Treatment for painful stiff shoulder in a patient with Parkinson's disease (PD)

Was wondering whether anyone could help me with an musculoskeletal problem in a patient of mine with Parkinson's Disease.

PROFILE:
My patient is a 68 year old lady currently in inpatient rehab for decreased mobility and uncertain living situation post-discharge. She was diagnosed with PD 8 years ago and had been living alone in her own home until being admitted but is not expected to return home post-discharge as she is no longer independent with transfers or ambulation on her 4WF.

PMH:
PD 8 years, lifelong severe anxiety, autonomic dysfunction resulting in severe hypotensive episodes with postural changes, depression.

CMH (For the purposes of this problem):
6months ago my patient got up from her bed and was walking around to the door when she suffered a 'drop attack' and fell on her L arm/shoulder on a low-lying window ledge. During this episode she fractured her proximal humerus and anteriorly dislocated her shoulder. It was managed conservatively in a sling for 3 weeks and then she reported holding it in to her body to reduce the pain. Unsurprisingly, she found that after a while she was unable to move her left shoulder and is currently seeing me to regain shoulder ROM/strength and function.

OBJECTIVE:
Anterior shoulder posture, resting position of L shoulder IR/Adduction, Elbow flexion.

AROM:
R Shoulder - within normal limits
L Shoulder - Flexion = 20 degrees, Abduction = 15degrees, ER = neutral, extension = 20 degrees.

PROM:
L shoulder - Flexion = 70 degrees // pain/tightness triceps
- Abduction = 80 degrees // pain/tightness pect. minor + biceps LH
- Ext. Rotation = +10degrees // pain tightness pec minor.

ADDED INFO:
This patient also has quite significant tone in her upper limbs - particularly proximal musculature, which is exacerbated by her anxiety.

MY TREATMENTS
I have been trying a number of treatment methods, but none seem to be effectively managing this problem. I have used:
- STM of pec minor/biceps/triceps prior to treatment
- Sustained hold focusing on getting the patient to let go of UL musculature.
- PNF work based on reciprocal inhibition and hold/relax techniques.
- Individual exercise programme including pulley work and self assisted flexion exercises as well as scapular retraction and postural work.
- Encouraged constraint induced principles - using L arm as much as possible.

I have been seeing her for 4 weeks and so far nothing seems to be having much of an impact. Was wondering whether anyone else has encountered such a problem and what they have found has made a difference.

Cheers.

In traumatic anterior Dislocation of shoulder there is complete separation of the articular surfaces of the glenohumeral joint caused by direct or indirect forces applied to the shoulder. Anterior dislocation most frequently occurs when there is a blow to the humerus while it is in a position of external rotation and abduction. Stability normally is provided by the subscapularis, glenohumeral ligament, and long head of the biceps when in that position. Poor integrity of any of these structures can predispose the joint to dislocation, or a significant blow to the arm may damage them along with the attachment of the anterior capsule and glenoid labrum (Bankart lesion). When dislocated, the humeral head usually rests in the subcoracoid region, rarely subclavicular or intrathoracic. Traumatic anterior dislocation is usually associated with a complete rupture of the rotator cuff. Neurologic or vascular injuries may occur during dislocations. The axillary nerve is most commonly injured, but the brachial plexus or one of the peripheral nerves could be stretched or compressed.

Common Impairments

After an acute traumatic injury, symptoms from tissue damage include pain and muscle guarding from bleeding and inflammation. When a dislocation is associated with a complete rotator cuff tear, there is an inability to abduct the humerus against gravity, except the range provided by the scapulothoracic muscles. Asymmetric joint restrictions/hypermobilities. In an anterior instability, the posterior capsule may be tight; in a posterior instability, the anterior capsule may be tight. After healing, there may be adhesions.

With recurrent dislocations, the individual can dislocate the shoulder at will, or the shoulder may just dislocate when doing specific activities.

Common Functional Limitations/Disabilities

With rotator cuff rupture, inability to reach or lift objects to the level of horizontal, thus interfering with all activities using humeral elevation Possibility of recurrence when replicating the dislocating action With anterior dislocation, restricted ability in sports activities such as pitching, swimming, serving (tennis, volleyball), spiking (volleyball) Restricted ability, particularly when overhead or horizontal abduction movements are required in dressing, such as putting on a shirt or jacket, and with self-grooming, such as combing the back of the hair Discomfort or pain when sleeping on the involved side in some cases.

Management: Protection Phase After Closed Reduction of Anterior Dislocation

Reduction manipulations should be undertaken only by someone specially trained in the maneuver because of the vulnerability of the brachial plexus and axillary blood vessels.

Protect the Healing Tissue

After acute anterior dislocation in a young patient, the arm is immobilized for 3 to 4 weeks in a sling, which is removed only for exercise. During the first week, the patient’s arm may be continuously immobilized because of pain and muscle guarding. An older, less active patient (over 40 years of age) may require immobilization for only 2 weeks. The position of dislocation must be avoided when exercising, when dressing, or doing other daily activities.

Promote Tissue Health

Use protected ROM, intermittent muscle setting of the rotator cuff, deltoid, and biceps brachii muscles, and grade II joint techniques.

Precautions: In order not to disrupt healing of the capsule and other damaged tissues after anterior dislocation, ROM into external rotation is performed with the elbow at the patient’s side, with the shoulder flexed in the sagittal plane, and with the shoulder in the resting position (in the plane of the scapula, abducted 55 degrees and 30 to 45 degrees anterior to the frontal plane), but not in the 90-degree abducted position. The forearm is moved from in front of the trunk (maximal internal rotation) to 0 or possibly 10 to 15
degrees external rotation. Extension beyond 0 degrees is contraindicated. Intermittent muscle setting of the rotator cuff, deltoid, and biceps brachii muscles Grade II joint techniques: Maintain joint play by using sustained grade II distraction or gentle grade II oscillations with the glenohumeral joint at the side or in the resting position.

Management: Controlled Motion Phase After Closed Reduction of Anterior Dislocation

Provide Protection

The patient continues to wear the sling for 3 weeks, then increases the time the sling is off; the sling is used when the shoulder is tired or if protection is needed.

Increase Shoulder Mobility

Begin mobilization techniques using all appropriate glides except the anterior glide. The anterior glide is contraindicated even though external rotation is necessary for functional elevation of the humerus. To safely stretch for external rotation, place the shoulder in the resting position (abducted 55 degrees and horizontally adducted 30 degrees), then externally rotate it to the limit of its range, and then apply a grade III distraction force perpendicular to the treatment plane in the glenoid fossa.
Passively stretch the posterior joint structures with horizontal adduction self-stretching techniques.

Increase Stability and Strength of Rotator Cuff and Scapular Muscles

Both the internal and external rotators need to be strengthened as healing occurs. The internal rotators and adductors must be strong to support the anterior capsule. The external rotators must be strong to stabilize the humeral head against anterior translating forces and to participate in the deltoid-rotator cuff force couple when abducting and laterally rotating the humerus. Scapular stability is important for normal shoulder function. Begin with isometric resistance exercises with the joint positioned at the side and progress to various pain-free positions within the available ranges. Initiate closed-chain, partial weight-bearing, and stabilization exercises. Progress to dynamic resistance, limiting external rotation to 50 degrees and avoiding the position of dislocation. At 3 weeks, begin supervised isokinetic resistance for internal rotation and adduction at speeds 180 degrees per second or higher. Position the patient standing with the arm at the side or in slight flexion and elbow flexed 90 degrees. The patient performs internal rotation beginning at the zero

Mobilizing to increase external rotation when an anterior glide is contraindicated.

Place the shoulder in resting position, externally rotate it, then apply a grade III distraction force. position with the hand pointing anteriorly and moving across the front of the body. Progress to positioning the shoulder at 90 degrees flexion, then perform the exercise from zero to full internal rotation. Do not position in 90 degrees abduction.
By 5 weeks, all shoulder motions are incorporated into exercises on isokinetic or other mechanical equipment except in the position of 90 degrees abduction with external rotation.

Return to Function Phase After Anterior Shoulder Dislocation

Restore Functional Control

Develop a balance in strength of all shoulder and scapular muscles. Develop coordination between scapular and arm motions. Develop endurance for each exercise as previously described for shoulder instabilities.
As stability improves, progress eccentric training to maximum load, increase speed and control, and progress to simulating desired functional patterns for activity.

Return to Maximum Function

Help the patient learn to recognize signs of fatigue and impingement and stay within the tolerance of the tissues. The patient can return to normal activities when there is no muscle imbalance, when good coordination of skill is present, and when the apprehension test is negative. Full rehabilitation takes 2 1/2 to 4 months.

Management After Posterior Dislocation of the Shoulder with Closed Reduction

The management approach is the same as anterior dislocation with the exception of avoiding the position of flexion with adduction and internal rotation during the acute and healing phases.

Protect the Part

The arm is immobilized. A sling may be uncomfortable because of the adducted and internally rotated position, particularly if the sling elevates the humerus so the head translates in a superior and posterior direction. The patient may be more comfortable with the arm hanging freely in a dependent position while kept immobile.

Increase Limited Ranges

Begin joint mobilization techniques using all appropriate glides except the posterior glide. Posterior glide is contraindicated. If adhesions develop, preventing internal rotation, mobility can safely be regained by placing the shoulder in the resting position (abducted 55 degrees and horizontally adducted 30 degrees), internally rotating it to the limit of its range, and then applying a grade III distraction force perpendicular to the treatment plane in the glenoid fossa with the arm internally rotated.

Hi,
The previous response was very comprehensive, and covers the usual approach to this type of problem over various age groups.
The significant parts of your specific problem are: Parkinsons' in an elderly anxious person 6 months post shoulder trauma, resulting in lack of movement.
If scans, MRI and ultrasound, have not been undertaken, it would be useful to have them undertaken, but not 100% required.
Diagnosis
I suspect that your patient has an adhesive capsulitis, compounded by a fear reaction of muscle guarding, plus the overlay of a Parkinsons' stiff Tx.
Treatment
If the shoulder structures are stable, which I assume they are, then your best bet would be to have her undertake a glenohumeral hydrodilatation of the adhered capsule. Ensure that this is done by an experienced person. My preference is the non guided technique, provided it is done by a person with good surface anatomy knowledge and experience. My experience with radiologists is mixed, regarding outcome.

Immediately post procedure, the patient should have the arm moved through available range, and continue pendular and self assisted range of movement to avoid readherence of the capsule.
Have the person performing the technique report back to you regarding the feeling of capsule release as felt through the syringe, and at what fluid volume this occurred. eg release at 15 & 25 millilitres of fluid.
Repeat injection can occur at 8-12 weeks, if required.
A small amount of local anaesthetic and cortisone (eg Celestone) is used in conjunction with the saline (up to 40 ml saline).
Check with treating specialists regarding medication interactions before proceeeding.
Hope the above is helpful.
MrPhysio+

Thank you,

I was suspecting adhesive capsulitis but wanted to ensure that I had not missed anything glaringly obvious. I was also interested in seeing if there were any other conservative methods to deal with this problem, but sadly none of my approaches had worked, and it doesn't seem as though there are many other options to trial.

Thanks for your help MrPhysio+.