Physical Therapy and Shoulder Pain

Dr. Sechrest: Hello, I’m Dr. Randale Sechrest, your host for eOrthopod.TV. Today I have as my guest, Dr. Angela Listug-Vap. Dr. Listug-Vap is a Doctor of Physical Therapy who works at Alpine Physical Therapy here in Missoula, Montana. Thanks for joining us today, Angela. Well, what I thought we would talk about a bit today is how you use those skills in terms of dealing with patients who have shoulder problems, and what I thought we would limit this discussion to is patients who really haven’t had surgery. We’re not going necessarily focus on patients after a shoulder surgery. But what I’d like to do is focus on your approach, as an orthopaedic manual physical therapist, to the patient who may be referred to you with some type of problem in the shoulder, and it’s most likely causing either pain or a combination and loss of function. So I guess, first of all, can you help us define how you assess that patient and what you’re looking for and what you’re decision-making process is when you first see that patient.

Dr. Listug-Vap: So when a patient first comes in to me with shoulder pain there’s usually pain and disability or loss of function. Those two things often go hand in hand. The first thing that I do is evaluate them with the idea that I’m trying to figure out where the primary nature of the problem is coming from. Often it’s coming from the shoulder but I definitely have to rule out the cervical and thoracic spine as the source of the problem because I would say, 50% of the time when they get to me and surgery is not an option for them, their pain is coming from the spine. So Step 1 is just finding out where is the primary source of pain.

Dr. Sechrest: I think one of the things that we should point out for patients who are viewing this video is that I think things are changing a bit in the physical therapy and the relationship of physical therapists with both orthopaedic surgeons and family practitioners, people who see patients with shoulder pain. I think in the old days typically the surgeon would send a patient to a physical therapist with a very specific exercise program or very specific instructions about what they wanted done. Now I think that still occurs, don’t get me wrong, and some shoulder specialists, they may continue to send with very specific instructions. But I think physical therapists, such as yourself, have become much more adept at both diagnosis and also beginning to be a part of the treatment team that not only just does specific treatments, but also assesses and tries to send some information back to that physician about what’s really going on with this patient and help with that diagnostic process. So I think that if you could explain a little bit about that diagnostic process in a little bit more detail that you go through as you assess the patient. What are you looking for in terms of your physical assessment?

Dr. Listug-Vap: Well, you’re exactly right. I will get – to back up just a little and respond to your first point – sometimes a patient will come in with a very specific shoulder diagnosis from an orthopaedic surgeon and if I know the diagnosis I usually just confirm it and then continue on. But more often than not we now get a diagnosis of just nonspecific shoulder pain and that’s where I will start to go into my evaluation and my evaluation will include looking at movement. So, of course, their active movement, not just in the shoulder but in the neck and the thoracic spine because the shoulder shares muscles across both joints – so if you think of the spine as several joints. You’re looking at movement. I look at movement in two ways. I look at movement in terms of, it’s called physiological movement, and that’s the movement we all think about, just raising the arm or out to the side. But then I look at how the joint is actually moving where the two bones meet each other, that’s called accessory movement, and usually for that I’ll have a person lying on their back and I actually put my hands right on the joint line and go in all the directions that it needs to move. So those are two ways that I look at movement. The other thing that I start to look at is strength, not just brute strength. I do, of course, look at how strong are they if I give them some resistance, but also do they have an accurate firing pattern of the muscles. In shoulder problems often we see that people can get their arm up but they’ll get a big hike here and that tells me that they aren’t firing muscles in a way that actually get smooth joint movement and can create impingement type problems. Those are the three main areas that I start with and then, of course, I get my hands on their tissues, just local tissues, feeling for whether or not a tissue feels healthy under my hand or often an inflamed or angry type tissue will feel very thick and almost rope-like when I go over tendons or muscle tissue. We call that palpation when we actually just put our fingers on to feel that tissue.

Dr. Sechrest: Now, what sort of conditions are you used to seeing patients come in with, in terms of the diagnoses that you and I may make in terms of clinical diagnosis. We typically put shoulder problems in different categories whether they’re rotator cuff problems, they may be impingement problems as you’ve suggested. There are all sorts of different problems that can cause pain on the inside of the shoulder – different dysfunctions. What sort of common diagnoses are you used to seeing present to your clinic with the diagnosis of nonspecific shoulder pain, and what sort of conditions are those patients suffering from?

Dr. Listug-Vap: I think I understand your question correctly. If I answer this and am going down the wrong path let me know. I definitely see impingement as a primary problem in nonspecific shoulder pain and impingement happens for a couple reasons. One is we think of it as a hyper-mobile joint and that means that it moves too much and, therefore, when you go to use your arm you’re actually frictioning against tissue creating an impingement problem. The other impingement is a hypo-mobile type problem and that’s where a joint might be too stiff or, because of degenerative process in our lives, space for tendons is reduced and there’s not really good movement happening at joints and so you end up with impingement problems. So there’s are two common ones. Another common diagnosis that we see on quite a continuum is adhesive capsulitis and that’s a diagnosis that doesn’t often warrant surgery and, if we can catch it in certain phases of that diagnosis, we can speed up the process of recovery. Other problems might be small rotator cuff tears where people don’t want to have surgery and still have the ability to gain strength. Large rotator cuff tears, often those are surgically addressed first and then they’ll end up in physical therapy afterward. Other types of problems might be acromioclavicular sprains, the acromioclavicular sprain. People might know as a separated shoulder so those are very common things to see in the clinic.

Dr. Sechrest: Now when you see these patients and you begin to formulate a treatment plan, it sounds to me like your role in the process of helping physicians, or treating these patients, and being a member of that treatment team is twofold. One is, as you mentioned, to really define the diagnosis to try to identify all the dysfunctions in the shoulder. Physicians sometimes will make a diagnosis of rotator cuff disease or something like that but I don’t think physicians necessarily are capable, in some cases, of really defining what that means in terms of shoulder function. So we don’t necessarily go in to trying to understand what the different muscle groups, the balance in the muscles, those sorts of things. I think we understand it in a global way, but I don’t necessarily think that we have the training that you do in order to really understand what do I need to do to balance this shoulder? What different components do I need to do? I think we rely on the physical therapist to really define that and then move forward and create a treatment program. So when you’re doing that next step, when you’re beginning to work with the patient to really define and progress them in a program – how are you going to approach that with a patient?

Dr. Listug-Vap: In addressing your first point I completely, again, that a doctor will often send us a diagnosis that is completely accurate but it’s really the physical therapist’s role in this stage of health care to find out what we call ‘all the impairments’ that contribute toward the problem. In physical therapy we don’t really call it a diagnosis. We call it an assessment and that includes all those small impairments. So when a person comes in and we go through that evaluation we’re, in our heads and then later on paper, making a list of all the things that we need to address for them. How I usually approach that problem is I start with movement at the joint. Because if they don’t have enough movement or correct movement at the joint, what I referred to earlier as accessory movement, then everything else isn’t going to work right. So if there’s an impairment in that area, I address that first. I follow that up by physiological movement training and that might just be passive range-of-motion. That might be shoulder stretches. That, again, is the entire movement. That’s what we all think about movement is that physiological movement, so we address that next. After they gain a decent amount of range, then we move on to training a good movement pattern. Sometimes we start in supine – which just means that you’re on your back – and we’re helping you move really nicely through a range rather than getting into all the little bad habits that people have developed when they’ve been under pain. We’ll train good movement patterns there, then we take it into sitting where it’s definitely different because now you’re working against gravity. Sometimes even before I get to sitting positions, they’re down on the mat and I go from passive, to where they’re helping me with it, to where I’m resisting that movement pattern. So you’re just training movement patterns. Then the next step is getting stronger or more stable and I think of those two words differently. I think of ‘strength’ as being how much power can a muscle generate, and I think of stability as really all the muscles working together in a coordinated fashion to keep the joint in place no matter where it is in space. But that’s definitely where we get into muscle training, and for shoulder problems that’s going to include muscles around the shoulder blade and, of course, the rotator cuff. After you get good muscle control of that shoulder joint, focused on those muscle groups, then we move into more functional type strengthening or training. That’s where we’re really working the big muscle groups in addition to the smaller rotator cuff muscle group and then the shoulder blade. So you just layer it on.

Dr. Sechrest: I think a lot of patients are listening to this and they’re saying, “Well, gosh, how long is this going to take me to achieve some gains in terms of my shoulder function?”. I guess it falls into two categories. One is just the logistics of a patient who is coming into the clinic and beginning to go through a shoulder rehabilitation program after they, maybe have had pain for 6 months or so. They’ve finally gone to a physician. They’ve had some x-rays. They don’t really have anything surgical. They’re sent to your clinic. How often do you see them per week? How long are these sessions that you see them in? Then clearly people are going to want to know is how long does this take? Is it a matter of weeks? Is it months? How long is it going to take them to get to a point to where they’ve either regained the motion in their shoulder? Regained the function in their shoulder? Or you’ve basically said, “You’ve hit a plateau and we’re probably as good as we’re going to get.” I know I’ve given you a lot of questions there but just give us some ideas about the logistics of what a patient should expect.

Dr. Listug-Vap: The first time a patient comes in to a physical therapy clinic, they should expect to be there for about an hour. Of course, I’m talking about my clinic. Other clinics might do it a little bit differently but, generally, the first visit’s going to take about an hour because that’s the time for the physical therapist to learn about not only your body, but what do you need to get back to? What are the hobbies and recreational activities and occupational demands on your body. So that’s a longer visit that first time. Following that, and I hate to give you something so general, but it definitely depends on several factors. The ‘stage’ of the problem? Has this been going on six months or two years? That’s going to help me give the person and estimate about how long it might take and what the expectations for success are. Additionally, how healthy is the tissue we’re starting out with, and I know people don’t always put stake in these other things, but you’re fitness level, your age to some point, your nutrition, how much you drink water. Those type of things really do affect tissue healing down the road. So a person that is stacked in healthy tissue is going to take less time than a person that doesn’t take care of their body on the whole. Reasonable expectations? I would say on average I might see somebody twice a week to start with and then as they begin to be able to do more on their own, that would be down to one time a week, and I would say that on the short end I see people maybe 4-6 visits, and then on the long end it might be 6 months.

Dr. Sechrest: I think we should point out to patients that are listening. I think that a lot of folks feel that they come into the healthcare system and the person who is engaged with them is going to fix their problem. I think that we should point out to patients who engage in a rehabilitation program for their shoulder, like any other part of the body, they really need to take ownership of this. This is their shoulder and you’re there to really help them get a plan, but they’re going to have to do a lot of this work on their own. It’s not just when they come to the physical therapist. But I’m assuming that you’re trying to get them to do something literally every day. So when they’re not in the physical therapist’s office, they’ve got some things that they should be working on. Is that accurate?

Dr. Listug-Vap: That is very accurate. In fact, Day One people will leave with, what you could say, ‘homework’ and sometimes that might be what I would call relative rest, meaning staying away from things that are continuing to aggravate it. Sometimes that might be exercise right away – specific exercise. Exercise that for them might be as simple as hanging their arm over and moving it in a specific way just to loosen up the joint a little bit. But 100% success depends on the person in front of them and what they take away from physical therapy. Definitely a physical therapist is not able to fix any problem. They can guide the recovery.

Dr. Sechrest: I think the other thing we probably ought to point out is that you’ve not really said anything about anything that you and I would term ‘passive modalities’. Again, I think, people are used to coming to a health care provider and having something done to them: surgeons do operations on them; physicians provide and prescribe medications. Physical therapists, in some cases, do things to the patient in terms of ultrasound, those sorts of modalities as we would refer to them. Do you see a role for modalities in shoulder rehabilitation and do you use any types of modalities?

Dr. Listug-Vap: There is a role for modalities. A person that comes in with a lot of inflammation in the beginning, ice is probably my favorite passive modality. It’s something we might do in the clinic. It’s also something they’re probably asked to do at home. Ultrasound has a place, especially if there are adhesions and tissue that sometimes can help warm up the tissue a little bit deeper than the surface and allow for better mobility of that tissue. Electrical stimulation can be used to re-educate muscles. It can also be used to just drive out inflammation. I have to be honest though, that in my practice, I use those types of modalities, except for ice, very little and I rely more on movement to lead them to success. Modalities, at one point, were a huge part of physical therapy, and they’re not quite as utilized as much as they used to be. I do think there is still a place for them. I don’t find that I need them that often.

Dr. Sechrest: Well, is there anything specific that you like to see a shoulder rehabilitation patient focus on? Is there something that you really want a patient, that comes into your clinic, to leave with on that first visit? A plan? Some sort of key elements to their program? What are you trying to instill in that patient on that first visit?

Dr. Listug-Vap: That first visit I want them to walk away understanding what we’re going to be doing in the whole progression of treatment. I want them to understand their problem from a physical therapy standpoint not just a diagnosis. I want them to understand what I’m going to be asking them to do. Usually I’ve talked to them about the role of posture in shoulder rehabilitation and that that’s going to be an important piece of it. So I would say Day One those are the things that I want them to walk away with. I think if people understand the problem and they understand what they have to do to address it, they’re a little more committed to the overall program.

Dr. Sechrest: Well, I think this has been a wonderful discussion about shoulder rehabilitation and your approach to shoulder rehabilitation. Is there anything that you would like patients to know that we haven’t discussed during this interview in terms of shoulder rehabilitation or perhaps just things that they should know about your approach to physical therapy in general?

Dr. Listug-Vap: I think when it comes to treating the shoulder one thing that I want people to understand maybe a little bit more is that the shoulder blade, we don’t talk about that very much, people are very focused on the rotator cuff. But shoulder blade is a huge component to the shoulder. In fact, it actually makes up the socket. We all know that a shoulder is a ball and socket joint. But the socket is actually a piece of that shoulder blade, and so, often, your posture and really getting stronger on the muscles around that shoulder blade, are going to play a huge role in regaining pain-free movement and function in the shoulder complex. So I think people don’t expect that. They don’t maybe always understand, “Why am I doing all this stuff about my posture or about my shoulder blade when it’s the rotator cuff that’s the problem”. So that’s one thing that I think get ignored sometimes and is vital to success. As far as my approach to physical therapy, to rehabilitation overall, I just really believe that you have to regain healthy movement and that you have to then train muscle control of that movement, and then progress people as far as you need to take them to meet the demands of the life that they live, and that is the simple way of describing my approach.

Dr. Sechrest: I want to thank you for joining us today, and I thing you’ve given us some excellent information to think about. So thank you very much.

Dr. Listug-Vap: Thank you. It was my pleasure.