Shoulder disorders (shoulder) are more common. Almost 30% of people who experience shoulder pain at some stage of their lives.For people aged over 65 years of shoulder pain are the most common musculus-skeletal problem.
Msc. Pht. M.Tifeku Irfan
Master of Physiotherapy
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Besides high incidence, scapular dysfunction is often continuous and repeated in 54% of people who have had continuous reporting of symptoms of 3 years. Manshetes pathology Rotator (Rotator Cuff) and subacromial bursa considered to be the main causes of pain and symptoms arising from the shoulders. What is worrying is that the shoulder pathology is associated with substantial dysfunction and morbidity.
There are several studies about the effectiveness of conservative treatment. Although the current evidence is insufficient to allow definitive conclusions to conservative treatment deletions of "rotate cuff" subacromiale of shoulder pain is usually treated with therapy non-operative training, drugs non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroid injection, shock-wave therapy, and other approaches.
Results of tests (tests) controlled random and systematic review of interventions for pathology "Rotate Cuff" and shoulder pain suggest that exercise can be an effective treatment, but there is a definite need for trials (tests) well-planned controlled to investigate the effectiveness of exercise in the management of the full and massive Tear "Rotator Cuff".
Presentation of the case study
The patient was a 53-year-old man who was suffering from a moderate pain in his right shoulder because he pulled a heavy object. Two days after the incident, due to the fall in an outstretched hand while climbing, he felt a very severe pain in the same area. Three days after the second incident, the patient was introduced in physical therapy clinic "Physiotherapy". He reported pain in his right shoulder, the first visit (Visual Analog Scale (VAS) = 9-10). In assessing the goniometer, right shoulder forward flexion was 150 degrees and 130 degrees abduksion painful. Internal rotation can be done with a lot of pain, not suitable for measuring the goniometer. Other movements were relatively normal shoulder and left shoulder was completely normal. Tests on the right shoulder showed a positive result for NEER sign violation, Empty Can test, Hawkins Kennedy and Speed Test test. In assessing the neck, string movement was normal and there was no pain. In evaluating postures that patient had chest kyphotic Posture, Posture of the head forward, arms straight scapular; and muscle shrinking right upper trapezius and levator scapulae.
During the five days mentioned, there is no treatment used except Trigger point massage therapist and manual on the injured shoulder for relaxation.There was no disease in the patient's medical history and he does not use any special treatment.
His history of the sport showed that in the past 10 years he went regularly twice a week for two hours each session, he went mountain climbing about 10 hours a week, and ran 20 kilometers at least 2 days a week.
In ultrasonography of the right shoulder that has had a complete tear of the supraspinatus tendon and other tendons were suspected of rupture and leakage was reported about tendines the biceps that was in favor of biceps tendonitis.
In MRI without contrast in the shoulder of the patient, a 17-mm gap reported in the introduction of the supraspinatus tendon. The fluid in the joint space of under-Deltoid, sub-acromial is also reported. Cuff rupture of ligaments and biceps tendon is not reported in MRI. Bone marrow edema was evident in greater tuberosity.
After the first visit, 10 sessions of physical therapy modalities (tens, US, heating the surface) are done once in two days, each session for 45 minutes. Besides modality, 15 mg tablet Meloxicam was prescribed for the patient twice a day, which is taken only for the first three days by the patient. An exercise program started by the fifth session of physical therapy modalities (2 weeks after the injury).
Exercise program under the supervision of physiotherapist twice a week in the first month of training and exercises are performed every day at home.The cooperation of the patient during 6 months of treatment was excellent and he head learned exercises with high precision. In the early days of the training program, the patient consulted two orthopedic surgeon, both suggested a surgery on tendons of manshetës. However, due to his fear he decided to carry out fiscal program for 6 months. If fiscal program failed, he would have had an operation. Patient benefit was that you left a surgical intervention.
In the first phase of the program of practice, passive ROM exercises are done in the form of forward flexion, internal rotation, external rotation, and abduksionit. Pendulum exercise, exercise isometrike shoulder, chin tuck, back extension, exercise shrug been made at this stage also. All these exercises are done 30 times a day. Expansion exercises (stretching) to the posterior capsule (posterior), previous capsule (anterior), inferior capsule, and trapezius muscles were done twice a day. Every time 5 repetitions were made for 15 seconds. During the first month of treatment, they were supervised training exercises twice a week for an hour under the supervision of physiotherapist doctor. If there was a problem in carrying out exercises by the patient, provided necessary recommendations. On other days of the exercises are done in-house.
After receiving the full passive ROM shoulder including a reduction of pain, the drug electrophoresis., Training of manpower for Rotator Cuff was initiated from the second month as the second phase of treatment. Phase includes exercise (0 -30 degree abduction), internal strengthening exercises to external rotatory (0 abduction scale, scaption (0-60 scale), internal rotate and external (45 degree abduction), and biceps ( 0-90 scale) exercise. Three weeks later the third stage exercises have begun and are developing attractive strength training and exercises (stretching) for the neck.
At the beginning of the third month of therapy, muscle training periscapular Foam is added to the previous exercises. Postponing (push up) of the wall, extending the wall up with medical ball, "push up" plus were conducted as 3 sets of 10 repetitions every other day except exercise. Rigorous training strengthening the scourge has grown gradually over the coming months as 3 sets of 15 repetitions and abduction was done in high angles. Medical ball exercises are done to push up workout quadruped, diagonal drill. At the beginning of each treatment session sport, systematic heat 10-15 minutes of brisk walking is done. At the end of each session of treatment, the ice is applied on the right shoulder for 20 min. After three months of training therapy, the patient was allowed to swim twice a week. Given a little pain in full abduction, he was advised not to have full strokes.
At the end of the training program of 6 months, the patient's pain according to VAS amounted to 0. In fiscal program evaluation after 6 months, there was a negative result for NEER sign violation, Empty Can test, Hawkins Kennedy test, and the test speed; however, the scapular winging continued. These results continued through the month 9. In examining goniometer, there were 146 degree and 170 degree flexing abduction front right shoulder.
At the end of 6 months of treatment, ultrasonically of the shoulder showed difference compared to before treatment. In contrast MRI on the shoulder without patient, a 14-mm gap reported in the introduction of tendon supranational. Lingual joint space under-acromial sub-triangle is reported. Bone marrow edema was evident in greater tuberculosis. After completing the program, the patient has initiated mountain climbing twice a week, and he swam twice a week, each time for 2 hours.
It is better to follow-up patients 3 years after treatment to study the long term effects of conservative therapy.
Patient house was very close to the place of inpatient treatment. On the other hand, since the patient was retired, he could take part in a session of treatment or supervision and he had a satisfactory cooperation. It can be concluded that familiarity and having a history of sports and exercise, and careful execution models trained by the patient were very helpful in his treatment outcome. Having regard to the opinion of the therapist, the patient's cooperation in carrying out exercises prudent is one of the most important factors in the effectiveness of exercise therapy. / Telegraph /
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