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

„ Scope Most Common Conditions (Non-op)

„ Most Common Conditions „ Rotator cuff tendinopathy
„ Limit to Non-operative care „ aka Impingement syndrome, tendinitis, tendinosis,
„ Evidenced based subacromial bursitis
„ Classification important and should guide rehab „ Frozen Shoulder
„ ICF Nomenclature „ Glenohumeral Instability

Millar JOSPT, 2006

van der Windt, Ann Rheum Dis, 1995

The Shoulder and ICF Shoulder Dx /Classification

Popular Label 1o ICD 9 ICF Body
Function
ICF Body
Structure
Activities/ „ Rotator Cuff Tendinopathy / Impingement
Participation
Rotator Cuff 726.1 B7300 S7202 D4452 Reaching „ Glenohumeral Instability
Power of isolated Muscles of shoulder D4300 Lifting
Tendinopathy Rot Cuff
Syndrome
muscles and muscle region D850 Work „ Frozen Shoulder
(Impingement) groups D520 Caring for
B7100 S7201 body parts
Frozen Shoulder 726.0 D4451 Pushing
Mobility of a single Joints of the
Adhesive joint shoulder region D4452 Reaching „ Are these homogenous groups?
Capsulitis D4300 Throwing

Glenohumeral 840.2 B7601 S7203

„ Are these dx’s specific enough to direct
Instability Shoulder
Control of complex
voluntary
Ligaments and
fasciae of shoulder
rehabilitation?
ligament movements region

sprain
„ Lessons learned from the spine…

1
 Med Dx and PT Dx
Med Dx and PT Dx
Med Dx Rot Froz GH Treatment
„ Medical Diagnosis „ PT Diagnosis
or Cuff Shdr Instab Strategy
„ Pathoanatomic „ Sx Severity / Impairment
„ Primary Tissue „ “Irritability”
PT Dx
Pathology „ Current intensity Pain +/ +/ -- Activity
„ Stable over episode of „ Often changes over +++ +++ Mod
care episode of care
„ Guides general Rx Weak ++ / -- / + ++ / Strengthen
„ Guides specific rehab Rx
strategy +++ +++
„ May inform prognosis
„ Informs prognosis Stiff -- / + +++ -- Mob
Laxity -- /+ -- +++ Strength/
coord

Level 1
Level 2
Complaint of “Shoulder Symptom”
Pt c/o Shoulder Pain
Level 1
Screen Specific Phys Exam (D)
History, Basic PE, Red Flags
Key History (A)

Non-shoulder origin of sx Shoulder origin of sx

Basic Phys Exam (B)
Rot Cuff
Froz Shdr
Level 2 Specific Phys Exam (D) Red Flags (C) GH Instab
Med Dx
NO
Rotator Cuff / Glenohumeral YES YES
Frozen Shoulder
Impingement Instability Hx and PE
consistent with Other Dx
Shdr Dx ? GH Arthritis
Level 3 Fractures
Continue to AC jt
PT Dx Neural Entrap
NO Specific Dx Myofascial
High Irritability Mod Irritability Low Irritability Fibromyalgia
Post-Op
Referral / Other

Consultation

A: Key Hx B: Basic Phys Ex C: Red Flags All Shoulder Problems

• Age • Observation • Acute Trauma
• Occupation / sports • Posture • Tumor
• Hand Dominance • Upper Quarter Screen • Infection
• PMH
• Onset /duration sx’s
• r/o C-spine
• r/o neurologic
• Referred Pain
2nd Level Shoulder Classification
• AROM / PROM
• Hx trauma / disloc
•Pain •Elev, IR, ER Specific Exam
•Location •Strength
•Intensity •Elev, IR, ER Yellow Flags
•Factors ↑ ↓or
•Fear Avoidance
•Night pain Rotator Cuff / Glenohumeral
•Psychosocial Frozen Shoulder Other
•Other CC Sx’s
Factors Impingement Instability
•Weakness
•Paras/numbness
•Stiffness Key Positive: Key Positive: Key Positive: GH Arthritis
•Self-report •impingement signs •Spontaneous •Age usu < 40 Fractures
Function/disability •Painful arc progressive pain •Hx disloc / sublux AC jt
•Pain w/ isom resist •Loss of motion in •Apprehension Neural Entrap
•Weakness multiple planes •Generalized laxity Myofascial
•Atrophy •Pain at end-range
Fibromyalgia
Key negative: Key negative: Key negative: Post-Op
Sig loss of motion Normal motion No hx disloc Red Flag Conditions
Instability signs Age < 40 No apprehension

2
 High Irritability (E) Moderate Irritability (F) Low Irritability (G)
(3/5 to categorize) (3/5 to categorize) (3/5 to categorize)

• High Pain (> 7/10) • Mod Pain (4-6/10) •Low Pain (< 3/10)
• night or rest pain • night or rest pain • night or rest pain
Rotator Cuff / Glenohumeral • consistent • none
Frozen Shoulder • intermittent
Impingement Instability • Pain before end ROM • Min pain w/overpressure
• Pain at end ROM
• AROM < PROM • AROM ~ PROM • AROM = PROM
• High Disability • Mod Disability • Low Disability
3rd Level Shoulder Classification •(DASH, ASES) •(DASH, ASES) •(DASH, ASES)
Irritability Level
Rx focus: Rx focus:
High Irritability High Irritability High Irritability Rx focus: • pain reduction • High demand functional
• pain reduction • impairments activity restoration
• basic function

Mod Irritability Mod Irritability Mod Irritability

Low Irritability Low Irritability Low Irritability

Level 1
Level 2
Pt c/o Shoulder Pain
Level 2
Specific Phys Exam (D)
Key History (A) Rotator Cuff / Glenohumeral
Frozen Shoulder
Impingement Instability

High Irritability High Irritability High Irritability

Basic Phys Exam (B) Level 3
Rot Cuff Mod Irritability Mod Irritability Mod Irritability
Froz Shdr Low Irritability Low Irritability Low Irritability
Red Flags (C) GH Instab

NO Good Continue PT
Response to PT
YES YES until goals met
after 4-6 visits (H)
Hx and PE
consistent with Other Dx
Shdr Dx ? GH Arthritis Poor
Fractures
Continue to AC jt
Neural Entrap Adjust PT
NO Specific Dx Myofascial Referral Likely Explanation?
Fibromyalgia
Treatment
Inject, further dx, other NO Compliance, mis-dx, etc Yes
Post-Op
Referral / Other

Consultation

Treatment Response Criteria (H) Matched Treatment Strategy

High Irritability Moderate Low Irritability
Irritability
Good response Poor response
Modalities +/-- + / -- --
„ Pain improved (> 2 pts on „ Pain is unimproved or Activity + + / -- --
NPRS) worsened Modification
„ Function / disability improved: „ Function / disability ROM/ Stretch Pain-free passive AAROM Æ End-range/
> MDC in self-report outcome unimproved or worsened AAROM AROM overpressure
(DASH=13pts, ASES= 9.4pts) „ Patient dissatisfied Manual Techniques Low grade Low / High High grade
grade
„ Patient satisfaction improved
Strengthen -- Light Æ mod Mod Æ high
(> 2 pt on 11pt scale)
resistance resistance
Mid-ranges End-ranges
Functional -- Basic High demand
Activities
Patient Education + + +
Taping / functional + / -- + / -- + / --
support (brace /
external)