Development of Shoulder Rehabilitation Guidelines with ICF Classifications

Martin Kelley PT, DPT, OCS John Kuhn MD Phil McClure PT, PhD Lori Michener PT, PhD, ATC, SCS Mike Shaffer PT, OCS, ATC Amee Seitz PT, DPT, OCS Tim Uhl PT, PhD, ATC

Shoulder Rehabilitation Guidelines

Shoulder Rehabilitation Guidelines

Most Common Conditions (Non-op) Rotator cuff tendinopathy

Scope
Most Common Conditions Limit to Non-operative care Evidenced based Classification important and should guide rehab

aka Impingement syndrome, tendinitis, tendinosis, subacromial bursitis

ICF Nomenclature

Frozen Shoulder Glenohumeral Instability

Millar JOSPT, 2006 van der Windt, Ann Rheum Dis, 1995

The Shoulder and ICF

Popular Label Rotator Cuff Tendinopathy (Impingement) Frozen Shoulder 1o ICD 9 726.1
Rot Cuff Syndrome

Shoulder Dx /Classification

ICF Body Function

B7300 Power of isolated muscles and muscle groups B7100 Mobility of a single joint

ICF Body Structure

S7202 Muscles of shoulder region S7201 Joints of the shoulder region

Activities/ Participation
D4452 Reaching D4300 Lifting D850 Work D520 Caring for body parts D4451 Pushing D4452 Reaching D4300 Throwing

Rotator Cuff Tendinopathy / Impingement Glenohumeral Instability Frozen Shoulder Are these homogenous groups? Are these dxs specific enough to direct rehabilitation? Lessons learned from the spine

726.0 Adhesive Capsulitis 840.2 Shoulder ligament sprain

Glenohumeral Instability

B7601 Control of complex voluntary movements

S7203 Ligaments and fasciae of shoulder region

Med Dx and PT Dx

Med Dx and PT Dx
Med Dx or PT Dx Pain Weak Stiff Laxity Rot Cuff +/ +++ ++ / +++ -- / + -- /+ Froz Shdr +/ +++ -- / + +++ -GH Treatment Instab Strategy -++ / +++ -+++ Activity Mod Strengthen Mob Strength/ coord

Medical Diagnosis

PT Diagnosis

Pathoanatomic Primary Tissue Pathology Stable over episode of care Guides general Rx strategy Informs prognosis

Sx Severity / Impairment Irritability

Current intensity

Often changes over episode of care Guides specific rehab Rx May inform prognosis

Level 1 Complaint of Shoulder Symptom Level 1 Screen History, Basic PE, Red Flags Shoulder origin of sx Basic Phys Exam (B) Level 2 Med Dx
Rotator Cuff / Impingement

Level 2 Specific Phys Exam (D)

Pt c/o Shoulder Pain Key History (A)

Non-shoulder origin of sx

Specific Phys Exam (D)

Glenohumeral Instability

Red Flags (C)

Rot Cuff Froz Shdr GH Instab NO

Frozen Shoulder

YES Hx and PE consistent with Shdr Dx ? NO Referral / Consultation

YES
Other Dx
GH Arthritis Fractures AC jt Neural Entrap Myofascial Fibromyalgia Post-Op Other

Level 3 PT Dx
High Irritability Mod Irritability Low Irritability

Continue to Specific Dx

A: Key Hx
Age Occupation / sports Hand Dominance PMH Onset /duration sxs Hx trauma / disloc Pain
Location Intensity Factors or Night pain

B: Basic Phys Ex
Observation Posture Upper Quarter Screen r/o C-spine r/o neurologic AROM / PROM Elev, IR, ER Strength Elev, IR, ER

C: Red Flags
Acute Trauma Tumor Infection Referred Pain

All Shoulder Problems

2nd Level Shoulder Classification

Specific Exam
Rotator Cuff / Impingement

Other CC Sxs
Weakness Paras/numbness Stiffness

Yellow Flags Fear Avoidance Psychosocial Factors

Frozen Shoulder Key Positive:

Spontaneous progressive pain Loss of motion in multiple planes Pain at end-range Key negative: Normal motion Age < 40

Glenohumeral Instability Key Positive:

Age usu < 40 Hx disloc / sublux Apprehension Generalized laxity Key negative: No hx disloc No apprehension

Other

Key Positive:
impingement signs Painful arc Pain w/ isom resist Weakness Atrophy Key negative: Sig loss of motion Instability signs

Self-report Function/disability

GH Arthritis Fractures AC jt Neural Entrap Myofascial Fibromyalgia Post-Op Red Flag Conditions

High Irritability (E) (3/5 to categorize) High Pain (> 7/10) night or rest pain consistent Pain before end ROM AROM < PROM High Disability
(DASH, ASES)

Moderate Irritability (F)

(3/5 to categorize) Mod Pain (4-6/10)

night or rest pain intermittent Pain at end ROM AROM ~ PROM Mod Disability
(DASH, ASES)

Low Irritability (G) (3/5 to categorize) Low Pain (< 3/10) night or rest pain none Min pain w/overpressure AROM = PROM Low Disability
(DASH, ASES)

Rotator Cuff / Impingement

Frozen Shoulder

Glenohumeral Instability

3rd Level Shoulder Classification

Irritability Level
High Irritability High Irritability High Irritability

Rx focus: pain reduction

Rx focus: pain reduction impairments basic function

Rx focus: High demand functional activity restoration

Mod Irritability

Mod Irritability

Mod Irritability

Low Irritability

Low Irritability

Low Irritability

Level 1 Pt c/o Shoulder Pain

Level 2 Specific Phys Exam (D) Level 2

Rotator Cuff / Impingement

Key History (A) Basic Phys Exam (B) Red Flags (C) Level 3

Frozen Shoulder High Irritability Mod Irritability Low Irritability

Glenohumeral Instability High Irritability Mod Irritability Low Irritability

Rot Cuff Froz Shdr GH Instab NO

High Irritability Mod Irritability Low Irritability

YES Hx and PE consistent with Shdr Dx ? NO Referral / Consultation

YES
Other Dx
GH Arthritis Fractures AC jt Neural Entrap Myofascial Fibromyalgia Post-Op Other

Response to PT after 4-6 visits (H) Poor Likely Explanation? NO

Compliance, mis-dx, etc

Good

Continue PT until goals met

Continue to Specific Dx

Referral Inject, further dx, other

Yes

Adjust PT Treatment

Treatment Response Criteria (H)

Good response Pain improved (> 2 pts on NPRS) Function / disability improved: > MDC in self-report outcome (DASH=13pts, ASES= 9.4pts) Patient satisfaction improved (> 2 pt on 11pt scale) Poor response Pain is unimproved or worsened Function / disability unimproved or worsened Patient dissatisfied
Modalities

Matched Treatment Strategy

High Irritability
+/-+ Pain-free passive AAROM Low grade --

Moderate Irritability
+ / -+ / -AAROM AROM Low / High grade Light mod resistance Mid-ranges Basic + + / --

Low
---

Irritability

Activity Modification ROM/ Stretch Manual Techniques Strengthen

End-range/ overpressure High grade Mod high resistance End-ranges High demand + + / --

Functional Activities Patient Education Taping / functional support (brace / external)

-+ + / --