Date implemented:

Client’s Initials and Age: SD, 78 y.o. Time allotted for session: 30 min
09/19/18
Diagnosis and any Precautions: (1) Diagnosis: L proximal humerus fracture; Precautions: NWB LUE sling, no
PROM forward flexion greater than 120, no PROM external rotation greater than 30, no AROM hand/wrist/elbow
pendulums
Goal/s being addressed: (1) increase L UE PROM to increase independence in UB dressing; increase R UE muscle strength to 5/5 to increase
independence with functional transfers; increase R UE reach & AROM to increase independence in household management
Activity Demands (setting,
Specific Objectives for this Modifications (provided during the
Intervention Activities materials, and social
activity (list 2-3) activity and planned for next
(5) requirements)
(5) session) (5)
(5)
PROM of L UE: Position patient
sitting upright in w/c. Carefully Results:
remove pt’s sling, supporting the 1. Pt demo L UE PROM 5/145
L UE under elbow and wrist. elbow flexion/extension
Perform the following PROM 2. Pt demo L UE PROM of 20
exercises: 20 reps elbow elbow external rotation
extension, 20 reps elbow flexion, 3. Pt demo L UE PROM of 78
20 reps elbow external rotation, shoulder forward flexion
20 reps elbow internal rotation,
20 reps shoulder forward flexion, Overall, this activity went well. It was
20 reps wrist extension, 20 reps 1. Pt. will demo L UE Setting: Therapy gym recommended and supported by my
wrist flexion, 20 reps PROM of 5/150 elbow FWEd, who was there to guide me on
MCP/PIP/DIP extension, & 20 flexion/extension Materials: gloves, 2 chairs (or 1 proper PROM techniques. Initially, I
reps MCP/DIP/PIP flexion. chair, 1 wheelchair), 2 small moved through the PROM exercises too
Carefully return L UE to sling, 2. Pt. will demo L UE towels quickly, and my FWEd instructed me to
supporting elbow with small PROM of 25 elbow slow down. I also ranged the joints too
towel and placing small rolled external rotation Grade Up: instruct pt to attempt far initially, and my FWEd instructed me
towel in pt’s L hand to prevent AROM exercises to start with a small degree of movement,
contracture of the fingers. 3. Pt. will demo L UE gradually working toward a larger range
PROM of 100 shoulder Grade Down: decrease number of motion. I also planned for this activity
Time: Planned: 10 minutes; forward flexion of reps to take about 10 minutes to complete,
Actual: 17 minutes when in reality it took about 15 minutes.
Next time, I plan to move more slowly
Clinical reasoning: With the and more gradually with the patient, as
primary diagnosis of L shoulder well as to allot more time for PROM
fracture, the top priority of the OT activities.
is to reduce pt’s UE impairment
and improve pt’s upper limb Though I do wish I could have
function. The pt’s current plan of implemented an activity that required
care includes PROM until more skill and involvement of the pt, my
fracture is healed enough to FWEd and I came to the conclusion that
involve L AROM activities. it was in the client’s best interest to begin
According to current evidence- the session with PROM activities given
based practice, resistive the pt’s current status.
exercises and/or active
functional activities involving the
affected limb (including top-down
ADL activities) are
recommended during the later
phase of rehabilitation, after
significant healing has occurred;
therefore, PROM exercise,
though a bottom-up activity, is an
appropriate use of therapy time
given client’s current status.

Results:
1. Pt. perf 20 overhead presses
with 2lb weight using R arm, form
declining with fatigue
2. Pt perf 15 bicep curls with 2lb
Strengthening exercises of R UE:
1. Pt. will perform 20 weight using R arm, form
overhead presses with declining with fatigue
Time: 10 minutes
2lb weight using R arm, 3. Pt perf 15 side shoulder raises
Setting: Therapy gym
maintaining proper form with 2lb weight using R arm,
Clinical reasoning: During pt’s
throughout maintaining proper form
initial evaluation, it was noted Materials: gloves, 2 chairs (or 1
throughout
that the pt demo impaired muscle chair, 1 wheelchair), one 2lb
2. Pt. will perform 20 bicep
strength of the unaffected R UE. weight
curls with 2lb weight Overall, the activity went smoothly. The
The pt’s plan of care included
using R arm, maintaining patient is quite motivated to improve and
muscle strengthening exercises Grade Up: increase reps and/or
proper form throughout therefore happily performed the
to improve upper extremity weight
exercises. However, she became quite
strength. Additionally, given that
3. Pt. will perform 20 side fatigued toward the end of the activity,
the client’s L arm is currently Grade Down: decrease reps
shoulder raises with 2lb and her form significantly declined. To
immobilized in a sling, and/or weight
weight using R arm, accommodate, I decreased the number
strengthening the unaffected arm
maintaining proper form of reps from 20 to 15 during the last few
will increase pt’s independence
throughout sets of exercises. Next time, I believe it
in functional activities.
may be more appropriate to use a 1lb
weight for the last few sets of exercise in
order to maintain proper form.

Looking back, I wish I would have

changed this activity to be more
 functionally-based. As an OT, top-down
activities are ideal for treatment. I had a
third intervention activity in mind that
was functionally-based / top-down
(upper body dressing) if time permitted;
however, time did not permit for this
activity to occur. Given that this activity
involved the patient’s non-affected arm,
it would have been appropriate (and
even recommended) to use functional
tasks and activities to strengthen client’s
arm. Current evidence shows that
functional activities are more effective at
improving overall function than non-
functional exercises.

S/OT name: Claudia Konstand

Citation
MacIntyre NJ, Kwan LL, Johal H, Lefaivre KA, Guy P, Sprague S, et al. Rehabilitation of Proximal Humerus Fractures- A Scoping Review. SM J
Trauma Care. 2017; 1(1): 1001.

Abstract

Purpose: This scoping review maps the breadth of rehabilitation literature with specific relevance to the non-surgical management of proximal
humerus fractures (PHF) in order to make recommendations for current practice and future research.

Methods: We searched 8 electronic data bases to July 16, 2015 for eligible studies; targeted citation tracking and hand-searches were continued
thereafter. Eligibility screening and data charting were conducted in duplicate. Data extraction included publication details, objective, participant
characteristics, interventions (and comparator if applicable), outcome measures, and authors’ main conclusions. Data were catalogued according to
research focus and outcomes assessed.

Results: The search yielded 1599 articles for full-text review; 26 articles (describing 22 unique primary studies and 5 knowledge translation studies)
were eligible for inclusion. Dates of publication range from 1979 to 2017. The majority of the studies (88.5%) were conducted in Europe. Half were
randomized controlled studies (RCTs). Typically, participants were older women. Research foci included: PT practice patterns in PHF rehabilitation
(n=1), effectiveness of a specific PT element (n=3), timing (n=8), methods of delivery (n=3), non- surgical versus surgical management (n=7), and
knowledge translation to guide clinical practice (n=5). Few studies provided complete descriptions of both the fracture characteristics and the main
elements in the PHF rehabilitation therapy interventions.

Conclusions: Current ‘good practice’ in PHF rehabilitation is informed by this literature however no definitive evidence-based protocols exist. Using
this scoping review technique driven by knowledge users, next steps have been identified such as developing summary sheets for rehabilitation
team members and patients with PHF to address options and expectations regarding treatments and outcomes. High quality prospective studies,
both prognostic and RCTs, are needed to investigate the effectiveness of key elements of rehabilitation therapy in patient groups with various types
of PHF classified according to risk for poor functional outcome.

How This Supports My Intervention Plan

According to this scoping review, evidence supports the use of PROM activities for the rehabilitation of a proximal humeral fracture, especially
during the early phase of healing. To achieve maximum achievable AROM, range of motion activities should progress during the rehabilitation
process from passive, to assisted active, to active. In order to regain full shoulder functional activity, it is recommended that active and resistive
exercises occur during the later phase of rehab, progressing as tolerated.

Find one peer-reviewed article that supports the intervention you planned/provided. At the bottom of your plan, paste the abstract and
citation and then in your own words describe how this supports your intervention plan. (5)
Total: 27 points