The American Society of Shoulder and Elbow Therapists' consensus statement on rehabilitation following arthroscopic rotator cuff repair.

This is a consensus statement on rehabilitation developed by the American Society of Shoulder and Elbow Therapists. The purpose of this statement is to aid clinical decision making during the rehabilitation of patients after arthroscopic rotator cuff repair. The overarching philosophy of rehabilitation is centered on the principle of the gradual application of controlled stresses to the healing rotator cuff repair with consideration of rotator cuff tear size, tissue quality, and patient variables. This statement describes a rehabilitation framework that includes a 2-week period of strict immobilization and a staged introduction of protected, passive range of motion during weeks 2-6 postoperatively, followed by restoration of active range of motion, and then progressive strengthening beginning at postoperative week 12. When appropriate, rehabilitation continues with a functional progression for return to athletic or demanding work activities. This document represents the first consensus rehabilitation statement developed by a multidisciplinary society of international rehabilitation professionals specifically for the postoperative care of patients after arthroscopic rotator cuff repair.

Team Approach: Treatment of Shoulder Instability in Athletes.

¼: Shoulder instability is a complex problem with a high rate of recurrence in athletes. Treatment of a first-time subluxation or dislocation event is controversial and depends on patient-specific factors as well as the identified pathology. ¼: Athletic trainers and physical therapists are an integral part of the treatment team of an in-season athlete who has experienced a shoulder instability event. Through comprehensive physiological assessments, these providers can effectively suggest modifications to the patient's training regimen as well as an appropriate rehabilitation program. ¼: Surgical intervention for shoulder stabilization should use an individualized approach for technique and timing. ¼: A team-based approach is necessary to optimize the care of this high-demand, high-risk population.

The American Society of Shoulder and Elbow Therapists' consensus rehabilitation guideline for arthroscopic anterior capsulolabral repair of the shoulder.

SYNOPSIS: This manuscript describes the consensus rehabilitation guideline developed by the American Society of Shoulder and Elbow Therapists. The purpose of this guideline is to facilitate clinical decision making during the rehabilitation of patients following arthroscopic anterior capsulolabral repair of the shoulder. This guideline is centered on the principle of the gradual application of stress to the healing capsulolabral repair through appropriate integration of range of motion, strengthening, and shoulder girdle stabilization exercises during rehabilitation and daily activities. Components of this guideline include a 0- to 4-week period of absolute immobilization, a staged recovery of full range of motion over a 3-month period, a strengthening progression beginning at postoperative week 6, and a functional progression for return to athletic or demanding work activities between postoperative months 4 and 6. This document represents the first consensus rehabilitation guideline developed by a multidisciplinary society of international rehabilitation professionals specifically for the postoperative care of patients following arthroscopic anterior capsulolabral repair of the shoulder.

Modified Outpatient Physical Therapy Improvement in Movement Assessment Log (mOPTIMAL): A Responsive and Reliable Tool for Patients with Non-Operative Shoulder Pain.

Background: Medicare regulations require that physical therapists report functional limitations and severity modifiers utilizing a claims-based data collection tool. The Modified Outpatient Physical Therapy Improvement in Movement Assessment Log (mOPTIMAL) captures key constructs about patient confidence and difficulty but has not been evaluated for responsiveness/ reliability during a routine clinical encounter with patients who have shoulder pathology. The purposes of this retrospective study are to 1) explore if mOPTIMAL changes after a single session with a physical therapist, and 2) determine if the tool is reliable among people with non-operative shoulder pain. Methods: We included 106 individuals (58% female; mean age 45.8; range: 18-94 yrs.) with "non-operative" shoulder pathology who were seen in outpatient physical therapy from 2011 to 2012. Subjects completed a mOPTIMAL survey and a pain scale before and immediately after the initial physical therapy visit. The mOPTIMAL is a patient-centered instrument that assesses how much "Difficulty" and "Confidence" a client has in performing a battery of functional tasks. T-tests, Cronbach's Alpha, and Intra-class Correlations were used to assess responsiveness, internal consistency, and reliability, respectively. Results: After a single visit, participants reported improved Confidence with sleeping, dressing/ bathing, throwing, carrying, and lifting (adjusted for ceiling effects; p<0.002) but no change in pain. Cronbach's Alpha and Intra-class Correlations were excellent (0.821-0.923; 0.967, respectively). Conclusions: mOPTIMAL is a reliable and responsive tool with excellent internal consistency. This observational study revealed that patient Confidence may change independent of Pain after a single physical therapy visit. Taken together, the mOPTIMAL appears to be an excellent tool to report severity modifiers in compliance with Medicare regulations.Level of Evidence: IV.

Speed, resistance, and unexpected accelerations modulate feed forward and feedback control during a novel weight bearing task.

We developed a method to investigate feed-forward and feedback movement control during a weight bearing visuomotor knee tracking task. We hypothesized that a systematic increase in speed and resistance would show a linear decrease in movement accuracy, while unexpected perturbations would induce a velocity-dependent decrease in movement accuracy. We determined the effects of manipulating the speed, resistance, and unexpected events on error during a functional weight bearing task. Our long term objective is to benchmark neuromuscular control performance across various groups based on age, injury, disease, rehabilitation status, and/or training. Twenty-six healthy adults between the ages of 19-45 participated in this study. The study involved a single session using a custom designed apparatus to perform a single limb weight bearing task under nine testing conditions: three movement speeds (0.2, 0.4, and 0.6Hz) in combination with three levels of brake resistance (5%, 10%, and 15% of individual's body weight). Individuals were to perform the task according to a target with a fixed trajectory across all speeds, corresponding to a∼0 (extension) to 30° (flexion) of knee motion. An increase in error occurred with speed (p<0.0001, effect size (eta2): η2=0.50) and resistance (p<0.0001, η2=0.01). Likewise, during unexpected perturbations, the ratio of perturbed/non-perturbed error increased with each increment in velocity (p<0.0014, η2=0.08), and resistance (p<0.0001, η2=0.11). The hierarchical framework of these measurements offers a standardized functional weight bearing strategy to assess impaired neuro-muscular control and/or test the efficacy of therapeutic rehabilitation interventions designed to influence neuromuscular control of the knee.

The Penn shoulder score: reliability and validity.

STUDY DESIGN: Psychometric evaluation of a cross-sectional survey. OBJECTIVES: The purpose of this study was to examine the psychometric properties of reliability and validity of the Penn Shoulder Score (PSS). BACKGROUND: Shoulder outcome measures are used to assess patient self-report levels of pain, satisfaction, and function. The PSS is a 100-point shoulder-specific self-report questionnaire consisting of 3 subscales of pain, satisfaction, and function. This scale has been utilized in the literature. However, the measurement properties of reliability and validity, including responsiveness, of the PSS subscales and overall scale need to be established. METHODS AND MEASURES: Patients (n = 40) with shoulder disorders undergoing a course of outpatient physical therapy completed the PSS at initial visit and again within 72 hours to assess test-retest reliability. The Constant Shoulder Score (CSS) and the American Shoulder and Elbow Surgeons Shoulder Score (ASES) were also completed at the initial visit and compared to the PSS to assess convergent construct validity. A separate cohort of patients (n = 109) completed the PSS at initial visit and 4 weeks later. These scores were used to assess internal consistency and responsiveness. RESULTS: Reliability analysis revealed a test-retest ICC2,1 of 0.94 (95% CI, 0.89-0.97). Internal consistency analysis revealed a Cronbach alpha of 0.93. The standard error of measurement (SEM) was +/- 8.5 scale points (based on a 90% CI) and the minimal detectable change (MDC) was +/- 12.1 scale points (based on a 90% CI). The minimal clinically important difference (MCID) for improvement was 11.4 points. Pearson product moment correlation coefficients between the PSS and the CSS and ASES were 0.85 and 0.87, respectively. Responsiveness analysis revealed an effect size of 1.01 and a standardized response mean of 1.27. CONCLUSIONS: This study has demonstrated that the PSS is a reliable and valid measure for reporting outcome of patients with various shoulder disorders.

Knowing the speed limit: weighing the benefits and risks of rehabilitation progression after arthroscopic rotator cuff repair.

Rotator cuff repairs have increased. Although clinical trials have examined the effect of immobilization and timing of passive range of motion (ROM) on patient outcomes and structural integrity, there is controversy as to the timing and progression for therapy. Primary goals are restoring function while maintaining the structural integrity of the repair. We advocate for a protocol of 4 to 6 weeks of immobilization, followed by protected passive ROM, which is followed by a gradual progression to active ROM and then appropriate resistance exercise program for most all rotator cuff repairs. The rate of progression should be adjusted individually.

The immediate effects of muscle energy technique on posterior shoulder tightness: a randomized controlled trial.

STUDY DESIGN: Randomized controlled trial. OBJECTIVES: To compare a muscle energy technique (MET) for the glenohumeral joint (GHJ) horizontal abductors and an MET for the GHJ external rotators to improve GHJ range of motion (ROM) in baseball players. BACKGROUND: Overhead athletes often exhibit loss of GHJ ROM in internal rotation, which has been associated with shoulder pathology. Current stretching protocols aimed at improving flexibility of the posterior shoulder have resulted in inconsistent outcomes. Although utilization of MET has been hypothesized to lengthen tissue, there are limited empirical data describing the effectiveness of such stretches for treating posterior shoulder tightness. METHODS: Sixty-one Division I baseball players were randomly assigned to 1 of 3 groups: MET for the GHJ horizontal abductors (n = 19), MET for the GHJ external rotators (n = 22), and control (n = 20). We measured preintervention and postintervention GHJ horizontal adduction and internal rotation ROM, and conducted analyses of covariance, followed by Tukey honestly significant difference post hoc analysis for significant group-by-time interactions (P<.05). RESULTS: The group treated with the MET for the horizontal abductors had a significantly greater increase in GHJ horizontal adduction ROM postintervention (mean ± SD, 6.8° ± 10.5°) compared to the control group (-1.1° ± 6.8°) (P = .011) and a greater increase in internal rotation ROM postintervention (4.2° ± 5.3°) compared to the group treated with the MET for the external rotators (0.2° ± 6.3°) (P = .020) and the control group (-0.2° ± 4.0°) (P = .029). No significant differences among groups were found for any other variables (P>.05). CONCLUSION: A single application of an MET for the GHJ horizontal abductors provides immediate improvements in both GHJ horizontal adduction and internal rotation ROM in asymptomatic collegiate baseball players. Application of MET for the horizontal abductors may be useful to gain ROM in overhead athletes. LEVEL OF EVIDENCE: Therapy, level 2b-.