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A 64-year-old female presents with complaints of bilateral shoulder pain. The patient stated that she had noticed the pain for almost 1 year. Initially, a chronic aching pain began in the right shoulder directly over the humeral head and then developed in the left shoulder 1 month later. The patient also noticed progressive weakness with overhead movements. Pain and restricted range of motion prevented her from performing activities of daily living (e.g., combing her hair). The patient's medical history included the diagnosis of colon cancer five years previously. She had surgery to remove the adenocarcinoma that had metastasized to the lung and liver. The patient underwent a course of successful chemotherapy. The patient also had a history of right lower extremity cellulitis. Her initial list of medications at the time of presentation included aspirin, folic acid, famotidine, and NSAIDs. Notable findings from her social history included a 50 pack-year smoking habit and 1 to 2 alcoholic drinks per night for several years. A recent plain radiographic film of the patient's shoulders showed notable sclerotic and cystic changes bilaterally with flattening of the left humeral head with a subsequent diagnosis of stage III avascular necrosis (AVN) in the left shoulder and stage IV in the right shoulder. The patient declined to risk surgery to replace her shoulder joints and instead chose conservative treatment. The physical examination findings from the physician revealed:

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  • Decreased active range of motion (secondary to pain) in shoulder abduction (85° bilaterally) while passive range of motion equaled 135°; in the right shoulder and 120° in the left shoulder. Her forward flexion was also limited actively (85° bilaterally) and passively (135° bilaterally)
  • Decreased symmetrical strength in abduction.

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Given that your physical examination findings confirm the physician's diagnosis, what will be the goals of your intervention plan?

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The goals of the intervention plan should be to help the patient with her management of pain while simultaneously maintaining or increasing the upper extremity function.

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Can physical therapy improve the patient's disease?

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While physical therapy cannot affect the disease process, it may be able to lessen the secondary effects.

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What type of shoulder motions/activities would you advise the patient to avoid?

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The treatment should include stretching exercises, the avoidance all repetitive strenuous overhead arm motions, and the application of cryotherapy/thermotherapy and electrotherapeutic modalities to help control pain.

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Avascular necrosis represents a compromised circulation of blood to an area of bone. Eventually the involved area of bone dies and necrosis develops. The femoral head and the humeral head are the joints most often affected by AVN. The mechanisms for the impedance of flow include:

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  • Intraluminal obstruction (thromboembolism, sludging of blood cells, or stasis)
  • Vascular compression (vasospasm)
  • Physical disruption of the vessel.

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