introduction to panel members - orthopaedic section to panel members • joseph godges, dpt,...
TRANSCRIPT
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12/9/2013
1
Diagnosis Dialog:
Classification of Shoulder Disorders in the ICF‐based Clinical Practice
Guideline and Alternative Approaches
Introduction to Panel Members
• Joseph Godges, DPT, University of Southern California
• Paula M. Ludewig, PhD, PT, University of Minnesota
• Aimee B. Klein, PT, DPT, DSc, University of South Florida
• Philip McClure, PT, PhD, FAPTA, Arcadia University
• Shirley A. Sahrmann, PT, PhD, FAPTA, Washington University in St. Louis
• Barbara J. Norton, PT, PhD, FAPTA, Washington University in St. Louis
Purposes of Session
• Provide a brief overview of the Diagnosis Dialogs
• Provide a context for discussion regarding labels to use for diagnosis in physical therapy
• Provide case examples based on two systems for diagnosis
• Engage audience in collegial discussion
Brief Overview of the
Diagnosis Dialogs
Barbara J. Norton, PT, PhD, FAPTA
Washington University in St. Louis
When, Why, and Who?
• When?– July 2006 for 2+ days and 10 times since then
• Why?– Inherent in Vision 2020 was the need to diagnose– Cyndi Zadai’s call to action in her 2004 Maley Lecture– We decided we need to define the diagnoses
• Who?– Individuals who were
• known to have an interest in the topic• able to help support their own participation in the effort
Sample of Questions Discussed
• What is a diagnosis?
• How should we refer to the diagnoses?
• How important is it that we establish our professional identity with the movement system?
• To what extent and how should existing conceptual models be used to inform the development of diagnoses related to physical therapy?
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More Questions
• How do we define and differentiate among the concepts of diagnosis, differential diagnosis, screening, & classification?
• What are the rules for defining our diagnosis labels?
• What are the names (labels) for the diagnoses?
• How do we describe and label the conditions that are relevant to the movement system?
Answers to Questions
• Group has reached consensus on answers to some but not all questions
• Issues resurface and are reconsidered as specific examples are presented
• Summaries of discussions are posted on‐line
– http://dxdialog.wusm.wustl.edu
• Focus today is on just a few points that will provide some context for the session
Relevant Points for Today
• Use the word “diagnosis” alone – or perhaps the term physical therapist’s diagnosis
– not PT diagnosis
• Use existing conceptual models of enablement or disablement (e.g., ICF) to inform but not constrain the choice of diagnostic descriptors
• Focus on the human movement system
• Use current working set of guidelines for naming diagnoses
Guidelines for Naming Diagnoses
• Use recognized anatomical, physiological or movement‐related terms to describe the condition or syndrome of the human movement system.
• Include, if deemed necessary for clarity, the name of the pathology, disease*, disorder, or symptom that is associated with the diagnosis.
• Be as short as possible to improve clinical usefulness.
What next?
• Recent action by the 2013 HOD on the identity statement associated with the new vision increases focus on movement system
• Even greater imperative to decide
• Present two viable approaches
• Compare and contrast the approaches
• Present case example of each approach
• Engage in collegial dialog with audience
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McClure:Shoulder Diagnosis CSM 2014
1
Classification of Shoulder Disorders: A Staged Algorithm for
RehabilitationRehabilitation
Phil McClure PT, PhD, FAPTA
Arcadia University
Acknowledgements:Martin Kelley PT, DPT, OCSJohn Kuhn MDPhil McClure PT, PhDLori Michener PT, PhD, ATC, SCSMike Shaffer PT, OCS, ATCAmee Seitz PT, DPT, OCS Tim Uhl PT, PhD, ATC
The Shoulder and ICF
Popular Label 1o ICD 9 ICF Body Function
ICF Body Structure
Activities/
Participation
Rotator Cuff Tendinopathy
(Impingement)
726.1Rot Cuff Syndrome
B7300
Power of isolated muscles and muscle groups
S7202
Muscles of shoulder region
D4452 Reaching
D4300 Lifting
D850 Work
D520 Caring for body parts
D4451 Pushing
D4452 Reaching
D4300 Throwing
Frozen Shoulder 726.0
Adhesive Capsulitis
B7100
Mobility of a single joint
S7201
Joints of the shoulder region
Glenohumeral Instability
840.2
Shoulder ligament sprain
B7601
Control of complex voluntary movements
S7203
Ligaments and fasciae of shoulder region
Why Classify?
• Direct Intervention
• Prognosis
• Communication
• Other?
Shoulder Dx /ClassificationPathoanatomic Classification• Rotator Cuff “Syndrome” / Impingement• Glenohumeral Instability• Adhesive Capsulitis• Others
i i hi h i d lAssumptions within a Pathoanatomic Model• Tissue pathology represents an homogenous group
– i.e. they look similar and should be treated similar
• Strong relationship between tissue pathology and patient complaints– i.e. must “fix” pathologic anatomy for pain and function to improve
Complaint of “Shoulder Symptom”
Level 2: Pathoanatomic Dx
Specific Physical Exam
Non-shoulder origin of sxShoulder origin of sx
Level 1: ScreeningHistory, Basic Physical Exam, Red or Yellow Flags
Appropriate for PTAppropriate for PT
And ReferralNot Appropriate for PT
Level 3: Rehab Classificationa) Tissue Irritability ( guides intensity of physical stress )b) Impairments ( guides specific intervention tactics)
Rotator Cuff “Syndrome” Adhesive CapsulitisGlenohumeral
InstabilityOther
High Irritability &Identified Impairments
Moderate Irritability &Identified Impairments
Low Irritability &Identified Impairments
Three‐level Staged Algorithm for Rehabilitation classification for shoulder pain
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McClure:Shoulder Diagnosis CSM 2014
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Key positive findings•impingement signs•Painful arc•Pain w/ isom resist•Weakness•Atrophy
Key positive findings•Spontaneous progressive pain•Loss of motion in multiple planes•Pain at end-range
Key positive findings•Age usu < 40•Hx disloc / sublux•Apprehension•Generalized laxity
•GH Arthritis•Fractures•AC jt•Neural Entrap•Myofascial•Fibromyalgia
Rotator Cuff /Impingement
Adhes CapsulitisGlenohumeral
Instability Other
“Rule in”
Pathoanatomic DiagnosesLevel 2
Key negative findings• Sig loss of motion• Instability signs
Key negative findings• Normal motion• Age < 40
Key negative findings• No hx disloc• No apprehension
•Fibromyalgia•Post-Op
Pathoanatomic diagnosis based on specific physical examination. Most diagnostic accuracy studies address this level. As examples, findings are listed for the three most common diagnoses only.
“Rule Out”
Rehabilitation ClassificationLevel 3
• Tissue Irritability ( guides intensity of physical stress )• Impairments ( guides specific intervention tactics)
Tissue Irritability
High Moderate Low
History and Exam
• High Pain (> 7/10)• night or rest pain
• consistent• Pain before end ROM
AROM PROM
• Mod Pain (4-6/10)• night or rest pain
• intermittent• Pain at end ROM
AROM PROM
•Low Pain (< 3/10)• night or rest pain
• none• Min pain
/• AROM < PROM• High Disability
•(DASH, ASES)
• AROM ~ PROM • Mod Disability
•(DASH, ASES)
w/overpressure• AROM = PROM• Low Disability
•(DASH, ASES)
Intervention Focus
• Minimize Physical Stressthrough activity modification
• Monitor impairments
• Mild - Moderate Physical Stress
• Restoreimpairments • Basic level functional activity restoration
• Mod – High Physical Stress
• Restoreimpairments • High demand functional activity restoration
Rehabilitation ClassificationLevel 3
• Tissue Irritability ( guides intensity of physical stress )• Impairments ( guides specific intervention tactics)
ImpairmentHigh Irritability Moderate Irritability Low Irritability
Pain Assoc Local Tissue Injury
ModalitiesActivity modification
Limited modality use Activity modification
No modalities
Pain Assoc with Central Sensitization
Progressive exposure to activity Medical Mgmt
Limited Passive Mobility: joint / muscle / neural
ROM, stretching, manual therapy: Pain-free only, typically non-end range
ROM, stretching, manual therapy: Comfortable end-range stretch, typically intermittent
ROM, stretching, manual therapy: Tolerable stretch sensation at end range. Typically longer duration and frequency
Excessive Passive Protect joint or tissue from end-range Develop active control in mid-range Develop active control during full-range Excessive Passive Mobility
j g p gwhile avoiding end-range in basic activity
Address hypomobility of adjacent joints or tissues
p g gduring high level functional activity
Address hypomobility of adjacent joints or tissues
Neuromuscular Weakness: Assoc with atrophy, disuse, deconditioning
AROM within pain-free ranges Light mod resistance to fatigueMid-ranges
Mod high resistance to fatigueEnd-ranges
Neuromuscular Weakness : Assoc with poor motor control or neural activation
AROM within pain-free ranges
Consider use of biofeedback, neuromuscular electric stimulation or other activation strategies
Basic movement training with emphasis on quality/precision rather than resistance according to motor learning principles
High demand movement training with emphasis on quality rather than resistance according to motor learning principles
Functional Activity intolerance
Protect joint or tissue from end-range, encourage use of unaffected regions
Progressively engage in basic functional activity
Progressively engage in high demand functional activity
Poor patient understanding leading to inappropriate activity (or avoidance of activity)
Appropriate patient education Appropriate patient education Appropriate patient education
Level 2: Pathoanatomic Dx
Specific Physical Exam
Level 1: ScreeningHx, Basic Phys Exam, Red or Yellow Flags
Key Decisions:
PT and/or Referral ?
General Intervention strategy ?• Rehab vs Surgery• Key tissue and movement precautions
Prognosis and Patient Education
Level 3: Rehab Classification• Tissue Irritability• Impairments
What Physical Stress Intensity?• Minimal• Moderate• High
What are the Key Impairments?
DiscussionComparison of Pathoanatomic Dx and Rehab Classification
• Pathoanatomic Dx– Primary Tissue
Pathology
– Stable over episode of care
• Rehab Classification– Irritability / Impairment
– Often changes over episode of care
care
– Guides general Rx strategy
– Informs prognosis
– Important for Surgical Decisions
– Guides specific rehab Rx• Physical stress dosage
• Specific Impairments
– May inform prognosis ?
Discussion: A Staged Algorithm for Rehabilitation
Limitations( at least a few)
• Does “irritability” capture key features determining application
Potential Features
• Relatively simple
• Captures thought process of many
of physical stress?
• Does not address “non‐physical” issues
• Reliability
• Validity
process of many seasoned clinicians
• Possible broad application
• Not “separate” from medical framework
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Movement System Impairment Syndromes
Shirley Sahrmann, PT, PhD, FAPTAProfessor Emeritus
Washington University School of Medicine – St. LouisProgram in Physical therapy
APTA Vision Statement
• Transformation Society by optimizing movement to improve health and participation in life.
• Guidelines: Identity
– The profession will define and promote the movement system as the foundation for optimizing movement.
– The recognition and validation of the movement system is essential to fully understand the physiological function and potential of the human body.
Movement System Definition
• “The movement system is a physiological system that functions to produce motion of the body as a whole or of its component parts.
• The functional interaction of structures that contribute to the act of moving”.9
• Steadman’s dictionary
Movement System
Movement
Skeletal
Muscular
Nervous
cardio‐vascular
pulmonary
endocrine
biomechanics
Effectors
Supporters
All of the contributing systems are affected by movement
Defining Professional Expertise
• If professional identity is movement system• If identifying movement system impairments is your core expertise
• Then need labels that convey to public and other health professionals that expertise
• Convey that impaired movement can cause pathology as well as result from pathology
• Why movement can be used for treatment• Why PT is important for guiding development & prevention the movement system
Consistent with Other Health Professions
• PT does not treat pathoanatomical tissues by surgery or medication
• If use same label does not convey the difference in identifying cause and developing treatment
• Other professions learn new labels – e.g, FAI (even Lady Gaga)
• PT learns labels of other professions, certainly they can learn our labels
• Using Movement System Dx – would clarify differences in– focus & scope of practice – alert other practitioners to variations in mechanisms
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Movement System Models
Kinesiopathologic ‐ cause Pathokinesiologic ‐ result
• Movement impairments –– deviations in precision of
movement
– Accessory motion hyper‐mobility
– Subthreshold for pathology ‐initially
• Cause tissue injury and eventual tissue pathology
• Movement impairments/pathologies
• Result of a lesion in a component system – Nervous system – stroke –
Neural ‐ dennervation
– Skeletal – rheumatoid arthritis
– Trauma – Fracture – tissue injury
Kinesiopathologic Model of Movement System
Muscular ‐ Skeletal Nervous Cardio – respirendocrine
Biomechanics
Repeated movementsSustained alignments
MODIFIERSINDUCERS Personal Characteristics
Tissue Adaptations
Accessory motionHypermobility
Imbalanced MuscleRelative Stiffness
Intrinsic joint mobilityLig laxity, capsular laxity
+Muscle activation Impair
Micro Macro trauma
+ Relative Flexibility
Scapular and Humeral Diagnoses
Diagnosis assigned based on:
–Alignment and movement impairments noted throughout exam
– The movement impairments that, when corrected, best alleviate the symptoms determine the diagnosis
–Both a scapular & humeral diagnosis can be assigned, if appropriate
9
MSI Scapular Syndromes
Scapular internal rotation (AC joint)
• With anterior tilt (AC joint)
• with insufficient UR (SC and AC joint)
• with abduction (SC joint protraction)
Scapular depression (SC depression)
Scapular external rotation/adduction
(SC retraction; AC ER)
Scapular Winging (pathological) (AC joint)
Scapular elevation (SC elevation)
10
Humeral MSI Syndromes (Diagnoses)
• Humeral Anterior Glide
• Humeral Superior Glide
• Glenohumeral Multidirectional Accessory Motion Hypermobility
• Shoulder Medial Rotation
• Glenohumeral Hypomobility
Scapular Internal Rotation with Anterior Tilt (muscle activation)
• Movement Impairments as the result of muscle activation impairments (timing)– Scapulohumeral activity prolonged – dominant– Axioscapular activity decreased too rapidly
• These patients usually have a combination of IR and tilting
12
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Scapular Internal Rotation with Anterior Tilt (muscle activation)
13
Scapular motion controlled – elbow extended – post 3 visits
Scapular IR with Ant. Tilting: return from Flexion(strength 3/5 on MMT)(muscle activation problem)
15
If weakness should occur during Concentriccontraction not Eccentric contraction
Scapular Internal Rotation with Insufficient Upward RotationGlenohumeral Anterior Glide
8‐15‐0616
Scap 40 degGH 140 deg
Scapular Depression (With Insufficient Upward Rotation)
scapdrleft17
Neck Pain (Cervical Flexion) with Scapular Depression
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Pilates Instructor
videos
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Pathokinesiologic MSI SyndromeInsufficient upward rotation – abduction
Left Side Involved
19
Onset after biking trip for several weeks with backpack on back; 20 y/o
20
21 22
Video: initial (left) and 6 weeks later (right)
Humeral Diagnoses
• Humeral Anterior Glide
• Humeral Superior Glide
• Shoulder Medial Rotation
• Glenohumeral Hypomobility
• Glenohumeral Multidirectional Accessory Hypermobility
Humeral Anterior Glide
Resting Alignment: humeral head relative to anterolateral corner of acromion
Humeral head more anterior relative toacromion during active abduction
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Humeral Anterior Glide
video
Humeral Anterior/Inferior GlideCorrectedInvolved
Normal
Humeral Anterior/Inferior Glide
Alignment
Humeral Anterior/Inferior Glide
Summary
• Professional Identity – mandates conveying of that expertise to public & other health professionals
• Conveys PT expertise in a body system• Contributes to awareness of other mechanisms of injury
• Directs treatment clarifies to patient their role instead of just identifying pathological tissue
• Parallels the practice patterns of other professionals with expertise in body systems
• (No one will know there are movement impairments and that they can be diagnosed unless we develop and use labels describing these syndromes)
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Comparison of Alternative Diagnostic Labeling Systems
Paula M Ludewig, PhD, PT
The University of Minnesota
Acknowledgements
• Becky Lawrence, PT, OCS
• Justin Staker, PT, OCS, SCS
• Jon Braman, MD
• Diagnosis Dialog Group
Why Classify?
• Direct Intervention
• Prognosis
• Communication
• Others– Influence reimbursement
– Define homogenous subgroups for research
Provide a Diagnostic Label
Pathoanatomic Diagnostic Labels
• Common and “Traditional”
• Communication with Physicians/Surgeons
• Focuses on identifying tissue pathology that is the basis for the patients pain or dysfunction
• Important to surgical decision making
• Important for physical therapy decision making
Concerns with Pathoanatomic Labels
• Often do not adequately direct physical therapy intervention
• Disconnect between our diagnostic and treatment process
• Often we cannot determine an anatomical source
• What about co‐existing pathologies?
• Inconsistent use confounds communication
Diagnosis as Pattern Recognition
• Assumes subgroups of subjects exist for which similar treatment interventions are useful
• For orthopaedic physical therapy, what best defines these subgroups?
• Should they be based in the movement system?
• Should they be based in movement impairments?
• How far do we need to “drill down”?
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Clinical Practice Guidelines/ICF Approach
• Shoulder Pain & Mobility Deficits: Adhesive Capsulitis
• Shoulder Stability & Movement Coordination Impairments
• Shoulder Pain and Muscle Power Deficits: Rotator Cuff Syndrome
Pathokinesiologic Model
• Focus on identification of characteristic movement impairments that are the cause of the patients pain or dysfunction
• Also (more) important for physical therapy decision making – greater potential to guide interventions
• Stronger relationship between impairment and function, easier integration with ICF
• Does not presume or preclude specific tissue pathology
Possible Labels
• Glenohumeral mobility deficit associated with capsular contracture
• Glenohumeral mobility deficit associated with osteoarthritis
• Inadequate scapular upward rotation associated with rotator cuff disease
• Inadequate scapular upward rotation associated with multi‐directional instability
Other Advantages
• “reorders the label” consistent with physical therapist identity as movement system experts
• Prioritizes movement in diagnostic process
• No issues of scope of practice
• Avoids “misdirection” of intervention from tissue pathology that may not relate to function
Concerns About PathokinesiologicModel
• Creating a new and unfamiliar language/ system
• Are we just “afraid” to use traditional labels or advances in diagnostic tools (imaging)?
• Reliability/validity not established
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Screening for Referral
Movement Impairments
Tissue Pathology
Impairments
Staging
Diagnosis
Shoulder Origin
Hypermobility(Instabilities)
Hypomobility
(Adhesive Capsulitis, Arthritis, Post‐Fx)
Aberrant Motion
(Rotator Cuff, Impingement, Labral
Tears)
Non‐Shoulder Origin
Rotator Cuff Syndrome/ Impingement
Scapular Dyskinesia
Decreased upward rotation
Decreased posterior tilting
Humeral Translation
Humeral External
Rotation Deficit
Scapular Upward
Rotation Deficit
SubacromialImpingement
Inferior Instability
Internal Impingement
Questions
• Do we agree on the most common clusters of patients?
• Do we want to classify or stage within traditional medical diagnostic labels, or associate tissue impairments with movement diagnoses?
• Is the status quo adequate?
• How do we most efficiently teach students to think like seasoned clinicians?
• How should health care reform/cost accountability impact our approach?
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Case&Example&&
Shoulder&Pain&and&Mobility&Deficits&&&Joe&Godges&DPT&
&Coordinator,&ICFGbased&Clinical&PracHce&Guidelines&Project&
Orthopaedic&SecHon,&APTA&&
Associate&Professor&University&of&Southern&California&
Profile&
• 53&yearGold&female&• Film&editor&–&intermiQently&employed&• Typically&exercises&doing&aquaHc&exercises&• Prior&history&of&moderate&traumaHc&brain&injury&and&recurrent&cervical&radiculopathies&
Reported&Problems&/&Concerns&
• 3&month&history&of&shoulder&pain&• Onset&related&to&reaching&strain&–&to&back&seat&• SHffness¬ed&in&past&6&weeks&• Difficulty&with&sleeping&–&posiHon&changes&are&painful&
• Saw&a&PT&for&one&visit&2&weeks&ago&–&produced&“terrible”&pain&for&several&days&following&shoulder&“stretching&procedures”&
• Expresses&fear/anxiety&over&disabling&pain&
Primary&AcHvity&LimitaHons&Visit&1&
• Sleep&disturbances:&&wakes&up&every&2&hours&at&night&because&of&the&pain&
• Deskwork&and&driving&limitaHons:&&pain&with&reaching&above&shoulder&level&of&objects&
Relevant&Physical&Impairments&Visit&
• External&RotaHon&PROM:&&40o&at&45o&abducHon&• Internal&RotaHon&PROM:&&15o&at&45o&&abducHon&• Pain&before&resistance&with&GH&PROM&tests&• PosiHve&Upper&Limb&Nerve&Tension&Test&–&reproduces&reported&shoulder&pain&
• Limited&1st&Rib&inferior&glide&• Infraspinatus&trigger&point&–&reproduces&reported&shoulder&pain&
IntervenHons&Visit&
• MobilizaHon/ManipulaHon:&– Upper&Thoracic&and&Rib&ManipulaHon&
• Sod&Tissue&MobilizaHon&– Ulnar&and&Radial&Nerve&Entrapment&Sites&– Infraspinatus&Myofascia/TPs&(with&PNF)&
• TherapeuHc&Exercises&– Nerve&Mobility&Exercises&in&Pain&Free&Ranges&– Glenohumeral&RotaHon&AROM&Ex’s&in&Pain&Free&Ranges&
• Counseling&– Sleeping&and&Deskwork&Ergonomic&InstrucHons&
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Visit&2–&one&week&later&Primary&AcHvity&LimitaHons&
• Sleep&disturbances:&&wakes&up&only&once&at&night&because&of&the&pain&
• Deskwork&and&driving&limitaHons:&&able&to&reach&to&shoulder&height&–&pain&with&reaching&above&head&height&
• Would&like&to&return&to&aquaHc&&&gym&exercises&
Relevant&Physical&Impairments&Visit&
• External&RotaHon&PROM:&&60o&at&45o&abducHon&• External&RotaHon&PROM:&&30o&at&80o&abducHon&• Internal&RotaHon&PROM:&&45o&at&45o&&abducHon&• Subscapularis&trigger&point&–&reproduces&reported&shoulder&pain&
• Pain&with&resistance&G&end&ranges&of&GH&moHons&– moderate&irritability&(improved&from&last&visit)&
IntervenHons&Visit&
• Repeat&IntervenHons&of&Visit&Add&• Sod&Tissue&MobilizaHon&and&Manual&Stretching&– Subscapularis&
• TherapeuHc&Exercises&– Scapular&AcHvaHon&with&GH&AROM&exercises&– IniHate&AquaHc&Exercises&in&pain&free&ranges&
Visit&3–&two&weeks&later&Primary&AcHvity&LimitaHons&
• Sleep&disturbances:&&able&to&sleep&through&night&
• Deskwork&and&driving&limitaHons:&&able&to&reach&above&head&height&–&pain&only&at&end&ranges&of&overhead&reaching&
• Feels&competent&with&care&progress,&less&fearful&of&disablement&
Relevant&Physical&Impairments&Visit&
• External&RotaHon&PROM:&&70o&at&45o&abducHon&• External&RotaHon&PROM:&&40o&at&80o&abducHon&• Internal&RotaHon&PROM:&&50o&at&45o&&abducHon&
• Pain&with&resistance&–&at&end&ranges&of&glenohumeral&moHons&– moderate&irritability&
Relevant&Physical&Impairments&Visit&
• External&RotaHon&PROM:&&60o&at&45o&abducHon&• External&RotaHon&PROM:&&30o&at&80o&abducHon&• Internal&RotaHon&PROM:&&45o&at&45o&&abducHon&• Pain&with&resistance&G&end&ranges&of&GH&moHons&– moderate&irritability&(improved&from&last&visit)&
• Restricted&GH&Accessory&MoHon&TesHng&• ULTT&–&radial&nerve&tension&test&and&provocaHon&of&entrapment&site&in&humeral&radial&groove&reproduces&reported&shoulder&pain&
![Page 15: Introduction to Panel Members - Orthopaedic Section to Panel Members • Joseph Godges, DPT, University of Southern California • Paula M. Ludewig, PhD, PT, University of Minnesota](https://reader031.vdocuments.net/reader031/viewer/2022030419/5aa5f1c87f8b9a2f048e1ef2/html5/thumbnails/15.jpg)
12/9/13&
3&
IntervenHons&Visit&
• Repeat&IntervenHons&of&Visit&&&2&Add&• Sod&Tissue&MobilizaHon&– Relevant&Radial&Nerve&Entrapment&Sites&
• Joint&MobilizaHon&– Humeral&Posterior&Glide&in&loose&pack&posiHon&(Grade&IIGIII:&mobs&into&Hssue&resistance,&mild&pain&with&resistance&–&does¬&worsens&with&repeated&mobs)&
Progression&Summary&Visits&#&4&to&8&
Once&every&other&week&• Infraspinatus,&Subscapularis,&and&Radial&Nerve&mobility&normalized&by&visit&6&
• Focus&of&visits&4&to&8&were&on&glenohumeral&joint&mobilizaHon,&progressive&home&stretching&instrucHons&and&acHvity&tolerance&training&
• At&discharge:&– Minimal&to&no&pain&with&daily&acHviHes&and&exercises&– PROM:&70o&ER&at&90o&abducHon&– AROM:&150o&flexion&before&onset&of&pain&