Transcript Shoulder Derangement with an Underlying Dysfunction from a MDT

Keeley Garrou
Regis University
Objectives
 Audience will be able to differentiate derangement and
dysfunction in terms of Mechanical Diagnosis and
Therapy by end of presentation
 Audience will be able to list possible treatment
interventions for rotator cuff tendinopathy by end of
presentation
 Audience will be able to apply the literature and
physiology of tissue remodeling to physical therapy
exercise by the end of presentation
Meet Sammie
 15 year old female




softball player
Plays 1st base
Has been playing softball
since she was six
Cannot remember the
last time she has had
time off of playing
softball
Right shoulder pain
 Many people, both
young and old suffer
from shoulder pain from
no traumatic mechanism
of injury
 At any point in time, 6.926% of people have
shoulder pain
 Lifetime prevalence is
from 6.7-66.7%2
Mechanical Diagnosis and Therapy
 Comprehensive and
logical step-by-step
process that classifies
patient conditions by
level of pain or
limitation that results
from certain movement
or positions10
 Three steps10
 Assessment
 Treatment
 Prevention
Mechanical Diagnosis and Therapy
 Assessment
 Algorithm that leads to
classification of disorders which
is based the “relationship
between historical pain behavior
as well as the pain response to
repeated test movements,
positions and activities during
the assessment process10”
Mechanical Diagnosis and Therapy
 Assessment Continued
 The assessment is a systematic progression of applied
forces and responses to separate patients into defined
subgroups to guide treatment
 Two of the basic classifications for the extremities are


Derangement: Anatomical disruption or displacement
within the motion segment
Dysfunction: End-range stress of shortened structures
(scarring, fibrosis, n.root adherence)10
Mechanical Diagnosis and Therapy
 Treatment - most
treatment is with
repeated motion,
with a progression of
unloading, clinician
overpressure,
mobilization and
manipulation as
needed10
 MDT emphasizes
patient education
and involvement so
that the patient can
manage themselves
without having to
come in and be
dependent on the
clinician10
 Goals – to reduce
pain quickly and
restore function and
independence10
Purpose
 The purpose of this case report is to illustrate and
describe the assessment and treatment for shoulder
pain using the Mechanical Diagnosis and Therapy
method
Initial Evaluation
 History:
 Pt came in with the
complaint of right shoulder
pain
 Pain started in March after a
double softball practice
 Currently, shoulder aches all
the time; heavy lifting
increases pain
 Pain is not that bad when
playing softball but it aches
afterward
• Pt has practice once per
week with tournaments
approximately every other
weekend playing up to five
games
• Pt received MRI – negative
for tears but did show
swelling in her shoulder
• Pt was prescribed an antiinflammatory; she reports
she does not take them as
prescribed
• She often takes Advil or
Tylenol for pain
• Pt reported no other comorbidities
Initial Evaluation
Examination
 Measured AROM with
Initial AROMs
Abduction
147°
Flexion
145°
Internal rotation
arm behind back
Thumb to T8 with
pain
Internal rotation
30°
External rotation
112° with pain
large goniometer
 Measured IR behind
back with palpation of
spinous process
 to measure ROM
limitations which then
translate into functional
limitations
 In order to reference
improvement
 PROM in supine: No pain
Initial Evaluation
 Special Tests
Cervical spine AROM
Spurlings Test
ULNT
Active compression
AC Distraction
AC sheer
Sulcus Test
Load and Shift
Neer’s
No symptom provocation
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Negative
 Anterior instability and impingement are common in baseball and have been
linked to decreased in IR and concurrent increases in ER,7 therefore wanted to
test for impingement and instability
Initial Evaluation
 Strength Testing (MMT)
 Abduction

Could not test secondary to pain
 External Rotation
 5/5 with pain
 Scapular dyskinesia
 Initial Treatment
 Attempted mobilization with
movement with shoulder
abduction to increase ROM
with reduced pain4

Results – patient could not
tolerate secondary to pain
 Kinesiotape to reduce shoulder
pain

Results – patient reported
reduced pain with movement and
resistance
 Evidence6
 Thelen M, Dauber J, Stoneman P.
The clinical efficacy of kinesio
tape for shoulder pain: a
randomized, double-blinded,
clinical trial.
 Investigated efficacy of kinesio
tape when applied to college
students diagnosed with rotator
cuff tendonitis/impingement
 Conclusion: Kinesio tape may
assist clinicians in improving
pain-free AROM immediately
after taping
The Patient-Specific Functional
Scale
Activity
Score
Throw soft ball
7
Do a push up
6
Play Basketball
6
Average Score
6.3
 Primary Functional Goal: Sammie will score
8.8/10 or greater on The Patient-Specific
Functional Scale indicating improvement in
overall function
 Minimum detectable change for average score = 25
Visit 2
 Beginning ROMs: R shoulder Abd 124° with pain, Flex 152°
 Used MDT for assessment and treatment: Repeated shoulder
extension and repeated shoulder extension with clinician
overpressure
 Instructed patient to extend her arm, palm facing up, as high as she





can
Patient was instructed to repeat 10 times
Rechecked abduction – less pain but still painful
Patient repeated 4 sets of shoulder extension until pain had
reduced to a constant
Then, patient extended shoulder and clinician gave overpressure
Continued extension with overpressure for 4 sets of 10 repeating it
until she had no pain with abduction
 Post treatment: Abd 163° with no pain
Visit 2
 The abolishment of symptoms lead to the MDT diagnosis
of reducible derangement because the symptoms were
decreased with repeated movement (extension) and then
abolished with therapeutic loading strategies (extension
with overpressure) , which was accompanied by
improvements in the mechanical presentation (ROM)3
 Began therapeutic exercise to improve muscle performance
 Home Exercise Program – Patient instructed to perform 10
repeated extensions every 2-3 hours, particularly before
and after softball games and when she felt pain
Visit 3
 Assessment: Sammie
presents with no
shoulder pain and no
significant loss of ROM
allowing for increased
function with daily
activities. Sammie
requires further
monitoring and
strengthening to return
to prior level of
scholastic athletics.
 Plan:
Continue/alter/progress
extension principles;
assess response to
softball practice,
continue therapeutic
exercises for
strengthening for return
to sport
As treatment continued . . .
 Sammie reported that
shoulder no longer hurt
during the day but would
still hurt after softball
practice
 Repeated extension always
reduced pain with
movement however there
was an underlying pain
when given resistance with
external rotation at 0° and
abduction at 90°
 Hypothesis: Sammie
presents with a reducible
derangement with an
underlying soft tissue
dysfunction
 Reasoning: Sammie had
pain consistently with
resisted abduction at 90°
and external rotation at 0°
but with no other
positions. Pain would
subside once the force was
removed
Tendinopathy
 Tendon injury can occur from acute trauma or
repetitive loading from overuse
 Of all injury related physician visits, almost 7% are
from overuse injuries
 The most common site for an overuse injury is at the
osteotendinous junction
 Tendons are predisposed to hypoxic tendon
degeneration from the low blood supply to the tendon
insertion8
Treatments for Tendinopathy
 Most common and
effective treatments8
 Relative rest of affected
 Goal of treatment
 Reduce pain
 Return to function
area
 Stretching
 Ice
 Analgesics
Visit 8: ASTYM
 ASTYM is “‘a stimulation’ of the body’s
healing response, which results in the
remodeling/resorption of scar tissue
and the regeneration of degenerated
tendons.9”
 ASTYM restarts the body’s
inflammation process which can then
start healing/tissue remodeling
 PT certified in ASTYM performed an
assessment and treatment on Sammie’s
right upper extremity and noted
increased tissue texture in right
anterior shoulder, AC joint and long
head of biceps
 This finding helped confirm the
hypothesis that Sammie had an
underlying soft tissue dysfunction in
the shoulder with scarring and fibrosis
Therapeutic Exercise to Promote
Tissue Remodeling
 Eccentric External Rotation
 With green TheraTube in
doorway with towel under
elbow
 Fast external rotation with
slow eccentric internal
rotation
 4 sets of 15 repetitions
 Scaption
 At 45° angle lifting to
approximately 90°
 3 lb weights
 2 sets of 15 repetitions with
slow eccentric lowering
 Bicep Curls
 Bicep curl palms up, lower
with palms down
 3 lb weight
 3 sets of 15 repetitions with
slow eccentric lowering
 This will help remodel the tissue
to resolve the dysfunction
 Mechanotherapy – load is used
therapeutically to stimulate
tissue repair and remodeling in
tendon, muscle, cartilage and
bone1
Visit 10 – Last Available Visit
 The Patient-Specific Functional Scale average score = 8.3
 Abduction AROM 175° with no pain
 Sammie reported minimal pain with softball games
 No joint mobility restrictions
 Continues to have pain with resisted external rotation
demonstrating tissue dysfunction requiring further
treatment for tissue remodeling
 Sammie will benefit from up to 4 more treatments for
ASTYM for tissue remodeling and to progress her to an
independent home exercise program
Summary of Case
 Sammie presented with
 ASTYM assessment and
shoulder pain and
decreased ROM
 Pain was reduced and
ROM increased with
repeated shoulder
extension reducing the
derangement
 Sammie continued to have
residual pain with resisted
movement consistent with
soft tissue dysfunction
treatment confirmed
dysfunction
 Dysfunction was treated by
continued ASTYM and
repeated eccentric loading
to remodel tissue and
resolve dysfunction
Limitations
 Did not record PROM
 Not generalizable to all
measurements
 Did not record initial
strength measurements
for all shoulder motions
 Physical Therapist
Student not
certified/proficient in
Mechanical Diagnosis
and Therapy method
patients
 Did not perform intrarater reliability
 Some missing data
collection
 Patient not yet
discharged
Were you listening?
 What MDT diagnosies am I demonstrating?
 What is the theory behind ASTYM?
 What type of exercises are best for tissue remodeling?
References
Khan K, Scott A. Mechanotherapy: how physical therapists' prescription of exercise promotes
tissue repair. British Journal of Sports Medicine [serial online]. April 2009;43(4):247-252.
2. Luime J, Koes B, Heridriksen I, et al. Prevalence and incidence of shoulder pain in the general
population; a systematic review. Scandinavian Journal of Rheumatology [serial online]. March
2004;33(2):73-81.
3. McKenzie R, May S. The human extremities mechanical diagnosis and therapy. New Zealand:
Spinal Publications Ltd; 2000.
4. Mulligan BR. Manual Therapy 'Nags'. 'Snags', -MWM'. etc. 4'"ed. Wellington, New Zealand:
Plane View Series Ltd, 1999.
5. Stratford P, Gill C, Westaway M, Binkley J. Assessing disability and change on individual
patients: a report of a patient specific scale measure. Physiotherapy Canada. 1995;47:258-263.
6. Thelen M, Dauber J, Stoneman P. The clinical efficacy of kinesio tape for shoulder pain: a
randomized, double-blinded, clinical trial. Journal of Orthopaedic & Sports Physical Therapy
[serial online]. July 2008;38(7):389-395.
7. Thomas S, Swanik K, Swanik C, Huxel K, Kelly IV J. Change in Glenohumeral Rotation and
Scapular Position After Competitive High School Baseball. Journal of Sport Rehabilitation
[serial online]. May 2010;19(2):125-135.
8. Wilson J, Best T. Common overuse tendon problems: a review and recommendations for
treatment. American Family Physician [serial online]. September 2005;72(5):811.
9. www.astym.com
10. www.mckenziemdt.org
1.