Preliminary Development of a Clinical Prediction Rule for Treatment of Patients With Suspected SLAP Tears Stephanie D. Moore-Reed, Ph.D., A.T.C., W. Ben Kibler, M.D., Aaron D. Sciascia, M.S., A.T.C., and Tim Uhl, Ph.D., P.T., A.T.C.
Purpose: To use the clinical prediction rule process to identify patient variables, measured on initial clinical presentation, that would be predictive of failure to achieve satisfactory improvement, while following a rehabilitation program, in the modification of SLAP injury symptoms and dysfunction. Methods: A cohort of patients received the clinical diagnosis of a SLAP lesion based on specific history and examination findings and/or magnetic resonance imaging. They underwent a physical examination of the kinetic chain and shoulder, including tests for labral injury. Patients followed a standardized physical therapy program emphasizing restoration of demonstrated strength, flexibility, and strength-balance deficits. At 6 weeks’ follow-up, patients were re-evaluated and divided into those recommended for surgery (RS) and those not recommended for surgery (NRS). Bivariate logistic regression was performed to identify the best combination of predictive factors. Results: Fifty-eight patients (aged 39 11 years, 45 men) were included. Of these, 31 (53%) were categorized as NRS and 27 (47%) as RS. The presence of a painful arc of motion (odds ratio, 3.95; P ¼ .024) and the presence of increased forward scapular posture (odds ratio, 1.27; P ¼ .094) on the injured side were predictive of being in the RS group. This finding indicates that the odds of being in the RS group increased 4 times when a positive painful arc was present and increased 27% with every 1-cm increase in involved anterior shoulder posture. Conclusions: A structured rehabilitation program resulted in modification of symptoms and improved function at 6 weeks’ follow-up in over half of patients in the study group. On initial evaluation, the presence of a painful arc of overhead motion, indicating loss of normal glenohumeral kinematics, and the presence of forward shoulder posture, indicating an altered scapular position, represent negative predictive factors for success of rehabilitation. Future validation of the model in a larger population is necessary. Level of Evidence: Level II, prospective comparative study.
T
here is a growing awareness of the need to develop more efficacious methods of evaluating, accurately diagnosing, and treating all types of shoulder pathology. The clinical prediction rule process has been developed as a method to identify which patient variables, measured on initial clinical examination, could be predictive of
From the Department of Kinesiology, California State University (S.D.M-R.), Fresno, California; Shoulder Center of Kentucky (W.B.K., A.D.S.), Lexington, Kentucky; and Division of Athletic Training, University of Kentucky (A.D.S., T.U.), Lexington, Kentucky, U.S.A. The authors report the following potential conflict of interest or source of funding: The Lexington Clinic entered into a contract to pay the University of Kentucky for a doctoral student, S.D.M-R. (co-author), as a part-time research assistant as she completed her doctoral degree. T.U. receives support from American Society of Shoulder and Elbow Therapists. T.U. received reimbursement to present components of these data at the International Congress of Shoulder and Elbow Therapists in April 2013 in Nagoya, Japan. Received September 11, 2013; accepted June 13, 2014. Address correspondence to Aaron D. Sciascia, M.S., A.T.C., 1221 S Broadway, Lexington, KY 40504, U.S.A. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 0749-8063/13668/$36.00 http://dx.doi.org/10.1016/j.arthro.2014.06.015
success of a particular treatment program. The prediction rule process has the potential to instill continuity and uniformity within health care decision making and can help guide care.1 This article reports the outcomes of a study applying the clinical prediction rule process to a cohort of patients determined to have clinical findings consistent with a SLAP injury. In patients with this diagnosis, surgical outcomes are not uniformly successful,2,3 in part because of inconsistency in the diagnostic process and inconsistency in surgical indications.4 Rehabilitation protocols are often advocated as the first step in the treatment of SLAP and other shoulder injuries, but evidence regarding the exact indications, role, and effectiveness of rehabilitation in SLAP injury is sparse and not clear. One previous retrospective study reported that 49% of patients managed with nonoperative rehabilitation had a positive outcome.5 Another study, performed in professional baseball players, all of whom had a SLAP injury and in whom a rehabilitation program had failed, showed that a comprehensive rehabilitation program resulted in 40% of players returning to play.6
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol
-,
No
-
(Month), 2014: pp 1-10
1
2
S. D. MOORE-REED ET AL.
Fig 1. Participant flowchart.
The purpose of this prospective study was to use a clinical prediction rule process to attempt to identify patient variables, measured on initial clinical presentation, that would be predictive of failure to achieve satisfactory improvement, while following a rehabilitation program, in the modification of symptoms and dysfunction in patients with a clinical diagnosis of SLAP injury. We hypothesized that in patients who did not respond, there would be specific measurable patient factors that were associated with failure to respond to a rehabilitation program.
Methods Patients Fifty-eight patients (mean age, 39 11 years; mean mass, 83 25 kg; mean height, 170 35 cm) who were determined to have a clinical history consistent with shoulder dysfunction resulting from injury to the superior labrum were included.7 The history included pain at the posterior joint line, pain with abduction/ external rotation, popping, clicking on shoulder rotation, and pain or limitation of performance with repetitive overhead activity. These 58 patients were part of a group of 211 patients presenting with shoulder pain to an orthopaedic surgeon (W.B.K.) (Fig 1). All participants were patients of the lead author (W.B.K.), a sports medicine and shoulder surgeon with more than 30 years of experience in clinically evaluating and treating shoulder pathology. There are varying opinions regarding the exact criteria to establish a diagnosis of a clinically significant SLAP tear, with no literatureestablished gold standard that is universally recognized. Therefore patient inclusion was based on meeting
specific criteria relating to history, clinical examination findings, and/or diagnostic imaging findings to include all possible criteria for detecting the anatomic and functional alterations associated with the SLAP injury. The clinical examination inclusion criteria were modified from previously identified criteria for diagnosing labral tears reported by Walsworth et al.8 The criteria for our study required a positive finding for at least 3 of the following 4 clinical signs: history of popping or catching, positive anterior-slide maneuver, positive modified dynamic labral shear (M-DLS) maneuver,9 or positive active compression test.8,9 Patients with a SLAP tear diagnosed by advanced imaging (i.e., magnetic resonance imaging [MRI] or magnetic resonance arthrography [MRA]) were included if they also had 1 or 2 of the clinical examination inclusion criteria because the addition of history and clinical examination evidence has been shown to change the information from the imaging.10 Reliance was not placed on 1 examination or imaging test because no single test has been shown to be uniformly satisfactory to make the complete diagnosis.4,11,12 A recent systematic review by Hegedus et al.13 supports the concept of using clusters of tests to make the diagnosis in shoulder pathology, although the M-DLS maneuver has been shown in a Level I study to have high clinical utility.9 Patients were excluded from the study if they had numbness or tingling in the upper extremity; signs and symptoms consistent with cervical radiculopathy,14 adhesive capsulitis,15 or glenohumeral arthritis16; patient-reported steroid injections in the involved shoulder within the previous month; or surgery on the involved shoulder within the past year. They were also excluded if they had clinical examination and/or imaging findings consistent with a diagnosis of acromioclavicular joint injury/arthrosis, glenohumeral instability, or full-thickness rotator cuff tear. This study was approved by the appropriate institutional review boards. Before enrollment in the study, all patients read and signed an informed consent form that was approved by the institutional review boards of the University of Kentucky and Lexington Clinic. Patients completed a standard history form and underwent standard examination by the orthopaedic surgeon (W.B.K.). All patients completed a numeric pain rating scale regarding current pain, worst pain, and least pain in the past week17 (0, no pain; 10, highest pain). In addition, patients completed the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire, which is scored from 0, no disability, to 100, severe disability; the American Shoulder and Elbow Surgeons (ASES) Shoulder Assessment Form, with a score ranging from 0, poor function, to 100, normal function18-20; and the Patient-Specific Functional Scale (PSFS).21 The PSFS questionnaire requires the patient to list 3 to 5 activities that he or she has difficulty doing because of his or her
LABRAL CLINICAL PREDICTION DEVELOPMENT
shoulder problem and to rate each item from 0 (cannot perform activity at all) to 10 (can perform activity at the same level as before the injury). Glenohumeral range of motion (ROM), strength, and posture were also assessed. ROM was assessed with a digital inclinometer (Dualer; JTech Medical, Salt Lake City, UT). Passive internal and external rotation ROM and horizontal adduction ROM were measured with the patient supine and shoulder abducted to 90 with the scapula stabilized until resistance was first felt or the patient reported pain, as previously described.22 Active shoulder flexion ROM was measured with the patient seated. The patient was instructed to raise his or her arm as high as possible in the sagittal plane with the thumb up.23 The clinician aligned the inclinometer with the long axis of the humerus, and the angle was recorded in degrees. Inter-rater intraclass correlation coefficients (ICCs) were calculated a priori for internal rotation ROM (ICC, 0.795), external rotation ROM (ICC, 0.839), horizontal adduction ROM (ICC, 0.518), and active flexion ROM (ICC, 0.863). Isometric muscle strength was measured with a handheld dynamometer24 (model 01163; Lafayette Instruments, Lafayette, IN). Forward flexion strength was measured with the participant seated, the scapula in a retracted position, the shoulder in 90 of flexion, and the palm down.24 The dynamometer was placed just proximal to the wrist, and the participant was instructed to push up for 5 seconds. External rotation strength was measured with the participant supine, the shoulder abducted to 90 , the elbow flexed to 90 , and the humerus in neutral rotation and supported. The dynamometer was placed parallel with the forearm. For each strength measure, 2 maximum-effort trials were performed and averaged for analysis. Each arm was tested in alternating fashion to allow for approximately 30 seconds of rest between trials (flexion strength ICC, 0.897; external rotation strength ICC, 0.842). Finally, scapular posture was assessed with the participant standing and using a double square instrument as previously described by Kluemper et al.25 The participant was asked to stand against the wall and assume his or her normal posture after taking a deep breath to relax. The double square instrument was aligned with the wall and the anterior aspect of the acromion. This distance was measured and recorded bilaterally. Reliability was determined a priori (ICC, 0.946). After the initial clinical visit and data collection, all patients were prescribed physical therapy and provided with a standardized rehabilitation protocol consisting of stretching exercises and strengthening exercises for shoulder musculature, but the protocol was individualized depending on each patient’s examination findings by the treating physical therapist. This protocol was well outlined (Table 1). It consisted of 4 phases, each
3
having mobility and strengthening components that were progressed at each phase. The protocol was designed based on the concepts put forth by Ellenbecker and Cools26 for treating patients with shoulder pain and scapular dysfunction. Mobility exercises progressed from gentle mobility to static stretching of posterior, anterior, and inferior shoulder mobility restrictions. Strengthening exercises progressed from scapular muscular orientation to gain motor control, using the kinetic chain theories of incorporating the entire body, to short and then to long lever-arm resistive exercises, on the basis of kinetic chain theories of incorporating the lower extremity. Ballistic and eccentric exercises were incorporated in the protocol if the treating therapist believed that they were appropriate for an individual patient (Table 1). The rehabilitation protocol was provided to the patients at the initial visit. Patients were allowed to go to the physical therapists of their choosing, with instructions to follow the specific protocol. The physical therapists were provided a letter describing the study and requesting that the patients follow the established protocol. Exercise logs were provided for the patients to record their compliance with the therapy. Detailed physical therapy records were obtained from over two-thirds of the patients (40 of 58). At a follow-up visit with the orthopaedic surgeon (W.B.K.) 6 weeks after the initial visit (median, 6 weeks; range, 4 to 24 weeks), participants again completed the QuickDASH questionnaire, ASES form, numeric pain rating scale, and PSFS questionnaire. Strength, ROM, and posture were also reassessed. In addition, the Global Rating of Change (GROC) score was obtained. The GROC is a 15-point scale ranging from 7 (a great deal worse) to þ7 (a great deal better), with 0 indicating no change.27 Exercise logs and physical therapy notes were collected from patients at this time. After the intervention and follow-up appointment, patients were categorized into 2 groups based on their report of their clinical status and the clinical examination findings: recommended for surgery (RS) or not recommended for surgery (NRS). The recommendation for surgery was based on continued or worsened subjective and objective symptoms of shoulder pain and dysfunction, failure to progress in rehabilitation, and a patient’s unwillingness or inability to tolerate the dysfunction, with clinical input from the physician (Table 2). This process followed the normal procedure of consultation and decision making regarding treatment between physician and patient. The decision to counsel and recommend surgery was made at this time point because most studies indicate that it takes around 6 weeks to observe significant changes in physiological factors such as flexibility and strength and therefore affect the clinical symptoms, which were the goals of the rehabilitation protocol.28-30 In addition, this is
4
Table 1. Rehabilitation Exercise Program Exercise Category Scapular orientation
Below shoulder level: isometric
Scapular protraction
Humeral rotation
Level II
Level III
Below shoulder level: isotonic (e.g., dynamic low row, lawnmower, robbery) Punch (e.g., supine punch, scapular punches)
Isotonic at shoulder level: short lever arm (e.g., pull downs, fencing, rows)
Isotonic (e.g., prone horizontal abduction lifts at 90 or 135 )
Push-ups (e.g., incline)
Push-ups (e.g., knee, standard)
Punch (e.g., standing punch) At shoulder level (e.g., ER/IR with elastic band, 90 /90 )
Diagonal (e.g., upper cut) Humeral rotation at shoulder level (e.g., 90 /90 rotation, side-lying ER eccentric exercises) Long lever arm (e.g., flexion, abduction, plyometrics, weighted-ball drops)
Below shoulder level: isotonic (e.g., IR/ER with arm at side with resistance)
Humeral elevation Stretching Anterior
Posterior Elevation
Short lever arm (e.g., overhead press)
Supine pectoral stretch with arm at side ER with arm at side Cross body Table slides Forward bows
ER, external rotation; IR, internal rotation.
Active scapular retraction with arms at 90
Supine pectoral stretch with overpressure ER with arm away from side Wall slides Assisted elevation with pulley
Level IV
Sleeper stretch Latissimus dorsi stretch
Sleeper stretch in more abducted position Active latissimus dorsi stretch
S. D. MOORE-REED ET AL.
Muscle strengthening Scapular retraction
Level I Scapular protraction and retraction (e.g., scapular clock) Scapular and humeral depression (e.g., inferior glide)
5
LABRAL CLINICAL PREDICTION DEVELOPMENT Table 2. Improvements in Outcome Measures From Initial Evaluation to 6 Weeks’ Follow-up Outcome Measure ASES score QuickDASH score Current pain PSFS score GROC score
NRS Group (n ¼ 31) 14 16 13 15 1 2 23 32
RS Group (n ¼ 27) 2 16 0 16 02 03 02
P Value .006 .001 .047 .033
Purpose: To use the clinical prediction rule process to identify patient variables, measured on initial clinical presentation, that would be predictive of failure to achieve satisfactory improvement, while following a rehabilitation program, in the modification of SLAP injury symptoms and dysfunction. Methods: A cohort of patients received the clinical diagnosis of a SLAP lesion based on specific history and examination findings and/or magnetic resonance imaging. They underwent a physical examination of the kinetic chain and shoulder, including tests for labral injury. Patients followed a standardized physical therapy program emphasizing restoration of demonstrated strength, flexibility, and strength-balance deficits. At 6 weeks’ follow-up, patients were re-evaluated and divided into those recommended for surgery (RS) and those not recommended for surgery (NRS). Bivariate logistic regression was performed to identify the best combination of predictive factors. Results: Fifty-eight patients (aged 39 11 years, 45 men) were included. Of these, 31 (53%) were categorized as NRS and 27 (47%) as RS. The presence of a painful arc of motion (odds ratio, 3.95; P ¼ .024) and the presence of increased forward scapular posture (odds ratio, 1.27; P ¼ .094) on the injured side were predictive of being in the RS group. This finding indicates that the odds of being in the RS group increased 4 times when a positive painful arc was present and increased 27% with every 1-cm increase in involved anterior shoulder posture. Conclusions: A structured rehabilitation program resulted in modification of symptoms and improved function at 6 weeks’ follow-up in over half of patients in the study group. On initial evaluation, the presence of a painful arc of overhead motion, indicating loss of normal glenohumeral kinematics, and the presence of forward shoulder posture, indicating an altered scapular position, represent negative predictive factors for success of rehabilitation. Future validation of the model in a larger population is necessary. Level of Evidence: Level II, prospective comparative study.
T
here is a growing awareness of the need to develop more efficacious methods of evaluating, accurately diagnosing, and treating all types of shoulder pathology. The clinical prediction rule process has been developed as a method to identify which patient variables, measured on initial clinical examination, could be predictive of
From the Department of Kinesiology, California State University (S.D.M-R.), Fresno, California; Shoulder Center of Kentucky (W.B.K., A.D.S.), Lexington, Kentucky; and Division of Athletic Training, University of Kentucky (A.D.S., T.U.), Lexington, Kentucky, U.S.A. The authors report the following potential conflict of interest or source of funding: The Lexington Clinic entered into a contract to pay the University of Kentucky for a doctoral student, S.D.M-R. (co-author), as a part-time research assistant as she completed her doctoral degree. T.U. receives support from American Society of Shoulder and Elbow Therapists. T.U. received reimbursement to present components of these data at the International Congress of Shoulder and Elbow Therapists in April 2013 in Nagoya, Japan. Received September 11, 2013; accepted June 13, 2014. Address correspondence to Aaron D. Sciascia, M.S., A.T.C., 1221 S Broadway, Lexington, KY 40504, U.S.A. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 0749-8063/13668/$36.00 http://dx.doi.org/10.1016/j.arthro.2014.06.015
success of a particular treatment program. The prediction rule process has the potential to instill continuity and uniformity within health care decision making and can help guide care.1 This article reports the outcomes of a study applying the clinical prediction rule process to a cohort of patients determined to have clinical findings consistent with a SLAP injury. In patients with this diagnosis, surgical outcomes are not uniformly successful,2,3 in part because of inconsistency in the diagnostic process and inconsistency in surgical indications.4 Rehabilitation protocols are often advocated as the first step in the treatment of SLAP and other shoulder injuries, but evidence regarding the exact indications, role, and effectiveness of rehabilitation in SLAP injury is sparse and not clear. One previous retrospective study reported that 49% of patients managed with nonoperative rehabilitation had a positive outcome.5 Another study, performed in professional baseball players, all of whom had a SLAP injury and in whom a rehabilitation program had failed, showed that a comprehensive rehabilitation program resulted in 40% of players returning to play.6
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol
-,
No
-
(Month), 2014: pp 1-10
1
2
S. D. MOORE-REED ET AL.
Fig 1. Participant flowchart.
The purpose of this prospective study was to use a clinical prediction rule process to attempt to identify patient variables, measured on initial clinical presentation, that would be predictive of failure to achieve satisfactory improvement, while following a rehabilitation program, in the modification of symptoms and dysfunction in patients with a clinical diagnosis of SLAP injury. We hypothesized that in patients who did not respond, there would be specific measurable patient factors that were associated with failure to respond to a rehabilitation program.
Methods Patients Fifty-eight patients (mean age, 39 11 years; mean mass, 83 25 kg; mean height, 170 35 cm) who were determined to have a clinical history consistent with shoulder dysfunction resulting from injury to the superior labrum were included.7 The history included pain at the posterior joint line, pain with abduction/ external rotation, popping, clicking on shoulder rotation, and pain or limitation of performance with repetitive overhead activity. These 58 patients were part of a group of 211 patients presenting with shoulder pain to an orthopaedic surgeon (W.B.K.) (Fig 1). All participants were patients of the lead author (W.B.K.), a sports medicine and shoulder surgeon with more than 30 years of experience in clinically evaluating and treating shoulder pathology. There are varying opinions regarding the exact criteria to establish a diagnosis of a clinically significant SLAP tear, with no literatureestablished gold standard that is universally recognized. Therefore patient inclusion was based on meeting
specific criteria relating to history, clinical examination findings, and/or diagnostic imaging findings to include all possible criteria for detecting the anatomic and functional alterations associated with the SLAP injury. The clinical examination inclusion criteria were modified from previously identified criteria for diagnosing labral tears reported by Walsworth et al.8 The criteria for our study required a positive finding for at least 3 of the following 4 clinical signs: history of popping or catching, positive anterior-slide maneuver, positive modified dynamic labral shear (M-DLS) maneuver,9 or positive active compression test.8,9 Patients with a SLAP tear diagnosed by advanced imaging (i.e., magnetic resonance imaging [MRI] or magnetic resonance arthrography [MRA]) were included if they also had 1 or 2 of the clinical examination inclusion criteria because the addition of history and clinical examination evidence has been shown to change the information from the imaging.10 Reliance was not placed on 1 examination or imaging test because no single test has been shown to be uniformly satisfactory to make the complete diagnosis.4,11,12 A recent systematic review by Hegedus et al.13 supports the concept of using clusters of tests to make the diagnosis in shoulder pathology, although the M-DLS maneuver has been shown in a Level I study to have high clinical utility.9 Patients were excluded from the study if they had numbness or tingling in the upper extremity; signs and symptoms consistent with cervical radiculopathy,14 adhesive capsulitis,15 or glenohumeral arthritis16; patient-reported steroid injections in the involved shoulder within the previous month; or surgery on the involved shoulder within the past year. They were also excluded if they had clinical examination and/or imaging findings consistent with a diagnosis of acromioclavicular joint injury/arthrosis, glenohumeral instability, or full-thickness rotator cuff tear. This study was approved by the appropriate institutional review boards. Before enrollment in the study, all patients read and signed an informed consent form that was approved by the institutional review boards of the University of Kentucky and Lexington Clinic. Patients completed a standard history form and underwent standard examination by the orthopaedic surgeon (W.B.K.). All patients completed a numeric pain rating scale regarding current pain, worst pain, and least pain in the past week17 (0, no pain; 10, highest pain). In addition, patients completed the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire, which is scored from 0, no disability, to 100, severe disability; the American Shoulder and Elbow Surgeons (ASES) Shoulder Assessment Form, with a score ranging from 0, poor function, to 100, normal function18-20; and the Patient-Specific Functional Scale (PSFS).21 The PSFS questionnaire requires the patient to list 3 to 5 activities that he or she has difficulty doing because of his or her
LABRAL CLINICAL PREDICTION DEVELOPMENT
shoulder problem and to rate each item from 0 (cannot perform activity at all) to 10 (can perform activity at the same level as before the injury). Glenohumeral range of motion (ROM), strength, and posture were also assessed. ROM was assessed with a digital inclinometer (Dualer; JTech Medical, Salt Lake City, UT). Passive internal and external rotation ROM and horizontal adduction ROM were measured with the patient supine and shoulder abducted to 90 with the scapula stabilized until resistance was first felt or the patient reported pain, as previously described.22 Active shoulder flexion ROM was measured with the patient seated. The patient was instructed to raise his or her arm as high as possible in the sagittal plane with the thumb up.23 The clinician aligned the inclinometer with the long axis of the humerus, and the angle was recorded in degrees. Inter-rater intraclass correlation coefficients (ICCs) were calculated a priori for internal rotation ROM (ICC, 0.795), external rotation ROM (ICC, 0.839), horizontal adduction ROM (ICC, 0.518), and active flexion ROM (ICC, 0.863). Isometric muscle strength was measured with a handheld dynamometer24 (model 01163; Lafayette Instruments, Lafayette, IN). Forward flexion strength was measured with the participant seated, the scapula in a retracted position, the shoulder in 90 of flexion, and the palm down.24 The dynamometer was placed just proximal to the wrist, and the participant was instructed to push up for 5 seconds. External rotation strength was measured with the participant supine, the shoulder abducted to 90 , the elbow flexed to 90 , and the humerus in neutral rotation and supported. The dynamometer was placed parallel with the forearm. For each strength measure, 2 maximum-effort trials were performed and averaged for analysis. Each arm was tested in alternating fashion to allow for approximately 30 seconds of rest between trials (flexion strength ICC, 0.897; external rotation strength ICC, 0.842). Finally, scapular posture was assessed with the participant standing and using a double square instrument as previously described by Kluemper et al.25 The participant was asked to stand against the wall and assume his or her normal posture after taking a deep breath to relax. The double square instrument was aligned with the wall and the anterior aspect of the acromion. This distance was measured and recorded bilaterally. Reliability was determined a priori (ICC, 0.946). After the initial clinical visit and data collection, all patients were prescribed physical therapy and provided with a standardized rehabilitation protocol consisting of stretching exercises and strengthening exercises for shoulder musculature, but the protocol was individualized depending on each patient’s examination findings by the treating physical therapist. This protocol was well outlined (Table 1). It consisted of 4 phases, each
3
having mobility and strengthening components that were progressed at each phase. The protocol was designed based on the concepts put forth by Ellenbecker and Cools26 for treating patients with shoulder pain and scapular dysfunction. Mobility exercises progressed from gentle mobility to static stretching of posterior, anterior, and inferior shoulder mobility restrictions. Strengthening exercises progressed from scapular muscular orientation to gain motor control, using the kinetic chain theories of incorporating the entire body, to short and then to long lever-arm resistive exercises, on the basis of kinetic chain theories of incorporating the lower extremity. Ballistic and eccentric exercises were incorporated in the protocol if the treating therapist believed that they were appropriate for an individual patient (Table 1). The rehabilitation protocol was provided to the patients at the initial visit. Patients were allowed to go to the physical therapists of their choosing, with instructions to follow the specific protocol. The physical therapists were provided a letter describing the study and requesting that the patients follow the established protocol. Exercise logs were provided for the patients to record their compliance with the therapy. Detailed physical therapy records were obtained from over two-thirds of the patients (40 of 58). At a follow-up visit with the orthopaedic surgeon (W.B.K.) 6 weeks after the initial visit (median, 6 weeks; range, 4 to 24 weeks), participants again completed the QuickDASH questionnaire, ASES form, numeric pain rating scale, and PSFS questionnaire. Strength, ROM, and posture were also reassessed. In addition, the Global Rating of Change (GROC) score was obtained. The GROC is a 15-point scale ranging from 7 (a great deal worse) to þ7 (a great deal better), with 0 indicating no change.27 Exercise logs and physical therapy notes were collected from patients at this time. After the intervention and follow-up appointment, patients were categorized into 2 groups based on their report of their clinical status and the clinical examination findings: recommended for surgery (RS) or not recommended for surgery (NRS). The recommendation for surgery was based on continued or worsened subjective and objective symptoms of shoulder pain and dysfunction, failure to progress in rehabilitation, and a patient’s unwillingness or inability to tolerate the dysfunction, with clinical input from the physician (Table 2). This process followed the normal procedure of consultation and decision making regarding treatment between physician and patient. The decision to counsel and recommend surgery was made at this time point because most studies indicate that it takes around 6 weeks to observe significant changes in physiological factors such as flexibility and strength and therefore affect the clinical symptoms, which were the goals of the rehabilitation protocol.28-30 In addition, this is
4
Table 1. Rehabilitation Exercise Program Exercise Category Scapular orientation
Below shoulder level: isometric
Scapular protraction
Humeral rotation
Level II
Level III
Below shoulder level: isotonic (e.g., dynamic low row, lawnmower, robbery) Punch (e.g., supine punch, scapular punches)
Isotonic at shoulder level: short lever arm (e.g., pull downs, fencing, rows)
Isotonic (e.g., prone horizontal abduction lifts at 90 or 135 )
Push-ups (e.g., incline)
Push-ups (e.g., knee, standard)
Punch (e.g., standing punch) At shoulder level (e.g., ER/IR with elastic band, 90 /90 )
Diagonal (e.g., upper cut) Humeral rotation at shoulder level (e.g., 90 /90 rotation, side-lying ER eccentric exercises) Long lever arm (e.g., flexion, abduction, plyometrics, weighted-ball drops)
Below shoulder level: isotonic (e.g., IR/ER with arm at side with resistance)
Humeral elevation Stretching Anterior
Posterior Elevation
Short lever arm (e.g., overhead press)
Supine pectoral stretch with arm at side ER with arm at side Cross body Table slides Forward bows
ER, external rotation; IR, internal rotation.
Active scapular retraction with arms at 90
Supine pectoral stretch with overpressure ER with arm away from side Wall slides Assisted elevation with pulley
Level IV
Sleeper stretch Latissimus dorsi stretch
Sleeper stretch in more abducted position Active latissimus dorsi stretch
S. D. MOORE-REED ET AL.
Muscle strengthening Scapular retraction
Level I Scapular protraction and retraction (e.g., scapular clock) Scapular and humeral depression (e.g., inferior glide)
5
LABRAL CLINICAL PREDICTION DEVELOPMENT Table 2. Improvements in Outcome Measures From Initial Evaluation to 6 Weeks’ Follow-up Outcome Measure ASES score QuickDASH score Current pain PSFS score GROC score
NRS Group (n ¼ 31) 14 16 13 15 1 2 23 32
RS Group (n ¼ 27) 2 16 0 16 02 03 02
P Value .006 .001 .047 .033
