Treatment of shoulder pathologies based on irritability: a case series.

Study Design: Case Series. Background: Shoulder pain is a prevalent problem in health care. Traditionally, treatment is based on a pathoanatomical diagnosis determined through the use of special tests. The validity of these special tests is questionable and minimal evidence exists to support these tests to guide treatment. The purpose of this case series is to apply the principles of irritability, proposed by McClure and Michener in the Staged Approach Rehabilitation Classification, to adult patients with varying anatomical diagnoses. Case Description: Three patients diagnosed with different shoulder pathologies by referring physicians were recruited from a physical therapy clinic. Diagnoses included unspecified disorder of synovium and tendon, adhesive capsulitis, and other shoulder lesions. Patients were classified using a system based on stages of irritability. Patients received treatment based on impairments and irritability. Outcomes: Patients were treated for a total of 14-18 visits over a course of 7 to 8 weeks. Primary outcome measures included pain measured by the numeric pain rating scale (NPRS) and disability measured by FOTO (Focus on Therapeutic Outcomes). Pain was reduced to 0/10 in all cases and all patients exceeded their predicted outcome scores on FOTO. Discussion: This case series describes the use of an irritability-based classification system for treatment of adults with varying shoulder diagnoses. The positive outcomes indicate that treatment guided by irritability appeared to be beneficial for conservative treatment of three patients in a physical therapy setting. Further research, including randomized controlled trials, is needed to determine effectiveness in a larger population.

Reliability and validity of active and passive pectoralis minor muscle length measures.

BACKGROUND: Pectoralis minor muscle length is believed to play an important role in shoulder pain and dysfunction. Current clinical procedures for assessing pectoralis minor muscle length may not provide the most useful information for clinical decision making. OBJECTIVE: To establish the reliability and construct validity of a novel technique to measure pectoralis minor muscle length under actively and passively lengthened conditions. DESIGN: Cross-sectional repeated measures. METHODS: Thirty-four healthy adults (age: 23.9, SD=1.6 years; 18 females) participated in this study. Pectoralis minor muscle length was measured on the dominant arm in three length conditions: resting, actively lengthened, and passively lengthened. Based upon availability, two raters, out of a pool of five, used a caliper to measure the distance between the coracoid process and the 4th rib. The average of two pectoralis minor muscle length measures was used for all muscle length conditions and analyses. Intraclass correlation coefficients determined intra-and inter-rater reliability, and measurement error was determined via standard error of measurement and minimal detectable change. Construct validity was assessed by ANOVA to determine differences in muscle length across the three conditions. RESULTS: Our intra- and inter-rater reliability values across all three conditions ranged from 0.84 to 0.92 and from 0.80 to 0.90, respectively. Significant differences (p<0.001) in muscle length were found among all three conditions: rest-active (3.66; SD=1.36cm), rest-passive (4.72, SD=1.41cm), and active-passive (1.06, SD=0.47cm). CONCLUSIONS: The techniques described in this study for measuring pectoralis minor muscle length under resting and actively and passively lengthened conditions have acceptable reliability for clinical decision making.