Case Study #6Case Study #6 Presentation Presentation

Group:Group:Jessi BradleyJessi Bradley

Kathryn PearsonKathryn PearsonCorrin PorterCorrin PorterMatt VerboomMatt VerboomTara RubertoTara Ruberto

Jimmy WarnerJimmy Warner

Larry LatexLarry Latex

37yr old, male37yr old, male 6ft, 280lbs6ft, 280lbs Put on 80lbs over past 10 yrsPut on 80lbs over past 10 yrs MarriedMarried Has 8 kids (9Has 8 kids (9thth on the way) on the way) Wife and 5 kids are overweight or obeseWife and 5 kids are overweight or obese Past activities: trumpet player in local band, Past activities: trumpet player in local band,

lineman on a football team.lineman on a football team. Graduated with a degree in businessGraduated with a degree in business

OccupationOccupation Marketing manager and educational support Marketing manager and educational support

person promoting products for a company which person promoting products for a company which manufactures birth control devicesmanufactures birth control devices

Required to move merchandise weighing up to Required to move merchandise weighing up to 50lbs.50lbs.

Spends most days in an officeSpends most days in an office Travels for regional meetings and to surrounding Travels for regional meetings and to surrounding

towns to meet with reps.towns to meet with reps. Owns pizza delivery franchise that is run by a Owns pizza delivery franchise that is run by a

managermanager 3 kids are employed there as delivery drivers3 kids are employed there as delivery drivers

Injury StatusInjury Status Past Injury:Past Injury:

-Back injury 3 years ago-Back injury 3 years ago-Cause: unloading boxes from trunk of car-Cause: unloading boxes from trunk of car-Has moderate to sever back pain on a regular -Has moderate to sever back pain on a regular

basisbasis

Recent Injury:Recent Injury:-Rotator cuff injury: partially torn infraspinatus -Rotator cuff injury: partially torn infraspinatus and teres minor and completely torn and teres minor and completely torn supraspinatussupraspinatus-Back pain has become severe due to inactivity -Back pain has become severe due to inactivity and he is now driven everywhere by his wifeand he is now driven everywhere by his wife

RehabilitationRehabilitation

Surgery for supraspinatus tear and muscle Surgery for supraspinatus tear and muscle reattached to head of humerusreattached to head of humerus

In a brace for 8wksIn a brace for 8wks Seeing a physiotherapist for 6 wksSeeing a physiotherapist for 6 wks ROM at glenohumeral joint:ROM at glenohumeral joint:

60% of abduction60% of abduction 30% lateral rotation30% lateral rotation

Goals/ MotivationGoals/ Motivation

Increase ROM in shoulderIncrease ROM in shoulder Strengthen back and shoulderStrengthen back and shoulder Weight lossWeight loss

Reasons:Reasons: Return to work and be functional and capable to Return to work and be functional and capable to

need job demandsneed job demands Drive againDrive again Increase energy to be able to work all day and Increase energy to be able to work all day and

then come home and play with kids then come home and play with kids

BarriersBarriers TimeTime AdherenceAdherence Weight in relation to performing exercisesWeight in relation to performing exercises Dietary: cutting down on pizza even Dietary: cutting down on pizza even

though its freethough its free

******To help involve family in program as To help involve family in program as support system.support system.******

Support SystemSupport System

Involve entire family in nutritional changesInvolve entire family in nutritional changes If required: refer to dietician to help outline If required: refer to dietician to help outline

how to make changes effectivelyhow to make changes effectively Get out walking after dinner:Get out walking after dinner:

Good for the mom because she’s pregnantGood for the mom because she’s pregnant Walk to the park so kids are out playing and Walk to the park so kids are out playing and

increasing the amount pf physical activity they increasing the amount pf physical activity they get.get.

NutritionNutrition

Refer to Canada’s Food Guide:Refer to Canada’s Food Guide:

-Grain Products 5-12-Grain Products 5-12

-fruits and vegetables 5-10-fruits and vegetables 5-10

-milk products 3-4-milk products 3-4

-meat and alternates 2-3-meat and alternates 2-3 Concentrate on eating smaller portionsConcentrate on eating smaller portions Pizza only once a weekPizza only once a week

RangeRangeof of

MotionMotion

Glenohumeral Joint AbductionGlenohumeral Joint AbductionAROM:AROM: Patient is not able to perform isolated glenohumeral joint Patient is not able to perform isolated glenohumeral joint

abduction ROM without scapula being stabilizedabduction ROM without scapula being stabilizedPROM:PROM: Start Position:Start Position: Patient is supine or sitting. The arm is at the Patient is supine or sitting. The arm is at the

side with the elbow flexed to 90side with the elbow flexed to 90°° Stabilization: Therapist stabilizes the scapula and clavicle Stabilization: Therapist stabilizes the scapula and clavicle Goniometer Axis:Goniometer Axis: The axis is placed at the midpoint of the The axis is placed at the midpoint of the

anterior or posterior aspect of the glenohumeral joint, about anterior or posterior aspect of the glenohumeral joint, about 1.3 cm inferior and lateral to the coracoid process1.3 cm inferior and lateral to the coracoid process

Stationary Arm:Stationary Arm: Parallel to the sternumParallel to the sternum Moveable Arm:Moveable Arm: Parallel to the longitudinal axis of the Parallel to the longitudinal axis of the

humerushumerus End Position:End Position: Humerus is moved laterally and upward to the Humerus is moved laterally and upward to the

limit of motion (90-120°) to measure glenohumeral joint limit of motion (90-120°) to measure glenohumeral joint abductionabduction

Shoulder External Shoulder External RotationRotation

AROM: AROM: Lay supine with shoulder in 90Lay supine with shoulder in 90° ° abduction: elbow extension, scapular abduction: elbow extension, scapular depression, and shoulder adduction.depression, and shoulder adduction.

PROM:PROM: Start Position:Start Position: Patient is supine Patient is supine End Position:End Position: The dorsum of the hand The dorsum of the hand

moves toward the floor to the limit of moves toward the floor to the limit of motion in external rotation (90°) motion in external rotation (90°)

Trunk Flexion and Extension Trunk Flexion and Extension Lumbar SpineLumbar Spine

Start Position:Start Position: Patient is standing with feet shoulder width apart Patient is standing with feet shoulder width apartEnd Position:End Position: Patient flexes the trunk forward to the limit of Patient flexes the trunk forward to the limit of

motionmotion

Measurement:Measurement: Flexion:Flexion: A tape measure is used to measure a distance and A tape measure is used to measure a distance and

mark a point 10 cm above the spinous process of S2. A mark a point 10 cm above the spinous process of S2. A measure is taken in the start position and at the limit of measure is taken in the start position and at the limit of motion. The difference between the two measures is the motion. The difference between the two measures is the lumbar spinal flexion ROM. (Method of measurement AKA lumbar spinal flexion ROM. (Method of measurement AKA Schober test)Schober test)

Extension:Extension: Patient stands with hands placed on the iliac crests Patient stands with hands placed on the iliac crests and into the small of the back. Patient extends the trunk and into the small of the back. Patient extends the trunk backward to the limit of motion for lumbar extension and the backward to the limit of motion for lumbar extension and the difference between the two measures is the lumbar spinal difference between the two measures is the lumbar spinal extension ROM.extension ROM.

ROM: Trunk RotationROM: Trunk Rotation

Start Position:Start Position: Patient is sitting with the feet supported on Patient is sitting with the feet supported on a stool and the arms crossed in front of the chesta stool and the arms crossed in front of the chest

Stabilization:Stabilization: Therapist stabilizes the pelvis Therapist stabilizes the pelvis

End Position:End Position: Patient rotates the trunk to the limit of Patient rotates the trunk to the limit of motion. The therapist visually estimates the trunk motion. The therapist visually estimates the trunk rotation ROM (45rotation ROM (45°)°)

Substitution/Trick Movement:Substitution/Trick Movement: Trunk flexion, trunk Trunk flexion, trunk extension, and shoulder horizontal abduction in the extension, and shoulder horizontal abduction in the direction of trunk rotationdirection of trunk rotation

Muscle TestingMuscle Testing

Drop Arm TestDrop Arm Test Patient sits or stands with affected arm passively Patient sits or stands with affected arm passively

abducted to 90 and is instructed to slowly lower arm.abducted to 90 and is instructed to slowly lower arm. If rotator cuff injury is present (especially supraspinatus) If rotator cuff injury is present (especially supraspinatus)

patient will not be able to lower arm slowly and smoothly; patient will not be able to lower arm slowly and smoothly; arm will drop to patients side.arm will drop to patients side.

Symptoms of rotator cuff injury may include pain in the Symptoms of rotator cuff injury may include pain in the lateral aspect of the shoulder, weakness in the shoulder, lateral aspect of the shoulder, weakness in the shoulder, and a serious decrease in active range of motion.and a serious decrease in active range of motion.

Muscles affected in rotator cuff injuries are often the Muscles affected in rotator cuff injuries are often the teres minor, subscapularis, supraspintus and teres minor, subscapularis, supraspintus and infraspinatus. infraspinatus.

Common causes of rotator cuff injuries may include Common causes of rotator cuff injuries may include falling, lifting and repetitive arm activities, especially falling, lifting and repetitive arm activities, especially those done overhead. those done overhead.

Shoulder External RotationShoulder External Rotation

Accessory Muscles: posterior fibres of the deltoidAccessory Muscles: posterior fibres of the deltoid

The patient lies in the prone position (face down) while The patient lies in the prone position (face down) while the shoulder is abducted to 90 degrees, elbow flexed at the shoulder is abducted to 90 degrees, elbow flexed at 90 degrees, and the upper arm lies on the bed90 degrees, and the upper arm lies on the bed

The therapist stabilizes the humerus to prevent shoulder The therapist stabilizes the humerus to prevent shoulder adductionadduction

Patient externally rotates the shoulder by moving the Patient externally rotates the shoulder by moving the dorsum (back) of the hand toward the ceilingdorsum (back) of the hand toward the ceiling

The therapist palpates the infraspinatus over the body of The therapist palpates the infraspinatus over the body of the scapula inferior to the spine of scapula (the teres the scapula inferior to the spine of scapula (the teres minor is not palpable)minor is not palpable)

The triceps may act as a trick mover when they act in The triceps may act as a trick mover when they act in elbow extension and the lower fibres of the trapezius elbow extension and the lower fibres of the trapezius cause scapular depressioncause scapular depression

Resistance may be applied proximal to the wrist on the Resistance may be applied proximal to the wrist on the posterior aspect of the forearmposterior aspect of the forearm

The resistance is applied in the direction of internal The resistance is applied in the direction of internal rotationrotation

The major muscles involved include the infraspinatus The major muscles involved include the infraspinatus and the teres minor muscle.and the teres minor muscle.

Trunk ExtensionTrunk Extension Accessory Muscles: interspinales, quadratus Accessory Muscles: interspinales, quadratus

lumborum, and latissimus dorsilumborum, and latissimus dorsi Test strength of neck and hip extensors prior to Test strength of neck and hip extensors prior to

testing trunk extensiontesting trunk extension If neck extensors are injured the head may have If neck extensors are injured the head may have

to be supportedto be supported If hip extensors are injured or weak the pelvis If hip extensors are injured or weak the pelvis

will not be adequately fixed in an extended will not be adequately fixed in an extended position on the thighposition on the thigh

The back extensors are tested as an entire The back extensors are tested as an entire group in a position where they are working group in a position where they are working against gravityagainst gravity

The patient lies in a prone position (chest down) The patient lies in a prone position (chest down) with a pillow under the abdomen and Anterior with a pillow under the abdomen and Anterior Superior Iliac Spine.Superior Iliac Spine.

A strap is placed over the pelvis to isolate the A strap is placed over the pelvis to isolate the lumbar extensor muscles while the therapist lumbar extensor muscles while the therapist stabalizes the legs proximal to the ankle jointsstabalizes the legs proximal to the ankle joints

Movement: A grade 1 is measured as a flicker of Movement: A grade 1 is measured as a flicker of a muscle contraction or observed as the patient a muscle contraction or observed as the patient attempts to lift their headattempts to lift their head

Palpate the trunk extensor muscles as a group Palpate the trunk extensor muscles as a group paravertebral to the lumbar and thoracic spinesparavertebral to the lumbar and thoracic spines

With a grade 2 the patient is able to lift their With a grade 2 the patient is able to lift their head and the upper portion of the sternum off head and the upper portion of the sternum off the bedthe bed

In a grade 3 with the hands of the patient held In a grade 3 with the hands of the patient held behind their back, they are able to extend the behind their back, they are able to extend the trunk and lift head and sternum enough that the trunk and lift head and sternum enough that the xyphoid process is cleared from the bedxyphoid process is cleared from the bed

There are no trick or substitution movements for There are no trick or substitution movements for this testthis test

Resistance can be applied by the patient not the Resistance can be applied by the patient not the therapisttherapist

This resistance is added through hand This resistance is added through hand placementplacement The hands may be positioned at either behind the low The hands may be positioned at either behind the low

back, or behind the head in order to test for grades 4 back, or behind the head in order to test for grades 4 and 5 respectively.and 5 respectively.

The major muscles involved in this movement include The major muscles involved in this movement include the iliocostalis thoracis, iliocostalis lumborum, the iliocostalis thoracis, iliocostalis lumborum, longissimus thoracis, spinalis thoracis, semispinalis longissimus thoracis, spinalis thoracis, semispinalis thoracis, multifidus, and erector spinaethoracis, multifidus, and erector spinae

Functional TestsFunctional Tests

Shoulder: Lateral RotationShoulder: Lateral Rotation

Action is achieved through the action of the Action is achieved through the action of the infraspinatus, teres minor, and posterior deltoid.infraspinatus, teres minor, and posterior deltoid.

External rotation has a direct functional link with External rotation has a direct functional link with supinators of the forearm when the elbow is supinators of the forearm when the elbow is extended.extended.

Ex. Turning a screw driver (supination) with Ex. Turning a screw driver (supination) with arm extended.arm extended.

Shoulder: AbductionShoulder: Abduction

Abduction at the glenohumeral joint is Abduction at the glenohumeral joint is achieved by action of the deltoid and achieved by action of the deltoid and supraspinatus. supraspinatus.

Ex. Standing perpendicular to a book shelf Ex. Standing perpendicular to a book shelf and placing a book on the shelf.and placing a book on the shelf.

• Can be done at different heights as well as Can be done at different heights as well as different distances away from the shelf. different distances away from the shelf.

Lower Back: Trunk FlexionLower Back: Trunk Flexion

Trunk flexion is achieved through Trunk flexion is achieved through contraction of the abdominals, and the contraction of the abdominals, and the vertebral portion of the psoas major vertebral portion of the psoas major muscle. Once trunk is inclined, gravity muscle. Once trunk is inclined, gravity takes over to flex the trunk, while the takes over to flex the trunk, while the erector spinae muscles control the erector spinae muscles control the contraction. contraction. Ex. Putting on a sock from a seated position.Ex. Putting on a sock from a seated position.

Lower Back: Trunk Extension Lower Back: Trunk Extension

Trunk extension when lifting objects out of Trunk extension when lifting objects out of a car is achieved through contraction of a car is achieved through contraction of the erector spinae muscles until erect the erector spinae muscles until erect position is reached. position is reached.

Ex. Picking up a pencil from the floor while Ex. Picking up a pencil from the floor while flexing at the hip. flexing at the hip.

ExerciseExercisePrescriptionPrescription

Shoulder FlexibilityShoulder FlexibilitySupraspinatus:Supraspinatus: Patient positions involved arm behind the body with the Patient positions involved arm behind the body with the

elbow flexed and grabs the chair back elbow flexed and grabs the chair back Leans away from the handLeans away from the hand Alternative: grasp the hand behind the back with Alternative: grasp the hand behind the back with

opposite hand and pull gentlyopposite hand and pull gently

Infraspinatus:Infraspinatus: Patient positions involved arm in medial rotation in front Patient positions involved arm in medial rotation in front

of body of body Grabs involved wrist with involved arm and pulls the arm Grabs involved wrist with involved arm and pulls the arm

across the body while maintaining medial rotation across the body while maintaining medial rotation Keep trunk neutral Keep trunk neutral

Back FlexilibilityBack Flexilibility

Lumbar Rock: Patient is positioned on hands and knees Lumbar Rock: Patient is positioned on hands and knees with hands shoulder width apart, knees under hipswith hands shoulder width apart, knees under hips

1. Arch back (Hold stretch) 1. Arch back (Hold stretch) 2. Push ankles together as shoulders go down to floor2. Push ankles together as shoulders go down to floor 3. Patient then moves forward to beginning position and 3. Patient then moves forward to beginning position and

pushes bellybutton down into the matpushes bellybutton down into the mat

Quadratus Lumbordum Stretch (from sitting position)Quadratus Lumbordum Stretch (from sitting position) One thigh parallel to wall and flexed at knee – sole of One thigh parallel to wall and flexed at knee – sole of

foot is placed on inner thigh of opposite legfoot is placed on inner thigh of opposite leg Opposite leg is extend to side and close to perpendicular Opposite leg is extend to side and close to perpendicular

wall wall Hips remain on the floorHips remain on the floor Arm farthest from wall is in front of ipsilateral leg and the Arm farthest from wall is in front of ipsilateral leg and the

hand nearest wall is placed on wall to push away hand nearest wall is placed on wall to push away (maintain pelvic tilt)(maintain pelvic tilt)

Shoulder StrengtheningShoulder Strengthening Secure elastic at waist level. Hold elbow at 90 degrees Secure elastic at waist level. Hold elbow at 90 degrees

arm at side. Pull hand across body as shown in handout. arm at side. Pull hand across body as shown in handout.

Secure elastic at waist level. Hold elbow at 90 degrees Secure elastic at waist level. Hold elbow at 90 degrees arm at side. Pull hand away from body as shown. arm at side. Pull hand away from body as shown.

Secure elastic at waist level. Arm at side fully extended. Secure elastic at waist level. Arm at side fully extended. Pull hand forward, keeping elbow straight. Pull hand forward, keeping elbow straight.

Sit upright and hold both arms out beside your body. Sit upright and hold both arms out beside your body. Hold your arms a little lower than shoulder level. With Hold your arms a little lower than shoulder level. With weights in both hands, raise your arms until your hands weights in both hands, raise your arms until your hands are at shoulder level. Keep your thumbs pointed down. are at shoulder level. Keep your thumbs pointed down.

Back StrengtheningBack Strengthening

Thoracic extensionThoracic extension Bird-DogBird-Dog BridgingBridging Abdominal crunchesAbdominal crunches

For all strengthening exercises do 3 sets For all strengthening exercises do 3 sets of 10 reps every second day. of 10 reps every second day.

(view handout for complete information and diagrams)(view handout for complete information and diagrams)

Program ModificationsProgram Modifications

Increase the following:Increase the following:-Reps-Reps

-Frequency-Frequency-Intensity-Intensity

Incorporate, different more challenging Incorporate, different more challenging exercisesexercises

Decrease rest time between reps Decrease rest time between reps After back pain improves add more After back pain improves add more

cardiovascular endurance exercisecardiovascular endurance exercise