Professional Documents
Culture Documents
S.Y. 2016-2017
SEMINAR 1
MEDICAL BACKGROUND ON
ADHESIVE CAPSULITIS
SUBMITTED TO:
Bernardo Tayaban Jr., PTRP
Maverick Kaypee Colet, PTRP
SUBMITTED BY:
Gurtiza, Joanna Eden A.
I.
Introduction
The first reported description of frozen shoulder was made by Duplay in the late
1800s.They used the label scapulohumeral periarthritis to describe a broad
spectrum of pathologies of the shoulder that resulted to pain, stiffness, and
dysfunction. This label served as an umbrella term that encompassed disorders
such as rotator cuff tendonitis ad tears, biceps tendonitis and tears, calcific
deposits, AC arthritis, and other painful shoulder syndromes.
The term frozen shoulder was later coined in 1934 by Codman, who
characterized the condition as involving a slow onset, pain near the deltoid
insertion, inability to sleep on the affected side, painful and restricted elevation
and lateral rotation, and a normal radiological appearance.
Codman described the condition as difficult to define, difficult to treat and difficult
to explain from the point of view of pathology.
Lundberg introduced the terms primary and secondary further describe frozen
shoulders in 1969. Primary frozen shoulder, are those with idiopathic onset,
whereas secondary frozen shoulders occur following trauma and or
immobilization. Secondary frozen shoulders have been further classified into
intrinsic, extrinsic, and systemic categories by Zuckeman and Rokito.
Naviaser describes adhesive capsulitis as a distinct entity with four identifiable
stages that are arthroscopically distinct:
Stage 1 (painful stage)
- Shoulder motion is restricted little if at all during this stage.
- Arthroscopy shows an erythematous fibrinous pannus over the
synovium, primarily around the dependent fold.
- The articular cartilage is normal in condition
- Duration of symptoms: 0-3 months
Stage 2 (freezing stage)
- Characterized by pain with associated loss of motion in all planes
- Arthroscopically, the synovium appears red, thickened, and
inflamed.
- Adhesions across the dependent fold can be seen.
- There is loss of the space between the humeral head and glenoid
as well as between the humeral head and biceps tendon.
- Duration of symptoms:3-9 months
Stage 3 (frozen stage)
- Characterized by the transition from inflammatory synovitis to
chronic fibrosis and by markedly decreased size of the
dependent fold.
- There is complete obliteration of the space between the humeral
head and biceps tendon.
- Duration of symptoms:9-15 months
Stage 4 (thrawing stage)
- There is no longer synovitis present
- The dependent fold has become severely contracted by this
stage
- Shoulder motion s severely limited.
- Duration of symptoms:15-24 months
II.
Definition of Terms
Adhesive capsulitis
o is a syndrome defined in its purest sense as idiopathic painful restriction
of shoulder movement that results in global restriction of the
glenohumeral joint. It is not associated with a specific underlying
condition. It has also been described as a condition of "unknown etiology
characterized by gradually progressive, painful restriction of all joint
motion . . . with spontaneous restoration of partial or complete motion
over months to years.
Arthrogram
o is a series of images of a joint after injection of a contrast medium, usually
done byfluoroscopy or MRI.
Atraumatic Instability
o is a condition where the dislocation occurs with minimal or no causative
trauma in any direction.
Cytokinesis
o is the process during cell division in which the cytoplasm of a
single eukaryotic cell is divided to form two daughter cells.
Cervical spondylosis
o is a general term for age-related wear and tear affecting the spinal disks
in your neck.
Dynamic sonography
o is a diagnostic imaging technique based on the application of ultrasound.
Frozen shoulder (sometimes called adhesive capsulitis of the shoulder)
o is a condition where a shoulder becomes painful and stiff
Impingement syndrome
o is a clinical syndrome which occurs when the tendons of the rotator
cuff muscles become irritated and inflamed as they pass through the
subacromial space, the passage beneath the acromion.
Nociceptor
o is a sensory nerve cell that responds to damaging or potentially damaging
stimuli by sending signals to the spinal cord and brain.
Manipulation Under Anesthesia (MUA)
o is multidisciplinary manual therapy treatment system which is used to
improve articular and soft tissue movement using specifically controlled
release, myofascial manipulation, and mobilization techniques while the
patient is under moderate to deep IV sedation using monitorized
anesthesia care (MAC).
Primary Frozen Shoulder
o This occurs without an identifiable cause.
Rotator cuff
III.
Epidemiology
Prevalence of frozen shoulder
is 2% to 5% in the general population
- 10%-20% in patient with diabetes.
Sex
Females are more commonly affected than males.
Age
- Most frequently seen in individuals between 40-60 years old.
Work
- Sedentary workers are commonly affected than laborers.
Diabetes
people with diabetes are more likely to develop the condition and it also takes longer to
recover
Immobility
not moving a shoulder often enough after an injury can turn into a frozen shoulder
Systemic diseases such as tuberculosis, thyroid issues, Parkinsons disease and
cardiovascular disease puts people more at risk.
IV.
BONES
Manubrium
Clavicle
The manubrium (L. manubrium, handle) is the most cephalic aspect of the
sternum and the site at which the left and right clavicles secure the upper
extremities to the axial skeleton.
Scapula
The scapula (L. scapula, shoulder blade) is a flat, triangular-shaped bone with three
sides and three angles that sits against the posterior thorax.
It has a dual function:
to provide a place for muscles controlling the glenohumeral joint to
venture from and to provide a stable base from which the
glenohumeral joint can function.
- It works intimately with the clavicle to provide the glenohumeral joint
more motion so the hand can be placed in more positions.]
Parts of scapula
inferior angle of the scapula
- where the vertebral border and lateral border meet
glenoid fossa
- is the superior lateral aspect of the scapula that forms the
concave portion of the glenohumeral joint.
superior border
is difficult to palpate but lies essentially parallel to the spine of
the scapula.
scapular spine
lies on the posterior scapula and divides the scapula into two
fossae, the supraspinatus fossa and the infraspinatus fossa.
supraspinatus fossa
- above the spine
infraspinatus fossa
- below the spine
acromion process
- sits over the glenohumeral joint to protect it from overhead
forces applied down toward the shoulder
coracoid process.
- This process sits below the clavicle and is medial to the glenoid
fossa.
- It protrudes anteriorly from the scapula and is a site of multiple
ligament and muscle attachments.
Humerus
Parts of humerus
head of the humerus
- is the convex segment that interfaces with the concave glenoid
fossa to form the glenohumeral joint.
greater tubercle
- sits lateral to the lesser tubercle and is a large round
protuberance.
lesser tubercle
- is smaller and sharper and lies more medially.
JOINTS
the clavicle articulates with the manubrium of the sternum at the sternoclavicular
(SC) joint;
the clavicle and the scapula join at the acromioclavicular (AC) joint; and
the humerus articulates with the scapula at the glenohumeral (GH) joint.
During movements of the shoulder complex, the scapula also slides on the thorax;
this connection is the scapulothoracic (ST) joint.
GLENOHUMERAL JOINT
BONES:
Reverse Actions:
The muscles of the GH joint are generally considered to move the more distal
arm on the more proximal scapula.
However, the scapula can move at the GH joint relative to the humerus; this is
especially true if the arm is fixed such as when the hand is gripping an
immovable objectin other words, during a closedchain activity
The major reverse actions of the scapula at the GH joint are
- upward rotation and downward rotation.
The capsule of the GH joint is extremely lax and permits a great deal of motion.
The GH joint capsule is so lax that if the musculature of the shoulder joint is completely
relaxed, the head of the humerus can be moved away from the glenoid fossa 1 to 2
inches (2.5 to 5.0 cm).
The GH joint capsule is thickened and strengthened by glenohumeral (GH) ligaments.
o Three GH ligaments exist:
- (1) the superior glenohumeral ligament
- (2) the middle glenohumeral ligament
- (3) the inferior glenohumeral ligament
These ligaments are thickenings of the anterior and inferior joint capsule.
Function:
- They prevent dislocation of the humeral head anteriorly and inferiorly.
- As a group, these three ligaments also limit the extremes of all GH joint
motions.
- There is a small region of the anterior GH joint capsule called the foramen
of Weitbrecht that is located between the superior and middle
glenohumeral (GH) ligaments.
- The foramen of Weitbrecht is a relatively weak region where the majority
of shoulder dislocations occur.
Coracohumeral Ligament:
Location:
- The coracohumeral ligament is located between the coracoid process of
the scapula and the greater tubercle of the humerus.
Function:
- It prevents dislocation of the humeral head anteriorly and inferiorly and
limits extremes of flexion, extension, and lateral rotation.
MISCELLANEOUS:
BONES:
The scapula and the ribcage
- More specifically, the anterior surface of the scapula and the posterior
surface of the ribcage
Joint type: Functional joint
The ScC joint is unusual in that it is not an anatomic joint because no actual
union of the scapula and the ribcage is formed by connective tissue. However,
because it behaves as a joint does in that movement of the scapula relative to
the ribcage occurs, it is considered to be a functional joint.
MAJOR MOTIONS ALLOWED:
Major motions allowed are as follows
Of all the scapular actions possible:
o only elevation/ depression and protraction/retraction can be primary
movements, meaning that each one of these movements can be
created separately by itself.
The other scapular actions are secondary in that they must occur secondary to
an action of the arm at the glenohumeral (GH) joint.
o Protraction and retraction (nonaxial movements) of the scapula
o Elevation and depression (nonaxial movements) of the scapula
o Upward rotation and downward rotation (axial movements) of the
scapula
o Note: Upward rotation and downward rotation of the scapula occur
within the frontal plane around an anteroposterior axis (these are
approximations of the plane and axis, because the scapula is not
situated perfectly within the frontal plane because of the shape of the
posterior ribcage wall).
Accessory Movements:
Accessory movements include the following:
Lateral tilt and medial tilt (axial movements) of the scapula
Upward tilt and downward tilt (axial movements) of the scapula
Lateral tilt of the scapula is usually referred to in lay terms as winging of
the scapula.
Reverse Actions:
The ribcage (i.e., the trunk) can move relative to the scapula.
One example of a reverse action at the scapulocostal (ScC) joint in which the
ribcage (i.e., the trunk) moves relative to the scapula is when :
- push-ups are done.
- The objective of a push-up is to exercise muscles by pushing the body
up and away from the floor. At the very end of a push-up, after the upper
extremities are perfectly vertical, a little more elevation of the trunk away
from the floor is possible.
This motion is caused by protractors of the scapula such as the serratus
anterior contracting and pulling the trunk (which is more mobile) up
toward the scapulae (which are fixed, because the hands are planted
firmly on the floor).
Fibrous capsule
Acromioclavicular (AC) ligament
Coracoclavicular ligament (trapezoid and conoid)
Function:
- The coracoclavicular ligament does not directly cross the AC joint itself, but it
does cross from the scapula to the clavicle and therefore adds stability to the
AC joint.
Distal attachment:
- Medial border of the scapula.
Innervation:
- Long thoracic nerve (C5-C7)
Anatomic actions:
Abduction and upward rotation of the scapula.
Trapezius
Connects the scapula with the vertebral column, lie underneath the trapezius.
Upper portion: rhomboids minor
Lower portion: rhomboids major
Proximal attachments:
- Ligamentum nuchae and spinous processes of the lowest two cervical
and the upper four thoracic vertebrae
Distal attachment:
- Medial border of the scapula
Innervation:
- Dorsal scapular nerve (C4-C5)
Anatomic actions:
- Downward rotation, adduction, and elevation of the scapula.
Pectoralis minor
Levator Scapulae
Proximal attachment:
- transverse processes of the upper cervical vertebrae
Distal attachment:
- medial border of the scapula, above the spine, near the superior angle
Innervation:
- Dorsal Scapular Nerve
Action:
- Elevation and downward rotation of the scapula
- Lateral flexion and ipsilateral rotation of the cervical spine
Supraspinatus
Described together because they are closely related in location and action
Proximal attachment:
Infraspinatus infraspinous fossa
- Teres Minor Lateral border of the scapula
Distal attachment:
- Infraspinatus greater tubercle of the middle facet
- Teres Minor greater tubercle of the lower facet
Innervation:
- Infraspinatus Suprascapular Nerve
- Teres Minor Axillary Nerve
Action:
External rotation and abduction of the glenohumeral joint
Teres Major
Located at the axillary border of the scapula, distal to the teres minor
Proximal attachment:
Inferior angle of the scapula
Distal attachment:
- crest of lesser tubercle of the humerus
Innervation:
- Subscapular nerve
Action:
- Flexion and adduction of the glenohumeral joint
Coracobrachialis
Proximal attachment:
Coracoid process of the scapula
Distal attachment:
- medial surface of the humerus
Innervation:
- Musculocutaneous Nerve
Action:
- Flexion and adduction of the glenohumeral joint
The two head of the biceps and the long head of the triceps cross the shoulder joint and
there for act on it
Attachment:
heads of the biceps attach to the supraglenoid tubercle and to the
coracoids process
- Triceps attaches to the infraglenoid tubercle
Action:
Biceps flexor and abductor of the glenohumeral joint
Triceps extensor and adductor of the glenohumeral joint
Pectoralis Major
SCAPULOHUMERAL RHYTHM
V.
for total ROM have a 2:1 ratio (e.g. 180 of abduction have 120 of
glenohumeral mvmt and 60 of scapular mvmt.
Etiology
The causes of frozen shoulder are not fully understood. There is no clear connection to
arm dominance or occupation. A few factors may put you more at risk for developing frozen
shoulder.
The causes for frozen shoulder could be:
a) Intrinsic, e.g. associated with shoulder disorder or trauma
(1) Stiffness following shoulder surgery
(2) Rotator cuff pathology
(3) Impingement syndrome
(4) Glenohumeral osteoarthritis
VI.
Primary: Here the exact cause is not known and it could be idiopathic.
Secondary: According to Lumberg, the secondary causes could be:
- Shoulder causes: Problems directly related to shoulder joint which
can give rise to frozen shoulder are tendonitis of rotator cuff, bicipital
tendinitis, fractures and dislocations around the shoulder, etc.
- Nonshoulder causes: problems not related to shoulder joint like
diabetes, cardiovascular diseases with referred pain to the shoulder,
which keeps the joint immobile, reflex sympathetic dystrophy, frozen
hand shoulder syndrome, a complication of Colles fracture, can lead
to frozen shoulder. The reason could be prolonged immobilization of
the shoulder joint due to referred paun, et
Pathophysiology/Mechanism of Injury/Pathology
Secondary (Less
Primary
(Idiopathic):Unknown
etiology, but
associated with
autoimmune disorders
(diabetes mellitus,
thyroid disease)
Prolonged shoulder
injury (i.e. post
shoulder surgery,
rotator cuff tear,
humeral head fracture).
Prolonged shoulder
immobility (i.e. after a
stroke that cause
hemiplegia, or during
recovery after
v
VII.
VIII.
declines
Stimulus :
No activation of
local nociceptor.
Severe in
space and
90joint
flexion
and joint
No shoulder
pain
Shoulder stiffness (
active AND passive
slight range
ER, elbow
extension
of motion
in
shoulder, any
movement is mostly
scapulothoracic).
Hawkins
kennedy
impingement
test
flexible ligaments.
3rd
stage
and 5-24
extension
Spontaneous
resolution, selflimited disease
time).
Position:
sitting
Mechanis
Stimulus: Signs/symptom/lab
- passive
findingflexion to 90 and IR of the arm with the elbow flexion;
m
- Stabilized elbow and push down on the wrist into more IR.
(+)response:
pain in the area of supraspinatus tendon/ coracoacromial ligament
Drop arm (codmans test)
Position:
sitting/standing
Stimulus:
examiner abducts arm to 90 and pt. drops the arm slowly
(+)response:
- inability to return arm slowly or has severe pain
Neer impingement test
Position:
- Sitting
Pathophysiology
2nd
stage:
4-12
shoulder
1st
stage:29 mos
Stimulus:
- Pt.s arm is forcibly elevated thru forward flexion by examiner causing
jamming of the greater tuberosity against the inferior border of the
acromion.
(+)response:
- Pain shows on pt.s face
Supraspinatus (empty can )test
Position
- Sitting
Stimulus:
- Pt.s soulder abducted to 90 with neutral rotation, examiner resist
- Shoulder is then IR(thumbs down) and angled forward 30(empty can
position) as resistance is given again.
(+)response:
- Weakness and pain
Apleys scratch test
Position
- Sitting or standing
Stimulus:
- Passive adduction, approximating elbow to opposite shoulder
(+)response:
- Pain at AC jt,.
Diagnostic tools:
IX.
Frozen Shoulder
Atraumatic
Instability
Cervical
Spondylosis
History
Observation
Active
movement
Passive
movement
Resisted
isometric
movement
Age 30-50
years
Pain and
weakness
after eccentric
load
Normal bone
and soft
tissue outlines
Protective
shoulder hike
may be seen
Weakness of
abduction or
rotation, or
both
Crepitus may
be present
Pain f
impingement
occurs
Pain and
weakness on
abduction and
lateral rotation
Age 45+
Insidious
onset or after trauma
or
surgery
Functional
restriction of
lateral
rotation,
abduction,
and
medial
rotation
Normal bone
and soft
tissue
outlines
Age
10-35 years
Pain
and instability
with activity
No history of
trauma
Normal bone
and soft
tissue
outlines
Drop-arm test
positive
Empty can
positive
50+
or
Minimal or no
cervical
spine
movement
Torticollis
may
be
present
Restricted
ROM
Shoulder
hiking`
Full or
excessive
ROM
Limited ROM
with pain
Limited ROM,
especially in
lateral,
rotation,
abduction,
and medial
rotation
(capsular
pattern)
Normal, when
arm by side
Normal or
excessive
ROM
Limited ROM
Normal
Normal
except
if
nerve
root
compressed
Myotome
may
be
affected
Spurlins test
positive
Distraction
test positive
ULTT
Special test
Age
years
Acute
chronic
None
Load and
shift test
positive
Apprehensio
n test positive
Sensory
function
reflexes
Not affected
Not affected
Relocation
test positive
Augmentatio
n test positive
and
-
positive
Shoulder
abduction
test positive
Dermatomes
affected
Reflexes
affected
Palpation
Tender over
rotator cuff
Not painful
unless
capsule is
stretched
Anterior or
posterior pain
Tender over
appropriate
vertebra or
facet
Diagnostic
imaging
Radiography:
upward
displacement
of humeral
head;
acromial
spurring
MRI
diagnostic
Radiography:
negative
Anthrography
: decreased
capsular size
Negative
Radiography:
narrowing
osteophytes
X.
Managements
Pharmacological Management
Non-steroidal anti- inflammatory drugs:
- Aspirin and ibuprofen to reduce pain and swelling
Steroid injections:
- Cortisone is a powerful anti-inflammatory medicine that injected directly
into the shoulder joint.
Medical and Surgical Management
Manipulation under anesthesia
- which may be done in combination with steroid injection, distension
arthrography, or arthroscopy.
Contraindications to closed manipulation under anesthesia include anticoagulation or bleeding diatheses, significant osteopenia, or recent
surgical repair of shoulder soft tissue, fracture or neurological lesion.
Complications may include humeral fracture, dislocation, cuff injuries,
labral tears or brachial plexus injury.
Arthroscopic capsular release or open surgical release
- may be appropriate in rare cases with failure of previous methods and
when the patient has demonstrated ability to follow through with required
physical and occupational therapy. Other disorders, such as impingement
Heat modalities
Heat
-
prior to exercise for pain relief, to promote relaxation and to increase tissue
extensibility
Ultrasound
-
is the application of heat through sound waves to deep tissue of the body. It is
used to reduce pain, relax tight muscles and reduce muscle spasm.
Ultrasound is shown to have an analgesic effect from the vasodilatation that it
causes, which may help remove the byproducts of the injured tissue, that often
stimulates the pain fibers.
Ultrasound is also shown to relieve muscle spasms by decreasing receptor
activity and sensitivity to stretching
TENS has been shown to significantly increase range of motion more than heat.
There are two theories of why TENS is effective in pain relief:
- The first theory the gate control theory of pain states that if the fibers
transmitting touch and proprioception sensations are over stimulated,
they may flood the pathways to the brain, preventing the pain signals
from reaching the brain.
- The second theory postulates that the electrical stimulation of nerve
fibers causes the release of bodys own natural opiates, thereby
decreasing pain.
The pain relief is directly proportional to the TENS parameters of frequency and
amplitude. As both frequency and amplitude increase, pain relief also increases
Soft tissue mobilization and deep friction massage may have benefits in the
treatment of SAC.
Deep friction massage using the Cyriax Method is shown to be superior to
superficial heat and diathermy treatment of SAC.
Utilizing the Cyriax method, STM directed at the specific limitation of the
periarticular structures in combination with a simple home exercise program
appeared to be an effective treatment in patients with SAC stage II, as measured
by improved ROM of the subjects
Therapeutic exercises:
-
Most commonly used exercises for patients with SAC are active-assistive range
of motion (AAROM) exercises and passive ROM.
Pt uses the uninvolved arm, or equipment such as the rope and pulley, wand/ T
bar or exercise balls. Generally, these exercises are performed for flexion,
abduction and external and internal rotation range of motions. Improved in pain,
ROM, and shoulder function.
Resistive exercises
-
typically include strengthening of the scapular stabilizers, rotator cuff, and lower
trapezium muscles.
As the range of motion improves, shoulder strengthening is appropriate
intervention as long as the therapist stimulates normal movement pattern without
substitution of scapular movements over GHJ mobility.
PNF is the application of specific stimuli to elicit and improve motor activity
are used for anterior deltoid muscles in the end range of forward flexion in supine
after passive stretch to train the deltoid muscles to contract isometrically for 3-5
seconds.
The patient can improve strength in the gained range during therapy sessions
and maintain this range of motion.
These techniques, when used effectively, can improve the patient outcome.
Home program
-
Wall Climb Stretch Stand facing a wall, place the hand of the affected arm on the wall. Slide
the hand up the wall, allowing the hand and arm to go upward. As you are able to stretch the
hand and arm higher, you should move your body closer to the wall. Hold the stretch for 15to 20
seconds. Do 10 repetitions.
Internal Rotation: Behind-the-Back Stretch Sitting in a chair or standing, place the hand of the
affected arm behind your back at the waistline. Use your opposite hand to help the other hand
higher toward the shoulder blade of the opposite shoulder. Do 10 repetitions.
Supine External Rotation with Abduction Lie on your back. Place your hands behind vour head
as shown in the top illustration. Slowly lower your elbows to stretch the shoulders toward the
surface you are lying on. Do 10 repetitions.
Horizontal Adduction Stretch Lying on your back, hold the elbow of the affected arm with your
opposite hand. Gently stretch the, elbow toward the opposite shoulder. Later, this stretch can be
done standing. Do 10 repetitions.
Standing Neutral External Rotation Hold a door handle or frame with the hand of the involved
arm. While keeping the involved arm firmly against your side and the elbow at a right (90
degree) angle, Rotate your body away from the door to produce outward rotation at the
shoulder. Do 10 repetitions.
External Rotation in Corner Standing facing a comer, position the arms as illustrated with the
elbows at shoulder level. Lean your body gently forward toward the comer until a stretch Is felt.
Hold this position gently for15 to 20 seconds. Repeat 10 times
.Internal Rotation Stretch Standing facing a comer, position the arms as illustrated with the
elbows at shoulder level. The throwing arm is the one with the hand pointed down. Lean your
body gently forward toward a comer until a stretch is felt Hold this position gently for 15 to 20
seconds. Repeat 10 times.
Shoulder Shrugs and Scapular Retraction Shrug shoulders upward as illustrated in figure 1.
Pinch shoulder blades backward and together.
Active warm-up
AAROM exercise
Single-plane, end-range mobilization
Stretching technique (physiologic, CR,HR)
End-range stretching
End-range submaximal isometrics
Self-capsular stretching
Home program (8-10 times daily)
Frequent stretching and ROM exercise
Sustained stretch at end range
Heat
Active warm-up (AAROM,UBE)
LLLD stretch with concomitant superficial heat
Aggressive joint mobilization
Single multi-planar glides and combined glides
Joint mobilization- emphasize inferior glides
CR,HR stretching
Self- joint mobilization at home
Sustained stretching at home (TERT principle)
Strengthening (PNF)exercises
Home program (4-6 times daily)
- Keep it moving
Note: AAROM active resisted range of motion; CR contract relax; HR hold relax; LLLD low load
long duration; PNF proprioceptive neuromuscular fasciculation; TERT total end range time; UBE
upper body ergometer
XII. REFFERENCES
Physical Medicine and Rehabilitation 1st Edition by: Randall L. Braddom, M.D, M.S
Rehabilitation Medicine Principles and Practice 2nd Edition by: Joel A. DeLisa and Bruce
M. Gans
Brunnstoms clinical kinesiology 5th edition
The Athlete's Shoulder By Kevin E. Wilk, Michael M. Reinold, James Rheuben Andrews