Shoulder impingement syndrome and Physical Therapy

Shoulder impingement results from the compression of the rotator cuff muscles under the coracoacromial arch.
Inflammation and pain occurs and is aggravated by the shoulder and arm movements.Pain is felt on antero lateral aspect of shoulder radiating down to mid arm at times.
It can be confirmed with Hawkins-Kennedy impingement test and Neer's impingement test.

ETIOLOGY of shoulder impingement syndrome is multifactorial-

1. Acute trauma: fall on to the shoulder or direct blow on the shoulder.

2. Chronic injury from:
a) Repeated overhead activity like throwing, lifting and catching.
b) Improper postural habits leading to muscle imbalances between deltoid and infraspinatus, teres minor, subscapularis or between supraspinatus and gravity. As a result one group of muscles become tight and other gets stretched and become weak.Loss of rotator cuff strength causes superior migration of humerus resulting in impingement.

3.Outlet impingement due to subacromial osteophytes, hooked or beaked acromion shape, thickened or calcified coracoacromial ligament.


TREATMENT GOALS

1-Decrease the inflammation

*Cryotherapy-Use ice packs for a maximum of 15 minutes, 3 times a day
*Anti inflammatory medication
*Relative rest-Avoiding aggravating and loading activities like overhead reaching and lifting heavy weights in order to prevent further injury to the rotator cuff.

2-Improve posture and shoulder ROM

*Gentle stretching exercises and ROM
-Downward and backward pulling of both the arms with the hands clasped behind the back
-Scapular retraction exercises
-Codman pendular exercises
-Horizontal adduction stretch
-Triceps stretching
-Corner stretch-to stretch the front of the shoulder and the pectorals muscles by pushing against a wall in the corner of the room.
-Biceps stretch

* Sit with back fully supported and work with shoulders being close to the body.

3-Strengthen the rotator cuff muscles and scapular stabilizers.

*Bilateral shoulder extension exercises in prone or standing position.
*Resisted shoulder external and internal rotation in the gravity eliminated plane.
*Supraspinatus strenthening by resisting shoulder abduction in empty can position of the hand.
*Bilateral shoulder abduction in prone
*Supine press
*Biceps curls

Peripheral Neuropathy and Physiotherapy

Peripheral neuropathy is a disorder of the peripheral nervous system due to damage to the peripheral nerves resulting from a variety of causes like trauma,
infections, autoimmune disorders, systemic infections,inherited disorders, metabolic or endocrine disorders, toxic causes and vitamin deficiency especially vitamin B12.

Peripheral Neuropathy is of four types mainly-

1.Sensory neuropathy, in which part of the sensory system is damaged causing pain, tingling, numbness, or loss of sensation. It usually progress from distal to proximal i.e. it first starts in fingers or toes.

2.Motor neuropathy is characterized by damage to the motor nerves resulting in motor weakness and atrophy. Also symptoms of tiredness, heaviness,cramps, tremor, muscle twitch (fasciculations) and gait abnormalities are present.

3.Autonomic neuropathy is characterized by damage to the autonomic nervous system which affects blood pressure, heart rate, sweating, digestion, and bowel and bladder function.Symptoms may include urinary incontinence, constipation, diarrhea, dizziness and fainting.

4.Mixed neuropathy, in which two or more of the above mentioned types are present.

The objectives of Physiotherapy management for peripheral neuropathy includes-

(a)Pain Relief-TENS, Transcutaneous Electrical Nerve Stimulation therapy has shown to be effective and safe in the treatment of diabetic peripheral neuropathy

(b)Flexiblity or stretching exercises-They are important for improving muscle mobility, function and blood circulation in the affected area.It also helps in
maintaining range of motion.

(c)Strengthening of muscles-It improves muscle strength and reduces the feeling of numbness and tingling.It can be done by using weights or strengthening bands to target the necessary muscle.

(d)Braces or splints- To improve balance and posture.It can be used for compression neuropathies like carpal tunnel syndrome.

(e)Practicing functional activities are also important.

(f)Treatment through vibrations or ultrasound.

(g)Balance training to improve gait and posture.

Safety is an important consideration for patients with peripheral neuropathy.Muscle weakness and loss of sensation increase the risk of falls.It can be prevented by following measures

* Testing water temperature before bathing
* Avoiding open toes or high heels and not to walk barefoot.
* Take care while cooking by using heat resistant ladles and pot holders
* Inspect your feet regularly for any cut,bruise or blister
* Wear socks and gloves when needed
* keep the skin moisturised.
* Make environment safe by removing obstacles in home, use adequate light at night, use handrails while ascending or descending stairs,Use non slip bath mats in bathroom.