Upper Extremity Interventions PDF

Upper Extremity Interventions Michael Garrison, PT, DSc Board-Certified Clinical Specialist in Sports Physical Therapy Board-Certified Clinical Specialist in Orthopedic Physical Therapy Clinical Associate Professor  Medical Model Pathoanatomic diagnosis and treatment Patient...

Upper Extremity Interventions Michael Garrison, PT, DSc Board-Certified Clinical Specialist in Sports Physical Therapy Board-Certified Clinical Specialist in Orthopedic Physical Therapy Clinical Associate Professor  Medical Model Pathoanatomic diagnosis and treatment Patient A with RCT receives Rx A Patient B with SAPS receives Rx B Find the diagnosis = finding the Rx What happens with Rx B helps patient A Issues with pathoanatomic model – No reliable correlation with symptoms – Doesn’t guide rehab clinical decision making  Medical Model Take history Perform physical exam Assign a diagnosis Prescribe Rx based on diagnosis Valid model for some MSK disorders – Fracture management – Surgical treatment Inadequate model for most rehab patients  Example - SAPS Patient A – subacromial pain, 9/10 at worst – Recent exacerbation related to painting – Educate, rule out cuff involvement – Optimal management – rest, NSAIDs, isometrics Patient B – subacromial pain, 0/10 pain at rest – Pain only with elevation, chronic intermittent pain – Educate, focus on task specific activities – Optimal management – sleeper, eccentric post RC SINS and impairments guide interventions  Rehab Model Not strictly for UE disorders Include pathoanatomic diagnosis – Patients want a label, don’t add fear – Other medical providers familiar with labels Integrate irritability and impairments – Guide rehab decision making – Improve outcomes – Reduce healthcare costs Focus on self-efficacious interventions  Physical Examination Subjective complete, screening complete Previous imaging Visualize GH and scapular regions Have patient articulate the chief complaint Point where they experience pain Clear the neck – ROM with overpressure – Compression, Spurlings, Quadrant Neuro screen if indicated  Social Determinants of Health Economic Stability – job, bills, support Neighborhood and Physical Environment – Housing, transportation, parks – Safety, walkability Education – literacy, language, understanding Food – hunger, nutrition Community and Social Context – engagement Health Care System – coverage, competency Interventions  Manual Therapy Hands on eval and Rx is ideal How you apply OMT not as important What is manual therapy Low grades for pain control Higher grades for capsular motion loss Assess, intervene, reassess Remember arthrokinematics – Restricted elevation – inferior glides – Restricted internal rotation – posterior glides  Manual Therapy Arthrokinematics are a good place to start Addressing capsular restriction will help Restricted external rotation motion – Arthrokinematics – anterior glides – Reality – posterior or anterior are effective Perform what’s comfortable for you Consider patient comfort and habitus  Patient Scenario Acute shoulder pain No MOI, 35 years old 4/10 at rest, 7/10 with all movement AROM limited to 50% in all directions Full PROM with pain at end range LTG – full return to overhead lifting Impairments – pain, motion, fear  Staged Approach For Rehab McClure 2015  Interventions Pain – Low grade mobilizations – Maximal isometrics Motion – Pain free AAROM – Avoid painful end range Fear – Build therapeutic alliance – Calming and reassuring language – SMART formatted goals Manual Therapy Posterior glides  Home Exercises - Motion Wall walks – FF only Table slides Sleeper Side lying ER ER doorway stretch  Strength Progressions Submaximal isometrics Maximal isometrics Multi-angle isometrics Limited range concentric Full range concentric Heavy slow resistance Eccentric training Heavy load eccentric training Plyometric functional training  Always Integrate Strength Exercises with high levels of 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 Eccentric Post Cuff Eccentric Post Cuff Eccentric Post Cuff  EMG Activity Supraspinatus High levels of activity – Push-up plus – Prone horizontal ABD 90 and 100 – Prone ER at 90 – Full can scaption Low levels of activity – Supine and upright bar assisted ER – Wall assisted ER – Supine PT assisted elevation – Forward bow  EMG Activity Infraspinatus High levels of activity – Push-up plus – Full can scaption – Prone ER at 90 – Prone horizontal ABD Low levels of activity – Forward bow – Supine PT assisted elevation – Supine bar assisted ER – Wall assisted ER  EMG Activity Subscapularis High levels of activity – Resisted elevation – Standing row – IR at 90 of ABD – Resisted shoulder EXT Low levels of activity – Pulley assisted elevation – Table slide – Prone shoulder flexion  Patient Scenario Chronic lateral elbow pain No MOI, 42-year-old mechanic 1/10 at rest, 7/10 at end of workday AROM within normal limits Pain with resisted extension LTG – full return to mechanic work Impairments – Functional intolerance – ergonomics, endurance – Weakness and/or endurance – strengthening – Understanding of the condition – education  Radial Head Manipulation Patient R arm Examiner L hand PA to radial head Wrist flexion Pronation Maintain PA glide Quick elbow Ext  Mobilization with Movement Patient L arm Stabilize humerus Lateral glide ulna Arms parallel Grip exercises Mob until pain free Adjust elbow Ext Epicondylitis Eccentric Exercise Eccentrics for Epicondylosis DeQuervains Carpal Tunnel Syndrome Clinical Practice Guideline, JOSPT, 2019  Proximal Carpal Mobilizations Improve Wrist EXT Improve Wrist FLEX  ULTT 2a – Median Nerve Shoulder girdle depression Elbow extension Forearm supination Whole arm external rotation Wrist, finger and thumb extension Cervical side bending Questions