PT 🦀 Issue 134 - Shoulder Arthritis CPG

What up y’all,

This week, I was really excited to see a new CPG from PTJ about PT management of GH joint OA. I think that’s the most acronyms I’ve ever used in one sentence. Ever.

Anyway, after reading through the CPGs published in April, I came away less impressed than I went in. Honestly, I was a bit surprised that it was published at all since it seems a bit light on research and premature. But I’ve often said that my role in PT Crab is (largely) not to criticize research. I’m not an expert. Rather, I find experts and journals that I trust and then I trust them. It’s not what they teach you in school, but it’s all I have time to do. I’m a firm believer that PTs shouldn’t have to figure out what articles to trust, tear them apart bit by bit, and analyze them to see if they’re useful. What are we paying the journals all this money for if that’s not it? With that in mind, I’m presenting to you these GHOA CPGs uncommented upon, mostly.

This is also a good time to remind everyone that there’s a full(ish) list of PT clinical practice guidelines available on the PT Crab website, easier to find than literally anywhere else. They’re not protected by a paywall or a login, it’s just a list of direct links to 47 clinical practice guidelines (or similar articles) dating back to 2013. You won’t find an easier to use list anywhere and I recommend you download all the CPGs you can since I don’t trust the journals to leave them up and neither should you.

Now, all that being said, let’s dive in!

What should we do with a broken shoulder? What should we do with a broken shoulder? What should we do with a broken shoulder early in the morning?

The Gist - We should probably save their belly with a rusty razor.

Anyway, I’ve been listening to too many sea shanties because they’re really good for long runs and bike rides. But let’s talk about what these clinical practice guidelines say we should do with people who have glenohumeral osteoarthritis.

While it’s advertised as an article about GHOA, it really turns out to be about total shoulder replacement since the evidence they could find for other elements was nil. The areas of insufficient evidence include “Preoperative physical therapy for patients scheduled for TSA”, “Nonoperative physical therapy comparison to other management strategies”, “Nonoperative physical therapist intervention options”, “Postoperative physical therapy outcomes”, and “Postoperative physical therapy edema management”.

We do actually have evidence for a few useful things, including that MRIs are great for diagnosis (duh), history + physical exam + radiographs are pretty good for diagnosis (no surprise here), that we should use a sling and progressive ROM exercises post-op for TSA (more on that soon) and that post-op PT helps with pain management and doesn’t need to start until week four.

I’m going to expand on those last two. First, there’s a high quality study that showed that people who were randomized into immediate motion vs. delayed motion (4 weeks in a sling) turned out about the same after 1 year while another study showed that people immobilized in slings for 6 weeks had better pain, ROM, and patient-reported outcome measure results, including better ROM at 1 year when they used a neutral shoulder position sling.

Going out of the study here for a second, the last clinic that I worked at was a physician-owned practice that sent patients for sling fits a few weeks before rotator cuff surgery. As a PT in that situation, it was pretty cool to get to spend 45 minutes teaching how to get a sling on and off and talking about the first few weeks after surgery. I know that patient who hadn’t had sling fits were consistently mis- or ill-informed about the rehab process, so it was nice to get them ahead of time. Idk how we billed for it though so your mileage may vary if you’re interested in it.

To get back in, here’s how the researchers closed that section

There is no harm in ROM and functional outcomes (ASES) with delayed ROM (4 weeks) compared with immediate active assistive ROM exercises with follow-up at 6 months and 1 year. While earlier gains in ROM can occur when ROM exercises are initiated immediately postoperative, there is a small risk for adverse healing of subscapularis with immediate ROM versus the delayed group following TSA.

Tell Me More - Let’s talk timing. This is closely related to the bit above and idk why they separated them, but they did. I already said I’m not going to criticize this paper, so 🤷 it is what it is. One high-quality study was available here that demonstrated patient-reported outcome measures are no worse in people who do 4 weeks of sling use with no ROM vs. those who do. The immediate motion group was better in the first couple of months, but the gap closed by the end. Concerningly, 5 of the 27 people in the immediate ROM group had trouble healing their lesser tuberosity osteotomy while only 1 of 28 in the delayed group did. The researchers are careful to say “although this study is related to shoulder exercises, this does not preclude the need for exercising the other upper quadrant muscles and joints, such as neck, elbow, and hand.” They’re not saying no PT, they’re saying no shoulder PT. As someone who treated a patient this spring with an elbow flexion contracture after TSA because they were just told not to move at all (ick, I know), this is a really important point.

So what have we learned today? Well, mostly that this CPG was probably premature since we don’t have too much research to go on. But it was done by the foremost in this area, so it is indeed the best we have. Overall, we have some info on being careful in the first few weeks after post-op, which isn’t nothing since immediate motion has been pushed a lot recently and it seems that the research has caught up to say we’re good to wait a month. The use of a neutral position sling, rather than an internal rotation one, is good too, though PTs often don’t have much control over that, so your mileage may vary.

We’ve also learned that you can get access to many more CPGs (46ish more) at PTCrab.org/clinical-practice-guidelines and you can let me know if I’m missing any. I know I don’t have the one about return to work after rotator cuff tears b/c it’s paywalled by JOSPT (booo!) but otherwise I think I have pretty much all of them. Go look!

With that, here’s a link to this one on that page: https://ptcrab.org/clinical-practice-guidelines/#upper-limb

I’m going to spend a bit more time here to draw your attention to some of my favorite resources from that page. First up, this Core Set of Outcome Measures for Adults with Neurologic Conditions. Next, this one on why blood pressure screening is important and how to do it. And lastly, this one from last year about PT management of osteoporosis.

If you have a favorite CPG or see one I’m missing, do let me know. I gotta catch ‘em all!

With that, have a great week!