Addressing neurodynamic irritability in a patient with adhesive capsulitis: a case report

Biopsychosocial contributors to irritability in individuals with shoulder or low back pain

OBJECTIVES

Irritability is a foundational clinical reasoning concept in rehabilitation to evaluate reactivity of the examination and treatment. While originally theorized to reflect tissue damage, a large body of evidence supports pain is a biopsychosocial experience impacted by pain sensitivity and psychological factors. Therefore, the purpose of this study was to examine biopsychosocial contributors to irritability.

METHODS

40 patients with shoulder (n = 20) and low back (n = 20) pain underwent Quantitative Sensory Testing (QST) (Pressure Pain Threshold, Heat Pain Threshold, Conditioned Pain Modulation, Temporal Summation), completed pain-related psychological questionnaires, an Exercise-Induced Hypoalgesia protocol, and standardized irritability assessment based on Clinical Practice Guidelines. Participants were then categorized as irritable or not irritable based on Maitland's criteria and by irritability level based on Clinical Practice Guidelines. An independent samples t-test examined for differences in QST and psychological factors by irritability category. A MANOVA examined for differences in QST and psychological factors by irritability level (high, moderate, low).

RESULTS

Significantly lower heat and pressure pain thresholds at multiple locations (p < 0.05), as well as less efficient conditioned pain modulation (p = 0.02), were demonstrated in individuals categorized as irritable. Heat and pressure pain thresholds were also significantly lower in patients with high irritability compared to other levels. Significantly higher depression and anger, as well as lower self-efficacy, were reported in individuals with an irritable presentation.

DISCUSSION/CONCLUSION

Biopsychosocial factors, including widespread hyperalgesia and elevated psychological factors, may contribute to an irritable presentation.

Comparison of Kaltenborn mobilization technique and muscle energy technique on range of motion, pain and function in subjects with chronic shoulder adhesive capsulitis

Background

Shoulder adhesive capsulitis (AC) is a common musculoskeletal condition causing pain, loss of range of motion (ROM) in the shoulder, and a decrease in its functionality, yet poorly defined and understood since its identification. Kaltenborn mobilization technique (KMT) and muscle energy technique (MET) are commonly used physiotherapeutic techniques for their treatment. To the best of our understanding, there was no study found to compare the effectiveness of one technique over another.

Objective

The objective of this study was to compare the effectiveness of KMT and MET on the ROM, pain and function in subjects with chronic shoulder AC.

Methods

In this single-centred, single-blinded quasi-experimental study with a pretest-posttest design 35 subjects were randomized into two groups: Group A (n = 18 ) received KMT and Group B (n = 17 ) received MET along with the moist hot pack (MHP), supervised exercises and home exercises common to both the groups. A total of 32 subjects completed the study with three dropouts. Subjects were evaluated before and after 10 treatment sessions for the outcomes, shoulder external rotation passive range of motion (ER-PROM) and abduction passive range of motion (ABD-PROM) using the universal goniometer, intensity of pain using the numeric pain rating scale (NPRS) and functional disability using the shoulder pain and disability index (SPADI).

Results

Analysis of 32 subjects showed that both groups were homogenous at baseline. The within-group analysis showed significant improvement (p < 0 . 05 ) in both groups related to all the outcomes. But when we compared the groups, Group B showed significant (p < 0 . 05 ) improvement in NPRS and SPADI in comparison to Group A. However, there was non-significant (p > 0 . 05 ) difference found in ER-PROM and ABD-PROM.

Conclusion

Both KMT and MET are effective in improving ROM, pain and function but MET showed a significant reduction of pain and improvement in function in subjects with chronic shoulder AC, thus supporting its use as a physiotherapeutic treatment technique.

CLINICAL REASONING IN THE FACE OF UNCERTAINTY: CONSERVATIVE PHYSICAL THERAPY MANAGEMENT OF A TEENAGE ATHLETE DIAGNOSED WITH A PROXIMAL HUMERAL NON-OSSIFYING FIBROMA

BACKGROUND AND PURPOSE

There have been few published studies regarding the treatment of patients with non-ossifying fibromas (NOFs), either conservatively or operatively. The purpose of this case report is to discuss the clinical presentation and conservative management of a teenage athlete diagnosed with a proximal humerus NOF.

CASE DESCRIPTION

The subject was a 13-year-old male middle school student with a diagnosis of left shoulder pain over the prior year preventing him from participating in sports activities. The combination of radiological findings revealing a NOF and a thorough physical examination allowed for the development of a physical therapy plan of care to address impairments and functional limitations. The subject was seen for eight visits where a combination of manual therapy techniques, neural mobilizations, and therapeutic exercises were administered to the cervical and upper quarter regions. The subject's progress was tracked by measuring pain-free shoulder active range of motion (AROM) and monitoring changes using the Numerical Pain Rating Scale (NRPS) values throughout sessions.

OUTCOMES

After four sessions, AROM shoulder flexion and abduction increased from 123 º and 119 º to 160 º and 180 º respectively, and worst NRPS decreased from 9/10 to 3/10. Upon discharge after the eighth visit, the subject's DASH improved from 11.66 to 2.5. The subject remained pain free at an eight month follow up and returned to activity.

DISCUSSION

Thorough assessment of both neuromechanical sensitivity and musculoskeletal impairments may provide for the utilization of conservative treatment options for individuals with symptomatic NOFs.

LEVEL OF EVIDENCE

4.