Classification of Shoulder Pain

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Introduction

Classification provides a general framework for identifying subgroups of patients based on the primary goal of treatment, with the ultimate aim of matching indivuals to specific interventions from which they are most likely to benefit . Diagnostic algorithms and classification may be beneficial to clinical decision making and allows clinicians to easily identify the correct intervention strategy, guide treatment decision making and inform a patient’s prognosis. Additionally communication among health care providers, researchers, and those utilizing research findings is possible through the use of diagnostic categories.

Traditionally, diagnostic categories are based on a pathoanatomic medical model aimed at identifying the pathologic tissues. However, the pathoanatomic model may not provide diagnostic categories that effectively guide treatment decision making in rehabilitation.

Evidence for the conservative management of shoulder pain currently does not support any particular approach and it remains unclear as to what the most effective method of treatment is in terms of costs, time and resolution. As a result there has been a shift from the pathoanatomical model of diagnosis towards treatment or rehabilitation-oriented subgroups that will inform patient management and are more cost effective. This form of classification provides a general framework for identifying subgroups of patients based on the primary goal of treatment, with the ultimate aim of matching individuals to specific interventions from which they are most likely to benefit.

Classification Types

Pathoanatomical Model

Pathoanatomic medical model aimed at identifying the pathologic tissues has been the traditional approach used but much of the current research highlights the limited ability of special tests or imaging to make a specific diagnosis based on pathology alone. However, the pathoanatomic model may not provide diagnostic categories that effectively guide treatment decision making in rehabilitation. Recent evidence suggests a poor relationship between diagnostic label and chosen rehabilitation interventions among orthopedic physical therapists. musculoskeletal shoulder disorders are classified based on a pathoanatomic diagnosis to guide decisions for treatment and prognosis. Examples of these diagnoses are rotator cuff tear or tendinopathy, adhesive capsulitis, glenohumeral anterior instability, and superior labral anterior-posterior (SLAP) lesions. The pathoanatomic diagnosis infers that patients with the same tissue pathology form a homogeneous group. Also implicit in this model is that patients with the same pathology should be managed in the same way and have similar prognoses and that the diagnosis remains static over an episode of care. The pathoanatomic model also implies that the pathology explains patient symptoms and disability (activity limitations and participation restrictions) and that correcting the pathology will improve the symptoms and disability. Although the pathoanatomic system of diagnosis may be very appropriate for surgical decision making, it may be inadequate for guiding rehabilitation.[null 3] Pathoanatomic diagnostic categories may encompass patients with similar tissue pathology, but within each pathoanatomic category, there likely exists a heterogeneous group of patients who have different or varying degrees of impairment (loss of body structure and function) and pain that warrant different rehabilitation strategies.

Recent evidence suggests a poor relationship between diagnostic label and chosen rehabilitation interventions among orthopedic physical therapists.

Rehabilitation Model

Summary

Comparison of Features Between Pathoanatomic Diagnosis and Rehabilitation Classification

Pathoanatomic Classification	Rehabilitation Classification
Identifies primary tissue pathology	Identifies level of irritability and key impairments
Remains stable across an episode of care	Typically changes over an episode of care
Guides a general treatment strategy Surgery or nonoperative care? Key tissue and movement precautions?	Guides specific rehabilitation intervention Appropriate intensity of physical stress? Key impairments driving symptoms and loss of function?
Informs Prognosis	My Inform Prognosis

References