Objective Assessment of the Shoulder: Difference between revisions
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=== Causes of pain === | === Causes of pain === | ||
'''Serious conditions''' | '''Serious conditions''' | ||
* Infection | * Infection | ||
* Cancer/malignancy | * Cancer/malignancy | ||
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'''Pathoanatomic''' | '''Pathoanatomic''' | ||
* Fracture around the shoulder | * Fracture around the shoulder | ||
* Dislocation | * Dislocation | ||
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'''Non-specific pathoanatomic''' | '''Non-specific pathoanatomic''' | ||
* Impingement syndrome | * Impingement syndrome | ||
* Instability | * Instability | ||
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'''Neuropathic pain''' | '''Neuropathic pain''' | ||
* Central sensitisation | * Central sensitisation | ||
* Neurological dysfunction | * Neurological dysfunction | ||
| Line 33: | Line 29: | ||
'''Motor control''' | '''Motor control''' | ||
* Timing issue | * Timing issue | ||
* Quality of movement issue | * Quality of movement issue | ||
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=== History === | === History === | ||
'''Risk factors''' | '''Risk factors''' | ||
* Weight loss | * Weight loss | ||
* Non-mechanical pain | * Non-mechanical pain | ||
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'''1. Severity''' | '''1. Severity''' | ||
* Using the [[Visual Analogue Scale]] | * Using the [[Visual Analogue Scale]] | ||
'''2.Irritability''' <ref name=":0">Sayres LR. Defining irritability: the measure of easily aggravated symptoms. British Journal of Therapy and Rehabilitation. 1997 Jan;4(1):18-37.</ref> | '''2.Irritability''' <ref name=":0">Sayres LR. Defining irritability: the measure of easily aggravated symptoms. British Journal of Therapy and Rehabilitation. 1997 Jan;4(1):18-37.</ref> | ||
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2813500/ Irritability]<ref name=":0" /> can be assessed by | [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2813500/ Irritability]<ref name=":0" /> can be assessed by | ||
# The vigor of activity required to provoke a patient's symptoms | # The vigor of activity required to provoke a patient's symptoms | ||
# The severity of those symptoms | # The severity of those symptoms | ||
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'''3.Nature''' | '''3.Nature''' | ||
is to whether their condition is sort of | is to whether their condition is sort of | ||
* Inflammatory | * Inflammatory | ||
* Traumatic | * Traumatic | ||
Revision as of 13:22, 3 June 2021
Introduction[edit | edit source]
Following a successful subjective examination, there should be at least three top differential diagnoses for the patient's problem. The focus of the objective examination is to narrow down the differential diagnosis. An accurate diagnosis will enable us to manage and treat our patients more effectively.
Causes of pain[edit | edit source]
Serious conditions
- Infection
- Cancer/malignancy
- Cardiopulmonary
- Inflammatory disease
- Neurological problems
Pathoanatomic
- Fracture around the shoulder
- Dislocation
- Osteoarthrosis
- Calcific tendinopathy
Non-specific pathoanatomic
- Impingement syndrome
- Instability
- Dyskinesis
- Adhesive capsulitis (frozen shoulder)
Neuropathic pain
- Central sensitisation
- Neurological dysfunction
- Cranial nerves
- Local nerves around the shoulder
Motor control
- Timing issue
- Quality of movement issue
History[edit | edit source]
Risk factors
- Weight loss
- Non-mechanical pain
- There doesn't seem to be a pattern to the pain
- Fever
- Systemically unwell
- Unrelenting night pain
- Pain that waxes and wanes
- Family history
Objective Assessment[edit | edit source]
Exclude Cx spine[edit | edit source]
STAR Assessment[edit | edit source]
Staged Approach for Rehabilitation Classification: Shoulder Disorders (STAR-Shoulder)
For the rehabilitation classification, 3 levels of irritability are proposed and defined, with corresponding strategies guiding intensity of treatment based on the physical stress theory.(McClure PW, Michener LA. Staged Approach for Rehabilitation Classification: Shoulder Disorders (STAR-Shoulder). Phys Ther. 2015 May;95(5):791-800. doi: 10.2522/ptj.20140156. Epub 2014 Dec 11. PMID: 25504491.)
SIN[edit | edit source]
It is very important to asses the severity, irritability, and the nature of the problem before conducting the objective examination. SIN gives an indication of the intensity at which the objective examination is assessed. If SIN is not understood correctly, then we may flare up our patients very early on in the examination, thus having to stop the examination and will not confirm or negate the differential diagnosis.[1][2]
1. Severity
- Using the Visual Analogue Scale
2.Irritability [3] Irritability[3] can be assessed by
- The vigor of activity required to provoke a patient's symptoms
- The severity of those symptoms
- The time it takes for the symptoms to subside once aggravated (i.e., pain persistence)[4]
"WHAT activity, after HOW LONG, brings on HOW MUCH pain ? And HOW LONG does is take to subside?"
3.Nature is to whether their condition is sort of
- Inflammatory
- Traumatic
- Degenerative
- Mechanical
And they sort of give us these little classifications to think about there. So high VAS greater than seven, that sort of tends to disturb the sleep, moderate is four to six out of 10 may be intermittent pain at night and then a low, okay, no pain at rest. So again, this slightly gives us a bit of information. As I said previously, that i
Management options[edit | edit source]
Meaningful Task Analysis[edit | edit source]
ROM[edit | edit source]
Postural Ax[edit | edit source]
Active movement[edit | edit source]
Special tests[edit | edit source]
Shoulder Symptom Modification Procedure[edit | edit source]
Described by Jeremy Lewis in 2009[5] the Shoulder Symptom Modification Procedure(SSMP) is a reliable[6] approach to the assessment of individuals with rotator cuff and subacromial pathology. SSMP is a set of four mechanical techniques used in a sequence while the patient performs a movement that reproduces their symptoms. The aim is to identify one or more methods that reduce their symptoms and/or increasing movement and function.[7] This tool offers a method to objectively assess the shoulder with the focus being to identify movements and techniques that might be contributing factors to the symptomatic movement and not to label the pathology or exact cause of pain and then utilise these movements and techniques as a means to guide treatment.
The SSMP techniques[8] involve:
- Alterations to thoracic kyphosis - The first procedures of the SSMP aim to determine the influence of increasing and decreasing the thoracic kyphosis on the presenting symptoms. If the thoracic manoeuvre reduces the symptoms by 100%, then the assessment is complete and treatment is initiated with a combination of postural awareness, exercise (including motor control during the provocative activity), and manual therapy (to ensure adequate joint and soft tissue compliance). In this scenario, the aim of treatment is to improve thoracic extension, especially during the identified provocative activity or activities
- Scapular positioning techniques - If the thoracic procedures do not or only partially alleviate symptoms, then symptom changes secondary to scapular procedures are assessed.
- Humeral head positioning procedures - If the scapular procedures do not fully alleviate symptoms, the clinician progresses to assess the effects of the humeral head procedures. The purpose of the procedures is to positively influence the patient’s symptoms by applying techniques that aim to depress, elevate, or anteriorly or posteriorly glide the humeral head.
- Pain and symptom neuromodulation procedure - If the first 3 stages of the SSMP do not completely alleviate or reduce symptoms, then the final stage of the SSMP (neuromodulation) involves assessing the influence of manual procedures, such as pressure-based procedures (aimed at the soft tissues and joints), that may modulate shoulder symptoms and are routinely performed throughout the cervical, thoracic, and shoulder regions.
- Rotator Cuff Tendinopathy: Navigating the Diagnosis Management Conundrum[9]
- SSMP Tool
- SSMP summary by Eleanor Richardson & Jeremy Lewis
Force Assessment[edit | edit source]
Joint Position Sense[edit | edit source]
- ↑ Petersen EJ, Thurmond SM, Jensen GM. Severity, Irritability, Nature, Stage, and Stability (SINSS): A clinical perspective. Journal of Manual & Manipulative Therapy. 2021 May 15:1-3.
- ↑ Koury MJ, Scarpelli E. A manual therapy approach to evaluation and treatment of a patient with a chronic lumbar nerve root irritation. Physical therapy. 1994 Jun 1;74(6):548-60.
- ↑ 3.0 3.1 Sayres LR. Defining irritability: the measure of easily aggravated symptoms. British Journal of Therapy and Rehabilitation. 1997 Jan;4(1):18-37.
- ↑ Barakatt, E. T., Romano, P. S., Riddle, D. L., Beckett, L. A., & Kravitz, R. (2009). An Exploration of Maitland's Concept of Pain Irritability in Patients with Low Back Pain. The Journal of manual & manipulative therapy, 17(4), 196–205. https://doi.org/10.1179/106698109791352175
- ↑ Lewis, J. S. (2009) Rotator cuff tendinopathy/subacromial impingement syndrome: is it time for a new method of assessment? British Journal of Sports Medicine, Vol 43, pp. 259-264
- ↑ Lewis JS, McCreesh K, Barratt E, Hegedus EJ, Sim J. Inter-rater Reliability of the Shoulder Symptom Modification Procedure in People with Shoulder Pain. BMJ Open Sport & Exercise Medicine. 2016 Nov 1;2(1):e000181
- ↑ Eleanor Richardson & Jeremy Lewis. The Shoulder Symptom Modification Procedure (SSMP). https://www.shoulderdoc.co.uk/article/1478
- ↑ Lewis J, Mccreesh K, Roy JS, Ginn K. Rotator Cuff Tendinopathy: Navigating The Diagnosis-Management Conundrum. Journal Of Orthopaedic & Sports Physical Therapy. 2015 N
- ↑ Lewis J, McCreesh K, Roy JS, Ginn K. Rotator cuff tendinopathy: navigating the diagnosis-management conundrum. Journal of orthopaedic & sports physical therapy. 2015 Nov;45(11):923-37.
