Mr. Big Assessment
Mr. Big, the a 48 years old man, has come to the Physiotherapy Department due to having right shoulder pain and discomfort.
Assessing him for the first time, he was sitting on the chair. Mr. Big complained of having pain on his right shoulder, and the pain gradually increased from the past two weeks. He also told that the pain was worsening after doing weightlifting training for last five day. The past two years ago, Mr. Big was also having the same problem after playing some tennis games. He also has sustained some injury on the shoulder after falling on the shoulder. He has visited and sought medication attention to a family Doctor. After that, the injury has been healed, but the pain still on and off. For pain scale, Mr. Big will not feel so much pain while resting (the pain score only 3/10). However, pain increasing on movement while carrying or pulling some weight (the pain score is 7/10). The patient claim he feels dull and aching on the day but stabbing pain on the night, especially laying on the affected shoulder. Besides having pain, the patient was also complaining of having stiffness while moving his arm over the head.
After doing some observation, no swelling seen or skin color changes on his affected shoulder. While doing palpation patient complains having tenderness at the anterior and superior part of the shoulder. We can say that the patient may be having some minor injury, tension, stress, or overuse muscle at the rotator cuff muscle region. On the range of motion(ROM) test, Mr. Big can only do 100˚ on the right shoulder flexion and through elevation due to pain and stiffness, and muscle power test only at 4/5. After doing special tests such as Neer’s test and painful arch’s test, it shows a positive sign. While the speed test and Yergason test showing a negative sign. From here, we can tell that Mr. Big had a shoulder impingement, and the pain did not cause by pathological process and anatomical problem.
From this point, Mr. Big may have been ruled out as shoulder impingement or another name subacromial impingement syndrome. Shoulder impingement is a syndrome in which soft tissues that may be inflamed or irritated became painful entrapped in the area of the shoulder joint Brox (, 2003). Neer’s (1983) have classified shoulder impingement to 3 stages. The first stages are commonly caused by a younger person below twenty-five years old, usually, an athlete who uses many overhand activities. In this stage, the impingement happens because of edema and hemorrhage which come from mechanical irritation to the tendons. This stage can be mostly reversible for the lesion. The second stages usually happen after repeating the mechanical inflammation cause the thickening or enlarged the fibrosis on the subacromial bursae. Happen to people around twenty-five to forty years old. It was not reversible by modification of activities. Neer’s said will have tendon rupture and a bone spur on the impingement lesion for the third stage. From this point, full-thickening tear of the rotator cuff, partial-thickening tear rotator cuff, biceps tendon lesion, and bony alternation of the acromion and acromioclavicular joints will be one of the causes in this stage. Happen to people above forty years old. Mr. Big may be in the second stage of shoulder impingement right now due to repeating the mechanisms of injury and been overuse the shoulder muscle.
There will be no single test alone that will be accurate to diagnose the shoulder impingement syndrome or differentiate the other shoulder disorders, Hegedus et al. (2007). A combination of the test should be done to increase the probability of the diagnosis Murrell(2001). For Mr. Big, four special tests have been tested, such as Neer’s test, Painful arch test, Speed test, and Yergason’s test. From the test, only Neer’s test and Painful arch test positive. Helen et al. (2004) argue that after conducting the Neer’s test to his test subject. She found out that the test was purely based on the reproduction of pain in the affected area. It allows us to identify the syndrome. Mikel et al. (2011) also done some systematic review for several tests for diagnosing shoulder impingement syndrome and found that Neer’s tests have a 79% sensitivity and 79% specificity to diagnose shoulder impingement syndrome. Which mean the test is proven can be used when to test patient with shoulder impingement. He also claims that a painful arch test also excellent screening tools to diagnose shoulder impingement syndrome. Lori et al. (2009) also concluded that the Pain Arch test could also rule out shoulder impingement syndrome. They were using receiver operating characteristic (ROC) and compare between positive likelihood ratio and negative likelihood ratio. They found that the Pain Arch test has 95% sensitivity, which presents that this test absolutely can be used for confirming patient having shoulder impingement or not.
The treatment plan for Mr. Big will be divided into four phases, which will help Mr. Big to solve his problem according to his condition. For phase 1 was an acute phase in which the treatment will more to reduce patient pain. Phase 2 is for early mobilization, but within pain – range, in this phase, the treatment will improve the range of motion of the patient shoulder. After the patient achieved a full pain-free range of motion, phase 3 will be introduced to the patient, which more to the strengthening exercise, which will improve patient muscle weakness. After the patient feels no more pain and able to back to work without any chief complaint, the patient will be assessed again using the special test, and some other outcome measure before can be discharged (phase 4). For phase 1 treatment, to reducing Mr. Big pain, we can use Heat therapy such as Infrared treatment or hot pack on his right shoulder, avoiding mechanism of repetitive injury, and if the heat therapy can reduce the pain recommend Mr. Big to take the nonsteroidal anti-inflammatory drug (NSAID) for a while. The physiological effect of heat therapy can provide some reduction in pain and able to improve the elasticity of connective tissues, Gerard et al. (2014). After reducing the pain, phase 2 will be started. Manual scapular stabilization can be done to the patient. While the scapular protraction posture to scapular retraction posture, the subacromial space’s width was reduced, Solem-Bertoft et al. (1993). Young R. Y. (2017) have been done a systematic review of the effectiveness of massage therapy on improving the function of the shoulder pain. By doing massage therapy can reduce pain and reducing the shoulder stiffness on the affected side by manipulating the soft tissues of the body. The next stage of physiotherapy treatment is mobilizing exercise; mobilizing exercise can be done actively but did not do a movement that can reproduce the pain on the shoulder. For example, Pendulum exercise is one of the mobilizing exercises that significantly improves the shoulder range of motion without making any pain. By moving the arm in circumduction downward (around 45 – 50 degrees shoulder flexion) repetitive to form a small circle to a larger circle within the pain reach. Early mobilizing exercise plays an essential role in returning to normal shoulder function McCann P. D. et al. (1993). If the mobilizing exercise can significantly improve the shoulder range of motion, stretching exercises can be taught to Mr. Big. Stretching exercise can do actively by himself or passively by the therapist. Stretching exercise can help to improve the elasticity and muscle tone. Simple static stretching and Posterior shoulder stretch can be trained but ask Mr. Big to stretch only until at a pain-free range. Aim the upper trapezius, pectoral and biceps muscle for stretching. Ludewig & Borstad(2003) said that doing stretching exercises at the home show much improvement than the patient which not doing any exercise. Other than stretching exercise, joint mobilization for the glenohumeral and scapulothoracic joint also can be applied. For the early stage, only apply grade I and grade II to reduce pain and later apply grade III and Iv to improve range of motion and to reduce stiffness or muscle spasm. Posterior glenohumeral mobilization and scapulothoracic mobilization can be done. When Mr. Big was not having any pain anymore, phase III will be started. Strengthening exercise is used to strengthen the rotator cuff and the deltoids muscle. With strengthening exercise, it can help to improve the functional mechanism of the shoulder. When the muscle around the shoulder became more energetic, and it can maintain the position in their anatomical position and improving the functional activity of the patient, Morrison et al. (2000). First, we can use some resistive band or sandbag to strengthen the rotator cuff and the deltoid muscle. The exercise can be done in standing or sitting, and the exercise should be done in all planes, so all the muscles around the shoulder will be strengthened.
For this scenario, Mr. Big’s chief complaint is having a stiff feeling and having difficulty doing his primary job as a painter. From the treatment process above, Mr. Big should do stretching exercises. To facilitate the increased range of motion of the shoulder stretch can be used in proprioceptive neuromuscular facilitation Sullivan et al. (1982). By doing stretching exercises, the tightness of the muscle will be reduced, and this can make Mr. Big able to do some activity daily living. Koffler et al. (2001) said that the more tightness of the posterior capsular, the more the humeral head will shift to the superior anterior direction. Treatment such as passive stretching and joint mobilization can reduce the tightness and improve the shoulder range of motion. To improve patient muscle weakness doing the strengthening exercise is better. The evidence shows that this exercise can improve Mr. Big’s right shoulder range and motion and muscle power. With this exercise, Mr. Big should be able to perform his work with ease.
A few outcome measures can be used to identify the improvement of Mr. Big after all the treatment. Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and Upper Extremity Functional index outcome can be used to measure Mr. Big’s improvement. The special test is done before the treatment also can be used to determine the problem and limitation of Mr. Big have been solved or not.
DASH is a 30 – item questionnaire to access the ability of a patient to perform upper extremity activity Beaton D. E. et al. (2001). The score of this test ranges from zero to a hundred. The lower scores are indicative of, the lower level of disability and the higher scores are indicated of, the higher level of disability. This tool used a 5-point Likert scale so that the patient will choose the answer according to the patient’s functional level. DASH also has two optional modules which use to test for salarymen who have a disability or those having a disability that disturbing their ability to work. Beaton D.E et al. (2001) have done some review to find out the reliability and validity of this outcome measure and found out that the reliability of this test is ICC(2,1) = 0.96 and the validity is Pearson r > 0.70. which can be considered as an excellent outcome measure to determine patient have improving or not.
Other than DASH, another outcome measure that can be used is the Upper Extremity Functional index. This outcome measure has a 20 question withy 5 point scale, which assesses the difficulty of a person doing activity daily living, which uses the upper extremity of individuals with upper extremity dysfunctions Straford et al. (2001). Chesworth et al. (2014) show on his study the reliability of this test having an ICC=0.94 and MDC values is 9.4/80. Which almost the same as a result of DASH. The score for this questionnaire is over 80. The higher the score, the patient can function well, and the lower the score, the patient having difficulty functioning.
In conclusion, a physiotherapist can be given strengthening exercises to improve the muscle weakness of the patient. Stretching exercise can reduce muscle tightness and can improve range of motion.