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ICF-Based CPG Presentation 7/11/14 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) 1 7/11/14 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 2 7/11/14 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,
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