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PHTY3120 > L8: Management Overview of the Shoulder > Flashcards

L8: Management Overview of the Shoulder Flashcards

1
Q

What are the 4 treatments approaches for shoulder?

A
  1. Pathology-based approach
  2. Symptom-based approach
  3. Impairment-based approach
  4. Protocol-based approach
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2
Q

What is the pathology-based approach for management?

A

Need to understand pathology, but targeting management solely at that will not address all problems (or possibly the reason why they have symptoms)

  • Eg. How long it will take to heal?
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3
Q

What are the 2 features of pathology-based approach for management?

A
  1. e.g. pain, stiffness
  2. May help, but may not address the reason why they have symptoms
    • Give them symptomatic relief
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4
Q

What are the 3 features of impairment-based approach for management?

A
  1. Address the specific relevant impairments that the patient presents with
    • To why they have symptoms or the pathology
  2. TDTs help to determine whether impairments are contributing to symptoms
  3. Functional, patient-centred focus
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5
Q

What are the 2 features of protocol-based approach for management?

A
  1. e.g. clinical pathways, clinical guidelines, medical protocol
  2. Not going to work for every patient
    • While it can be a good guide
    • Healing is not based on time rather on individual (different factors)
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6
Q

What are the 4 pathological features of an acute anterior GHJ dislocation?

A
  1. Damaged/stretched capsule/ligaments of anterior shoulder + Bankart lesion (labral tear)
  2. Inflammatory response
  3. Muscle inhibition and guarding (Protective spasm)
  4. Altered proprioception
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7
Q

What are the 4 impairments of the acute anterior GHJ dislocation?

A
  1. Restricted and painful elevation & ER
  2. Fear of movement, feeling of instability
  3. Scapula dyskinesia
  4. May have restricted accessory glides

Should start with impairments to address problems

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8
Q

What are the 2 features in the integrative approach to management?

A
  1. Prioritise and ensure treatment is staged appropriately
  2. Assess and reassess – clinical and objective outcomes
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9
Q

What are features of the patient’s primary compliant, pathology, functional problems, impairments, contributing factors and scope of practice?

A
  1. Patient’s primary complaint: pain, weakness, instability; how do these interact?
  2. Pathology: instability, adhesive capsulitis; how relevant are any structural deficits?
  3. Functional problems:
    • What specific activity, which part of range, which structures are affected
    • ADL, ergonomics, sports performance
  4. Impairment: strength, control, stiffness, instability, etc.
  5. Associated or contributing problems
    • Cervical, thoracic, neural, functional kinetic chain (e.g. if thrower, ankle impairment can affect UL)
  6. Scope of your practice: physiotherapy skill and expertise; other profession?
    • Eg. do they need medicine just to help relieve plan in acute stage (medical practitioner)
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10
Q

What are 11 treatment options for management?

A
  1. Nothing (wait & see)
  2. Advice, education, reassurance
  3. Ergonomics
  4. Manual therapy
  5. Soft tissue techniques
  6. Exercise therapy
  7. Taping/bracing
  8. Electrophysical agents- Needs to have a very strong rationale to use (compared to other options)
  9. Multimodal/combined intervention
  10. Further investigations
  11. Non-physiotherapy interventions – possible referral
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11
Q

What are the 6 features of advice, education and reassurance?

A
  1. Don’t underestimate the value of rapport and good quality communication
  2. Understand what the patient wants to know
    • Cancer, fracture, surgery, permanent disability, etc.
    • Goals
    • Functional requirements
    • Sometimes they want to know exactly what the problem is –> motivates them. Sometimes, it is better not to.
  3. Reassurance
  4. Time frames (How long until Return to sport RTS)
    • Based on known time frames for tissue healing but will dependent on commitment to rehab and other factors (progress)
  5. Prognosis (once clear)
  6. Management strategies to achieve goals
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12
Q

What are 3 features of ergonomics?

A
  1. What work/recreation factors can be modified?
    • Desks/chair or unsuitable job for current injury
  2. What alternative activities can the patient do if not modifiable?
  3. Changes needed may appear subtle (but habitual), e.g.:
    1. Sitting in rotation
    2. Phone position- Phone between shoulder
    3. Mouse reach outside neutral zone
    4. Arm positioned in ER – can lead to tightness of posterior structures
    5. Sleeping postures (ACJ)- Sleeping on side (compress ACJ and GHJ)
    6. Reaching to clean top of blinds/curtains
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13
Q

What are 6 changes that may appear subtle (but habitual) in ergonomics?

A
  1. Sitting in rotation
  2. Phone position- Phone between shoulder
  3. Mouse reach outside neutral zone
  4. Arm positioned in ER – can lead to tightness of posterior structures
  5. Sleeping postures (ACJ)- Sleeping on side (compress ACJ and GHJ)
  6. Reaching to clean top of blinds/curtains
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14
Q

What are 6 possible effects of manual therapy?

A
  1. Pain relief – afferent input
  2. Biomechanical/pathomechanical
    1. Improve ROM – stiff vs. hypermobile vs. unstable
    2. Sustained techniques for tight/stiff structures
      • For 30-60secs = can start to induce creep in the tissues = can be a better effect
  3. Physiological/pathophysiological
    1. Condition
    2. Improve healing of structures (collagen matrix)
  4. Facilitate deficient movement – MWM
  5. Symptomatic approach –Maitland; may not work for specific pathology
  6. Differential diagnosis – treat multiple planes/joints and see what has the biggest effect on symptoms
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15
Q

What is the benefit of a sustained manual therapy technique?

A

For 30-60secs = can start to induce creep in the tissues = can be a better effect

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16
Q

What are the 4 degrees of mobilisation in passive manual therapy techniques?

A
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17
Q

What are the 2 features of position in manual therapy for the shoulder (irritable pain)?

A
  1. Comfort
  2. ⁃Loose packed – neutral rotation, 30o flexion, 30o adduction
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18
Q

What are the 2 features of grade and duration in manual therapy for the shoulder (irritable pain)?

A
  1. Depends on severity and irritability
  2. The more irritable the joint, or earlier in range the pain starts, or the more rapidly the pain increases in intensity early in range, the smaller the amplitude of mobilisation
    • Make sure they don’t exacerbate symptoms –> might cause latent flare up
    • Quite irritable or pain starts early in ROM = lower grades
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19
Q

What are 4 possible techniques for irritable pain (shoulder) using manual therapy?

A
  1. GHJ caud glide
  2. AP, PA
  3. GHJ lateral distraction
  4. Physiological – Flex III
20
Q

What is the aim for manual therapy (pathology) with a reduced suacromial space and pain?

A

Increase subacromial space (temporary or lasting effect)

  • Eg. impingement type symptoms
21
Q

What is the grade and duration for manual therapy (pathology) with a reduced suacromial space and pain?

A

Depends on severity and irritability

22
Q

What are 4 possible techniques for reduced subacromial space and pain (shoulder) using manual therapy?

A
  1. GHJ caud glide
  2. GHJ caud glide in abduction
  3. GHJ PA at EOR flexion
  4. MWM

Apply a glide in the direction that causes aggravation (if the right glide) = should decrease symptoms

23
Q

What are 3 features of capsular/ligamentous restriction for stiffness, EOR pain for manual therapy?

A
  1. Which structure?
  2. Sustained stretch?
  3. What position of the joint – EOR? Neutral? Combined position? Target specific structure (e.g. 90o abduction for IGHL)
24
Q

What is the grade and duration for manual therapy (pathology) with a stiffness, EOR pain?

A

If not irritable, can use higher grade

25
Q

What are 2 possible techniques for stiffness and EOR pain (shoulder) using manual therapy?

A
  1. Accessory (Is more effective in a stiff joint) vs. physiological (More general)
  2. Direction will depend on specific part of the capsule you want to target
26
Q

What are 3 assessment features of capsular tightness when interpreting assessment findings?

A
  1. Posterior capsule (vs. posterior shoulder tightness)
    1. Restricted IR, horizontal adduction and flexion – moving forward
    2. Restricted posterior glide
    3. Humeral head may sit anteriorly
  2. Anterior capsule
    • Restricted abduction, ER, extension and horizontal abduction – moving backward and outward
    • Restricted anterior glide, or posterior glide
    • Humeral head may sit also sit anteriorly (capsule pulls HH forward), or superiorly if anteroinferior capsule is tight
  3. Inferior capsule
    • Restricted abduction – moving upward/outward
    • Restricted inferior glide
    • Humeral head may sit superiorly
27
Q

What are 3 clinical features of posterior capsule stiffness?

A
  1. Restricted IR, horizontal adduction and flexion – moving forward
  2. Restricted posterior glide
  3. Humeral head may sit anteriorly
28
Q

What are 2 possible techniques for posterior capsule (shoulder) using manual therapy?

A
  1. GHJ AP at a point in range
  2. GHJ AP with restricted movement (IR, horizontal adduction, flexion)
  3. GHJ AP in HBB
  4. GHJ AP in EOR elevation (target posteroinferior capsule)
29
Q

What are 3 clinical features of anterior capsule stiffness?

A
  1. Restricted abduction, ER, extension and horizontal abduction – moving backward and outward
  2. Restricted anterior glide, or posterior glide
  3. Humeral head may sit also sit anteriorly (capsule pulls HH forward), or superiorly if anteroinferior capsule is tight
30
Q

What is a possible techniques for anterior stiffness (shoulder) using manual therapy?

A
  1. GHJ AP or PA in restricted position (abduction, ER, extension, horizontal abduction)
    • Direction of glide will depend on assessment findings
31
Q

What are 3 clinical features of inferior capsule stiffness?

A
  1. Restricted abduction – moving upward/outward
  2. Restricted inferior glide
  3. Humeral head may sit superiorly
32
Q

What is a possible techniques for inferior capsule (shoulder) using manual therapy?

A
  • GHJ caud glide in 90˚ abduction
    • Can bias direction to more anterior or posterior
33
Q

What are 4 features of a MWM for shoulder?

A
  1. Similar concept to TDT
    • Identify aggravating movement
    • Apply a sustained glide to the joint while patient repeats the movement
  2. Should not be pain provocative
  3. Must produce an immediate beneficial effect
  4. Repetitions (Do not sustain the glide through all repetitions?)
34
Q

What are 4 possible techniques for MWM (shoulder) using manual therapy?

A
  1. GHJ AP glide with flexion, abduction or horizontal adduction
  2. GHJ caud glide with flexion, abduction or HBB
  3. ACJ AP glide with EOR flexion
  4. Scapula glides with arm elevation
    • Encourage upward rotation when in flexion/abduction
35
Q

What are 3 assessments of soft tissue techniques?

A
  1. Identify which is the primary structure limiting movement
    • Musculotendinous? Capsuloligamentous?
  2. Think about why this structure has become short or tight
    • Chronic pain?
    • Ergonomics, posture?- Holding shoulder in different position
    • Repetitive movement (e.g. thrower- GIRD)
  3. Respect pathology e.g. instability, adhesive capsulitis (Frozen shoulder –> can become very irritable)
36
Q

What are 2 soft tissue techniques for shortening of capsuloligamentous structures?

A
  1. Manual therapy
  2. Sustained stretches
37
Q

What are 2 soft tissue techniques for posterior shoulder tightness?

A
  1. Sleeper stretch
  2. Horizontal adduction stretch
38
Q

What are 3 reasons why true muscle shortening occurs?

A
  1. Chronic pain
  2. Ergonomics/posture (eg. phone between ear)
  3. Repetitive movement (e.g. thrower)
39
Q

What are 3 treatments for true muscle shortening?

A
  1. Treat the problem, change habits
  2. Stretching
  3. Massage
40
Q

What are 2 reasons why overactivity occurs?

A
  1. Protective response (adaptive) – pain, instability
  2. Habitual (maladaptive) – poor patterning / substitution (e.g. for weakness)
41
Q

What are 3 treatments for overactivity?

A
  1. Treat the problem, change habits
  2. Reciprocal inhibition
  3. Massage
42
Q

What are the 2 purposes of taping?

A
  1. Positional/postural correction
  2. Support/proprioception
43
Q

How long does the mechanical effects of taping last?

A

Mechanical effect of tape lasts for 20-30mins

44
Q

What is rigid tape vs k tape?

A

Rules out rigid

  • Allergies

K tape

  • Less allergies but while there is proprioceptive input not enough to stop movement
45
Q

What are 2 adjacent structures of the shoulder?

A

Cervical spine:

  • In people with shoulder impingement and no Cx spine symptoms, lateral glide mobilisations of C5-7 resulted in:
    • Immediate reduction in pain (<2cm on VAS)
    • Immediate improvement in ROM of painful arc in abduction

Thoracic spine:

  • In people with shoulder impingement, thoracic mobilisations resulted in:
    • Reduced pain during Neer, Hawkins Kennedy, empty can, resisted ER, resisted IR and active abduction
    • Improved SPADI score
46
Q

What are 4 features of referral?

A
  1. Capabilities within your scope
  2. Referral to expert physiotherapists
    • Identify someone with high level expertise in shoulder conditions
    • Specialist Musculoskeletal or Sports Physiotherapist (FACP)
  3. Role of the physiotherapist with the GP and musculoskeletal health
  4. Other medical professionals (Red flags, imaging..etc)

PHTY3120 (29 decks)

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