STARES 3 - INTERVENTION

SITUATION
Mr M is a 64 yr old lady who was referred to physio after a fall on an outstretched arm that left her with a fractured proximal humerus that had to be fixed using a prosthesis on the left side. Since surgery she has had difficulties regaining her range of motion and when she tries to move her arm it feels a tight band around her arm stopping her moving. Mrs M has 50 degrees of flexion and 60 degrees of abduction, however the majority of the movement is through the shoulder girdle which she hitches for movement. This is severely limiting her function which is her main concern. She lives at home with her husband and they are both retired. She is right handed so still able to complete some tasks, however such activities like opening jars and washing her hair are limited. She has been attending physiotherapy for the past two months yet has only had limited gains. So far her treatment has included passive accessory movements, soft tissue mobilisations, heat packs and a home exercise program which consisted of pulley exercises, active assisted exercises and stretches.

TASK
To give Mrs M a appropriate and individualized treatment to help improve her range of movement in her left arm.

ACTION
Firstly I got Mrs M into supine, from there I started my treatment with trigger point release of lat dorsi, anterior and posterior deltoids as i found these muscles to be tight and had active trigger points. I then did grade 4 AP glide on the GHJ in 60 degrees of abduction, 3 sets of 30 secs. After this I did a grade 4 lateral glide the the GHJ 3 sets of 30 secs. Lastly we ran through her home exercise program to see if she was completing the exercises an whether she required progression of the exercises.

RESULT
At the end of the treatment Mrs M had and increase of her range of motion to 60 degrees flexion and 80 degrees of abduction. She still complained of the same tight-band feeling across her arm and she was still hitching her shoulder girdle significantly. She was performing her exercises correctly, however I regressed her from long lever pulley exercises to short lever pulley exercises which she found to be easier to achieve.

EVALUATION
Although I did manage to get a good result from the treatment that way I conducted the session could definitely be improved. Putting Mrs M in the supine position seemed like a good idea when performing trigger point releases the most appropriate position to put her in would have been side lying with her arm resting in flexion and horizontal adduction over a pillow to gain the best access to the shoulder and lat dorsi muscles. Having her arm over the pillow means that Mrs M could completely relax her muscles.
Another problem with my treatment session was that I probably did too much with her. Although I immediately saw improvements in Mrs M's range, I will not not know what part of my session that caused her to get the improvements. This will also be a problem if Mrs M returns next week to say she is worse, whether it was what she did after physio or whether it was my TPR, AP glides or just doing to much exercises with her.

STRATEGIES
Next time I see Mrs M I will only do one of my treatment options with her, then get her back later in the week and she if it improved, if not then try the other treatment option. Another way to suss out which technique improved her range, I should re-assess after each technique instead of at the end of the treatment session.I will also position her better in the side lying option, as that gives me better access to her shoulder complex.