Neurologic Differential Diagnosis for Physical Therapy:

Conservative management in an elderly woman with proximal humeral head fracture and massive rotator cuff tear who refused surgery: A case report

BACKGROUND

Proximal humerus fractures (PHFs) account for between 4% and 10% of all fractures in the elderly people and osteoporosis is frequently related to PHF. Furthermore, rotator cuff (RC) tears are also extremely common, affecting at least 10% of people aged over 60 in the United States. Among shoulder pathologies, the periarticular soft tissue disorders, including the RC, this is considered to be the most common. The incidence of full thickness RC tears increases with age. An aggressive surgical approach is often required for patients with massive RC tear and PHFs to restore the patients' functional daily living activities. To the best of the authors' knowledge, this is the first case report describing a successful conservative management in an elderly patient with a full thickness RC tear and PHF that refused surgery.

CASE DESCRIPTION

This report describes the case of a 90-year-old woman with a massive RC tear who fell over on the sidewalk and sustained a PHF. The patient refused surgery even though it was recommended and prescribed by an orthopaedic surgeon.

INTERVENTION

After having her shoulder immobilized with a brace as prescribed by the orthopaedic physician, the patient began a shoulder rehabilitation program with progressive work load exposure, functional movements and a pain and kinesiophobia education program.

OUTCOMES

After 3 and a half months, the patient achieved full recovery to her pre-injury level of function. Such outcome was assessed using the Numeric Pain Rating Scale (NPRS), the Disability of the Arm, Shoulder and Hand (DASH) scale, the Fear-Avoidance Beliefs Questionnaire (FABQ), the Pain Catastrophysing Scale (PCS), and the Global Rating of Change (GROC) scale.

DISCUSSION AND CONCLUSION

In an elderly patient with a massive RC tear and an undisplaced PHFs, patient education, pain reconceptualization and change of beliefs in combination with progressive work load exposure appeared to be an effective management strategy to achieve a return to the pre-injury level of function.

An integrated framework for decision making in neurologic physical therapist practice

Decision-making frameworks are used by clinicians to guide patient management, communicate with other health care providers, and educate patients and their families. A number of frameworks have been applied to guide clinical practice, but none are comprehensive in terms of patient management. This article proposes a unifying framework for application to decision making in the management of individuals who have neurologic dysfunction. The framework integrates both enablement and disablement perspectives. The framework has the following attributes: (1) it is patient-centered, (2) it is anchored by the patient/client management model from the Guide for Physical Therapist Practice, (3) it incorporates the Hypothesis-Oriented Algorithm for Clinicians (HOAC) at every step, and (4) it proposes a systematic approach to task analysis for interpretation of movement dysfunction. This framework provides a mechanism for making clinical decisions, developing clinical hypotheses, and formulating a plan of care. Application of the framework is illustrated with a case example of an individual with neurologic dysfunction.

Differential Diagnosis and Treatment in a Patient With Posterior Upper Thoracic Pain

Background and Purpose. Determining the source of a patient's pain in the upper thoracic region can be difficult. Costovertebral (CV) and costotransverse (CT) joint hypomobility and active trigger points (TrPs) are possible sources of upper thoracic pain. This case report describes the clinical decision-making process for a patient with posterior upper thoracic pain. Case Description. The patient had a 4-month history of pain; limited cervical, trunk, and shoulder active range of motion; limited and painful mobility of the right CV /CT joints of ribs 3 through 6; and periscapular TrPs. Interventions included CV / CT joint mobilizations, TrP release, and flexibility and postural exercises. Outcomes. The patient reported intermittent mild discomfort after 7 physical therapy sessions. Examination findings were normal, and he was able to resume all preinjury activities. Discussion. This case suggests that CV /CT mobilizations and active TrP release may have been beneficial in reducing pain and restoring function in this patient. [Fruth SJ. Differential diagnosis and treatment in a patient with posterior upper thoracic pain. Phys Ther. 2006;86:254-268.]