[PDF] - Teaching Home Exercises for the Rehabilitation of Upper Extremity PDF Document

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Teaching Home Exercises for the Rehabilitation of Upper Extremity Problems

Rotator Cuff Impingement, Adhesive Capsulitis, Elbow Epicondylitis

Tim Baldwin, MA, ATC Gina Biviano, MA ATC Hally Tappan, MA, ATC

December 2, 2017

UCSF DEPARTMENT OF SPORTS MEDICINE

Disclosure

We have nothing to disclose.

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What is an Athletic Trainer?

Unique and multi-skilled health care professionals who collaborate

with physicians to optimize activity of physically active patients.

Provide preventative services, emergency care, clinical

assessment, therapeutic intervention and rehabilitation of injuries and medical conditions.

ATs improve functional outcomes and specialize in patient

education to prevent injury and re-injury.

Employed in a variety of settings.

Objectives

Understand the importance of a Home Exercise Program

(HEP) for upper extremity chronic issues

Provide simple instructions on how to teach home exercise

programs for common shoulder and elbow injuries

Recognize red flags for orthopedic referral

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What is a Home Exercise Program?

A program detailing a range of physical exercises and the amount
f time each exercise should be performed
Not personalized so that it is usable with the largest patient

population

Little to no special equipment needed other than household items

Home Exercise Program

Why HEP?
PT not always necessary or

accessible

Pain control
Simple instructions for rotator

cuff and scapular strengthening

Correct postural imbalances
sportsrehab.ucsf.edu

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Improve HEP Effectiveness

Patient Compliance
Only 35% of patients adhered fully to HEP

‒ Only 19% adherence if chronic illness present (Kravitz, 1993) ‒ 76% followed regimen partly (Sluijs, 1993)

Best if used in addition to formal PT

Causes of Upper Extremity Pain

May be due to:
Traumatic injury
Lack of flexibility
Weakness of shoulder and back musculature
Overuse
Biomechanical issues
Impingement
Posture related factors of shoulder pain
Rolled forward shoulders
Poor posture (sitting at computer, reading, writing)
Tight pectoralis/weak scapula stabilizers
Repetitive overhead motions (Ludewig and Borstad, 2003)

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Effects of Poor Posture

Muscle Weakness:
Rotator cuff weakness will lead to unbalanced motion that can

cause migration of the humeral head (Ludewig and Borstad, 2003)

Weak scapular stabilizers can result in altered biomechanics

(Voight and Thompson 2000, Kibler 2008)

‒ Abnormal stresses to the anterior capsular structures ‒ Possibility of Rotator Cuff compression ‒ Decreased performance

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What Happens Without Exercises

Scapular Control Issues
Postural Changes
Long Term Motor Control Issues
Connective Tissue Changes—Fibrosis
Chronic Substitution Patterns
Over-recruit upper trap and levator scap
Underused lower trap and middle trap
PT Needed to Retrain Motor Control Patterns

Shoulder Pain

3rd most common musculoskeletal condition presenting in primary

care (Urwin 1998)

5th most common among injury among high school athletes (Powell

1999)

Approximately 13.7 million people in the US seek treatment from

a physician for a shoulder problem each year (Hing 2005)

Impingement Syndrome is the most common shoulder disorder

accounting for 44-65% of all physician visits for shoulder pain (van

Der Wint 1995)

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Rotator Cuff Impingement Rotator Cuff Impingement

Intrinsic Causation
Muscle Weakness
Muscle Fatigue
Overuse
Degenerative Issues
Poor Posture
Extrinsic Causation
Shape of acromion
Coracoacromial ligament

attachment

AC Joint

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Differential Diagnosis

Labral tear
OA
AC arthritis vs sprain
Distal Clavicle Injury
Biceps tendon rupture/tendinopathy
Calcific Tendonitis
Adhesive Capsulitis
Nerve injury
Spine pathology

HEP- Stretching

Doorway Stretch Frequency: 3 sets x 1 min 2-3 times per day Goal: Increased pectorals flexibility/improve posture

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HEP- Stretching

Sleeper Stretch Frequency: 3 sets x 10 reps 2-3 times per day Goal: Improve posterior capsule mobility

HEP- Strengthening

External Rotation Frequency: 3 sets x 10 reps 2-3 times per day Goal: Increase strength of scapular stabilizing muscles

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HEP- Strengthening

Horizontal Rows Frequency: 3 sets x 10 reps 2-3 times per day Goal: Increase strength of the scapular stabilizers

HEP- Lifestyle

Ergonomic Fixes for Postural

Issues

Contact HR about ergonomic

evaluation

Use standing desk
KT Tape
Comfort Clavicle Sling

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Adhesive Capsulitis aka “Frozen Shoulder"

Synovial inflammation &

capsular fibrosis

Leads to contracture of the

capsule

Etiology not clearly

understood

Adhesive Capsulitis “Frozen Shoulder"

Causation
Gradual loss of active and passive ROM
Most common in women 40-60 years old
Affects about 2% - 5% of the population
Strong association with Diabetes Mellitus

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Adhesive Capsulitis

Full duration of disease is 1-3.5 years
Presents unilaterally but will often affect the contralateral shoulder
Initial treatment of HEP combined with OTC analgesia/anti-

inflammatory meds is the most effective to treat this condition (Hsu

2011)

NSAIDS not effective when compared to placebos

Differential Diagnosis

Impingement, Calcific Tendinitis, and Osteoarthritis – PROM is

not painful/restricted in these conditions

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HEP- Stretching

Passive Shoulder Flexion Frequency: 3 sets x 1 min 2-3 times per day Goal: Increase Range of Motion

HEP- Stretching

Passive Abduction Frequency: 3 sets x 1 min 2-3 times per day Goal: Increase Range of Motion

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HEP- Stretching

External Rotation Frequency: 3 sets x 1 min 2-3 times per day Goal: Increase Range of Motion

HEP- Strengthening

Active Wall Spiders Frequency: 5x 2-3 times per day Goal: Increase Range of Motion

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HEP- Strengthening

Isometrics: Flexion/Abduction Frequency: 3 sets x 1 min 2-3 times per day Goal: Increase Range of Motion

Chronic Elbow Pain

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Epicondylitis

Lateral Epicondylitis
Common in primary care (Annual Incidence 1-3%) (Johnson 2007)
Repetitive activity at work or in recreation
Medial Epicondylitis
Less common diagnosis (only 10-20% of all epicondylitis

diagnoses) (Ciccoti 2004)

Similar treatment as lateral epicondylitis

Differential Diagnosis

Ulnar nerve disorders, cervical radiculopathy, ulnar collateral

ligament injury

'Little League elbow' and fractures of the medial epicondyle

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HEP- Stretching

Wrist Flexor Stretch Frequency: 3 sets x 1 min 2-3 times per day Goal: Increase Range of Motion Wrist Extensor Stretch Frequency: 3 sets x 1 min 2-3 times per day Goal: Increase Range of Motion

33

HEP- Strengthening

Grip Strengthening Frequency: 2-3 sets until fatigue 3 times per week Goal: Increase Grip Strength

34

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HEP- Strengthening

Wrist Extension Curls Frequency: 2-3 sets until fatigue 3x per week Goal: Increase Forearm Strength Wrist Flexion Curls Frequency: 2-3 set until fatigue 3x per week Goal: Increase Forearm Strength

HEP- Strengthening

Hammer twist Frequency: 2-3 sets until fatigue 3x per week Goal: Increase Forearm Strength

36

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What if HEP is not working

Check Patient Compliance
Re-examine Differential
Consider Advanced Imaging
Refer

References

Ciccotti MC, Schwartz MA, Ciccotti MG. Diagnosis and treatment of medial epicondylitis of the elbow. Clin Sports Med. 2004;

(23): 693-705.

Hing E, Cherry DK, Woodwell DA, et al. National Amubulatory Medical Care Survey: 2003 Summary. CDC Advance Data.

2005; 365: 1-48.

Hsu, JE, et al. Current Review of Adhesive Capsulitis. Journal of Shoulder and Elbow Surgery. 2011. 20(3): 502 – 514
Johnson GW, Cadwallader K, Scheffel SB, Epperly TD. Treatment of lateral epicondylitis. American Family Physician. 2007;

76(6): 883-848.

Kibler WB, Sciascia AD, Uhl TL, et al. Electromyographic analysis of specific exercises for scapular control in early phases of

shoulder rehabilitation. Am J Sports Med. 2008:(36)9:1789–179.

Kravitz RL, Hays RD, Sherbourne CD, et al. Recall of recommendations and adherence to advice among patients with

chronic medical conditions. Arch Intern Med. 1993; 153(16):1869-78.

Ludewig PM, Borstad JD. Effects of a home exercise programme on shoulder pain and functional status in construction
workers. Occupational and Environmental Medicine. 2003; 60: 841-849.
Powell, JW, Barber-Foss, KD. Injury Patterns in Selected High School Sports: A Review of the 1995-1997 Seasons. J Athl
Train. 1999; 34(3): 277–284.
Sluijs EM, Kok GJ, Van der Zee J. Correlates of Compliance in Physical Therapy. Physical Therapy. 1993; 73(11): 771-782.
van der Windt DA, Koes BW, de Jong BA, et al. Shoulder disorders in general practice: incidence, patient characteristics, and
management. Ann Rheum Dis.1995;54:959–64.
Voight ML, Thompson BC. The Role of the Scapula in the Rehabilitation of Shoulder Injuries. Journal of Athletic Training.

2000; 35(3): 364-372.

Urwin M, Symmons D, Allison T, et al. Estimating the burden of musculoskeletal disorders in the community: the comparative

prevalence of symptoms at different anatomical sites, and the relation to social deprivation. Ann Rheum Dis. 1998; 57(11):649-55.

SLIDE 20

For instructional videos of this protocol, visit sportsrehab.ucsf.edu

Adhesive Capsulitis PROTOCOL

`

BACKGROUND: STRETCHING EXERCISES:

Description
Typically between ages of 40-65.
Thickening of the capsule around the shoulder.
Causes
Previous shoulder injury.
Immobilization.
Diabetes.
Thyroid disorders.
Progression
1st Stage “Freezing” stage
Increased pain, decreased motion.
Can last 1-9 months.
2nd Stage “Frozen” stage
Decreased pain, but stiffness remains.
Can last 4-9 months.
3rd Stage “Thawing” stage
Slow return of motion.
Can last 5 months to 2 years.

P Pa as ss si iv ve e F Fo

r

rw w a ar rd d F Fl le e x xi io

n

n Using a broom or rod, grasp the end with hand 1 and the other end with hand 2. Use hand 2 to passively raise hand 1 up until a stretch is felt. Hold the position for 10 seconds and return to starting position. Frequency: 3 sets of 10 reps. 2-3 times per day. Goal: Increase/Maintain Shoulder Range of Motion

Conservative Treatment
Symptoms typically resolve on their own

regardless of treatment or no treatment.

Physical therapy.
Medication.
Injections.

P Pa as ss si iv ve e E Ex xt t e er rn na al l R Ro

t

t a a t ti io

n

n Grasp the end of the rod with hand 1 and the middle of the rod with hand 2. Use hand 2 to passively rotate hand 1 to the side while keeping the elbow in. Hold the stretch for 10 seconds and return to starting position. Frequency: 3 sets of 10 reps. 2-3 times per day. Goal: Increase/Maintain Shoulder Range of Motion P Pa as ss si iv ve e A Ab bd du uc ct ti io

n

n Grasp the end of the rod with hand 1 and the other end with hand 2. Use hand 2 to passively raise hand 1 up to the side until a stretch is felt. Hold the stretch for 10 seconds and return to starting position. Frequency: 3 sets of 10 reps. 2-3 times per day. Goal: Increase/Maintain Shoulder Range of Motion

1 1 2 2 2 2 1 1 1 1 2 2

SLIDE 21

For instructional videos of this protocol, visit sportsrehab.ucsf.edu

Adhesive Capsulitis PROTOCOL

I Is so

m

m e et tr ri ic c: : F Fl le ex xi io

n

n / / E Ex x t te en ns si io

n

n Stand with good posture, squeeze shoulders back. Bend and hold elbow at 90°. Flexion: Push hand into wall. Extension: Push elbow into wall. Hold 5 sec. Repeat TEN times. Frequency: 1 set. 3 times per day. Goal: Increase Strength of Deltoid Muscles F Fo

r

rw w a ar rd d W Wa al ll l C Cl li im mb be er rs s Patient stands facing the wall 2 feet from the wall. Slowly walk fingers up the wall as high as possible. Hold at the top for 10 seconds then slowly lower. Frequency: 5 times. 2-3 times per day Goal: Increase/Maintain Shoulder Range of Motion

SHOULDER STRENGTHENING EXERCISES:

S Si id de e W Wa al ll l C Cl li im mb be er rs s Patient stands with their involved shoulder 2 feet from the wall. Slowly walk fingers up the wall as high as possible. Hold at the top for 10 seconds then slowly lower. Frequency: 5 times. 2-3 times per day Goal: Increase/Maintain Shoulder Range of Motion I Is so

m

m e et tr ri ic c: : A AB Bd du uc ct ti io

n

n / / A AD Dd du uc ct ti io

n

n Stand with good posture, squeeze shoulders back. Bend and hold elbow at 90°. ABduction: Start hand on stomach. Push hand away from your stomach. ADduction: Start hand away from stomach. Pull hand into your stomach. Hold 5 sec. Repeat TEN times. Frequency: 1 set. 3 times per day. Goal: Increase Strength of Rotator Cuff Muscles

STRETCHING EXERCISES:

SLIDE 22

For instructional videos of this protocol, visit sportsrehab.ucsf.edu

Adhesive Capsulitis PROTOCOL

SHOULDER STRENGTHENING EXERCISES:

S Sc ca a p pu ul la ar r R Re et tr ra ac ct ti io

n

n ( (S Sh ho

u

ul ld de er r B Bl la ad de e S Sq qu ue ee e z ze es s) ) Relax head and neck. Stand with good posture, squeeze shoulders back. Avoid shrugging shoulders. Keeps abs tight. Hold 10 sec. Relax shoulder. Repeat 10 times. Frequency: 1 set. 3 times per day. Goal: Increase Strength of Scapular Stabilizing Muscles S Sc ca a p pu ul la ar r E El le ev va at ti io

n

n ( (S Sh ho

u

ul ld de er r S Sh hr ru ug gs s) ) Relax head and neck. Stand with good posture. Squeeze shoulder up towards your ears. Keep abs tight and hold 10 sec. Relax shoulders. Repeat 10 times. Frequency: 1 set. 3 times per day. Goal: Increase Strength of Scapular Stabilizing Muscles E Ex xt te er rn na al l R Ro

t

ta at ti io

n

n Attach theraband to a stable object at waist level. Roll shoulder back and down and maintain this position. Place towel between elbow and side. Slowly rotate hand AWAY from the abdomen. Hold 5 sec. Repeat 10 times. Frequency: 1 set. 3 times per day. Goal: Increase Strength of Rotator Cuff Muscles S Si id de e N N o

t

te e Do not perform exercises that increase your pain during or after the exercise. I In nt t e er rn na al l R Ro

t

ta at ti io

n

n Attach theraband to a stable object at waist level. Roll shoulder back and down and maintain this position. Place towel between elbow and side. Slowly rotate hand TOWARDS the abdomen. Hold 5 sec. Repeat 10 times. Frequency: 1 set. 3 times per day. Goal: Increase Strength of Rotator Cuff Muscles

SLIDE 23

For instructional videos of this protocol, visit sportsrehab.ucsf.edu

Elbow Injury PROTOCOL

`

BACKGROUND: STRETCHING EXERCISES:

Causes
Overuse activities.
Muscle weakness.
Improper technique or equipment use.
Related activities
Computer use.
Construction.
Racquet sports.
Signs and Symptoms
Pain and tenderness on medial or lateral side of elbow.
Pain and weakness with gripping activities.
Pain with rotation/twisting of the wrist.
Pain with lifting objects.
Conservative treatment
Rest.
Ice 15 minutes.
Stretching exercises.
Strengthening exercises.

W Wr ri is st t E Ex xt te e n ns so

r

r S St tr re et tc c h h Begin with elbow extended and palm facing down. Passive pull the finger and hand towards the ground. Continue until a comfortable stretch is felt. Frequency: 3 sets x 1 min. 2-3 times per day. Goal: Increase Range of Motion W Wr ri is st t F Fl le ex x o

r

r S St tr re et t c c h h Begin with elbow extended and palm facing up. Passive pull the finger and hand towards the ground. Continue until a comfortable stretch is felt. Frequency: 3 sets x 1 min. 2-3 times per day. Goal: Increase Range of Motion

SLIDE 24

For instructional videos of this protocol, visit sportsrehab.ucsf.edu

Elbow Injury PROTOCOL

ELBOW STRENGTHENING EXERCISES:

G Gr ri ip p S St tr re e n ng gt t h he en ni in ng g Hold a tennis ball, rubber ball or silly putty in your hand. Squeeze slowly and hold for five seconds. If the ball is too difficult or painful, try a sock or sponge. Frequency: 2-3 sets until fatigue. 3 times per week. Goal: Increase Grip Strength W Wr ri is st t F Fl le ex xi io

n

n C Cu ur rl ls s Rest arm on table with elbow extended. Grasp a small weight with palm facing up. Slowly curl wrist up towards the ceiling. Hold for three seconds then slowly lower. Frequency: 2-3 set until fatigue. 3 times per week. Goal: Increase Forearm Strength W Wr ri is st t E Ex xt te e n ns si io

n

n C Cu ur rl ls s Rest arm on a table with elbow extended. Grasp a small weight with palm facing down. Slowly curl wrist up towards the ceiling. Hold for three seconds then slowly lower. Frequency: 2-3 sets until fatigue. 3 times per week. Goal: Increase Forearm Strength H Ha am m m me er r T T w w i is st t Sit with you arm resting on your knee or table. Grasp a hammer in your hand. Slowly rotate the hammer side to side. Grasping the handle further from the head increases difficulty. Frequency: 2-3 sets until fatigue. 3 times per week. Goal: Increase Forearm Strength

SLIDE 25

For instructional videos of this protocol, visit sportsrehab.ucsf.edu

Scapular Stabilization PROTOCOL

`

BACKGROUND:

Description
The scapula is the base of support to the shoulder joint and all movements of the upper extremity.
Poor scapular stabilization can contribute to a variety of upper quadrant syndromes such as:

shoulder impingement, shoulder instability, cervical strain, nerve entrapments, and muscle strains.

Hints
While performing exercises, keep shoulder rolled back and down.

S Sc ca ap pu ul la ar r R Re et tr ra ac ct ti io

n

n ( (S Sh ho

u

ul ld de er r B Bl la ad de e S Sq qu ue ee ez ze es s) ) Relax head and neck. Stand with good posture, squeeze shoulders back. Avoid shrugging shoulders. Keeps abs tight. Hold 10 sec. Relax shoulder. Repeat 10 times. Frequency: 1 set. 3 times per day. Goal: Increase Strength of Scapular stabilizing Muscles.

SHOULDER ANATOMY:

E Ex xt te er rn na al l R Ro

t

ta at ti io

n

n Attach theraband to a stable object at waist level. Roll shoulders back and down and maintain this position. Place towel between elbow and side. Slowly rotate hand AWAY from the abdomen. Hold 3 sec. Repeat 12-15 times. Frequency: 1 set. 3 times per day. Goal: Increase Strength of Scapular stabilizing Muscles

SCAPULAR STRENGTHENING EXERCISES:

SLIDE 26

For instructional videos of this protocol, visit sportsrehab.ucsf.edu

Scapular Stabilization PROTOCOL

SCAPULAR STRENGTH EXERCISES:

S Sh ho

u

ul ld de er r D Di ia ag go

n

na al ls s Patient stands with theraband under their opposite foot. While grasping theraband, bring shoulders back and down. With your hand at your opposite hip, slowly raise it up across your body, as if you are drawing a sword. Hold 3 seconds and repeat 12-15 times. Frequency: 1 set. 3 times per day. Goal: Increase Strength of Scapular stabilizing Muscles H Ho

r

ri iz zo

n

nt ta al l R Ro

w

ws s Secure theraband around a stable object, like a pole. Patient can either kneel or stand. Grasp both ends of the theraband. Bring shoulders back and down . Slowly pull elbows back, squeezing your shoulder blades together. Hold 3 seconds and repeat 12-15 times. Frequency: 1 set. 3 times per day. Goal: Increase Strength of Scapular stabilizing Muscles S Sh ho

u

ul ld de er r E Ex xt te en ns si io

n

n Secure theraband around a stable object, like a pole. Patient can either kneel or stand. Grasp both ends of the theraband, bring shoulders back and down . With arms extended, slowly pull hands straight down until even with your hips. Hold 3 seconds and repeat 12-15 times. Frequency: 1 set. 3 times per day. Goal: Increase Strength of Scapular stabilizing Muscles A An ng ge el l W Wi in ng gs s Stand with arms overhead. Keeping elbows to the side, slowly lower arms. Try put your elbows into back pockets. Squeeze shoulder blades together. Hold 10 sec. Repeat 10 times. Frequency: 3 sets. 3 times per day. Goal: Increase Scapular Strength If strengthening exercises become too easy, the repetitions should be increased until muscle fatigue