ue pres final

8/6/2019 UE Pres Final

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REHABILITATION OF THE

UPPER EXTREMITY:

COMMON CONDITIONS

& THERAPEUTIC INTERVENTIONS

BY: DANIELLE LAWS


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Pathophysiology & Etiology

Purpose of RC stabilizes humeral headinthe glenohumeral joint

4 Muscles & their tendons: X Supraspinatus

Y Infraspinatus

Z Teres Minor

[ Subscapularis

Overall Etiology:

RCtendontensilestresstolerance = up to 100N/mm (1)

Compressive & shearforces- overloadssupraspinatus tendon

Chronic= tinytearsthat progressovertime

Extrinsic Factors:

ImpingementTheory(2)

Demographic Variables

Intrinsic Factors:

Degenerative-Microtrauma Model(5)(6)

Rotator Cuff Injury

2009 Blum et al.

Acromion Morphology % Tea rs % Tx Response

Type I flat 17 89

Type II curved 43 73Type III - hooked 39 58

(3) (4)


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Signs/Symptoms & Evaluation

Pain:

- rarelybelowelbow,oftenalong insertionofdeltiod

Weakness:

- painonly = potentiallytendonitis

- pain + weakness=RC

tearDecreased Shoulder ROM:

- AROM, particularly ERandabduction

- PROMtypically pain-free, unlesscomorbidities exist (i.e. OA)

Crepitus:

- humeralrotation

- significant = osteophytes and/or FTtears

Positive Impingement/RC Tests:

(seenextslide)

Rotator Cuff Injury


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Rotator Cuff Injury

Test Procedure Positive Results

Quick FT Screen * Position: shouldersneutral & elbowsflexed 90

- Resist @ dorsum ofhandwhile pt. ERshoulders

Shoulderadd & IR = FTRCtear

(supraspinatus & infraspinatusCross-body

adduction test

- passivelyadductedarm acrossbodytoopposite

shoulder.

Pain= ACjointdamage

Drop-Arm Test

(Codmans Test)

* Position: Shoulderabductedto 160

- instructtolowerarm slowly.

RCdamage= arm drops quickly

duetonocontrol

Hawkins-Kennedy

Impingement Test

* Position: shoulder & elbowflexed 90.

- stabilizeshoulder & IRshoulder

Pain= impingementand/orRC

tear

Neer Impingement

Test

- stabilizescapula & passively pronate during maximal

passiveshoulderflexion & IR

Pain = subacromial impingement

Patte Test * Position: shoulder & elbowflexed 90

- stabilizeelbow & resist @ wristwhile pt. ERshoulder

Weaknessor pain= infraspinatus

damage

Gerber Liftoff Test * Position: shoulderextendedwith dorsum ofhand

resting oniliaccrest

- resist @ wristwhile pt.raises hand 2-5 in.from back

Painorinabilityto hold position=

subscapularis damage

Speeds Test * Position: elbowextended,forearm supinated,

shoulderflexed 90

- palpatebicepts tendon & resist @ wristwhile pt.

flexesshoulder 60

Painortenderness = long head

ofthebiceps

Jobe Test

(EmptyCan Test)

* Position: (B) shouldersabducted 90 & IR

-applydownward pressuredistallywhile patientresists

Asym.weaknessorinabilityto

hold position= supraspinatusdamage

Signs/Symptoms & Evaluation: Provocative Tests (7)


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Therapeutic Intervention: Management & Rehab (8)Rotator Cuff Injury

Initial Phase: X Supervisedtx atleast 2-3x/wk

YManualtx

Z Establishmentofhome program

- Criteria forprogressing to maintenance phase:

a.) nolongerrequire manualtx

b.) safe, proficient, & (I) atestablished home program

Maintenance Phase: X Home program only:

* ROM & Flexibility daily

* Strengthening 3x/wk


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Rotator Cuff Injury

INTERVENTIONS RECOMMENDATIONS INSTRUCTIONS

Manual Tx Softtissue &joint mobilization

Modalities Heat,Cold,orboth US shouldnotbe used

ROM Posturalexercises x Shrugs & Scap.retraction

GH motion- progressascomfortallows

pendulum AAROM AROM

xAAROM- can use: cane,pulleys, otherarm

xAROM- preventothershoulderfrom hiking

with: mirror,other handontrapezius

Flexibility(Stretching)

Ant. Shoulder - corner/doorjamb Post. Shoulder- crossedbodyadd.

xHold30 seceach

x rep x 5

x 10 secrestbetweeneach

Strengthening TheraBand:

- IRwith arm adductedatside

- scaption (ifno pain)

Scap. Stabilizer:- chair press

- push up plus

- uprightrowswith elasticband

Combostrengthening while standing:

- forwardelevation

- extension

x3setsx 10 reps

x increaseelasticresistanceasstrength

improves

Therapeutic Intervention: Management & Rehab (8)

* NOTE: illustrations

provided


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Therapeutic Intervention: Non-conservative/SurgicalRotator Cuff Injury

Indications: (9)

X NoresponsetoconservativeapproachesY Profoundweakness/debility

Z AcuteTrauma

Size > 3cm

Procedures:

Open Openincision

RCaccess & acromioplasty viadissectionofdeltoid

Mini-Open Smallopenincision (3-5 cm)

RCaccess & acromioplasty viaarthroscopy

Arthroscopic 3-4smallarthroscopy portals

RCaccess & acromioplasty viaarthroscopy

Post-op Rehabilitation: Routinelyinvolves phases

~Protocols Vary WIDELY depending onthe procedureandthesurgeons

technique/preferences


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Therapeutic Intervention: Post-op Rehabilitation (General)Rotator Cuff Injury

Precautions: (10)

X Donotactively movearm awayfrom body (~4-6 wks)Y Donotlifting ANYTHING,evenifonly moving elbow

Z Initially Donotreach behindback (extend)

Donot push up/offstructures (~6wks)

Depending onsurgeon checkforrotation precautions (IR/ER)

Insupine rolledtowel underelbow

Activity & Environmental Adaptation/Accommodation:

Codmans positiontoaccess underarms

Extended handles

One-handed ADL techniques

AE: (justtonameafew..)

reachers button & zipper hooks curlyshoelaces

brella bag plate guards/scoop dishes furniture hoists/pulleys


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PHASE FOCUS PRECAUTIONS THERAPY

Phase I

(wk 1-wk 6)

Protect

repaired

tissues

Gain motion

Prevent

adhesions

No AROM

No pushing/pulling up

Noaggressive/painful

stretching

Sling/Immobilizer offfor

bathing & therapyonly

~4wks: startweaning fromimmobilization

Codmansexercises

Activeexerciseofother UE

jointswith arm add.atside

~elbow dependsonbiceps

involvement

ModalitiesPRN

Scar management

Safetyeducation

Phase II

(wk6-12)

Normalize

motion

Normalize

ADLs

Nolifting or ROMbeyond

comfort nothing heavier

thencup ofwater

Nosupporting bodyweightNobehindback movements

Nojerky/sudden motions

Active functional useduring

ADLs

ModalitiesPRN

Cont.safetyedu.Gradually progress:

PROMAAROMAROM

AROM

- Lighttheraband

- Low-levelclosedchain

- Scapula


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PHASE FOCUS PRECAUTIONS THERAPY

Phase III

(wk 12 -16)

Strength

PLOF - motion,

endurance

returnto

normal ADLs,

work, and

modifiedrecreation

Nostraightarm lateralraise

Nolifting > 5 lbs

Nojerky/uncontrolled motion

Noarm raiseswith thumb

down (emptycan) keep

thumbs up

Free weights 1-4lbs

Progresstheraband resist.

ModalitiesPRN

moreaggressivestretching

Open-chainkinesthetic

awarenessdrills

Progressclosedchainactivities

Safetyeducation

Phase IV

(wk 16-24)

ROM

PLOF strength

& recreation

Home

program

Nolifting > 10lbs

Nosuddenlifting or pushing

Noactivitiesbeyondcurrent

ROMorstrength

Dailystretching

Progressive strengthening &

endurance

Phase V

(wk24 +)

Returntofull

PLOF

Criteria For FullReturntoPLOF:

1.) M.D. Clearance 3.) min 0 c/o pain

2.) ROM WFL forallregular ADLs 4.) regularHEPcompletion


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Pathophysiology & EtiologyArthritis

Osteoarthritis (OA) Rheumatoid Arthritis (RA)

Gradual, progressivebreakdownofarticular

cartilage & otherjointtissuesduetowear

andtear leading toovergrowth ofbone(11)

- wearing down & repair processaltered

- H2O & protein

- deterioration:

superficial deep= lesions= tears

- enzymes:thins= wearsaway

- osteophytes = triggering

- synovitis = decreasedsyn.fluid

Etiology: (16)

1.) Primary OA: unkown cause/factor

2.) Secondary OA: knowncause/factor

x Genetics/history x Obesity

x Trauma/infection x ChronicRCtear

x Cong. malformation x Radiation

x Alcohol/drugs x CS therapy

x Chronicdislocation x Sicklecell

Chronic,autoimmuneresponse/disease

markedbyinflammationofconnectivetissues

(synovial membrane) (11)

- thickenedsynoviallining

- formationofgranulationtissue

- destroysjointtissue & weakenscapsule

- adhesions deformity

Etiology: genetics + environment

Increased Risk: (12-15)

x F sex x Silicateexposure

x Family history x Smoking

x > 3CupsCoffee/Day (Decaf)

Decreased Risk: (14-15)

x Vit D intake x Tea

xOralContraception


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Arthritis

2008 Medicenet, Inc.

2008

2008

RA vs. OA


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Signs/Symptoms & Evaluation

Arthritis

Osteoarthritis (OA) Rheumatoid Arthritis (RA) Age x Morecommonwith age x Anyage

Gender x F=M x F>M

Distribution x Asymmetrical Symmetrical

x O

ftenlimitedto 1 setofjointshands/fingersorlarge WB joints

x Symmetrical

x

Small & largejoints

Typesof

Symptoms

x Limitedtoorthopedicsymptoms x Orthopedic,cardiac,respiratory,

fatigue, generalillness,ect.

Joint

Symptoms

x Mayacheandbestiff,but

limited swelling

x Painful,stiff,swelling


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ArthritisTherapeutic Intervention: Management & Rehab (17)

Condition Pathology Physical Findings Therapy

Rheumatoid

arthritis

x

Synovitis

x Vasculitis

x Onset:

earlyorlate

(>55 years)

x Bilateral & symmetrical

jointinvolvement

x Joint pain &

inflammationx Jointstiffness

x Contractures maybe

present

x Crepitus

x Fatigueoften

underappreciated

x Muscleweaknessx Enlargements- nodes

Acute exacerbation:- AROMexercises 2 reps/joint/day

- Frequentrestforfatigue

- Orthoses andsplintsforsupportive &

neutraljoint position

- Isometricexercises: 6-s hold,4reps

Subacute:- AROMexercises: 8-10 repetitions/joint/day

- Isometricexercises: 4-6 contractions

- Lightresistancedynamicexercises:

avoidifjointsare unstable, presenceof

tense

popliteal cystsorinternaljointderangement

- Aerobicexercise (aquatic/land): 15-20 min(3x/wk).

- Cardiaceval recommended: Establish HR

parameters & use perceivedROE scale

Stable disease:

- Asabove,butincreaseaerobicactivities


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ArthritisTherapeutic Intervention: Management & Rehab (17)

Condition Pathology Physical Findings Therapy

Osteoarthritis

x Cartilage

degeneration

xOnset:

Gradual &

progressive

x Stiffness & pain-

predominantlyinlarge,weight-bearingjoints

x Little-no Inflammation

x Joint malalignment

x Weakness

xJoint

instability/hypermobility

Mild disease:

- AROMexerciseswith dailyactivities:3-5 repsofflexibilityexercise & 8-10 repsof

staticexercises,each of6-sduration

- Dynamicexercises: 8-10 reps

- Low-impactaerobicactivities (aquatic & bikes):

20 min,3x/wk

- Balanceactivities (BAPS andtiltboard):

single-limbstanceModerate:

- Staticanddynamicexercises: reduceto 5 reps,

3-5 repsofflexibilityexercises

- Low-impactaerobicexercises (aquatic & bikes):

20 min,3x/week

-balance & proprioception activities- bilateral

Severe disease:- Low- tono-impactaerobicexercises (aquatic)

x Note: advisefunctionalactivitiestokeep

moving,fewtonorepsofdynamicexercises;

patienteducationisveryimportant

x Note: in patientswith ligamentous laxity &

malalignment, usecautionwith strengthening

exercises;orthoses,crutchesorwalker


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Introduction (9)Total Shoulder Arthroplasty (TSA)

7 Common Conditions:

OA RA AN

Post-traumaticarthritis Failed previousTSA Humeralfractures

RCrepair

4 Contraindications to TSA:

X Infectioninshoulderand/orsurrounding regions

Y Paralysisofdeltoid & RC

Z Neuropathicjoints

Bonyinsufficienciesthatcannotbeadequatelyreconstructed

Description:

In general,TSA involvestheremovalofanynecrotic/nonviabletissueafterwhich the

surfaceofthe glenoid anda portionofthe humeral headareremoved & replacedwith an

artificialimplantcalleda prosthesis.

*Keep In Mind: RCMuscles & Tissues


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ShoulderProstheses (9)Total Shoulder Arthroplasty (TSA)

2 Main Components:

X GlenoidComponent- replacesjointsocket

- durable, plasticinsertwith cuppedsurfaceon

onesideandfixation pegsontheother

Y HumeralComponent replaces humeral headanda portionoftheshaft- long metalstem thatfitsinto humeralcanal & a

half-sphereshaped, metal head

- head mountedontop ofstem & art.with glenoid


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Therapeutic Intervention: Post-op Rehabilitation (18-19)Total Shoulder Arthroplasty (TSA)

Phase I: Week 0-4

Goals: 1.) IncreasePROM

2.) DecreasePain3.) Retard Atrophy

Precautions:

x~3 Wks: nodriving

x 3-4 Wks: Sling atalltimesforcomfort & avoiding AROM

x 6-8 weeks: Supine- small pillowortowelrollshouldbe placedbehindelbowtoavoid

shoulder hyperextension/ant.capsule/subscapularis stretch (alwaysabletoseelbow)

x Avoidshoulder AROM

x Nolifting orsupporting bodyweight

Therapy:

x Cryotherapy

x CPM

x PROM: - Flexion = 0-90

- ER (at30 abduction) = 0-20 - IR (at30 abduction) = 0-30

x Pendulum

x Elbow/Wrist/HandROM & Grip Strength

x Rope & Pulley (wk #2)

x AAROM whencomfortallows


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Phase II: Not Before Week #4

Goals: 1.) Increase Strength 3.) DecreasePain/Inflammation

2.) IncreaseROM 4.) Increase Functional Activities Precautions:

x Sling- onlyduring sleep & graduallyremovedovernext 2 wks

x 6-8 weeks: Supine- small pillowortowelrollshouldbe placedbehindelbowtoavoid

shoulder hyperextension/ant.capsule/subscapularis stretch (alwaysabletoseelbow)

x Poorshoulder mechanics- avoidshoulder AROMinstanding

x Nolifting heavierthancoffeecup orsupporting weightwith involvedside

x Nosuddenjerky motions

Therapy:

x Cont.Cryotherapy

x Cont.PROM: - Flexion = 0-90

- ER (at30 abduction) = 0-20

- IR (at30 abduction) = 0-30

- Assisted hor.adductionx Greaterthan 90 PROM AAROM pulleys (flexion & elevation)

x Begin AROM (painfree) : flexion & elevation

x Isometrics: - Abductors

- IR/ER

x Progressdistalexerciseswith lightresist.astolerated

x Scap.strengthening astolerated

x GentleGH & STjoint mob.


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Phase III: Not BeforeWeek #6

Goals: 1.) GraduallyRestore Strength,Power, & Endurance

2.) Increase NMControl2.) Gradually Increase Functional Activities

Precautions:

x No heavylifting

x Nosuddenlifing/pushing/jerking

Therapy: Early Phase III

x Eliminatesling

x Progress AROM/activityastolerated

x AdvancePROM & stretching astolerated cont.PRN to maintainROM

x Initiate AAROM- IRbehindbackstretch

x Resisted- IR, ERinscap plane

x Isometrics: - Abductors

- IR/ER

x Beginlightfunctionalactivities Therapy: LaterPhase III

x Resistedflexion,elevationin planeofscap.,extension (therabands)

x Cont. progressing IR & ERstrengthening

x Progress IRstretch behindbackfrom AAROMto AROMastolerated

-


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Phase IV: Not Before Week #12

Goals: 1.) Maintain pain-free AROM

2.) Increase Functional Activities Precautions:

x Noexercise/funct. Activitiesthat p stressonant.capsule & surrounding structures

(example combined ER & abductionabove 80 ofabduction)

x Ensure progressionofstrengthening is gradual

Therapy: Early Phase IV:

~OnHEP3-4x/wk

x Gradually progressstrengthening

x Graduallyreturnto mod.functionalactivity

Therapy: Late Phase IV:

x Returntorecreational hobbies & occupations


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Occupation-Based Intervention Schedule

Phase 1:

Days 1-10ADL: Wash facewith affectedextremityindependently.

CPMortherapisttoassistinPROM

Cryotherapy

Days 10-21

ADL: Donanddoffshirt using hemidressing techniqueswith assist.

Sub maximalisometricexercisesagainstadoorwayorwall.

ContinuecryotherapyPhase 2:

ADL: Useaffectedextremitytobrush teeth

ADL: Eating using affectedextremity.

Lightstrength training using dumbbells (1-3lbs)

Continuecryotherapy

Phase 3:

ADL: Folding clothesLayinsupinewhilelifting dowelrodover head.

Internalandexternalrotationexercises using theraband.

Phase 4:

ADL: Driving- Practice putting onseatbeltandturning thesteering wheelwith affected

extremity (simulatedorreal)

Continuetheraband exercises

Light- moderate UE strength training orastolerated.


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THE END

Ron Leishman

Illustrationsof.com


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1.) Millet,P.J., Wilcox,R.B.,OHolleran,J.D., Warner,J.J.P. (2006).Rehabilitationoftherotatorcuff: Anevaluation-basedapproach.Journal of the

American Academy of OrthopedicSurgeons, 14, 599-609.

2.) Neer,C,Poppen, N. (1987). Supraspinatus outlet.Orthopedic Trans-actions,11, 234.

3.) Bigliani,I.,Morrison, K., April, E. (1986).The morphologyoftheacromion androtatorcuffimpingement.Orthopedic Trans-actions, 10, 228.

4.) Wang, F.,Murrel G., Wang,M. (2007).Oxidativestress-inducedc-Jun-N-terminalkinase (JNK) activationintendoncells upregulates MMP1 mRNA and

proteinexpression.Journal of Orthopedic Research,25,378-389.

5.) Yadav,H., Nho, S.Romeo, A., & MacGillivray,J. (2009).Rotatorcufftears: Pathologyandrepair.Knee Surgery, Sports Traumatology, andArthroscopy ,

17,409-421.

6.) Nho, S., Yadav,H., Shindle,M., & MacGillivray,J. (2008).Rotatorcuffdegeneration: Etiologyand pathogenesis. The American Journal of Sports

Medicine, 36, 987-993.

7.) Biese,J. (2007). Arthritis.In C.Cooper (Ed.), Fundamentals of hand therapy: Cliinicalreasoning and treatment guidelines forcommon Ddagnoses of the

upperextremity(pp.348-375). St. Louis,MI: Mosby Elsevier.

8.) KuhnJ. (2009). Exerciseinthetreatmentofrotatorcuffimpingement: asystematicreviewandasynthesizedevidence-basedrehabilitation protocol.

Journal ofShoulderand ElbowSurgery,18,38160.

9.) Namba,R., Skinner,J., & Gupta,R. (2003). Adultreconstructivesurgery. InH. Skinner (Ed.). Current diagnoses and treatment in orthopedics (pp.370-

415). New York: McGraw-Hill.

10.) MassachusettsGeneralHospitalPhysicalTherapy Services. (n.d.).Physical therapy guidelines forrehabilitation following arthroscopicrotatorcuff

repair. Massachusetts:Author.

11.) Firestein,G. (2005). Etiologyand pathogenesisofrheumatoidarthritis. In S.Ruddy, E.Harris,C. Sledge, & W. Kelley (Eds.). Kelleys textbook of

rheumatology(7th ed.) (pp.996-1042).Philadelphia,PA: W.B. Saunders.

12.) Harris, E. (2005).Clinicalfeaturesofrheumatoidarthritis. In S.Ruddy, E.Harris,C. Sledge, & W. Kelley (Eds.). Kelleys textbook ofrheumatology

(7th ed.) (pp1043-1078).Philadelphia,PA: W.B. Saunders.

13.) Kuder, S.,Peshimam, A., & Agraharam. S. (2002). Environmentalriskfactorsforrheumatoidarthritis. Revolutionary EnvironmentalHealth, 17, 307

15.

14.) Mikuls, T.,Cerhan,J.,Criswell, L.,Merlino L,Mudano, A., Burma M,etal. (2002) Coffee,tea,andcaffeineconsumptionandriskofrheumatoid

arthritis: Resultsfrom the Iowa WomensHealth Study. Arthritis and Rheumatology, 46, 8391.

15) Merlino, L.,Curtis, J,Mikuls,T.,Cerhan, J.,Criswell, L., & Saag, K.. (2004). Vitamin D intakeisinverselyassociatedwith rheumatoidarthritis: Results

from the Iowa WomensHealth Study. Arthritis and Rheumatology, 50, 727.

16.) Millett,P.,Gobezie,R, & Boykin,R. (2008). Shoulderosteoarthritis: Diagnosisand management.American Family Physician, 78, 605-611.

17.) Iversen M., Finckh, A., Liang,M. (2005). Exercise prescriptionsforthe majorinflammatoryandnon-inflammatoryarthritides. In W. Frontera, D.

Dawson, & D. Slovik (Eds).Exercise In Rehabilitation Medicine.Champaign, IL: Human Kinetics,Champaign.

18.) MassachusettsGeneralHospitalPhysicalTherapy Services. (n.d.).Physical therapy: Total shoulderarthroplasty/hemiarthroplasty protocol.

Massachusetts:Author.

19.) UAB Highlands. (n.d). Total shoulderreplacement post-operative rehabilitation program: Tissue deficientrehab. Group. Birmingham, Alabama: Author.

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