Post-Operative Rehabilitation for Scapular Muscle Reattachment: A Case Report

Background and Purpose: Scapular muscle detachment is a rare orthopedic problem that has been described in the literature in patients following traumatic events involving traction, direct trauma, or a motor vehicle accident. The purpose of this case report is to describe the post-operative rehabilitation following scapular muscle reattachment surgery. Unique to this case report is the patient\u27s perspective, an orthopedic physical therapist with 25 years of experience. Case Description: A 47-year-old female physical therapist experienced a traction injury to bilateral upper extremities during a medical procedure resulting in bilateral rhomboid, and bilateral lower trapezius muscles were detached from the medial scapular border. Reconstruction of the left scapulothoracic musculature occurred five and one-half years post-injury with the right repaired one year later. This case report describes the rehabilitation program that took one-year to recover for each arm with a period of protected motion for 16-weeks and gradual return to function as a manual physical therapist over a period of one-year. Outcomes: The American Shoulder and Elbow Surgeons (ASES) Standardized Assessment Form and pain-free range of motion was used pre- and postoperatively. Left and right shoulder pre-operative ASES scores were 68 and 72, respectively. At the one-year post-operative the left shoulder was rated at 82 and the right shoulder was 90. Pain-free range of motion was achieved in both arms by one year. Functional limitations requiring strength overhead were the slowest to return and were not completely back at one year following either surgery. Discussion: Rehabilitation protocols for scapular muscle reattachment surgery are not commonly available to allow physical therapists to guide their patients and structure a rehabilitation program. This case report provides a sample pre-operative set of educational guidelines and a post-operative protocol for use after scapular reattachment surgery. This case report is unique because it offers a patient perspective who is a physical therapist and underwent this surgery twice. Therefore, providing insight on how to prepare for such a unique operation. The slow recovery is due to three issues 1) the prolonged time from injury to diagnosis created significant muscle wasting and muscular imbalance of surrounding tissues, 2) once this tissue was repaired it requires months of protection to recover, 3) the involved scapulothoracic muscle have to regain adequate strength as the foundation for upper extremity functions. Level of evidence: Level 5

The role of the stratospheric polar vortex for the austral jet response to greenhouse gas forcing

Future shifts of the austral midlatitude jet are subject to large uncertainties in climate model projections. Here we show that, in addition to other previously identified sources of inter-model uncertainty, changes in the timing of the stratospheric polar vortex breakdown modulate the austral jet response to greenhouse gas forcing during summertime (December-February). The relationship is such that a larger delay in vortex breakdown favors a more poleward jet shift, with an estimated 0.7-0.8-degree increase in jet shift per 10 days delay in vortex breakdown. The causality of the link between the timing of the vortex breakdown and the tropospheric jet response is demonstrated through climate modeling experiments with imposed changes in the seasonality of the stratospheric polar vortex. The vortex response is estimated to account for about 30% of the inter-model variance in the shift of the summertime austral jet, and about 45% of the mean jet shift

Do Scapular Kinematics Alter during the Performance of the Scapular Assistance Test and Scapular Retraction Test: A Pilot Study

Objective: To describe to what degree and in what plane biomechanical alterations occur during the performance of the Scapular Retraction test (SRT) and Scapular Assistance Test (SAT). Design: Laboratory Pilot Study Participants: Eight symptomatic and 7 asymptomatic subjects were instrumented with electromagnetic sensors. Main Outcome Measures: The SRT and SAT were performed with the scapula stabilized and unstabilized. The scapular kinematic variables of posterior tilt, internal rotation, upward rotation, protraction, and elevation were measured during both tests. Results: Descriptive analysis of scapular kinematics suggested that posterior tilt was primarily increased during both clinical tests in both groups. Both groups decreased in scapular elevation, indicating that the scapula was being depressed during the SRT. There was no meaningful change in force during the SRT. Conclusion: These findings indicate that both the SRT and SAT appear to alter scapular motion in both groups. The interpretations of these results are limited due to the small sample size and large confidence intervals, but suggest that these tests change specific positions of the scapula. Further research into these tests is needed to confirm these biomechanical alterations, and to determine the value of these tests when developing rehabilitation protocols in patients with shoulder pain

Level of Patient-Physician Agreement in Assessment of Change Following Conservative Rehabilitation for Shoulder Pain

Background Assessment of health-related status has been shown to vary between patients and physicians, although the degree of patient–physician discordance in the assessment of the change in status is unknown. Methods Ninety-nine patients with shoulder dysfunction underwent a standardized physician examination and completed several self-reported questionnaires. All patients were prescribed the same physical therapy intervention. Six weeks later, the patients returned to the physician, when self-report questionnaires were re-assessed and the Global Rating of Change (GROC) was completed by the patient. The physician completed the GROC retrospectively. To determine agreement between patient and physician, intra-class correlation (ICC) coefficient and Pearson’s r using the 15-point GROC and weighted kappa using a consolidated three-point GROC were calculated. Results Utilizing the 15-point GROC, complete agreement was observed in 37 of 99 patients (37%). ICC and Pearson’s r between patient and physician were 0.62 and 0.63, respectively. Utilizing a consolidated three-point GROC, complete agreement was observed in 76 of 99 patients (77%). Weighted kappa was 0.62. Conclusions Assessment of change reported by the patient demonstrates moderate to good agreement with physician assessment. These findings indicate that the GROC does reflect and represent similar assessment of change in health status by patients and physicians. This can aid discussion of both past treatment results and future treatment plans

Conservative Treatment for Patients with Suspected SLAP Tears: A Case Series

Objective: Outcome following non-operative management of superior labral anterior to posterior (SLAP) lesions has been under reported with little empirical data demonstrating the effectiveness of conservative treatment. Material and Methods: 10 patients, 5 matched pairs, presenting with symptoms consistent with a SLAP lesion performed a standardized phased rehabilitation program completing patient reported outcome (PRO) and pain measures before and following rehabilitation. Physical therapy notes and home exercise logs were reviewed and all exercises were recorded and coded using the phased rehabilitation protocol as a guide. At followup, patients were divided into two groups; responders and non-responders to treatment based on PRO. The volume of exercise and type of exercise performed for each patient were compared using frequency counts. Results: The non-responders did on average 33 more stretching exercises than the responders. The non-responders did on average 21 more scapular orientation exercises than the responders. There were few to no differences in the volume of strengthening exercises between the two groups except responders performed 38 more scapular retraction exercises at shoulder level while non-responders performed 49 more scapular retraction exercises below shoulder level. Conclusions: This case series identified few exercises that were beneficial to patients\u27 responding to conservative intervention but more often identified exercises that were performed that did not facilitate an improved patient outcome. Therapeutic exercises are often the cornerstone of a rehabilitation program, yet limited evidence exists in which specific exercises are beneficial or not beneficial in patients with symptoms consistent with a SLAP lesion

Descriptive Analysis of Common Functional Limitations Identified by Patients with Shoulder Pain

Context: Recent establishment of G-codes by the US government requires therapists to report function limitations at initial evaluation. Limited information exists specific to the most common limitations in patients with shoulder pain. Objective: To describe the most commonly expressed shoulder limitations with activities and their severity/level of impairment from a patient’s perspective on the initial evaluation. Design: Descriptive. Setting: Patients reporting pain with overhead activity and seeking medical attention from one orthopedic surgeon were recruited as part of a cohort study. Patients: 176 with shoulder superior labral tear from anterior to posterior (SLAP), subacromial impingement, combined SLAP and rotator cuff, and nonspecific (female = 53, age = 41 ± 13 y; male = 123, age = 41 ± 12 y). Interventions: Data were obtained on the initial visit from the Patient-Specific Functional Scale (PSFS) questionnaire. Three researchers extracted meaningful concepts from the PSFS and linked them to the International Classification of Functioning (ICF) categories according to established ICF linking rules. Results: 176 participants yielded 765 meaningful concepts that were linked to the ICF with a 66% agreement between researchers before consensus. There were no differences between diagnoses. Of all patients, 88% reported functional limitations coded into meaningful concepts as represented by 10 ICF codes; 634 (83%) meaningful concepts were linked to the activities and participation domain while 129 (17%) were linked to the body function domain. Only 2 reported functional limitations that were considered nondefinable (nd). The overall average initial impairment score on the PSFS = 4 ± 2.5 out of 10 points. Conclusion: Meaningful concepts from the activities and participation domain were most commonly identified as functional limitations and were more prevalent than limitations from the body function domain. This information helps identify some of the most common limitations in patients with shoulder pain that therapists can use to efficiently document patient functional impairment

Reliability of an Observational Method Used to Assess Tennis Serve Mechanics in a Group of Novice Raters

Background: Previous research has developed an observational tennis serve analysis (OTSA) tool to assess serve mechanics. The OTSA has displayed substantial agreement between the two health care professionals that developed the tool; however, it is currently unknown if the OTSA is reliable when administered by novice users. Purpose: The purpose of this investigation was to determine if reliability for the OTSA could be established in novice users via an interactive classroom training session. Methods: Eight observers underwent a classroom instructional training protocol highlighting the OTSA. Following training, observers participated in two different rating sessions approximately a week apart. Each observer independently viewed 16 non-professional tennis players performing a first serve. All observers were asked to rate the tennis serve using the OTSA. Both intra and inter-observer reliability were determined using Kappa coefficients. Results: Kappa coefficients for intra and inter-observer agreement ranged from 0.09 to 0.83 depending on the body position. A majority of all body positions yeilded moderate agreement and higher. Conclusion: This study suggests that the majority of components associated with the OTSA are reliable and can be taught to novice users via a classroom training session

Genetic variation and exercise-induced muscle damage: implications for athletic performance, injury and ageing.

Prolonged unaccustomed exercise involving muscle lengthening (eccentric) actions can result in ultrastructural muscle disruption, impaired excitation-contraction coupling, inflammation and muscle protein degradation. This process is associated with delayed onset muscle soreness and is referred to as exercise-induced muscle damage. Although a certain amount of muscle damage may be necessary for adaptation to occur, excessive damage or inadequate recovery from exercise-induced muscle damage can increase injury risk, particularly in older individuals, who experience more damage and require longer to recover from muscle damaging exercise than younger adults. Furthermore, it is apparent that inter-individual variation exists in the response to exercise-induced muscle damage, and there is evidence that genetic variability may play a key role. Although this area of research is in its infancy, certain gene variations, or polymorphisms have been associated with exercise-induced muscle damage (i.e. individuals with certain genotypes experience greater muscle damage, and require longer recovery, following strenuous exercise). These polymorphisms include ACTN3 (R577X, rs1815739), TNF (-308 G>A, rs1800629), IL6 (-174 G>C, rs1800795), and IGF2 (ApaI, 17200 G>A, rs680). Knowing how someone is likely to respond to a particular type of exercise could help coaches/practitioners individualise the exercise training of their athletes/patients, thus maximising recovery and adaptation, while reducing overload-associated injury risk. The purpose of this review is to provide a critical analysis of the literature concerning gene polymorphisms associated with exercise-induced muscle damage, both in young and older individuals, and to highlight the potential mechanisms underpinning these associations, thus providing a better understanding of exercise-induced muscle damage