FEATURE ARTICLE: Clinical Reasoning For Clinical Decisions Of Shoulder Pain - DR.BHAVNA MHATRE

Introduction to direct access or first contact practice has increased the accountability of Physiotherapists within the profession and outside including competing for health practitioners and health-conscious consumers. Hence, a recognized need to define and promote those characteristics that lead to superior clinical performance exists within the profession to firmly establish physiotherapists as autonomous, competent health care professionals capable of sound clinical decision making and effective patient management. (Jones et al). Concern for this development of expert clinical performance has led to the rapidly growing interest in the topic of clinical reasoning. Clinical reasoning (CR) is defined as the cognitive process or thinking used in the evaluation and management of patients and involves the process of pattern recognition which facilitates hypothesis generation, testing, and modification of hypothesis that takes place through all aspects of the patient encounter. Too often attention is given only to examination and treatment techniques without the reasoning behind them. Therefore physiotherapists must strongly consider the reasoning behind inquiries, tests and management interventions to identify categories of hypotheses to achieve the aim of solving the patient’s problem efficiently and safely.

Discrete but related hypothesis categories include:   1) Dysfunctions 2) Pathobiological mechanism 3) Source of symptoms or dysfunctions 4) Contributing source of symptoms 5) Precautions and Contraindications 6) Prognosis 7) Management

This article is an attempt to get an insight into the CR process during the subjective and physical examination for a patient who has a shoulder dysfunction due to pain and stiffness. The hypothesis of the source and contributing source of symptoms are formed after completion of the subjective examination. These are tested through physical examination which is an extension of subjective examination and not a routine series of tests. Also, the extent of physical examination to be performed on the first day will depend on the hypothesis category of precautions and contraindications. When the structures at fault are identified then interventions are planned which are aimed at restoring functional independence. This process is considered to be successful if one has an organized knowledge base from which quality hypothesis is generated, the therapist's ability to analyze and synthesize the data collected and metacognitive skills which provide a critical review of cognitive performance.

The following clinical case illustrates the use of hypothesis categories: Radhabai, a 52 yr old female,  maid by occupation, complains of diffuse pain on the anterolateral aspect of the right glenohumeral joint and over the deltoid that increases with motion. Functionally she is unable to sleep on the affected side, has difficulty in wearing a blouse, hooks a brassier in the back, combing hair, applying soap to the upper back, and at the workplace, scrubbing and drying clothes on the overhead clothesline, mopping the floor and also lifting bucket full of clothes. She has also stopped going to the market because of the increase in pain intensity after carrying weight. She is married with one son who is currently studying and her husband is working as a ward boy in the hospital. Even with the above-mentioned information, the therapist will be able to treat this patient; however, the quality of treatment given without finding out the structures at fault will be compromised in terms of cost and time effectiveness.

An estimate of the extent to which a patient’s disorder appears amenable to physiotherapy and of the time frame in which recovery can be expected will not be possible if structural differentiation is not done. Depending on the vascularity, every structure has its own healing time and therefore should heal in a stipulated period, provided precautions and contraindications to physical examination and treatment are taken into considerations. Also, the effects of the contributing factors on the patient’s condition need to be controlled. Information regarding severity, irritability, the stage of tissue healing and healing potential, presence of normal (adaptive) or abnormal (maladaptive) pain mechanisms, degree of damage or injury, the length of history and progression of the disorder, general health of the patient, personality and lifestyle and patient’s expectations are all necessary to have a positive impact on treatment outcomes.

In the context of the case example, the patient’s complaint of diffuse anterolateral shoulder pain could be emanating from local structures such as the anterior capsule,  long head of biceps, subacromial structures, as well as remote structures C5-C6 somatic referred. The glenohumeral joint structures are mostly innervated by the C5 and C6 spinal nerves which also innervate the cervical structures which can refer pain to the lateral aspect of the arm. Therefore, it is imperative to examine every patient for both shoulder and cervical dysfunction.  The next step is asking the patient to put a finger on one spot or use a body chart for mapping to localize the exact area of the symptoms. The above mentioned hypothesized structures will hold if the patient has mapped two sites, anterior and around the lateral aspect of the glenohumeral joint line. Somatic referred pain from cervical structures can be ranked as the last option in this patient. A patient may demonstrate signs of illness behavior in the way they record pain in a widespread or follow non-anatomical distribution on a body chart. Quality and depth of pain may give a clue as to the anatomical structure of pain. If patient reports – deep, dull and poorly localized pain is attributed to deep ligaments, muscles, bone and referred from visceral structures. A superficial pain described as sharp and burning present on the anterolateral aspect is suggestive of supraspinatus tendinitis or subacromial bursitis. Pain present at rest may imply bursitis whereas pain aggravated by movements, suggests tendinitis.

The intensity of pain can be measured by numerical or visual analog scale(VAS). This can then be used to construct a pain profile from which the behavior of pain or the effectiveness of treatment upon pain can be judged. Pain on functional activities is rated as 5 on VAS and at rest 0, then one can infer that the intensity of symptoms is not very severe and pain due to bursitis can be ruled out.  Aggravating and easing factors hypothesizes what structures are being stressed and thereby causing symptoms. Kinematic analysis of functional activities  as informed by the patient implies abduction and external rotation movements are painful and stiff. These movements stress the anterior capsule which has lost its extensibility.  This will restrict external rotation movement required during elevation would cause impingement of rotator cuff and subacromial bursa and long head of biceps tendon. This data should then be correlated with the irritability level of the problem. Low irritability graded with Maitland’s concept, will allow all movements to be examined safely without provocation of symptoms. Thus from this data, we can hypothesize capsule and/or biceps tendon to be the source for anterior pain and supraspinatus tendon could be responsible for pain present on the lateral aspect. The dominant pain mechanism in the case presentation can be classified as nociceptive pain from the above data.

The therapist then decides which tests need to be included in the physical examination to confirm or refute the above hypothesis of the anterior capsule, biceps tendon and rotator cuff as the source for the patient’s symptom. Assessment of an active range of motion will reveal abnormal movement patterns and will confirm the patient’s functional abilities and disabilities. Functional movement testing for Radhabai will demonstrate the inability to put her hand behind the neck and back. To confirm the capsule as the source of symptom, evaluation of a cardinal and scapular plane active and passive range of motion will exhibit external rotation as the most limited motion followed by the abduction and internal rotation. To compensate for this impaired motion, excessive scapular motion altering the normal glenohumeral rhythm for abduction and flexion movements will be seen. The end feels examined at the end of the available range will also be abnormal. Irritability level according to Cyriax for this patient would be moderate which is pain and resistance encountered at the same time during passive movements which are found to be restricted. Restriction of anterior and inferior glide of the glenohumeral joint will be found will be with accessory mobility tests. The anterior and inferior capsular stretch test will also be positive. However, for a patient with marked restriction of range the test position will be difficult to achieve. Strong and painless contraction (Cyriax response) on a resisted isometric test of biceps muscle rules out biceps tendon as the source of a patient’s symptom.

 An arc of pain between 70 0 and 1200 during active elevation and strong and painful contraction on resisted shoulder abduction and external rotation suggests impingement of rotator cuff. Pain on accessory mobility testing of inferior glide with lateral distraction stretches the supraspinatus and posterior glide stretches the infraspinatus and teres minor portion of the cuff. Excessive scapular motion attempts to compensate for glenohumeral incompetence and pain. Secondary impairments of the stretch weakness of middle and lower trapezius and rhomboids and tight upper trapezius and levator scapulae is seen as a result of excessive scapular motion. The anterior tilt of the scapula warrants assessment of pectoralis minor and serratus anterior which may have shortened. Also, the adaptive shortening of the pectoralis major, the Lattisimus Dorsi, and the teres major is found due to the pattern of restricted motion results in the shoulder being held in adducted and internally rotated position. Trigger points in these muscles and evaluating them with palpatory techniques will implicate the impairment of tightness in these muscles since the restricted range will not allow the muscle to be assessed in the test position.   

Physical therapy interventions are planned after the evaluation of data gathered throughout the patient-therapist interaction. Summary of impairments for the patient’s source of symptoms for dysfunction and which can be remediated by physiotherapy are –  1) Anterior and inferior capsule giving rise to a restriction of external rotation followed by the abduction and medial rotation, 2)Rotator cuff impingement giving rise to inflammation and pain, 3) Stretch weakness of scapular retractors and depressor muscles and tight elevators. 4) The tightness of glenohumeral adductors and medial rotators further restricting the range, 5) Protracted and an anterior tilt of the scapula may cause tightness of pectoralis minor and serratus anterior muscle. Contributing source of symptoms - 1) Thoracic kyphosis  2) work-related to physical stress.

Level of irritability, severity is moderate and her tissues appear to be in the second stage which is characterized by repair and regeneration of the injured tissues. Rehabilitation during this stage is focussed on restoring a range of tissue and applying controlled stress to the newly formed tissue to promote alignment of the collagen fibers and minimize adhesions. Based on the above the following goals and treatment strategies are formulated with the reasoning behind every intervention

Goals - 1) To regain sufficient and pain-free motion to allow for independence with dressing, hair care and household activities which will be achieved by -a) Improving extensibility of the capsule and restoring the length of the muscles which have developed adaptive shortening b) Resolution of the inflamed supraspinatus tendon and relief of pain c) Strengthening and retraining of scapular depressors and retractors muscles with the relaxation of elevators d) Strengthening of rotator cuff muscles e) Correction of thoracic kyphotic posture.F) Patient education 2) To achieve a higher functional status at her workplace – a) Ergonomic advice b) Improving aerobic capacity

 Treatment strategies employed to achieve goals are- Moist heat will improve the extensibility of the superficial tissues and Ultrasound therapy to decrease inflammation and promote healing of the supraspinatus tendon and to improve the extensibility of the capsule. Graded mobilization techniques, static, dynamic stretching incorporating PNF techniques, pendular exercises, and active exercises in the gravity eliminated plane to improve mobility. Strengthening of scapular muscles that have developed stretch weakness and stretching of pectoralis minor and serratus muscle to restore the alignment of the scapula on the thorax. Thoracic spine mobilization and strengthening of the thoracic erector spinal muscle to restore extension and correct Kyphosis.Aerobic exercises will improve blood flow to the extremity, general postural tone, and psychological well being. To conclude, the clinical reasoning process enables the clinician to address all components of patients' problems in a comprehensive, integrated and holistic manner. 




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