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Gentle, Gentle, with that Shoulder!

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I'm an entry-level OTR who has observed problems with ADL because of shoulder limitations in older adults. How do I know when its frozen shoulder or some other old injury?

Sometimes it is difficult to discover all of your patient's problems during the initial evaluation. This is why it generally takes me more than one session to complete my assessment. When you rush your initial evaluation, you make errors. An older adult's past medical history may be complicated by extrinsic factors: old injuries, osteo and rheumatoid arthritis, joint trauma and other diseases. It could very well be a combination of conditions.

Frozen shoulder has been around for more than 100 years. The technical term for it is "adhesive capsulitis." It affects women more than men, and its primary feature is painful restriction of motion that often affects lifestyle and activity.

In older adults a key feature of frozen shoulder is the gradual and progressive loss of movement, and shoulder pain over several weeks and months. An older adult may say things like, "I can't reach that high anymore, or behind my back."

During the initial evaluation, complete a comprehensive upper-extremity assessment. This would include cervical, scapula, trunk mobility and rotation. Limited passive ROM is typical. The patient will typically complain of pain at the end joints. You usually find less than 80 degrees of shoulder abduction, with a capsular end feel. Palpating the biceps and surrounding musculature will help you to document any tenderness.

Behaviorally, the patient is usually guarding the arm and keeps it adducted, rotated inward or held very close to the body. In older people, the evaluation process may be complicated by cognitive deficits, non-ambulatory status and poor posture. Seniors may even yell out in pain for no apparent reason from the slightest bit of movement. Or they may be unable to sleep at all.

The ADL evaluation will probably reveal difficulty in reaching high and behind their backs, dressing, grooming and performing other simple tasks. Consultation with your physician and nursing staff, and review of the medical history may give you more data. This communication is necessary because your patient may need an analgesic or corticosteroid directly to the site.

It is important for OT staff to follow orders following a shoulder manipulation, which may include exercise. The primary objective in the early stage of treatment is to decrease pain and inflammation. OT intervention after that would include active and active-assistive exercise, wand exercises, pendulum exercises, and frequent passive ROM by the therapist-gently. I have observed many therapists inappropriately handling and stabilizing the upper extremity. It should not be jerked around or stretched too far or too fast. Clearly document in your notes a patient's complaint of pain or discomfort at any stage in the treatment process, specifying the location of the pain. This includes who you told about the pain, and when.

You will increase your chances of reimbursement if you do ongoing reassessment of the upper extremity. Therefore re-evaluation of shoulder function is warranted weekly.

OTs should encourage the patient to use the arm in ADL. I use many functional activities to achieve ROM, often with the patient being unaware of the pain. Engaging your client in purposeful activity helps to improve the emotional and psychological status. Our job is to prevent further injury and to teach the patient how to care for him or herself.

Caregiver training begins at the start of the program. In the SNF or ALF environment, restorative and other nursing personnel will need training in proper posture, positioning and pain management. This will include skin inspections, proper handling techniques and ROM techniques for the nursing staff.

Most of our discharge training is geared toward nursing management and CNAs. I have found that nursing leadership must be in the loop of therapy management for optimal carryover. We require strict documentation of gains made in OT, and they must be highlighted on the care plan. Someone has to be held accountable, and I believe that it begins with upper management, which eventually trickles down to the person who does the labor.

You will often find yourself in a counseling position. It is important that you tell the patient that it takes sometimes one to three years to recover or heal. Many older adults learn how to cope with the problem by adapting their environments to the deficit via adaptive and assistive equipment. Modifications may be warranted in the home, particularly in closet and cabinet areas. Safety and fall prevention should be a primary concern.

Here are some treatment approaches to consider for the frozen shoulder:

  • When possible, aggressively teach the patient how to perform his or her own ROM. Proof of good teaching is in patient follow-up. Use large visual handouts that are easy to follow. Pictures are better than words.

  • Try reaching tasks at various levels: lying, sitting and standing. I also monitor pain and blood pressure for over-the-head tasks. Prolonged pendulum exercises should be limited with patients who have syncope, cardiac and blood pressure problems.

  • Try joint mobilization. This will probably include both cephalad-caudad mobilization for pain and stiffness.

  • Caregiver hands-on training. Avoid discharging the patient without a written program. This sends the wrong message to Medicare, and it is simply unprofessional. You must have proof that someone was educated on your discharge OT program.

    It may be a good idea to attend several CE courses on shoulder dysfunction to improve your skill and confidence level. The more you experience, the better off you and your patient will be.

    Clarissa Fells Smith, PhD, OTR/L, has a doctorate in health services administration with a specialty in gerontology/geriatrics. She has worked as a manager and clinical education specialist and is currently an independent contractor, trainer, consultant and workshop leader in geriatric rehabilitation. Readers may contact her at clarissafsmith@aol.com.


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