Outcomes Following Astym Treatment in a 58 Year Old Female with Biceps Long Head Tendonitis: A Case Study Regan Heafy, SPT; Mark Erickson PT, DScPT,

Transcription

1 Outcomes Following Astym Treatment in a 58 Year Old Female with Biceps Long Head Tendonitis: A Case Study Regan Heafy, SPT; Mark Erickson PT, DScPT, MA, OCS Carroll University, Waukesha, WI

2 Abstract Upper extremity tendinitis is a common injury for which patients are referred to physical therapy. Research has looked at the effectiveness of soft tissue massage techniques in conjunction with strengthening for the treatment of tendinitis. Astym is a soft tissue technique that theoretically allows for the healing and reduction of scar tissue within the body. The subject in this case report was a 58 year old female with right biceps long head tendinitis, no previous history of shoulder injuries, and a past medical history significant for diabetes mellitus and hypertension. Baseline measurements of upper extremity A/PROM and strength were determined prior to implementing a comprehensive physical therapy plan of care integrating Astym with scapular and upper extremity strengthening interventions. Following the four week intervention, the subject was able to complete all work activities without an increase in shoulder pain greater than 1/10 on the visual analog scale. The subject reported she was functioning at 90% of her normal level of activity. The subject s score on the Upper Extremity Functional Scale improved from 51/80 at evaluation to 77/80 at discharge. The results from this case report suggest the use of Astym, in addition to postural awareness education, upper extremity and scapular stability strengthening, may have contributed to improved strength, range of motion, and pain levels in an individual with biceps long head tendinitis. The clinical relevance of this study proposes that Astym in combination with other interventions may effectively treat impairments associated with biceps long head tendinitis.

3 I. Background and Purpose Tendinitis is a prevalent diagnosis in today s population. A study by Walker-Bone et. al. researched upper limb pain and the specific pain source. Of the subjects found to have sitespecific pathologies, tendinitis was the second most common diagnosis after adhesive capsulitis 1. Tendinitis is typically described as an overuse injury and anti-inflammatory remedies such as rest, ice, pain medication, and corticosteroid injections along with physical therapy are utilized for treatment 2. This diagnosis, if not properly treated, can result in a worsening of the tendinitis leading to tendinosis or tendinopathy, often which are irreversible and require surgical interventions 2. Soft tissue mobilization is often prescribed by physical therapists during treatment with individuals who have limitations based on muscular impairments such as muscle trigger points, increased tone, and pain. Soft tissue massage techniques have been shown to be beneficial for individuals with tendinitis and there are currently a variety of different massage techniques used by physical therapists for the treatment of tendinitis 3,4. Astym is a soft tissue technique that theoretically allows for the healing and reduction of scar tissue within the body by promoting a physiological healing response of the soft tissues 5. The pressure applied to the abnormal tissue through the Astym instruments is thought to cause an increase of inflammatory mediators and start fibroblast activity to result in collagen synthesis. The use of Astym achieves the desired results in approximately 8-10 visits. A case report by McCormack found that Astym along with the use of eccentric strengthening was an effective treatment for hamstring tendinopathy 6. There is currently a limited amount of research for the use of Astym applied to patients with upper extremity tendonitis. Specifically, there is a lack of knowledge of the use of Astym along with strengthening for an individual with biceps long head tendinitis. The purpose of this

4 case report is to describe the outcomes and discuss the potential mechanism of effect of Astym treatment for an individual with biceps long head tendinitis. II. Case Description The subject of this case report was a 58 year old right hand dominant female referred to physical therapy with a diagnosis of right biceps long head tendinitis. The subject worked as a cook and fell onto her right arm while at work two weeks prior to her physical therapy evaluation. The subject denied any similar injuries in the past. The subject s chief complaints included pain in the anterior proximal bicep region, decreased motion, and decreased strength. Past medical history was significant for diabetes mellitus and hypertension. The subject s goals for physical therapy included decreasing her pain and regaining her motion and strength in her arm. She wished to return to her normal method of completing daily activities and work requirements. She stated it was difficult for her to complete her normal activities due to the pain and inability to move her right arm. III. Clinical Impression The subject in this case report was a good candidate for Astym treatment along with strengthening interventions because Astym has been found to be effective for the treatment of patients with tendinitis in other regions of the body in the past 6. Additionally, because this was not a chronic issue for the subject there will not be conflicting underlying issues to complicate the interventions implemented for the subject. The plan for the examination of this subject to determine if appropriate for the intervention described above included ruling out other pathologies such as a rotator cuff tear or instability or degeneration at the glenohumeral or acromioclavicular joints. Additionally, the plan for examination included gathering subjective and objective measures to determine an

5 appropriate and accurate problem list to determine if the subject would benefit from Astym treatment. IV. Examination The subject reported the pain in her right arm ranged from a 2/10 while at rest to an 8/10 with performing lifting or overhead tasks. Prior to starting physical therapy, the subject had been self-managing her pain with an over the counter non-steroidal anti-inflammatory drug (NSAID) in combination with heat which had intermittently alleviated her pain levels. The subject stated the pain in her arm was limiting her ability to sleep at night and complete her job duties at work. She reported waking on average 4 times per night due to the pain and felt she was functioning at 50% of her normal level of activity while performing work duties. Observation of the subject s sitting posture noted increased thoracic kyphosis, protracted shoulders, and a forward head. The subject completed the Upper Extremity Functional Scale and received a score of 51/80. Cervical active range of motion was within normal limits and pain free. Objective measurements were taken at the initial examination and can be seen in Tables 1 and 2. Flexion and abduction active range of motion (AROM) were measured in standing and internal and external rotation in supine. Passive range of motion (PROM) was measured in supine and included flexion, abduction, internal and external rotation. Hawkins Kennedy and Speeds tests were positive indicating that the biceps long head (BLH) tendon was a pain source. Hawkins Kennedy was found by Hegedus to have a 79% sensitivity for diagnosing primary impingement, of which BLH can be a pain source 7. Research conducted by Bennett found the Speeds test to have a 90% sensitivity for evaluation of the BLH tendon 8. Manual muscle testing was used to assess the subject s strength deficits including GH flexors, abductors, internal rotators, external rotators, and elbow flexors. Right upper extremity strength was decreased with MMT grades ranging from 2/5 to 3+/5.

6 The prognosis was good based on age, co-morbidities, and other lifestyle factors for return to prior level of function in six weeks. The subject led an active lifestyle playing with her grandchildren and working a job that had physically demanding work duties. While research specifically on the impact of diabetes mellitus and hypertension for BLH tendinitis has not been conducted, research has shown that diabetes mellitus does affect the healing rate of other shoulder pathologies such as rotator cuff injuries 9. Chung et. al. found that the failed healing rate of individuals with rotator cuff tears and diabetes mellitus was significantly higher than those without diabetes mellitus 9. The plan of care was determined based on the subject s impairments and included Astym, soft tissue mobilization, therapeutic exercises for range of motion, and therapeutic exercises for strengthening of the upper extremities and scapular stabilizers. Treatment sessions initially focused more on manual therapy including the Astym treatments and soft tissue mobilization. As the subject s pain levels improved more exercises were added into the treatment sessions. V. Clinical Impression Astym was chosen as a primary intervention for a number of reasons. Firstly, the subject was having pain in the shoulder and biceps long head region limiting her ability to lift her arm and carry objects. Secondly, the subject did not have a history of shoulder injuries or pain and the physical therapist identified increased tone through the biceps region during examination. Her stated goal was to return to her prior level of function as soon as possible and the treating physical therapist reasoned it was necessary to initially focus on pain reduction before implementing range of motion and strength interventions. As the subject progressed, subjective responses and objective tests and measures were used to evaluate the effectiveness of Astym. In addition to the subject s subjective information,

7 palpation of the subject s muscle tissue from the therapist performing the Astym was used to determine if the treatment was effective. VI. Intervention Over the 4 week intervention period the plan of care focused on the use of Astym in conjunction with therapeutic exercises targeting postural awareness, strengthening of the scapular and upper extremity musculature. The subject was seen twice per week in an outpatient physical therapy clinic and completed a home exercise program 5 days per week targeting improving postural awareness and increasing her scapular stability. The home exercise program was reviewed during treatment sessions to ensure the subject was completing the exercises correctly at home. See Table 3 for the home exercise program. As the subject progressed through the plan of care more exercises were added or modified to become more challenging. Appendix A includes images of the exercises used during the intervention. The Astym treatment was completed for a total of 6 sessions with the subject in a seated position with a pillow supporting her right arm during the treatments. Specific Astym tools used for the subject s treatment include the evaluator and the localizer. Each tool was used by completing 3 strokes both toward and away from the muscle insertion site in a direction parallel to the muscle fibers at a rate of 6-7 inches per second with the tools held at a 70 degree angle in relation to the subject s skin. A fan or multidirectional stroke was used over the distal aspect of the biceps long head insertion and the origin of the deltoid. The pressure of the strokes varied based on subject tolerance and objective examination findings. The specific areas targeted with the Astym included the right biceps, deltoid, pectoralis major, and upper trapezius. All Astym treatments were completed by a therapist certified in Astym. The progression of strengthening exercises included throughout the intervention period can be seen in table 4. During the fourth week of the intervention period, the subject was set up

8 with an independent exercise program using Precor brand weight machines as that was what was present in the wellness center where the subject was a member. VII. Outcomes Throughout the 4 week intervention period, physical therapy and patient goals were met. At discharge, the subject was able to complete all work activities without increased shoulder pain greater than 1/10 on the visual analog scale. Pain was no longer waking her during the night or limiting her ability to complete household tasks such as cleaning. She attributed her gains primarily to physical therapy intervention using Astym technique. Comparisons between objective measurements collected at evaluation and discharge can be seen in Table 5 and Table 6. Abduction AROM increased 37% from 104 degrees to 171 degrees at discharge and the Upper Extremity Functional Index score improved from 51/80 at evaluation to 77/80. The subject verbalized she experienced improved postural awareness and focused on correcting both her sitting and standing posture when she noticed herself having poor posture. The subject also stated she felt her level of functional activity had improved to 90% as compared to 50% at evaluation. After discharge the subject planned to perform her home exercise program 3 times per week at a wellness center to maintain the gains she made during physical therapy. Objective measurements used in this case report to monitor the subject s progress included measuring range of motion, manual muscle testing, and the Upper Extremity Functional Index. Manual muscle testing was performed based on the procedures outlined by Berryman and Reese 10. Inter-rater reliability for use of manual muscle testing in the upper extremity was found to be moderate-to-good by Jepsen 11. The Upper Extremity Functional Index was found to have excellent test-retest reliability 12. Range of motion measurements were obtained following procedures outlined by Norkin and White 13. According to Norkin and White, measurement of

9 joint position and ROM through use of a universal goniometer has been demonstrated to have good-to-excellent reliability 13. Additionally, with goniometric measurements, intra-tester reliability has been found to be higher compared to inter-tester reliability 12. VIII. Discussion This case report describes outcomes for a 58 year old female with biceps long head tendinitis achieved by prescribing Astym with strengthening exercises. The interventions used targeted the subject s complaints of pain in addition to the findings of increased muscular tone by incorporating postural awareness and strengthening the musculature surrounding the shoulder to avoid future related injuries. The interventions implemented seem to have aided in symptom management and restoration to the subject s prior level of function. A case study by McCormack found that the use of Astym with eccentric strengthening was a beneficial treatment for hamstring tendinopathy 6. While there is a limited amount of literature currently published on the use of Astym for treatment of tendinitis, the results of this study suggest that Astym and strengthening may be beneficial for impairments caused by biceps long head tendinitis. As reported by Sharma et. al., it is important during tendon healing to mobilize the tendon in order to prevent scar tissue adhesions from forming 14. Hypothetically, the use of Astym allowed for the mechanical loading and mobilization of the injured tendon without interfering with the physiological healing process. Other factors outside of physical therapy may have impacted the subject s improvement in symptoms. The subject s date of injury was 2 weeks prior to beginning therapy, therefore putting her at 6 weeks after injury at discharge from therapy. Based on the physiologic healing process, the maturation phase of healing occurs at approximately 6 weeks which could account for the resolution of the subject s symptoms.

10 A limitation of this study was the outcome measure used. Based on a literature review conducted, the Upper Extremity Functional Index is lacking in research related to the reliability and validity of this measure. Another limitation of this study was the lack of quality literature found for the use of Astym for treatment of tendinitis. The research currently published on Astym for the treatment of tendinitis includes case reports; no randomized control trials have been published in this area. Further research in this area will aid in the development of more valid outcomes from use of this intervention. The use of a handheld dynamometer would have improved the reliability of manual muscle testing values as dynamometer use had a higher intrarater and intersession reliability as compared to using MMT grades 8. While this study does have some limitations, the results of this case report suggest that the use of Astym with strengthening exercises may be a useful intervention as part of a comprehensive physical therapy plan of care to effectively treat individuals with biceps long head tendinitis. Future research is needed to determine if these interventions are appropriate for treating tendinitis in other regions of the body. In future studies, utilizing a larger sample size will also increase the validity of the use of Astym and strengthening for treatment of individuals with tendinitis.

11 Table 1. Range of Motion of the Shoulders (Measured in degrees) Right Left Flexion AROM 0-146* Flexion PROM 0-148*, pain before Not Measured resistance, empty end feel Abduction AROM 0-104* Abduction PROM 0-106*, pain before Not Measured resistance, empty end feel Internal Rotation AROM 0-40* 0-65 Internal Rotation PROM 0-46*, pain equal to Not Measured resistance, firm end feel External Rotation AROM External Rotation PROM 0-57, firm end feel Not Measured *Pt reported pain at end range Table 2. Strength (Graded with the Manual Muscle Testing Scores) Right Left GH Flexors 2+/5* 5/5 GH Abductors 2/5* 5/5 GH Internal Rotators 2+/5* 5/5 GH External Rotators 2+/5* 5/5 Elbow Flexors 3+/5* 5/5 *Pt reported pain with MMT Table 3. Home Exercise Program Exercise Doorway pectoral stretch 3 sets of 30 seconds Dosage Seated scapular retraction 2 sets of 15 Shoulder pull downs (with red theraband) 2 sets of 10 Shoulder horizontal abduction (with red 2 sets of 10 theraband)

12 Table 4. Treatment Strengthening Exercises Exercise Week One Interventions Bent over rows* 10 repetitions Bent over horizontal abduction* 10 repetitions Dosage Bent over extension* Standing D1 PNF diagonal pattern Standing D2 PNF diagonal pattern 10 repetitions 10 repetitions with 1 lb. 10 repetitions with 1 lb. Standing abduction Pull down Horizontal abduction Arm ergometer Standing scaption Pull down Horizontal abduction Chest press Bicep curl Tricep extension Seated row Pec fly Rear deltoid reverse fly 10 repetitions with 1 lb. Week Two Intervention Additions 10 repetitions with 10 lb. on cable column machine 10 repetitions with 5 lb. on cable column machine Week Three Intervention Additions 4 minutes 10 repetitions with 1 lb. 2 sets of 10 repetitions with 10 lb. on cable column machine 2 sets of 10 repetitions with 5 lb. on cable column machine 10 repetitions with 25 lb. on Precor machine 10 repetitions with 10 lb. on Precor machine 10 repetitions with 25 lb. on Precor machine 10 repetitions with 20 lb. on Precor machine Week Four Intervention Additions 10 repetitions with 10 lb. on Precor machine 10 repetitions with 10 lb. on Precor machine Shoulder press 10 repetitions with 20 lb. on Precor machine *Bent over exercises were completed with subject in a standing position with approximately 30 degrees of hip flexion, one hand planted on the mat table, and shoulders in a position parallel to the mat table.

13 Table 5. Range of Motion Results (Measured in degrees) Right- Evaluation Right- Discharge Percent Change Flexion AROM 0-146* % increase Abduction AROM 0-104* % increase Internal Rotation 0-40* % increase AROM External Rotation AROM % increase *Pt reported pain at end range Table 6. MMT Results Right- Evaluation Right- Discharge GH Flexors 2+/5* 4/5 GH Abductors 2/5* 4-/5* GH Internal 2+/5* 4/5 Rotators GH External 2+/5* 4+/5 Rotators Elbow Flexors 3+/5* 4/5* *Pt reported pain with MMT

14 Works Cited: 1. Walker-Bone, K., Palmer, K., Reading, I., Coggon, D., and Cooper, C. Prevalence and impact of musculoskeletal disorders of the upper limb in the general population. American College of Rheumatology. August 2004; 51(4): Churgay C. Diagnosis and treatment of biceps tendinitis and tendinosis. American Family Physician [serial online]. September 2009;80(5): Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed April 1, Joseph M, Taft K, Moskwa M, Denegar C. Deep Friction Massage to Treat Tendinopathy: A Systematic Review of a Classic Treatment in the Face of a New Paradigm of Understanding. Journal Of Sport Rehabilitation [serial online]. November 2012;21(4): Available from: SPORTDiscus with Full Text, Ipswich, MA. Accessed April 1, Pinkelman, K., Schilling, J. Treatment of Extensor Hallucis Longus Tendinosis in a Track Athlete. International Journal Of Athletic Therapy & Training [serial online]. July 2012;17(4):4-7. Available from: Academic Search Premier, Ipswich, MA. Accessed April 1, Slaven E, Mathers J. Management of chronic ankle pain using joint mobilization and ASTYM treatment: a case report. Journal Of Manual & Manipulative Therapy (Maney Publishing) [serial online]. May 2011;19(2): Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed April 1, Mccormack J. The management of bilateral high hamstring tendinopathy with ASTYM treatment and eccentric exercise: a case report. Journal Of Manual & Manipulative Therapy (Maney Publishing) [serial online]. August 2012;20(3): Available from: SPORTDiscus with Full Text, Ipswich, MA. Accessed April 1, Hegedus E. Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. British Journal Of Sports Medicine [serial online]. November 2012;46(14): Available from: SPORTDiscus with Full Text, Ipswich, MA. Accessed April 9, Bennett W. Specificity of the Speed's test: arthroscopic technique for evaluating the biceps tendon at the level of the bicipital groove. Arthroscopy: The Journal Of Arthroscopic & Related Surgery: Official Publication Of The Arthroscopy Association Of North America And The International Arthroscopy Association [serial online]. November 1998;14(8): Available from: MEDLINE with Full Text, Ipswich, MA. Accessed April 9, Chung S, Oh J, Gong H, Kim J, Kim S. Factors Affecting Rotator Cuff Healing After Arthroscopic Repair: Osteoporosis as One of the Independent Risk Factors. American Journal Of Sports Medicine [serial online]. October 2011;39(10): Available from: SPORTDiscus with Full Text, Ipswich, MA. Accessed April 1, Berryman Reese, N. (2012). Muscle and Sensory Testing. (3 rd edition). St. Louis,MO :Elsevier Saunders Inc.

15 11. Jepson, J., Lausen, L., Larsen, A., Hagert, C. Manual strength testing in 14 upper limb muscles: a study of inter-rater reliability. ACTA Orthopaedica Scandinavica. August 2004; 4: Stratford, P. W., Binkley, J. M., & Stratford, D.M. (2001). Development and initial validation of the upper extremity functional index. Physiotherapy Canada, 53(4), Norkin, C. C., & White, D. J. (2009). Measurements of joint motion: A guide to goniometry. (4 ed.). Philadelphia, PA: F.A. Davis Company. 14. Sharma P, Maffulli N. Basic biology of tendon injury and healing. Surgeon (Edinburgh University Press) [serial online]. October 2005;3(5): Available from: Academic Search Premier, Ipswich, MA. Accessed April 1, 2014.

16 Appendix A:

17

18

19

20

21

22