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The Flow State Scale for Rehabilitation Tasks: A New Flow Experience Questionnaire for Stroke Patients

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Beatrice Ottiger , Janne Marieke Veerbeek , Dario Cazzoli , Thomas Nyffeler , Tim Vanbellingen; The Flow State Scale for Rehabilitation Tasks: A New Flow Experience Questionnaire for Stroke Patients. Am J Occup Ther March/April 2024, Vol. 78(2), 7802180030. doi: https://doi.org/10.5014/ajot.2024.050401

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Importance: Flow can be described as a subjective state that people report when they fully engage in an activity and experience pleasure, satisfaction, and enjoyment. Flow experiences are measured to determine the extent to which patients engage in therapy activities. Several flow questionnaires are used in neurorehabilitation. However, none have been validated for patients with (sub)acute stroke.

Objective: To develop and validate a new flow questionnaire for patients with (sub)acute stroke.

Design: Single-center prospective cohort study.

Setting: Neurorehabilitation unit of the Neurocenter of the Luzerner Kantonsspital in Lucerne, Switzerland.

Participants: Fifty patients with (sub)acute stroke.

Outcomes and Measures: Development of the Flow State Scale for Rehabilitation Tasks (FSSRT) and determination of the psychometric properties of the FSSRT (internal consistency, test–retest reliability, structural and construct validity) in (sub)acute stroke patients.

Results: The FSSRT showed good internal consistency and excellent test–retest reliability. Composed of four components—concentration, pleasure, movement control, and absorption—the FSSRT correlated significantly negatively with the Hospital Anxiety and Depression Scale, indicating good divergent validity.

Conclusions and Relevance: The FSSRT is a reliable and valid questionnaire measuring flow experience in patients with (sub)acute stroke. This questionnaire can be easily used in occupational therapy as well as in physical therapy and gives therapists important information about the flow experience of patients during therapy to adjust the therapy accordingly.

Plain-Language Summary: Measuring flow experience, or the extent to which patients engage in therapy activities, in the context of occupational therapy and physical therapy is a new approach. This study confirmed that the Flow State Scale for Rehabilitation Tasks questionnaire is reliable and valid for measuring the flow experience of patients after (sub)acute stroke. Occupational therapists and physical therapists can use the FSSRT to optimally adjust the therapy program and increase patient engagement during therapy.

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Physical therapy in the management of frozen shoulder

Hui bin yvonne chan.

1 Care and Health Integration, Changi General Hospital, Singapore

Pek Ying Pua

2 Rehabilitative Services, Changi General Hospital, Singapore

Choon How How

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Frozen shoulder, also known as adhesive capsulitis, is a common presentation in the primary care setting and can be significantly painful and disabling. The condition progresses in three stages: freezing (painful), frozen (adhesive) and thawing, and is often self-.limiting. Common conservative treatments include nonsteroidal anti-.inflammatory drugs, oral glucocorticoids, intra-.articular glucocorticoid injections and/or physical therapy. However, many physicians may find themselves limited to prescribing medications for treatment. This article elaborates on physical therapy exercises targeted at adhesive capsulitis, which can be used in combination with common analgesics.

Lucy, a 53-year-old woman, visited you several times in the past year. She had an aching pain on her shoulder and, lately, had increasing difficulty lifting her arm or reaching behind her back. You previously gave her painkillers as treatment. However, due to her history of gastric problems, you were keen to explore physical therapy as part of management .

WHAT IS FROZEN SHOULDER?

Frozen shoulder, also known as adhesive capsulitis, is defined as “ a condition of uncertain aetiology, characterised by significant restriction of both active and passive shoulder motion that occurs in the absence of a known intrinsic shoulder disorder ”.( 1 ) Patients with frozen shoulder typically experience insidious shoulder stiffness, severe pain that usually worsens at night, and near-complete loss of passive and active external rotation of the shoulder.( 2 ) There are typically no significant findings in the patient’s history, clinical examination or radiographic evaluation to explain the loss of motion or pain.

Frozen shoulder can be classified as primary or secondary. Primary idiopathic frozen shoulder is often associated with other diseases and conditions, such as diabetes mellitus, and may be the first presentation of a diabetic patient.( 3 ) Patients with systemic diseases such as thyroid diseases( 4 , 5 ) and Parkinson’s disease( 6 ) are at higher risk. Secondary adhesive capsulitis can occur after shoulder injuries or immobilisation (e.g. rotator cuff tendon tear, subacromial impingement, biceps tenosynovitis and calcific tendonitis). These patients develop pain from the shoulder pathology, leading to reduced movement in that shoulder and thus developing frozen shoulder.

Frozen shoulder often progresses in three stages: the freezing (painful), frozen (adhesive) and thawing phases ( Fig. 1 ). In the freezing stage, which lasts about 2–9 months, there is a gradual onset of diffuse, severe shoulder pain that typically worsens at night. The pain will begin to subside during the frozen stage with a characteristic progressive loss of glenohumeral flexion, abduction, internal rotation and external rotation. This stage can last for 4–12 months. During the thawing stage, the patient experiences a gradual return of range of motion that takes about 5–26 months to complete.( 7 , 8 ) Although adhesive capsulitis is often self-limiting, usually resolving in 1–3 years,( 9 ) it can persist, presenting symptoms that are commonly mild; pain is the most common complaint.( 10 , 11 )

An external file that holds a picture, illustration, etc.
Object name is SMJ-58-685-g001.jpg

Chart shows the clinical presentation of frozen shoulder. Icons with facial expressions represent the level of pain of the patient.

HOW COMMON IS THIS IN MY PRACTICE?

Frozen shoulder is estimated to affect 2%–5% of the general population,( 12 ) and can be significantly painful and disabling. It most commonly affects those in their fourth to sixth decades of life, and more often occurs in women than in men.( 8 , 13 )

The term ‘frozen shoulder’ is often loosely used and wrongly attributed to other shoulder limitations such as a rotator cuff tear or osteoarthritis. Subacromial pathology (e.g. rotator cuff tendinopathy, subacromial bursitis and impingement syndrome) can closely resemble frozen shoulder in the early stages as well.( 7 ) For appropriate management, it is important for physicians to ascertain the diagnosis. As the physical therapy described in this article is specifically targeted at adhesive capsulitis, techniques for other shoulder conditions require further customisation.

WHAT CAN I DO IN MY PRACTICE?

Most frozen shoulder cases can be managed in the primary care setting. Clinicians are encouraged to start the treatment with patient education. Explaining the natural history of the condition often helps to reduce frustration, increase compliance and allay fears for the patient. It is also advisable to acknowledge that full range of motion may never be restored. Common conservative treatments for frozen shoulder include nonsteroidal anti-inflammatory drugs (NSAIDs), glucocorticoids given orally or as intra-articular injections, and/or physical therapy.( 14 ) Many practitioners, however, find themselves limited to prescribing medications to relieve pain and inflammation.

Many physical therapy and home exercises can be used as a first-line treatment for adhesive capsulitis.( 12 ) Physical therapy has been shown to bring about pain relief and return of functional motion.( 15 ) When used in combination with physical therapy, NSAIDs were proven to be more effective as compared to using NSAIDs alone.( 16 ) Similarly, various studies on intra-articular corticosteroids used in combination with physiotherapy resulted in better outcomes compared to intra-articular corticosteroids alone.( 17 , 18 )

The physical therapy for primary idiopathic frozen shoulder described herein can be useful for prescribing home exercises to increase shoulder mobility. Nevertheless, it is imperative to consider the patient’s symptoms and stage of the condition when selecting a physical treatment method for frozen shoulder. Table I summarises the key features of each stage.

A summary of the three phases of frozen shoulder.

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Object name is SMJ-58-685-g002.jpg

Freezing phase

Pain is often most severe during the freezing phase and patients in this phase would benefit from learning pain-relieving techniques. These exercises include gentle shoulder mobilisation exercises within the tolerated range (e.g. pendulum exercise, passive supine forward elevation, passive external rotation, and active assisted range of motion in extension, horizontal adduction, and internal rotation). A heat or ice pack can be applied as a modality to relieve pain before the start of these exercises. The application of moist heat in conjunction with stretching has been shown to improve muscle extensibility.( 19 ) Certain patients might also find it useful to take analgesics before physical therapy.

Patients should begin with short-duration (1–5 seconds) range of motion exercises, which should be in a relatively pain-free range.( 20 ) Fig. 2 shows three commonly performed stretching exercises that are particularly useful for patients in this painful stage. Pendulum exercises can be used in flexion or abduction or circular motion. Patients can also try pulley exercises, as tolerated, and neck or scapular muscle releases. It is important not to aggravate a frozen shoulder, as aggressive stretching beyond the pain threshold can result in inferior outcomes, particularly in the early phase of the condition.( 21 ) There has also been evidence that patients should avoid a forward shoulder posture as it may cause a loss of glenohumeral flexion and abduction.( 22 )

An external file that holds a picture, illustration, etc.
Object name is SMJ-58-685-g003.jpg

Photographs show examples of stretching exercises: (a) active assisted shoulder forward flexion with wand; (b) active assisted shoulder external rotation with wand; and (c & d) pendulum exercise.

Frozen phase

Similar to the freezing phase, a heat or ice pack can be applied during the frozen phase to relieve pain before commencing exercises. Home exercises such as those in Fig. 2 can be continued within the tolerated limit. In particular, stretching exercises for the chest muscles and muscles at the back of the shoulder should be maintained. Rotation before elevation exercises, such as an external rotation stretch, are also recommended to avoid increasing pain and inflammation.( 22 ) At this stage, strengthening exercises are added to maintain muscle strength. Isometric or static contractions are exercises that require no joint movement and can be done without worrying about increasing pain in the shoulder.

Fig. 3 shows strengthening exercises that can be performed at home. The scapular retraction exercises gently stretch the chest muscles and serve as basic strengthening for the scapular muscles. Isometric shoulder external rotation can also be used for flexion or abduction, within the available range, but care should still be taken to avoid introducing aggressive exercises, as overenthusiastic treatment could aggravate the capsular synovitis and subsequently cause pain.

An external file that holds a picture, illustration, etc.
Object name is SMJ-58-685-g004.jpg

Photographs show examples of strengthening exercises: (a) scapular retraction; (b) posterior capsule stretch; and (c) isometric shoulder external rotation. In scapular retraction, the scapulae are pulled towards each other (arrows in a).

Thawing phase

In the thawing phase, the patient experiences a gradual return of range of motion. It is crucial to get the shoulder back to normal as quickly as possible by regaining full movement and strength. Strengthening exercises are important, as the shoulder is considerably weakened after a few months of little movement. Compared to the frozen phase, the patient can perform more mobility exercises and stretches (e.g. Figs. ​ Figs.2 2 & 3 ) with a longer holding duration, within tolerated boundaries. Strengthening exercises can also progress from isometric or static contractions, to exercises using a resistance band, and eventually to free weights or weight machines. Rotator cuff exercises, as well as posture exercises and exercises for the deltoid and chest muscles, can be included in the treatment as well.

Referral to a physiotherapist can be made when the physician thinks that the patient’s condition needs more guidance and can benefit from a physiotherapist review, or when the patient’s condition fails to improve after trialling exercises such as the above. Referral to an orthopaedics specialist may be necessary if some investigations are needed, such as radiography of the shoulder (to look for calcific tendonitis or acromial bone spur, i.e. a Type 3 Bigliani spur) and magnetic resonance imaging of the shoulder to rule out cuff tear.

Manipulation of the frozen shoulder under regional anaesthesia together with intra-articular glenohumeral joint cortisone injection is an effective form of treatment in frozen shoulder without cuff tear. This is especially so if the patient would like a rapid improvement in symptoms and avoid the expected natural history of pain, stiffness and slow gradual thawing of the stiff shoulder.

TAKE HOME MESSAGES

  • Patients with frozen shoulder typically experience insidious shoulder stiffness and near-complete loss of passive and active external rotation of the shoulder.
  • Frozen shoulder occurs in three phases: freezing (painful), frozen (adhesive) and thawing, and is often self-limiting.
  • Common conservative treatments for frozen shoulder include NSAIDs, glucocorticoids given orally or as intra-articular injections, and/or physical therapy.
  • Physical therapy and home exercises can be a first-line treatment for frozen shoulder, with consideration of the patient’s symptoms and stage of the condition.
  • In the freezing (painful) stage, gentle stretching exercises can be done but should be kept within a short duration (1–5 seconds) and not go beyond the patient’s pain threshold.
  • In the frozen (adhesive) stage, strengthening exercises such as scapular retraction, posterior capsule stretch and isometric shoulder external rotation can be added to the patient’s exercises for maintenance of muscle strength.
  • In the thawing stage, the patient experiences a gradual return of range of motion; both stretching and strengthening exercises can increase in intensity, with a longer holding duration.

Lucy started on strengthening exercises at home, following your instructions. On her next visit to your clinic, she was happy to report that these exercises had relieved some of her pain and improved her shoulder movement. You assured her that her condition usually takes time to recover and instructed her to progress to resistance-based exercises. You noted that she was on track to recovery and did not refer her to a physiotherapist .

ACKNOWLEDGEMENT

Figs. ​ Figs.2 2 and ​ and3 3 are reproduced with permission of Changi General Hospital, Singapore.

IMAGES

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  13. Manual physical therapy for chronic pain: the complex whole is greater

    Figure 1. A comprehensive approach to manual physical therapy effectiveness accounting for interactions between patient, therapist, and intervention factors. Examples of factors include preferences, expectations, outcome assessment, and shared decision-making (SDM).

  14. The Flow State Scale for Rehabilitation Tasks: A New Flow Experience

    Plain-Language Summary: Measuring flow experience, or the extent to which patients engage in therapy activities, in the context of occupational therapy and physical therapy is a new approach. This study confirmed that the Flow State Scale for Rehabilitation Tasks questionnaire is reliable and valid for measuring the flow experience of patients ...

  15. APTA Magazine: Top 10 Articles of 2021

    Top 10 APTA Magazine Articles of 2021 The pandemic's effects, emerging practice settings, and the profession's future were just some of the topics grabbing readers' attention. Roundup Date: Monday, December 27, 2021 APTA Magazine brings members content that dives into the issues the profession is talking about, and 2021 was no exception.

  16. Advances in Rehabilitation Technology to Transform Health

    As guest editors of this PTJ featured collection, we hope that the lessons learned from these articles can be considered in relation to the Research Agenda for Physical Therapy from the American Physical Therapy Association (APTA). 17 Several of the research priorities directly address rehabilitation technology ("develop and/or determine the ...

  17. PT Articles

    APTA Sections Advisory Board Articles for PT CEUs Substance Misuse In The Elderly And Use Of Screening, Brief Intervention, And Referral To Treatment (SBIRT) Ingrid Provident, EdD, OTR/L, FAOTA December 4, 2023 Substance use disorders are a significant problem in the elderly population.

  18. APTA Article Search

    APTA Article Search Article Search (formerly at PTNow) provides APTA members with full-text access to research and articles from more than 5,000 clinical and academic publications through the EBSCO Discovery Service. Members Only Content

  19. Current Concepts in Muscle Stretching for Exercise and Rehabilitation

    HR=Hold relax; CR=Contract relax; CRAC= Contract relax, agonist contract; PIR= Post-isometric relaxation; PFS=Post-facilitation stretching, MET= Medical exercise therapy. Figure 3. Static stretching of the posterior shoulder (Used with permission of the Hygenic Corporation). There are 2 types of dynamic stretching: active and ballistic stretching.

  20. Issues

    Read the current issue of Physical Therapy. Skip to Main Content. Advertisement. Journals. Books. Search Menu; Menu; ... News From the Foundation for Physical Therapy Research Scholarships, Fellowships, and Grants. News From the Foundation for Physical Therapy Research, February 2024.

  21. Top Mentioned Articles of 2020

    Top Mentioned Articles of 2020 To mark another year of growth for the journal, PTJ invites you to explore a collection of the most talked-about articles from 2020. Continue to engage with PTJ on Twitter and Facebook in 2021. Manual Therapy Versus Surgery for Carpal Tunnel Syndrome: 4-Year Follow-Up From a Randomized Controlled Trial

  22. Lifestyle Medicine: The Role of the Physical Therapist

    However, in June 2015, the American Physical Therapy Association adopted the motion RC 12-15, The Role of The Physical Therapist in Diet and Nutrition, which cites, "As diet and nutrition are key components of primary, secondary, and tertiary prevention of many conditions managed by physical therapists, it is the role of the physical therapist t...

  23. Physical Therapy Research

    Physical Therapy Research (PTR) is an official journal of the Japanese Society of Physical Therapy. This peer-reviewed international journal focuses on research in physical therapy and related fields (previously Journal of the Japanese Physical Therapy Association (JJPTA)). Article types accepted are: Scientific Research Articles (Original ...

  24. APTA and APTA Section and Academy Journals

    APTA. Physical Therapy & Rehabilitation: The Journal of the American Physical Therapy Association: PTJ is available to all APTA members via Oxford University Press.Historic research is available via APTA Article Search [v. 80, n. 1 (2000)-v. 96, no. 12 (2016)].. Academy of Acute Care Physical Therapy

  25. News

    The latest issue of PTJ: Physical Therapy & Rehabilitation Journal offers a different take. ... The issue features a dozen articles including original research on the use of wearable sensors, web-based monitoring systems, smart phone apps, artificial intelligence, video-based systems, and more, as well as a scoping review that explores current ...

  26. Physical therapy in the management of frozen shoulder

    This article elaborates on physical therapy exercises targeted at adhesive capsulitis, which can be used in combination with common analgesics. Keywords: adhesive capsulitis, frozen shoulder, physical therapy, self-management Lucy, a 53-year-old woman, visited you several times in the past year.