Clinical Assessment of Upper Extremity Injury Outcomes

Transcription

1 Journal of Sport Rehabilitation, 2011, 20, Human Kinetics, Inc. Clinical Assessment of Upper Extremity Injury Outcomes Charles Thigpen and Ellen Shanley Patient Scenario: The patient presented is a high school baseball pitcher who was unable to throw because of shoulder pain. He subsequently failed nonoperative management but was able to return to pitching after surgery and successful rehabilitation. Clinical Outcomes Assessment: The Disabilities of Arm, Shoulder and Hand (DASH) and the Pennsylvania Shoulder Score (PENN) were selected as clinical outcome assessment tools to quantify the patient s perceived ability to perform common daily tasks and sport tasks and current symptoms such as pain and patient satisfaction. Clinical Decision Making: The DASH and PENN provide important information that can be used to target specific interventions, set appropriate patient goals, assess between-sessions changes in patient status, and quantify patients functional loss. Clinical Bottom Line: Best clinical practice involves the use of clinical outcome assessment tools to garner an objective measure of the impact of a patient s disease process on functional expectations. This process should facilitate a patient-centered approach by clinicians while they select the optimal intervention strategies and establish prognostic timelines. Keywords: case report, return to play, shoulder Pitching overuse injuries are common, costly, and debilitating in professional baseball. More than 60% of baseball pitchers report shoulder or elbow pain that has limited their participation during their career. 1,2 Aggregate disability data from 1989 to 1998 (American Specialty Insurance-Redbook) suggests that pitching injuries account for 50% of baseball injuries, with approximately 70% of these injuries occurring to the throwing shoulder and elbow in Major League Baseball, resulting in an estimated $1 billion in disability payments. 2,3 Pitching injuries are attributed primarily to mechanisms of overuse related to factors such as increased pitch counts, certain pitch types, and poor pitching mechanics. 4 7 However, pitching injuries appear to continue to increase in spite of regimented monitoring of pitching schedules and pitch counts in professional baseball. This suggests that just reducing exposure is not the solution to decreasing injury risk in pitchers. Physical factors are also implicated, including glenohumeral internal-rotation loss, posterior shoulder tightness, and decreased humeral retroversion. 4,8 10 Alterations in the physical characteristics of the thrower s shoulder are thought to be the result of repetitive overhead use. 4,5 Based on these results, The authors are with Proaxis Therapy, Greenville, SC. 61

2 62 Thigpen and Shanley deficits in internal rotation greater than 20 without concurrent increases in external rotation are thought to be based on soft-tissue tightness and to be potentially pathological. 10,11 13 These alterations should be considered in the development of the rehabilitation plan. In addition to physical impairments, patient-oriented outcome assessments are advocated to guide treatment decisions, determine prognosis, and aid in clinical judgments of the response to treatment. 14,15 The use of patient-oriented outcomes facilitates a patient-centered process not only focusing on a patient s diagnosis and related impairments but also recognizing the effects of the disease process on the whole person by placing the patient condition in the context of individual expectations for function and ability. 16 The following patient scenario will provide an example of how patient-oriented clinical outcomes tools can help guide the rehabilitation of an athlete with an upper extremity injury. Patient Scenario A 17-year-old male right-hand pitcher preparing for his senior baseball season was referred by a board-certified, fellowship-trained orthopedic surgeon for physical therapy. The medical record revealed that the athlete had received a subacromial cortisone injection 5 days earlier and that he was diagnosed with internal impingement and glenohumeral internal-rotation deficit. The athlete s medical history was unremarkable on intake examination and questioning. He completed the Disabilities of Arm, Shoulder and Hand (DASH), the DASH Sports Module (DASH-SM), and the Pennsylvania Shoulder Score (PENN), all patient-based outcomes instruments. The athlete presented with complaints of increased right shoulder pain and decreased pitching velocity over the preceding month. He reported that his preinjury fastball velocity was in the high 80s to low 90s miles/h and indicated that he has been throwing a circle change and curveball over the past 3 years. In addition, the athlete reported mild right elbow pain and minimal numbness in his fourth and fifth digits within the past year. Pain at night prevented him from sleeping on the right (injured) shoulder, and while pitching his average pain was reported as an 8/10 on the visual analog scale (0 10). Since the cortisone injection, pain at rest had decreased by 2 points, improving from 4/10 to 2/10 over the preceding 5 days. The athlete stated that he was unable to pitch because of posterior shoulder pain in the late cocking phase of the throw and a general dead arm feeling associated with throwing. Further questioning revealed that he experienced very sharp and deep pain at the maximum cocking position during his throwing motion, with dull aching and shoulder weakness after throwing sessions. Selected examination characteristics are reported in Table 1. The athlete s primary goals were to decrease his shoulder pain at night and return to pitching at his previous level. Based on his age, goals, injury, medical history, results of the DASH and PENN, and physical examination we believed his prognosis to reach his goals with successful rehabilitation was good (Figure 1). A nonoperative approach was agreed on by the sports-medicine team (patient, family, physical therapist, athletic trainer, and physician) based on the athlete s goals and recent research suggesting that even isolated labral injuries in pitchers may negatively affect their postoperative performance. 17

3 Table 1 Nonoperative Selected Physical Examination and Patient Self-Report Outcomes Initial examination Nonoperative week 12 Function and Outcomes Patient-identified Inability to sleep undisturbed (on throwing side), inability Inability to throw without pain and with power functional loss to throw without pain and with power DASH 23 (items 14, 18, 19, 23, 25, 28, and 29) 9 (19, 23, and 25) DASH Sport Module PENN pain (30) 20 (67%) 20 (67%; no change in strenuous-activities pain) satisfaction (10) 0 0 function (60) 48/60 = 80% 54/60 = 90% Other Unable to tolerate resisted-activities ER/IR between 10 and 2 o clock in the 90 abducted position Physical Examination General Forward head, scapula internally rotated and elevated Forward head, scapula internally rotated and elevated Sensation/Reflexes Normal/Symmetrical Normal/Symmetrical ROM Symmetrical overhead elevation and ER at the side Symmetrical overhead elevation and ER at the side Rotational PROM L = 170 (95 ER, 75 IR), R = 144 (90 ER, 54 IR); 170 bilaterally; L 95 ER/75 IR; R 90 ER/80 IR pain with end ROM and during transition from ER/IR motion Strength tested Posterior rotator cuff = 4/5 Posterior rotator cuff = 4+/5 against gravity at 0 and 90 Myotomal testing (C6-T1) 5/5 5/5 Special tests + Hawkins Kennedy Impingement sign; + relocation test for pain; + crank test; obvious scapular dyskinesis (Tate) + relocation test for pain; + crank test; subtle scapular dyskinesis (Tate) DASH, Disabilities of Arm, Shoulder and Hand; PENN, Pennsylvania Shoulder Score; ER, external rotation; IR, internal rotation; ROM, range of motion; PROM, passive ROM; L, left; R, right; +, positive. 63

4 64 Figure 1 The International Classification of Function model promotes optimal patient-centered care by focusing on all factors that may influence a person s desired level of activity.

5 Assessment of Upper Extremity Outcomes 65 Clinical Outcomes Assessment There are a wide variety of published patient-oriented outcomes and functional measures available with established measurement properties to assess shoulder function and disability, including the American Shoulder and Elbow Score, UCLA Shoulder Scale, Simple Shoulder Test, and Western Ontario Shoulder Instability Index, so selecting an instrument is difficult Recent studies of patient-rated measures of shoulder functional loss and disability in patients with instability or undergoing shoulder surgery indicate that one measure is likely not superior to another. 18,24 In addition, optimal patient-oriented care should consider impact on total health status using tools such as the Short Form-12 (SF-12). 25 The SF-12 s physical component scale (PCS) has been shown to correlate to DASH scores. For our patient case, we were most interested in evaluating the patient s perception of pain, function, disability, and satisfaction. As a result, we evaluated the specific questions on several instruments and found that the SF-12, DASH, and PENN contained questions that most closely addressed these areas. The SF-12 was selected to assess the athlete s general health status; in particular, we monitored the PCS portion. We also selected the DASH, DASH-SM, and PENN as outcome assessment tools. The SF-12 provides insight on the impact of patients physical impairment on their general health status, and 2 subcategories of the PCS and mental component status reflect emotional well-being. The DASH is a region-specific outcome measurement tool that is widely used in rehabilitation medicine and has been validated across a wide range of populations Using the DASH, patients evaluate their arm, shoulder, or hand conditions based on perceived ability to perform common daily tasks and sport tasks, as well as current symptoms. In terms of disablement models, the DASH investigates the areas of body structures and functions (ie, impairments), activity (ie, functional limitations), and participation (ie, disability), helping provide a more holistic evaluation of the injury. Several studies have investigated the reliability and responsiveness of the DASH after rehabilitation and surgery, 27 with values ranging from 40% to 75% in patients with shoulder dysfunction and a score >90 considered normal responsiveness in patients after rehabilitation and surgery. 27,29 The DASH-SM is similar and asks questions specifically related to the individual s sport participation, providing a separate measure of perceived sport function. The PENN is a joint-specific outcome assessment tool that contains 3 subscales related to pain, satisfaction, and function and 1 aggregate, or total, score. The PENN also includes questions related to body structure and functions, activity, and participation. The PENN, like the DASH, has been validated across a variety of shoulder disorders and demonstrates good responsiveness. 30 The PENN and the DASH were chosen because of the extensive body of literature supporting their use for upper extremity injuries and their well-established measurement properties that support clinical decision making. However, it should be noted that in a recent study of college athletes, the DASH was shown to suffer ceiling effects, which may limit the instrument s validity in high-demand athletic populations. 31 Therefore, a sport-specific upper extremity outcomes instrument should also be considered when evaluating high-demand overhead athletes. 32,33 The minimal detectable change (MDC) was considered in selection of both instruments. The MDC is important because it provides the amount of change in

6 66 Thigpen and Shanley score that is beyond measurement error and is crucial for interpreting scale scores. The MDC for the DASH is 13%, but there is no reported MDC for the sport module alone. 27,30 The MDC for the aggregate total PENN score is 12 points: 5 points for the pain section, 2 points for the satisfaction section, and 9 points for the function section. 30 Although there are no published normative data for specific shoulder diagnoses, the DASH and PENN used in a wide range of shoulder conditions displayed similar MDC values for low- and high-functioning patients. In addition to the scores from the DASH and PENN, these questionnaires provide rich information about the patient s condition. We suggest briefly reviewing the questionnaires before the patient interview to help guide the interview and allow for more specific questions that may help you understand the patient s current complaint and expectations. For example, our patient indicated high disability related to pain when sleeping. On further questioning he revealed he prefers to sleep on his throwing side with his arm in an abducted and externally rotated position. After the physical examination, we recommend identifying relationships between impairments with specific items from the DASH and PENN. We believe that this allows for prioritization of impairments and formulation of the most effective treatment plan with targeted interventions. Finally, careful review of the DASH and PENN items considered with findings from the physical examination will help clarify the patient s prognosis. For example, our athlete interview and review of outcome tools revealed the late cocking position during sport and sleeping position as the athlete s most significant functional limitation. The physical examination findings with the best clinical correlation to these were posterior shoulder tightness and pain level. Therefore, our initial interventions focused on improving the athlete s internal rotation and horizontal adduction, as well as modifying his sleeping posture. Although we could have reached this process without the outcome measure, the outcome measure provides a consistent method of making the most appropriate patient-specific rehabilitation diagnosis, intervention plan, and prognosis. Several limitations to the outcome tools selected should be noted. First, the sensitivity of the DASH and PENN to changes in our patient s function made it difficult to use for shorter between-sessions changes. This is important because betweensessions changes should be a primary consideration in selecting and modifying treatment strategies. In a similar manner our patient scored nearly perfectly on the DASH and PENN before he completed his interval-throwing program. At this point in the patient s progression we used the DASH-SM and PENN patient-satisfaction subscale as indicators that his interval-throwing program was progressing normally. Therefore, aggregate scores from the DASH, DASH-SM, and PENN or other currently available tools may not be appropriate for return-to-play decisions. In addition, it is important to remember in return-to-play decisions that these 2 region-specific tools do not fully assess patients health-related quality of life and potential impact that the shoulder injury may have on their overall health status. Thus, use of tools that reflect overall health status, such as the SF-12, should be considered. Clinical Decision Making Identified impairments that were most related to the patient s pain and inability to pitch were decreased posterior shoulder mobility, decreased posterior and inferior glenohumeral glides, and poor scapular control. The patient was treated 8 times.

7 Assessment of Upper Extremity Outcomes 67 Improvements were noted in his rotational range of motion, and posterior and inferior glides on the injured shoulder returned to normal (Table 1). In addition, the patient demonstrated an improvement in scapular control and rotator-cuff strength. However, he remained unable to throw a baseball or exercise at the maximum external rotation in abduction secondary to a deep pain and a clicking sensation. The inability to work in this position negatively affected the athlete s ability to play baseball; he could not tolerate or generate power through his pitching motion. Although he demonstrated a significant improvement in measures of symptoms and body function per the DASH (23% to 9%), DASH-SM (100), and PENN (67%), his level of participation in functional activities remained diminished. His score on the SF-12 PCS was 50%, suggesting that his physical limitations were affecting his physical health status. Based on these he was referred back to the surgeon for further consultation.(table 1). On return to the orthopedic surgeon approximately 12 weeks postinjury, the patient and family agreed that a diagnostic arthroscopy was the next step toward identifying and eliminating pathology in the hope of recovering maximum function in the arm and participation in the sport. Surgical repair of the posterior labrum with a concurrent anterior capsular shift procedure was performed. The athlete began physical therapy on the first postoperative day. During this first therapy visit, SF-12 PCS (90%), MCS (60%), DASH (90%), DASH-SM (100%), and PENN (0) outcomes instruments were completed and goals were set with the athlete, using items from the outcomes instruments as a guide for the treatment plan. The athlete s initial goals targeted ease of self-care and comfort, which were estimated as attainable within the first 6 weeks. The patient identified his long-term goal as returning to pitching without pain or limits, which was estimated as attainable within 6 months. The patient progressed through each early phase of rehabilitation unremarkably with a reduction in impairments and improvement in function as recorded by the serial SF-12 PCS (70%), MCS (60%), DASH (9%), DASH-SM (100), and PENN (78%) scores reflecting clinically meaningful improvement in health status and outcome scores: Change in the DASH indicated a 91% decrease in disability, and in the PENN, a 78% increase in ability (Table 2). The patient satisfaction scores measured by the PENN satisfaction subscale progressed more slowly, as demonstrated by initial and follow-up scores of 0/30, 20/30, and 30/30. The satisfaction subscore (from 0/10 to 6/10 to 10/10) and SF-12 MCS (60%) were helpful because they were used to create open dialogue with the patient and served as a talking point to address questions of prognosis and deal with the athlete s fears about recovery and return to full participation. The athlete was noticeably anxious to resume baseball activities around postoperative week 12 as baseball season approached. The patient satisfaction score, measured by the PENN satisfaction subscale, demonstrated a slower progression as illustrated by a consistent score of 30, as well as the SF-12 MCS being 40%, compared with the PENN function subscale of 78% and the DASH of 9%. These values suggest that although function was improving and disability was decreasing, the athlete remained dissatisfied with the performance of his of his throwing arm and it affected his mental status relative to his expectations. In addition, although the athlete was gradually returning to hitting and progressing with an intervalthrowing program, he reported that he had stopped attending practice and was not going to play baseball this season. He missed several physical therapy appointments

8 Table 2 Postoperative Selected Physical Examination and Patient Self-Report Outcomes Postoperative week 1 Postoperative week 12 Postoperative month 5 Function and Outcomes Patient-identified functional loss Dependent in all ADLs secondary to pain, loss of ROM and strength, dependent in driving, unable to participate in team activities Independent in basic ADLs and household activities, independent in school activities, independent in driving DASH DASH Sport Module 100 (unable to participate in high school baseball) 100 (unable to participate in high school baseball) PENN pain (30) satisfaction (10) function (60) 0 47/60 = 78% 58/60 = 97% Other Unable to tolerate resisted activities, ER/IR between 10 and 2 o clock in the 90 abducted position (continued) 68

9 Table 2 (continued) Postoperative week 1 Postoperative week 12 Postoperative month 5 Physical Examination General FHP, sling-dependent posture, unremarkable cervical scan Sensation/Reflexes Decreased sensation at arthroscopic port sites; otherwise normal/symmetrical ROM Cervical ROM, WFL and nonpainful; shoulder elevation 90 and 0 of ER at the side FHP, scapula neutral position + dynamic control, unremarkable cervical scan FHP, scapula neutral position + dynamic control, unremarkable cervical scan Normal/Symmetrical Normal/Symmetrical Rotational PROM Not measured per protocol 170 L (95 ER, 75 IR); 160 R (100 ER, 60 IR) Strength tested against gravity at 0 and 90 Myotomal testing (C6-T1) WFL and symmetrical bilaterally WFL and symmetrical bilaterally 170 L (95 ER, 75 IR); 160 R 100 ER, 60 IR) Not measured per protocol Posterior rotator cuff = 4+/5 Posterior rotator cuff = 5/5 Not measured per protocol 5/5 5/5 Special tests Postoperative day 1 Negative for all special tests Negative for all special tests ADLs, activities of daily living; ROM, range of motion; DASH, Disabilities of Arm, Shoulder and Hand; PENN, Pennsylvania Shoulder Score; ER, external rotation; IR, internal rotation; FHP, forward head posture; WFL, within functional limits; PROM, passive ROM; L, left; R, right; +, positive. 69

10 70 Thigpen and Shanley and his grandmother (his guardian) called the therapist to report that her grandson seemed extremely down. The low satisfaction and MCS subscore, along with his missed appointments, were helpful in initiating open dialogue with the patient and addressing questions of prognosis to deal with his fears about recovery and return to full participation. The pitcher returned to therapy at the urging of his family and coach, and a plan was established to involve him in more team activities. He began batting in early February and playing in games as the designated hitter by the end of that month. An interval-throwing program was initiated in early March, and the athlete advanced to bullpen sessions in May. His throwing progress was slowed by minor painful episodes, but, overall, he progressed through the remaining interval-throwing program without incident. On discharge from formalized therapy, the patient had returned to full participation. He was satisfied with his recovery as indicated by his PENN satisfaction subscale score of 10/10 and SF-12 score of 100% and was confident that with continued competition he would regain his full form. He also resumed his normal participation in practice and playing first base on days when he was not pitching. He reported no pain with hitting, fielding, or throwing. We chose to use the DASH and PENN; although the instruments capture similar disablement-model components, they address these areas differently. For example, the PENN has separate subscales for pain and satisfaction, and the DASH does not. These subscales allow the clinician to obtain greater insight into the progression of pain the patient experiences, as well as capture the satisfaction that the patient has with the injured body part. In our case scenario, these 2 subscales were integral to our understanding of the patient s health status and provided useful information to assist in directing patient care. Specifically, the PENN provides an aggregate score and 3 subscale scores related to shoulder function, pain, and patient satisfaction. We believe that the pain and satisfaction subscales identify important information for clinical prognosis and intervention in patients with shoulder pain. The pain score is a combination of 3 pain scores indicating shoulder pain at rest, during usual activities, and during strenuous activities. The patient satisfaction score provides an indication of how pleased patients are with their current shoulder function related to their expectations. We believe that this is important in athletes because of the likely ceiling effects of the function portion of the DASH and PENN. The addition of the DASH-SM allows the clinician to evaluate the injury in terms of its impact on sports activities. Because our patient is a baseball player, we felt it important to measure the impact of his shoulder injury on his ability to continue participation as a baseball player. By including this subscale, we were able to quantify the impact of our patient s injury on his sport performance, as well as his progression in his long-term goal of return to pitching.for our baseball athlete, we chose to administer the DASH, DASH-SM, and PENN at 2- to 4-week intervals to measure change over time. We administered the measures at 2 weeks early on in treatment, both nonoperatively and postoperatively, when we expected relatively quick improvements in scores, but as overall improvement reached maximum scores we increased the interval to 4 weeks. The DASH and PENN were used in 3 ways. First, as we have described, the DASH and PENN scores provided data that allowed for targeting specific interventions and for goal setting. In addition, these instruments were used to discuss and clarify patient goals and to identify the patient s response to intervention. Between-sessions changes aided in adjusting the treatment plan during both the presurgical and the postsurgi-

11 Assessment of Upper Extremity Outcomes 71 cal intervention periods. Although some of the impairments had improved it did not result in a change in the patient s perception of functional loss as demonstrated by serial PENN and DASH scores. However, the patient s perception of functional loss and lack of improvement demonstrated by serial PENN and DASH-SM was used as a portion of the decision algorithm for the team (patient, family, physical therapist, athletic trainer, and physician) to proceed with surgical intervention. Summary Clinical outcome assessment tools provide clinicians with objective information to assess the impact of a patient s disease process on his or her expectations for function and ability. Integration of these tools is the standard of best clinical practice, allowing for clinical expertise to assess the best evidence and choose the appropriate intervention in the context of an individual patient. This is important in sport rehabilitation because these patients have very high expectations of return to sport that must be balanced against the disease process with which they are coping. The clinical outcome assessment tools currently available do have limitations that should be recognized; in particular, they are not disease specific and there are limited reports of their use in athletes. In addition, current validated tools do appear to have a ceiling effect that should be considered in their use. 31 Even so, these tools provide valuable clinical information for the prognosis and clinical decision-making process for sport rehabilitation patients. Sport-specific clinical outcomes instruments should be developed for high-demand athletic patients. Acknowledgments This article is part of a special issue of JSR on clinical outcomes assessment. References 1. Alberta FG, ElAttrache NS, Bissell S, et al. The development and validation of a functional assessment tool for the upper extremity in the overhead athlete. Am J Sports Med. 2010;38(5): Beaton DE, Katz JN, Fossel AH, Wright JG, Tarasuk V, Bombardier C. Measuring the whole or the parts? validity, reliability and responsiveness of the DASH outcome measure in different regions of the upper extremity. J Hand Ther. 2001;14(2): Boissonnault WG, Badke MB, Wooden MJ, Ekedahl S, Fly K. Patient outcome following rehabilitation for rotator cuff repair surgery: the impact of selected medical comorbidities. J Orthop Sports Phys Ther. 2007;37(6): Borsa PA, Laudner KG, Sauers EL. Mobility and stability adaptations in the shoulder of the overhead athlete: a theoretical and evidence-based perspective. Sports Med. 2008;38(1): Burkhart SS, Morgan CD, Kibler WB. Shoulder injuries in overhead athletes. the dead arm revisited. Clin Sports Med. 2000;19(1): Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology part III: the SICK scapula, scapular dyskinesis, the kinetic chain, and rehabilitation. Arthroscopy. 2003;19(6): Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology. part II: evaluation and treatment of SLAP lesions in throwers. Arthroscopy. 2003;19(5):

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