The Jones (1995) model is commonly used as a guide by clinicians, to support their working hypothesis, showing logical clinical reasoning of the patients subjective and objective findings. Clinical reasoning is the process of taking a holistic approach to treating a patient using, knowledge and the subjective and objective evidence to make a well concluded decision on the patient’s outcome (Higgs, 2008). Utilizing the Jones model, this essay will evaluate the subjective findings of Ms Southfield (MS), who is 54-year-old women, experiencing intermittent pain in the lateral aspect of her right shoulder. The structure of this model will provide a supported clinical hypothesis which relates to the subjective findings. The main assessment procedures will then be discussed, outlining the expected objective findings relating to the hypothesis. Using the knowledge and evidence available a clear plan will be outlined suggesting the best management and treatment for the patient, commenting on the prognosis of the condition.
The jones model firstly considers the patients source of symptoms; this refers to where the patient’s symptoms arise from, considering arthrogenic, neurogenic and myogenic structures around the symptomatic area (Higgs & Jones, 1995). Neurogenic causes must be considered first to eliminate any symptoms which would infer that the pain is referring from the cervical or thoracic spine. Although there are no specific neurogenic symptoms which may infer serious neurogenic cause, as the pain comes on after 20 minutes of walking this could arise from applying a neural stretch to the nerves that pass the shoulder which could then cause MS’s pain (Jull & Greive, 2015). Arthrogenic causes considers any abnormality or dysfunction affecting the articulation at the joint (Petty, 2011). Ms’s symptom provocation is consistent at specific movements specifically in flexion, this could suggest a arthrogenic cause however this can overlap with myogenic symptoms. Myogenic refers to the myofascial tissue at the local area of symptoms (petty, 2011). Ms’s symptoms closely link to myogenic symptoms, with clear aggravating factors in specific movements. Lewis, (2016) makes a link to lateral shoulder pain to rotator cuff disorders so this must be considered. The deltoid is also local to the area and links to the patient’s symptoms with her arm elevated above head height.
The jones model then refers to the patients Mechanism of symptoms which is used to establish the most justifiable cause of their symptoms (Higgs & Jones, 1995). Neuropathic pain is associated with damage or dysfunction to the nervous system (Smart et al, 2009). Pain into the arm can be referred from the cervical and upper thoracic spine. MS’s symptoms do not infer a neurogenic cause which would include symptoms of: pins and needles, numbness or any abnormal weakness (Petty, 2011). Inflammatory pain is associated with irritation to the nociceptors at the local area from an inflammatory response to tissue damage as part of the healing process (Griensven et al, 2014). MS states she wakes when sleeping which could infer an inflammatory involvement. Although MS has pain on waking this is less linked to inflammatory pain as this would usually ease after beginning to move the shoulder (petty, 2011). This should be investigated further to see how she is using the arm as if she is avoiding movements then this pain may not ease. Mechanical pain is caused by stress to the local tissues or structures, which most commonly cause symptoms local to the area of injury (Moseley & Butler, 2017). MS’s symptoms suggests pain of a nociceptive mechanical nature. MS has local intermittent pain which is associated to specific movements. The pain is also eased by using co-codamol; a narcotic analgesic which suggests that it is pain of a mechanical nature (Cks.nice.org.uk, 2017).
Contributing factors which may affect the prognosis of the patient must be considered (Higgs & jones, 1995). MS is a single mother of two teenage children and a self-employed hairdresser. Throughout the say she completes repetitive movements at work and at home which would increase the likelihood of a chronic injury (Rhode, 2015). Being self-employed the patient has found reducing the number of appointments she carries out per day financially straining. As she is right hand dominant and unable to reduce her working hours this could negatively affect her recovery if she needed to offload her right arm. Ms is 54 years old, which would be the age most women reach the menopause, there has been a link made in post-menopausal women and a reduce in muscle strength which could increase strain on her Activities of daily living (Lee & Lee, 2013). Although a small amount of stress due to financial strain and providing for her family, there is little evidence to suggest any major yellow flags which may hinder recovery (Stewart et al, 2011).
After reviewing Ms Southfields subjective assessment, the primary hypothesis which has been concluded is a rotator cuff tendinopathy. MS’s subjective suggests that her pain is from a myogenic mechanical source. She also stated that she had decorated two rooms at the weekend before, Seitz et al, (2011) states that rotator cuff tendinopathies are more prevalent in females over 40 years old who have rapidly increased exposure to an activity. The stage of tendinopathy Would most likely be the disrepair phase as over the course of the 8 weeks the injury has not responded well to rest and is still irritated (Cook & Purdam, 2009).
To ensure patient safety, precautions or contraindications must be reviewed before carrying out and objective assessment and treatment. Precautions are symptoms or conditions the patient may present with that may change your management (Batavia, 2014). Contraindications to treatment would infer that a patient would be unsuitable for specific assessment and treatment methods (Batavia, 2014). MS’ subjective doesn’t indicate any clear contraindications which would suggest that she is unsuitable for physiotherapy. A precaution to physiotherapy would be two previous fractures occurred, it is important to check the level of trauma these occurred from. This is important as she may have osteopenia which is an early stage of osteoporosis if these were sustained under a low trauma accident. Osteoporosis is most prevalent in women aged over 50 which increases the likelihood that MS could present with low bone density (Puth et al, 2018).
An objective assessment will then be carried out which will help to comply with or contradict the primary hypothesis. A study from Lewis et al (2015) states there is no specific diagnostic test for rotator cuff tendinopathy and therefore should eliminate other pathologies that the patient could present with. A functional marker will be recorded; this is an activity the condition is currently limiting. This can then be referred back to, to see if there has been any improvement from treatment (petty, 2011). For MS, the objective markers set will taking her top off over her head and reaching for items above head height. Active range of movement will firstly be taken at the neck to eliminate any cervical spine pathologies. Active range of movement will be measured using a goniometer to measure all planes of movement at the shoulder. All of these movements will be compared to the unaffected side to get a baseline of the patient’s normal mobility. These movements will then be carried out passively by the therapist to feel for any differences with the muscle relaxed. MS’s passive range of movement would be expected to have no limitation as this would suggest a myogenic limitation. This will help to eliminate any joint pathologies which may be indicated to reduced passive range of movement, such as adhesive capsulitis or bone spurs (Walmsley et al, 2009). Accessory glides at the shoulder should then be carried out at the glenohumeral joint to eliminate any stiffness or laxity at the shoulder. With a rotator cuff, related condition there could be instability at the shoulder as the rotator cuff helps to stabilize the humeral head (Lewis, 2016). Strength can then be tested specifically in internal rotation, external rotation, flexion and abduction. The shoulder symptom modification procedure can then be applied to see if there is a significant reduction in symptoms, specifically with rotator cuff activation.
Mellor et al (2015) states that a graduated exercise programme along with educating the patient is the most effective way of treating a tendinopathy. For MS, education is important so that she fully understands her diagnosis and the implications of not complying with physiotherapy treatment. If the patient does not comply with physiotherapy this could lead to long term irreversible damage or even a rupture (Neviaser et al, 2012). Advice should be given on how the patient could offload the rotator cuff whilst working and carrying out activities of daily living. MS should be prescribed with a graduated exercise programme to slowly expose the tendon to increased overload (Cook & Purdam, 2009). To start with the patient should carry out isometric exercises to provide tension at the tendon. To advance this to apply more stress to the tendon concentric and eccentric exercises should then be carried out by the patient. once symptom free with concentric and eccentric exercises load should be added to the exercise from an external force such as a Thera band or a weight. As the patient is a hairdresser she should then focus on strengthening the rotator cuff in positions she will use at work, in shoulder flexion and abduction. If the shoulder symptom modification were to make a significant improvement, then this could also be used as a treatment. Kinesiology taping at the shoulder can be used to help off load the muscles, supporting the rotator cuff has been shown to aid as an adjunct to treatment, so this could be considered as a treatment option for MS (Frassanito et al, 2018).
Prognosis of a tendinopathy can often be unclear, according to coombes et al (2015) who states that tendinopathies are not a ‘one size fits all’ model, and that the history from the patient must be considered as well as the contributing factors which may affect recovery. Research shows there are 3 phases to tendon healing: inflammatory, proliferation, and the remodelling phases. The remodelling phase commences around 6 weeks and can take up to a year to fully form and realign scar tissue at the tendon (Spargoli, 2018). This means that there could be benefits from therapy to the tendon structure up to a year after injury. Due to tendon injury being very specific to the patient this also means that recovery time for a tendinopathy can be complex (Thomopoulos et al, 2015). For MS who has a manual upper limb based job, and is unable to reduce her activity levels due to financial strain of being a single mother her current prognosis is poor. If the patient were to subscribe to physiotherapy treatment in her current condition, and reduce the number of clients per day, pain would be expected to reduce and full mobility would be aimed for at the shoulder in six to 12 weeks. If she was unable to reduce the number of clients per day for this period recovery would be limited and increase stress to the tendon would increase her chance of a chronic tendon tear (Seitz et al, 2011). If this were to happen then it would be important to be aware of other medical pathways which could intervene and support with treatment.
To conclude, MS presented with what appeared to be rotator cuff related pain at the shoulder. Linking this to the external factors such as increased level activity, her age and history of present conditions the most likely differential diagnosis was a rotator cuff tendinopathy in the disrepair phase. This was supported throughout the objective assessment where tests were able to eliminate potential secondary hypotheses at joint. regarding the findings, it was then supported to give a graduated exercise programme to support with tendon healing along with the use of Kinesiology tape to support the rotator cuff in partially offloading in its stability role at the shoulder to reduce chance of further injury. Although there were factors which could hinder MS’s recovery, advise will be given to the patient on how she can overcome these factors to aid her recovery, whilst also being aware of the multidisciplinary team and other pathways that can be taken if physiotherapy is unable to support recovery of the patient.
References
• Batavia, M. (2014). Contraindications in physical rehabilitation: Doing no harm. St. Louis: Elsevier Health Sciences.
• Cook, J. L., & Purdam, C. R. (2009). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine, 43(6), 409-416. doi:10.1136/bjsm.2008.051193
• Coombes, B. K., Bisset, L., & Vicenzino, B. (2015). Management of lateral elbow tendinopathy: One size does not fit all. Journal of Orthopaedic and Sports Physical Therapy, 45(11), 938-949. doi:10.2519/jospt.2015.5841
• Cks.nice.org.uk. (2017). Shoulder pain – NICE CKS. [online] Available at: https://cks.nice.org.uk/shoulder-pain#!scenario:2 [Accessed 23 Dec. 2018].
•
• Frassanito P, Cavalieri C, Maestri R, Felicetti G. Effectiveness of Extracorporeal Shock Wave Therapy and kinesio taping in calcific tendinopathy of the shoulder: a randomized controlled trial. Eur J Phys Rehabil Med 2018;54:333-40. DOI: 10.23736/S1973-9087.17.04749-9
• Griensven, H. v., Strong, J., & Unruh, A. M. (2014). Pain: A textbook for health professionals(Second ed.). New York;Edinburgh;: Churchill Livingstone.
• Hattam, P. & Smeatham, A. (2010). Special tests in musculoskeletal examination; an evidence based guide for clinicians. Edinburgh: Churchill Livingstone
• Higgs, J., & Jones, M. A. (1995). Clinical reasoning in the health professions. Oxford: Butterworth-Heinermann.
• Higgs, J. (2008). Clinical reasoning in the health professions (3rd ed.). Oxford: Butterworth-Heinemann.
• Jull, G. A., & Grieve, G. P. (2015). Grieve's modern musculoskeletal physiotherapy (Fourth ed.). Edinburgh: Churchill Livingstone.
• Kenyon, K, & Kenyon, J. (2009). The physiotherapist’s pocketbook: essential facts at your fingertips (2nd ed.). Edinburgh: Churchill Livingstone.
• Lee, J., & Lee, D. (2013). Muscle strength and quality are associated with severity of menopausal symptoms in peri- and post-menopausal women. Maturitas, 76(1), 88-94. doi:10.1016/j.maturitas.2013.06.007
• Lewis, J., Dr. (2016). Rotator cuff related shoulder pain: Assessment, management and uncertainties. Manual Therapy, 23, 57-68. doi:10.1016/j.math.2016.03.009
• Lewis, J., McCreesh, K., Roy, J., & Ginn, K. (2015). Rotator cuff tendinopathy: Managing the diagnosis-management conundrum
• Mellor, R., Bennell, K., Grimaldi, A., Nicolson, P., Kasza, J., Hodges, P., . . . Vicenzino, B. (2018). Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: Prospective, single blinded, randomised clinical trial. BMJ (Clinical Research Ed.), 361, k1662. doi:10.1136/bmj.k1662
• Moseley, G. L., & Butler, D. S. (2017). Explain pain supercharged: The clinician's manual. Adelaide, Australia: Noigroup Publications.
• Neviaser, A., MD, Andarawis-Puri, N., PhD, & Flatow, E., MD. (2012). Basic mechanisms of tendon fatigue damage. Journal of Shoulder and Elbow Surgery, 21(2), 158-163. doi:10.1016/j.jse.2011.11.014
• Petty, N. J. (2011). Principles of neuromusculoskeletal treatment and management: A guide for therapists (2nd ed.). Edinburgh: Churchill Livingstone
• Puth, M., Klaschik, M., Schmid, M., Weckbecker, K., & Münster, E. (2018). Prevalence and comorbidity of osteoporosis- a cross-sectional analysis on 10,660 adults aged 50 years and older in germany. BMC Musculoskeletal Disorders, 19(1), 144-8. doi:10.1186/s12891-018-2060-4
• Rhode BA, Rhode WS (2015) Occupational Risk Factors for Shoulder Tendon Disorders 2015 Update. MOJ Orthop Rheumatol 3(4): 00104. DOI: 10.15406/mojor.2015.03.00104
• Seitz, A. L., McClure, P. W., Finucane, S., Boardman, N. D., & Michener, L. A. (2011). Mechanisms of rotator cuff tendinopathy: Intrinsic, extrinsic, or both? Clinical Biomechanics, 26(1), 1-12. doi:10.1016/j.clinbiomech.2010.08.001
• Smart, K. M., Blake, C., Staines, A., & Doody, C. (2009). Clinical indicators of ‘nociceptive’, ‘peripheral neuropathic’ and ‘central’ mechanisms of musculoskeletal pain. A delphi survey of expert clinicians. Manual Therapy, 15(1), 80-87. doi:10.1016/j.math.2009.07.005
• Spargoli, G. (2018). supraspinatus tendon pathomechanics: A current concepts review.International Journal of Sports Physical Therapy, 13(6), 1083-1094. doi:10.26603/ijspt20181083
• Stewart, J., Kempenaar, L., & Lauchlan, D. (2011). Rethinking yellow flags. Manual Therapy, 16(2), 196-198. doi:10.1016/j.math.2010.11.005
• Thomopoulos, S., Parks, W. C., Rifkin, D. B., & Derwin, K. A. (2015). Mechanisms of tendon injury and repair. Journal of orthopaedic research : official publication of the Orthopaedic Research Society, 33(6), 832-9.
• Walmsley S, Rivett DA, Osmotherly PG. Adhesive capsulitis: establishing consensus on clinical identifiers for stage 1 using the DELPHI technique. Phys Ther. 2009;89(9):906–917.
• Walton, J., & Russell, S. (2015). Physiotherapy assessment of shoulder stiffness and how it influences management. Shoulder & Elbow, 7(3), 205-213. doi:10.1177/1758573215586152