The SUPPORT Trial - Keele University · The SUPPORT Trial: ... 1.2.3 Isometric resisted exercises ... can be progressed from assisted to full active exercises

SUPPORT Physiotherapy Intervention Training Manual, Version 3.0: 04/01/11

1

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) – Orthopaedic / A&E Physiotherapy Practitioner Julie Shufflebotham (JS) – Senior Physiotherapist Kay Stevenson (KS) – Consultant Physiotherapist


2

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 pain-

free 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


3

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


4

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


5

3. Stage 1 of Physiotherapy Intervention Scapula control exercises

10 repetitions, holding for 10 seconds

If patient can achieve this, progress to sitting

To be done hourly

Flexion and Abduction only to 90 degrees with control


If patient can achieve, progress to standing

To be done hourly

Flexion and Abduction only to 90 degrees with control


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

Prone

Standing

Sitting

Proprioception

To be done hourly

Progression


6

Physiotherapy exercises from Physio Tools

Stage 1

Scapula Setting

Control ROM

Proprioception / Weight Bearing

Personal Exercise Program

Provided by : SUPPORT Trial

© PhysioTools Ltd

Stage 1 Exercise 1

Lie on your front with your forehead supported by a folded towel and, withyour pelvis and upper back relaxed with your arm by your side.

Move the front of the shoulder backwards slightly. Make sure that theshoulder does not move up or down. It must move in a precise forward and back direction.

Built on PhysioTools®

Hold this position seconds. Repeat times. L R

© PhysioTools Ltd

Stage 1 Exercise 2

Sit tall and unsupported, with your head aligned over your shoulders andyour upper body balanced over the pelvis. Bring your shoulder blade down and back.

Hold this position seconds. Repeat times.





© PhysioTools Ltd

Stage 1 Exercise 3

Stand tall and unsupported, with your head aligned over your shouldersand the upper back balanced over the pelvis and your arm by your side. Bring your shoulder blade down and back.

Hold this position seconds. Repeat times.



© PhysioTools Ltd

Stage 1 Exercise 4

Sit/Stand tall with your arm by your side, bring the shoulder blade downand back.

Lift your arm forwards to the level of your shoulder. Keep your shoulderblade still and lower your arm to your side.

Repeat times. L R





© PhysioTools Ltd

Stage 1 Exercise 5

Sit/Stand tall with your arm by your side, bring your shoulder blade downand back.

Lift your arm sideways leading with your thumb to just below the level ofyour shoulder. Keep your shoulder blade still and lower your arm to your side.




© PhysioTools Ltd

Stage 1 Exercise 6

Sit/Stand tall with your arm by your side and your elbow bent at a rightangle. Bring your shoulder blade down and back.

Move your hand inwards (towards your tummy) and outwards (away fromyour tummy) keeping your shoulder still.





© PhysioTools Ltd

Stage 1 Exercise 7

Crawling position. Bring the shoulder blade down and back.

Lean forward and transfer your weight onto your arms, then shift yourweight backwards and to the sides.

Repeat times.


© PhysioTools Ltd

Stage 1 Exercise 8

Stand with both your hands supported on a table. Bring the shoulderblade down and back.

Shift your weight over onto one arm. Repeat to other side.

Repeat times.




© PhysioTools Ltd

Stage 1 Exercise 9

Sit with forearms resting on a table. Bring the shoulder blade down andback.

Shift your weight onto one arm. Repeat on the other arm.

Repeat times.




© PhysioTools Ltd

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.

Repeat times.




© PhysioTools Ltd

Stage1 Exercise 11

Stand facing a wall with your arms straight and hands on the wall. Bringthe shoulder blade down and back.

Do push-ups against the wall keeping your body in a straight line.

Repeat times.





18

4. Stage 2 of Physiotherapy Intervention

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

In standing with scapula correction

In neutral position, pain free

Flex, Ext, Add, Abd, MR, LR

10 second contraction

5-10 repetitions


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


Standing

Isometrics-

neutral position

Isometrics-

in range

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

Pro

gre

ssio

n


19


Stage 2

Scapula Control and control through pain free

range

Stretches

Isometrics neutral and through range



© PhysioTools Ltd

Stage 2 Exercise 1


Lift your arm forwards to the level of your shoulder. Relax the shoulderblade 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.

© PhysioTools Ltd

Stage 2 Exercise 2


Lift your arm sideways leading with the thumb to just below the level ofyour 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 shoulderblade and lower your arm to your side.






© PhysioTools Ltd

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 thestretching at the back of your upper arm. Hold the stretch for 20 to 30 seconds.

Repeat times.


© PhysioTools Ltd

Stage 2 Exercise 4

Stand with arms behind your back. Grasp the wrist of the arm you want toexercise.

Slide your hands up the back. Hold the stretch for 20 to 30 seconds.

Repeat times.




© PhysioTools Ltd

Stage 2 Exercise 5

Stand in a walking position. Bend your elbow and support the forearmagainst a door frame or corner.

Gently rotate your upper trunk away from the arm until the stretching canbe felt in the chest muscles. Hold the stretch for 20 to 30 seconds.

Repeat times.




© PhysioTools Ltd

Stage 2 Exercise 6

Stand or sit.

Stretch one arm over to the opposite shoulder by pushing it at the elbowwith your other arm. Hold the stretch for 20 to 30 seconds.

Repeat times.






© PhysioTools Ltd

Stage 2 Exercise 7

Stand facing a wall. Keep your upper arm close to your side with yourelbow bent at a right angle.

Push your fist against the wall. Hold for seconds.

Repeat times.





© PhysioTools Ltd

Stage 2 Exercise 8

Stand with your back against the wall. Keep your upper arm close to yourside with your elbow at a right angle.

Push the elbow back against the wall, supporting your body weight. Holdfor seconds.

Repeat times.




© PhysioTools Ltd

Stage 2 Exercise 9

Stand sideways against a wall with your upper arm close to your side andyour elbow bent at a right angle.

Push your elbow against the wall. Hold for seconds.

Repeat times.




© PhysioTools Ltd

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.

Repeat times.




© PhysioTools Ltd

Stage 2 Exercise 11

Stand with your upper arm close to your side, with your elbow bent at aright angle and the back of your hand against a wall.

Push the back of your hand against the wall. Hold for seconds.

Repeat times.

© PhysioTools Ltd

Stage 2 Exercise 12

Stand in a doorway with your elbow close to your body and bent at a rightangle. Place your hand against the wall.

Push your hand inwards against the wall. Hold for seconds.

Repeat times.







a) upwards b) downwards c) outwards d) inwards e) turn the forearm inwards f) turn the forearm outwards

Hold the contraction for seconds.

Repeat times.

© PhysioTools Ltd

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 :-


33

5. Stage 3 of Physiotherapy Intervention

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

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 will only be applicable for those patients that can achieve this stage

Sport and occupational specific exercises will be dependant on patient needs

Resisted exercise with

RED theraband


BLUE theraband


BLACK theraband

Sport and occupational specific

exercises

Pro

gre

ssio

n


34


Stage 3

Resisted with theraband



© PhysioTools Ltd

Stage 3 Exercise 1

Secure the THERABAND firmly to a stable object i.e. a closed doorhandle.

Stand facing away from the THERABAND. Bring the shoulder blade downand back. Pull the band forward and upwards.

Repeat times.


© PhysioTools Ltd

Stage 3 Exercise 2


Stand facing the THERABAND. Bring the shoulder blade back and down.Bring your arm straight back whilst pulling the band.

Repeat times.




© PhysioTools Ltd

Stage 3 Exercise 3


Stand with your affected arm away from the wall. Bring the shoulder bladeback and down. Lift the arm out to the side, keeping your elbow straight.

Repeat times.




© PhysioTools Ltd

Stage 3 Exercise 4


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.

Repeat times.




© PhysioTools Ltd

Stage 3 Exercise 5


Stand keeping your upper arm close to your side with your elbow bent ata right angle. Hold the THERABAND. Bring the shoulder blade down and back. Pull the band by turning your forearm outwards.

Repeat times.




© PhysioTools Ltd

Stage 3 Exercise 6


Stand keeping your upper arm close to the side with your elbow bent at aright angle. Hold on to the THERABAND. Bring your shoulder blade down and back. Pull the band toward your stomach.

Repeat times.




© PhysioTools Ltd

Stage 3 Exercise 7


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.

Repeat times.




© PhysioTools Ltd

Stage 3 Exercise 8


Stand with the hand of the arm to be exercised in front of your oppositehip. Hold on to the THERABAND. Bring your shoulder blade down and back. Pull the band up and away to the opposite side.

Repeat times.






© PhysioTools Ltd

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


Repeat times.




© PhysioTools Ltd

Stage 3 Exercise 10

Lying face down with your arms by your sides or in a T-position and yourpalms 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.

Repeat times.




© PhysioTools Ltd

Stage 3 Exercise 11

Lying face down with your arms above your head and in line with yourbody.

Lift your upper trunk off the floor. Breathe in during the exercise.

Hold for seconds.

Repeat times.

© PhysioTools Ltd

Stage 3 Exercise 12

Stand leaning on a table with one hand.

Let your other arm hang relaxed straight down. Bend your elbow bringingit behind your back and pull your shoulder blades together.

Hold for seconds.

Repeat times.




© PhysioTools Ltd

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.

Repeat times.






© PhysioTools Ltd

Stage 3 Exercise 14

Sit/Stand unsupported with you shoulder blade down and back. Bend yourelbow 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.

Repeat times. L R



SUPPORT Trial: Advanced controlProvided by : SUPPORT Trial

© PhysioTools Ltd

Stage 3 Exercise 15

Stand tall with your arm by your side, bring your shoulder blade down andback. Lift your arm forward so that your fingers point towards the corner of the room. In this position draw the alphabet or your name.

Repeat times.





© PhysioTools Ltd

Stage 3 Exercise 16

Standing tall with your arm by your side, facing a box. Bring your shoulderblade down and back. Lift the box from waist height onto a shelf or into a cupboard.

Repeat times.

SUPPORT Trial: Advanced control




© PhysioTools Ltd

Stage 3 Exercise 17

Standing tall with your arm by your side, bring the shoulder blade downand back. Hold a cloth in your hand, raise your arm forwards to degrees and practise cleaning windows. Move your arm in a circularmotion clockwise / anticlockwise.

Repeat times.

SUPPORT Trial: Advanced control


52

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?

The SUPPORT Trial - Keele University · The SUPPORT Trial: ... 1.2.3 Isometric resisted exercises ... can be progressed from assisted to full active exercises

Documents