Phys Rehab 2 - Shoulder

Front 1

Why would someone with lower extremity conditions (Ex: total hip joint replacement) need to be checked for shoulder problems?

Back 1

People with LE conditions use their arms more to lift things (such as lifting themselves off a chair), which lead to UE shoulder issues.

Front 2

What bones make up the shoulder girdle?.

Back 2

Humerus, clavicle and scapula

Front 3

Describe scapular movement with shoulder flexion, through various degrees of movement with the motion

Back 3

- GH movement (0-60 degrees)

- Scapulothoracic movement (60-140 degrees): "middle/critical phase)

- GH movement (140-180 degrees)

Front 4

- What is this called?

- What muscle is likely weak

Back 4

- Scapular winging

- Serratus Anterior

Front 5

- When is immobilization a good recommendation for someone suffering from shoulder pain? WHY?

Back 5

- ONLY with humeral fracture, or post-surgical, otherwise immobilization will increase shoulder stiffness. (SLINGS ARE NORMALLY BAD)

Front 6

Posture and the Shoulder

- What does rounded shoulders cause? How is this corrected?

- What does a forward head posture cause? How is this corrected?

Back 6

- Weakness in rotator cuff over time/Cuff must be strengthened

- Cervical and shoulder dysfunction/Strengthen cervical retractors and extensors

Front 7

- What happens if the shoulder becomes too flexible?

- What happens if the shoulder becomes too stable?

- If a shoulder is too flexible, what should an OT consider?

Back 7

- Becomes unstable (can lead to soft tissue tears)

- Frozen shoulder
- Need to consider if person is just very flexible or if the flexibility is from a tear (was the patient always this way, or is the flexibility new)

Front 8

What types of diagnostic imaging is available for the shoulder? What are the benefits/drawbacks?

Back 8

1.) X-ray: Can show misalignment of bones and arthritis, but does not show soft tissue abnormalities

2.) MRI: Best test/expensive, insurance will only order if surgery is likely (typically try therapy before ordering one)

3.) Arthrogram- dye is injected/can show bones and soft tissue

4.) Ultrasound

Front 9

Etiology/Symptoms/Diagnosis

Shoulder Impingement

Back 9

Etiology: Rotator cuff weakness, causing head of humerus to elevate into joint space and impinge tendons and nerves

Symptoms: Anterior-Superior shoulder pain, limited ROM and strength, possible numbless going distally to elbow

Diagnosis: Painful arc test & Hawkins-Kennedy Sign

Front 10

Which test? Desceribe

Back 10

Painful arc test

Front 11

Which test? Describe

Back 11

- Hawkins Kennedy

- Examiner passively moves patient into shoulder flexion of 90 degrees with internal rotation; anterior/superior pain indicates shoulder impingement

Front 12

- Which is the worst of the acromion morphology types

Back 12

- Type 3 - it is hooked down so it can impinge structures and scrape bones

Front 13

Etiology/Symptoms/Diagnosis

Shoulder Arthritis

Back 13

Etiology: Genetic (ex: type 3 acromion), or related to UE overuse

Symptoms: Pain in various locations of shoulder, limited ROM and strength, crepitus (crunching sound) during shoulder movement, can include impingement

Diagnosis: X-ray can confirm: Can see misalignment of GH, or bone spur under acromion, which can deteriorate cartilage/tendons (appearance of string cheese)

Front 14

Etiology/Symptoms/Diagnosis

Rotator Cuff Tendonitis

Back 14

Etiology: Overuse of rotator cuff, usually from repetitive lifting (especially overhead). Can also occur as a result of other shoulder injuries. Most often supraspinatus is affected.

Diagnosis: Drop arm test and palpation of other tendons

Symptoms: Pain over tendon site, limited ROM and strength when muscle is used.

Front 15

Etiology/Symptoms/Diagnosis

Rotator Cuff Tear

Back 15

Etiology: Trauma and/or bone spur under acromion from arthritis

Symptoms: Mid-deltoid pain, edema, limited ROM and strength

Diagnosis: Can be identified by external rotation lag sign (infraspinatus) and internal rotation lag sign (subscapularis) - can be hard to identify

Front 16

Describe a external rotation lag sign

Back 16

Front 17

Describe internal rotation lag sign

Back 17

Front 18

Etiology/Symptoms/Diagnosis

Labral Pathology

Back 18

Etiology: trauma/dislocation to GH

Symptoms: Weakness, limited ROM, sharp momentary pain somewhere in arc of motion, pain in circle around GH, instability of joint

Diagnosis: Crank test

Front 19

Etiology/Symptoms/Diagnosis

GH Dislocation

Back 19

Etiology: Trauma, normally anterior (most common) or posterior.

Symptoms: "My shoulder popped out", weakness, edema, limited ROM, tendency to dislocate at 90 degrees abduction and full external rotation

Diagnosis: Apprehension (patient is afraid to move shoulder), than relation tests NO DEMO

Front 20

Etiology/Symptoms/Diagnosis

Acromioclavicular (AC) Dysfunction (pic is a grade III AC separation)

Back 20

Etiology: Usually trauma, AC can be dislocated, separated or has poor alignment

Symptoms: Pain with horizontal adduction, edema, limited ROM, tenderness w/ active compression of AC

Diagnosis: Cross arm test + painful palpation

Front 21

Etiology/ Symptoms/Diagnosis

Biceps Tendonitis

Back 21

Etiology: RC dysfunction, overuse and/or excessive lifting. Also occurs as a consequence of supraspinatus tendonitis, RC weakness/dysfynction.

Symptoms: Weakness and EXTREAME pain over the tendon located in bicipital groove. Pain during limited shoulder AROM.

Diagnosis: Speed's Test & Palpation of bicepts tendon to identify

Front 22

- What is the Speeds Test?

- What does it check for?

Back 22

- Biceps tendonitis

Front 23

Etiology/Symptoms/Diagnosis

Adhesive Capsulitis

Back 23

Etiology: "Frozen Shoulder"-scar tissue tigthens shoulder capsule- Painful injury of shoulder followed by voluntary immobilization and/or non-use,

Symptoms: Shoulder pain and poor AROM and PROM (AROM = PROM), edema

Diagnosis:

Front 24

- What occupational performance areas will a OT likely assess with shoulder dysfunction? (7)

Back 24

1 ADL/IADL Independence and History

2 Work/leisure history (Ex: repetitive lifting)

3 Health history and diagnostic imaging

4 PROM/AROM

• If PROM > AROM problem is weakness. Strengthen weak muscles
• If PROM = AROM problem is stiffness. Do stretches and strengthening

5 Strength (MMT)

6 Posture

7 Sensation (especially numbness and pain)

Front 25

- What is the key concept of OT shoulder rehab

- Provide example

Back 25

- Treatment is dictated by patients deficits. Understand underlying problems to resolve symptoms.

- Ex: If patient has difficulty with shoulder internal rotation. Is subscapularis weak? Is pec minor too short?

Front 26

- What is staging?

- How do you stage?

Back 26

- Treat inflammation before you begin strengthening

- Staging

• Inflammatory Stage: Look for edema, stiffness and lack of ROM, weakness and pain (biggest indication)
• Strengthening stage: Pain is decreasing, patient's ROM is increased, strength is improving, edema is decreased.

Front 27

Common features of:

1. Upper Trapezius
2. Weak RC
3. Serratus Anterior Dysfunction
4. Pec minor shortening

Back 27

1. Common, look for shoulder hiking
2. Deltoid compensates, trigger points present
3. Scapular Wining
4. Forward shoulders

Front 28

- How is cervical nerve impingement related to shoulder dysfunction

- How do the two present themselves differently?

Back 28

- Many patients develop cervical nerve impingement as a result of shoulder dysfunction (or vice-versa).

- Patterns of pain are different. UE Numbness is more common when cervical spine is involved

Front 29

- Which frame of reference is most often used to treat and assess shoulder dysfunction

Back 29

- biomechanical frame of reference - approach is consistent with deficits and precautions are followed to prevent further injury

Front 30

- What is a general rule of shoulder treatment

Back 30

- Exercise and ROM should be limited to 90 degrees and below, due to likelyhood of shoulder impingement and cervical compensatory patterns (UT)

- Above the shoulder exercises should only be used towards the end of treatment when pain is minimal and patient isint waking up during the night as a result of pain

Front 31

OT Interventions: Shoulder Dysfunction

Manual Therapy Types (4)

Back 31

1. Trigger point release/soft tissue massage: find point of muscle spasm and use pressure to try to release tension
2. Myofascial release (MFR): Evaluate skin for fascial restrictions, than gently traction skin against restriction and hold until release is felt
3. Joint mobilization: Move joint in different planes to restore joint play and ROM
4. Manual Edema mobilization: to reduce edema

Front 32

OT Interventions: Shoulder Dysfunction

1. Neuro-Reducation -Types (4)

2. Therapeutic exercise - Types (3)

3. Therapeutic Activity - describe/example

4. Self care retraining - describe

5. Physical agent modalities (7)

6. Adaptive equipment - NONE

7. Kinesiotaping - none

Back 32

1. Nerve glides, postural re-education, coordination exercises, nerve mobilization

2. Stretching (for decreased ROM), active range of motion and strengthening

3. Functional activity with multiple parameters (Ex: throwing a ball)

4. ADL activities to increase independence

5. Ultrasound, iontophoresis, electrical stimulation, fluidotherapy, paraffin bath, cold laser, vasocompression

Front 33

- How to know when patient is progressing in treament (4)

- What do you do if patient is not improving

Back 33

- Demonstrates greater ROM and MMT

- States pain score is lower than previously

- No longer requires relieving modailities

- Meets functional goals set initially

- Patient may need referral to orthopedic surgeon