Algorithm

10/25/2013
A Functional Testing
Algorithm for clinical
decision making to
return athletes back to
Sports following a
Shoulder Injury
Clinical DecisionDecision-Making: Specific Parameters to
return an athlete back to sports following a
shoulder injury
What amazes me, is that many of us
need to make this decision on a
regular basis, however, there are:
1) very few guidelines published
2) few objective tests documented to
support the clinical decision making
process
3) limited evidence to support this
process
„
What are the very specific
criteria we use to discharge a
patient from rehabilitation
back to a high risk activity like
competitive sports ?
Do we have absolute
confidence in our
decision making?
Rationale
„
„
„
„
„
„
„
„
„
„
„
PubMed Search: 10/1/13
Shoulder injuries AND:
Return to play
Criteria to return to play
Return to sports
Discharge criteria
Evidence--based practice
Evidence
Clinical decision making
Etc.
Limits (High levels evidence):
0-zerozero-zipzip-nonenone-zilch………
How many of us really have specific
criteria that would stand up to:
1
1.
2.
3.
Rationale
?????Questions?????
„
Clinical DecisionDecision-Making: Specific Parameters to
return an athlete back to sports following a
shoulder injury
„
„
Obremskey, WT, et.al. Level of evidence in
Obremskey,
JBJS--A. 87:2632
87:2632--8, 2005
orthopaedic journals. JBJS
Bhandari, M, et.al. Design, conduct, and
Bhandari,
interpretation of nonrandomized orthopaedic
studies: a practical approach. (ALL) EVIDENCE
MATTERS. JBJSJBJS-A. 91:Suppl 3:1, 2009
„
„
„
Almost 90% of the orthopaedic literature
represents research findings from
nonrandomized study designs, ranging from
the more popular case series to prospective
cohort studies. (Lower Levels of Evidence)
So we do not feel too badly with the limited
evidence, because it’s frankly as good as most
of what is already being done.
Critical peer review
High levels of evidence to support
our clinical decision making
Medico--legal critical analysis
Medico
?????
Rationale
„
„
„
„
„
Evidence-Based Practice:
Evidence1) Best research evidence and best
practice patterns
2) Patient values and considerations
3) Clinical experience and expertise
Therefore this presentation will try to
integrate the 3 parts of EBP, and
acknowledging we have limited
research evidence for this process,
therefore, we have to also rely on # 3:
Clinical experience and expertise
Clearance to Return to
Sports
Clearance to Return to
Sports
„ One
„ Being
method is to have
baseline prepreparticipation information,
and have the athlete
return back to “normal”
for all the parameters
medically cleared
to return to sports does
not mean that the
patient/athlete is
functionally ready to
return to sports!!!
1
10/25/2013
“Clinical Decision Making”
„ Since
pp
what happens
when an athlete
returns to sports after
being “cleared by us”,
and then they get
reinjured???
„ So
Clearance to Return to
Sports
“Experience”
I have been
there and have made
more mistakes
i
k than
h
most in the audience,
I can assure you that
it is not a good
feeling….
Clinical DecisionDecisionMaking
„So,
what else
can we do???
„
„
„
If a physician, physical therapist or
athletic trainer allows an athlete to
p
, they
y may
y be legally
g y
return to sports,
held responsible if the athlete
encounters a serious injury.
Creighton, DW, et.al. ReturnReturn-toto-play in sport: a
decision--based model.
decision
Clin J Sports Med. 20(5):379
20(5):379--385,
2010
Algorithm
„A
process consisting of
steps, each step depending
steps,
on the outcome of the
previous one.
„ Stedman’s
Medical
Dictionary, 2002
Algorithm
„ In
clinical medicine, a stepstepby-step protocol for
bymanagement of a health
care problem
„ Stedman’s
Medical
Dictionary, 2002
So how do we do it ???
„ Numerous
examples for
Lower Extremities:
„ Davies,
Davies GJ,
GJ 1980
„ Myer, JOSPT, 2006
„ Hurd
Hurd,, AJSM, 2008
„ Meyer, JOSPT, 2011
2
10/25/2013
Functional Testing AlgorithmAlgorithm-UE
Functional Testing
Algorithm - Shoulder
UE - FTA
We are unaware of a FTA that is
published for parameters for
returning someone back to
sports following a shoulder
injury,
1998
Other than this publication…..
Functional Testing Algorithm
Clinician-rated
Clinicianimpairment measures
Functional Testing Algorithm
TIME:
Soft tissue healing from
the
or
th injury
i j
from a
„
Functional Testing
„
Strength/P
trength/Power Testing
„
Basic Measurements
Disability
Functional
Limitations
Impairments
Functional Testing Algorithm –
Shoulder - 1998
„
„
„
„
„
„
„
Sport Specific Testing
FT
OKC--Functional Throwing Performance Index
OKC
Closed Kinetic Chain – Upper Extremity
Stability Test
Isokinetic Testing
S/P
Kinesthetic/Proprioceptive Testing
Basic Measurements
Basic
Visual Analog scale
post-surgical condition
Functional Testing Algorithm –
Shoulder - 1998
„
„
„
„
„
„
„
„
Sports Specific Testing – specificity for sport
F T P I: ♂ 33
33--60%; ♀ 17
17--41
41%
%
C K C – U E: ♂ 21 touches; ♀ 23 touches
Isokinetic Testing: < 15% Bilateral Difference;
Difference;
Normative Data – For FTPI Test
Isokinetic Testing: < 25% Bilateral Difference;
Difference;
Normative Data – For CKC Test
Kinesthetic/Proprioceptive Testing: ♂ <3 ± 2;
♀ <4 ± 3
Basic Measurements: < 10% Bilateral
Difference
Visual Analog scale (0(0-10): < 3
Functional Testing Algorithm –
Shoulder--1998
Shoulder
„
„
„
„
„
„
„
Sport Specific Testing
Functional Throwing Performance
Index
Closed Kinetic Chain – Upper
Extremity Stability Test
Isokinetic Testing
Kinesthetic/Proprioceptive Testing
Basic Measurements
Visual Analog scale
Functional Testing Algorithm –
Shoulder –
1998
2013
3
10/25/2013
Functional Testing Algorithm –
Shoulder -2013
„
„
„
„
„
„
„
„
„
„
Sport Specific Testing
Underkoeffler Overhand Softball Throw for
Distance
Functional Throwing Performance Index
1-Arm Seated Shot Put – Medicine Ball Power
Test
Closed Kinetic Chain – Upper Extremity
Stability Test
OKC 3
3--D muscle power testing – BBI
OKC Isokinetic Testing
Sensorimotor System Testing:
Kinesthetic/Proprioceptive Testing
Basic Measurements
Visual Analog scale
Functional Testing Algorithm –
Shoulder
„
„
„
Progression to the next higher level of
testing difficulty is predicated upon
passing the prior test in the series…
Each successive test and its associated
training regimen places increasing
stress on the patient while at the same
time decreasing clinical control
So how does it really work?
Functional Testing Algorithm –
Shoulder
Functional Testing Algorithm –
Shoulder -2013
„
„
„
„
„
„
„
„
„
„
„
Sport Specific Testing: Sport Specific Norms
Underkoeffler Overhand Softball Throw for Distance:
Norms
Functional Throwing Performance Index: ♂ 33
33--60%; ♀
17--41%
17
1-Arm Seated Shot Put – Medicine Ball Power Test: Norms
Closed Kinetic Chain – Upper Extremity Stability Test: ♂ 21
touches; ♀ 23 touches
OKC 33-D muscle power testing – BBI - Norms
OKC Isokinetic Testing: < 15% bilateral comparison
to perform FTPI
OKC Isokinetic Testing: < 25% bilateral comparison
to perform CKCUEST
Sensorimotor System Testing: Kinesthetic/Proprioceptive
Testing: ♂ <3 ± 2; ♀ <4 ± 3
Basic Measurements: < 10% bilateral comparison
Visual Analog scale: < 3/10
Within 151525%--YES
25%
We can rehabilitate patients
faster than ever because by
testing
g them,
them, we always
y know
where the patient is in the
rehab program and can focus
the interventions specifically
on the patient’s particular
condition and status
Focused
Rehab-Rehab
Isolated
Exercises
OKC Power
Testing
Within
10%-YES
10%-
NOT
Within
10%-10%
<3°
<3
°/<4
/<4°
°
Focused
Rehab-Rehab
Kinesthesia
SensoriSensorimotor
testing
Within
10%-YES
10%-
DC to
Sports
Within
10%-YES
10%-
NOT
Within
Norms
Focused
Specificity
Rehab
Specificity
Testing
Within Norms
Norms-YES
NOT
Within
Norms
Focused
Rehab-Rehab
Functional
OKC
Exercises
Functional
Testing
NOT
Within
10%
Focused
Rehab
Basic
MeasureMeasurements
Within 21/2321/23YES
NOT
Within
21/23
Focused
Rehab-Rehab
CKC
Exercises
CKC
Testing
Functional Testing Algorithm –
Shoulder
„
„
NOT
Within
15-25%
15-
„
„
Patient only progresses through
the level that is appropriate for
them
Not every patient performs every
test:
Ex: If the patient is not an
overhead athlete, then they may
not perform the last few tests in
the FTA
4
10/25/2013
Functional Testing Algorithm –
Shoulder -2013
„
„
„
„
„
„
„
„
„
„
Sport Specific Testing
Underkoeffler Overhand Softball Throw for
Distance
Functional Throwing Performance Index
1-Arm Seated Shot Put – Medicine Ball Power
Test
Closed Kinetic Chain – Upper Extremity
Stability Test
OKC 3
3--D muscle power testing – BBI
OKC Isokinetic Testing
Sensorimotor System Testing:
Kinesthetic/Proprioceptive Testing
Basic Measurements
Visual Analog scale
Basic Measurements
Time/soft tissue healing
„ VAS (0(0-10 scale) (<3+1)
„ Anthropometric measurements
„ AROM (<10%)
„ PROM
„ Core testing
„ LE
LE--Movement
assessment
„ Qualitative & Quantitative (Q &Q)
Movement assessment
„ Etc.
„
FTA – Shoulder -2013
2013--Modified
No Fancy Equipment Needed
„
„
„
„
„
„
„
„
„
„
Sport Specific Testing
Underkoeffler Overhand Softball Throw for
Distance
Functional Throwing Performance Index
1-Arm Seated Shot Put – Medicine Ball Power
Test
Closed Kinetic Chain – Upper Extremity
Stability Test
OKC 3
3--D muscle power testing – BBI
OKC Isokinetic Testing (MMT/HHD)
Sensorimotor System Testing:
Kinesthetic/Proprioceptive Testing
Basic Measurements
Visual Analog scale
Basic Measurements
„
„
„
„
„
PSM, 1981
Basic Measurements
Quantitative and qualitative movement
assessment (UE & LE) - FMS
FMS--???
„
Parchmann, CJ, et.al.
Parchmann,
Relationship between FMS and athletic
performance. JSCR.25:3378JSCR.25:3378-3384, 2011
„
No sign. Correlations between FMS and:
sprint time, 20
20--m sprint time, VJ height, agility TTtest time, club head velocity (D
(D--I golfers)
The lack of relationship suggests the FMS is not
an adequate field test and does not relate to any
aspect of athletic performance
If less 10% bilateral
difference, patient progresses
If greater than 10% bilateral
difference, then patient’s rehab
program is focused on the
specific parameter, i.e.,
swelling, ROM, etc.
Functional Testing Algorithm –
Shoulder -2013
Continuous
overlap of
Rehab
interventions
„
„
Continuous
overlap of
R h b
Rehab
interventions
„
Continuous
overlap of
Rehab
interventions
„
„
„
„
„
„
„
Sport Specific Testing
Underkoeffler Overhand Softball Throw for
Distance
Functional Throwing Performance Index
1-Arm Seated Shot Put – Medicine Ball Power
Test
Closed Kinetic Chain – Upper Extremity
Stability Test
OKC 3
3--D muscle power testing – BBI
OKC Isokinetic Testing
Sensorimotor System Testing:
Kinesthetic/Proprioceptive Testing
Basic Measurements
Visual Analog scale
5
10/25/2013
Functional Testing
Algorithm
JOSPT,
1993
kSensorimotor System
Testing:
Proprioception, Kinesthetic
Tests, AJR Testing, TSM,
End-ROM reproduction,
Movement screening tests
SHOULDER
KINESTHESIA
Functional Testing Algorithm
Test Protocol: Angular Joint
Replication
Testing
Goniometry
Lab
Tests
Clinical
Field
Tests
2003
Test Protocol: Angular Joint
Replication
A
Davies, GJ, et.al
JOSPT,
1993
Davies, GJ, et.al
JOSPT,
1993
6
10/25/2013
Why use OKC tests for the
U.E.?
3-D
Motion Analysis
Sensorimotor
System Testing
(Joint Reposition
Testing: concentric,
eccentric, dynamic)
Functional Testing Algorithm –
Shoulder -2013
„
„
„
„
„
„
„
„
„
„
Sport Specific Testing
Underkoeffler Overhand Softball Throw for
Distance
Functional Throwing Performance Index
1-Arm Seated Shot Put – Medicine Ball Power
Test
Closed Kinetic Chain – Upper Extremity
Stability Test
OKC 3
3--D muscle power testing – BBI
OKC (Muscle Testing) Isokinetic Testing
Sensorimotor System Testing:
Kinesthetic/Proprioceptive Testing
Basic Measurements
Visual Analog scale
REFERENCE
„
„
Lower-extremity compensations
Lowerfollowing ACL reconstruction
Ernst, GP, et.al. PT, 80:251
80:251--260, 2000
Purpose of performing OKC
Isolated muscle testing
„ Isokinetic
I ki ti
„
„
„
CKC (Multi
(Multi--joint)
or
Integrated
Approach
Functional Testing Algorithm
MMT -
„
„
Isokinetics – 1984 – 1994 (4 Editions)
Vertical Jump - No difference in
summated ext. moment
OKC testing - Knee extensor moment
significantly lower
Hip and/or ankle extensors
compensate for knee
Functional activity is the
key, but Function is made up of
individual “LINKS” in the
kinematic chain
HHD - Riemann, BL, Davies, GJ, et.al.
Hand--held dynamometer testing of the
Hand
i t
l and
d external
t
l rotator
t t
internal
musculature based on selected positions
to establish normative data and
unilateral ratios.
JSES. 19:117519:1175-1183, 2010
„
„
Dynamometry
Testing
T ti
How do you objectively measure
muscle performance?
„
OKC (Isolated)
VS
„ MMT
„ Handheld
EBP and KNEE TESTING
Testing
Lab
Tests
Clinical
Field
Tests
7
10/25/2013
MMT (static)
Vs
Isokinetic
Dynamic
Dynamometry
Testing
MMT
Vs
Isokinetic
Dynamic
Dynamometry
g
Testing
MMT:
•Subjective
•One point in ROM
•Does not correlate with
dynamic mm testing
•Static MMT does not
correlate with
dynamic functional tests
How do you measure ST
musculature?
How do you measure ST
musculature?
„
„
„
„
N=344 scapulo
scapulo--thoracic
tests
„
„
„
Purpose was to measure ST
protraction or retraction both
with and without the involvement
of the GH joint
Williams, D, Rousch
Rousch,, JR, Davies, GJ, et.al.
Alternative methods for measuring
scapular muscles protraction and retraction
maximal isometric forces
International J Sports Phys Ther
4:200--209, 2009
4:200
„
„
1720
tests
Turner, N,….Davies, GJ. Establishing
normative data on scapulothoracic
musculature using handheld
dynamometry.
J Sport Rehab. 18:50218:502-518, 2009
How do you measure ST
musculature?
„
ScapuloScapuloThoracic
HHD
Testing
Handheld Dynamometry
„
„
„
„
How do you measure ST
musculature?
„ Intra
Intra--session
reliability –
ICCs:0.95-0.98
ICCs:0.95„ Inter
Inter--session reliability –
ICCs; 0.94
0.94--0.96
„ With
GH always had higher
values, but not SS
Rank order: UT, SA, MT, R, LT
Unilateral Ratios:
Elevation/depression (UT/LT):
2.62
Protraction/retraction (SA/R):
1.45
UR/DR (SA/MT):
1.23
181 SUBJECTS
R + L SIDES
IR + ER
3 Positions =
2172 Tests
Riemann, BL, Davies,
GJ, et.al.
J Shoulder Elbow
Surg
19:1175--1183, 2010
19:1175
8
10/25/2013
How do you measure
GH/RTC musculature?
HHD - ER
„
„
HHD - Riemann, BL, Davies, GJ, et.al.
Hand-held dynamometer testing of the
Handi t
internal
l and
d external
t
l rotator
t t
musculature based on selected positions
to establish normative data and
unilateral ratios.
JSES. 19:117519:1175-1183, 2010
„
Isokinetics – 1984 – 1994 (4 Editions)
„
Functional Testing Algorithm
First Book
Published on
Isokinetics
Davies, GJ. A Compendium of
I ki ti in
Isokinetics
i Clinical
Cli i l Usage.
U
S&S Publishers, LaCrosse
LaCrosse,, WI.,
kOKC Isokinetic Dynamic Muscle
Performance Tests
Shoulder isokinetic testing
„
„
Computerized Cybex 340
Isokinetic Dynamometer and
attachments (CSMI,
Stoughton, MA)
JAT,
2000
1984
Isokinetic
Testing
Peak torque of concentric
shoulder internal and external
rotators at 300 /second
„
4 gradient warm ups
„
5 maximal repetitions at
60/180/300 /second
„
MMT -
Total arc of motion=140
– ER = 80
– IR = 60
Davies, GJ. Compendium,
1984
9
10/25/2013
Isokinetics
„
„
„
„
„
„
„
•Bilateral comparison
•Unilateral ratio of agonist/antagonist
•Torque to body weight (relative/normalized data)
•TAS, TBS
•Angle specific torques
•TAE/TRTD
•Endurance analysis
<25 %
•Normative data
CKC Tests
< 15 %
•Functional correlation
FTPI
•Sport specific correlation
Isokinetics
Zebis, MK, et.al. Rapid hamstring/quadriceps
Zebis,
force capacity in male and female elite soccer
players. JSCR. 25:198925:1989-1993, 2011
„
„
„
(Davies, GJ, A Compendium of Isokinetics, 1984, 1992)
Data Analysis
87 articles reviewed
Results:
Isokinetic evaluation of the shoulder is
valid
Reliability is satisfactory with rigorous
test methodology
Normal values are dependent on several
variables: age, gender, BMI, type and
intensity of activity
Isokinetics
„
Data Analysis
Isokinetic
Codine, P, et.al. Isokinetic strength
Codine,
measurement and training of the
shoulder: methodology and results. Ann
Readapt Med Phys 48:8048:80-92, 2005
Although maximal muscle strength has often
been used to evaluate muscle ratios, the ability
p y develop
p force ((RFD)) is more relevant
to rapidly
in relation to fast dynamic movements.
The high reliability of the new rate of force
development (RFD) H/Q strength ratio
indicates the method is a clinical relevant tool
in standardized clinical evaluation of the knee
joint agonist
agonist--antagonist relationship.
„
Davies, et.al, Research in progress - 187
subjects. 2012
Although maximal muscle strength has often
been used to evaluate muscle ratios, the ability
to rapidly develop force (RFD) is more relevant
in relation to fast dynamic movements.
The high reliability of the new rate of force
development (RFD) H/Q strength ratio
indicates the method is a clinical relevant tool
in standardized clinical evaluation of the RTC
joint agonist
agonist--antagonist relationship.
„ Replicating
IR/ER
data for RTC –
Isokinetics
„
„
„
Hurd, WJ, et.al. The effects of anthropometric
Hurd,
scaling parameters on normalized muscle
strength in uninjured baseball pitchers.
J Sport Rehab. 20:31120:311-320, 2011
Muscle force must be normalized for
between--subjects comparisons of
between
strength
h to b
be valid
lid
„
„
1984
Using body weight (BW) to scale muscle
force was the most effective
anthropometric parameter for
normalizing strength values based on
the group of statistical measures of
variability
Isokinetics
„
„
„
„
Hurd, WJ, et.al. The effects of anthropometric
Hurd,
scaling parameters on normalized muscle
strength in uninjured baseball pitchers.
J Sport Rehab. 20:31120:311-320, 2011
This study provides objective support for
scaling muscle strength to subject BW
This approach to normalizing muscle strength
uses methods readily accessible to clinicians
and researchers and may facilitate the
identification of differences in strength
between individuals with diverse physical
characteristics
10
10/25/2013
Isokinetic velocity spectrum
power profile testing of the
shoulder muscles
Functional Testing Algorithm
Rex,at.al. In search of the “GOLD STANDARD”
for power testing of the upper extremity.
Searching for reliable, valid, responsive,
minimal equipment needed, easy to administer
UE power test that can be used as a field test.
Compared and looking for correlations between:
1) force plate kinetics
2) CKCUEST
3) velocity spectrum power profile isokinetic
testing of the shoulder muscles
4) seated shot put power test
5) upper extremity dynamic balance test.
What is the Correlation
to Functional Ability?
Speed
Peak Torque
Power
60 °/ sec
100 ft. lbs. =
6000
90 °/ sec
90 ft. lbs. =
8100
120 °/ sec
80 ft.
ft lbs.
lbs =
9600
150 °/ sec
70 ft. lbs. =
10,500
180 °/ sec
60 ft. lbs. =
10,800
210 °/ sec
50 ft. lbs. =
10,500
240 °/ sec
40 ft. lbs. =
9,600
270 °/ sec
30 ft. lbs. =
8,100
300 °/ sec
20 ft. lbs. =
6,000
Isolated Training
& Correlation to Functional
Performance
Ellenbecker,, Davies,
Ellenbecker
Davies et al,
al AJSM,
AJSM 1988
Mont, et al, AJSM, 1994
Treiber, et al, AJSM, 1998
Davies, et.al., Shoulder & Elbow, 2011
Functional Testing Algorithm –
Shoulder -2013
„
„
„
„
„
„
„
„
„
„
Functional Testing Algorithm –
Shoulder -2013
„
„
„
„
„
„
„
„
„
„
Sport Specific Testing
Underkoeffler Overhand Softball Throw for
Distance
Functional Throwing Performance Index
1-Arm Seated Shot Put – Medicine Ball Power
Test
Closed Kinetic Chain – Upper Extremity
Stability Test
OKC 3
3--D muscle power testing – BBI
OKC Isokinetic Testing
Sensorimotor System Testing:
Kinesthetic/Proprioceptive Testing
Basic Measurements
Visual Analog scale
Why use CKC tests for the
U.E.?
Sport Specific Testing
Underkoeffler Overhand Softball Throw for
Distance
Functional Throwing Performance Index
1-Arm Seated Shot Put – Medicine Ball Power
Test
Closed Kinetic Chain – Upper Extremity
Stability Test
OKC 3
3--D muscle power testing – BBI
OKC Isokinetic Testing
Sensorimotor System Testing:
Kinesthetic/Proprioceptive Testing
Basic Measurements
Visual Analog scale
11
10/25/2013
Functional Testing Algorithm
Testing
Ortho PT Clinics
North America
2000
Lab
Tests
Clinical
Field
Tests
Functional Testing
Algorithm
2000
„
„
kClosed Kinetic Chain
Upper Extremity
Stability Test (Dynamic)
„
„
ICCs:
.922
(CKCUEST)
CKC Upper Extremity
Stability Test
CKC UE Stability Test
2000
„
CKC UE Stability Test
CKC UE Stability Test
„
„ Males
– 21 touches
– 23 touches
„ --------------------------------
„
„ Females
„ ICC’s
- > .922
Line 3 feet apart
4 gradient sub
sub--max to max warm
warm-ups
Males--pushMales
push-up position; femalesfemalesknees
Touch both hands to each line as
many times as possible in 15
seconds
3 tests, average scores
„
Conclusion:
The CKCUEST appears to be a
clinically useful test for UE function.
Rousch, JR, et.al. reference values for
Rousch,
the CKC Upper Extremity Stability
Test (CKCUEST) for collegiate
baseball players.
International J Sports PT. 2:159
2:159--163,
2007
12
10/25/2013
CKC UE Stability Test
Pontillo, M, et.al. Prediction of inPontillo,
inseason shoulder injury from
preseason testing in DD-I collegiate
football players.
JOSPT. 42:SPL4,, 2012
Sweeny, AE, et.al. ReturnReturn-to
to--sport
rehabilitation for a rugby athlete
following posterior shoulder
stabilization procedure.
JOSPT. 42:SPL18, 2012
13