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CPG Shoulder Instability 2019 Handouts CSM 2019 Shoulder Instability Clinical 1/24/19 Practice Guidelines Shoulder Stability and Movement Coordination Impairments: Shoulder Instability Clinical Shoulder Instability Guideline Leaders Practice Guideline Amee Seitz and Tim Uhl Co-Leaders Amee L Seitz, PT, PhD, DPT, OCS & Timothy Uhl, PT, ATC PhD Lori Michener, PT, ATC, PhD, SCS* Support by Orthopedic Section Office (Brenda Johnson, Christine McDonouGh) and APTA and Michael Shaffer, PT, MS, ATC Linda O'Dwyer Certified Science Librarian Martin Kelley, PT, DPT Diagnosis Intervention Angela Tate, PT, PhD Clinical Course/ Prognosis Examination Section Leaders Section Leaders Section Leaders Section Leaders 2600 articles, 260 full-text 6500 titles and abstracts, Margie Olds, PT MHSC, BPHty 5000 titles/abstracts 12,300 titles /abstracts reviews 120 full text reviews Aaron Sciascia, PhD, ATC, PES Tim Uhl PhD, PT, ATC Kyle Matsel, PT, DPT, SCS, CSCS Eric HeGedus PT, DPT, PhD, OCS, Lori Michener PhD, PT, ATC, Amee Seitz PhD PT, DPT, OCS Kyle Matsel DPT, SCS, CSCS CSCS SCS, FAPTA Mike Shaffer PT, MSPT, OCS, Eric Hegedus, PT, PhD, DPT, OCS, CSCS Carolyn Hettrich MD, MPH Aaron Scisascia PhD, ATC, PES AnGela Tate PhD, PT, Cert ATC Marty Kelley PT, DPT, OCS Nitin Jain, MD, MPH MDT MarGie Olds MHSC, BPHty Carolyn Hettrich, MD, MPH DPT Students at DPT Students/ Research Orthopaedic DPT Residents Northwestern Assistants Non-authors; Nitin Jain, MD (Non-authors; acknowledGed (Non-auhtors; acknowledGed acknowledGed contributors) contributors) contributors) Disclosures Objectives of Session • All Authors have no conflicts related to 1. Explain the shoulder pain classification and methods used to categorize development of the CPG patients into shoulder CPG categories, specifically shoulder instability • Funded by the Academy of Orthopaedic Physical 2. Understand the evidence with regard to establishing a prognosis for patients Therapy & Academy of Sports Physical Therapy with shoulder instability including pathoanatomic features as well as the limitation of evidence for the risk factors for operative versus non-operative and by the APTA. treatment 3. Recognize current best practice and recent evidence supporting the physical therapy examination, treatment and outcome assessment in patients with shoulder pain related to shoulder instability and movement coordination deficits 4. Recognize the strengths and limitations in CPGs to define best practices that meet the needs of patients under most circumstances but do not replace the need for sound clinical decision making for individual patients Outline 2013 First Shoulder Clinical Practice Guideline • Staged Algorithm for Rehabilitation of Shoulder Pain – (STAR) Shoulder Movement Diagnosis and Rehabilitation Classification Overview (Tim Uhl) • Clinical Course: Typical outcomes of patients with instability including pathoanatomic diagnoses and other potential clinical factors that may impact prognosis of rehabilitation (Kyle Matsel) • Diagnosis: Best evidence and clinical recommendations for examination procedures to identify patients with shoulder instability (Eric Hegedus) • Intervention: Best evidence and clinical recommendations for physical therapy interventions including immobilization, exercise, neuromuscular retraining, and bracing (Amee Seitz) • Outcome Assessment: What self-reported and performance based measures best capture patient rehabilitation treatment outcomes in patients with shoulder instability (Lori Michener) • Questions Property of presenting authors, not to be copied without written permission 1 CSM 2019 Shoulder Instability Clinical 1/24/19 Practice Guidelines 4 Component Model with Tissue Irritability TISSUE SCREEN IRRITABILITY DIFFFERENTIAL EVALUATION TREAT -McClure & Michener Phy Ther 2015 Pathoanatomic Diagnosis vs. Rehab Classification OSPRO ROS OSPRO YF • Level 2 Pathoanatomic Dx • Level 3 Rehabilitation • Primary Tissue Pathology Classification • Stable over an episode of • Irritability / Impairment care • Often changes over episode of care • Guides general Rx strategy • Guides specific rehab treatment • Informs prognosis • Physical stress dosage • Surgical Decisions • Specific Impairments • May inform prognosis Level 2 Level 3 Rehabilitation Classification Pathoanatomic Diagnoses • Tissue Irritability ( guides intensity of physical stress ) • Impairments ( guides specific intervention tactics) Adhesive Glenohumeral Tissue Irritability: Pain , Motion, Disability Subacromial Pain Other Syndrome Capsulitis Instability Rotator Cuff High Moderate Low Key positive findings Key positive findings Key positive findings History • High Pain (> 7/10) • Mod Pain (4-6/10) •Low Pain (< 3/10) •GH Arthritis •impingement signs •Spontaneous •Age usu < 40 • night or rest pain • night or rest pain • night or rest pain “Rule in” •Fractures •Painful arc progressive pain •Hx disloc / sublux and • consistent • intermittent • none •AC jt •Pain w/ isom resist •Loss of motion in •Apprehension •Neural Entrap Exam • Pain before end ROM • Pain at end ROM • Min pain •Weakness multiple planes •Generalized laxity •Myofascial • AROM < PROM • AROM ~ PROM w/overpressure •Atrophy (tear) •Pain at end-range “Rule Out” •Fibromyalgia • High Disability • Mod Disability • AROM = PROM •Post-Op Key negative findings Key negative findings Key negative findings •(DASH, ASES) •(DASH, ASES) • Low Disability • Sig loss of motion • Normal motion • No hx disloc •(DASH, ASES) • Instability signs • Age < 40 • No apprehension Intervention Minimize Physical Stress Mild - Moderate Mod – High Physical Physical Stress Stress Focus • Activity modification • Address impairments • Address impairments Pathoanatomic diagnosis based on specific physical examination (+/- imaging). Most • Monitor impairments • Basic level functional • High demand diagnostic accuracy studies address this level. As examples, findings are listed for the three activity restoration functional activity most common diagnoses only. restoration Property of presenting authors, not to be copied without written permission 2 CSM 2019 Shoulder Instability Clinical 1/24/19 Practice Guidelines Rehab Classification • Tissue Irritability ( guides intensity of physical stress ) • Impairments ( guides specific intervention tactics) High Irritability Moderate Irritability Low Irritability CPG for Shoulder Instability Impairment Pain: Assoc Local Tissue Modalities Limited modality use No modalities Injury Activity modification Activity modification • Systematic Review of Evidence • Make a recommendation Pain: Assoc with Central Progressive exposure to activity Sensitization Medical Mgmt Limited Passive Mobility: ROM, stretching, manual therapy: Pain-free ROM, stretching, manual therapy: ROM, stretching, manual therapy: • Summarize highest level for joint / muscle / neural only, typically non-end range Comfortable end-range stretch, Tolerable stretch sensation at end range. typically intermittent Typically longer duration and frequency Diagnosis/Classification, Examination, Excessive Passive Mobility Protect joint or tissue from end-range Develop active control in mid- Develop active control during full-range Intervention range while avoiding end-range in during high level functional activity basic activity Address hypomobility of adjacent joints Address hypomobility of adjacent or tissues joints or tissues Neuromuscular Weakness: AROM within pain-free ranges Light à mod resistance to fatigue Mod à high resistance to fatigue Assoc with atrophy, disuse, Mid-ranges Include End-ranges deconditioning Neuromuscular Weakness : AROM within pain-free ranges Basic movement training with High demand movement training with Assoc with poor motor control emphasis on quality/precision emphasis on quality rather than or neural activation Consider use of biofeedback, neuromuscular rather than resistance according to resistance according to motor learning electric stimulation or other activation motor learning principles principles strategies Functional Activity Protect joint or tissue from end-range, Progressively engage in basic Progressively engage in high demand intolerance encourage use of unaffected regions functional activity functional activity Poor patient understanding Appropriate patient education Appropriate patient education Appropriate patient education leading to inappropriate activity (or avoidance of activity) Thank You • Next • Discuss the evidence with regard to establishing a prognosis for Clinical Practice Guidelines for patients with shoulder instability • Classification Shoulder Instability • Incidence Prognosis • Pathoanatomical features • Clinical Course • Risk Factors Kyle Matsel DPT, SCS, CSCS FEDS Classification System Defining Shoulder Instability • Frequency – The patient is asked, “how many episodes have you had in the last year?” • Solitary – “1 episode” • Numerous shoulder classifications exist but most are based on • Occasional – “2 to 5 episodes” expert opinion and lack consistency and widespread acceptance • Frequent – “> 5 episodes” • Kuhn JSES 2011 • Etiology – The patient is asked, “did you have an injury to cause this?” • Traumatic – “Yes” • Without established, validated, and well defined diagnostic criteria • Atraumatic – “No” for classifying shoulder instability, comparing studying and compiling • Direction – The patient is asked, “what direction does the shoulder go out most of the data in a systematic manner is difficult time?” • Kuhn JSES 2011 • Anterior – “Out the front” • Shoulder instability = discomfort and a feeling of looseness, slipping, • Posterior – “Out the back” or the shoulder
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