The SUPPORT Trial: SUbacromial impingement syndrome and Pain: a randomised controlled trial Of exercise and injection SUPPORT Physiotherapy Intervention Training Manual Authors: Sue Jackson (SJ) Julie Shufflebotham (JS) Kay Stevenson (KS) Orthopaedic / A&E Physiotherapy Practitioner Senior Physiotherapist Consultant Physiotherapist SUPPORT Physiotherapy Intervention Training Manual, Version 3.0: 04/01/11 1
Table of Contents 1. General Overview of Physiotherapy Intervention.... 3 1.1 Stage 1 Physiotherapy Assessment... 3 1.1.1 Assess for posture.. 3 1.1.2 Assess for scapula stability... 3 1.1.3 Include proprioception / weight bearing type exercise.. 3 1.2 Stage 2 Progress to ROM exercises, with scapula control and painfree range..... 3 1.2.1 Forward flexion, abduction, internal and external rotation.... 3 1.2.2 ROM stretching exercises.. 3 1.2.3 Isometric resisted exercises (to be commenced)....... 3 1.3 Stage 3 Progress resisted exercises through range to encourage rotator cuff strengthening... 3 1.3.1 All range of movements, short and long lever.... 3 1.3.2 Use of theraband, weights. 3 1.3.3 The inclusion of appropriate functional and sports specific exercises overhead activities... 3 1.4 Dose of exercise sessions. 3 2. Stage 1 of Physiotherapy Intervention Assessment, observation, posture and humeral head position 4 2.1 Subjective history 4 2.2 Objective examination 4 2.2.1 To correct position in standing.. 4 2.3 Clear cervical spine. 4 2.4 Observe scapular stability.. 4 2.5 Passive range of motion. 4 2.6 Resisted tests.. 4 2.7 Special tests, including impingement tests. 4 2.8 Palpation... 4 3. Stage 1 of Physiotherapy Intervention, including Physio Tools exercises. 5 4. Stage 2 of Physiotherapy Intervention, including Physio Tools exercises. 18 5. Stage 3 of Physiotherapy Intervention, including Physio Tools exercises. 33 6. Physiotherapy Assessment between Treatment Sessions.. 52 6.1 Subjective assessment... 52 6.2 Objective assessment. 52 6.3 Exercise adherence 52 SUPPORT Physiotherapy Intervention Training Manual, Version 3.0: 04/01/11 2
1. General Overview of Physiotherapy Intervention 1.1 Stage 1 Physiotherapy assessment 1.1.1 Assess for posture - correct as required can use taping, anterior soft tissue release techniques 1.1.2 Assess for scapula stability - correct / retrain if required use progressive scapula setting exercises in prone, sitting, gym ball and standing initial minimal active movement - short lever, long lever visual clues, red dot 1.1.3 Include proprioception / weight bearing type exercises sitting push up, push up against wall, 4 point kneel - gym ball or wobble board 1.2 Stage 2 Progress to ROM exercises, with scapula control and pain-free range 1.2.1 Forward flexion, abduction, internal and external rotation can be progressed from assisted to full active exercises can be progressed to standing can include eccentric and concentric exercises if pain free 1.2.2 ROM stretching exercises (if required), to gain end of range position - pain free hand behind head, hand behind back, door frame stretch, scarf stretch 1.2.3 Isometric resisted exercises (to be commenced) isometric exercises in neutral and progress to fixed ROM positions - pain free use of doorframe, self resistance 1.3 Stage 3 Progress resisted exercises through range to encourage rotator cuff strengthening 1.3.1 All range of movements, short and long lever 1.3.2 Use of theraband, weights 1.3.3 The inclusion of appropriate functional and sports specific exercises - overhead activity 1.4 Dose of exercise sessions 6-8 treatment sessions, over a 12-16 week period teach between 2-6 new exercises / progressions per session (if patient able) number of repetitions will depend on the individual / fatigue level (they must progress at each session frequency is daily - stage one exercises to be done hourly - stages 2 to be done 3-4 times day - and stage to be done 3 times a week SUPPORT Physiotherapy Intervention Training Manual, Version 3.0: 04/01/11 3
2. Stage 1 of Physiotherapy Intervention Assessment, observation, posture and humeral head position Physiotherapy assessment will include the following aspects:- 2.1 Subjective history This will include:- history of presenting condition aggravating and easing factors drug history social history past medical history occupational and recreation factors fears and beliefs A proforma will be available to assist you 2.2 Objective examination Observation in standing position to:- ensure scapula equi-distant from thoracic spine check for kyphosis/ scoliosis check position of humeral head, that it is inferiorly located (protracted) 2.2.1 To correct posture in standing ensure good lumbar spine position re-correct position of humeral head and scapula position identify tight structures for stretching identify requirement for propiroceptive taping 2.3 Clear cervical spine active range of motion of shoulder complex 2.4 Observe scapula stability observe in - prone - sitting - standing - on gym ball 2.5 Passive range of motion observe scapular stability during range of motion 2.6 Resisted tests 2.7 Special tests, including impingement tests 2.8 Palpation SUPPORT Physiotherapy Intervention Training Manual, Version 3.0: 04/01/11 4
3. Stage 1 of Physiotherapy Intervention Scapula control exercises Progression Prone 10 repetitions, holding for 10 seconds If patient can achieve this, progress to sitting To be done hourly Sitting Flexion and Abduction only to 90 degrees with control 10 repetitions, holding for 10 seconds If patient can achieve, progress to standing To be done hourly Standing Proprioception To be done hourly Flexion and Abduction only to 90 degrees with control 10 repetitions, holding for 10 seconds To be done hourly Gym Ball Table Wall If the patient can achieve good posture and scapula control without re-training, then progress onto Phase 2. Add in capsular stretches if required see PhysioTools exercises SUPPORT Physiotherapy Intervention Training Manual, Version 3.0: 04/01/11 5
Physiotherapy exercises from Physio Tools Stage 1 Scapula Setting Control ROM Proprioception / Weight Bearing SUPPORT Physiotherapy Intervention Training Manual, Version 3.0: 04/01/11 6
Stage 1 Exercise 1 Lie on your front with your forehead supported by a folded towel and, with your pelvis and upper back relaxed with your arm by your side. Move the front of the shoulder backwards slightly. Make sure that the shoulder does not move up or down. It must move in a precise forward and back direction. Hold this position seconds. L R
Stage 1 Exercise 2 Sit tall and unsupported, with your head aligned over your shoulders and your upper body balanced over the pelvis. Bring your shoulder blade down and back. Hold this position seconds.
Stage 1 Exercise 3 Stand tall and unsupported, with your head aligned over your shoulders and the upper back balanced over the pelvis and your arm by your side. Bring your shoulder blade down and back. Hold this position seconds.
Stage 1 Exercise 4 Sit/Stand tall with your arm by your side, bring the shoulder blade down and back. Lift your arm forwards to the level of your shoulder. Keep your shoulder blade still and lower your arm to your side. L R
Stage 1 Exercise 5 Sit/Stand tall with your arm by your side, bring your shoulder blade down and back. Lift your arm sideways leading with your thumb to just below the level of your shoulder. Keep your shoulder blade still and lower your arm to your side.
Stage 1 Exercise 6 Sit/Stand tall with your arm by your side and your elbow bent at a right angle. Bring your shoulder blade down and back. Move your hand inwards (towards your tummy) and outwards (away from your tummy) keeping your shoulder still.
Stage 1 Exercise 7 Crawling position. Bring the shoulder blade down and back. Lean forward and transfer your weight onto your arms, then shift your weight backwards and to the sides.
Stage 1 Exercise 8 Stand with both your hands supported on a table. Bring the shoulder blade down and back. Shift your weight over onto one arm. to other side.
Stage 1 Exercise 9 Sit with forearms resting on a table. Bring the shoulder blade down and back. Shift your weight onto one arm. on the other arm.
Stage 1 Exercise 10 Sitting on a chair, back straight. Bring the shoulder blade down and back. Clasp the arms of the chair and lift your bottom from the seat by straightening your arms and pushing the shoulders down. Do not let your chin poke forward.
Stage1 Exercise 11 Stand facing a wall with your arms straight and hands on the wall. Bring the shoulder blade down and back. Do push-ups against the wall keeping your body in a straight line.
4. Stage 2 of Physiotherapy Intervention Standing Flexion and Abduction, Internal and External Rotation 10 repetitions of pain free range of motion, progressing to full range When patient can achieve, progress to isometrics To be done 3 times a day Progression Isometricsneutral position In standing with scapula correction In neutral position, pain free Flex, Ext, Add, Abd, MR, LR 10 second contraction 5-10 repetitions To be done 3 times a day Stretches in functional position. Lateral rotation, horizontal flexion, Hand Behind Head, Hand Behind Back 20-30 sec hold To be done 5 times and 3-4 times daily Isometricsin range In standing with scapula correction in pain free position Flexion, Extension, Adduction, Abduction, Medial rotation, Lateral rotation in range 10 second contraction 5-10 repetitions To be done 3 times a day SUPPORT Physiotherapy Intervention Training Manual, Version 3.0: 04/01/11 18
Physiotherapy exercises from Physio Tools Stage 2 Scapula Control and control through pain free range Stretches Isometrics neutral and through range SUPPORT Physiotherapy Intervention Training Manual, Version 3.0: 04/01/11 19
Stage 2 Exercise 1 Sit/Stand tall with your arm by your side, bring your shoulder blade down and back. Lift your arm forwards to the level of your shoulder. Relax the shoulder blade and continue to lift the arm forward as far as is comfortable. Lower your hand slowly to the level of your shoulder, reset your shoulder blade and lower your arm to your side.
Stage 2 Exercise 2 Sit/Stand tall with your arm by your side, bring your shoulder blade down and back. Lift your arm sideways leading with the thumb to just below the level of your shoulder. Relax the shoulder blade and continue to lift the arm sideways as far as is comfortable. Lower your hand slowly to the level of your shoulder reset your shoulder blade and lower your arm to your side.
Stage 2 Exercise 3 Stand or sit. Bend and lift the arm to be stretched. Grasp your elbow with the other hand and push up until you can feel the stretching at the back of your upper arm. Hold the stretch for 20 to 30 seconds.
Stage 2 Exercise 4 Stand with arms behind your back. Grasp the wrist of the arm you want to exercise. Slide your hands up the back. Hold the stretch for 20 to 30 seconds.
Stage 2 Exercise 5 Stand in a walking position. Bend your elbow and support the forearm against a door frame or corner. Gently rotate your upper trunk away from the arm until the stretching can be felt in the chest muscles. Hold the stretch for 20 to 30 seconds.
Stage 2 Exercise 6 Stand or sit. Stretch one arm over to the opposite shoulder by pushing it at the elbow with your other arm. Hold the stretch for 20 to 30 seconds.
Stage 2 Exercise 7 Stand facing a wall. Keep your upper arm closetoyour side with your elbow bent at a right angle. Push your fist against the wall. Hold for seconds.
Stage 2 Exercise 8 Stand with your back against the wall. Keep your upper arm close to your side with your elbow at a right angle. Push the elbow back against the wall, supporting your body weight. Hold for seconds.
Stage 2 Exercise 9 Stand sideways against a wall with your upper arm close to your side and your elbow bent at a right angle. Push your elbow against the wall. Hold for seconds.
Stage 2 Exercise 10 Stand with a pillow between your elbow and your body. Pull your elbow into your side, Squeezing the pillow. Hold for seconds.
Stage 2 Exercise 11 Stand with your upper arm close to your side, with your elbow bent at a right angle and the back of your hand against a wall. Push the back of your hand against the wall. Hold for seconds.
Stage 2 Exercise 12 Stand in a doorway with your elbow close to your body and bent at a right angle. Place your hand against the wall. Push your hand inwards against the wall. Hold for seconds.
a) upwards b) downwards c) outwards d) inwards e) turn the forearm inwards f) turn the forearm outwards Hold the contraction for seconds. Stage 2 Exercise 13 Lift your arm forwards to degrees (as advised by your Physiotherapist), keep your elbow bent at a right angle. Bring your shoulder blade down and back. Use your opposite hand as resistance to push either :-
5. Stage 3 of Physiotherapy Intervention Resisted exercise with RED theraband All ranges to be included Resistance through range Start at 10 repetitions, and increase to a maximum of 20 If the patient is able to achieve this, then progress to Blue theraband Resisted exercise with BLUE theraband Progression All ranges to be included Resistance through range Start at 10 repetitions, and increase to a maximum of 20 If the patient is able to achieve this, then progress to Black theraband Resisted exercise with BLACK theraband Resisted exercise with Black theraband will only be applicable for those patients that can achieve this stage Sport and occupational specific exercises Sport and occupational specific exercises will be dependant on patient needs SUPPORT Physiotherapy Intervention Training Manual, Version 3.0: 04/01/11 33
Physiotherapy exercises from Physio Tools Stage 3 Resisted with theraband SUPPORT Physiotherapy Intervention Training Manual, Version 3.0: 04/01/11 34
Stage 3 Exercise 1 Secure the THERABAND firmly to a stable object i.e. a closed door handle. Stand facing away from the THERABAND. Bring the shoulder blade down and back. Pull the band forward and upwards.
Stage 3 Exercise 2 Secure the THERABAND firmly to a stable object i.e. a closed door handle. Stand facing the THERABAND. Bring the shoulder blade back and down. Bring your arm straight back whilst pulling the band.
Stage 3 Exercise 3 Secure the THERABAND firmly to a stable object i.e. a closed door handle. Stand with your affected arm away from the wall. Bring the shoulder blade back and down. Lift the arm out to the side, keeping your elbow straight.
Stage 3 Exercise 4 Secure the THERABAND firmly to a stable object i.e. a closed door handle. Stand with your arm out to the side. Hold on to a the THERABAND. Bring your shoulder blade down and back. Pull the band in towards your side.
Stage 3 Exercise 5 Secure the THERABAND firmly to a stable object i.e. a closed door handle. Stand keeping your upper arm closetoyour side with your elbow bent at a right angle. Hold the THERABAND. Bring the shoulder blade down and back. Pull the band by turning your forearm outwards.
Stage 3 Exercise 6 Secure the THERABAND firmly to a stable object i.e. a closed door handle. Stand keeping your upper arm close to the side with your elbow bent at a right angle. Hold on to the THERABAND. Bring your shoulder blade down and back. Pull the band toward your stomach.
Stage 3 Exercise 7 Secure the THERABAND firmly to a stable object i.e. a closed door handle. Stand with your arm down and out to the side. Hold on to the THERABAND. Bring your shoulder blade down and back. Pull the band up and across your body letting your thumb lead the movement.
Stage 3 Exercise 8 Secure the THERABAND firmly to a stable object i.e. a closed door handle. Stand with the hand of the arm tobeexercised in front of your opposite hip. Hold on to the THERABAND. Bring your shoulder blade down and back. Pull the band up and away to the opposite side.
Stage 3 Exercise 9 Lying face down, arms behind your back. Lift your upper trunk off the floor and pull your shoulder blades together. Look down at the floor whilst you are doing the exercise. Hold for seconds
Stage 3 Exercise 10 Lying face down with your arms by your sides or in a T-position and your palms facing the floor. Lift your upper trunk off the floor and pull your shoulder blades together. Keep your neck straight and look at the floor during the exercise. Hold for seconds.
Stage 3 Exercise 11 Lying face down with your arms above your head and in line with your body. Lift your upper trunk off the floor. Breathe in during the exercise. Hold for seconds.
Stage 3 Exercise 12 Stand leaning on a table with one hand. Let your other arm hang relaxed straight down. Bend your elbow bringing it behind your back and pull your shoulder blades together. Hold for seconds.
Stage 3 Exercise 13 Lying face down with a cushion/stool under your lower legs. Do push-ups keeping your body in a straight line.
Stage 3 Exercise 14 Sit/Stand unsupported with you shoulder blade down and back. Bend your elbow to a right angle and take your arm to the side to the level of your shoulder. Slowly rotate the arm so that the hand rotates up towards the ceiling and then change direction to rotate the hand down towards the pelvis. L R
SUPPORT Trial: Advanced control Stage 3 Exercise 15 Stand tall with your arm by your side, bring your shoulder blade down and back. Lift your arm forward so that your fingers point towards the corner of the room. In this position draw the alphabet or your name.
SUPPORT Trial: Advanced control Stage 3 Exercise 16 Standing tall with your arm by your side, facing a box. Bring your shoulder blade down and back. Lift the box from waist height onto a shelf or into a cupboard.
SUPPORT Trial: Advanced control Stage 3 Exercise 17 Standing tall with your arm by your side, bring the shoulder blade down and back. Hold a cloth in your hand, raise your arm forwards to degrees and practise cleaning windows. Move your arm in a circular motion clockwise / anticlockwise.
6. Physiotherapy Assessment between Treatment Sessions Physiotherapists will assess patient progress in between treatment sessions. A subjective and objective re-assessment will take place at the start of each treatment session. 6.1 Subjective assessment This may include such questions as:- How would you currently rate your pain? Are your symptoms improving? Do you feel you have improved functionally? Is your sleep being disturbed? Visual Analogue Score (VAS) of pain 6.2 Objective assessment This may include:- Active range of motion (re-assessing scapular stability) 6.3 Exercise adherence Questions will also be asked about exercise adherence, for example:- Have you been able to complete the exercises you were given at the last / first visit Are there any obstacles preventing you undertaking the exercises? SUPPORT Physiotherapy Intervention Training Manual, Version 3.0: 04/01/11 52