prominence of inferior angle as a result of anterior tilting of scapula in sagittal plane o Medial dysfunction: prominence of the entire medial scapular border due to internal rotation of the scapula in the transverse plane o Superior dysfunction: excessive and early elevation of the scapula during elevation Causes: o Neurologic ▪ Nerve palsy Lesion of long thoracic nerve affecting serratus anterior or weak serratus anterior Difficulty elevating arm above 120 degrees Results in prominence of medial scapular border The arm cannot be abducted above the horizontal position because the serratus anterior is unable to rotate the glenoid cavity superiorly to allow complete abduction of the limb Nerve commonly affected after mastectomy Trapezius palsy (spinal accessory nerve) - less common cause of scapular winging Inability to shrug shoulder Results in depression and lateral translation of the scapula - inferior angle translated laterally Rhomboid palsy (dorsal scapular nerve) uncommon Difficulty pushing elbow back against resistance (with hand on hip) May result in protrusion of inferior angle - inferior angle translated laterally ▪ Cervical radiculopathy o Muscular Tight pectoralis minor or short head of biceps Attached to coracoid and pull scapula anteriorly, tipping inferior angle of scapula away from ribcage Weak serratus anterior, lower fibers of trapezius, rhomboids Voluntary action 2024 Written Course Manual | Page 74 of 383  Painful shoulder causing muscle inhibition o Bony Thoracic kyphosis Multidirectional instability Clavicle fracture (shortened clavicular union) Special tests: o Observation with no active motion o Wall push up where the patient performs a push-up off of the wall from a standing position and therapist observes for asymmetric winging of the scapula. o Resisted flexion with the arm below the horizontal will place the serratus under maximum resistance and will demonstrate winging. o Active GH scapulothoracic movement (humeral flexion in the scaption plane) Scapular dyskinesia A deviation in the normal resting or active position of the scapula during shoulder movement. Normal scapular humeral rhythm Occurs when the scapula and humerus move in 1:2 ratio. When the arm is abducted 180 degrees, 60 degrees occurs by rotation of the scapula and 120 degrees from rotation of the humerus at the shoulder joint. Appendix Anterior Shoulder Dislocation: Conservative Protocol Rehabilitation can vary from 2.5 – 4 months and is composed of 3 phases that can overlap. Rehabilitation for anterior shoulder instability will vary in length depending on factors such as: Degree of shoulder instability/laxity Acute vs. chronic condition Length of time immobilized Strength/ROM status Performance/activity demands Initial assessment Evaluate posture Observe shoulder active/passive range of motion Observe cervical/elbow/wrist active range of motion Ask about pain and inflammation Sling May be worn between a few days to 4 weeks depending on the individual and wean as able. It can be removed for exercises prescribed by physiotherapist. 2024 Written Course Manual | Page 75 of 383 Phase 1 During phases 1 and 2, caution must be taken during all exercises to avoid placing undue stress on the anterior joint capsule. Weeks 1-4 Precautions: o No combination of abduction/external rotation movements o No extension past neutral o It is common to have hypersensitive in axillary nerve distribution o No active shoulder abduction past 90 degrees ▪ Normal biomechanics requires external rotation of the humerus with abduction past 90. External rotation combined with abduction is not safe in the acute stage. Goals: o Full passive range of motion o Active range of motion within 20° of uninvolved shoulder (normal ROM) o Stop muscular atrophy o Decrease pain and inflammation o Allow capsular healing Treatment: o Modalities as indicated to control and decrease pain/inflammation/muscle guarding o Stretch posterior cuff and capsule ▪ Posterior cuff stretches in supine position (cross arm adduction/sleeper stretch) o Mobilizations: ▪ Gentle joint oscillations ▪ Grade I and II joint mobilizations and progress as dictated by patient's tolerance Joint mobilization of AC joint, SC joint, and scapulothoracic junction if indicated Joint mobilization of glenohumeral joint may include posterior glides o ROM: ▪ Perform range of motion exercises (passive, active-assisted, active) as tolerated DO NOT allow abduction and external rotation combination ▪ Initiate pain-free active range of motion exercises and home exercise program to include cervical/elbow/wrist active range of motion and flexibility exercises Examples of exercises appropriate for this stage: o Pendulum exercises o Active assisted range of motion exercises: ▪ Wall pulley for flexion and abduction ▪ Cane exercises for flexion, extension, internal/external rotation External rotation and abduction in the plane of the scapula only o Strengthening for IR/ER with arm at side and elbow at 90 degrees o Scapular strengthening (scapular retraction, push up plus etc.) o Shoulder extension in prone position: do not move the shoulder past the plane of the body o Serratus punch in supine position 2024 Written Course Manual | Page 76 of 383 Phase 2 Weeks 4 - 6 Precautions: o No abduction/external rotation combination at 90° abduction Treatment: o Continue posterior cuff/capsule stretch, mobilizations, and range of motion exercises o ROM: ▪ Can progress to stretching into external rotation to 60° and 90° abduction as dictated by patient tolerance o Function: ▪ Initiate proprioception/functional activities ▪ Begin skill development at a low intensity level For throwing athlete, if dominant arm, initiate short/long toss with tennis ball progressing to full throwing for both distances and speed ▪ Total body conditioning with emphasis on strength and endurance, including flexibility exercises as needed Examples of exercises appropriate for this stage: o Prone row or T's o Standing with TheraBand in scaption plane o Proprioception drills o Serratus punch in standing o Posterior capsule stretch o Push up plus Phase 3 This phase focuses on progressing exercises in preparation for returning to prior activity level (sports, work, recreational activity, etc.). Weeks 7 to Discharge (~12 weeks) Precautions: o Be careful with wide grip or overhead strengthening exercises, i.e. bench press or military press Treatment: o ROM: ▪ Continue with manual stretching as indicated - progress to stretching into external rotation to 90° of abduction and greater o Strength: ▪ Continue with comprehensive upper extremity strengthening program to emphasize rotator cuff, scapular stabilizers and deltoid o Function: ▪ Progress upper extremity proprioception and function ▪ Activity specific exercises Examples of exercises appropriate for this stage: o All exercises as above + functional exercises 2024 Written Course Manual | Page 77 of 383 Appendix Stages of Frozen Shoulder Stage Signs and Symptoms General Recovery Timelines* Freezing Painful, progressive stiffening of the shoulder Onset-9 months o Intense pain even at rest and limitation of ROM o Reduced ER with arm by side (