Measurement Properties of the Timed Functional Arm and Shoulder Test in Patients With Shoulder Problems.

OBJECTIVE: The purpose of this study was to determine the feasibility, reliability, validity, and responsiveness of the Timed Functional Arm and Shoulder Test (TFAST) in patients with shoulder problems. METHODS: This study was a repeated-measures clinical measurement observational cohort study. A total of 104 patients who were symptomatic participated in this study. The TFAST was collected as part of an patient's outpatient physical therapist care at 6 different sites. The test and data collection were performed at 3 time points: baseline (initial evaluation), follow-up at the patient's first return visit within 7 days of evaluation, and discharge at the patient's final visit for care. RESULTS: All participants were able to perform the TFAST at baseline, with 1 exception, and 67 participants completed data collection at all 3 time points. There were no adverse effects in any participant related to performing the TFAST. Intrarater intersession reliability, reported as ICC(2,1), was 0.91 (95% CI = 0.79-0.95). The mean difference in TFAST scores for the affected arm was 23.2 repetitions (77.4 at baseline to 100.6 at discharge). The Cohen d effect size was 1.02, and the standardized response mean was 0.95. The minimal clinically important difference was determined to be 21 repetitions. CONCLUSION: The TFAST seems to be feasible and appropriate for use in a wider population than other existing shoulder performance measures. The TFAST has demonstrated adequate reliability, validity, and responsiveness in patients with shoulder problems. Clinicians may consider using the TFAST to objectively assess patient performance. IMPACT: The TFAST may be used to expand measurement of objective shoulder performance in a wide population of patients with shoulder problems. This test may provide information beyond an patient's self-report and contribute to clinical decision-making.

The 4-Element Movement System Model to Guide Physical Therapist Education, Practice, and Movement-Related Research.

The movement system has been adopted as the key identity for the physical therapy profession, and recognition of physical therapists' primary expertise in managing movement dysfunction is an important achievement. However, existing movement system models seem inadequate for guiding education, practice, or research. Lack of a clear, broadly applicable model may hamper progress in physical therapists actually adopting this identity. We propose a model composed of 4 primary elements essential to all movement: motion, force, energy, and control. Although these elements overlap and interact, they can each be examined and tested with some degree of specificity. The proposed 4-element model incorporates specific guidance for visual, qualitative assessment of movement during functional tasks that can be used to develop hypotheses about movement dysfunction and serve as a precursor to more quantitative tests and measures. Human movement always occurs within an environmental context and is affected by personal factors, and these concepts are represented within the model. The proposed scheme is consistent with other widely used models within the profession, such as the International Classification of Functioning, Disability and Health and the Patient Management Model. We demonstrate with multiple examples how the model can be applied to a broad spectrum of patients across the lifespan with musculoskeletal, neurologic, and cardiopulmonary disorders.

Shoulder muscle force and electromyography activity during make versus break tests.

BACKGROUND: Shoulder muscle force is commonly assessed during clinical examination using both an isometric "make" test against a fixed resistance or a "break" test where the examiner exerts enough force to break the isometric contraction. The purpose of this study was to explain the difference in force produced during these two forms of testing. METHODS: Data were collected on 25 subjects. Both shoulder external rotation and elevation force were measured over three trials, isometrically, for approximately 3 s, after which the examiner exerted enough force to move the arm. Surface EMG was recorded for the infraspinatus for external rotation and middle deltoid for elevation. Peak isometric and break forces, and normalized, averaged EMG data at peak isometric and break forces were compared with paired t-tests. FINDINGS: External rotation peak break force was 46.9% (SD33.6, range - 3% to 108.6%) greater than isometric force (p < 0.01). EMG for the infraspinatus was 17.0% (20.8) greater at break (p < 0.01). For elevation, peak break force was 63% (73.1, range - 3.5 to 238.16%) greater than isometric force (p < 0.01). EMG for the middle deltoid was 11.1% (30.8) greater during peak break force (not significant). INTERPRETATIONS: There is a difference in both force and muscle activity between "make" and "break" tests. Clinicians should use a consistent method when measuring force and a break test will provide the maximum force. The cause of greater force produced during a break test is likely attributable to the brief eccentric contraction rather than greater recruitment. Future analysis will include examining the differences in make and break forces based on activity levels.

Neuropathic Glenohumeral Joint Resorption.

An 81-year-old woman was evaluated by a physical therapist at a skilled nursing facility 3 days post total knee arthroplasty (TKA). Following the evaluation, the on-call physician was consulted and radiographs were ordered. Radiographs revealed a chronic neuropathic joint with complete resorption of the humeral head and heterotopic ossification at the scapula. J Orthop Sports Phys Ther 2020;50(8):466. doi:10.2519/jospt.2020.9174.

Physical and Functional Differences in Youth Baseball Players With and Without Throwing-Related Pain.

BACKGROUND: Identifying risk factors that contribute to shoulder and elbow pain within youth baseball players is important for improving injury prevention and rehabilitation strategies. HYPOTHESIS: Differences will exist between youth baseball players with and without a history of upper extremity pain on measures related to growth, shoulder performance, and baseball exposure. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A total of 84 youth baseball players were divided into 2 groups based on self-reported history of throwing-related arm pain. Group differences for growth-related, shoulder performance, and baseball exposure variables were analyzed by use of parametric and nonparametric tests, as appropriate. Multivariate logistic regression was used to assess variables most predictive of pain. RESULTS: The group of athletes with pain (n = 16) were taller and heavier, played more baseball per year, and had greater pitching velocity. Athletes with pain also had greater loss of internal rotation range of motion and greater side-to-side asymmetry in humeral retrotorsion (HRT), attributable to lower degrees of HRT within the nondominant humerus. Multivariate analysis revealed that player height was most predictive of pain, with a 1-inch increase in height resulting in a 77% increased risk of pain. CONCLUSION: Vertical growth that accompanies adolescence increases the risk of experiencing throwing-related pain in youth baseball players. Players who are taller, particularly those with faster pitching velocities, are at the greatest risk for developing pain and should be more carefully monitored for resultant injury. The degree of nondominant HRT may have a relationship to the development of pain, but further research is required to better understand the implications of this observation.

Early Development and Reliability of the Timed Functional Arm and Shoulder Test.

Study Design Repeated-measures clinical measurement reliability study. Background While there are some shoulder functional tests for athletes, no widely used performance test of arm and shoulder function currently exists to assess lower-level upper extremity functional demands in, for example, a nonathlete population or elderly individuals. In these individuals, functional measures rely on patient self-report. Objectives Describe the development of the Timed Functional Arm and Shoulder Test (TFAST), age-related scores, and between-session reliability in a group of asymptomatic high school athletes, young adults, middle-aged adults, older adults, and a preliminary group of symptomatic patients. Methods One hundred forty asymptomatic individuals participated in the study: 36 high school athletes (14-18 years of age), 34 young adults (19-35 years of age), 37 middle-aged adults (36-65 years of age), 33 older adults (over 65 years of age), and 16 symptomatic patients (22-66 years of age). The TFAST is a functional test that includes 3 tasks: hand to head and back, wall wash, and gallon lift. Total repetitions were noted for each task, and the total TFAST score was calculated. Results Mean total TFAST scores were higher for young adults (107.9; 95% confidence interval [CI]: 102.5, 113.4) and middle-aged adults (105.2; 95% CI: 99.1, 111.3) as compared to the high school athletes (89.9; 95% CI: 81.2, 98.5) and older adults (74.5; 95% CI: 65.6, 83.5). All groups were significantly different (P<.05) from each other, except the young and middle-aged adults. For patients, the mean score for the symptomatic side was 100.1 (95% CI: 89.6, 110.5). The between-session reliability values for the total TFAST scores in the asymptomatic individuals were as follows: intraclass correlation coefficient (ICC) = 0.93; 95% CI: 0.60, 0.98; standard error of measurement, 6.7; and minimal detectable change based on a 95% CI, 18.5 repetitions. The ICC values for individual tasks ranged from 0.80 to 0.94 (95% CI range, 0.44-0.98). The reliability for the patient group was 0.83 (95% CI: 0.51, 0.94). Conclusion The TFAST was sensitive to detect differences in functional performance between age groups, demonstrated adequate between-session reliability, and demonstrated feasibility in a symptomatic patient group. Further assessment is needed to refine the TFAST. Development of a feasible and valid test of arm function would enhance clinical evaluation and outcome measurement. J Orthop Sports Phys Ther 2017;47(6):420-431. Epub 3 Mar 2017. doi:10.2519/jospt.2017.7136.

Relationship Between Skin Intrinsic Fluorescence--an Indicator of Advanced Glycation End Products-and Upper Extremity Impairments in Individuals With Diabetes Mellitus.

BACKGROUND: Accumulation of advanced glycation end products (AGEs) is thought to contribute to limited joint mobility in people with diabetes mellitus (DM), but the relationships among AGEs, shoulder structural changes, movement, and disability are not understood. OBJECTIVE: The purpose of this study was to determine the differences and relationships among skin intrinsic fluorescence (SIF), a proxy measure of AGEs, biceps and supraspinatus tendon thickness, upper extremity movement, and disability in groups with and without DM. DESIGN: This was a cross-sectional, case-control study. METHODS: Fifty-two individuals participated: 26 with type 2 DM and 26 controls matched for sex, age, and body mass index. The main outcome measures were: SIF; biceps and supraspinatus tendon thickness; 3-dimensional peak shoulder motion; and Disability of the Arm, Shoulder and Hand (DASH) questionnaire scores. RESULTS: Mean SIF measurements were 19% higher in the DM group compared with the control group (P<.05). Biceps tendons (mean and 95% confidence interval [CI]) (4.7 mm [4.4, 5.0] versus 3.2 mm [2.9, 3.5]) and supraspinatus tendons (6.4 mm [5.9, 6.8] versus 4.9 mm [4.4, 5.3]) were thicker and peak humerothoracic elevation (139° [135°, 146°] versus 150° [146°, 155°]) and glenohumeral external rotation (35° [26°, 46°] versus 51° [41°, 58°]) were reduced in the DM group compared with the control group (P<.05). In the DM group, SIF was correlated to biceps tendon thickness, DASH score, and shoulder motion (r=.44-.51, P<.05). The SIF score and shoulder strength explained 64% of the DASH scores (P<.01). LIMITATIONS: Because this was a cross-sectional study design, a cause-effect relationship could not be established. CONCLUSIONS: Accumulation of AGEs in the connective tissues of individuals with DM appears to be associated with increased tendon thickness and decreased shoulder joint mobility and upper extremity function. Physical therapists should be aware of these possible metabolic effects on structure, movement, and disability when treating people with diabetes.

Shoulder limited joint mobility in people with diabetes mellitus.

BACKGROUND: Limited joint mobility at the shoulder is an understudied problem in people with diabetes mellitus. The purpose of this study was to determine the differences in shoulder kinematics between a group with diabetes and those without diabetes. METHODS: Fifty-two participants were recruited, 26 with diabetes and 26 non-diabetes controls (matched for age, BMI and sex). Three-dimensional position of the trunk, scapula and humerus were collected using electromagnetic tracking sensors during scapular plane elevation and rotation movements. FINDINGS: Glenohumeral external rotation was reduced by 11.1°-16.3° (P<0.05) throughout the humerothoracic elevation range of motion, from neutral to peak elevation, in individuals with diabetes as compared to controls. Peak humerothoracic elevation was decreased by 10-14°, and peak external rotation with the arm abducted was decreased 22° in the diabetes group compared to controls (P<0.05). Scapulothoracic and glenohumeral internal rotation motions were not different between the two groups. INTERPRETATION: Shoulder limited joint mobility, in particular decreased external rotation, was seen in individuals with diabetes as compared to control participants. Future research should investigate causes of diabetic limited joint mobility and strategies to improve shoulder mobility and prevent additional detrimental changes in movement and function.

Effect of selected exercises on in-shoe plantar pressures in people with diabetes and peripheral neuropathy.

BACKGROUND: In people with diabetes and peripheral neuropathy (DM+PN), injury risk is not clearly known for weight bearing (WB) vs. non-weight bearing (NWB) exercise. In-shoe peak plantar pressures (PPP) often are used as a surrogate indicator of injury to the insensitive foot. OBJECTIVE: Compare PPPs in people with DM+PN during selected WB and NWB exercises. METHODS: Fifteen subjects with DM+PN participated. PPPs were recorded for the forefoot, midfoot, and heel during level walking and compared to; WB exercises--treadmill walking, heel and toe raises, sit to stands, stair climbing, single leg standing; and NWB exercises--stationary bicycling, balance ball exercise and plantar flexion exercise. RESULTS: Compared to level walking; mean forefoot PPP during treadmill walking was 13% higher, but this difference was eliminated when walking speed was used as a covariate. Mean PPPs were similar or substantially lower for other exercises, except for higher forefoot PPP with heel raise exercises. CONCLUSIONS: Slow progression and regular monitoring of insensitive feet are recommended for all exercises, but especially for heel raises, and increases in walking speed. The remaining WB and NWB exercises pose no greater risk to the insensitive foot due to increases in PPP compared to level walking.