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Aims of the Guidelines Shoulder Disorders: Orthopaedic Section, APTA, Inc ICF-based Clinical Practice Guidelines Describe diagnostic classifications based upon ICF terminology Philip McClure, PT, PhD Describe best outcome measures to use Martin J. Kelley, DPT Describe best intervention strategies that Lori A. Michener, PT, PhD are matched to the classification Joe Godges, DPT in other words: - reduce unwarranted variation - do the right thing at the right time for the right patient

Aims of the Guidelines Orthopaedic Section Orthopaedic Section, APTA, Inc pilot study – 2012 & 2013 - an associated benefit - Clinical Practice Strategic Outcome 1 – Standards of Practice: Guidelines enable a seamless creation Objective B – Develop National Orthopaedic of “minimal data Physical Therapy Outcomes Database sets” – a critical foundation of outcome databases

Minimal Data Set Needs Published Clinical Practice Guidelines:

1. Neck Pain 1. Heel Pain / Plantar Fasciitis (2008) 2. Shoulder Disorders 2. Neck Pain (2008) 3. Hip Osteoarthritis (2009) 3. Low Back Pain 4. Knee Ligament Sprain (2010) 4. Knee Disorders 5. Knee Meniscal Disorders (2010) 6. Ankle Tendinitis (2010) served by process & rigor of clinical guideline development 7. Low Back Pain (2012)

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Published Clinical Practice Guidelines:

1. Heel Pain / Plantar Fasciitis (2008) 2. Neck Pain (2008) 3. Hip Osteoarthritis (2009) 4. Knee Ligament Sprain (2010) 5. Knee Meniscal Disorders (2010) 6. Ankle Tendinitis (2010) 7. Low Back Pain (2012) 8. Shoulder Adhesive Capsulitis (2013)

Shoulder Pain & Mobility Deficits/ Shoulder Pain & Mobility Deficits/ Adhesive Capsulitis Adhesive Capsulitis (May 2013) Martin J. Kelley DPT Content Expert Reviewers Michael A. Shaffer MSPT John E. Kuhn MD George J. Davies DPT, MEd, MA Lori A. Michener PT, PhD Paula M. Ludewig PT, PhD Amee L. Seitz PT, PhD Paul J. Roubal DPT, PhD Timothy L. Uhl PT, PhD Kevin Wilk DPT Joseph J. Godges DPT, MA Philip W. McClure PT, PhD

Published Clinical Practice Guidelines: Published Clinical Practice Guidelines: 1. Heel Pain / Plantar Fasciitis (2008) 2. Neck Pain (2008) www.jospt.org Open access 3. Hip Osteoarthritis (2009) 4. Knee Ligament Sprain (2010) 5. Knee Meniscal Disorders (2010) www.orthopt.org Feedback requested 6. Ankle Tendinitis (2010) 7. Low Back Pain (2012) 8. Shoulder Adhesive Capsulitis (2013) www.guidelines.gov AHQR National Guidelines 9. Ankle Sprains (Sept.2013) Clearinghouse

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ICF Guidelines Current Status ICF Guidelines Current Status Guidelines – in Review: Guidelines – under construction:

10. Non-arthritic Hip Joint Pain 11. Patellofemoral Pain Syndrome

12. Carpal Tunnel Syndrome Look for publication later this spring (collaborating with the Hand Rehabilitation Section)

13. Distal Radius Fractures (collaborating with the Hand Rehabilitation Section)

ICF Guidelines Current Status Future Clinical Practice Guidelines: Guidelines – under construction:

17. Subacromial Pain Syndrome 14. Hip Fractures (collaborating with the Section on Geriatrics) 18. Shoulder Instability 15. Medical Screening (collaborating with the Federal PT Section) 19 + . Potential Collaboration(s) with

16. Elbow Epicondylitis the Sports PT Section (collaborating with the Hand Rehabilitation Section)

Shoulder Disorders: ICF-based Clinical Practice Guidelines

Philip McClure, PT, PhD Martin J. Kelley, DPT Lori A. Michener, PT, PhD

Feedback / Comments Very Welcomed!

3 McClure:Shoulder ICF CSM 2014

Acknowledgements:

Classification of Shoulder Disorders: Martin Kelley PT, DPT, OCS John Kuhn MD Phil McClure PT, PhD A Staged Algorithm for Lori Michener PT, PhD, ATC, SCS Mike Shaffer PT, OCS, ATC Amee Seitz PT, DPT, OCS Rehabilitation Tim Uhl PT, PhD, ATC

Phil McClure PT, PhD, FAPTA Arcadia University

The Shoulder and ICF Why Classify? Impairments Popular Label 1o ICD 9 ICF Body ICF Body Activities/ Function Structure Participation • Direct Intervention Rotator Cuff 726.1 B7300 S7202 D4452 Reaching Power of isolated Muscles of shoulder D4300 Lifting Tendinopathy Rot Cuff • Prognosis muscles and muscle region D850 Work (Impingement) Syndrome groups D520 Caring for body parts • Communication Frozen Shoulder 726.0 B7100 S7201 Mobility of a single Joints of the D4451 Pus hing Adhesive joint shoulder region D4452 Reaching – Research Capsulitis D4300 Throwing – Payors Glenohumeral 840.2 B7601 S7203 Control of complex Ligaments and • Instability Shoulder voluntary fasciae of shoulder Other? ligament movements region sprain

Complaint of “Shoulder Symptom”

Level 1: Screening Shoulder Dx /Classification History, Basic Physical Exam, Red or Yellow Flags

Appropriate for PT Pathoanatomic Classification Appropriate for PT Not Appropriate for PT And Referral • Rotator Cuff “Syndrome” / Impingement • Glenohumeral Instability Level 2: Pathoanatomic Dx • Adhesive Capsulitis Specific Physical Exam • Others Shoulder origin of sx Non-shoulder origin of sx Assumptions wihiithin a Pathihoanatomic Modldel

• Tissue pathology represents an homogenous group Rotator Cuff Glenohumeral Adhesive Capsulitis Other – i.e. they look similar and should be treated similar “Syndrome” Instability

• Strong relationship between tissue pathology and patient Level 3: Rehab Classification complaints a) Tissue Irritability ( guides intensity of physical stress ) b) Impairments ( guides specific intervention tactics) – i.e. must “fix” pathologic anatomy for pain and function to improve

High Irritability & Moderate Irritability & Low Irritability & Identified Impairments Identified Impairments Identified Impairments

Three‐level Staged Algorithm for Rehabilitation classification for shoulder pain

1 McClure:Shoulder ICF CSM 2014

Complaint of “Shoulder Symptom”

Level 1: Screening Level 2 History, Basic Physical Exam, Red or Yellow Flags Pathoanatomic Diagnoses

Appropriate for PT Appropriate for PT Not Appropriate for PT And Referral Rotator Cuff Adhesive Glenohumeral “Syndrome” Capsulitis Instability Other

Level 2: Pathoanatomic Dx Key positive findings Key positive findings Key positive findings •GH Arthritis •impingement signs •Spontaneous •Age usu < 40 Specific Physical Exam •Fractures •Painful arc progressive pain •Hx disloc / sublux “Rule in” •AC jt •Pain w/ isom resist •Loss of motion in •Apprehension •Neural Entrap •Weakness multiple planes •Generalized laxity Shoulder origin of sx Non-shoulder origin of sx •Myofascial •Atrophy (tear) •Pain at end-range •Fibromyalgia •Post-Op Key negative findings Key negative findings Key negative findings “Rule Out” • Sig loss of motion • Normal motion • No hx disloc Rotator Cuff Glenohumeral Adhesive Capsulitis Other • Instability signs • Age < 40 • No apprehension “Syndrome” Instability

Pathoanatomic diagnosis based on specific physical examination (+/‐ imaging). Most Level 3: Rehab Classification a) Tissue Irritability ( guides intensity of physical stress ) diagnostic accuracy studies address this level. As examples, findings are listed for the three b) Impairments ( guides specific intervention tactics) most common diagnoses only.

High Irritability & Moderate Irritability & Low Irritability & Identified Impairments Identified Impairments Identified Impairments

Three‐level Staged Algorithm for Rehabilitation classification for shoulder pain

Complaint of “Shoulder Symptom” Level 3 Rehabilitation Classification Level 1: Screening History, Basic Physical Exam, Red or Yellow Flags • Tissue Irritability ( guides intensity of physical stress ) • Impairments ( guides specific intervention tactics) Appropriate for PT Appropriate for PT Not Appropriate for PT And Referral Tissue Irritability: Pain , Motion, Disability High Moderate Low Level 2: Pathoanatomic Dx History • High Pain (> 7/10) • Mod Pain (4-6/10) •Low Pain (< 3/10) Specific Physical Exam and • night or rest pain • night or rest pain • night or rest pain Exam • consistent • intermittent • none • Pain before end ROM • Pain at end ROM • Min pain Shoulder origin of sx Non-shoulder origin of sx •AROM < PROM •AROM ~ PROM w/overpressure • High Disability • Mod Disability •AROM = PROM •(DASH, ASES) •(DASH, ASES) • Low Disability Glenohumeral Rotator Cuff “Syndrome” Adhesive Capsulitis Other •(DASH, ASES) Instability

Minimize Physical Mild - Moderate Mod – High Level 3: Rehab Classification Intervention a) Tissue Irritability ( guides intensity of physical stress ) Focus Stress Physical Stress Physical Stress b) Impairments ( guides specific intervention tactics) • Activity modification • Address • Address impairments impairments High Irritability & Moderate Irritability & Low Irritability & • Monitor impairments • Basic level • High demand Identified Impairments Identified Impairments Identified Impairments functional activity functional activity restoration restoration Three‐level Staged Algorithm for Rehabilitation classification for shoulder pain

Complaint of “Shoulder Symptom” Level 3 Rehabilitation Classification Level 1: Screening • Tissue Irritability ( guides intensity of physical stress ) History, Basic Physical Exam, Red or Yellow Flags • Impairments ( guides specific intervention tactics) High Irritability Moderate Irritability Low Irritability Impairment Appropriate for PT Appropriate for PT Not Appropriate for PT And Referral Pain: Assoc Local Modalities Limited modality use No modalities Tissue Injury Activity modification Activity modification Pain: Assoc with Central Progressive exposure to activity Sensitization Medical Mgmt Level 2: Pathoanatomic Dx Limited Passive Mobility: ROM, stretching, manual therapy: Pain-free ROM, stretching, manual ROM, stretching, manual therapy: Specific Physical Exam joint / muscle / neural only, typically non-end range therapy: Comfortable end-range Tolerable stretch sensation at end stretch, typically intermittent range. Typically longer duration and frequency Excessive Passive Protect joint or tissue from end-range Develop active control in mid- Develop active control during full- Shoulder origin of sx Non-shoulder origin of sx Mobility range while avoiding end-range range during high level functional in basic activity activity

Address hypomobility of Address hypomobility of adjacent adjacent joints or tissues joints or tissues Glenohumeral Rotator Cuff “Syndrome” Adhesive Capsulitis Other Neuromuscular AROM within pain-free ranges Light  mod resistance to Mod  high resistance to fatigue Instability Weakness: Assoc with fatigue Include End-ranges Mid-ranges atrophy, disuse, deconditioning Level 3: Rehab Classification Neuromuscular AROM within pain-free ranges Basic movement training with High demand movement training with a) Tissue Irritability ( guides intensity of physical stress ) Weakness : Assoc with emphasis on quality/precision emphasis on quality rather than Consider use of biofeedback, rather than resistance according resistance according to motor learning b) Impairments ( guides specific intervention tactics) poor motor control or neuromuscular electric stimulation or other to motor learning principles principles neural activation activation strategies Functional Activity Protect joint or tissue from end-range, Progressively engage in basic Progressively engage in high demand encourage use of unaffected regions functional activity functional activity intolerance High Irritability & Moderate Irritability & Low Irritability & Poor patient Appropriate patient education Appropriate patient education Appropriate patient education Identified Impairments Identified Impairments Identified Impairments understanding leading to inappropriate activity (or avoidance of activity) Three‐level Staged Algorithm for Rehabilitation classification for shoulder pain

2 McClure:Shoulder ICF CSM 2014

Does the Pathoanatomic Dx Matter? Key Decisions: Level 1: Screening Impairment: Limited GH mobility:Capsular Hx, Basic Phys Exam, PT and/or Referral ? Red or Yellow Flags

• 30 yo Post Fx Stiffness • Prognosis Specific Tissue Disorder? Level 2: Pathoanatomic Dx General Intervention strategy ? Specific Physical Exam • Rehab vs Surgery • Key tissue and movement precautions • 50 yo Adhesive Capsulitis • Natural History Prognosis and Patient Education

• 70 yo GH Arthritis • Rehab Strategy What Physical Stress Intensity? Level 3: Rehab Classification • Minimal • Tissue Irritability • Moderate • Impairments • High

What are the Key Impairments driving symptoms or functional loss?

Discussion Discussion: Comparison of Pathoanatomic Dx and Rehab Classification A Staged Algorithm for Rehabilitation Limitations (at least a few) Potential Features • Pathoanatomic Dx • Rehab Classification • Conceptual Stage • Relatively simple – Primary Tissue – Irritability / Impairment • Does “irritability” • Captures thought Pathology – Often changes over – Stable over episode of capture key features process of many episode of care determining application seasoned clinicians care – Guides specific rehab Rx of physical stress? • Possible broad – Guides general Rx • Physical stress dosage • Does not address “non‐ application strategy • Specific Impairments physical” issues – Informs prognosis – May inform prognosis ? • Not “separate” from – Surgical Decisions • Reliability medical framework • Validity

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3 Adhesive Capsulitis: Clinical Practice Guidelines Martin J. Kelley, DPT, Michael A. Shaffer, MSPT, John E. Adhesive Capsulitis Kuhn, MD, Lori A. Michener, PT, PhD, Amee L. Seitz, PT, PhD, Timothy L. Uhl, PT, PhD, Joseph J. Godges, DPT, MA, • An entity of unknown etiology resulting in Philip W. McClure, PT, PhD painful and limited active and passive shoulder motion, however, it demonstrates a characteristic history, presentation and recovery

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ETIOLOGY This is not Adhesive Capsulitis • Auto-immune response • Biceps tenosynovitis • Trigger points-subscapularis • Autonomic reflex dysfunction • Relationship to increased cytokines levels – Hutchinson et al. 1998 reported on 12 patients with gastric cancer who were treated with synthetic matrix metalloprotienase – Six developed frozen shoulder

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Etiology Purpose • Describe evidence-based physical therapy practice for • Cytokines adhesive capsulitis – Involved in the initiation and termination of • Classify and define adhesive capsulitis using the tissue repair World Health Organization’s terminology – May be involved in the inflammatory and • Identify interventions supported by current best fibrotic process relate to adhesive capsulitis evidence – Sustained production can result in fibrosis • Identify appropriate outcome measures to assess – Imbalance between aggressive healing, changes resulting from physical therapy interventions scarring, contracture and a failure of • Provide a description to policy makers, payers and remodeling may lead to protracted stiffening of claims reviewers regarding the practice of orthopaedic the capsule physical therapy • Create a reference publication for orthopaedic Rodeo et al., J Orthop Res., 1997 physical therapy clinicians, academic instructors and PENN Therapy and Fitness PENN Shoulder and PENN Therapy and Fitness PENN Shoulder and Penn Presbyterian Medical Center Bunker, Reilly et al. 2000 Elbow Service studentsPenn Presbyterian Medical Center Elbow Service

– 1 Method • The American Physical Therapy Association Method (APTA) Orthopaedic section appointed content • Performed a systematic search of MEDLINE, experts CINAHL, and the Cochrane Database of • The content experts identified impairments of body Systematic Reviews (1966 through September function and structure, activity limitations, and 2011) for any relevant articles participation restrictions using ICF terminology to: • These guidelines were issued in 2013, based on – (1) categorize patients into mutually exclusive publications in the scientific literature prior to impairment patterns to base intervention September 2011 strategies • These guidelines will be considered for review in – (2) serve as measures of changes in function over 2017, or sooner if new evidence becomes the course of an episode of care. available. • The content experts described interventions and supporting evidence PENN Therapy and Fitness PENN Shoulder and PENN Therapy and Fitness PENN Shoulder and Penn Presbyterian Medical Center Elbow Service Penn Presbyterian Medical Center Elbow Service

Levels of Evidence Grades of Evidence GRADES OF STRENGTH OF EVIDENCE RECOMMENDATION BASED ON I Evidence obtained from high-quality diagnostic studies, A Strong evidence A preponderance of level I and/or level II studies support prospective studies, or randomized controlled trials the recommendation. This must include at least 1 level I study II Evidence obtained from lesser-quality diagnostic B Moderate evidence A single high-quality randomized con- trolled trial or a studies, prospective studies, or randomized controlled preponderance of level II studies support the trials (eg. weaker diagnostic criteria and reference recommendation C Weak evidence A single level II study or a preponderance of level III and standards, improper randomization, no blinding, less IV studies, including statements of consensus by content than 80% follow-up) experts, support the recommendation D Conflicting evidence Higher-quality studies conducted on this topic disagree with III Case-controlled studies or retrospective studies respect to their conclusions. The recommendation is based IV Case series on these conflicting studies E Theoretical/ preponderance of evidence from animal or cadaver studies, V Expert opinion foundational evidence from conceptual models/principles, or from basic science/ bench research supports this conclusion F Expert opinion Best practice based on the clinical experience of the guidelines development team

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Adhesive Capsulitis-Frozen Shoulder Classification Natural History

PRIMARY SECONDARY POST (Idiopathic) (Known Disorders) SURGERY Stage III Stage IV

Stage II

SYSTEMIC EXTRINSIC INTRINSIC IDDM CVA RC Tendon Stage I Hypo/ MI Biceps tendon hyperthyroidism Cervical DD Calcific tendon Immobility AC arthritis FX

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– 2 Synovitis/ Examination Angiogenesis • Hallmark finding is the loss of passive external rotation with the arm at the side

Fibroplasia

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Intervention Recommendations CORTICOSTEROID A Strong evidence Intervention-based Classification INJECTIONS Oh, 2011 Intra-articular corticosteroid injections High Irritability Moderate Irritability Low Irritability Lorbach, 2010 combined with shoulder mobility and Blanchard, 2009 stretching exercises are more effective in Modalities Heat/ice/electrical Heat/ice/electrical -- Jacobs, 2009 stimulation stimulation Ryans, 2005 providing short-term (4-6 weeks) pain Activity Modification yes yes -- Carrette, 2003 relief and improved function compared

ROM/ Stretch Short duration (1-5 secs) Short duration (5-15 secs) End-range/overpressure to shoulder mobility and stretching Pain-free passive  Passive, AAROM  Increase duration AAROM AROM Cyclic loading exercises alone

Manual Techniques Low grade mobilization Low high grade High grade mobilization/ Mobilization sustained hold Strengthen -- -- Light  high resistance End-ranges

Functional Activities -- Basic High demand

Patient Education + + + Kelley, JOSPT, 2009 PENN Therapy and Fitness PENN Shoulder and PENN Therapy and Fitness PENN Shoulder and Penn Presbyterian Medical Center Elbow Service Penn Presbyterian Medical Center Elbow Service

Intra-articular Corticosteroids , Supervised Results Physiotherapy, or a Combination of the Two • At 6 weeks in the Treatment of Adhesive Capsulitis of the – injection/PT SPADI highest Shoulder • Prospective and randomized – ROM increased in all groups but injection/PT • 93 patients group had greatest increase • Criteria • At 6 months SPADI scores were not – > 25 % lose in at least 2 directions (FF,Abd,ER,IR) different but AROM and PROM were better – SPADI total score > 30 in injection/PT group. Four groups • No difference at 12 months • GH joint steroid injection under fluoroscopy • GH joint steroid injection under fluoroscopy and • PT no better than placebo supervised PT (12 one hour sessions X 4 weeks) • Saline injection and PT PENN Therapy and Fitness PENN Shoulder and CarettePENN et al., Therapy Arth andand FitnessRheum, 2003 PENN Shoulder and • SalinePenn Presbyterianinjection Medical alone Center Carette et al., Arth and Elbow Rheum, Service 2003 Penn Presbyterian Medical Center Elbow Service

– 3 Intervention Recommendations Intervention Recommendations

MODALITIES C Weak evidence PATIENT B Moderate evidence Cheing, 2008 Clinicians may utilize shortwave EDUCATION Clinicians should utilize patient Dogru, 2008 Diercks, 2004 education that (1) describes the natural Leung, 2008 diathermy, ultrasound, or electrical Guler-Uysal, 2004 stimulation combined with mobility and course of the disease, (2) promotes stretching exercises to reduce pain and activity modification to encourage improve shoulder ROM in patients with functional, pain-free ROM, and (3) adhesive capsulitis. matches the intensity of stretching to the patient’s current level of irritability.

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Intervention Recommendations Joint Mobilization JOINT C Weak evidence MOBILIZATION Clinicians may utilize joint mobilization Effect- Tanaka, 2010 procedures primarily directed to the Chen, 2009 • Reducing pain and influencing tissue length is Johnson, 2007 glenohumeral joint to reduce pain and what restores motion and normal arthrokinematics. Yang, 2007 increase motion and function in patients Vermeulen, 2006 with adhesive capsulitis. • Vermullen et al., 2000 Nicholson, 1985 Bulgen, 1984 – Intense end range mobilization • Vermullen et al., 2006 – High-grade vs. low-grade mobilization – The high-grade mobilization group did better but only a minority of comparisons reached statistical significance and the overall differences between the two interventions was small.

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Intervention Recommendations Intervention Recommendations TRANSLATIONAL C Weak evidence STRETCHING B Moderate evidence MANIPULATION Clinicians may utilize translational EXERCISES Clinicians should instruct patients with Roubal, 1996 manipulation under anesthesia directed Çelik, 2010 adhesive capsulitis in stretching Placzek, 1998 Tanaka, 2010 to the glenohumeral joint in patients Kivimäki, 2007 exercises. The intensity of the exercises with adhesive capsulitis who are not Levine, 2007 should be determined by the patient’s responding to conservative Diercks, 2004 tissue irritability level. Griggs, 2000 interventions. Lee, 1974

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– 4 Joint Mobilization and Self- Exercise • N=110 Results • Investigated the relationship of frequency • No relationship between frequency of (supervised PT) to outcome treatment and motion gain or time to reach • Patients received joint mobilization at high plateau frequency (>2X a week), moderate • Was a significant relationship between frequency (1X a week) and low frequency frequency of HEP and both motion gained (< 1X a week) and shorter time to plateau • All groups performed a HEP of pendulum and wall walks

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Adhesive Capsulitis Intervention Algorithm

Dx= Adhesive Capsulitis Intervention Options: 1. Therapist instructed home ex. program (HEP) When To Discharge? 2. Intraarticular steroid injection (ISI) and HEP 3. Intraarticular injection/supervised therapy (ISI/ST) 4. Supervised therapy (ST) Assigned intervention • Improved pain, satisfaction and function 1-4 • Minimal irritability- can give overpressure at end range with little or no pain Assess response • 0 – 5-10 degree intra-session change and minimal or no irritability • Stagnant inter-session change in motion Not responding Reassign intervention Continue HEP or ST manipulation/capsular If worse send for ISI and reduce visits release “Hit the Fibrotic Wall”

ST-HEP treatment Discharge and continue HEP PENN Therapy and Fitness PENN Shoulder and PENN Therapy and Fitness PENN Shoulder and Penn Presbyterian Medical Center Elbow Service Penn Presbyterian Medical Center Elbow Service

Conclusion • Strong evidence exist for intra-articular injections providing Thank You significant short-term relief • Patients with frozen shoulder can dramatically respond to both a therapist instructed home exercise program and short duration supervised physical therapy • Using an algorithmic treatment approach helps to determined response to treatment, need for treatment and a pathway for further intervention.

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– 5 Shoulder Muscle Power and Rotator Cuff Disease Movement Coordination Impairments: Prevalence: 7 –26% ((LuimeLuimeJJ, et al, ScadJ Rheumatol,Rheumatol, 2004) Rotator Cuff Disease Ro ta tor Cu ff Disease Lori Michener, PhD, PT, ATC, SCS What does this involve? Virginia Commonwealth University Richmond, VA

Complaint of “Shoulder Symptom” Level 1 Rotator Cuff Disease Screen History, Basic Phys Exam, Red/Yellow Flags

––FullFull--thicknessthickness RC tear Non-shoulder origin of sx Shoulder origin of sx – Partial thickness RC tear – Bursitis Level 2 Medical Dx Specific Physical Exam – Tendinitis – Tendinopathy Rotator Cuff Frozen Glenohumeral Other – Subacromial (‘impingement’) pain syndrome Syndrome Shoulder Instability Level 3 ** Is it better to label this RC SyndromeSyndrome-- Rehab Dx as we are not sure of the pathology High Irritability Moderate Irritability Low Irritability & Impairments & Impairments & Impairments

Rotator Cuff Syndrome Level 2 Pathoanatomic Diagnoses What are the Dx criteria? Rotator Cuff Adhesive Glenohumeral Other Rotator cuff disease All likely Syndrome Capsulitis Instability ––FullFull--thicknessthickness RC tear present with Key positive findings similar “Rule •impingement signs •Painful arc – Partial thickness RC tear syypmptoms -- In” •Pain w/ isom resist – Bursitis pain in the •Weakness Subacromial “Rule •Atrophy – Tendinitis Out” Space Key negative findings – Tendinopathy • Sig loss of motion – Subacromial ‘impingement’ Subacromial • Instability signs syndrome Pain Syndrome Pathoanatomic Dx based on specific physical exam (+/‐ imaging). Dx RCD - Lots of SystReviews 1. Hermans J, JAMA, 2013; 2. Hanchard NCA, Cochrane, 2013; Special Tests – RC Disease 3. Hegedus EJ, BMJ, 2012; 4. Alqunaee M, APMR, 2012 Painful arc Full Can Test Confirm RCD Screen Out RCD Hawkin’s test Empty Can / Jobe (R/In) –single– single tests (R/Out) ––singlesingle tests Neer’s Test Drop Arm 11-- Painful arc 11-- Painful arc 22--ResistedResisted ER Speed’s test ER lag (ERRT)– pain or 22--HawkinsHawkins weakness 33-- Neer Yergason’s Test Belly Press/ Lift Off 33-- Full Can 44--ResistedResisted ER (ERRT) ER Resistance Test More.. 44--DropDrop Arm – pain or weakness IR Resistance Test 55-- Empty Can Combination of 66-- Full Can tests

Level 2 Combination of Tests: RCD Pathoanatomic Diagnoses

Rotator Cuff Adhesive Glenohumeral • Test Combo (Michener LA, Archives PM&R, 2009) Syndrome Capsulitis Instability Other > 3+/5: Painful arc, Neer, R/In +LR: 2.93 Hawkin’s, ERRT Key positive findings “Rule •impingement signs Empty Can/ Jobe •Painful arc In” •Pain w/ isom resist < 3+ / 5 (as above)R/Out -LR:-LR: 0.34 •Weakness – abd / ER “Rule •Atrophy Out” • Test Combo (Park HB, JBJS, 2005) Key negative findings 3+: Hawkins, painful arc, ERRT R/In +LR:10.6 • Sig loss of motion • Instability signs 33--:: Hawkins, painful arc, ERRT R/Out --LR:0.17LR:0.17

Pathoanatomic Dx based on specific physical exam (+/‐ imaging).

Dx FTFT--RCTRCT - Lots of Syst Reviews Combination of Tests: FTFT--RCT 1. Hermans J, JAMA, 2013; 2. Hanchard NCA, Cochrane, 2013; 3. Hegedus EJ, BMJ, 2012; 4. Alqunaee M, APMR, 2012 Confirm FTFT--RCTRCT only Screen Out FTFT--RCTRCT • Test Combo (Park HB, et al; JBJS, 2005) (R/In) –single– single tests (R/Out) ––singlesingle tests 3 Tests: Drop arm, Painful arc, ERRT 11-- Painful arc 11--IRIR lag & Lift-Lift-offoff All 3 tests +R/In +LR: 15.57 22--ResistedResisted ER ––painpain subscapularis or weakness All 3 tests -R/Out- R/Out -LR:-LR: 0.16 33--ERER lag test – 2- Res is te d ER (ERRT) supraspinatus – pain or weakness • Test Combo ((LitakerLitakerD, et al; J Am Geriatr Soc, 2000) infraspinatus 33-- Empty Can 44-- IR lag &Lift off >65yo, ER weak, night pain subscapularis 44-- Full Can 55--DropDrop arm All 3 +: R/In +LR: 9.84 66-- Atrophy of infraspinfrasp.. All 3 -:-: R/Out -LR:- LR: 0.54 77-- Belly off Complaint of “Shoulder Symptom” Systematic Reviews of SA pain Level 1 ((HanrattyHanratty CE, 2012, Littlewood C, 2012, Brudvig TJ, 2011; Marinko LN, 2011; Screen History, Basic Phys Exam, Red/Yellow Flags Kromer TO, 2009; Kuhn JE, 2009; Ainsworth, 2007; Michener LA, 2004; DesmeulesDesmeules,, 2003) Non-shoulder origin of sx Shoulder origin of sx • 99-- 16 RCTs •  pain &  function / disability: Level 2 Medical Dx Specific Physical Exam • ExerciseExercise-- stretch & strengthen/ MC • Exercise + manual therapy to the Rotator Cuff Frozen Glenohumeral Other glenohumeral joint and/ or spine Syndrome Shoulder Instability • Home exercise programs Level 3 Rehab Dx • Passive treatments: not recommended High Irritability Moderate Irritability Low Irritability • US: not effective & Impairments & Impairments & Impairments

RCD Management 5. Modalities –limited use, only in combination with active treatment Treatment approach . 6. Manual: Spine OR combined (GH, spine) 1. Strengthen /Motor Control – Rotator cuff, . Pain,  joint motion, other neurophysiological scapular, shoulder effects, ?? biomechanical at spine?? Motor control alone –unclear of effectiveness . GH ––alonealone --doesn’tdoesn’t appear effective 2. Flexibility –post cuff, pec minor, lats, CT spine 3. Scapular Dysf–S –Scap taping + Motor Control, addition of scapular stabilization exercises 4. Home exercise program + supervised or just HEP if appropriate

Evidence – Manual Therapy (MT) 5. Modalities –limited use, only in combination with active treatment . Spine & GH MT + ex vsexercise alone 6. Manual: Spine OR combined (GH, spine) . Addition of MT improved function . Pain,  joint motion, other neurophysiological (Bang M, 2000; Bennell,Bennell, 2010; Winters, 1999) effects, ?? biomechanical at spine?? . GH mobs alone or added to ex vs. ex . GH ––alonealone --doesn’tdoesn’t appear effective . No diff in outcomes ((YiasemidesYiasemidesR, 2011; Kachingwe A, 2008) 7. Use of impairments . Better outcomes, but small trials & effect . Guiding Treatment sizes ((SenbursaSenbursa,, 2011; Senbursa,Senbursa, 2007; Conroy, 1998) . Hi – Moderate –Lo irritability . Is spinal MT the active ingredient? . Dose: Hi reps (dose) . RCT – improved outcomes with thoracic manipulation/ mobs (Bergman, 2004; Winters J, 1999) Dose - Evidence Treatment Approach – no evidence . HighHigh--dosedose vs lowlow--dosedose chronic imping.imping. . Unsure (limited or no evidence): ((OsterasOsterasH, Open Ortho, 2010; Osteras H, Physiother Res Int,Int, 2010) . Scapular taping –immediate–immediate effects only . HiHi--dose:dose:  pain & function 3, 6 & 12 . Scapular motor control and stabilization months post exercise focus . HighHigh--dose:dose: . Core stability training . 11--hrhr session, 9-9-1111 exercises, 3 x 30 reps, . Eccentrics focus 1000 reps per treatment, aerobic ex . Low –dose:–dose: 2 x 10 reps/ exercise . Frequency of treatment . Progression of treatment . Dose of exercise and manual therapy

Questions?