week 6 summary MSK.pdf

6.1 management/tx of shoulder injuries shldr pathology rehab specific intervention strategies rotator cuff syndrome -non op/post op ant GHJ instability sup labral lesions shldr osteoarthritis -non op...

6.1 management/tx of shoulder injuries shldr pathology rehab specific intervention strategies rotator cuff syndrome -non op/post op ant GHJ instability sup labral lesions shldr osteoarthritis -non op/ post op adhesive capsulitis how we manage out pt holistic, & individualized intervention -treat the whole person! biopsychosocial assessment mental health: anxiety, depression, distress cognitive fxn; cain catastrophizing, optimism behavioral characteristics: kinesiophobia, fear avoidance, self efficacy sleep quality: interrupted bc pain and discomfort adverse psychosocial factors all have. negative impact on prog and recovery & arguably more influential than physical impairments sleep quality p < 0.01 between adhesive capsulitis and subacromial impingement groups adhesive capsulitis- sleep was terrible note that PSQI does not differentiate rotator cuff status * Habitual Sleep Efficiency = time asleep/time in bed rehabilitation focus is based on: psychosocial status pt values, goals and outcome expectations tissue irritability impairment findings imaging findings tissue irritability guides the intensity of physical stress we should know this bc he said he added it in 3 lectures on purpose  impairment level guides intensity of intervention tactics research: some takeaways “Rest” and “Medication” most common perceptions “Exercise” is always lower rated than “PT”--make it dose specific Say “rotator cuff” and surgery is perceived Say “bursitis” and PT is less valued basically live long enough..most likely RC tear -doesnt mean it’ll be symptomatic consideration of MOI & fxnal requirements in rehab Job/Activity Demands of Shoulder to incorporate in rehab: Above shoulder height,chest height,below chest height, or behind back Need to carry–push–pull–handle–throw– reach Free motion(NWB or OKC)–reverse chain motion (NWB or CKC) Noise-lighting–temperature-vibration  6.2 subacromial pain tx SAIS: subacromial impingement syndrome is it really an “impingement” extrinsic factors, like contact pressure can only partially explain the cause of shldr six’s spectrum of soft tissue shldr pain should be labeled RC diseases as opposed to an impingement syndrome until we can better identify its multifactorial contributions subacromial pain syndrome hx subacromial pain syndrome typical exam findings impingement syndrome differential objective examination subacromial pain syndrome general approach more education or modalities shldr manual therapy to restore soft tissue/jnt mobility and offer pain modulation cervicothoracic spine scapulothoracic spine glenohumeral jnts ac/sc jnts common impairment areas to address -thoracic ext stiffness -inadequate scapular post tilt -pec minor tightness -posteroinferior GHJ capsular stiffness and restrictions -causes obligate translation -tight ER short term benefit of t-spine thrust manipulation in SAIS @ 48 hr follow up -NPRS for provocative impingement tests were significantly decreased (p50% of ER in dependent position as compared to uninvolved side this mvmt restriction should have a duration of at least 1 month w/ stable/worsening status more female, can be traumatic but that will affect natural hx Frost: pt first notices pain Freezing: Inflammatory Frozen: stiff Thawing: spontaneous recovery 8-12 best case scenario  frozen: pain at rest decrease but increase stiff Contradictory Perspectives pts don’t necessarily progress through painful, stiff, recovery phases all based off pts don’t necessarily reach full resolution w/o supervision F literature motion recovery = more prevalent in earlier phases of progression Study Results Fxn about 70% limit in ER conclusion: not really going to gain back their full ROM Questions to ask to help stage your patient can you sleep through the night? - no = freezing phase chief complaint? - pain: freezing phase - stiffness: frozen phase have you seen a lot of improvement in your range recently? - yes: thawing phase Goals of Physical Therapy Intervention freezing - interrupt cycle of pain & inflammation frozen phase - minimize capsular restrictions & tissue inextensibility thawing phase - restoration of fxnal motion/strength Freezing phase points of emphasis global/holistic approach - address systemic inflammation w/ sleep, diet, & mental health prospective postural training/awareness Mirror therapy “gentle”, sub-pain threshold, biomechanically correct exercise - motion is lotion, “allota littlebits” - PT vacations (conserve visits, supervised visits) - aerobic fitness (walking/elliptical program) manual therapy as potential pain modifier pain control - cryotherapy/TENS Frozen phase points of emphasis frozen phase: primary goal = reacquisition of GHJ ROM - UQ manual therapy including oscillatory/prolonged mobilization @ end of physiological range - thermotherapy (heat treat cool) assisted P/A/AAROM exercise in all planes - LLPD static stretching devices prn mully study…. advice and education small mvmts supervised visits at first  see immediately after procedure More studies… Interventions associated w/ an increased/decreased likelihood of pain relief & improved fxn pain = more likely reduced in pt who received jt mob (OR = 1.35) (good) fxn was more likely increased in pt who received exercise therapy (OR=1.5) (good) use of ultrasound, phonophoresis, iontophoresis, or massage reduced the chance of QOL, pain, or fxn improvements by 19-32% (bad)  6.4 Anterior Shoulder Instability FEDS Classification Frequency - solitary (1) vs occasional (2-5) vs frequent (>5 Etiology: AMBRI -> TUBS - Traumatic (born) vs. Atraumatic (worn) Direction - anterior - posterior - inferior Severity: subluxation vs. dislocation Over 40% pts fall into solitary, occasional, trauma ant displacement catergory AMBRI = Atraumatic multidirectional instab TUBS = traumatic unilateral bankart lesion injury Traumatic = normally anterior to get pressure off axillary n. traction: stab scap, inf glide along long axis to humerus prone 90 degrees w/ weight repetitive disolacation: knee hold for distraction don’t benefit from immob just protect arc risks: being a younger male & OH contact activity n safe range, keep hands/ elbows in field of view infraspinatus can have synergistic effect!! pulls back on humeral head hornblower pos: arms in 90 degrees in sag plane  will see young pt often post op bankhart lesion = sx capsular shrinkage - thermal assisted laser muscle tendon slings bone block - bristol helfet muscle tendon shortening - putti-plat muscle tendon transfer - magnusson - stack bone blocks - eden-hybinette osteotomies - weber or saha not good enough stab or too much causing arthritis suture to restore labral alignment Laterjet - Bristow Technique transfer of coracoid process (along w/ intact short head of biceps & coracobrachialis) into area of bony defect coracoid graft is shaped. contoured, secured w/ screw fixation to fill bony defect attached tendons = dynamic sling -> enhancing stability in provacative positions of elevation  Remplissage Procedure: transfer of infraspinatus tend into hill sach’s lesion prevent engagement of lesion on ant glenoid rim provide checkrein to decrease ant translation rehab particulars - longer immob (4-6 weeks) - delayed return to activity - mild ER ROM deficits expected Post op considerations sx approach - arthroscopic vs open - method of fixation: shrunk, sutured, anchored, capsular plication how was the subscapularis handled bony involvement - laterjet/and or remplissage pre-op status - of instab prior to sx - type of pre op instab (torn-born-worn) pt individualization - age/gender - rehab goals - ADL/sport specific - tightness achieved on operating table - Beighton hyper mobility index DO NOT over stress healing tissue rehab for proximal stab first and distal mob later all elevation motions ant to scap plane respect ROM constraints DO NOT stretch anteriorinferior capsule - careful of progression in ER, extension, & horizontal abduction - do not combine these mvmt patterns during early phases - no passive stretching into horizontal abd or ER for at least 10-12 weeks & then only if motion barrier is muscular tension Early Rehab Instab inflammation/pain control (6 weeks) immobilization/ROM per physician protocol - limit flexion to 90 degrees & ER to 30 degrees in first 3 weeks and to 135 degrees flexion and 45 degrees in first 6 weeks - ER below 45 degrees & ant to scap plane in first 6 weeks begin scap mob & stabilization activities distal ROM & strength cervical spine assessment/tx pre postural awareness training HEP Phase 1 Points of Emphasis 0-6 Weeks grade 1-2 post glides avoid rotator cuff shutdown - submax intensity rotator cuff isos scapular PNF (D1/D2 patterns for awareness/control) no passive stretching (use AROM/AAROM) avoid combination mvmts - ER- elevation-h ABD, abd-ext Phase 11 points of emphasis 6-12 weeks AROM w/ pain free & protected arcs - ER in 45-90 degree range but still ant to scap plane - ER can begin post to scap plane after 10-12 weeks, if solid capsular end feel build scapular base posterior muscular stretching rotator cuff PRE program - infraspin emphasis proprioceptive training - rhythmic stab training total arm strength & aerobic activities - UBE advance and update HEP Anterior Instab Rehab Precautions prevent poor scapulohumeral rhythm or rotator cuff “shut down” prevent internal rotation contractures - key indicator of pt satisfaction = return of fxnal ER rom (5 degrees per week to avoid IR contractures) beware of too rapid of a return to normal ROM beware of active dislocation: latissumus can dislocate humeral head Weight training modifications - precautions lat pull downs (front, not back) pullover machines (limit arc) dips (minimize extension) pec deck (limited arc) bench press - mandatory hand off - flat or decline surface - narrow grip ( 50% of subjects who met inclusion criteria self-selected to participate in a study of non-operative intervnetion over 400 subjects in a multi-center MOON trial w FT tears -average age: 62 -15% had sup humeral head migration -70% were supraspinatus only tears -other 30% had additional tears as well intervnetion Structured program of daily postural, AAROM, flexibility, axioscapular stabilization, and strengthening exercises for 6 weeks. Patients progressed to HEP when manual therapy no longer necessary after an average of 8 clinic visits At 6 weeks patients assigned themselves to 1 of 3 groups Cured (discharged) Improved (continued HEP) No better (could elect surgery) results Significant improvement in mobility and self-report of function Vast majority of patient selected to delay surgery for at least 2 years dont operate on the tear- operate on the pts fxnal limitations... because pain and sleep quality not impacted by tear morphology RCT- NON-traumatic RC tear management 173 subjects randomized to three groups — PT — PT/Acromioplasty — PT/Acromioplasty/RC Repair At one year follow-up there was no significant difference in function based on Constant score Further evidence that PT should be first choice and patient must fail therapy in order to consider surgical options  more evidence for non-op management no significant difference in clinical outcomes bw surgical and non-op management at one yr follow up 5 yrs quality of life follow up -75% success (asymptomatic, no need for surgery) from comprehensive, home-based tx program ortho guidelines: surgery decision making: appropriate use criteria *always consider who your pt is* Post-Op Rotator Cuff Repair Important Prognostic Indicators to answer pts questions according to hx results trend towards more conservative management ongoing debate Is healed and stiff better than mobile but torn? Should rotator cuff repairs be immobilized for 6 weeks (regardless of size)? PRO: improves tendon healing CON: limits motion acquisition — However, shown NOT to be the case in the long term However, IMO, there is limited evidence that prolonged immobilization ensures healing or that tendon healing correlates with pain or function  Meta-analyses of 8 studies that compared pain and self-report function in cohorts of healed and non-healed rotator cuff repairs Confirmed in study of 1600 consecutive RCRs. No difference in pain or function but those with re-tears (13%) had decreased strength Meta-Analyses Delayed vs. early motion following arthroscopic RCR No absolute superior protocol (early vs. delayed) No difference in ASES scores No difference in re-tear rates No clinically important difference in elevation or ER ROM Tear size may be influential -There is evidence in the literature that early ROM may allow slightly better mobility early in the rehab process but equalizes by one-year post-op post-op rotator cuff repair progression expectations  6.6 Rotator Cuff Tear Rehabilitation Basic Principles of Rehabilitation - Tension is the enemy - Customary for patient to start w/ Codman’s or Pendulum exercise - Puts little tension on sutures Exercise Phase Philosophy Progression Rotator Cuff ROM Exercises - Pendulum Exercise - Most common - Cane assisted of active assisted exercise - Fingers interlocked - Educate on ADLs (dressing self) will put tension - Pulleys in scapular plane - Very introductory, safe % EMG activity levels for common ADLs Repaired Rotator Cuff Exercises: Supraspinatus Safe - All exercises 60-65 Conditions that may result in Arthroplasty - Primary - Osteoarthritis (OA) - Inflammatory Disease (RA) - Rotator Cuff Arthropathy - Secondary - Post traumatic/acute comminuted fractures - Avascular Necrosis - Post capsulorraphy from chronic dislocations/recurrent instability - Asymmetric tightening of capsule & anterior soft tissue structures cause post subluxation - Accelerates wear on posterior glenoid capsule - Neoplasms Surgical Prosthesis Algorithm Anatomical Total Arthroplasty - Standard bipolar OA - Stemmed humeral head w/ polyethylene glenoid cup - Predictable improvements in pain, motion, fxn - Concern for long term glenoid loosening - Younger, more active patients Reverse Total Arthroplasty - Principle indication is painful pseudoparalysis of extremity in older, low demand patient - Inverted joint morphology - Allows deltoid to elevate to overcome lack of RTC ability to stabilize center of ROT - Key Surgical Considerations - Medial & distal placement of CoR to reduce torque on glenoid, improve deltoid capacity - Non-anatomic vagus angle of humeral implant to max deltoid generating tension Reverse Total Arthroplasty CONT - Information - Contraindicated if deltoid is deficient - Better outcome if > 90 elevation pre-op - Not uncommon to lose IR ROM & behind back reaching ability - Unknown long term satisfaction & longevity - Higher complication rates - Guidelines Reverse TSA Rehab Guidelines - Standard procedure (may be slower progression) - Most will be immobilized in sling for first 2-3 wks unless very controlled environment - Much higher risk for dislocation - Precautions - Avoid EXT part neutral - Especially if combined w/ ADD/IR for first 3 months - Bathroom hygiene, tucking in shirt, don/doff bra, reaching for wallet - Deltoid restoration is paramount importance to outcome - Be careful 1st 6 wks as it can cause acromial stress fracture TSA points of Emphasis - Aggressive ER stretching or early, vigorous IR AVOIDED - Wherever suture tension on subscap repair, limit passive ER for 6-8 wks - Extreme care w/ HORZ ABD or EXT maneuvers - No active or resistive IR or cross body maneuvers for 6-8 wks - No behind back activities or weight bearing stress for first 3 months - Avoid quick or unexpected shoulder movements - Low load, higher reps Reverse TSA Generalities - Post-op ROM restoration is variable & evaluated case by case w/ full return of motion unlikely - If lot of post op stiffness, begin ROM earlier in scapular plane - Begin strengthening of peri scapular & deltoid muscles at 6 weeks - Need to work closely w/ referral source regarding protocol - High complication rate (15-25%) - Secondary to higher medical co-morbidities Post-OP Stiffness Study - Somewhat common - “Stiffness” defined as